Carter et al 10.1177/1534735403251168 Carter Prescriptive et al Exercise Intervention After Bilateral Mastectomies
ARTICLE
A Case Study: Prescriptive Exercise Intervention After Bilateral Mastectomies Susan D. Carter, MD, Scott N. Drum, MS, Reid Hayward, PhD, and Carole M. Schneider, PhD
Exercise for cancer patients is gaining support. In the current case study, a female breast cancer patient was diagnosed with breast cancer at the age of 29 years; she underwent a left modified radical mastectomy. She developed cancer again in the opposite breast at the age of 57 years and had a right modified radical mastectomy. After the second mastectomy (the right breast), the patient received chemotherapy and radiation. Following her cancer treatments, she participated in an exercise intervention for 6 months at the University of Northern Colorado’s Rocky Mountain Cancer Rehabilitation Institute. A 6-month reassessment showed that she increased her muscular strength and cardiovascular function in addition to attenuating her cancer-related fatigue and depression. It is recommended that health professionals work together to ensure that a collaborative effort is undertaken to increase functional work capacity that will significantly improve patients’ quality of life. Keywords: cancer; exercise; prescriptive; rehabilitation; mastectomies; case study
A 59-year-old white female (gravida1 para1) is currently attending cancer rehabilitation exercise training sessions at the Rocky Mountain Cancer Rehabilitation Institute (RMCRI). Prior to her beginning cancer rehabilitation exercise sessions, the patient underwent an initial exercise assessment, which was repeated following a 6-month exercise intervention. Comparative results from the initial to the follow-up exercise reassessment revealed improvements in physical and emotional functioning. The patient’s level of cancer-treatment-related fatigue decreased as her physical fitness improved. These results will be discussed later. The patient’s cancer history is as follows. In 1971, she was diagnosed with an “infiltrating carcinoma” (stage and grade unknown) in the left breast. At the age of 29 years, she had a left modified radical mastectomy. Following the mastectomy, she had no radiation, chemotherapy, or other adjuvant therapy. The patient had numerous mammograms throughout the 1980s and early 1990s. The mammograms DOI: 10.1177/1534735403251168
34
showed microcalcifications but no abnormalities suggestive of malignancy. The patient, at 57 years of age, completed a right mammogram on February 13, 1998. The mammogram indicated that previously observed microcalcifications had increased in number but remained benign in morphology. A 1-year follow-up was recommended. In September of 1998, she felt a pea-sized mass in her remaining right breast. Her primary care physician described a large palpable mass in her right lateral breast, and she was sent for radiographic evaluation. An ultrasound of the breast showed an ill-defined suspicious hypoechoic solid mass measuring 1.4 cm (length) × 0.8 cm (depth) × 1.2 cm (width) at the 8:30 position of the right breast. Following the ultrasound, a mammogram showed 2 groups of indeterminate calcifications in the area, suspicious for malignancy. Surgical consultation was recommended for biopsy of the abnormalities. On October 15, 1998, the patient underwent a right breast biopsy with a frozen section positive for infiltrating ductal carcinoma. An immediate mastectomy was performed as had been discussed preoperatively. Modified radical mastectomy and axillary dissection was performed. The final pathology report confirmed that the excised breast tissue biopsy+ contained a 2.8-cm infiltrating ductal carcinoma, moderately differentiated along with intraductal carcinoma comprising 10% of the total tumor mass. The right mastectomy specimen showed focal residual infiltrating ductal carcinoma, intraductal carcinoma, atypical ductal hyperplasia, dense fibrosis, and numerous benign cysts. The nipple was positive for carcinoma; the margins were negative. Twelve of 18 axillary nodes were positive for metastatic carcinoma. The clinical and pathological evaluation staged the patient at a IIB (T2N1M0) infiltrating ductal carcinoma of the right SDC is at the Regional Breast Center of Northern Colorado, Greeley, Colorado. SND, RH, and CMS are at the University of Northern Colorado, Greeley, Colorado. Correspondence: Carole M. Schneider, PhD, Rocky Mountain Cancer Rehabilitation Institute, Department of Exercise Science, University of Northern Colorado, 2590 Gunter Hall, Greeley, CO 80639. E-mail:
[email protected].
INTEGRATIVE CANCER THERAPIES 2(1); 2003 pp. 34-38 Downloaded from ict.sagepub.com by guest on February 10, 2016
Prescriptive Exercise Intervention After Bilateral Mastectomies breast. Immunohistochemistry on the tumor showed estrogen receptor positive, progesterone receptor negative, and HER-2-neu positive. The patient had an uneventful recovery period following the right mastectomy. A CAT scan of the chest, abdomen, and pelvis and a bone scan in November of 1998 were negative for distant metastatic disease. Afterward, she received systemic chemotherapy with 4 cycles of Cytoxan and Adriamycin given mid-November (1998) through mid-February (1999). The patient went on to receive high-dose chemotherapy with stem cell rescue. Thiotepa, Cytoxan, carboplatin, and etoposide were utilized. Treatment was completed in April of 1999. The 2-month postchemotherapy laboratory values were clinically expected: white cell count at 9 3.1 (× 10 /L); hemoglobin and hematocrit at 11.6 (g/ dl) and 35(%), respectively; and platelet count at 101 (× 109/L). When the patient recovered from chemotherapy, she underwent radical radiation therapy to the chest wall and regional lymph nodes to help decrease the risk of disease recurrence. The physical examination showed no suspicious masses or areas of irregularities found on either chest wall. Radiation therapy began in July of 1999 and continued for 6 weeks. Pertinent past medical history reveals that the patient has adult-onset diabetes mellitus and hypothyroidism. Past surgical history includes remote partial thyroidectomy and tonsillectomy. Current medications include Glucophage, tamoxifen, ferrous sulfate, Zoloft, and Claritin. Social history indicates that the patient denies alcohol and smoking, is married, and has 2 grown children (1 adopted). Review of systems revealed pain and decreased motor activity in the left shoulder since December of 1999. Radiologic workup included a negative bone scan and an arthrogram. On May 19, 2000, the patient was diagnosed with adhesive capsulitis. Subsequently, the patient underwent left shoulder surgery for release of adhesions. With the above cancer history and the fact that the patient was experiencing cancer-treatment-related fatigue, it was recommended by her oncologist that she undergo cancer rehabilitation exercise sessions at RMCRI.
Literature Review on Exercise in Cancer Rehabilitation In support of cancer rehabilitation therapy, studies illustrate that exercise has been shown to decrease cancer fatigue and other symptoms. Dimeo et al1 concluded that an exercise program that focuses on aerobic activity should be prescribed as therapy for primary fatigue in cancer patients. The
researchers underscored the importance of precisely defined intensity, duration, and frequency of exercise for best results. Another group of researchers, Segal et al,2 found that physical exercise can blunt some of the negative side effects during breast cancer treatment. These researchers randomized 123 women with stages I and II breast cancer into 1 of 3 groups: usual care (control group), self-directed exercise, or supervised exercise. They found improved physical functioning in the exercise groups compared to the control group. Other researchers support exercise therapy prescribed during cancer treatment. Mock et al3 studied the effects of exercise on fatigue, physical functioning, and emotional distress in breast cancer patients during radiation therapy. They found that an individualized, self-paced, home-based walking program maintained throughout cancer treatment helped to manage symptoms and increased physical functioning during radiation therapy compared to the usual care group. The exercise or home-based walking group scored significantly better in relation to symptom intensity, particularly in relation to fatigue levels, anxiety, and difficulty sleeping compared to the usual care group. Dimeo et al4 observed a group of cancer patients receiving high-dose chemotherapy followed by peripheral blood stem cell transplantation (n = 27) during an in-hospital exercise program. The program consisted of supine biking on an ergometer, which followed an interval-training pattern for 30 minutes daily. A control group (n = 32) did not train. Overall, the researchers concluded that aerobic exercise decreased fatigue and improved psychological distress in cancer patients receiving chemotherapy versus the nontraining control group. In conjunction with the above studies, RMCRI researchers have found similar results. Bentz et al5 measured physiological parameters (cardiopulmonary, strength and endurance, and flexibility) in cancer patients. Sixteen patients volunteered for the study, of which 5 had surgery only and 11 had received adjuvant therapy (chemotherapy and/or radiation treatment). The results indicated that irrespective of cancer treatment, the patients improved significantly, which emphasized the need for exercise intervention to improve the recovery of cancer patients. The researchers also determined that based on the length of time posttherapy (surgery, chemotherapy, or radiation), patients that were the furthest out from treatment demonstrated decreased total body fitness. Therefore, there is a need for exercise specialists to direct the development of scientific and educationally sound exercise programs close to diagnosis to augment the quality of life of cancer patients.
INTEGRATIVE CANCER THERAPIES 2(1); 2003 Downloaded from ict.sagepub.com by guest on February 10, 2016
35
Carter et al 6
Schneider et al investigated prescriptive exercise rehabilitation adaptations in cancer patients. Twelve patients from RMCRI were referred to and volunteered for the study. Measurements included cardiovascular endurance, muscle strength and endurance, and range of motion parameters assessed preintervention and postintervention. The 6-month intervention consisted of a carefully designed and implemented exercise program that was unique to each patient’s prescription goals. The patients showed an increase in all fitness parameters observed: cardiovascular endurance (+32.7%), muscle strength (+1.5%), muscular endurance (+52.9%), and upper (+1.2%) and lower (+0.8%) body range of motion. Fatigue was shown to have decreased by 16.7%. The researchers stated that specific exercises positively influenced the fatigue status of cancer patients by enhancing their physiological and psychological well-being. Another study by Dennehy et al7 determined the effects of prescriptive exercise intervention on cancertreatment-related symptoms. The RMCRI researchers found that the precise use of exercise prescription has positive physiological with concurrent psychological benefits. Moreover, prescriptive exercise intervention appeared to help reverse cancer-treatment-related fatigue. Therefore, medical oncologists, radiologists, surgeons, and exercise physiologists need to collaborate to provide therapies to decrease treatmentrelated symptoms and to improve recovery for cancer patients. Dennehy et al8 investigated the value of prescriptive, individualized exercise intervention in cancer patients undergoing chemotherapy and radiation. Twenty patients were followed for 52 weeks and underwent prephysiological and prepsychological assessments followed by postexercise reassessments. The results indicated that the exercise intervention improved pulmonary function (+2.8%), duration of aerobic activity (+73.6%), muscular strength (+124%), and muscular endurance (+134%). These data indicate the positive effects of prescriptive exercise intervention during and following chemotherapy and radiation on the recovery process of cancer patients by decreasing cancer-treatment-related symptoms and improving patient quality of life.
Exercise Intervention In regard to the current case study, the patient underwent an initial exercise assessment 6½ months following radiation therapy on May 1, 2000, with a subsequent 6-month prescriptive exercise intervention. The exercise intervention consisted of a carefully
36
designed exercise prescription, which called for 2 to 3 exercise sessions per week performed at RMCRI. Each session gradually progressed to approximately 1 hour and contained a warm-up phase followed by stretching exercises. The patient used either a stationary bicycle or walked on a treadmill, gradually working up to more than 30 minutes of continuous aerobic exercise by May 16, 2000. The goal of this whole-body work was to increase her energy level and decrease her treatment-related fatigue. In addition, the patient began to perform light strength-training exercises that consisted of biceps curl, triceps extension, arm raises, wheel range of motion (ROM), and rope ROM exercises. The following session, the patient performed the usual warm-up, stretching, and aerobic exercises followed by lower extremity strength training consisting of wall squats with a thera-band ball, leg adductor exercises with tubing, and gluteus maximus exercises with tubing. This split routine of alternating upper- and lower-body exercises lasted through May 17, 2000, at which time the patient’s routine excluded upper-body exercises because of upper-extremity discomfort in the left shoulder. On May 19, 2000, the patient completed a warm-up period, stretching phase, aerobic exercise phase, and a lower-body strength routine, which consisted of wall squats and adductor tubing leg exercises. On May 25, 2000, the patient had shoulder surgery for release of adhesions. The exercise specialist began limited upper-body work and stressed lower-body work. She gradually gained ROM and strength in the left shoulder to more closely balance with the right shoulder. In June 2000, the patient was able to perform lateral pull-downs with minimal weight, bench press with minimal weight, abdominal crunches, and rope pulley for ROM along with varying leg exercises. On November 1, 2000, she completed her 6-month exercise reassessment. Overall, the patient demonstrated improvements (see Table 1) from the initial assessment to the follow-up reassessment on cardiovascular endurance, percentage body fat (skinfold calipers), muscular strength and endurance, and flexibility and range of motion. Some of the muscular strength and endurance parameters were not assessed on the patient during the initial exercise assessment due to upper-extremity pain and discomfort. However, during the 6-month follow-up exercise reassessment, the patient was fully able to complete the muscular strength and endurance testing, illustrating improved muscular fitness. In addition, the patient greatly improved on her rating of fatigue (Piper Revised Fatigue Scale9) from her initial assessment to
INTEGRATIVE CANCER THERAPIES 2(1); 2003 Downloaded from ict.sagepub.com by guest on February 10, 2016
Prescriptive Exercise Intervention After Bilateral Mastectomies Table 1.
Assessment Parameters for the Preexercise and Postexercise Intervention
Premeasure Cardiovascular 75% V& O2max (ml/kg/min) Time on treadmill (minutes) Resting heart rate (beats per minute) Systolic blood pressure (mm HG) FVC (% predicted) FVC1 (% predicted) Percentage body fat Muscular strength and endurance Abdominal crunches (repetitions) Right handgrip (kg) Left handgrip (kg) Biceps curl, left (repetitions) Biceps curl, right Bench press Lateral pull-down Triceps press-down Leg extension Leg curl Leg press Shoulder press Flexibility/range of motion Sit and reach test (inches) Right shoulder reach Left shoulder reach Right shoulder flexion (degrees) Left shoulder flexion Right shoulder extension Left shoulder extension Right shoulder abduction Left shoulder abduction Right hip flexion Left hip flexion Fatigue Piper Fatigue Scale Depression Beck Depression Scale
Postmeasure
Percentage Change
10.31 1.01 99.00 118.00 103.00 81.00 23.74
21.00 6.00 91.00 104.00 99.00 79.00 19.73
+104.0 +494.0 –8.0 –12.0 –4.0 –2.5 –16.9
20.00 26.00 13.50 NA 40 at 5.0 lbs NA NA NA NA NA NA NA
30.00 28.00 33.00 17 at 8.5 lbs 20 at 8.5 lbs 11 at 45 lbs 15 at 45 lbs 7 at 30 lbs 25 at 45 lbs 25 at 45 lbs 25 at 60 lbs NA
+50.0 +7.7 +144.0
14.50 4.00 NA 180.00 180.00 80.00 55.00 180.00 130.00 110.00 110.00
13.50 3.00 NA 180.00 180.00 85.00 65.00 180.00 180.00 119.00 110.00
–6.9 –25.0 NA 0 0 +6.3 +18.2 0 +38.5 +8.2 0
5.01
1.32
–74.0
21.00
2.00
–90.5
FVC = forced vital capacity, FVC1 = forced vital capacity in 1.0 seconds, NA = not available (patient could not complete).
her 6-month reassessment along with a significantly improved Beck Depression score. For both measures, a lower score indicates an improved state.
state, even after the cancer has been ameliorated by traditional means. Cancer exercise rehabilitation holds the promise of improved quality of life for cancer patients.
Conclusion It appears that a carefully constructed and implemented exercise intervention, which includes gradual progression for aerobic, strength, and ROM exercises, is an effective means to improve a cancer patient’s overall well-being and quality of life. The patient’s fatigue score decreased as her cardiovascular and muscular systems improved, as noted from the initial exercise assessment to the 6-month reassessment. Therefore, the continued well-being of the cancer patient depends on realizing the need for an exercise intervention to help restore the patient to a fully functional
References 1. Dimeo F, Rumberger BG, Keul J. Aerobic exercise as therapy for cancer fatigue. Med Sci Sports Exerc. 1998;30:475-478. 2. Segal R, Evans W, Johnson D, et al. Structured exercise improves physical functioning in women with stages I and II breast cancer: results of a randomized controlled trial. J Clin Oncology. 2001;19:657-665. 3. Mock V, Dow K, Meares C, et al. Effects of exercise on fatigue, physical functioning, and emotional distress during radiation therapy for breast cancer. Oncol Nurs Forum. 1997;24:991-1000. 4. Dimeo F, Stieglitz R, Novelli-Fischer U, Fetscher S, Keul J. Effects of physical activity on the fatigue and psychologic status of cancer patients during chemotherapy. Cancer. 1999;85:22732277.
INTEGRATIVE CANCER THERAPIES 2(1); 2003 Downloaded from ict.sagepub.com by guest on February 10, 2016
37
Carter et al 5.
6.
7.
38
Bentz A, Dennehy CA, Busing K, Carter SD, Schneider CM. Physiological alterations with adjuvant cancer therapy. Med Sci Sports Exerc. 1999;31(5):S363. Schneider, CM, Stephens K, Bentz A, Quick K, Carter SD, Dennehy CA. Prescriptive exercise rehabilitation adaptations in cancer patients. Med Sci Sports Exerc. 2000;32(5):S234. Dennehy CA, Carter SD, Schneider CM. Physiological manifestations of prescriptive exercise on cancer treatment-related fatigue. The Physiologist. 2000;43(4):357.
8.
9.
Dennehy CA, Schneider CM, Carter SD, Bentz A, Stephens K, Quick K. Exercise intervention for cancer-related fatigue. Res Q Exer Sport. 2000;71(suppl 1):A-27. Piper BF, Dibble SL, Dodd MJ, Weiss MC, Slaughter RE, Paul SM. The revised Piper Fatigue Scale: psychometric evaluation i n w o m e n w i t h b r e a s t c a n c e r. O n c o l N u r s F o r u m. 1998;25(4):677-684.
INTEGRATIVE CANCER THERAPIES 2(1); 2003 Downloaded from ict.sagepub.com by guest on February 10, 2016
