NEW THEORIES FOR LYMPHEDEMA AFTER BREAST CANCER SURGERY

August 14, 2009 — Slowly progressive weight lifting may be helpful in breast cancer survivors with lymphedema, according to the results of a randomized controlled trial reported in the August 13 issue of the New England Journal of Medicine.

"Weight lifting has generally been proscribed for women with breast-cancer–related lymphedema, preventing them from obtaining the well-established health benefits of weight lifting, including increases in bone density," write Kathryn H. Schmitz, PhD, MPH, from the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine and Abramson Cancer Center in Philadelphia, and colleagues.

"A program of controlled exercise through weight lifting may increase the physical-work capacity of the affected arm, thereby protecting it from injury sustained during common daily activities. Weight lifting offers additional benefits particularly relevant to breast-cancer survivors, including control of body fat and improved functional outcomes and bone health."

Weight-Lifting Improved Secondary Endpoints

In this study, 141 breast cancer survivors with stable lymphedema of the arm were randomly assigned to a group that received twice-weekly progressive weight lifting or to a control group. While weight lifting, participants were required to wear a well-fitted compression garment. The main study endpoint was the change in arm and hand swelling, measured by displaced water volume of the involved and uninvolved upper extremity, at 1 year. Secondary endpoints were the incidence of exacerbations of lymphedema, number and severity of lymphedema symptoms, and muscle strength.

Limb swelling increase of at least 5% occurred in 11% of the weight-lifting group and in 12% of the control group (cumulative incidence ratio, 1.00; 95% confidence interval, 0.88 – 1.13).

The weight-lifting group had greater improvements than the control group in self-reported severity of lymphedema symptoms (P = .03) and upper- and lower-body strength (P < .001 for both comparisons). In addition, the weight-lifting group had a lower incidence of lymphedema exacerbations, as determined by a certified lymphedema specialist (14% vs 29%; P = .04). Weight lifting was not associated with any serious adverse events.

"In breast-cancer survivors with lymphedema, slowly progressive weight lifting had no significant effect on limb swelling and resulted in a decreased incidence of exacerbations of lymphedema, reduced symptoms, and increased strength," the study authors write. "The results of this study reduce concerns that weight lifting will worsen arm and hand swelling associated with lymphedema in breast-cancer survivors."

Limitations of this study include incomplete blinding, that multiple therapists were used to evaluate for exacerbations, and possible reporting bias.

"The substantive treatment-related increases in strength, coupled with the lack of change in lean mass, indicate that the program was more focused on building muscle strength than on hypertrophy, as intended," the study authors conclude. "Further research is needed to determine the critical components of this intervention in order to facilitate its optimal use by breast-cancer survivors with lymphedema.... These findings support the potential benefits of a slowly progressive weight-lifting program in women with breast-cancer–related lymphedema, in conjunction with appropriate use of compression garments and close monitoring for arm and hand swelling."

Promising Results, More Research Needed

In an accompanying editorial, Wendy Demark-Wahnefried, PhD, RD, from M.D. Anderson Cancer Center in Houston, Texas, calls this intervention "promising" but recommends critical follow-up research, including detailed cost analysis and dissemination analyses.

"The report by Schmitz et al. provides strong reassurance regarding the safety of appropriately supervised weight training in women with a history of breast cancer and lymphedema," Dr. Demark-Wahnefried writes.

"A comprehensive strategy to improve the outcomes in these women should include dietary and exercise interventions aimed at weight management, since overweight, obesity, and weight gain after diagnosis are recognized as significant risk factors for lymphedema as well as for breast-cancer–associated death. Multifactor interventions that promote healthy eating, regular exercise (e.g., aerobic and progressive resistance training), and other lifestyle improvements (e.g., reducing smoking and alcohol use) have the potential to substantially improve overall health and survival among women with this common cancer."

The National Cancer Institute and the National Center for Research Resources supported this study. BSN Medical provided custom-fitted compression garments, and the fitness centers where the weight-lifting sessions took place (YMCA of Philadelphia and Vicinity, Sisters in Shape, and the Family YMCA of Burlington County, NJ) provided discounted membership fees for study participants. The study authors have disclosed no relevant financial relationships. Dr. Demark-Wahnefried has disclosed that she receives honoraria for consulting at the Livestrong Centers for Excellence at Ohio State University and at the University of Pennsylvania.

N Engl J Med. 2009;361:664–673; 710–711. Abstract