Weight lifting in women with breast cancer related lymphoedema
December, 2009
Commentary by Dr Sandi Hayes
The article
Schmitz KH, Ahmed RL, Troxel A, et al. Weight lifting in women with breast-cancer-related lymphedema. N Engl J Med 2009;361:664-73
The reviewer
Dr Sandi Hayes is a Senior Research Fellow at the School of Public Health, Institute of Health and Biomedical Innovation, Queensland University of Technology.
SUMMARY
Study Design
The article describes a randomised controlled trial of 141 breast cancer survivors with stable lymphoedema assigned to either twice-weekly progressive weight lifting or a control group for one year. Participants in the weight lifting group participated in exercise sessions at a local community fitness centre, attending twice-weekly supervised sessions for the first 13 weeks and for the remaining 39 weeks, they continued twice-weekly unsupervised exercise. Those in the control group were asked not to change their exercise level during study participation. All trial participants were given a custom-fitted compression garment and those in the weight lifting group were required to wear these during weight lifting.
The primary outcome of the study was change in arm and hand swelling at one year. Secondary outcomes were incidence of exacerbations of lymphoedema, number and severity of lymphoedema symptoms and muscle strength. Measurements were obtained at baseline and at 12 months.
Findings
The study groups were well balanced for age, anthropometric measures, diet, physical activity and time since cancer diagnosis.
Compared to the control group, women in the weight lifting group had:
- no significant difference in the proportion of women who had a change in limb swelling of 5% or more
- lower incidence of lymphoedema exacerbations as assessed by a certified lymphoedema specialist (14% versus 29%, p=0.04)
- greater decrease in the number (p=0.07) and severity (p=0.03) of lymphoedema symptoms reported
- increased strength as measured by bench press and leg press (p<0.001).
There were no serious adverse events related to the intervention.
Conclusion
Progressive weight lifting had no significant effect on arm and hand swelling associated with lymphoedema in breast cancer survivors, and resulted in decreased incidence of exacerbations of lymphoedema, reduced symptoms and increased strength. The authors also concluded that this study supports the potential benefits of a slowly progressive weight lifting program in women with breast cancer-related lymphoedema, in conjunction with appropriate use of compression garments and close monitoring for arm and hand swelling.
COMMENTARY
What does this article add to existing clinical evidence in this area?
This study represents the largest trial investigating the effect of exercise on lymphoedema and does so using the most optimal study design. The work set out to evaluate the effect of weight training on existing lymphoedema. Specifically, does progressive weight training exacerbate, improve or have no effect on lymphoedema, does weight training have an impact on other factors such as muscle strength and do those with lymphoedema find weight training an acceptable and feasible form of exercise? This study provides stronger evidence that supports previous, smaller studies1,2 that weight training does not exacerbate secondary lymphoedema.
How adequate was the methodology used in addressing the aim of this study?
This was a randomised controlled trial involving women with breast cancer-related lymphoedema of a range of severities. In short, this was a well designed, high quality study testing a pragmatic intervention on an appropriate sample of women with lymphoedema following breast cancer.
What are the implications of this study for clinical practice in Australia?
The results of this study demonstrate that participation in a progressive weight lifting program for those with lymphoedema can lead to a range of benefits that positively influence short- and longer-term health, without adverse changes to lymphoedema status. Further, participation in a weight training program may assist in lymphoedema management by reducing the number and severity of associated symptoms and reducing the number of lymphoedema flare-ups experienced. While cost-effectiveness was not evaluated in the study, the accompanying editorial3 noted that the weight lifting intervention has the potential to result in cost savings by reducing direct health costs, risk of disability and potentially enabling women to return to work at full capacity.
While the study did not directly address prevention of lymphoedema, there may be potential prevention implications from the finding that weight lifting did not worsen existing lymphoedema. Lymphoedema prevention advice has traditionally included suggestions to avoid lifting children, heavy bags or other objects with the affected arm, to reduce the risk of developing lymphoedema.3 However, as Schmitz et al4 indicate, adhering to this advice may restrict use of the arm and/or limit participation in activities that may in fact be beneficial to recovery. The evidence relating to risk reduction strategies for breast cancer-related lymphoedema is scarce.
With further research on weight lifting interventions, we may see changes in advice on prevention and management of lymphoedema whereby the emphasis on ‘avoiding’ specific activities is replaced with an emphasis on the importance of regular participation in planned and progressive physical activity including weight training.
References
- Ahmed RL, Thomas W, Yee D et al. Randomized controlled trial of weight training and lymphedema in breast cancer survivors. J Clin Oncol 2006;24:2765–72.
- Johansson K, Tibe K, Weibull A et al. Low intensity resistance exercise for breast cancer patients with arm lymphedema with or without compression sleeve. Lymphology 2005;38:167–80.
- Denmark-Wahnefried W. A weighty matter – lifting after breast cancer. N Engl J Med 2009;361:770-1
- Schmitz KH, Ahmed RL, Troxel A, et al. Weight lifting in women with breast-cancer-related lymphedema. N Engl J Med 2009;361:664-73
Editor: Dr Anne Nelson, Evidence Review and Research Leader, National Breast and Ovarian Cancer Centre
Clinical Update – Breast Cancer Editorial Committee: Mr John Collins - Surgeon, Ms Jo Keyser - Specialist Breast Nurse, Dr Warwick Lee - Radiologist, A/Prof Liz Lobb – Senior Research Fellow, Dr Sue-Anne McLachlan - Medical Oncologist, Dr Sally Meade - Breast Surgeon, Dr Sue Pendlebury - Radiation Oncologist, A/Prof Martin Stockler - Medical Oncologist.
Disclaimer
Clinical Update - Breast Cancer is produced by National Breast and Ovarian Cancer Centre (NBOCC) and is intended to provide health professionals with timely expert commentary on new research in breast and ovarian cancer. Commentaries included in Clinical Update - Breast Cancer do not replace recommendations included in NBOCC clinical practice guidelines.
Information contained in Clinical Update - Breast Cancer is not intended to be used as substitute for an independent health professional's advice. NBOCC does not accept any liability for any injury, loss or damage incurred by use of or reliance on the information contained in Clinical Update - Breast Cancer. NBOCC develops material based on the best available evidence however cannot guarantee and assumes no legal liability or responsibility for the currency or completeness of the information.
