Exercise is Medicine

Exercise in the Prevention and Treatment

of Breast Cancer: What Clinicians Need to
Tell Their Patients
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Jennifer L. Kraschnewski1 and Kathryn H. Schmitz2

a recent meta-analysis of 43 studies (26).

ABSTRACT Combined obesity and physical inactivity
In 2016, nearly a quarter-million women were diagnosed with invasive breast can- account for an estimated 25% to 33% of
cer, the second deadliest cancer type. Lifestyle behaviors are well-established risk all breast cancer (18).
factors for both the development of, and negative outcomes from, breast cancer. Factors known to be protective for breast
New findings demonstrate that engaging in even minimal amounts of exercise is cancer include maintaining a healthy weight
protective against breast cancer. Further, numerous studies have identified the role and engaging in regular moderate or vigor-
of exercise in the treatment of breast cancer and improvement in treatment side ef- ous exercise. Unfortunately, exercise remains
fects, quality of life, and overall survival. Unfortunately, few patients are physically an underused preventive strategy, with ob-
active due to multiple barriers. Physicians may be helpful in engaging patients in jective studies observing fewer than 10%
being more active. Further research is necessary to identify programs and approaches of US adults engaging in the recommended
to help patients both with, and at-risk for, breast cancer to engage in exercise. amount of physical activity (9,34). Patients
who are concerned about their cancer risk,
as well as those who are cancer survivors, represent an impor-
tant target population given the additional impact exercise can
INTRODUCTION have in improving their health. Further, patients affected by
Nearly a quarter-million women were diagnosed with inva- cancer may be particularly motivated to exercise if made
sive breast cancer in 2016 (1). Further, an estimated 40,000 aware of these potential health benefits. Clinicians can play a
women lost their lives to breast cancer, making it the second dead- critical role in motivating patients to make behavioral changes
liest type of cancer (1). Over the past decade, incidence rates of for healthier lifestyles (25). Unfortunately, the rate of clinician
breast cancer have largely remained stable, although mortality counseling for exercise has declined in the face of the obesity
rates have slightly declined (1). Despite these positive changes, epidemic (15).
more work is necessary to better understand how to prevent Primary care clinicians serve on the frontline of patient care,
and treat breast cancer to improve overall population health. and therefore, can benefit from the latest findings in the field of
Lifestyle behaviors have long been identified as risk factors breast cancer prevention and treatment. The purpose of this re-
for both the development of, and negative outcomes from, can- view is to highlight recent articles that examine the impact of
cer. For example, obesity (body mass index [BMI] of 30 kg·m−2 exercise on breast cancer prevention and treatment. Under-
or higher) is associated with a 20% to 40% increased risk of standing the current literature in this area can help clinicians
breast cancer in postmenopausal women (22). Further, in pa- understand how best to interpret study results for patients and en-
tients diagnosed with breast cancer, obesity is associated with courage exercise counseling. Successfully engaging more women
a 33% increased risk of recurrence and all-cause mortality in in exercise can decrease breast cancer morbidity and mortality
and ultimately improve the health of the US population.
1
Departments of Medicine, Pediatrics and Public Health Sciences, College of
Medicine, The Pennsylvania State University, Hershey, PA, and 2Penn State Can- Role of Exercise in Prevention of Breast Cancer
cer Institute, The Pennsylvania State University, Hershey, PA Although physical activity is well known to decrease risk of
heart disease and all-cause mortality (11,21), the association with
Address for correspondence: Kathryn H. Schmitz, PhD, FACSM, Penn
State Cancer Institute 500 University Drive, Mailstop CH69, Hershey, PA 17033
cancer risk has only recently been better understood. Given in-
(E-mail: kschmitz@phs.psu.edu). creasing scientific literature in this area, the World Cancer Re-
search Fund, in partnership with the American Institute for
This article originally appeared in Curr. Sports Med. Rep. 2017; 16(4): 263–267. Cancer Research, updated their 1997 report to include physical
2379-2868/0215/0092–0096 activity in 2007 — “Food, Nutrition, Physical Activity, and the
Translational Journal of the ACSM Prevention of Cancer: a Global Perspective”(36). The second rec-
Copyright © 2017 by the American College of Sports Medicine ommendation of this report is to “be physically active as part of

92 Volume 2 • Number 15 • August 1 2017

Copyright © 2017 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
everyday life,” given the increased awareness that physical activity
is protective against cancers as well as weight gain, overweight,
and obesity. With particular regard to postmenopausal breast
cancer, this literature review identified sufficient evidence from
prospective studies that higher levels of physical activity, with a
dose-response relationship, lowered the risk (36). Further, the
American Cancer Society also recommends engaging in a physi-
cally active lifestyle, in line with the 2008 Physical Activity Guide-
lines for Americans (16). Physical activity impacts cancer risk
through various mechanisms, including metabolic (i.e., caloric
balance), hormonal, and immune effects (19).
A recent study by Moore and colleagues (20) pooled data from
12 prospective US and European cohorts with self-reported phys-
ical activity measures to determine the association of physical ac-
tivity with incidence of 26 types of cancer. A total of 1.44 million
participants with 186,932 cancers were included in the analysis.
Leisure-time physical activity was determined for each individual
and examined for contrast in those individuals with either high (at
the 90th percentile) or low (at the 10th percentile) activity levels.
High versus low levels of physical activity was associated with
lower risk of 13 cancers, including breast cancer (hazard ratio
[HR], 0.9; 95% confidence interval [CI], 0.87 to 0.93). Further,
this study extended current understanding of high levels of physi-
cal activity and its inverse association in patients with estrogen
receptor-negative breast cancer (20). The study authors concluded
that health care professions should emphasize with patients the
benefits of being physically active in cancer prevention, even in
the setting of high BMI or smoking history.
Understanding how to help women be more physically active
to reduce cancer risk remains a challenge. Technology-based inter-
ventions have been explored as an avenue for women at risk for
breast cancer. Hartman and colleagues (10) tested the efficacy of
a 3-month social cognitive theory grounded Internet-based physi-
cal activity targeting sedentary women with a family history of
breast cancer. Given that this intervention was delivered entirely
through technology, it overcomes several barriers of program dis-
semination, including being time intensive and having expensive
delivery channels. The intervention was modified from a print-
based physical activity intervention and included an Internet-based
program with brief telephone counseling for personalized goal
setting and discussion. Participants were encouraged to work up
to 45 to 60 min of moderate intensity physical activity most days
of the week. Participants (n = 56) had a mean age of 42.6 yr, pre-
dominantly white (93%) with a mean BMI of 27.3 kg·m−2. At
3 months, intervention participants had significantly greater in-
creases in minutes of moderate to vigorous intensity physical ac-
tivity (approximately 14 to 213 min·wk−1) as compared with
the participants in the control arm (30 to 129 min·wk−1). Signifi-
cant differences were maintained at 5 months, 2 months after the
intervention ended. Study authors suggested that the maintained
benefit after the conclusion of the intervention was a result of im-
provement in self-efficacy (10). Understanding effective interventions
utilizing Internet-based programming has tremendous potential
for future dissemination.
Role of Exercise After a Diagnosis of Breast Cancer
Numerous recent studies have investigated the role of exercise
after a diagnosis of breast cancer, demonstrating improvement
for perioperative outcomes, treatment side effects, quality of life,
and overall survival.
Given that postoperative recovery is important for both pa-
tients and society through health care expenditures, understand-
ing how exercise can be of benefit is important. Preoperative
exercise may be useful for perioperative outcomes among women
with breast cancer. A study of 220 patients undergoing breast can-
cer surgery found that women who were more active had an 85%
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increased chance of feeling physically recovered 3 wk postopera-
tively (relative risk [RR], 1.85; 95% CI, 1.2 to 2.85) (24). How-
ever, no difference was demonstrated at 6 wk, due to the fact
that most women felt physically recovered. Further, no difference
was found in length of sick leave or self-assessed mental recovery
between patients who were inactive versus active (24).
A Cochrane Review was conducted in 2016 to assess the effect
of aerobic or resistance exercise interventions during adjuvant
treatment for breast cancer on treatment-related side effects (6).
This review was an update of the original Cochrane review pub-
lished in 2006 and included randomized controlled trials of exer-
cise interventions on outcomes including physical deterioration,
fatigue, quality of life, depression, and cognitive dysfunction. A
total of 32 studies were included with 2626 randomized women.
The review concluded that physical exercise during adjuvant treat-
ment for breast cancer probably improves physical fitness (stan-
dardized mean difference [SMD], 0.42; 95% CI, 0.25 to 0.59,
moderate-quality evidence) and slightly reduces fatigue (SMD, −0.28;
95% CI, −0.41 to −0.16). Unfortunately, exercise led to little or
no improvement in health-related and cancer-specific quality of
life and depression. The study authors concluded that exercise
can be regarded as a supportive self-care intervention with proba-
ble improvement on fatigue and physical fitness. However, at least
nine current studies were ongoing at the time of the review to help
answer the questions of if, and how much, exercise helps with
both these and other treatment side effects.
A second Cochrane Review published in 2017 focused on the
role of yoga in improving health-related quality of life, mental
health, and cancer-related symptoms in women diagnosed with
breast cancer. Although also a form of exercise, yoga additionally
incorporates meditation and breathing exercises as well as spiri-
tual practice and is a complementary therapy often recommended
for patient with cancer. This review included 24 randomized con-
trolled trials with a total of 2166 participants. Moderate-quality
evidence supported yoga as having a short-term (≤12 wk effect
improving health-related quality of life (SMD, 0.22; 95% CI,
0.04 to 0.4), reduced fatigued (−0.48; 95%CI, −0.75 to −0.20),
and reduced sleep disturbances (SMD, −0.25; 95% CI −0.4 to
−0.09). However, the review did not find that yoga reduced de-
pression or anxiety or improved health-related quality of life and
fatigue in the medium term (30 to 48 months).
Another treatment-related side effect of breast cancer that exer-
cise may address is lymphedema. Breast cancer-related lymphedema
is the accumulation of fluid in the interstitial tissues in the arm,
shoulder, neck, or torso attributed to the damage of lymph nodes
during breast cancer treatments involving radiation and axillary
node dissection (23). Nelson (23) conducted a systematic review
of the literature of randomized controlled trials investigating the
effect of resistance exercise in those with, or at risk for, breast
cancer-related lymphedema. A total of six good quality random-
ized controlled trials were identified, including 805 breast cancer
survivors. Strong evidence was identified that breast cancer survi-
vors can perform resistance training exercise to produce signifi-
cant gains in strength without risk of incidence or exacerbation
of lymphedema. Practical applications suggested by this review in-
cluded that progressive resistance exercise training can be safely
performed two to three times a week on nonconsecutive days.
However, medical approval was recommended before initiation
of a resistance exercise training program.
In addition to impacting treatment side effects, evidence suggests
that physical activity decreases breast cancer recurrence and over-
all mortality. A systematic review of 16 prospective studies of breast
cancer survivors found a summary relative risk of total and breast
cancer mortality of 0.77 (95% CI, 0.69 to 0.88) and 0.77 (95%
CI, 0.66 to 0.9), respectively, for cancer survivors with the highest
versus lowest levels of prediagnosis physical activity (29). For
Translational Journal of the ACSM 93
postdiagnosis physical activity, the summary RR of total and breast
cancer mortality were 0.52 (95% CI, 0.42 to 0.64) and 0.72 (95%
CI, 0.60 to 0.85), respectively. Further, survival was incrementally
tied to amount of exercise: each 10 metabolic equivalent task-
hour per week increase in postdiagnosis activity was associated
with 24% (95% CI, 11% to 36%) decreased total mortality risk
among breast cancer survivors. Schmid and Leitzmann’s review
also demonstrated that benefit for survivors who were sedentary
before diagnosis: survivors who increased their physical activity
by any level from prediagnosis to postdiagnosis showed decreased
total mortality risk (RR, 0.61; 95% CI, 0.46 to 0.80) compared
with those who did not change their physical activity level (29).
Borch and colleagues (2) further added to this evidence in their
study of 1327 women with breast cancer from the population-
based Norwegian Women and Cancer study. Although they did
not find an association of prediagnostic physical activity levels
with all-cause or breast cancer-specific mortality, postdiagnostic
physical activity level was associated with a significant decrease.
Specifically, all-cause mortality (HR, 1.76; 95% CI, 1.21 to 2.56)
and breast cancer-specific mortality (HR, 2.05; 95% CI, 1.35 to
3.10) increased among women who were less active after diagno-
sis. These findings highlight the importance of integrating physical
activity postdiagnosis, regardless of prediagnosis activity level.
Clinicians may find that sharing this evidence with patients who
are currently sedentary may be particularly motivating.
In addition to the side effects outlined above, treatment for breast
cancer also is associated with increased body fat and decreased
lean body mass, unfortunate changes which increase the risk of
obesity and resultant increased risk of cancer recurrence and mor-
tality (5). Zhu and colleagues (38) conducted a meta-analysis of
randomized controlled trials investigating the effects of exercise
intervention in breast cancer survivors. Thirty-three trials met in-
clusion criteria and were included with a total of 2659 patients. In
addition to results demonstrated in the Cochrane Review (quality
of life, self-esteem, and depression and anxiety symptoms), exer-
cise was found to increase muscular strength and improve body
composition, including reducing BMI and fat mass and increasing
lean mass (38).
Aromatase inhibitors, guideline-concordant treatment for post-
menopausal women with hormone receptor-positive breast can-
cer, are associated with several negative side effects. Up to 50%
of patients treated with aromatase inhibitors have associated ar-
thralgias, resulting in poor medication adherence and increased
mortality. Breast cancer treatment with aromatase inhibitors also
is associated with decreased bone mineral density, a risk factor for
osteoporosis and fragility fractures (28,37). The Hormone and
Physical Exercise (HOPE) study examined the effects of an exer-
cise intervention on severity of aromatase inhibitor-induced ar-
thralgia (primary outcome)(14) and bone mineral density (33).
The HOPE study was a randomized controlled trial of exercise
versus usual care involving 121 postmenopausal women within
0.5 to 4.0 yr of diagnosis of hormone receptor positive stage I to
III breast cancer taking an aromatase inhibitor before enrollment.
The yearlong exercise intervention engaged participants in a twice
weekly supervised resistance training at a local health club with
instructions to complete 150 min of moderate-intensity aerobic
exercise at home (primarily brisk walking). At the end of the trial,
women reported increasing their exercise by 159 min·wk−1 (SD,
136 min·wk−1) and attended 70% of strength training sessions.
Women in the exercise intervention had decreased worst joint pain
scores and pain severity and interference compared with increased
pain in women in the control intervention (P < 0.001) (14).
Further analysis of the HOPE women explored the effect of ex-
ercise on body composition and bone mineral density. The women
in the exercise group had a 1.4% decrease in percent body fat and
a 0.32-kg increase in lean body mass as compared with those in
94 Volume 2 • Number 15 • August 1 2017
Copyright © 2017 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
the control group (33). Despite the small magnitude of these changes,
the reverse findings were identified in the usual care group as ex-
pected for women on aromatase inhibitors. In this way, the exer-
cise program successfully combated the changes typically associated
with aromatase inhibitors. Importantly, the HOPE study demon-
strated the feasibility of an exercise program in breast cancer survi-
vors with arthralgia and supports referral of this target population
to community-based exercise programs, such as LIVESTRONG®
at YMCA. Sharing the ways exercise can combat the negative side
effects of aromatase inhibitors with patients and providers may
help overcome barriers of concern about the ability to engage in
physical activity.
TOWARD THE GOAL OF CONSISTENT PHYSICAL ACTIVITY AFTER
BREAST CANCER
Unfortunately, being physically active during times of good health
is challenging, and barriers are even greater during times of per-
sonal illness. Engaging and remaining engaged in physical activity
posttreatment for breast cancer remains particularly challenging
for survivors. Despite the importance placed on exercise by orga-
nizations, such as the Institute of Medicine (IOM), American Can-
cer Society, and American College of Sports Medicine, similar
rates of breast cancer survivors (10%) participate in physical ac-
tivity as the general population (8,27,31,35). Henriksson et al.
(12) recently studied the perceived barriers to, and facilitators
of, exercise during adjuvant cancer treatment. Semistructured focus
group and individual interviews were conducted with 23 patients.
Three categories were identified: 1) physical and emotional bar-
riers, 2) perspective and attitudes, and 3) support and practicalities.
Patients identified physical and emotional barriers to exercise, in-
cluding the side effects of cancer treatment, comorbid conditions,
and emotional distress. Perspectives and attitudes included self-
efficacy and self-image, preference of exercise type (i.e., something
enjoyable), concerns and expectations about being physically ac-
tive, experiences with physical activity, and cancer as a “teachable
moment.” Patients also identified support and practicalities as
both potential barriers and facilitators, including overprotective
supports inhibiting physical activity, environmental support and
practical issues (i.e., time), motivational support, and strategies
to help engage in exercise (12). An improved understanding of
the barriers and facilitators specific to patients with cancer can
aid in the development of future successful exercise interventions
for this important target population.
Motivation plays an important role in being physically active,
particularly in patients dealing with the challenge of a breast can-
cer diagnosis. Courneya et al. (3) studied patient motivation for
different types and doses of exercise during breast cancer chemo-
therapy in a randomized controlled trial. Patients with breast can-
cer initiating chemotherapy (n = 301) were randomized to a
standard dose of 25 to 30 min of aerobic exercise, a higher dose
of 50 to 60 min of aerobic exercise, or a combined dose of 50 to
60 min of aerobic and resistance exercise. Despite varying before
initiation of exercise program, motivational outcomes after the
three interventions were similar. This is an important finding, sug-
gesting that clinicians can recommend any of these exercise pro-
grams for patients with breast cancer undergoing chemotherapy
(3). Further, higher rates of motivation can be expected to im-
prove rates of continuation and better long-term outcomes for
breast cancer survivors.
Despite the many benefits of physical activity after a diagnosis
of breast cancer, health care professionals face barriers to pro-
moting exercise. Smith-Turchyn and colleagues (32) conducted
a qualitative study with health care professionals who care for
breast cancer survivors. Semistructured interviews were con-
ducted with 24 professionals to investigate both the barriers
and facilitators of exercise promotion. Five main categories were
identified, including: 1) institutional barriers, 2) health care pro-
fessional barriers, 3) perceived patient barriers, 4) facilitators (re-
source and service needs), and 5) patient characteristics. Overall,
barriers were similar to those identified by health care profes-
sionals in general. Institutional barriers reported included limited
time with patients and a lack of funding for exercise interventions
and appropriate rehabilitation professionals within the institu-
tion. Health care professional barriers were similar, including lack
of knowledge, low priority, personal limitations, and forgetting to
discuss exercise. Perceived patient barriers echoed the findings de-
scribed above by Henriksson et al., including cost, lack of accessi-
bility, transportation, time, patient side effects and symptoms, and
a negative attitude toward exercise. Health care professionals did
identify institutional supports as facilitators of exercise promo-
tion, including inclusion of a rehabilitation professional as part
of the breast disease site team and exercise programs housed within
the institution. Health care professional education and champion
leaders were additionally identified as supportive. Individual sup-
ports discussed included patient-facing educational materials, such
as pamphlets, posters, prescription pads, and handouts (32). These
institutional and individual supports are important to note, given
that they may be successfully implemented in similar clinical set-
tings with the necessary resources.
RECENT AND ONGOING STUDIES TO IMPROVE PHYSICAL ACTIVITY
AFTER BREAST CANCER
Given the limited engagement in physical activity of breast can-
cer survivors, innovative approaches are needed to successfully
engage women in physical activity. Technology-based interven-
tions overcome typical programming barriers, such as distance,
time, and cost. Lyons and colleagues (17) currently are conducting
the Self-Monitoring Activity: A Randomized Trial of Game-
Oriented Applications (SMARTGOAL) study to test a 6-month
intervention using narratives and video games as one approach
to engage patients. Galiano-Castillo and colleagues (7) conducted
a randomized controlled trial evaluating the impact of an Internet-
based exercise intervention in breast cancer survivors. The objec-
tive of this study was to determine the effectiveness of a telehealth
system, an online system that facilitates the development of re-
mote rehabilitation, to improve adverse side effects in breast can-
cer at 8 and 24 wk. Patients (n = 81) were randomized to the either
the intervention or control group, consisting of usual care. The in-
tervention was found to significantly improve the quality of life,
pain, muscle strength and fatigue, with results maintained after
the 6-month follow-up period (7). These technology-based ap-
proaches provide opportunity to determine disseminable, low-
cost programming to engage breast cancer survivors in physical
activity and keep them motivated over time.
Eakin and colleagues (4) are testing a telephone-delivered healthy
lifestyle program for cancer survivors in the Healthy Living after
Cancer study. This study is a national dissemination and imple-
mentation study to test the integration of an evidence-based life-
style intervention for cancer survivors into an existing telephone
cancer support service delivered in Australia. Patients will receive
12 health coaching calls over 6 months from nurses/allied health
professionals with goals to improve physical activity, healthy eating,
and weight control. The Healthy Living after Cancer study will target
900 patients over a 3-yr period, providing much-needed practice-
based evidence on how best to support cancer survivors (4).
CONCLUSIONS
Evidence is convincingly mounting for the benefit of in-
corporating exercise into breast cancer prevention and treatment.
Evidence aside, however, anecdotes of the power of exercise after
a cancer diagnosis are persuasive. Dr. Hope, in her article
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entitled, “A survivor's perspective on the power of exercise af-
ter a cancer diagnosis,” described the shock and fear after her
diagnosis and how exercise helped her cope, adjust and regain
hope throughout her treatment. “It would be a game changer
if we could prescribe exercise for patients with cancer and give
them the resources they need to be healthier as they navigate
treatment” (13).
Significant barriers are faced by both patients for engaging
in exercise and health care professionals in promoting exercise.
Despite the many benefits of exercise in the prevention and
treatment of breast cancer, an inability to successfully engage
patient and health care professionals will drastically limit any
impact on public health. Therefore, future research is necessary
to determine innovative approaches to address and overcome
these barriers. Research across disciplinary lines, such as con-
ducted by the National Cancer Institute’s Transdisciplinary
Research on Energetics and Cancer (TREC) Centers, has the
potential to identify innovative approaches to engaging pa-
tients in physical activity for both the prevention and treat-
ment of breast cancer (30).
The authors declare no conflict of interest and do not have any
financial disclosures.
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