Case Study: Breast Cancer
Angela, a litigation partner at a San Francisco law firm, was a perfectly healthy 36-year-old woman who had just adopted a 4-month-old Guatemalan baby. On July 30, 2002, she was diagnosed with stage 2 invasive ductal carcinoma.
While Angela had no family health history of breast cancer, she had smoked cigarettes from age 17 to age 32 and had exercised only intermittently. She knew that exercise was good for her, but between her stressful job and inertia she just hadn’t been able to get off the couch. The minute she was diagnosed with cancer, she decided to save her own life.
What brings a nonexerciser with such a life-changing situation through the gym doors? “I immediately knew that a rigorous exercise program would help me mentally and physically with my battle against cancer,” says Angela. “I also knew that I would never go to a gym unless I had an appointment with a trainer whom I really trusted and liked.”
Angela arrived on Sol Gym’s doorstep 3 weeks after having a lumpectomy plus an axillary node dissection to see if the cancer had spread to her lymph nodes. This was a big operation that had left numbness and pain in the pectorals, deltoid, triceps and biceps on her left side. Angela was also experiencing the fatigue normally associated with surgery. Because she was scheduled to begin chemotherapy (six sessions, once every 3 weeks) a week after her first personal training appointment, it was important to minimize stress. Angela and I decided to use health history, subjective assessment measures and body weight as our guidelines. I worked in concert with other trainers at my San Francisco location when implementing Angela’s program.
Her health history was unremarkable, with the exception of mild asthma. Because of the unique nature of Angela’s situation, we reassessed her before each session. Her fatigue level and nausea varied dramatically from visit to visit, so we relied on her feedback to shape each day’s program.
It was critical to keep Angela’s body weight as high as possible. She weighed 105 pounds prior to chemotherapy. Steroids she would take throughout chemotherapy would cause her to gain weight, but radiation would make her lose weight. Since her initial body weight was so light, we wanted to design a program that would not cause weight loss. Building Angela’s cardiovascular efficiency was the highest priority.
The chemotherapy drugs (Adriamycin, Cytoxan and 5FU) were known to cause cardiac toxicity. She had several heart scans throughout her chemotherapy to monitor her heart’s condition. While it was affected, she stayed within safe limits and completed all six chemotherapy sessions.
We challenged Angela’s cardiovascular system without using an aerobic component that would promote weight loss. She never exceeded 15 minutes of walking on the treadmill. We added a 3 percent elevation to involve larger muscle groups, thereby increasing her workload. We then set her speed at 3 miles per hour to maintain a heart rate of 119 beats per minute (bpm), 65 percent of maximum. As she became better conditioned, we adjusted the speed to maintain 119 bpm.
I perceived Angela’s situation to be much like that of an athlete. She was training for the game on Saturday. However, her “game on Saturday” was chemotherapy on Thursday. I designed her program using the principles of periodization, as if she were training for an event. The macrocycle covered the full 18-week period of chemotherapy. The microcycles, the six smaller cycles within the macrocycle, were designed around the 3-week chemotherapy intervals. All exercises were customized around how the chemotherapy sessions affected Angela.
Based on information Angela’s physician gave her about how she was likely to feel after chemotherapy, we designed the 3-week intervals to be conservative in the beginning, when Angela was likely to feel nauseous, and to peak at the end, prior to her next chemotherapy session, when she was likely to feel stronger:
Week 1: Angela receives her chemotherapy and is unlikely to feel well. If she is able to work out, weights will be light with high repetitions and long rest periods.
Week 2: Angela is likely to feel better and be able to work out at a faster pace with less rest time. Weight load will probably increase as repetitions decrease, with shorter rest periods.
Week 3: Angela is likely to feel good and be able to enter a strength phase with a higher weight load. We may add a set, lower the repetitions and rest for 30-second periods.
First Chemotherapy Session
Weeks 1-3: Angela felt no side effects, so we took an aggressive approach to her weight load. The surgery left her with tightness and pain in her left axillary region. Therefore, all upper-body weight-loaded exercises had a limited range of motion, not allowing her arm to elevate above parallel to the floor.
Second Chemotherapy Session
Weeks 4-6: Angela still felt great, so we took advantage of her high energy level and continued to be aggressive with her training. The range of motion in Angela’s left arm began to improve, so we added a few exercises with an overhead component—for example, cable crossovers and high pulls. >
Third Chemotherapy Session
Weeks 7-9: Angela remained strong and experienced only slight nausea through the halfway mark. Trainer’s notes: “She is in good spirits with bright eyes but is fatigued by the nausea.” (She never looked otherwise throughout all the chemotherapy treatments.) To avoid causing any additional nausea, we adjusted her program so she wouldn’t need to get up and down too much. We grouped exercises together based on whether they were performed lying down or standing.
Fourth Chemotherapy Session
Weeks 10-12: The drugs’ anticipated side effects became manifest. Angela became quite ill and missed several sessions, but she still motivated herself to come in for some of her personal training appointments. This made me think of the busy corporate types I train and how difficult it is to get them into the gym.
At this point we made several program changes specific to her treatments. The drugs she took to kill the cancer were also toxic to her arm veins and they collapsed. Because of this, she had a central line surgically inserted into her chest through her jugular vein so that she could finish her final two chemotherapy sessions. We changed her strength programming to eliminate upper-body work and included an assisted stretching component. The assisted stretches made Angela feel so good that we chose to compromise a small portion of the strength program. I wanted her to leave the gym feeling wonderful so that she would look forward to the next time. A year later, she confided in me that stretching felt like a prize for all the other hard work and it motivated her, just as I’d hoped.
Fifth Chemotherapy Session
Weeks 13-15: This was a challenging microcycle. Angela missed even more workouts than she had in the previous microcycle and became very weak. Toward the end of this cycle she developed neutropenic fever, a truly life-threatening problem. She was hospitalized for 5 days because she had no immune system left and her body was being swamped by infections. Angela did not return until after her sixth and final chemotherapy session.
Sixth Chemotherapy Session
Weeks 16-18: Angela was extremely nauseous and tired and had lower-back pain. In spite of this, she always showed up cheery and ready to do her best. Pilates-based exercises became a larger part of her programming. She welcomed this gentle, smooth exercise format. Her body continued to ache for a month after her last chemotherapy session and then the aches disappeared.
I was recently invited to Angela’s 1-year survivor party. If not for her tenacious, strong and positive attitude, she wouldn’t have met her goals. The fact that she walked through the gym doors week after week is hard to fathom, considering her ordeal.
Subsequent heart scans indicated minimal damage to her heart. During the chemotherapy, Angela gained weight as a result of taking steroids. By the time she had completed 33 radiation sessions—the next step she took to become cancer-free—she was back to her original weight.
On July 2, almost 1 year from her diagnosis date, Angela had surgery to remove her ovaries and fallopian tubes to reduce risk of recurrence; as a result estrogen was also removed from her body. Stage 2 invasive ductal carcinoma thrives on estrogen, so she is unable to take estrogen replacement. We are now faced with new programming. Our goals are to prevent osteoporosis, of which she has family history, and to keep her heart strong.
I didn’t realize how much impact Angela’s training had on her life-threatening situation. I felt my role was more that of a motivator—I honestly never thought that she might die. I never saw a very sick woman; I pictured her as an athlete training for an event.
Angela explains how personal training affected her life: “Sol Gym was an answer to my prayers. The one-on-one work really motivated me to keep coming back, and all of the trainers’ positive attitudes toward me and my cancer made me feel safe and supported. Honestly, during each workout, as I worked hard to lift weights, I would think, ‘I’m going to beat this cancer!’ or ‘I refuse to die anytime soon!’ or ‘I am strong enough to win this battle!’ The gym became a crucial part of my cancer recovery program. Not just the exercise, but the personal connections with my trainers, all of whom treated me as a real human being with unlimited potential, even though I was obviously quite ill (and bald).”
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A study in the May 2001 issue of Medicine & Science in Sports & Exercise (MSSE) suggests that a regular exercise program of low to moderate intensity is effective in maintaining functional ability and reducing fatigue in women with breast cancer who are receiving chemotherapy.
Seventy-two newly diagnosed women were trained in a home-based, moderate-intensity exercise program. Functional ability, energy expenditure and fatigue were measured at baseline and posttest. Subjects maintained daily records of four types of fatigue, along with exercise duration, intensity and type. Exercise significantly reduced all four types of fatigue. As the exercise duration increased, fatigue intensity declined.
Source: Schwartz, A., et al. 2001. Exercise reduces daily fatigue in women with breast cancer receiving chemotherapy. MSSE, 33
First Microcycle, Week 3: restricted range of motion in arms due to surgery.
- treadmill: 15 minutes
- dumbbell (DB) bench press, reverse crunches
- incline DB flyes & v-ups
- seated low rows, isometric abdominal crunches
- one-arm DB bent rows, stability ball crunches
- lateral raises, balance cone drill
- upright rows on Smith press, pectoral stretch
- EZ bar curls, oblique crunches on stability ball
- hammer curls, side-lying oblique crunches
- triceps press, shoulder stretch
- Gravitron dips, squats on BOSU
Third Microcycle, Week 1: halfway through the macrocycle; nausea- induced fatigue.
- treadmill: 15 minutes
- Pilates-based leg press, assisted hamstring stretch
- Pilates-based adduction and assisted piriformis stretch
- Pilates-based abduction, short adductors stretch
- DB bench press lateral raises
- upright rows on Smith press
- triceps press with rope grip
- DB curls
Final Microcycle, Week 1: 1 week after hospitalization and final chemotherapy treatment; excessive nausea.
- treadmill: 15 minutes
- Pilates-based leg press, assisted hamstring stretch
- seated rows, isometric abdominal crunch
- lateral raises, assisted shoulder stretch
- triceps press, DB biceps curls
- assisted stretches
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