Roxanne Nelson, BSN, RN

January 30, 2017

SAN DIEGO, California ― Exercise does not appear to have any effect on the development of lymphedema in breast cancer patients, according to findings presented here at the Cancer Survivorship Symposium (CSS) Advancing Care and Research.

Rates of lymphedema were almost the same for women randomly allocated to receive education only and for women allocated to receive education plus personalized exercise instruction from a physical therapist.

At 18 months, there was no difference in the incidence of lymphedema. The lymphedema free rate was 58% in the education-only arm vs 55% in education-plus-exercise group.

"Poor adherence in the education-plus-exercise arm may have been a factor," said lead author Electra Paskett, PhD, from the Ohio State University Comprehensive Cancer Center, Columbus. "We are now in the process of doing a more in-depth analysis of quality of life and symptom data by intervention arm and lymphedema status."

The exercise component included the use of an elastic compression garment during heavy arm use, but only one third of patients used it at least 75% of the time.

Only 50% of the patients performed the exercises at least weekly.

"But we do need more research to prevent lymphedema after breast cancer surgery and find ways to improve adherence," Dr Paskett said.

Lymphedema affects from 8% to 56% of breast cancer patients. It is caused by disruption of lymph flow. No prevention strategies have proved effective.

Dr Paskett noted that some providers point to sentinel node dissection as a means of preventing lymphedema. Although that approach offers some benefit, "it doesn't prevent every case of lymphedema."

Exercise Not Effective

The goal of the current study was to test the effectiveness of two interventions on lymphedema incidence. One consisted of education only. In that approach, patients were given information on lymphedema, including causes, signs, symptoms, and risk reduction strategies. The other approach involved education plus personalized exercise instruction, as well as instruction on the use of an elastic compression garment, to be worn during heavy arm use and air travel.

The cohort comprised 5568 women with newly diagnosed stage I-III breast cancer. Randomization occurred following surgery. Arm circumference and range of motion were measured prior to surgery, and the patients were stratified according to type of node dissection (sentinel or axillary).

Of this cohort, 47% underwent sentinel node dissection, 35% underwent a mastectomy (15% had immediate reconstruction), and 37% received chemotherapy.

"The trial was randomized, but it was group randomized by clinics, so as to avoid potential contamination within the groups," said Dr Paskett.

Arm measurements were taken at baseline and at 12 and 18 months. At the times of those assessments, women self-reported the occurrence of lymphedema. They also reported on whether they were experiencing pain and swelling, and they provided information on range of motion, quality of life, adherence to risk reduction strategies, exercise, and the use of the compression sleeve.

The authors found that 31% of the patients wore the sleeve about 75% of the time. Forgetting to wear the sleeve and discomfort were the most frequently cited barriers to its use.

For exercise, 55.4% of the patients performed stretching exercises one or more times a week; 47.4% performed strengthening exercises; and 48% performed stretching and lymph flow exercises. Being "too busy" was the most common reason for not doing the exercises. The attitudes toward exercise were either neutral or favorable.

For quality of life, the education-only group experienced a larger decrease in breast cancer anxiety compared to the education-and-exercise group (from baseline to 12 months, P = .04; to 18 months, P = .04).

Not surprisingly, Dr Paskett noted, lymphedema status did affect quality of life. At 18 months, scores on the FACT-Band 4 lymphedema subscales were worse for those with lymphedema than those without it (P = .002).

Strength Training No Longer Taboo

In a discussion of the paper, Ann Partridge, MD, from the Dana Farber Cancer Center, Boston, Massachusetts, commented that these results are disappointing and that they could perhaps be explained by several hypotheses.

One is that the wrong type of exercise may have been used. "Maybe it was not the type of exercise that would benefit these patients," said Dr Partridge.

"The physical therapists could have been more focused on range of motion and less on cardiovascular and strength training," she explained, adding that when this study was initiated, strength training was considered somewhat taboo for this population and that that view changed during the study period.

Since this study began, research on the use of gradual strength training for breast cancer patients has been published, Dr Partridge pointed out. "These results suggest that not only is progressive weight training not bad for these patients, but it can also improve exacerbation of lymphedema. The study didn't look at prevention, but exercise did not cause it to occur."

Another hypothesis is that confounders may have affected the results. "Even though this was a randomized study, it could have been unbalanced," she said. "They tried to prevent contamination, but we all know that unless you are testing a novel, targeted therapy that you can only get in the cancer center, it is difficult to prevent this."

For example, patients can go out and exercise, or they can see a physical therapist. "I think the researchers have collected those data on the patients who were not in this intervention, so we may have more information on that," she said.

There are also unmeasured confounders. "One of the biggest predictors of lymphedema is the receipt of radiation to the breast and axillary region," Dr Partridge emphasized. "I should say that it was measured, but the impact has not yet been analyzed."

The quality of life data showed that the women in the intervention group experienced more anxiety than the control patients. "Were they upset because they were not adherent, for example?" she questioned. "This really highlights the need for rigorous evaluation of interventions before we adopt them into clinical practice."

The study was funded by the CALGB COOP, the Alliance CCRP Research Base, the National Center for Advancing Translational Sciences of the NIH, the Alliance Statistical Center, Susan G. Komen for the Cure, and the Lance Armstrong Foundation. Dr Paskett has relationships with Meridian Bioscience Inc, Pfizer, and Merck Sharp & Dohme (inst). Several coauthors also have relationships with industry. Dr Partridge has served in a consulting or advisory role with Pfizer.

Cancer Survivorship Symposium (CSS) Advancing Care and Research. Abstract 104, presented January 27, 2017.

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