AN ASSESSMENT OF BODY COMPOSITION, BALANCE, AND MUSCULAR
STRENGTH AND ENDURANCE IN BREAST CANCER SURVIVORS
A Thesis by
Cori Beth Sullard
Bachelor of Science, Florida State University, 2009
Submitted to the Department of Human Performance Studies
and the faculty of the Graduate School of
Wichita State University
in partial fulfillment of
the requirements for the degree of
Master of Education
December 2011
© Copyright 2011 by Cori Beth Sullard
All Rights Reserved
AN ASSESSMENT OF BODY COMPOSITION, BALANCE, AND MUSCULAR
STRENGTH AND ENDURANCE IN BREAST CANCER SURVIVORS
The following faculty members have examined the final copy of this thesis for form and
content, and recommend that it be accepted in partial fulfillment of the requirement for
the degree of Master of Education with a major in Exercise Science.
__________________________________
Jeremy Patterson, Committee Chair
__________________________________
Michael Rogers, Committee Member
__________________________________
Michael Jorgensen, Outside Committee Member
iii
DEDICATION
To Orlando Wright, for all your personal sacrifices and support, thank you.
iv
ACKNOWLEDGEMENTS
Thank you to Dr. Patterson, who has gone above and beyond my expectations of
an advisor and provided valuable mentorship and support throughout my graduate
education. Thank you to the Susan G. Komen Foundation for funding to support these
research processes. To The University of Kansas School of Medicine – Wichita, thank
you for allowing collaboration of institutions to complete this project. Angie Carr, thank
you for being such a great liaison between institutions, your assistance was invaluable.
To Jared Reyes, thank you for assisting with edits and offering support in the final
stages of this process. Finally, to my mom, for allowing my needs to come first for so
long, you have always supported me in all I seek to achieve – thank you.
v
ABSTRACT
Incidence rates for breast cancer continue to rise with improved methods of
screening, detection, diagnosis and treatment. The chance of developing breast cancer
is 12%, or 1 out of 8 women (American Cancer Society, 2011b). Increased survival
equates to increased needs for support services to restore or promote healthy living.
This includes leading an active lifestyle with independent physical and mental
capabilities. This study assesses body composition, balance, and upper extremity
muscular strength and endurance in breast cancer survivors (BCS) shortly after
diagnosis and during and after chemotherapy. Design: Prospective exploratory design
with one control arm. Methods: Adult females (N = 7) within 1 month of breast cancer
diagnosis, currently undergoing chemotherapy and/or have completed chemotherapy
for the treatment of breast cancer were recruited for this study. Variables assessed
include weight, body fat percentage, lean body mass percentage, body mass index
(BMI), bone mineral density (BMD), bone mineral content (BMC), balance (sway index),
and upper extremity muscular strength and endurance (peak torque, power, and total
work). Results: Lean body mass percentage was significantly lower than healthy, agematched controls (p=0.047). BCS had increased body fat percentage and weight
compared to controls, and showed a significant increase in weight from initial diagnosis
to treatment completion (p=0.037). BMI, BMD, and BMC did not significantly differ from
controls. BCS produced increased measures of sway compared to normative values.
Muscular strength and endurance did not differ between affected and unaffected arm.
Conclusion: Current findings align with previous studies in terms of body composition
and balance and serve to inform future research utilizing larger sample sizes.
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TABLE OF CONTENTS
CHAPTER
PAGE
CHAPTER 1.
INTRODUCTION……………………………………………………………………………….. 1
Statement of Problem………………………………………………………………………….. 2
1.1Purpose ……………………………………………………………………………………... 3
1.2 Significance of Study ……………………………………………………………………… 3
1.3 Variables …………………………………………………………………………………… 3
1.4 Hypothesis …………………………………………………………………………………. 4
1.5 Definitions ………………………………………………………………………………….. 4
1.6 Assumptions ……………………………………………………………………………….. 6
1.7 Limitations ………………………………………………………………………………….. 6
1.8 Delimitations ……………………………………………………………………………….. 7
CHAPTER 2.
LITERATURE REVIEW ………………………………………………………………………. 8
2.1 Overview of Breast Cancer ………………………………………………………………. 8
2.1.1 Healthy Breast …………………………………………………………………………… 9
2.1.2 Types of Breast Cancer ………………………………………………………………. 11
2.2 Epidemiology ……………………………………………………………………………... 11
2.2.1 Incidence and Prevalence …………………………………………………………….. 12
2.2.2 Mortality ……………………………………………………………………………….... 13
2.3 Treatment …………………………………………………………………………………. 14
2.3.1 Treatment Associated Outcomes ……………………………………………………. 14
2.3.2 Bone Density …………………………………………………………………………… 15
2.3.3 Lean Mass and Adiposity ……………………………………………………………... 16
2.3.4 Upper Body Function …………………………………………………………………. 17
2.3.5 Balance …………………………………………………………………………………. 19
2.3.6 Quality of Life …………………………………………………………………………... 21
2.3.7 Return to Work Issues ………………………………………………………………… 22
2.4 Exercise …………………………………………………………………………………… 23
2.4.1 Exercise and Upper Extremity Outcomes …………………………………………... 33
2.4.2 Quality of Life and Exercise ……………………..................................................... 34
2.5 Exercise Recommendations ……………………………………………………………. 35
CHAPTER 3.
METHODS ……………………………………………………………………………………. 38
3.1 Participants ……………………………………………………………………………….. 38
3.2 Apparatus …………………………………………………………………………………. 39
vii
TABLE OF CONTENTS (continued)
CHAPTER
PAGE
3.3 Procedures ……………………………………………………………………………….. 39
3.3.1 Dual Energy X-ray Absorptiometry …………………………………………………... 39
3.3.2 Isokinetic Dynamometry ………………………………………………………………. 40
3.3.3 Balance …………………………………………………………………………………. 40
3.4 Data Analysis …………………………………………………………………………….. 42
CHAPTER 4.
RESULTS ……………………………………………………………………………………... 43
4.1 Overview ………………………………………………………………………………….. 43
4.2 Hypothesis 1 ……………………………………………………………………………… 44
4.3 Hypothesis 2 ……………………………………………………………………………… 47
4.4 Hypothesis 3 ……………………………………………………………………………… 49
4.5 Hypothesis 4 ……………………………………………………………………………… 50
CHAPTER 5.
DISCUSSION …………………………………………………………………………………. 54
5.1 Overview ………………………………………………………………………………….. 55
5.1.1 Establishment of Study ……………………………………………………………….. 55
5.1.2 Upper Body Function …………………………………………………………………. 57
5.1.3 Cognitive Memory and Balance ……………………………………………………… 61
5.1.4 Limitations on BCS Population ………………………………………………………. 62
5.2 Conclusion ……………………………………………………………………………….. 63
5.3 Recommendations for Future Research ………………………………………………. 63
REFERENCES ……………………………………………………………………………….. 65
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LIST OF TABLES
TABLE
PAGE
1.
Group Differences in Body Composition (post-treatment) ……..………………... 45
2.
Difference in Weight Pre-Post Treatment in BCS ………………………………... 48
3.
Difference in Power Between Affected and Unaffected Upper Arm and
Chest …………………………………………………………………………………... 51
4.
Difference in Peak Torque Between Affected and Unaffected Upper Arm
and Chest ……………………………………………………………………………... 52
5.
Difference in Muscular Endurance (Total Work)…………………………………… 53
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LIST OF FIGURES
FIGURES
PAGE
1.
The normal breast …..…………………………………………………………………. 9
2.
The lymph system of the breast …………………………………………………….. 10
3.
Difference in total work between affected and unaffected upper arm
and chest ……………………………………………………………………………… 58
4.
Difference in muscular endurance between affected and unaffected upper
arm and chest ………………………………………………………………………… 58
5.
Ratio of upper arm muscular strength……………………………………………… 60
x
CHAPTER ONE
INTRODUCTION
Cancer rates in the United States have steadily declined over the past decade.
Even so, over 40% of Americans born today will be diagnosed with some form of cancer
during their lifetime (Howlader et al., 2011). Females are especially at risk for breast
cancer as it is the second leading form of cancer diagnosed in women after skin cancer,
and is a leading killer among all other forms of cancer (Centers for Disease Control and
Prevention, 2011b). Current guidelines for detection and screening have increased early
diagnosis of breast cancer, and improved methods for treatment have increased
survival rates.
The long-term effects of cancer treatments are not fully understood. With an
increasing population of BCS, care after treatment has become increasing relevant in
research and critical to the rehabilitation of patients – physically, mentally, and socially.
Many BCS suffer from decreased physical function, fatigue, quality of life (QOL), and
mental health. Physical activity has been suggested as a method for decreasing or
eliminating many of these outcomes. Multiple randomized controlled trials have
provided evidence supporting the benefits of exercise during and following treatment,
although methods and study designs are inconsistent (Galvão & Newton, 2005). A lack
of information for baseline measures at diagnosis and repeated assessments during the
course of treatment and post-treatment contribute to the absence of exercise guidelines
for this population. Only recently in 2009 did the American College of Sports Medicine
publish exercise prescription guidelines for cancer patients. Although, instructions do
1
not fully inform BCS as the recommended protocols lack specificity for stages of
disease, different treatments, and age, and is therefore an incomplete resource.
Statement of Problem
The National Cancer Institute estimates that approximately 2.6 million American
women with a history of breast cancer were alive in January 2008, more than half of
whom were diagnosed less than 10 years earlier (Howlader et al., 2011). The 5-year
relative survival rate among women diagnosed with breast cancer before age 40 is 84%
and women diagnosed at 40 years of age or older is 90%. Survival rates are based on
several factors: age at diagnosis, stage of disease, race/ethnicity, socioeconomic
factors, obesity, physical activity, diet, and tumor characteristics (American Cancer
Society, 2011c). Knowledge for prevention, screening, detection and diagnosis of breast
cancer continues to increase the life expectancy of many BCS (World Health
Organization, 2011). This raises the question: How do we care for and rehabilitate
patients from the moment of diagnosis? To answer this, gaps in the literature must be
investigated. Measures of body composition at diagnosis and throughout treatment are
needed to provide knowledge and guidance for exercise prescription. Repeated
measures for physical function to include muscular strength and balance are needed to
elucidate predictors for reentering the workforce, functioning physically and mentally
independently, as well as leading an active healthy lifestyle. This study seeks to answer
four questions with these objectives in mind.
1. What is the difference in body composition between newly diagnosed BCS, those
currently undergoing treatment, those who have completed treatment, and
healthy, age-matched controls?
2
2. What is the difference in body composition over time within newly diagnosed
BCS, those currently undergoing treatment, and those who have completed
treatment?
3. Do BCS show changes in balance compared to normative values?
4. How will muscular strength and endurance of the affected upper arm and chest
compare to the unaffected extremity in BCS?
1.2
Purpose
The purpose of this study is to assess body composition, balance, and muscular
strength and endurance in BCS shortly after diagnosis and during and after
chemotherapy.
1.3
Significance of Study
This is the first study to assess a mixed population of BCS (i.e. patients at initial
diagnosis, those undergoing chemotherapy, and those who have completed treatment)
using measures of body composition, balance, and muscular strength and endurance.
Additionally, this study is the first to analyze balance in BCS using the Balance System
SD testing apparatus and the modified Clinical Test of Sensory Interaction on Balance.
1.4
Variables
1.4.1 Independent Variable
The independent variables for this study were the stage of breast cancer, age,
and sex.
1.4.2 Dependent Variable
3
The dependent variables for this study include lean body mass, body fat
percentage, BMD, BMC, weight, muscular strength (peak angular torque and power)
and endurance (total work), and balance (sway index).
1.5
Hypothesis
1.5.1 Hypothesis 1
It is hypothesized a significant difference in body composition will be observed
between newly diagnosed breast cancer patients, those currently undergoing treatment,
those who have completed treatment, and healthy, age-matched controls.
1.5.2 Hypothesis 2
It is hypothesized a significant difference in body composition will occur over time
within newly diagnosed breast cancer patients, those currently undergoing treatment,
and those who have completed treatment.
1.5.3 Hypothesis 3
It is hypothesized BCS will have decreased balance (increased sway index)
compared to normative values.
1.5.4 Hypothesis 4
It is hypothesized that muscular strength and endurance of the affected upper
arm and chest will be reduced compared to the unaffected extremity.
1.6
Definitions
1. Breast Cancer: A malignant tumor initiating in the cells of the breast with the
possibility of invading surrounding tissues of the breast or metastasizing to
distant areas of the body (American Cancer Society, 2011a).
4
2. Breast Cancer Survivor: Individuals diagnosed with breast cancer are
considered survivors from the initial cancer diagnosis through the balance of
his or her life (National Cancer Institute, 2011b).
3. Carcinoma: Cancerous cells originating in the epithelial cells of the skin or
connective tissue lining organs (U.S. National Institutes of Health & National
Cancer Institute, 2011a).
4. In situ: Refers to cells situated in their initial place of origin (U.S. National
Institutes of Health & National Cancer Institute, 2011a).
5. Surgical Treatment: Oldest form of breast cancer treatment to include
invasive techniques ranging from minor procedures to extensive operations
for tumor removal. Surgical treatments are employed for prophylactic,
diagnostic, staging, curative, palliative, supportive, and restorative or
reconstructive purposes. Laser therapy is also a form of surgical treatment
(American Cancer Society, 2011a).
6. Non-surgical Treatment: Non-surgical treatment includes chemotherapy,
radiation therapy, targeted therapy, immunotherapy, hyperthermia, bone
marrow and peripheral blood stem cell transplant, photodynamic therapy,
blood product transfusion, hormone therapy, and molecular targeted therapy
(American Cancer Society, 2011a).
7. Lean Body Mass: Characterized as all tissues of the body, minus fat storage.
8. Adiposity: Whole body fat mass.
9. Bone Density: Refers to the amount of matter per square centimeter of bone.
5
10. Balance: The ability to maintain equilibrium while stationary or moving
(American College of Sports Medicine, 2010).
11. Muscular Strength: Refers to the peak angular torque and power output
throughout the range of motion in an upright chest press movement.
12. Quality of Life: The physical and psychosocial well-being affected by the
disease itself or treatment of breast cancer as reported by the individuals over
the course of care (National Cancer Institute, 2011c).
13. Exercise: A type of physical activity that is planned, structured, and repetitive,
using physiological adaptations to increase or maintain physical fitness
(Caspersen, Powell, & Christenson, 1985).
1.7
Assumptions
1. It is assumed subjects are free of other disease or disorders affecting the
musculoskeletal system, body composition, balance, and cognition.
2. It is assumed that each individual participated in the balance and muscular
strength and endurance assessments to the best of her ability giving an accurate
measure for each test.
1.8
Limitations
The author recognizes the limitations to this study design and will briefly discuss
them in this section:
1. The major limitation of this study was the inability to recruit participants and
lack of follow-up assessments by participants.
2. The small sample size inhibited statistical analysis and the generalizability of
results.
6
3. The geographic location of recruitment was a single Midwestern community,
which may have negatively affected participation. In addition, results may not
be representative of other populations.
1.9
Delimitations
This study design included three delimitations which may impact the validity of
results.
1. No control arm was included for tests of muscular strength and endurance.
Comparisons cannot be made to healthy individuals and may question the
validity of our findings.
2. BMD and BMC were assessed utilizing a whole body scan (Dual Energy Xray Absorptiometry (DEXA)) versus more reliable options such as forearm
and femoral head and neck images, possibly impacting the validity of results.
Additionally, results from similar studies may not yield like findings.
7
CHAPTER TWO
REVIEW OF LITERATURE
2.1
Overview of Breast Cancer
Breast Cancer is the second leading form of cancer diagnosed in American
females today (Centers for Disease Control and Prevention, 2011a). The chance of
developing breast cancer is 12%, or 1 out of 8 women (American Cancer Society,
2011b). The most recent and accessible data (2007) on prevalence and incidence
shows nearly a quarter million women were diagnosed with breast cancer with over
40,000 related deaths (Centers for Disease Control and Prevention, 2010). It is
estimated 230,480 women will be diagnosed with breast cancer in 2011, and 39,520 will
die of the disease (U.S. Cancer Statistics Working Group, 2010).
The human body is comprised of trillions of living cells that operate in an
organized pattern of growth, division, and death. When this pattern is interrupted and
specifically identified cells of the body begin to proliferate in random and/or accelerated
patterns, possibly invading other tissues, the cells become classified as cancer cells.
Regardless of where a cancer propagates, it is named for the initial place of origin.
Breast cancer is a malignant tumor first developed in the cells of the breast (American
Cancer Society, 2011c). The incidence is predominantly identified in females, but males
are susceptible as well, occurring in about 1 out of every 100,000 men (U.S. National
Institutes of Health, National Cancer Institute, & Surveillance Epidemiology and End
Results, 2011).
8
2.1.1 Healthy Breast
The anatomy of the breasts includes glands (lobules), ducts, fatty and connective
tissue, blood vessels, and lymph vessels. Most commonly, breast cancer will start in
cells that line the ducts, and occasionally in the lobules (Figure 1) (American Cancer
Society, 2011d).
Figure 1. The normal breast (American Cancer Society, 2011d).
Metastasis of breast cancer primarily occurs through the lymph system, comprised of
small nodes connected by lymphatic vessels functioning as a transport system to move
fluid away from the breast. Cancerous cells can enter the vessels and travel into the
lymph nodes, where they expand and attack larger areas. Many lymph nodes are
located under the arm (axillary nodes), and adjacent to the clavicle (infra- and
9
supraclavicular nodes) and lateral edges of the sternum (internal mammary nodes)
(Figure 2) (American Cancer Society, 2011d).
Figure 2. The lymph system of the breast (American Cancer Society, 2011d).
The nodes and respective lymphatic vessels of this area trace the boundary of the
pectoralis major muscle, which may be affected during treatment, such as during radical
mastectomies, resulting in biomechanical deficiencies to the upper limb (Zurrida et al.,
2011). The pectoralis major is the primary muscle that flexes, adducts, and medially
rotates the upper arm. Changes or removal of this muscle, as well as lymphedema
secondary to tumor manifestation, surgical or radiation therapy, will result in reductions
of range of motion, muscular strength and endurance, functional capacity (ability to
perform activities of daily living (ADL)) and quality of life measures leading to a complex
recovery (U.S. National Institutes of Health & National Cancer Institute, 2011b).
10
2.1.2 Types of Breast Cancer
Several types of breast cancer exist and may emerge in multiple forms
simultaneously. Most clinical diagnoses include ductal carcinoma in situ, lobular
carcinoma in situ, invasive or infiltrating ductal carcinoma, and invasive or infiltrating
lobular carcinoma (American Cancer Society, 2011d). Less frequently diagnosed than
the aforementioned are inflammatory breast cancer, triple-negative cancer, Paget
disease of the nipple, phyllodes tumor, and angiosarcoma (American Cancer Society,
2011d). The National Cancer Institute identifies breast cancer based on cellular
histology. Cancer originating in the mammary collecting ducts include intraductal in situ,
invasive with predominant intraductal component, invasive (not otherwise specified,
(NOS)), comedo, inflammatory, medullary with lymphocytic infiltrate, mucinous (colloid),
papillary, scirrhous, and tubular. The Lobular cancer classification includes: in situ,
invasive with predominant in situ component, and invasive. Paget disease (NOS), Paget
disease with intraductal carcinoma, and Paget disease with invasive ductal carcinoma
comprise those cancers which originate in the nipple. Immature, unidentifiable cancer
cells that divide and rapidly grow are considered undifferentiated carcinomas and
classified as “other”.
2.2
Epidemiology
According to the Department of Health and Human Services (DHHS), the
Centers for Disease Control and Prevention (CDC) and the National Cancer Institute
(NCI), breast cancer is the second leading form of cancer diagnosed and cancer
causing death among females in the United States (U.S. Cancer Statistics Working
11
Group, 2010). Worldwide, breast cancer is the third most diagnosed cancer and is the
most common malignancy and cause of death among women (Stuckey, 2011).
2.2.1. Incidence and Prevalence
Clinical screening for breast cancer initiated in 1975 and has since provoked
fluctuations in incidence rates among American women (Stuckey, 2011). Within the past
decade, incidence of breast cancer diagnoses has decreased as compared to the
previous 25 years. In the late 1970s and again in the early to mid-1990s, rates remained
unchanged and/or steadily increased due to early diagnosis. In 1999, the first decline in
breast cancer diagnosis was observed and continued by 2% each year through 2006
(Ries et al., posted to the SEER website, 2006). The 2007 incidence rate reported by
the CDC was 120.4 per 100,000 women (U.S Cancer Statistics Working Group, 2010).
The Surveillance, Epidemiology, and End Results (SEER) Program of the NIC reported
the age-adjusted incidence rate for breast cancer as 124.0 per 100,000 women per year
between 2004 and 2008 (Howlader et al., 1975-2008). A report by the World Health
Organization (2011) stated incidence rates for 2011 are rising in developed countries
due to increased life expectancy and increased urbanization and adoption of western
culture lifestyles. Modifiable risk factors such as alcohol intake, overweight and obesity,
and physical inactivity are attributed to 21% of global breast cancer deaths. High
income countries showed a 27% higher proportion of this, with the variable of greatest
contribution being overweight and obesity. In low- to middle-income populated
countries, physical inactivity was the most influential determinant (Danaei, Vander
Hoorn, Lopez, Murray, & Ezzati, 2005). Report of prevalence in the United States based
on data from January 1, 2008 (the most current and available information), is
12
approximately 2,632,005 women, to include females with the active disease, those
cured and those diagnosed prior to January 1, 2008 (Howlader et al., 1975-2008).
Trends for decreased prevalence and increased incidence further define the
growing life expectancy for BCS. Although, survivorship does not equate to good health;
and the sequela related to breast cancer and concomitant therapies render the initiation
of physical activity difficult. Further evidence for supportive therapies to sustain
longevity of life is critical. A need exists for further evaluation of physical activity and
subsequent exercise prescription if cancer survivors are to effectively function in
activities of daily living (i.e. personal environment, employment setting, lead a healthy
lifestyle). Through the modification of risks, incidence of overweight and obese BCS will
decrease, thus increasing life expectancy.
2.2.2 Mortality
Based on 2003 – 2007 data, the current age-adjusted death rate for breast
cancer is 24.0 per 100,000 women with a median age at death of 68 (Howlader et al.,
1975-2008). The mortality rate is 40.0 per 100,000 women (U.S. Cancer Statistics
Working Group, 2010). Relative survival rate is calculated over a five year period (2001
– 2007) and is reported at 89.1% (Howlader et al., 1975-2008). At 10 years the rate
decreases to 82% and at 15 years to 75% (American Cancer Society, 2011c). As
mortality rates decrease and life expectancy grows, population focused research of
modifiable risk factors (i.e. overweight and obesity, physical activity) for mortality
becomes critical.
13
2.3.
Treatment
Breast cancer management is determined by the current stage of disease,
likelihood of cure, treatment options, age, general health and patient comfort towards
selected treatment (NCI, 2006). According to Vogel, Helmes, & Hasenburg (2008),
patients’ mental health should also be considered by physicians during the decisionmaking process. Although conflicting results exist, it has been suggested depression
may impact patients’ ability to play an active role in treatment selection (Vogel et al.,
2008).
Three surgical options are available for the treatment of breast cancer: (1)
breast-conserving surgery, (2) mastectomy with reconstruction, and (3) mastectomy
alone (Greenberg et al., 2011; National Cancer Institute, 2009). Breast-conserving
surgery, also known as breast-sparing surgery, refers to a lumpectomy,
quadrantectomy, or segmental mastectomy procedure (National Cancer Institute, 2009).
Cancer therapy is often a multi-method approach involving both surgical and
non-surgical treatments. Non-surgical management may consist of one or more
treatment options such as radiation therapy, hormone therapy, chemotherapy, and
targeted therapy. Each therapy is used to kill or retard the proliferation of malignant
cells, and is dependent on cell pathology (National Cancer Institute, 2009).
2.3.1. Treatment Associated Outcomes
Complete cancer remission reflects the absence of disease progression or tumor
within the body. The state of being “cured” cannot accurately be assessed and is
therefore not often used in clinical settings, as dormant cells may exist or the mutation
of new cells may occur (American Cancer Society, 2011e). Long-term breast cancer
14
survivors and those with chronic exposure to breast cancer treatments suffer physically
and mentally years after recovery (Ganz et al., 2002). Declined sexual activity and
increased complaints of cognitive impairment (Ganz et al., 2002) as well as fatigue,
muscle and joint pain have been reported four years following recovery (Nieboer et al.,
2005).
To better understand treatment associated outcomes, repeated measures of
body composition, physical activity, and muscular strength and endurance at different
periods of time (i.e. at diagnosis, subsequent stages of disease and treatment cycles,
post-treatment, and remission) are needed. Evidence based medicine lacks data to
define preventative measures and rehabilitation guidelines for BCS. By assessing
changes over the timeline of disease and treatment, modifiable risks, such as the
compounding physical effects of inactivity, may be stopped or reversed.
2.3.2 Bone Density
Chemotherapy and hormone therapy have been examined for their long-term
detrimental effects on the skeleton within the past decade (Brown & Coleman, 2002).
Chemotherapy produces gonadal toxicity which inhibits the replenishment of oocytes in
fertile women (Bines, Oleske, & Cobleigh, 1996; Byrne et al., 1992; Chapman, Sutcliffe,
& Malpas, 1979; Meirow & Nugent, 2001). Osteoporosis is a late symptom and side
effect of chemotherapy (Kalantaridou et al., 2006; Nuver, Smit, Postma, Sleijfer, &
Gietema, 2002; Saarto et al., 1997; Vehmanen et al., 2001). Shapiro, Manola, and
Leboff (2001) found chemotherapy-induced ovarian failure caused significant bone loss
of the spine and increased risks for osteopenia and osteoporosis. Skeletal changes
provide a need for greater measures of the prevention of such treatment effects. Weight
15
bearing exercises are widely recognized as a method for enhancing bone strength.
Clarification for when such exercises should be initiated in this population, as well as
specific guidelines for activities is needed.
2.3.3 Lean Mass and Adiposity
The type and length of chemotherapy (Demark-Wahnefried et al., 1997; Goodwin
et al., 1999; Ingram & Brown, 2004; Kutynec, McCargar, Barr, & Hislop, 1999), fatigue,
inactivity or lessened physical activity (Demark-Wahnefried et al., 2001; Irwin et al.,
2003; Rock et al., 1999), increased energy intake (Rock et al., 1999), decreasing resting
energy expenditure (Demark-Wahnefried et al., 2001), and therapy induced amenorrhea
or menopause (Goodwin et al., 1999) have been cited as reasons for weight gain
following adjuvant therapy. Lean body mass has been shown to remain unchanged or
reduced following adjuvant chemotherapy (Campbell, Lane, Martin, Gelmon, &
McKenzie, 2007; Demark-Wahnefried et al., 2001; M. L. Winningham et al., 1994).
Chemotherapy induced weight gain is atypical in that increases in fat mass, rather than
the combined growth of fat mass and lean mass, account for increased body weight
(Demark-Wahnefried et al., 2001). Consistent findings reveal increases in weight gain
due to fat mass alone (Campbell et al., 2007; Demark-Wahnefried et al., 2001; Kutynec
et al., 1999). Women receiving adjuvant chemotherapy have been found to increase fat
mass of the trunk and upper legs without increases in lean mass (Demark-Wahnefried
et al., 2001; Gordon, Hurwitz, Shapiro, & Leboff, 2011). Nissen, Shapiro, and Swenson
(2011) found BMI to be inversely associated with weight gain and fat mass of the torso
in women receiving chemotherapy. Lean mass measurements were not reported in this
study; however, reductions in lean mass are a feasible explanation for this inverse
16
association. Reports of a strong association between body mass index and the
frequency and severity of arm edema have also been made but require further research
to determine the link (Meric et al., 2002; Roses, Brooks, Harris, Shapiro, & Mitnick,
1999).
Muscle mass is integral to many metabolic processes and in the prevention of
common pathologic conditions and chronic diseases (Wolfe, 2006). A prospective
cohort study by Ruiz, et al. (2009) demonstrated muscular strength as an independent
predictor of all-cause mortality in male cancer patients. The study adjusted for overall
adiposity (i.e. BMI and body fat percent) and central adiposity (i.e. umbilicus waist
circumference), cardiorespiratory fitness, and confounding factors of age, smoking,
alcohol intake, and health status. Therefore, lessening the reduction of lean mass in
BCS will modify their risk for mortality. Baseline measurements of BCS throughout
treatment and remission are needed to further assess when lean mass changes occur,
as well as how the impact of muscular development (i.e. resistance training) best
benefits BCS.
2.3.4. Upper Body Function
It can be assumed the muscular strength needed to perform daily activities such
as carrying or lifting objects may be enhanced through resistance training. Upper body
function (UBF) may be restored and the effects of negative physical activity behaviors
may be combatted as well. Current literature lacks assessments for muscular strength
in BCS, specifically for analyses that parallel Ruiz et al. Independent activities of daily
living, returning to work, performing tasks requiring physical strength, and general
quality of life necessitate optimal UBF (Ferrell, Grant, Funk, Otis-Green, & Garcia,
17
1997). Complications resulting from breast cancer treatments impair UBF (Carrick et al.,
1998). Swelling of the shoulder, reduced strength and flexibility, decreased function,
and pain may be experienced for up to one year post- treatment (Hladiuk, Huchcroft,
Temple, & Schnurr, 1992; Keramopoulos, Tsionou, Minaretzis, Michalas, & Aravantinos,
1993; Satariano, Ragland, & DeLorenze, 1996). Thirty to 50% of patients undergoing
therapy endure the added discomfort of lymphedema. This condition symptomatically
manifests as heaviness of the arm, parasthesia, swelling, loss of sensation, increased
risk of infection, loss of function, aesthetic unsightliness (Petrek & Heelan, 1998). The
post-surgical complications alone include swelling, numbness of the arm, stiffness of the
upper limb and shoulder, as well as shoulder neuropathies (Rahman, 2011; Wechter,
2011).
Based on a systematic review of upper limb complications following combined
surgical and radiation treatment for early breast cancer, patients experiencing impaired
shoulder range of motion spanned from less than 1% to 67% (non-surgical versus
surgical arm and/or pre- versus post-operative measures) (Lee, Kilbreath, Refshauge,
Herbert, & Beith, 2008). Females suffering from lymphedema ranged from 0% to 34%
and the prevalence of shoulder and/or arm pain from 9% to 68%. Objective muscular
strength measures did not differ significantly between arms or between periods of
measurement (pre-radiation, post-radiation, 7 months post-radiation) (Rahman, 2011;
Wechter, 2011).
Combination therapy, that is radiotherapy plus breast conservation therapy, has
emerged as the standard of care for early-stage breast cancer (Coalition, 2011; Meric et
al., 2002). Neuropathic complications for this treatment have been documented in the
18
literature. A cohort study conducted by Meric, et al. (2002) observed 294 breast cancer
patients treated at The University of Texas M.D. Anderson Cancer Center over a twoyear period. A median follow-up period of 89 months examined post-treatment
complications. Only 0.7% of the population experienced significant neuropathies of the
upper limbs with subsequent radiating arm pain. The incidence rate of brachial plexus
involvement was 1.3% and only occurred in patients receiving adjuvant therapy to the
axilla. Although, 70% to 80% of patients following axillary dissection experienced loss of
sensation in the distribution of the intercostobrachial nerve (Recht, 1995).
It is obvious outcomes of UBF differ widely among BCS depending on the
treatment underwent. Focused assessments are required to determine how therapy
over time affects UBF. Further examination of muscular strength is important in
determining changes in physical function as well its relationship to lean body mass, as
discussed earlier.
2.3.5 Balance
Maintaining postural balance involves complex coordination and integration of
multiple sensory, motor, and biomechanical components. Body position is sensed in
relation to gravity and environmental surroundings by combining somatosensory,
vestibular, and visual inputs (Marieb & Hoehn, 2007). The nervous system accesses
preprogrammed strategies to simplify movement, similar to a database for motor
memories. The central nervous system works with groups of muscles that respond in a
repeatable sequence that had been successful to maintain stability in the past. An
individual’s ability to access these stored repeatable sequences allows the nervous
system to determine a motor reaction in response to sensory input. These reactions are
19
automatic and have evolved over time, taking into account biomechanical and
environmental constraints, this is sometimes referred to as muscle memory or motor
learning (Marieb & Hoehn, 2007).
Few studies have analyzed the impact of non-surgical interventions on the
cognitive demands of sensory integration and balance. Sensory integration refers to the
cumulative input of three systems for balance to occur: visual, vestibular, and
somatosensory. The term “chemobrain” refers to the cognitive dysfunction breast
cancer patients experience during chemotherapy and following treatment. Breast cancer
patients were the first to report mental disturbances, although symptoms of cognitive
impairments affect those with other forms of cancer (Asher, 2011). Results from a
preliminary investigation of neuromuscular, balance, and vision factors associated with
falls experienced by post-menopausal BCS suggest breast cancer treatment may alter
vestibular input for balance control (Winters-Stone et al., 2011). These findings parallel
outcomes of Wampers et al. (2007) where the postural instability of 22 BCS treated with
taxane chemotherapy (used for advanced stage breast cancer) was assessed.
Compared to healthy controls, greater instability resulted from vestibular input while
standing on an unstable surface with absent or conflicting visual feedback (Wampler et
al., 2007). The evaluation of balance at initial diagnosis and throughout treatment and
the establishment of a standardized method of assessment for comparison to normative
data, are necessary to further develop preliminary outcomes and clarify findings. The
Balance System SD (BIODEX®; New York, NY, USA) is a relatively new technology
proven valid and reliable in the evaluation of balance. The instrument automatically
compares results to normative values of sway index (Cohen, Blatchly, & Gombash,
20
1993). In addition, the Balance System SD tests the three systems used to maintain
equilibrium by challenging each independently and in combination. This technology has
not been utilized within a female breast cancer population but is a worthy option for
future investigations.
2.3.6 Quality of Life
Health-related quality of life (HRQoL) outcomes encompass the physical,
psychological, and social aspects of health influenced by individual experiences, beliefs,
expectations, and perceptions (Testa & Simonson, 1996). No single HRQoL
assessment for BCS exists. Patient reported outcomes have been approved as the
method of assessment of QOL by oncologists in theory, but clinical translation has yet
to occur (National Cancer Institute, 2008).
QOL is greatly diminished among cancer patients receiving palliative care and is
commonly associated with depression and anxiety disorders (Wilson et al., 2007). Poor
mental health has been observed as a strong predictor of fatigue (Nieboer et al., 2005).
Fifteen to 25% of cancer patients suffer from major depressive disorder (BodurkaBevers et al., 2000; Leonard R. Derogatis et al., 1983; Henriksson, Isometsä, Hietanen,
Aro, & Lönnqvist, 1995; M. Lloyd-Williams & Friedman, 2001). Following cancer
diagnosis a careful assessment of depression symptoms, treatment effects, physical
and mental status and associated laboratory results should be reviewed (National
Cancer Institute, 2011a). Depression screenings in the clinical setting can be
administered using several accepted methods or validated tools (National Cancer
Institute, 2011a), these include: a single item interview asking, “Are you depressed?”
(Chochinov, Wilson, Enns, & Lander, 1997) or by asking the patient to rate their mood
21
by stating, “Please grade your mood during the past week by assigning it a score from 0
to 100, with a score of 100 representing your usual relaxed mood,” (a score of 60 is a
passing grade) (Akizuki et al., 2003); the Hospital Anxiety and Depression Scale
(Zigmond & Snaith, 1983); the Psychological Distress Inventory (Morasso, Costantini,
Baracco, Borreani, & Capelli, 1996); the Edinburgh Depression Scale (Mari LloydWilliams & Riddleston, 2002); the Brief Symptom Inventory (L.R. Derogatis &
Melisaratos, 1983); the Zung Self-Rating Depression Scale (Dugan et al., 1998); and
the Distress Thermometer (Roth et al., 1998). The culmination of poor mental health,
deleterious physical effects, and fatigue hinder initiation and adherence to an active
lifestyle and slow the process of restoring healthy physical function.
2.3.7 Return to Work issues
Many cancer survivors report physical performance limitations five years or more
post-treatment because of difficulty crouching or kneeling, standing for two hours, lifting
or carrying greater than 10 pounds, and walking one quarter of a mile (Ness, Wall,
Oakes, Robison, & Gurney, 2006). A meta-analysis of 36 studies investigating
employment outcomes found cancer survivors were more likely to be unemployed than
healthy counterparts (33.8% vs. 15.2%; pooled RR, 1.37 [95% CI, 1.21-1.55]) (de Boer,
Taskila, Ojajarvi, van Dijk, & Verbeek, 2009). An evaluation of employment status on
369 BCS psychosocial well-being, showed continued employment while undergoing and
following treatment had the lowest levels of psychosocial distress and the highest level
of physical and mental functioning and QOL. Those choosing unemployment during or
following treatment experienced the highest levels of psychosocial distress and lowest
levels of physical and mental functioning and QOL (Mahar, BrintzenhofeSzoc, &
22
Shields, 2008). In 2008, the importance of optimism and social resources in
employment were compared between breast cancer survivors and their referents.
Outcomes showed no significant differences in employment status, education, or in
participants’ current or chronic diseases between groups (Hakanen & Lindbohm, 2008).
The vast range of factors associated with employment following breast cancer diagnosis
remains unclear. Further exploration of the physical limitations should be first assessed
as this is a modifiable variable.
2.4
Exercise
Immediately post-diagnosis, patients should initiate an exercise program in
preparation for the ensuing treatment (American College of Sports Medicine, 2010;
Newton & Galvao, 2008). It has been shown that cancer patients with higher
cardiorespiratory fitness will experience improved surgical outcomes, and that increased
body fat associated with anesthesia may be mediated with exercise (Jones et al., 2007).
A 10-week aerobic exercise program which decreased symptoms of nausea (M.L.
Winningham & MacVicar, 1988) also demonstrated significant differences in maximal
oxygen uptake (MacVicar, Winningham, & Nickel, 1989).
In a review of 26 exercise interventional studies by Galvão and Newton (2005),
the authors found an overall lack of randomized controlled trials (RCT) and scientific
methodological criteria; Many studies were also limited by small sample sizes. Table 1
demonstrates the diversity of research design, methodology, and interventions as well
as the effects of exercise on BCS over the past decade.
23
TABLE 1
BCS AND PHYSICAL ACTIVITY INTERVENTIONAL STUDIES
YEAR
2001
AUTHOR
Mock, et al.
DESIGN
Pilot
RCT
POPULATION
N=52; currently
undergoing adjuvant
chemotherapy or radiation
therapy
INTERVENTION
2 arms: walking
exercise prgm for
those with radiation
therapy (6 wks) and
chemotherapy (4-6
months)
CONTROL
UC
RESULTS
IG: Sig. ↑ in physical functioning; ↑
mean levels of vigor vs. CG and ↓
levels of fatigue and general mood
disturbance
2001
Segal, et al.
RCT
N=123; women with stage
I and II cancer
2 arms: (a)Progressive
walking program at
50-60% VO2max,
3Xs/wk for 26 wks;
(b)home exercise
prescription, 5Xs/wk
for 26 wks
UC
IG(a): ↑ aerobic capacity and ↓
body wt. vs. CG
2002
Picket, et al.
RCT
N=52; currently
undergoing adjuvant
chemotherapy or radiation
therapy
Usual care +
individualized walking
program (60-80%
MHR) 5 d/wk
UC
CG: 50% maintained or ↑ PA to a
mod-int level; IG: 33% did not
exercise at prescribed levels
2003
Corneya, et al.
RCT
N=53; postmenopausal
BCS
Trained on upright
cycle ergometers
3Xs/wk for 15 wks at
power output of 7075%
Did not train
IG: Peak O2 consumption ↑ by 0.24
L/min; CG: ↓ by 0.05 L/min
N=86; completed stage 0II BC Tx
Mod. int. activities at
55-65% of MHR such
as brisk walking,
biking, swimming, or
use of home exercise
equipment for 12 wks
No change in
activity for 12
wks
IG: more likely than CG to engage
in mod.-int. PA at least 5 d/wk, 30
min./session
2005
Pinto, et al.
Pilot
RCT
24
TABLE 1 (CONTINUED)
2005
Sprod, et al.
RCT
N=12; Hx of mastectomy,
breast conservation
therapy, axillary lymph
node dissection,
chemotherapy, or
radiation
20 min. aerobic
workout + strength
training; with walking
poles
20 min.
aerobic
exercise +
strength
training; no
walking poles
Sig. diff. in muscular endurance
between IG and CG during bench
press and latissimus pull down
2005
Thorson, et al.
RCT
N=111; Hx of lymphomas
or breast, gynecologic, or
testicular cancer
N=78; 14 wk exercise
training program,
2Xs/wk, 30
min./session +
stretching intervention
Maintain
current
physical
activities
IG: VO2max ↑ by 6.4 mL/kg/min
and fatigue score ↓ by 5.8 points;
CG: VO2max ↑ by 3.1 mL/kg/min
and fatigue score ↓ by 17.0 points
2006
Ahmed, et al.
RCT
4-36 months post-BC Tx
with axillary dissection
Supervised upper- and
lower-body weight
training, 2Xs/wk for 6
months
No
intervention
No sig. change in Dx lymphedema
or self-reported Sxs
2006
Cho, et al.
QE ≠
CG
N=55; histologically
confirmed, stage I or II
BCS with no evidence of
recurrent or progressive
disease; within 2 years
post-mastectomy or
completion of
chemotherapy or hormone
therapy; no mental
disease or systemic
disease
Comprehensive group
rehab prgm:
psychology based
education, exercise
and peer support
group activity; 1Xs/wk
for 10 wks. Exercise:
warm-up, main
exercise not to exceed
40-60% MHR, and
cool down; 3
sessions/wk for 10
wks
No group
rehab
IG: Affected shoulder ROM sig. ↑
from pre- to post-intervention ; CG:
No sig. changes in shoulder ROM;
Sig. diff. between IG and CG in all
areas
25
TABLE 1 (CONTINUED)
2006
Culos-Reed,
et al.
RCT
N=38; cancer survivors
(primarily BC) at least 3
months post-Tx; no
additional health concerns
7 wk yoga program;
75 min. sessions
No yoga
No main effects for group
membership on any of the physical
indices. Time effects were noted on
multiple measures.
2006
Kim, et al.
RCT
N=41; newly diagnosed
BCS, currently receiving
adjuvant therapy
8 wk mod-int aerobic
exercise intervention
with biweekly data
collection phone calls
No
intervention,
received
monthly data
collection
phone calls
IG: Sig. ↓ in RHR and resting and
maximum SBP; sig. ↑ in VO2 peak
2006
Mustian, et al.
RCT
N=21; Hx of BC Tx
Tai chi chuan, 60 min
sessions, 3Xs/wk for
12 wks
Psychosocial
support
therapy, 60
min sessions,
3Xs/week for
12 wks; No
change in
daily PA
IG: sig. ↑ in distance walked , sig. ↑
in handgrip strength ; CG: ↓ in
distance walked , no sig. change in
handgrip strength. No sig. group
diff.
2007
Heim, et al.
RCT
N=63; cancer patients with
cancer-related chronic
fatigue
Structured physical
training prgm and
additional muscle
strength and aerobic
exercises
Standard
complex
rehab prgm
No sig. group diff. for functional
aerobic capacity; IG: ↑ of muscular
strength
26
TABLE 1 (CONTINUED)
2007
Matthews, et
al.
RCT
N=34; BCS post-Tx
Supervised 12 wk
exercise prgm in
addition to UC
Wait-list; UC
with no
changes in
BL PA levels
No sig. changes in body wt. or
composition
2007
Mutrie, et al.
UR
N=177; early stage BCS
undergoing Tx
UC + a supervised
group exercise prgrm
for 12 wks, 45
min/session, 2Xs/wk
(50-75% MHR)
UC + an
exercise
guideline
handout for
cancer
patients
No sig. intervention effect for QOL.
Non-sig. trends towards ↑ in the
functional, social, and emotional
components of the QOL domain
2008
DemarkWahnefried, et
al.
RT
N=90; premenopausal
patients with BC on
adjuvant chemotherapy
IG1: Calcium-rich diet
+ aerobic and strength
training exercises;
IG2: Calcium-rich diet
+ aerobic and strength
training exercises and
high fruit and
vegetable, low-fat diet
Calcium rich
diet
Consistent ↑ for all measures of
adiposity over time and among all
groups, with exception of IG2 (waist
circumference ↓); F/U measures of
adiposity were sig.
and pos. associated with BL levels,
and neg. associated with age and
Hx of vigorous PA
2008
Ligibel, et. al
RCT
N=101; overweight BCS
16 wk CV and strength
training exercise prgm
UC
Trend towards ↑ in insulin
resistance for IG; sig. ↓ in hip
measurements with no change in
wt. or body measurements
2008
Payne, et al.
LS, RCT
N=20; post-menopausal,
older women receiving
hormonal Tx for BC
Home-based walking
exercise prgm, 20 min.
in duration, 4
sessions/wk
UC
No sig. diff. between groups for
fatigue or depressive symptoms.
IG: sig. ↓ in sleep disturbances
27
TABLE 1 (CONTINUED)
2009
Griffith, et al.
RCT
N=126; patients with
breast and prostate
cancer undergoing
radiation or chemotherapy
12 wk, home-based
walking exercise;
mod-int that
corresponds to 5070% of MHR for 20-30
min.
Received biweekly phone
calls from
study nurse
to encourage
the
maintenance
of current
activity levels
Sig. diff. between IG and CG noted
on all variables (fitness, physical
function, and pain) except exercise
group assignment
2009
Hayes, et al.
RCT,
singleblind
N=32; BCS at least 6
months post-Tx
20 supervised, group,
aerobic and resistance
exercise sessions over
12 wks
Continue
habitual
activities
No sig. diff. in lymphedema status
at BL or changes between testing
phases observed between the IG
and CG
2009
Irwin, et al.
RCT
N=75; physically inactive
postmenopausal BCS
150 min/wk of
supervised gym- and
home-based mod-int
aerobic exercise
UC and
maintain
current PA
level
Exercisers experienced ↓ BF% and
↑ LBM compared with ↑ in BF and ↓
in LBM in usual care participants
2009b
Irwin, et al.
RCT
N=75; physically inactive
postmenopausal BCS
150 min/wk of
supervised gym- and
home-based mod-int
aerobic exercise
UC and
maintain
current PA
level
Between-group diff. in insulin, IGF-I,
and IGFBP-3 were 20.7%, 8.9%,
and 7.9%, respectively
2009
Morey, et al.
RCT
N=641; overweight, longterm (> or = 5 years)
survivors of colorectal,
breast, and prostate
cancer
A 12-month, homebased tailored
program of telephone
counseling and mailed
materials promoting
exercise, improved
diet quality, and
modest wt. loss. The
control group was
wait-listed for 12
months.
The CG was
wait-listed for
12 months
PA, dietary behaviors, and overall
QOL ↑ sig. in the IG vs. CG; wt.
loss was also >
28
TABLE 1 (CONTINUED)
2009
Rogers, et al.
RCT
N=41; sedentary women
on estrogen receptor
modulators or aromatase
inhibitors for stage I, II, or
IIIA BC
12 wk multidisciplinary
PA behavior change
intervention
UC
IG: Sig. changes in accelerometer
PA counts, aerobic fitness, back/leg
muscle strength, waist-to-hip ratio,
and social well-being. IG reported >
↑ in joint stiffness
2009
Vadiraja, et al.
RCT
N=88; stage II and III BC
outpatients undergoing
adjuvant radiotherapy
Yoga sessions lasting
60 min. daily
Imparted
supportive
therapy once
in 10 days
during the
course of
their adjuvant
radiotherapy
Sig. ↑ in activity level of IG vs. CG.
Sig. pos. correlation between
physical and psychological distress
and fatigue, nausea and vomiting,
pain, dyspnea, insomnia, appetite
loss, and constipation. Sig. neg.
correlation between the activity
level and fatigue, nausea and
vomiting, pain, dyspnea, insomnia,
and appetite loss.
2010
Haines, et al.
Blinded
RT
N=89; women undergoing
adjuvant therapy following
surgery for BC
A multimedia,
multimodal exercise
prgm comprising
strength, balance and
endurance training
elements
A sham
flexibility and
relaxation
prgm
delivered
using similar
materials
IG: greater ↑ in HRQoL between
baseline and the 3-month
assessment vs. CG + ↑ physical
function
2010
Jones, et al.
Singlecenter
RCT
N=174; postmenopausal
women (58 patients/study
arm) with histologically
confirmed, operable BC
following completion of
primary Tx (including
surgery, radiation therapy,
and chemotherapy)
2 arms: (a)150
min/week of
supervised treadmill
walking at an intensity
of 60-70% (mod-int) or
(b)60-100% (mod- to
high-int) of the
individually
determined VOpeak
between 20-45
min/session for 16 wks
Progressive
stretching
prgm for 16
wks + oneon-one
instruction
Not yet published
29
TABLE 1 (CONTINUED)
2010
Schmitz, et al.
RCT
N=134; BCS 1 to 5 years
post unilateral BC, with at
least 2 lymph nodes
removed and without
clinical signs of BCRL at
study entry
Weight lifting
intervention included a
gym membership and
13 wks of supervised
instruction and 9
months unsupervised
No exercise
Among women with 5 or > lymph
nodes removed, the proportion who
experienced incident BCRL onset
was 7% (3 of 45) in the IG and 3
women in the CG
2010
Speck, et al.
RCT
N=234; BCS
Twice-weekly strength
training
Wait-list; no
change in PA
Sig. ↑ in BIRS total score BL to 12
months in Tx vs. CG; IG:
Differential impact of the
intervention on the Strength and
Health subscale was observed for
older women (>50 years old); Sig. ↑
in bench and leg press among IG
vs. CG, regardless of lymphedema;
IG effects independent of strength
and QOL changes
2010
Swensen, et
al.
LS
N=29; BCS receiving
adjuvant Tx
Participants were
advised to walk
10,000 steps/day and
received initial PT
consultation and
ongoing motivational
interviewing
No CG
First 6 weeks = 280,571 steps; 67%
of prescribed steps; Excluding days
when no steps were recorded
during 1st 6 weeks, mean = 7,363 ;
74% adherence rate; Sig. linear ↑
occurred in steps/day after
chemotherapy in a TX cycle
2010
Vallance, et al.
OS
N=377; BCS
2 arms: both arms
recommended to
perform 30 min. of
mod- to vig-int PA, 5
d/wk. Arm IG(a)
received an additional
exercise guide. Arm
IG(b) received a
pedometer
Received a
standard PH
recommendat
ion
BCS meeting PA guidelines at
baseline and post-intervention had
a > likelihood of meeting PA
guidelines at 6 months F/U
30
TABLE 1 (CONTINUED)
2010
van Waart, et
al.
RT
N=360; patients receiving
adjuvant chemotherapy for
BC or CC
2 arms: (a)A low to
mod-int, home-based,
self-management PA
prgm, and (b)a high
intensity, structured,
supervised exercise
prgm
(cardiorespiratory
fitness and muscle
strength)
Usual care
Not yet published
2011
Hayes, et al.
Cohort,
RCT
N=295; BCS post-Tx
12 months of wt. lifting
UC
No between-group diff. were noted
in the proportion of women who had
a change in interlimb volume, size,
ratio, or survey score
2011
Kim, et al.
RCT
N=45; BCS post-Tx
12 wk individualized
intervention promoting
prescribed exercise
and a balanced diet
through stagematched telephone
counseling and a
workbook (SSED)
UC
IG indicated it was feasible and
acceptable; Objective data also
supported the SSED intervention's
feasibility; CG vs. IG showed sig. >
↑ in motivational readiness for
exercise and diet, emotional
functioning, fatigue, and depression
2011
Saarto, et al.
RCT
N=573, BCS aged 35-68
years after adjuvant
treatments, 498 (87%)
were included in final
analysis
12-month exercise
intervention comprised
weekly supervised
step aerobics- and
circuit-exercises and
similar home training
UC
In premenopausal women, bone
loss at the femoral neck was
prevented by exercise; L-spine
bone loss could not be prevented;
In postmenopausal women, no sig.
exercise-effect on BMD was found
either at the L-spine or femoral
neck
31
TABLE 1 (CONTINUED)
2011
Wang, et al.
LS
Taiwanese women newly
diagnosed with earlystage BC
6-wk walking prgm
UC
IG: Sig. better exercise self-efficacy
vs. CG; Sig. effect on ↓ fatigue vs.
CG; Sig. diff. for exercise capacity
at 2nd and 3rd measure
Abbreviations Key: RCT = randomized controlled trial, CG = control group, IG = intervention group, sig. = significant, ↑ = increase or improve, ↓
= decrease, diff. = difference, vs. = versus, VO2max = maximal oxygen uptake, Xs/wk = times per week, wks = weeks, + = plus, MHR = Maximal
heart rate, d/wk = days per week, PA = physical activity, mod-int= moderate intensity, BCS = breast cancer survivors, O2 = oxygen, BC = breast
cancer, Tx = treatment, / = per, min. = minutes, Hx = history, Dx = diagnosed, Sxs = symptoms, ROM = range of motion, rehab = rehabilitation,
prgm = program, RHR = resting heart rate, SBP = systolic blood pressure, wt. = weight, F/U = follow up, CV = cardiovascular, BF% = body fat
percentage, LBM = lean body mass, BF = body fat, neg. = negative, pos. = positive, RT = randomized trial, VOpeak = peak oxygen consumption, Lspine = lumbar spine, CC = colon cancer, PC = prostate cancer, vig-int = vigorous intensity, PH = public health, PT = physical therapy, BL =
baseline, > = greater, LS = longitudinal study, OS = observational study, UR = unbalance randomization, ≠ = non-equivalent
32
2.4.1 Exercise and Upper Extremity Outcomes
Current literature reflects the effects of exercise on upper extremity outcomes as
mostly beneficial. The positive outcomes of exercise on muscular strength are shown in
Table 1. According to Chan, Lui, and So (2010) early introduction of shoulder mobility
exercises subsequent to surgical removal of cancerous tumors limits losses of shoulder
range of motion. Two RCTs involving females with modified radical mastectomies and
axillary lymph node dissections displayed significant increases in shoulder mobility
following prescribed physical therapy versus control groups (Beurskens, van Uden,
Strobbe, Oostendorp, & Wobbes, 2007; Cinar et al., 2008). A study of pre- and postoperative shoulder strength and mobility in patients receiving breast conservation
therapy or a modified radical mastectomy with axillary lymph node dissection followed
by a progressive exercise program, showed a significant increase of shoulder abduction
and an achievement of preoperative levels more quickly as compared to controls (who
were given an exercise instruction booklet only) (Box, Reul-Hirche, Bullock-Saxton, &
Furnival, 2002). Kilgour, Jones, and Keyserlingk (2008) completed a RCT of 27 females
with modified radical mastectomies and axillary lymph node dissections. An evaluation
of shoulder range of motion, strength, and forearm circumference after an 11-day,
home-based video exercise program was compared to controls who received only
verbal and written exercise instructions. The intervention group displayed significant
increases in shoulder flexion and abduction, as well as increases in shoulder abduction,
flexion and external rotation, and decreases in forearm circumference over time.
Similarly, the control group exhibited significant increases in shoulder external rotation
and changes in forearm circumference over time (Kilgour, Jones, & Keyserlingk, 2008).
33
Two studies found little changes in lymphedema following exercise interventions.
Females who underwent resistance and flexibility training following axillary lymph node
dissections did not differ in self-reported lymphedema and circumferential arm
measurements from controls (Ahmed, Thomas, Yee, & Schmitz, 2006). In a similar
RCT, significant increases in shoulder range of motion following radical mastectomies
and quandrantectomies with axillary lymph node dissection was observed. Results,
however, did not show significant differences in arm volumes or lymphedema when
compared to controls (Bendz & Fagevik Olsen, 2002).
Resistance training and flexibility exercises are effective methods for combatting
the detrimental effects of breast cancer therapy on flexibility, muscular strength, and
some cases of lymphedema.
2.4.2 Quality of Life and Exercise
Primary non-metastatic breast cancer patients showed significant improvement in
self-reported levels of anxiety, depression, and individual body image; as well as
significant increases in maximal oxygen uptake following a 10-week exercise
intervention (Mehnert et al., 2011). Recently, an article by Campbell, Neil, and WintersStone (2011) reviewed 29 randomized controlled trials to evaluate exercise training
principles administered to breast cancer survivors. Results demonstrated a
comprehensive neglect for the inclusion of all principles of exercise training within
interventions. Specificity, progression, overload, initial values, diminishing returns and
reversibility were the only components assessed (Campbell et al., 2011). According to
the American College of Sports Medicine Roundtable on Exercise Guidelines for Cancer
Survivors, future evidence will guide exercise interventions for a given cancer site at
34
each phase of the cancer trajectory (e.g. during chemotherapy, survivorship, end of life).
In addition, interventions for specific end points (e.g. fatigue, physical function, QOL,
survival) will be addressed as research progresses (Schmitz et al., 2010). Turner,
Hayes, and Reul-Hirche (2004) ensued a preliminary investigation regarding the impact
of a structured exercise intervention on QOL and measurements of fitness. Results
indicated a mixed-method, moderate-intensity exercise program improved overall QOL.
2.5
Exercise Recommendations
Several institutions support exercise recommendations for breast cancer
patients, including the Centers for Disease Control and Prevention, the National Cancer
Institute, the American Cancer Society, and the Lance Armstrong Foundation. In 2006,
The American College of Sports Medicine (ACSM) established national guidelines and
physical activity recommendations for cancer patients and survivors (Doyle et al., 2006;
McNeely, Peddle, Parliament, & Courneya, 2006). Currently, the American Cancer
Society recommends 30 to 60 minutes of moderate- to vigorous-intensity physical
activity at least 5 days per week (Doyle et al., 2006). Clinical standards of practice
utilize the same recommendations and align with ACSM guidelines for exercise
prescription (American College of Sports Medicine, 2010; McNeely et al., 2006). Aerobic
activities should last 20 to 60 minutes in duration to include accumulated shorter bouts,
if necessary. BCS should participate in resistance training and flexibility activities as
well. Frequency of resistance training should occur 2 to 3 days per week with 48 hours
or more of recovery time for each muscle group, with 1 to 3 sets of 8 to 12 repetitions
per exercise (upper limit of 15 repetitions). Cancer patients should reach an intensity of
40-60% of 1 repetition maximum. Flexibility training recommendations consist of slow
35
static stretching techniques, aggressive to the point of muscle tension, lasting 10 to 30
seconds for 4 repetitions, 2 to 7 days per week (American College of Sports Medicine,
2010).
The ACSM and ACS have collaborated to develop the ACSM/ACS Certified
Cancer Exercise TrainerSM (CET) certification to support cancer survivors in lifestyle
changes and fitness endeavors, as well to provide knowledgeable resources for
exercise prescription for this specific population (American College of Sports Medicine,
2011). Physical Therapists, Occupational Therapists, and Medical Doctors may seek an
International Certification in Lymphedema Management to rehabilitate and restore UBF
in BCS with an emphasis in decreasing the manifestations of lymphedema throughout
and following treatment (A division of Pacific Therapy Education, Inc., & Coast to Coast
School of Lymphedema Management, 2011).
Disease processes and ensuing treatments for BCS have several deleterious
impacts on health. Increases in fat mass, late stage variations in skeletal content,
decreased muscular strength and UBF, and declines in QOL outcomes grow in
significance as mortality rates for this disease decrease and incidence continues to rise.
Supportive therapy to address lifestyle changes will be crucial in restoring this
population’s ability to function independently and lead a productive, healthy lifestyle.
With increased life expectancy, return to work issues emerge and warrant further
assessments of upper body function to perform daily tasks and normal activities.
Cognitive changes effecting standing balance may be an additional barrier to returning
to work. The current literature is inadequate to address the problems associated with life
post-treatment. Equally lacking is research targeting the prevention of disease sequela.
36
The purpose of this study is to assess body composition, balance, and muscular
strength and endurance of the upper arm and chest in BCS shortly after diagnosis and
during and after chemotherapy. We aim to answer four questions: (1) What is the
difference in body composition between newly diagnosed BCS, those currently
undergoing treatment, those who have completed treatment, and healthy, age-matched
controls? (2) What is the difference in body composition over time within newly
diagnosed BCS, those currently undergoing treatment, and those who have completed
treatment? (3) Do BCS show changes in balance compared to normative values? (4)
How will muscular strength and endurance of the affected upper arm and chest
compare to the unaffected extremity in BCS?
37
CHAPTER THREE
METHODS
3.1
Participants
Participants for this study were required to meet inclusion criterion: (1) at least 18
years of age, (2) English speaking, (3) female, (4) within 1 month of breast cancer
diagnosis and/or previously underwent chemotherapy for the treatment of breast
cancer, (5) negative pregnancy screening, and (6) have obtained permission from
primary care physician and/or oncologist to participate in study. Recruitment occurred at
the KU Wichita Center for Breast Cancer Survivorship. Participants were offered a
physical activity assessment and subsequent physical activity recommendations
following their participation. The option to join the Center for Physical Activity and Aging
Program at Wichita State University (WSU), free of charge, was also extended. No
monetary incentives were provided. Informed consent was obtained prior to study
participation. The Institutional Review Board of WSU and the Human Subjects
Committee of the University of Kansas School of Medicine-Wichita (KUSM-W) reviewed
and approved the protocol.
Participants meeting the inclusion criteria and their physician’s approval to
participate were referred to the Patient Navigator at KUSM-W to schedule an
appointment for a physical activity assessment with WSU research personnel. The
Patient Navigator contacted WSU investigators to schedule a date and time for
participants’ assessments and immediately forwarded all corresponding medical history
via electronic mail to WSU investigators. Following testing procedures at WSU,
38
participants were asked to follow-up for reassessment after three months of adherence
to physical activity recommendations.
Healthy, age-matched control subjects were randomly selected from the Hologic
QDR 4500 database from the dual energy x-ray absorptiometry (DEXA) unit for
comparisons of body composition to the BCS group. Control subjects meeting the
following criterion were accepted: no medical history of cancer related illness or family
history of cancer, no medical history of osteoporosis or previous indicators of impaired
bone health, and successful completion of a whole body DEXA scan.
3.2
Apparatus
Instrumentation for this study included a DEXA (Hologic QDR 4500) unit to
quantify muscle, fat, bone mineral content, and bone mineral density of the whole body;
the Quick Set Pro isokinetic dynamometer (BIODEX®; Quick Set System 4 Pro, New
York, NY, USA) with microprocessor, for bilateral skeletal muscle strength and
endurance throughout horizontal adduction/abduction of the glenohumeral joint, which
was calibrated for torque and angular velocity according to manufacturer protocols; and
a Balance System SD (BIODEX®; New York, NY, USA) platform to assess standing
sway and stability.
3.3
Procedures
3.3.1 Dual Energy X-ray Absorptiometry
Participants were first measured for height and body weight. Due to the low x-ray
emission of the DXA machine, as a precautionary measure pre-menopausal female
participants were administered a pregnancy test by the KU Wichita Center for Breast
39
Cancer Survivorship prior to arrival for testing. Those testing positive were not allowed
to continue with the study. Participants were then scanned using the whole body mode.
3.3.2 Isokinetic Dynamometry
Limb position was calibrated prior to each movement pattern. Limb and torso
alignments and machine settings were recorded for replication in future investigations.
Full range of movement within the constraints of the equipment were prescribed for
each movement pattern to eliminate errors caused by participants failing to complete full
repetitions. Standard instructions were issued with regard to both the technique and the
maximal effort required during each test. Movement patterns were practiced just prior to
each trial. If smooth curves for torque were not obtained during practice, they were
required to repeat these after a brief rest. Testing protocols are validated and used in
previous research (Brown, 2000). Strength of the glenohumeral horizontal adductors
and abductors (musculature of the shoulder) were measured as the peak angular force
(torque, Nm) and power (watts) generated during three maximal continuous repetitions
at 60º.s-1 angular velocity. Following two minutes of rest, endurance is determined as
the total angular work (joules) achieved during the middle 16 of 20 consecutive maximal
repetitions at 240º.s-1. A recovery period of two minutes was allowed between each of
the two (i.e. shoulder strength and shoulder endurance) maneuvers.
3.3.3 Balance
Sway and stability index were assessed using the Modified Clinical Test of
Sensory Interaction and Balance (M-CTSIB), a standardized test for balance
assessment on a static surface and an accepted method of measurement (Cachupe,
2001). The test provided a generalized assessment of individual ability to integrate
40
various senses with respect to balance and compensate when one or more of those
senses are compromised. The stability index is the individual’s mean center of pressure,
and the sway index is the standard deviation of the stability index. The higher the sway
index, the more unsteady the person was during the test. This is an objective
quantification of a time-based pass/fail for completing the M-CTSIB stage in 30 seconds
without falling, or assigning a value of 1-4 to characterize the sway. A score of 1 is
equivalent to minimal sway, and 4 equates to a fall. The stability index is the average
position from center. Foot placement on the balance platform is standardized and based
on height, and labeled line charts on the platform allow for one to determine correct foot
angle. The M-CTSIB consists of four, 30 second tests; Condition 1 – eyes open firm
surface (baseline: incorporates visual, vestibular and somatosensory inputs), Condition
2 – eyes closed firm surface (eliminate visual input to evaluate vestibular and
somatosensory inputs), Condition 3 – eyes open on a dynamic surface (used to
evaluate somatosensory interaction with visual input), Condition 4 – eyes closed on
dynamic surface (used to evaluate somatosensory interaction with vestibular input).
Standard instructions were provided for each test. Results are presented relative to the
upper limit of the “normal” reference data. Participants’ results are reported as better,
equal to or worse than normal. The higher the sway index score, the more unstable the
person was for the condition. Normative data was validated and deemed reliable in a
randomized controlled trial by Cohen, et al. (1993). Participants underwent a
familiarization period with each Condition prior to recorded measurements to ensure
understanding of and comfort with equipment.
41
3.4
Data Analysis
The Statistical Package for Social Sciences (SPSS) 17.0, eighth edition, was
used to analyze data from the DEXA and Biodex Quick Set Pro isokinetic dynamometer.
Descriptive statistics were utilized to assess demographics. Paired sample t-tests were
used to assess significance in weight change from pre-diagnosis to post-treatment. The
same test compared muscular strength and endurance between affected (involved) and
unaffected (uninvolved) upper arm and chest or, if applicable, difference between
bilaterally affected musculature. Between group comparisons of age, weight, BMI, BMD,
BMC, body fat percentage, and lean body mass percentage were made with
independent sample t-tests. The computer software engineered by Biodex Balance SD
analyzed sway index, the standard deviation of the mean stability index, in static
balance against normative values of sway in each of the four Conditions tested.
42
CHAPTER FOUR
RESULTS
4.1
Overview
A total of seven post-chemotherapy participants (N=7) volunteered to undergo an
assessment of body composition, muscular strength and endurance measurements,
and an evaluation of balance. Six individuals’ (N=6) data were available for muscular
strength and endurance and balance analysis, as one participant’s (N=1) data set was
deleted due to software malfunctions. All participants’ (N=7) data for body composition
was included in analysis (Post-treatment values of BCS versus healthy, age-matched
controls). BCS group mean age was 50.57 ± 7.68 years and control group mean age
was 48.71 ± 7.87 years; the groups did not differ significantly in age (p=0.663; p<0.05).
Between groups, no significant difference was observed in BMI, BMD, BMC, weight, or
body fat percentage (p>0.05). Lean body mass significantly differed between BCS
group and control group (p=0.047; p<0.05).
A significant increase in weight occurred from pre- to post-treatment (p=0.037;
p<0.05). Muscular strength and endurance of the upper arm and chest did not differ
significantly between affected and unaffected side (p>0.05). The majority of participants’
(67%) balance assessments were within normative values for Conditions 1 and 2. For
Condition 3, the majority of participants’ (67%) sway index was higher than the upper
limit of normative data, and sway index results for Condition 4 were above the
normative range for all participants (100%) with a statistically significant group mean
(p=.002; p<.05). Group means for Conditions 1-3 did not differ significantly from
normative values (p>0.05). No falls were observed throughout testing conditions (1-4)
43
and all participants completed assessments without faltering from the standing position
or opening eyes to steady balance. Table 2 displays demographic information of BCS
and control participants.
TABLE 2
DEMOGRAPHICS
AGE (years)
HEIGHT (m)
WEIGHT (kg)
BMI (kg/m2)
BCS
50.57 ± 7.68
1.64 ± 0.04
84.56 ± 13.62
31.45 ± 4.71
CONTROLS
48.71 ± 7.87
1.59 ± 0.06
68.28 ± 17.61
27.17 ± 8.27
4.2 Body Composition between BCS and Controls
Hypothesis 1: A significant difference in body composition will be observed
between newly diagnosed breast cancer patients, those currently undergoing treatment,
those who have completed treatment, and healthy, age-matched controls.
Technique: Independent samples t-test
Analysis: Table 3, Table 4
Interpretation: No significant difference (p < .05) observed between BCS group
(post-treatment) and control group in weight (p=0.077), BMI (p=0.258), body fat
percentage (p=0.072), BMC (p=0.576), or BMD (p=0.538). Lean body mass percentage
differed significantly between groups (p=0.047).
44
TABLE 3-4
GROUP DIFFERENCES IN BODY COMPOSITION (POST-TREATMENT)
TABLE 3
Std.
Deviation
Std. Error
Mean
N
Mean
Weight BCS
(kg)
Controls
7
84.5625
13.62054
5.14808
7
68.2792
17.61124
6.65642
BMI
BCS
2
(kg/m ) Controls
7
31.4471
4.71291
1.78131
7
27.1692
8.27253
3.12672
BMD BCS
(kg/c3) Controls
7
1.1017
.13605
.05142
7
1.1483
.13902
.05254
BMC BCS
(kg/c3) Controls
7
2244.8929 435.79171
164.71378
7
2117.1871 394.43027
149.08063
BF%
BCS
7
44.7714
4.08237
1.54299
Controls
7
36.2920
10.60998
4.01019
7
54.6729
4.46833
1.68887
7
64.7369
11.15978
4.21800
*LBM% BCS
Controls
*Indicates statistical significance
45
TABLE 4
Levene's Test
F
Weight
(kg)
EVA
0.291
Sig.
0.599
EVA
0.861
EVA
0.001
EVA
0.234
EVA
1.138
EVNA
LBM %
EVA
EVNA
1.335
Mean Diff.
Std. Error Diff.
Lower
Upper
8.415
-2.051
34.618
1.935 11.286
0.078
16.283
8.415
-2.181
34.747
1.189 12.000
0.258
4.278
3.599
-3.563
12.119
1.189
9.524
0.263
4.278
3.599
-3.795
12.351
0.982 -0.633 12.000
0.538
-0.047
0.074
-0.207
0.114
-0.633 11.994
0.538
-0.047
0.074
-0.207
0.114
0.575 12.000
0.576
127.706
222.161
-356.342
611.754
0.575 11.883
0.576
127.706
222.161
-356.873
612.285
1.973 12.000
0.072
8.479
4.297
-0.883
17.841
1.973
7.738
0.085
8.479
4.297
-1.488
18.446
0.270 -2.215 12.000
0.047
-10.064
4.544
-19.964
-0.165
0.058
-10.064
4.544
-20.570
0.442
0.372
0.637
EVNA
BF %
Sig. (2-tailed)
16.283
EVNA
BMC
(kg/c3)
Df
0.077
EVNA
BMD
(kg/c3)
T
95% CI of the Diff.
1.935 12.000
EVNA
BMI
(kg/m2)
t-test for Difference of Means
0.307
-2.215
7.876
*Abbreviations Key: EVA = Equality of Variance Assumed, EVNA = Equality of Variance Not Assumed
46
4.3
Weight Pre-Post Treatment in BCS
Hypothesis 2: A significant difference in body composition will occur over time
within newly diagnosed breast cancer patients, those currently undergoing treatment,
and those who have completed treatment.
Technique: Paired samples t-test
Analysis: Table 5, Table 6, Table 7
Interpretation: A significant difference in body weight occurred in BCS from time
of diagnosis to post-treatment (p=0.037; p<0.05).
47
TABLE 5-7
DIFFERENCE IN WEIGHT PRE-POST TREATMENT IN BCS
TABLE 5
Pair 1 Wt. (kg) Post-treatment
Wt. (kg) at Diagnosis
Mean
N
Std. Deviation
Std. Error Mean
86.039
7
13.926
5.263
79.416
7
18.540
7.007
TABLE 6
Pair 1
Wt. at Post-treatment &
Wt. at Diagnosis
N
Correlation
Sig.
7
0.958
0.001
TABLE 7
Paired Differences
Mean
Pair 1 Wt. at Post-treatment –
Wt. at Diagnosis
6.623
Std.
Std. Error
Deviation
Mean
6.539
2.472
48
95% Confidence Interval
of the Difference
Lower
Upper
t
df
Sig.(2-tailed)
.576
12.671
2.680
6
0.037
4.4
Differences in Sway Index between BCS and Normative Data
Hypothesis 3: BCS will have decreased balance (increased sway index)
compared to normative values.
Technique: Normative data comparisons (Table 8)
Analysis: Table 9
Interpretation: The majority of BCS (N=4; 67%) scored within normative range
for Conditions 1 and 2, and above normative measures for Condition 3 (N=4; 67%). All
BCS scored above the normative range for Condition 4 (N = 6; 100%). All participant
results within normative range were near the upper limit.
TABLE 8
M-CTSIB NORMATIVE RANGE FOR SWAY INDEX
Condition 1
Condition 2
Condition 3
Condition 4
Eyes Open Firm Surface
Eyes Closed Firm Surface
Eyes Open Foam Surface
Eyes Closed Foam Surface
0.21 - 0.48
0.48 - 0.99
0.38 - 0.71
0.70 - 2.22
TABLE 9
SWAY INDEX RESULTS FOR BCS
BCS
Condition 1 Condition 2 Condition 3 Condition 4
Participant
1
0.50
0.85
0.92
2.44
2
0.47
0.94
0.78
2.84
3
0.34
1.23
0.62
2.54
4
0.46
0.94
0.65
2.72
5
0.54
1.17
0.97
2.91
6
0.44
0.82
1.29
2.82
*Shaded areas indicate measures greater than normative values
49
4.5
Differences in Upper Body Strength and Strength Endurance in BCS
Hypothesis 4: Muscular strength and endurance of the affected upper arm and
chest will be reduced compared to the unaffected extremity.
Technique: Paired samples t-test
Analysis: Table 10, Table 11, Table 12, Table 13, Table 14, Table 15
Interpretation: Total work produced by affected upper arm and chest was
greater than unaffected side. Total work produced during the push movement was
greater than total work produced during the pull movement. No significant differences (α
level=0.05) observed during the push or pull movement in terms of power (p=0.208 and
p=0.136, respectively) or peak torque (p=0.145 and p=0.197, respectively). A significant
difference was observed in total work (p=0.036) during the push phase but not in the
pull phase (p=0.216) between affected and unaffected musculature of the upper arm
and chest.
50
TABLE 10-11
DIFFERENCE IN POWER BETWEEN AFFECTED AND UNAFFECTED UPPER ARM AND CHEST
TABLE 10
Isokinetic Dynamometry 60°s-1
Mean
N
Std. Deviation
Std. Error Mean
PUSH
Affected
45.067
6
11.185
4.566
Unaffected
40.533
6
20.454
8.350
Affected
44.433
6
16.517
6.743
Unaffected
38.383
6
18.414
7.518
PULL
TABLE 11
Paired Differences
95% CI of the Diff.
Isokinetic Dynamometry
60°s-1
PUSH Affected vs.
Unaffected
Affected vs.
PULL
Unaffected
Mean
4.533
6.050
Std.
Std. Error
Deviation
Mean
12.536
5.118
11.982
4.891
51
Lower
-8.622
Upper
17.689
T
0.886
Df
5
Sig. (1-tailed)
0.208
-6.524
18.624
1.237
5
0.136
TABLE 12-13
DIFFERENCE IN PEAK TORQUE BETWEEN AFFFECTED AND UNAFFECTED UPPER ARM AND CHEST
TABLE 12
Isokinetic Dynamometry
60°s-1
Mean
N
Std. Deviation
Std. Error Mean
PUSH
Involved
52.483
6
12.173
4.969
PULL
Uninvolved
Involved
46.750
54.817
6
6
19.388
23.471
7.915
9.582
Uninvolved
47.000
6
20.260
8.271
TABLE 13
Paired Differences
95% Confidence Interval
of the Difference
Mean
Std.
Deviation
Std. Error
Mean
Lower
Upper
t
Df
Sig. (1-tailed)
Involved vs.
Uninvolved
5.733
11.848
4.837
-6.701
18.168
1.185
5
0.145
Involved vs.
Uninvolved
7.817
20.518
8.376
-13.715
29.349
0.933
5
0.197
Isokinetic Dynamometry
60°s-1
PUSH
PULL
52
TABLE 14-15
DIFFERENCE IN MUSCULAR ENDURANCE (TOTAL WORK)
TABLE 14
Isokinetic Dynamometry
240°s-1
PUSH
PULL
Mean
N
Std. Deviation
Std. Error Mean
Involved
499.367
6
187.814
76.675
Uninvolved
428.000
6
227.660
92.942
Involved
488.250
6
253.453
103.472
Uninvolved
412.467
6
171.635
70.070
TABLE 15
Paired Differences
95% CI of the Difference
Isokinetic
Dynamometry 240°s-1
PUSH Involved vs.
Uninvolved
PULL Involved vs.
Uninvolved
Mean
Std.
Deviation
Std. Error
Mean
Lower
Upper
T
df
Sig. (1-tailed)
71.367
76.809
31.357
-9.239
151.973
2.276
5
0.036
75.783
217.094
88.628
-152.042
303.609
0.855
5
0.216
53
CHAPTER FIVE
DISCUSSION
5.1
Overview
This study has assessed multiple variables of body composition, balance, and
muscular strength and endurance of female BCS following chemotherapy. We found
significant group differences in lean body mass percentage, however, weight, BMI,
BMC, BMD, and body fat percentage did not significantly differ between groups.
Muscular strength and endurance measures did not reveal significant differences
between affected and unaffected upper arm and chest except during the push phase,
and results of balance indicate normal function of the vestibular, somatosensory, and
visual systems in three out of the four conditions assessed.
Supporting published research parallels findings of decreased lean body mass
(Winningham et al., 1994) and poor balance with the removal of visual input and
challenged somatosensory input in BCS who have completed treatment (Winters-Stone
et al., 2011). Numerous studies have focused on treatment effects on lean body mass,
adiposity, BMI, changes in skeletal tissue, and strength and flexibility of the upper body.
This study sought to evaluate a mixed population of newly diagnosed BCS, those
currently undergoing treatment, and those who have completed treatment, a population
in which no other publications using the same variables have completed. Based on
previous findings, a difference in body composition was expected between groups. This
study and investigations by Wampler et al. (2007) and Winters-Stone et al. (2011) are
the first to seek objective reasoning for balance disturbances associated with
chemotherapy. Upper body function and muscular strength in BCS are well researched,
54
although a link between these variables and lean mass and mortality has not been
discussed until now. The following topics will be in this discussion: discuss weight, BMI,
BMC, BMD, body fat percentage, and lean body mass percentage among BCS, discuss
muscular strength and endurance and upper body function in BCS, discuss cognitive
memory and balance in BCS, and discuss limitations within the BCS population.
5.1.1 Established Reliability of the Study
Breast cancer treatment associated outcomes of weight and body composition
are well documented and most findings within this study align with previous research.
Figure 3 highlights the results of body composition in BCS versus healthy, age-matched
controls.
FIGURE 3
DIFFERENCE IN BODY COMPOSITION BETWEEN BCS AND
HEALTHY AGE- MATCHED CONTROLS
No Sig.
Body Composition
BCS
*BMC not shown
Control
*p = 0.047
84.56
68.28
64.74
No Sig.
54.67
No Sig.
44.77
36.29
31.45
27.17
No Sig.
1.10 1.15
Weight (kg)
LBM %
BF%
55
BMI (kg/m2)
BMD (kg/c3)
In Visovsky’s (2006) review of literature involving body composition, muscular
strength, and physical activity in BCS, the author stated the need for baseline measures
occurring at diagnosis of breast cancer. This study assessed weight change from time
of diagnosis to survivorship and found a significant difference over time (exact time
varied between individuals) (p=0.037). Unfortunately, all participants were BCS who had
completed treatment; therefore no other comparisons over time could be made due to a
lack of baseline data and an absence of newly diagnosed participants or BCS currently
undergoing treatment.
A significant deficit in lean body mass (p=0.047) was observed in BCS (posttreatment) compared to controls. Body fat percentage and BMI did not differ significantly
as hypothesized, although results revealed a trend for increased adiposity in BCS
(p=0.072). Lack of significance between groups may be a result of the study’s small
sample size. Nonetheless, findings correspond with previous research as lean body
mass percentage has been shown to decrease following cancer therapies. Weight gain
is also common among BCS. As stated previously, results from this study showed a
significant increase in weight over time in BCS. Weight gain may influence upper and
lower extremity strength, compounding treatment induced fatigue, and consequently
predisposing women to muscle atrophy and weakness (Winningham et al., 1994). Ruiz
et al. (2009) examined the associations between muscular strength, markers of overall
and central adiposity, and cancer mortality in men. The authors established muscle
mass as an independent predictor of all-cause mortality. Weight gain subsequent to
increased fat mass and decreased lean mass may present several problems to BCS.
Potential outcomes include greater risk for mortality due to reduced lean body mass, as
56
well as heightened risks for cardiovascular disease, diabetes, and stroke resulting from
increased adiposity (American College of Sports Medicine, 2010).
Advancements in breast cancer treatment and diagnosis have increased the
number of cancer survivors. With greater prevalence of survival and treatment induced
muscle atrophy, and thereby increased risk of mortality, progress appears contradictory.
A knowledge deficit over how to properly care for and rehabilitate BCS to healthy,
functioning individuals exists. Protocols to increase muscle mass and maintain healthy
levels of adiposity over treatment cycles and for the sustainment of gains thereafter are
necessary to support this population.
5.1.2 Upper Body Function
UBF is often impaired in BCS following cancer therapies. Previous studies have
shown 15-45% of women suffer from impaired UBF for up to a year following treatment
(Hladiuk et al., 1992; Keramopoulos et al., 1993; Satariano et al., 1996). Others have
reported continual problems longer term (Liljegren & Holmberg, 1997). Our study
demonstrated greater muscular strength of the affected upper arm and chest through
greater measures of peak angular torque and power as compared to the unaffected side
(Figure 4). Muscular endurance (total work) of the affected musculature was also
greater (Figure 5) overall and during the push phase of the chest press.
57
FIGURE 4
DIFFERENCE IN TOTAL WORK BETWEEN AFFECTED AND
UNAFFECTED UPPER ARM AND CHEST
*denotes statistical
PUSH vs. PULL (Nm)
significance
AFFECTED
UNAFFECTED
1177
945
315 281
329 282
267 259
266
123
PUSH
Strength
* PUSH
Endurance
PULL
Strength
PULL
TOTAL Work
Endurance
FIGURE 5
DIFFERENCE IN MUSCULAR ENDURANCE BETWEEN AFFECTED AND
UNAFFECTED UPPER ARM AND CHEST
Muscle Endurance
Total Work (Nm)
Affected
Unaffected
533.3
382.5
Total Work (Nm)
58
Currently, physical therapy following treatment is not a standard of care in the
clinical setting for BCS. Although many physicians recommend their patients engage in
formal physical therapy, guidelines for rehabilitation are lacking. Older age, lower
socioeconomic status, treatments on the dominant side and/or more extensive surgery
to the chest wall or axilla are each independent predictors for declines in UBF (Hayes,
Rye, Battistutta, DiSipio, & Newman, 2010). Hayes et al. (2010) highlighted the
importance of subjective and objective measures of UBF, reporting differences based
on the location of breast cancer (dominant or non-dominant side), age, and early
postoperative exercises. One aspect unexplored is the internal processes of
rehabilitation. If outcomes of muscular strength and endurance of affected musculature
produce greater total work than the unaffected extremity, proper attention to the
unaffected side may be limited during the course of rehabilitation. With the support of
previous research, this study illustrates the need for baseline measures and measures
over time or disease stages to render definitive conclusions, and eventually construct
guidelines for physical therapy with BCS.
Return to work issues have been cited in women with impaired UBF. A review by
Mehnert (2011) revealed 26-53% of cancer survivors lose or quit their employment
within a 6 year period following treatment, 23-75% are reemployed, with nearly 65%
overall returning to work. Existing guidelines for screening women in the work force for
breast cancer are in place to detect and treat the disease at the earliest possible point.
Therefore, returning to work is an objective indicator of recovery in BCS (Bradley,
Neumark, Bednarek, & Schenk, 2005).
59
Our study showed total work produced during the pull phase was greater than
total work of the push phase (ratio of 1.122), conflicting with the normative
agonist/antagonist strength ratio (mean value of dominant and non-dominant strength is
0.45, SD=0.14) of the shoulder joint at 90° of glenohumeral flexion (Hughes, Johnson,
O'Driscoll, & An, 1999) (Figure 6). Reasons for this finding may include muscle
imbalances and postural abnormalities secondary to surgery, as well as scar tissue
formation preventing full and/or normal shoulder motion. Overtime, stretching of
muscles involved in the pull phase of motion become weak and inefficient.
FIGURE 6
RATIO OF UPPER ARM MUSCULAR STRENGTH
TOTAL
PUSH
PULL
315
329
267
266
281
282
259
123
1122
1000
Agonist/Antagonist Ratio =
1.122
Physical symptoms, lack of access to rehabilitative services, and fatigue are some of
the barriers cited by BCS to employment and reemployment. Bradley et al. (2005)
conducted a longitudinal cohort of the short-term effects of breast cancer on the labor
market and reported 74% of his cohort listed “illness” as reason for not working. The
authors interpreted this as an inability to match physical demands of work tasks. The
atypical strength ratio of BCS in this study may contribute to impaired UBF and
subsequent difficulties in the labor market.
60
5.1.3 Cognitive Memory and Balance
This investigation was the first to utilize the M-CTSIB and the Balance System
SD to identify balance disturbances in BCS. The majority of BCS scored within
normative range for balance assessments of Conditions 1–3. All participants scored
above the normative range for Condition 4 (eyes closed on a foam surface) which tests
vestibular input of static equilibrium. Somatosensory input is challenged by the unstable
surface and visual input is eliminated by participants closing their eyes. Previous
research indicates vestibular system impairments are associated with imbalance in BCS
(Winters-Stone et al., 2011). This supports current findings and validates the use of the
M-CTSIB and the Balance System SD as appropriate instruments in the assessment of
balance in BCS. Reasons for current findings have yet to be determined, although
Doxobubicin (adriamycin), used in most combination chemotherapy for breast cancer, is
an aminoglycoside and has been associated with vestibular ototoxicity (Winters-Stone,
2011). Little research has investigated this link and declines in vestibular input and
balance of BCS should be further studied.
An association of balance and cognitive impairment has yet to be directly linked,
specifically in a population where the effects of long-term treatment are not fully
understood. The MayoClinic defines Mild Cognitive Impairment as “an intermediate
stage between the expected cognitive decline of normal aging and the more
pronounced decline of dementia. It involves problems with memory, language, thinking
and judgment that are greater than typical age-related changes” (MayoClinic, 2010).
Similar symptoms are often expressed by patients undergoing chemotherapy.
Significant changes in postural stability were observed by Wampler et al. (2007) in their
61
investigation of women treated with taxane chemotherapy compared with matched
healthy controls. Winters-Stone et al. (2011) made an indirect association of adjuvant
chemotherapy on balance through effects on the vestibular system when contrasted
with females receiving adjuvant chemotherapy and endocrine therapy, where no
association between falls and the vestibular system were observed. Increased cognition
has been observed in adults participating in ongoing physical activity, although few
investigations have involved balance as a training tool and those which have are
inconclusive (Angevaren, Aufdemkampe, Verhaar, Aleman, & Vanhees, 2008; van
Uffelen, Chin, Hopman-Rock, & van Mechelen, 2008). This study as well as previous
research assessed small sample sizes and therefore are useful for preliminary data and
intended to inform future studies.
5.1.4 Limitations on BCS population
Many studies have observed difficulties in the recruitment of BCS. The same
barrier was faced in this study as we were limited to observations of BCS who had
completed treatment. No baseline measures for newly diagnosed BCS or patients
currently undergoing therapy were available for comparison. These factors may account
for the lack of significant group findings in body composition as well as the absence of
comparisons over time. Results of balance are restricted in generalizability due to a
small sample size. Furthermore, within group differences could not be analyzed due to
the Balance System SD report of outcomes. The stability index is a mean standard
deviation, as is the sway index, therefore analysis was limited to a comparison to
normative data. The Quick Set Pro isokinetic dynamometer was not equipped with
normative data for chest press movements, and control participants were not prescribed
62
for this study. Literature shows a small number of studies reporting no differences in
muscular strength between affected and unaffected extremity which support this study’s
findings. However, it is recognized that comparisons to healthy, age-matched controls
are standard protocol in similar studies, and the inclusion of such may elucidate
variance in muscular strength and endurance among BCS.
5.2
Conclusion
This study assessed body composition, balance, and muscular strength and
endurance of the upper arm and chest of BCS following breast cancer therapy. This
study supports published findings of decreased lean body mass and increased adiposity
in BCS when contrasted with healthy age-matched controls. Findings of weight gain,
balance disturbances, and muscular strength abnormalities in BCS also parallel
previous research. Definitive conclusions and generalizations cannot be made due to
the shortage of participants and lack of variance among BCS in terms of stage of
disease.
5.3
Recommendations for Further Research
This study raised further questions regarding the association of lean body mass
and mortality, treatment effects and balance, and upper extremity strength ratios and
UBF. Future investigations should evaluate the association between lean body mass
and female all-cause mortality, as the link established was in a male population only.
Further investigation of the relationship between balance and cognitive impairment as
well as impaired sensory integration following breast cancer treatment is warranted.
Focused assessment of balance and cognitive status should be collected at time of
diagnosis through the progression of treatment, disease stages, and remission to clarify
63
current and previous findings. Baseline measures are also required to better understand
changes in muscular strength over time and to create exercise guidelines among BCS
from initial diagnosis to after completion of treatment. Finally, baseline and follow up
measures of body composition will further identify changes associated with breast
cancer treatment and supplement current exercise recommendations to combat the
deleterious effects of therapy, and to promote a healthy, physically active lifestyle. All
recommendations for future research should be applied utilizing various populations of
BCS to include different age groups, treatment types, and stages of disease.
64
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