Physical therapist Nicole Dugan, DPT, CLT, helps breast cancer survivor Brenda Laigaie with her strength-training exercises which keep the lymphedema in her arm under control.

For decades women were warned to avoid lifting anything over five pounds after breast cancer surgery. It was thought that doing so would lead to developing lymphedema, a painful and often debilitating condition affecting a significant minority of breast cancer survivors, or making it worse. Results of a Penn study, however, prove the opposite is true. The Physical Activity and Lymphedema (PAL) study shows unequivocally that exercise and weightlifting can not only keep lymphedema from worsening, but also prevent it from occurring at all.

“This study clearly shows that these women have a weapon to reduce their risk of developing lymphedema while reaping the many other rewards of weightlifting they have missed out on,” said Kathryn Schmitz, PhD, MPH, of Epidemiology and Biostatistics, the study’s principal investigator.

Giving Patients Back Their Lives

For women who had five or more lymph nodes removed during surgery, the risk of lymphedema was reduced by 70% with weightlifting.

The PAL study comprised two randomized trials. In the first, researchers enrolled 154 breast cancer survivors without lymphedema who had had breast cancer surgery within the previous five years. Half of the group participated in a slowly progressive weight lifting regimen, while the other half (the control group) continued their normal physical activity level. At the end of the year-long study, those in the weightlifting group cut their risk of developing lymphedema by 35%. Weightlifting appeared to be an even more effective for women who had undergone very invasive surgery—the removal of five or more lymph nodes during surgery. These women saw their risk of lymphedema reduced by 70%.

The second trial involved breast cancer survivors who were already diagnosed with lymphedema. One of the participants was Corrie Roberts, 77, a breast cancer survivor who had never exercised before joining the PAL program. She had suffered with lymphedema in one arm for several years and had been told to avoid using it. “I was definitely not a believer in exercise before,” she said. “When I first saw some of the things they were going to have us do, like stretching on a ball, I said, ‘You’ve got to be kidding!’”

In the study, the weightlifting group participated in small-group, twice-weekly, 90-minute exercise classes for 13 weeks, during which they worked up to greater resistance and more repetitions. “We started participants on the lightest possible weights and increased them only when the patient exercised without any discomfort or swelling for several sessions,” said Joy Cohn, physical therapist and team leader for Lymphedema Services at Penn Therapy and Fitness – Good Shepherd Penn Partners. She added that “slow and safe” was the mantra for the PAL study. 

After completing this first portion, the participants continued twice-weekly unsupervised exercise at community-based fitness centers for the following 39 weeks. After several months on the program, the swelling in Roberts’s arm began to subside…. results that other participants shared. At the end of the study, 19 women in the control group experienced a worsening of their lymphedema that required treatment from a physical therapist compared with 9 in the treatment group.  

“This trial challenged the assumption and showed it was 180 degrees wrong,” said Angela DeMichele, MD, of Hematology-Oncology. “Women fear lymphedema coming. Now they can be empowered to fight and prevent it. . . to get their lives back.”

“There are so many things we were told we couldn’t do and when you’re told not to, you don’t even try. When I found that I could do things, it lifted my spirits.” - A 10-year survivor with lymphedema

“It changed my whole feeling about exercise,” Roberts said. Now, when she doesn’t exercise, she gets a tight feeling in her arm and the arm swells up again. “If I miss a few sessions, my body tells me about it,” she joked.

Lorita Grant, MPH, MSW, project manager for the Center for Clinical Epidemiology and Biostatistics, saw this turnaround attitude in many of the PAL participants. “In the beginning, some women were cautious or even scared to lift weights because they had been told by their doctors not to.” By the end of the study, though, many had experienced a complete reversal in their thinking.

“There are so many things we were told we couldn’t do and when you’re told not to, you don’t even try,” said a 10-year survivor with lymphedema. “When I found that I could do things, it lifted my spirits.”

Said another, “It puts you back to where you were before you had the cancer.”

Caring for the Whole Person

Although the positive connection between lifting weights and preventing lymphedema is recent, the benefits of exercise for patients in general have been gaining momentum over the years. Schmitz said that, in 1955, when President Eisenhower suffered a myocardial infarction, he stayed in bed three weeks and even then his cardiologist was criticized for getting him out of bed too soon. Twenty years later, research showed that getting these patients out of bed as soon as possible led to a faster recovery. The same turnaround occurred with patients with back pain. By the 1990s, “we started to recognize that the advice to stay in bed was wrong.”

Schmitz used this same line of reasoning for helping breast cancer patients. “As an integrative physiologist, I’m interested in the whole body, not just the effect of a specific disease. A woman with breast cancer still has lungs, a heart and other organs,” she said. “Even when you have cancer, you still have millions of healthy cells, and they require exercise to stay healthy.   

Today, 90% of breast cancer patients live more than five years. “Breast cancer has essentially become a chronic disease and we need to begin managing it that way.” Kathryn Schmitz, PhD, MPH

“Years ago, the women who survived breast cancer were just happy to be alive, so they were not necessarily focusing on quality-of-life issues,” she continued. Today, 90% of breast cancer patients live more than five years. “Breast cancer has essentially become a chronic disease and we need to begin managing it that way.”

Schmitz believes the next step in breast cancer care will be to incorporate exercise into an interdisciplinary plan for breast cancer patients that would also include nutritional and psychological support, occupational therapy, and physical therapy. She imagines a program much like that in place for cardiac patients, where breast cancer patients would start exercise and physical therapy under hospital supervision and, once stabilized, continue their routine at a community-based fitness center like the YMCA.

“Penn would be the perfect place to pilot such a program,” said Schmitz, citing an infrastructure that includes the clinical oncology department, the physical therapy department, and the Clinical and Translational Research Center, a group that provides support for research studies.

“We don’t release cardiac patients from the hospital and say, ‘Well, you’re on your own. Good luck figuring out the right diet and exercise plan to prevent another heart attack,’” she said, “but it’s exactly what we do to breast cancer patients.” Now that the results of the PAL study having been published in JAMA and The New England Journal of Medicine, Schmitz is more hopeful than ever that women will get the resources they need to improve their lives post-surgery.