Breast cancer treatment, although effective for many patients, carries with it a physical, mental, and emotional toll that can substantially impact a patient's quality of life. Often, treatment for breast cancer can reduce physical strength as well as lung capacity, resulting in a decreased motivation and ability to engage in physical activity (In Vivo 2009;23(5):867-871, Breast Care (Basel) 2013;8(5):330-334).
Many women who undergo treatment for breast cancer and subsequently enter remission may experience depression and a period of uncertainty, especially in regard to the fear of disease recurrence (Eur J Oncol Nurs 2015;19(2):113-119). In this sense, the use of the term “cancer-related weakness” may refer to these patients' loss of strength encompassing the physical, mental, and emotional domains.
Importance of Physical Activity Post-Cancer
Considering physical activity is essential for improving physical, mental, and emotional fortitude, it would rationally follow to recommend exercise to patients who are experiencing a cancer-related weakness. Unfortunately, the physical activity recommendations for breast cancer survivors are fairly conservative in nature and generally focused on what should be avoided more than what should be included (Exerc Sport Sci Rev 2011;38(1):17-24). This advice is highly restrictive and further contributes to breast cancer survivors' feelings of weakness rather than that of empowerment.
Following lymph node removal, breast cancer patients are currently recommended against participating in overly strenuous activity in order to avoid lymphedema (Contemp Clin Trials 2009;30(3):233-245). Some women, however, have challenged the widely held belief that lymphedema represents a contraindication to physical activity (CMAJ 1996;155(7):969-971).
The fact remains that physical exercise directly and indirectly impacts the metabolism and excretion of female hormones, which research has consistently shown to be associated with a lower risk for cancer, as well as stress and depression (CMAJ 2017;21;189(7):E268-E274, Cancer Epidemiol Biomarkers Prev 2009;18(1):87-95, Prim Care Companion J Clin Psychiatry 2004;6(3):104-111).
Dragon Boat Racing
Dragon boat racing is an ancient Chinese ritual that originated approximately 2,000 years ago. Reportedly, participants in this sport raced dragon boats from the north of China, often referred to as “the region of death,” to the south of China, “the realm of life.” (Evid Based Complement Alternat Med 2012;2012:167651). Modern dragon boat racing has emerged as a popular sport among breast cancer survivors as a means for increasing physical strength, improving mental and emotional wellness, and helping survivors fight the feelings of isolation often experienced following breast cancer (BMC Complement Altern Med 2013;13:205).
Typically, each dragon boat holds approximately 22 paddlers, all of whom must paddle in unison to develop speed in the water. As a cancer-related physical and emotional therapy, dragon boat racing is an important health-building activity in which thousands of breast cancer patients participate in worldwide.
Ingrid Morris, a breast cancer survivor involved with the New Jersey Dragon Boat Club in Parsippany, first heard of dragon boat racing after seeing a flyer in her plastic surgeon's office. The flyer described the activity and its potential effects on improving physical strength following cancer treatment. “Because I'm a cancer survivor,” said Morris, “I wasn't physically active as I used to be. I didn't feel like I could do anything.” After getting the OK from her doctor, Morris signed up to join a team practice.
At the first dragon boat practice, she immediately felt the sense of comradery and team support. “I don't know about other people, but I was in love the first time in the boat,” commented Morris. In addition, the physical activity she was able to achieve convinced her this activity was going to be a long-term complementary therapy for her post-cancer care. During practice, Morris was advised to keep at her own pace, taking the pressure off her to exhibit similar performance to that of the more experienced.
“When I talk about dragon boat racing to anybody,” Morris said, “I tell them it's ‘therapy on the water.’” Although races are structured and every participant has an end goal in mind, practices are generally less restrictive in terms of the type of paddling that can be performed. “When we go out to paddle, we decide what type of day it's going to be,” said Morris. “Maybe we're going to talk, maybe it's going to be a leisurely paddle, maybe we want to enjoy the scenery on the lake, but we're moving at the same time.” This movement, according to Morris, has been essential in helping her experience an improvement in her emotional, mental, and physical strength.
Although her physical change wasn't immediate, Morris noticed a significant shift in her mental well-being. According to Morris, she felt the emotional benefits from the entire support team at the first practice. “My support [in dragon boat racing] is not just cancer-based support,” she noted, “it's support from every other area. You can find somebody in the team to relate to on every level.” The feeling of community is perhaps one of the most substantial contributors to cancer patients' ability to generate much-needed emotional and mental strength.
Following her husband's sudden death in an automobile accident, Morris' team was there for her. “I wouldn't have had that support if I wasn't on the team,” she stated. “You find yourself intertwined with people you would never have met. Although it's unfortunate that cancer brought you together, when you go you can find someone with whom you can relate.” Morris later met someone on her team who also lost her husband in a car accident. “The strength of us dealing with cancer also helped with those other things that came along.”
Lesley Andrews, Director of Pathways Team SOS-NJ dragon boat team, noted that, although it is a sport, its primary foundation is that of improving physical and emotional health. “There's some competitiveness to it,” she said, “but it's really for exercise.”
Previous research has demonstrated that dragon boat racing actually improved the physical and psychological health of breast cancer survivors, instead of placing them at risk for post-therapy complications (CMAJ 1998;159:376-378). In response, numerous dragon boating clubs began developing all across the country and around the world, dedicated to women with breast cancer to improve their strength and overall well-being. “This [exercise] is working to break the myth that physical activity is harmful after breast cancer surgery.”
According to Lesley, dragon boating extends beyond providing an outlet for physical activity. “You go through treatment and you're so traumatized and scared,” said Lesley, “and when you're done, everyone's happy. But there's post-traumatic stress that is common among survivors.” At Pathways SOS, women can come together and have a support system that's been there and is able to provide true understanding around what each woman has been through. This provides much-needed emotional support that many breast cancer survivors can't find anywhere else and that many are seeking when they arrive at their first boating practice.
Physical weakness is a common complaint among patients treated for breast cancer, with many patients becoming limited in the types of mobility exercises they can perform. This further reduces quality of life and may contribute to the decline in immune function as well as rise in depressive symptoms (Clin Sports Med 2007;26(3):311-319, Prim Care Companion J Clin Psychiatry 2004;6(3):104-111).
A randomized trial currently under way with the Kessler Institute for Rehabilitation in collaboration with Memorial Sloan Kettering Cancer Center is working toward discovering how mental energy and concentration can help improve hand grip strength and cancer-related fatigue in female patients who were previously treated for breast cancer.
“This study is kind of new in the area of oncology,” said Guang Yue, PhD, and Didier Allexandre, PhD, of the Kessler Foundation. “It's geared toward trying to remedy the long-term effects of cancer.” According to the researchers, one of the study's goals is to determine if there are other factors that play a role in the development of weakness related to cancer therapy.
According to the investigators, the study's findings may hold potential relevance in other therapeutic areas. “The findings of this trial can be readily incorporated into the field of therapy, not only [with] cancer patients who have weakness, but in others [with] cardiovascular disease, stroke, or who are generally weak or frail. Hopefully, this trial will demonstrate how clinicians can help patients increase their muscle strength.”
So far, the findings of this trial have been generally positive and will hopefully drive the change in the exercise recommendations of breast cancer patients. “There's been a notion for a long time that many patients are at risk for lymphedema if they do arm exercises,” explained Yue and Allexandre, “This will help remove a stigma around exercising and will help show the population the benefit of physical activity.”
Regardless of the approach or type of exercise, whether it be dragon boat racing, running, cycling, or any other upper body exercise, the investigators believe “the benefits of exercise are something that cancer survivors need to be more aware of” in order to improve post-therapeutic care.
Brandon May is a contributing writer.