Exercise truly is medicine in cancer survivorship

If you follow my FB page (Yoga with Leona), you saw that I recently posted an awesome interview that Dr Leslie Waltke (of The Recovery Room) did with Dr Kathryn Schmitz on the importance of exercise in cancer survivorship. If you haven’t had a chance to watch it, please do (https://www.facebook.com/lesliewaltkept/videos/386294369484336). They are both brilliant and dynamic leaders in their fields, each working for many years in different aspects of exercise in cancer. Dr Waltke is a physical therapist with many years specializing in cancer rehabilitation, and creator of the best practices in cancer physical therapy, and teaches physical therapists and other medical specialists from around the world how to best work with cancer survivors. Dr Schmitz is an exercise physiologist, a leading researcher in exercise oncology, has directed many of the important scientific studies looking at the benefits of exercise in cancer prevention and cancer survivorship, and co-developed the guidelines that we now use to recommend exercise in cancer. So these 2 are powerhouses! And their experience and work are so beautifully complementary to one another.

Exercise seems so simple that it is hard to believe that it is as powerful as it is. The benefits of exercise in cancer survivors are truly staggering. Not only does exercise help us feel better (improving fatigue, overall quality of life, sleep, lymphedema, physical function, depression and anxiety), but it also has been proven to reduce the chance of our breast cancer coming back AND to reduce the chance of us dying from breast cancer (for those who meet the recommended 150 minutes per week of moderate intensity exercise vs those who do not exercise)! Read that again. And those reductions in risk of recurrence and death are not small. Different studies report slightly different numbers, but the reductions are generally in the range of 40-60%! That is a huge difference, and is as much or even more than the benefit associated with some of our traditional treatments. I’ll write another blog about the proposed mechanisms by which exercise has these amazing benefits (otherwise you’d be here all day reading just this one!).

As I always say, we can’t control everything that happens in our cancer journey. And it is really important to learn to let go of our need for control so that we can establish some peace. However, there are some things that we can control. And how we move our bodies is one of them. No matter where we are in our cancer journey, we can work on moving our bodies, and try to strive for that goal of 150-300 minutes of moderate intensity exercise per week. If you do more vigorous forms of exercise as well, the minutes required are lower. How do you define “moderate intensity”? They give a perfect and simple guide in the video, which is that moderate intensity is any exercise that gets you working hard enough that you can still talk, but you couldn’t sing or speak in long, complicated sentences. In other words, your body should be taxed enough that it affects your breath, but not so much that you can’t really talk at all (that would be moving into the “vigorous” realm). So whether that means brisk walking, dancing, tennis, or vigorous yoga, get those minutes in!

Importantly, Dr Waltke and Dr Schmitz talk about the fact that what is moderate intensity for one person might not be moderate intensity for another, so we all need to evaluate the level of our exercise for our specific situation. AND, moderate intensity may look very different even for the same individual, at different times through their treatment. For example, the week of your chemotherapy, just getting up and walking to the mailbox or doing a load of laundry may constitute moderate intensity, while 2 weeks later when you have recovered a bit, you might need to walk all the way around the block one or a few times to get into that moderate range. So it is important to know that this will be a moving target, and that is ok. Also know that sometimes you may need to exercise in shorter periods, for example just 5-10 minutes several times per day, rather than 30-60 minutes all at once. This is a place where yoga philosophy and training ourselves to really tune in to our bodies, to study ourselves, to be flexible and compassionate with ourselves, and to use our energy rightly is so important. We can’t be so attached to some specific exercise goal (ie I must walk 2 miles 3 times a week or whatever) that we wind up hurting ourselves, and taking steps backward. So really listen to your body, adjust as needed, and just do your best. Learn to push on days when you feel up to it, and to back off on days when you need to. Eventually you will build strength and the exercise will get easier and easier for you. You will feel empowered, and you will also be much more in tune with yourself and your health.

Another very interesting challenge that they discuss is what to do for the person who really doesn’t like to exercise. First, they encourage us to explore lots of different types of exercise. There really are so many things we can do. From walking, to dancing, to swimming, weight lifting, yoga, aerobics, zumba, hiking, rowing, and walking your dog. Most people can find something they like. But if you truly can’t, then just buckle down and do it anyway! We all have to do some things we don’t like, right? But we do them anyway because we know they are important or good for us. I mean, do you really like brushing or flossing your teeth? But you do it anyway, right? Getting our exercise in truly is important, in so many ways. Aside from all of the benefits discussed above specific to cancer survivors, there is also extensive literature in the general population for the role of exercise in prevention and treatment of everything from heart health to blood sugar/diabetes, arthritis, and dementia. There are just so many reasons to get our bodies moving!

Please check out the website for the Exercise is Medicine/Moving through Cancer program for more information, great graphics, links, and references (https://www.exerciseismedicine.org/support_page.php/moving-through-cancer/).

Namaste friends

Yoga will optimize your coping strategies in cancer survivorship, greatly improving quality of life

If you’ve been following for a while, you’ve heard me say many times that yoga is SO much more than just the physical practices/exercises (asana). The full practice of yoga is a holistic mind-body practice for harmonizing our whole being, including guidance for thought patterns/behaviors, breathing practices, concentration, and meditation, along with the physical practices (click here for more info https://yogawithleona.com/2020/09/15/the-8-limbs-of-yoga-in-cancer-survivorship/). This whole mind-body program not only gets our physical bodies healthier, stronger, and more flexible, but also helps our minds to work with more clarity, balance, peace, and joy (and thereby less anxiety, tension, agitation, or confusion). How does it do this?? By training us in practices that not only tone our bodies, but that cultivate healthier mindsets, coping strategies, mental resilience, and tools to better manage our emotions. And just like anything, the more we practice all of these mind-body techniques, the better we get at them, and the more they become our baseline condition, making life and all of its challenges simpler and easier.

Let’s face it, cancer is the shits. I mean it. It is not easy. I recently learned that a cancer diagnosis is actually defined as a type of trauma in the DSM-5 (the book health care providers use to categorize mental disorders), and there is a whole literature on the traumatic experience of cancer. It literally rocks our worlds, threatens everything about our lives including our lives themselves, and puts us through innnumerable intense challenges of body and mind. I hear so many survivors (in active treatment or beyond) saying things like “Will I ever feel normal again?”, “Will this dark cloud hanging over me ever pass?”, “Why can’t I get back to my fun former self?”, “I can’t stop feeling sad and frustrated”, “My body is wrecked and I’m so down on myself”, and “Nobody around me understands”. But then, on the other end of the spectrum, some women seem to breeze through this awful experience, minimally affected, confident, active, and unscathed. So why the difference? Of course, there are clear differences in our bodies and how they handle treatment, and so some women suffer more severe side effects than others. Not to mention that our cancers are all different, so the treatments themselves vary as well. But some of this difference, I believe, comes from how we cope and the attitude that we bring to the table. From the lense through which we see this cancer experience. We all have different coping strategies that we have developed throughout our lives, from early childhood through adulthood, and all of our experiences along the way. These different patterns for how we cope and deal with stress have been studied extensively in cancer survivors, and have been shown to correlate with many outcomes, including overall quality of life, mood/depression/anxiety, fatigue, and even pain. Examples of different attitudes or coping strategies include: acceptance, positive refocusing, refocus on planning, positive reappraisal (attaching a positive meaning to a negative event in the context of personal growth), fighting spirit, catastrophizing, anxious preoccupation, helpless-hopelessness, rumination, and blame (self or others).

These coping strategies and attitudes, of course, are not fixed. They can be changed, but it takes some recognition and some effort. We have all developed the strategies and attitudes we have for a reason, likely related to trying to protect ourselves in some prior challenging situation. And in no way do I mean to suggest that our suffering is our own fault, for being the way that we are. I only mean to say that this is an area where we have some control over how our experience goes. We can learn to cultivate the healthier, more adaptive strategies and attitudes, and thereby help ourselves struggle less with the situation. For example, one can see how catastrophizing is one of the maladaptive strategies, and how it just leads to more anxiety and distress. Why would we want to keep doing that to ourselves, if we can see it and learn to change it? On the other hand, refocus on planning helps us to rationally consider what next steps we need to take to get through, giving us some sense of control and easing anxiety and fear of an unknown future. Similarly, acceptance (as opposed to ruminating on “why did this happen?” and struggling against things we cannot change, like the fact that we have this cancer diagnosis) brings a sense of peace and calm to our minds, allowing us to see with more clarity and less emotional reativity. You can go on and on, and investigate each quality and understand how it might have positive or negative impact on your state of mind, and your overall quality of life. Maybe take a few minutes looking at that list of coping strategies/attitudes and see if any of them sound like things that you commonly do in the face of stress or difficulty. Or specifically in the context of your cancer. Do you see them as helpful or harmful? Are there any that you would really like to down-regulate? Or any you’d like to get better at?

In the medical mental health world, we use something called Cognitive Behavioral Therapy (CBT) to help us identify and examine our thoughts/beliefs/attitudes, and then change them as needed to improve emotional regulation and optimize coping strategies. This type of therapy has been studied in breast cancer survivors, and found to help a number of things including sleep, fatigue, anxiety, relaxation, positive mood, and others. If you are really struggling, ask your Dr if you might be a candidate for a referral to a therapist to help you in this way.

In a prior blog introducing the idea of the 8 Limbs of Yoga, linked above, I describe an awesome TED talk in which a psychotherapist referred to yoga as “the original cognitive behavioral therapy”! Because just like in CBT in a therapist’s office, yoga helps us to look deeply and honestly at ourselves, to see how we react and how our minds and bodies respond to those reactions. Then yoga helps us by guiding us with ideas on more adaptive ways of seeing and thinking, and then asking us to practice those techniques over and over, until we begin to incorporate them. In doing so, yoga is truly a transformational practice. It not only improves our bodies and how they work, but with some effort and study, yoga can change the way our minds work, leaving us with healthier attitudes, thought patterns, habits, and coping mechanisms. Yoga trains us in some of the very things that CBT teaches, such as acceptance, positive reappraisal, trust, non-attachment, etc. This is why all of my yoga practices have a theme, an idea or mental practice to go along with the physical practice. And why I write so many blogs on such topics. Because I believe, especially for us cancer survivors, yoga’s ability to improve our minds may be even more important than the amazing benefits it carries for our bodies.

So yes, cancer sucks big time. That’s a fact. But we don’t have to let it suck the life, the fun, the love, and the joy out of us. With a little attention to our mindset and how we approach the experience, we can adjust our sails and traverse the suffering with so much more ease, minimizing side effects and optimizing our mood, quality of life, and overall experience. Why not give it a try?!


Breast cancer treatment is a pain in the armpit!

If you follow my FB page, you know I recently took about 6 days off from my yoga practice because I was traveling for my husband’s birthday. I often still practice when I travel, but for some reason on this trip, I just wanted it to be about us relaxing at the beach together, and I didn’t want to have to interrupt our time with my yoga practice. It felt great and we had a lovely time, and I actually wrote a short post on FB about how it is good, sometimes, to take a few days off for perspective and reflection on your practice.

Well, after we returned home, I remembered why I usually don’t take more than a day or two off from my practice. Ouch! I have felt, on and off since my mastectomy and full axillary node dissection, some strange nerve pains in the underarm, the side of my chest wall, and down into my upper inner arm. The pains range from a vague numb discomfort type sensation (like after your foot goes to sleep because you were sitting on it) to pins and needles, to sometimes a deep burning sensation like a hot poker is sticking into me, or even a very sharp searing/tearing sensation, like the muscle or skin is being ripped apart. The last one is really weird because I will be able to tell that I am clearly NOT overstretching anything or causing enough tension to result in that tearing sort of feeling. Sometimes it happens when I am sitting completely still! So clearly, these are all nerve sensations, related in some way to nerves that were damaged at surgery, maybe are trying to grow back, or to the development of neuromas (nerve overgrowths, in this case benign and related to trauma to the nerve). This syndrome is called Post Mastectomy Pain Syndrome (PMPS), and refers primarily to this nerve pain in the breast, chest wall, shoulderblade, underarm, and even down into the arm. But PMPS also often includes pain related to lymphedema, capsular contracture, shoulder dysfunction, or other downstream effects of breast surgery (mastectomy or lumpectomy), axillary node sampling, reconstruction, or radiation. Because it can occur with surgery other than mastectomy, it is sometimes called Post Breast Surgery Pain Syndrome instead.

Shockingly, PMPS occurs in as many as 50-60% of people who undergo these types of surgeries, so if you have it like me, you are in good company! Some things make it more likely, including full axillary node dissection (as opposed to sentinel node), implant reconstruction, and radiation. Interestingly, younger age, depression and anxiety, poor/passive coping strategies, lack of cognitive flexibility, and underlying other pain syndromes are also risk factors for PMPS. And protective factors, such as resilience (defined here as a person’s ability to maintain relatively stable, healthy levels of psychological and physical functioning even when exposed to highly disruptive events”) have been correlated with lower levels of PMPS. So how long does it last? To differentiate this from normal postsurgical healing, PMPS is defined as pain that persists beyond 3 months after surgery. Many women with PMPS will have slow improvement in pain over time, but a sizeable percentage will still have pain years later. In fact in one study of women reporting PMPS, nearly half of them still had symptoms at 9 years of follow up.

So for those of us who have this, we gotta learn how to minimize it so it doesn’t limit us or cause us to suffer any more than it has to! Fortunately we do have some control over how we deal with this.

As with most things in medicine, lots of different treatments have been studied, and some may work for some women and others better for others. As you may have guessed, physical exercise has been shown to improve outcomes, including reducing pain, improving function, and improving quality of life. It stretches the tissues, keeps shoulder alignment healthy, improves blood flow, and helps with scar tissue. This is why I think yoga helps me so much. If I stick to my regimen of regular yoga practice, it seems to me that I keep the tissues of my chest wall and underarm nice and mobile, stretched, soft, and elastic. If I don’t move my shoulder and chest wall enough, things seem to get stuck again, and wham! The pain comes back. I’ve been back from vacation for 4-5 days now, and back to my usual regimen of yoga, and the sharp searing pain I was having is basically gone. I need to remember this next time I think I’ll just skip stretching for days on end. As you know from my other blogs, yoga has specifically been studied in breast cancer survivors and shown to improve pain, physical function, mood, and quality of life (among other benefits). So yoga has got to be good for PMPS, and I am a perfect example.

Physical therapy, massage, and acupuncture have also been shown to be of benefit in some women. Medications are often used in severe cases, including nerve pain modulating medications, such as gabapentin. I saw one report of topical capsaicin being of some help. Psychological therapies, such as mindfulness based therapies, cognitive behavioral therapies, meditation, and hypnosis have also shown benefit. Interestingly, yoga incorporates many of these psychological strategies in our practices as well, so you get a double bonus benefit with yoga! And then finally, some surgical approaches and interventional procedures, such as nerve blocks, fat grafting, and targeted muscle reinnervation have been used in some refractory and severe cases.

So that may be waaay more than you ever wanted to know about post mastectomy pain. But since I occasionally suffer with it myself, I thought some of you might also be in the same boat. It is such a strange sensation. It helps me some just to know what it is, so that my fear response doesn’t kick in and start catastrophizing all of the horrible things that it might be. That being said, if you have pain that persists and/or worsens, talk to your Dr about whether you need any imaging, and especially about what options you might have for treatment. Because there are things that can help! And make sure you are moving your body. This is what helps me the most!

Namaste yogis