THERAPEUTIC EXERCISES FOR FEMALE BREAST CANCER SURVIVORS; ASSESSMENT OF CARDIOPULMONARY, ANTHROPOMETRIC AND QUALITY OF LIFE OUTCOMES

CHAPTER ONE

INTRODUCTION

1.1       BACKGROUND TO THE STUDY

Cancer is a group of diseases characterized by uncontrolled cell division leading to growth of abnormal tissue (Stephan, 2011). The two main characteristics are uncontrolled growth of the cells in the human body and the ability of these cells to migrate from the original site and spread to distant sites (metastasis). If the spread is not controlled, cancer can result in death. Breast Cancer (BC) is a malignant growth that begins from the cells of the breast (Stephan, 2011). It is increasingly considered to be not one disease, but a group of diseases distinguished by different molecular subtypes, risk factors, clinical behaviours and responses to treatment [American Cancer Society (ACS), 2013].

Breast Cancer is the commonest cancer affecting women in Nigeria with a steady increase in prevalence over the years (Adebamowo and Ajayi, 2000; Adetifa, 2009). According to global statistics on cancer, BC is the most frequently diagnosed cancer among women worldwide and the leading cause of cancer death among females, accounting for 23% of the total cancer cases and 14% of the cancer deaths (Jemal et  al., 2011). It is a prevalent disease that requires intense and prolonged treatment (ACS, 2005). Surgery to remove the tumor, especially when diagnosed early is usually the first line of management. Adjuncts to surgery include the use of chemotherapy, radiation therapy, hormone therapy, physiotherapy, and targeted or biological therapy (ACS, 2013).

 There has been improvement in survival rate of individuals with BC over the past 25 years in the Western countries resulting in a substantial number of BC survivors (ACS, 2012). In the United States of America, BC survivors are estimated to exceed 12 million and 68% of individuals diagnosed with cancer now live more than 5 years (ACS, 2012). This improvement in survival rate is attributed to early detection of the disease and improvement in cancer care (Berry et al., 2005; Jemal et al., 2011). In Nigeria, survival rate is still very low due to late detection of the disease and poor treatment compliance (Adesunkanmi et al., 2006). Increasingly, cancer care is being directed toward developing interventions to improve overall quality of life (QoL) as well as longevity (Courneya et al., 2003; Sternfeld et al., 2009). Therapeutic exercise has consistently been identified as a central element of rehabilitation for many chronic diseases and has been successful in improving QoL and reducing allcause mortality (McNeely et al., 2006). Observational evidence suggests that moderate-intensity levels of aerobic exercise may reduce the risk of death from BC and therefore may prove to be a valuable intervention to improve not only QoL but overall survival (Holmes et al., 2005).

Marshall et al. (2009) reported that it took men between 92 and 102 steps per minute to reach moderate-intensity aerobic exercise while the range was between 91 and 115 steps per minute for women. These data support a general recommendation of walking at more than 100 steps per minute on level terrain to meet the minimum of the moderate-intensity aerobic exercise guideline. Because health benefits can be achieved with bouts of exercise lasting at least 10 minutes, a useful starting point for an individual is to accumulate 1,000 steps in 10 minutes, before building up to 3,000 steps in 30 minutes (American College of Sports Medicine, 2006). Stretching exercise is a form of therapeutic exercise in which a specific skeletal muscle (or muscle group) is deliberately elongated, often by abduction from the torso, in order to improve the muscle’s felt elasticity and reaffirm comfortable muscle tone (Weerapong et al., 2004). It results in increased muscle control and flexibility as well as increased range of motion of the joints of the body (Weerapong et al., 2004). It is common for athletes to stretch before and after exercise in order to reduce injury and increase performance (Yessis, 2006). Stretching can also strengthen muscles (Weerapong et al., 2004).

Cardiopulmonary capacity may be compromised in BC survivors because of the pathology of the disease, therapeutic regimens, weight gain and inactivity secondary to treatment (Brockstein et al., 2000; Gianni et al., 2001; Courneya et al., 2003; Jones et al., 2010). In some studies, it was observed that cardiopulmonary fitness was approximately 30% below that of age-matched sedentary healthy women up to three years following the completion of adjuvant therapy (Jones et al., 2007; Mackey et al., 2009). The precise causes of poor cardiopulmonary fitness are not known but are likely to be a consequence of direct cytotoxic therapy-associated injury to the cardiovascular system together with lifestyle perturbations (e.g., deconditioning and weight gain) (Jones et al., 2010). This reduction in cardiopulmonary capacity may lead to reductions in QoL and premature death (Courneya et al., 2003). Emerging research evidence indicates that poor cardiopulmonary fitness may be of central importance for certain adverse late effects of the disease including impaired left ventricular ejection fraction, elevated cardiovascular disease (CVD) risk profile, poor QoL, and fatigue following the completion of adjuvant therapy for operable BC (Herroro et al., 2006; Jones et al., 2007). Again, weight gain and obesity are common occurrences in women diagnosed with BC (Demark-Wahnefried et al., 2001; McInnes and Knobf, 2001) and increasing body mass index (BMI) is a risk factor for the development of new cases of BC and also affects survival in women who have already been diagnosed with BC (McTiernan, 2006; Protani et al., 2010). Gain in weight usually ranges from 2.0 to 6.0 kg during the first year of diagnosis (Irwin et al., 2003). Multiple reasons for this post-diagnosis weight gain in BC survivors have been suggested and they include receiving chemotherapy, infertility following treatment after diagnosis, decreased physical activity, and increased total caloric intake (Irwin et al., 2003; McTiernan, 2006). Both weight gain and obesity adversely increase the risk for cardiovascular disease, hypertension, and diabetes (Calle et al., 1999; Kopelman, 2000), conditions for which women who have been diagnosed with BC are at increased risk (Aziz, 2002).

Studies evaluating the effects of different types of therapeutic exercises on cardiopulmonary, anthropometric and QoL parameters in BC survivors are few and most of them have been carried out in the western countries. This study was therefore designed to determine the effects of aerobic and/or stretching exercises on cardiopulmonary, anthropometric and QoL parameters in BC survivors in a Nigerian population.

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