Carter et al
10.1177/1534735403251168
Carter
Prescriptive
et al Exercise Intervention After Bilateral Mastectomies ARTICLE
A Case Study: Prescriptive Exercise Intervention
After Bilateral Mastectomies
Susan D. Carter, MD, Scott N. Drum, MS, Reid Hayward, PhD, and Carole M. Schneider, PhD
Exercise for cancer patients is gaining support. In the cur-
rent case study, a female breast cancer patient was diagnosed
with breast cancer at the age of 29 years; she underwent a left
modified radical mastectomy. She developed cancer again
in the opposite breast at the age of 57 years and had a right
modified radical mastectomy. After the second mastectomy
(the right breast), the patient received chemotherapy and ra-
diation. Following her cancer treatments, she participated
in an exercise intervention for 6 months at the University of
Northern Colorado’s Rocky Mountain Cancer Rehabilita-
tion Institute. A 6-month reassessment showed that she in-
creased her muscular strength and cardiovascular function
in addition to attenuating her cancer-related fatigue and de-
pression. It is recommended that health professionals work
together to ensure that a collaborative effort is undertaken
to increase functional work capacity that will significantly
improve patients’ quality of life.
Keywords: cancer; exercise; prescriptive; rehabilitation; mastec-
tomies; case study
A 59-year-old white female (gravida1 para1) is currently
attending cancer rehabilitation exercise training ses-
sions at the Rocky Mountain Cancer Rehabilitation
Institute (RMCRI). Prior to her beginning cancer
rehabilitation exercise sessions, the patient under-
went an initial exercise assessment, which was
repeated following a 6-month exercise intervention.
Comparative results from the initial to the follow-up
exercise reassessment revealed improvements in phys-
ical and emotional functioning. The patient’s level of
cancer-treatment-related fatigue decreased as her
physical fitness improved. These results will be dis-
cussed later.
The patient’s cancer history is as follows. In 1971,
she was diagnosed with an “infiltrating carcinoma”
(stage and grade unknown) in the left breast. At the
age of 29 years, she had a left modified radical mastec-
tomy. Following the mastectomy, she had no radiation,
chemotherapy, or other adjuvant therapy.
The patient had numerous mammograms through-
out the 1980s and early 1990s. The mammograms
DOI: 10.1177/1534735403251168
34
showed microcalcifications but no abnormalities sug-
gestive of malignancy. The patient, at 57 years of age,
completed a right mammogram on February 13, 1998.
The mammogram indicated that previously observed
microcalcifications had increased in number but
remained benign in morphology. A 1-year follow-up
was recommended. In September of 1998, she felt a
pea-sized mass in her remaining right breast. Her pri-
mary care physician described a large palpable mass in
her right lateral breast, and she was sent for radio-
graphic evaluation. An ultrasound of the breast
showed an ill-defined suspicious hypoechoic solid
mass measuring 1.4 cm (length) × 0.8 cm (depth) × 1.2
cm (width) at the 8:30 position of the right breast. Fol-
lowing the ultrasound, a mammogram showed 2
groups of indeterminate calcifications in the area, sus-
picious for malignancy. Surgical consultation was rec-
ommended for biopsy of the abnormalities.
On October 15, 1998, the patient underwent a right
breast biopsy with a frozen section positive for infiltrat-
ing ductal carcinoma. An immediate mastectomy was
performed as had been discussed preoperatively.
Modified radical mastectomy and axillary dissection
was performed.
The final pathology report confirmed that the
excised breast tissue biopsy+ contained a 2.8-cm infil-
trating ductal carcinoma, moderately differentiated
along with intraductal carcinoma comprising 10% of
the total tumor mass. The right mastectomy speci-
men showed focal residual infiltrating ductal carci-
noma, intraductal carcinoma, atypical ductal hyper-
plasia, dense fibrosis, and numerous benign cysts.
The nipple was positive for carcinoma; the margins
were negative. Twelve of 18 axillary nodes were posi-
tive for metastatic carcinoma. The clinical and patho-
logical evaluation staged the patient at a IIB
(T2N1M0) infiltrating ductal carcinoma of the right
SDC is at the Regional Breast Center of Northern Colorado,
Greeley, Colorado. SND, RH, and CMS are at the University of
Northern Colorado, Greeley, Colorado.
Correspondence: Carole M. Schneider, PhD, Rocky Mountain
Cancer Rehabilitation Institute, Department of Exercise Science,
University of Northern Colorado, 2590 Gunter Hall, Greeley, CO
80639. E-mail: carole.schneider@unco.edu.
INTEGRATIVE CANCER THERAPIES 2(1); 2003 pp. 34-38
 Prescriptive Exercise Intervention After Bilateral Mastectomies
breast. Immunohistochemistry on the tumor showed
estrogen receptor positive, progesterone receptor
negative, and HER-2-neu positive.
The patient had an uneventful recovery period fol-
lowing the right mastectomy. A CAT scan of the chest,
abdomen, and pelvis and a bone scan in November of
1998 were negative for distant metastatic disease. After-
ward, she received systemic chemotherapy with 4 cycles
of Cytoxan and Adriamycin given mid-November
(1998) through mid-February (1999). The patient
went on to receive high-dose chemotherapy with stem
cell rescue. Thiotepa, Cytoxan, carboplatin, and
etoposide were utilized. Treatment was completed in
April of 1999. The 2-month postchemotherapy labora-
tory values were clinically expected: white cell count at
9
3.1 (× 10 /L); hemoglobin and hematocrit at 11.6 (g/
dl) and 35(%), respectively; and platelet count at 101
(× 109/L).
When the patient recovered from chemotherapy,
she underwent radical radiation therapy to the chest
wall and regional lymph nodes to help decrease the
risk of disease recurrence. The physical examination
showed no suspicious masses or areas of irregularities
found on either chest wall. Radiation therapy began in
July of 1999 and continued for 6 weeks.
Pertinent past medical history reveals that the
patient has adult-onset diabetes mellitus and
hypothyroidism. Past surgical history includes remote
partial thyroidectomy and tonsillectomy. Current
medications include Glucophage, tamoxifen, ferrous
sulfate, Zoloft, and Claritin. Social history indicates
that the patient denies alcohol and smoking, is mar-
ried, and has 2 grown children (1 adopted). Review of
systems revealed pain and decreased motor activity in
the left shoulder since December of 1999. Radiologic
workup included a negative bone scan and an
arthrogram. On May 19, 2000, the patient was diag-
nosed with adhesive capsulitis. Subsequently, the
patient underwent left shoulder surgery for release of
adhesions.
With the above cancer history and the fact that the
patient was experiencing cancer-treatment-related
fatigue, it was recommended by her oncologist that
she undergo cancer rehabilitation exercise sessions at
RMCRI.
Literature Review on Exercise
in Cancer Rehabilitation
In support of cancer rehabilitation therapy, studies
illustrate that exercise has been shown to decrease
cancer fatigue and other symptoms.
Dimeo et al1 concluded that an exercise program
that focuses on aerobic activity should be prescribed as
therapy for primary fatigue in cancer patients. The
INTEGRATIVE CANCER THERAPIES 2(1); 2003
researchers underscored the importance of precisely
defined intensity, duration, and frequency of exercise
for best results. Another group of researchers, Segal
et al,2 found that physical exercise can blunt some of
the negative side effects during breast cancer treat-
ment. These researchers randomized 123 women with
stages I and II breast cancer into 1 of 3 groups: usual
care (control group), self-directed exercise, or super-
vised exercise. They found improved physical func-
tioning in the exercise groups compared to the con-
trol group.
Other researchers support exercise therapy pre-
scribed during cancer treatment. Mock et al3 studied
the effects of exercise on fatigue, physical functioning,
and emotional distress in breast cancer patients dur-
ing radiation therapy. They found that an individual-
ized, self-paced, home-based walking program main-
tained throughout cancer treatment helped to
manage symptoms and increased physical functioning
during radiation therapy compared to the usual care
group. The exercise or home-based walking group
scored significantly better in relation to symptom
intensity, particularly in relation to fatigue levels, anxi-
ety, and difficulty sleeping compared to the usual care
group. Dimeo et al4 observed a group of cancer
patients receiving high-dose chemotherapy followed
by peripheral blood stem cell transplantation (n = 27)
during an in-hospital exercise program. The program
consisted of supine biking on an ergometer, which fol-
lowed an interval-training pattern for 30 minutes
daily. A control group (n = 32) did not train. Overall,
the researchers concluded that aerobic exercise
decreased fatigue and improved psychological distress
in cancer patients receiving chemotherapy versus the
nontraining control group.
In conjunction with the above studies, RMCRI
researchers have found similar results. Bentz et al5
measured physiological parameters (cardiopulmon-
ary, strength and endurance, and flexibility) in cancer
patients. Sixteen patients volunteered for the study, of
which 5 had surgery only and 11 had received adjuvant
therapy (chemotherapy and/or radiation treatment).
The results indicated that irrespective of cancer treat-
ment, the patients improved significantly, which
emphasized the need for exercise intervention to
improve the recovery of cancer patients. The research-
ers also determined that based on the length of time
posttherapy (surgery, chemotherapy, or radiation),
patients that were the furthest out from treatment
demonstrated decreased total body fitness. Therefore,
there is a need for exercise specialists to direct the
development of scientific and educationally sound
exercise programs close to diagnosis to augment the
quality of life of cancer patients.
35
 Carter et al
6
Schneider et al investigated prescriptive exercise
rehabilitation adaptations in cancer patients. Twelve
patients from RMCRI were referred to and volun-
teered for the study. Measurements included cardio-
vascular endurance, muscle strength and endurance,
and range of motion parameters assessed preinter-
vention and postintervention. The 6-month interven-
tion consisted of a carefully designed and imple-
mented exercise program that was unique to each
patient’s prescription goals. The patients showed an
increase in all fitness parameters observed: cardiovas-
cular endurance (+32.7%), muscle strength (+1.5%),
muscular endurance (+52.9%), and upper (+1.2%)
and lower (+0.8%) body range of motion. Fatigue was
shown to have decreased by 16.7%. The researchers
stated that specific exercises positively influenced the
fatigue status of cancer patients by enhancing their
physiological and psychological well-being.
Another study by Dennehy et al7 determined the
effects of prescriptive exercise intervention on cancer-
treatment-related symptoms. The RMCRI researchers
found that the precise use of exercise prescription has
positive physiological with concurrent psychological
benefits. Moreover, prescriptive exercise intervention
appeared to help reverse cancer-treatment-related
fatigue. Therefore, medical oncologists, radiologists,
surgeons, and exercise physiologists need to collabo-
rate to provide therapies to decrease treatment-
related symptoms and to improve recovery for cancer
patients.
Dennehy et al8 investigated the value of prescrip-
tive, individualized exercise intervention in cancer
patients undergoing chemotherapy and radiation.
Twenty patients were followed for 52 weeks and under-
went prephysiological and prepsychological assess-
ments followed by postexercise reassessments. The
results indicated that the exercise intervention
improved pulmonary function (+2.8%), duration of
aerobic activity (+73.6%), muscular strength
(+124%), and muscular endurance (+134%). These
data indicate the positive effects of prescriptive exer-
cise intervention during and following chemotherapy
and radiation on the recovery process of cancer
patients by decreasing cancer-treatment-related symp-
toms and improving patient quality of life.
Exercise Intervention
In regard to the current case study, the patient
underwent an initial exercise assessment 6½ months
following radiation therapy on May 1, 2000, with a sub-
sequent 6-month prescriptive exercise intervention.
The exercise intervention consisted of a carefully
36
designed exercise prescription, which called for 2 to 3
exercise sessions per week performed at RMCRI. Each
session gradually progressed to approximately 1 hour
and contained a warm-up phase followed by stretching
exercises. The patient used either a stationary bicycle
or walked on a treadmill, gradually working up to
more than 30 minutes of continuous aerobic exercise
by May 16, 2000. The goal of this whole-body work
was to increase her energy level and decrease her
treatment-related fatigue. In addition, the patient
began to perform light strength-training exercises
that consisted of biceps curl, triceps extension, arm
raises, wheel range of motion (ROM), and rope ROM
exercises. The following session, the patient per-
formed the usual warm-up, stretching, and aerobic
exercises followed by lower extremity strength train-
ing consisting of wall squats with a thera-band ball, leg
adductor exercises with tubing, and gluteus maximus
exercises with tubing. This split routine of alternating
upper- and lower-body exercises lasted through May
17, 2000, at which time the patient’s routine excluded
upper-body exercises because of upper-extremity dis-
comfort in the left shoulder. On May 19, 2000, the
patient completed a warm-up period, stretching
phase, aerobic exercise phase, and a lower-body
strength routine, which consisted of wall squats and
adductor tubing leg exercises. On May 25, 2000, the
patient had shoulder surgery for release of adhesions.
The exercise specialist began limited upper-body work
and stressed lower-body work. She gradually gained
ROM and strength in the left shoulder to more closely
balance with the right shoulder. In June 2000, the
patient was able to perform lateral pull-downs with
minimal weight, bench press with minimal weight,
abdominal crunches, and rope pulley for ROM along
with varying leg exercises.
On November 1, 2000, she completed her 6-month
exercise reassessment. Overall, the patient demon-
strated improvements (see Table 1) from the initial
assessment to the follow-up reassessment on cardiovas-
cular endurance, percentage body fat (skinfold cali-
pers), muscular strength and endurance, and flexibil-
ity and range of motion. Some of the muscular
strength and endurance parameters were not assessed
on the patient during the initial exercise assessment
due to upper-extremity pain and discomfort. How-
ever, during the 6-month follow-up exercise reassess-
ment, the patient was fully able to complete the mus-
cular strength and endurance testing, illustrating
improved muscular fitness. In addition, the patient
greatly improved on her rating of fatigue (Piper
Revised Fatigue Scale9) from her initial assessment to
INTEGRATIVE CANCER THERAPIES 2(1); 2003
 Prescriptive Exercise Intervention After Bilateral Mastectomies

Table 1. Assessment Parameters for the Preexercise and Postexercise Intervention

Premeasure Postmeasure Percentage Change
Cardiovascular
75% V& O2max (ml/kg/min) 10.31 21.00 +104.0
Time on treadmill (minutes) 1.01 6.00 +494.0
Resting heart rate (beats per minute) 99.00 91.00 –8.0
Systolic blood pressure (mm HG) 118.00 104.00 –12.0
FVC (% predicted) 103.00 99.00 –4.0
FVC1 (% predicted) 81.00 79.00 –2.5
Percentage body fat 23.74 19.73 –16.9
Muscular strength and endurance
Abdominal crunches (repetitions) 20.00 30.00 +50.0
Right handgrip (kg) 26.00 28.00 +7.7
Left handgrip (kg) 13.50 33.00 +144.0
Biceps curl, left (repetitions) NA 17 at 8.5 lbs
Biceps curl, right 40 at 5.0 lbs 20 at 8.5 lbs
Bench press NA 11 at 45 lbs
Lateral pull-down NA 15 at 45 lbs
Triceps press-down NA 7 at 30 lbs
Leg extension NA 25 at 45 lbs
Leg curl NA 25 at 45 lbs
Leg press NA 25 at 60 lbs
Shoulder press NA NA
Flexibility/range of motion
Sit and reach test (inches) 14.50 13.50 –6.9
Right shoulder reach 4.00 3.00 –25.0
Left shoulder reach NA NA NA
Right shoulder flexion (degrees) 180.00 180.00 0
Left shoulder flexion 180.00 180.00 0
Right shoulder extension 80.00 85.00 +6.3
Left shoulder extension 55.00 65.00 +18.2
Right shoulder abduction 180.00 180.00 0
Left shoulder abduction 130.00 180.00 +38.5
Right hip flexion 110.00 119.00 +8.2
Left hip flexion 110.00 110.00 0
Fatigue
Piper Fatigue Scale 5.01 1.32 –74.0
Depression
Beck Depression Scale 21.00 2.00 –90.5

FVC = forced vital capacity, FVC1 = forced vital capacity in 1.0 seconds, NA = not available (patient could not complete).

her 6-month reassessment along with a significantly
improved Beck Depression score. For both measures,
a lower score indicates an improved state.
Conclusion
It appears that a carefully constructed and imple-
mented exercise intervention, which includes gradual
progression for aerobic, strength, and ROM exercises,
is an effective means to improve a cancer patient’s
overall well-being and quality of life. The patient’s
fatigue score decreased as her cardiovascular and mus-
cular systems improved, as noted from the initial exer-
cise assessment to the 6-month reassessment. There-
fore, the continued well-being of the cancer patient
depends on realizing the need for an exercise inter-
vention to help restore the patient to a fully functional
state, even after the cancer has been ameliorated by
traditional means. Cancer exercise rehabilitation
holds the promise of improved quality of life for can-
cer patients.
References
1. Dimeo F, Rumberger BG, Keul J. Aerobic exercise as therapy
for cancer fatigue. Med Sci Sports Exerc. 1998;30:475-478.
2. Segal R, Evans W, Johnson D, et al. Structured exercise
improves physical functioning in women with stages I and II
breast cancer: results of a randomized controlled trial. J Clin
Oncology. 2001;19:657-665.
3. Mock V, Dow K, Meares C, et al. Effects of exercise on fatigue,
physical functioning, and emotional distress during radiation
therapy for breast cancer. Oncol Nurs Forum. 1997;24:991-1000.
4. Dimeo F, Stieglitz R, Novelli-Fischer U, Fetscher S, Keul J.
Effects of physical activity on the fatigue and psychologic status
of cancer patients during chemotherapy. Cancer. 1999;85:2273-
2277.

INTEGRATIVE CANCER THERAPIES 2(1); 2003 37

 Carter et al
5. Bentz A, Dennehy CA, Busing K, Carter SD, Schneider CM.
Physiological alterations with adjuvant cancer therapy. Med Sci
Sports Exerc. 1999;31(5):S363.
6. Schneider, CM, Stephens K, Bentz A, Quick K, Carter SD,
Dennehy CA. Prescriptive exercise rehabilitation adaptations
in cancer patients. Med Sci Sports Exerc. 2000;32(5):S234.
7. Dennehy CA, Carter SD, Schneider CM. Physiological mani-
festations of prescriptive exercise on cancer treatment-related
fatigue. The Physiologist. 2000;43(4):357.
38
8. Dennehy CA, Schneider CM, Carter SD, Bentz A, Stephens K,
Quick K. Exercise intervention for cancer-related fatigue. Res
Q Exer Sport. 2000;71(suppl 1):A-27.
9. Piper BF, Dibble SL, Dodd MJ, Weiss MC, Slaughter RE, Paul
SM. The revised Piper Fatigue Scale: psychometric evaluation
i n w o m en w i t h b r ea s t c a n c er. O n c o l N u rs F o r u m .
1998;25(4):677-684.
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