Strength Training During Cancer Treatment

Treatment costs muscle. Weeks of low activity, poor appetite, steroids, and hospital days all pull in the same direction, and the loss shows up as trouble on stairs, trouble carrying groceries, and trouble getting off a low couch.

Strength training pushes back, and the evidence supports doing it during treatment rather than waiting.

NCI reports that the 2018 American College of Sports Medicine roundtable found exercise training and testing generally safe for cancer survivors. The same review found that moderate aerobic training, resistance exercise, or both, during and after cancer treatment, can reduce anxiety, depressive symptoms, and fatigue while improving quality of life and physical function.

Fatigue is the biggest prize. NCI reports that more than 80 percent of people receiving chemotherapy or radiation experience fatigue, and that exercise, including walking, may help people feel better and have more energy during and after treatment.

One useful detail from NCI's summary of that roundtable: anxiety and depression did not improve with resistance training alone, but did improve when resistance training was combined with aerobic work. Lifting is part of the plan, not the whole plan.

The federal Physical Activity Guidelines for Americans set the standard for adults: muscle-strengthening activities of moderate or greater intensity, working all major muscle groups, on at least 2 days a week. That sits alongside 150 to 300 minutes a week of moderate aerobic activity.

The American Cancer Society says the same for survivors: strength work on 2 or more days a week, using hand weights, exercise bands, or bodyweight moves such as push-ups and squats. NCI's summary of the ACSM roundtable puts the practical dose at resistance training twice a week, plus about 30 minutes of aerobic exercise three times a week.

For anyone who cannot reach those numbers, the guidelines are explicit. Adults with chronic conditions should be as physically active as their abilities allow, should avoid inactivity, and should be under the care of a health care provider. Two short sessions a week is a real program.

Twenty to twenty-five minutes, twice a week, is enough to start.

Cover the main patterns rather than chasing individual muscles:

• Legs. Sit-to-stand from a chair, or a bodyweight squat to a box.
• Hips. Bridges on the floor, or a hip hinge holding a light weight.
• Push. Wall push-ups, or a band press.
• Pull. A band row, anchored to a door.
• Carry or core. A short walk holding a weight in one hand, or a plank on the knees.

Start with 1 or 2 sets of 8 to 12 repetitions of each. Stop each set with 2 or 3 repetitions still in the tank. Rest a minute or two between sets. If the last repetition looks different from the first, the set is over.

ACS advises beginning slowly, doing a few minutes of activity each day, and using short periods of exercise with frequent rest breaks. That structure fits chemotherapy weeks well: three 8-minute blocks across a day count.

Progress one variable at a time. Add a repetition, or a set, or a small amount of weight, and never two at once. On chemotherapy weeks, hold steady rather than progressing.

Bone. NCI notes that chemotherapy, steroids, hormone therapy, and radiation can all thin bone, and that radiation thins it in the treated area. ACS advises caution with heavy weights or exercises that put too much stress on bones if you have osteoporosis, cancer that has spread to the bone, arthritis, nerve damage, poor vision, poor balance, or weakness. This is the single most important thing to clear with your oncologist before you load a barbell. Ask directly whether you have any bone involvement.

Blood counts. No federal guideline names a platelet number that stops resistance training, and cancer centers use different internal cutoffs. Ask for yours, in numbers, and ask what to do on days between blood draws. Low neutrophils change where you train more than how hard. Anemia lowers your ceiling, so cut intensity rather than skipping the session.

Lines and ports. ACS is specific here: with a feeding tube or a central line in the chest, avoid pool, lake, and ocean water and other exposures that may cause infection, and do not do strength training that uses the muscles around the catheter, because that can dislodge it. Also ask your team which chest, shoulder, and overhead movements are allowed while a port site is healing, and how long that lasts.

Nerves and balance. ACS notes that numbness in the feet or balance problems raise fall risk, and suggests asking about devices that can help. It also advises staying away from uneven surfaces and exercising in a safe, well-lit place. In practice that favors seated and machine-based lifting, a wall or counter within reach, and bands over heavy free weights if your grip is unreliable.

The old advice was to spare the limb. That has changed.

NCI describes exercise as a natural pump for the lymph system that can improve the flow of lymph fluid, and notes that staying at a healthy weight helps keep lymphedema under control. NCI also reports the ACSM roundtable finding that exercise is safe for people with, or at risk of, breast cancer-related lymphedema, and that twice-weekly resistance training carries no increased lymphedema risk.

The conditions attached to that finding matter. Start light. Increase slowly. Get taught by someone trained, ideally a certified lymphedema therapist or a physical therapist with oncology experience. Wear compression as your therapist advises. Report new heaviness, tightness, or swelling rather than training through it.

This feels backwards on a bad week, so plan for it in advance.

NCI advises choosing the activities most important to you, doing them when your energy is highest, and limiting the ones that add to fatigue. Apply that to lifting: put your session on the best day of the cycle, not a fixed weekday.

Then set a floor. On low days do half the plan rather than none. One set instead of two, or the two easiest movements instead of five. Keeping the habit alive means you are not rebuilding from nothing when the cycle turns.

• Do I have any bone involvement or bone thinning that limits lifting?
• What are your cutoffs for platelets, neutrophils, and hemoglobin?
• Are there movement limits from my surgery, port, or line, and until when?
• Were lymph nodes removed, and am I at risk for lymphedema?
• Do I have neuropathy that should change how I train?
• Will you refer me to physical therapy or a cancer rehabilitation program?
• Are there weeks in my treatment schedule when I should back off?

Stop the session and call 911 or go to an emergency department for:

• Chest pain or pressure, pain spreading to the jaw or an arm, or an irregular heartbeat.
• Breathlessness that does not settle when you stop, or coughing up blood.
• Fainting, or a sudden severe headache, or new confusion or trouble speaking.
• Sudden weakness in the legs, or new trouble controlling your bladder or bowel.
• Bleeding that will not stop with steady pressure.
• A temperature of 100.4 °F (38.0 °C) or higher while you are on treatment. CDC treats a fever during chemotherapy as a medical emergency, because it may be the only sign of an infection your blood counts cannot fight.

Stop the session and call your care team the same day for:

• Dizziness or vision changes that pass once you rest.
• New bone pain, or pain in one spot that does not settle with rest.
• Sudden swelling, heaviness, or tightness in an arm or leg.
• New or worsening numbness or weakness in the hands or feet.
• Unusual bruising.

See Exercise During Cancer Treatment and Exercise After Cancer Treatment for the broader plan. Also useful: Neuropathy During Cancer Treatment, Getting Enough Protein During Cancer Treatment, Returning to Exercise After Cancer Surgery, and Balance and Fall Prevention After Cancer Treatment.

• Physical Activity and Cancer Fact Sheet, National Cancer Institute
• Prescribing Exercise as Cancer Treatment, National Cancer Institute
• Fatigue and Cancer Treatment, National Cancer Institute
• Lymphedema and Cancer Treatment, National Cancer Institute
• Late Effects of Cancer Treatment, National Cancer Institute
• Physical Activity Guidelines for Americans, 2nd edition (PDF), U.S. Department of Health and Human Services
• ACS Nutrition and Physical Activity Guideline for Cancer Survivors, American Cancer Society
• Physical Activity When You Have Cancer, American Cancer Society
• Fever and Cancer Treatment, Centers for Disease Control and Prevention