緩慢地漸進式舉重有助於淋巴水腫的乳癌存活者

作者：Laurie Barclay, MD  
出處：WebMD醫學新聞

　　August 12, 2009 — 根據8月13日新英格蘭醫學期刊(New England Journal of Medicine)中一篇隨機控制試驗結果，緩慢地漸進式舉重有助於淋巴水腫的乳癌存活者。
　　
　　賓州大學醫學院Abramson癌症中心臨床流行病學與生物統計中心的Kathryn H. Schmitz博士等人寫道，有乳癌相關淋巴水腫的婦女一般被禁止舉重，使她們無法獲得舉重對健康的幫助，包括增加骨密度。
　　
　　一項透過舉重控制運動的計畫可以增加患臂的物理強度，因而可以免於一般日常活動時的持續損傷。舉重對於乳癌存活者還有其他額外好處，包括控制體脂肪、改善功能性結果與骨骼健康。
　　
　　【舉重改善次級終點】
　　在本研究中，手臂有穩定型淋巴水腫的141名乳癌存活者，被隨機分派到接受每週兩次的漸進式舉重組，或控制組。當舉重時，參與者被要求穿著合身的壓縮衣物。主要研究終點為一年時手臂與手的腫脹變化，測量方法為上臂放入與未放入水中時的水容積改變。次級終點為淋巴水腫惡化發生率、淋巴水腫症狀發生次數與嚴重度、肌肉強度。
　　
　　11%的舉重組以及12%的控制組，手臂腫脹增加至少5%(累積發生率、1.00；95%信心區間為0.88 – 1.13)。
　　
　　相較於控制組，舉重組在自我報告之淋巴水腫症狀嚴重度(P = .03)與上半身和下半身強度(兩種比較之P值均 < .001)有較大的改善。此外，經認證的淋巴水腫專家確認，舉重組的淋巴水腫惡化發生率較低(14% vs 29%；P = .04)。舉重與任何嚴重不良反應無關。
　　
　　研究作者寫道，對於有淋巴水腫的乳癌存活者，緩慢地漸進式舉重對於手臂腫脹沒有顯著影響，因此可降低淋巴水腫惡化發生率、減少症狀、增加肌肉強度。本研究之結果減少了舉重會惡化有淋巴水腫之乳癌存活者手臂和手腫脹的顧慮。
　　
　　研究限制包括，雙盲不完整，評估惡化的治療師太多，可能有報告偏差。
　　
　　研究作者結論表示，治療而獲得相當程度的強度增加，且肌肉量沒有改變，表示該計畫聚焦在建立肌肉強度而不會造成肥胖，正是我們所希望的。需要後續研究以確認此介入方式的重要因素，以使其可以被有淋巴水腫的乳癌存活者妥善運用。這些發現支持緩慢地漸進式舉重計畫對於有淋巴水腫的乳癌存活者有潛在幫助的論點，不過要同時使用合適的壓縮衣物和密切監測手臂和手的腫脹。
　　
　　【不錯的結果 但需要更多研究】
　　編輯評論中，休士頓安德森癌症中心的Wendy Demark-Wahnefried博士形容此介入方式有不錯的結果，但是建議嚴謹的追蹤研究，包括詳細的費用分析和宣傳分析。
　　
　　Demark-Wahnefried博士寫道，Schmitz博士等人的報告，提供了乳癌病史且有淋巴水腫之婦女接受適當監督舉重訓練之相關安全性的有力證據。
　　
　　改善此類婦女之結果的綜合策略，應包括著眼於體重管理的飲食和運動介入方式，因為過重、肥胖與診斷後體重增加都是淋巴水腫、乳癌相關死亡的顯著風險因素。促進健康飲食、規律運動的多元介入方式(例如有氧運動和漸進式阻抗訓練)，以及其他生活型態改善(如少抽菸和少喝酒)都有助於罹患此一常見癌症的婦女改善整體健康和存活。
　　
　　國家癌症研究中心以及國家研究資源中心支持本研究。BSN Medical公司提供客製化壓縮衣物，而舉行舉重課程的體適能中心(包括以下地點：費城周邊的YMCA、Sisters in Shape健身中心、以及紐澤西Burlington郡的 Family YMCA)則提供研究參與者會員費折扣。研究作者宣告無相關財務關係。Demark-Wahnefried博士宣告她接受俄亥俄州立大學與賓州大學之強化生命精進中心(Livestrong Centers for Excellence)的顧問費用。

Slowly Progressive Weight Lifting May Be Helpful in Breast Cancer Survivors With Lymphedema

By Laurie Barclay, MD
Medscape Medical News

August 12, 2009 — Slowly progressive weight lifting may be helpful in breast cancer survivors with lymphedema, according to the results of a randomized controlled trial reported in the August 13 issue of the New England Journal of Medicine.

"Weight lifting has generally been proscribed for women with breast-cancer–related lymphedema, preventing them from obtaining the well-established health benefits of weight lifting, including increases in bone density," write Kathryn H. Schmitz, PhD, MPH, from the Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine and Abramson Cancer Center in Philadelphia, and colleagues.

"A program of controlled exercise through weight lifting may increase the physical-work capacity of the affected arm, thereby protecting it from injury sustained during common daily activities. Weight lifting offers additional benefits particularly relevant to breast-cancer survivors, including control of body fat and improved functional outcomes and bone health."

Weight-Lifting Improved Secondary Endpoints

In this study, 141 breast cancer survivors with stable lymphedema of the arm were randomly assigned to a group that received twice-weekly progressive weight lifting or to a control group. While weight lifting, participants were required to wear a well-fitted compression garment. The main study endpoint was the change in arm and hand swelling, measured by displaced water volume of the involved and uninvolved upper extremity, at 1 year. Secondary endpoints were the incidence of exacerbations of lymphedema, number and severity of lymphedema symptoms, and muscle strength.

Limb swelling increase of at least 5% occurred in 11% of the weight-lifting group and in 12% of the control group (cumulative incidence ratio, 1.00; 95% confidence interval, 0.88 – 1.13).

The weight-lifting group had greater improvements than the control group in self-reported severity of lymphedema symptoms (P = .03) and upper- and lower-body strength (P < .001 for both comparisons). In addition, the weight-lifting group had a lower incidence of lymphedema exacerbations, as determined by a certified lymphedema specialist (14% vs 29%; P = .04). Weight lifting was not associated with any serious adverse events.

"In breast-cancer survivors with lymphedema, slowly progressive weight lifting had no significant effect on limb swelling and resulted in a decreased incidence of exacerbations of lymphedema, reduced symptoms, and increased strength," the study authors write. "The results of this study reduce concerns that weight lifting will worsen arm and hand swelling associated with lymphedema in breast-cancer survivors."

Limitations of this study include incomplete blinding, that multiple therapists were used to evaluate for exacerbations, and possible reporting bias.

"The substantive treatment-related increases in strength, coupled with the lack of change in lean mass, indicate that the program was more focused on building muscle strength than on hypertrophy, as intended," the study authors conclude. "Further research is needed to determine the critical components of this intervention in order to facilitate its optimal use by breast-cancer survivors with lymphedema.... These findings support the potential benefits of a slowly progressive weight-lifting program in women with breast-cancer–related lymphedema, in conjunction with appropriate use of compression garments and close monitoring for arm and hand swelling."

Promising Results, More Research Needed

In an accompanying editorial, Wendy Demark-Wahnefried, PhD, RD, from M.D. Anderson Cancer Center in Houston, Texas, calls this intervention "promising" but recommends critical follow-up research, including detailed cost analysis and dissemination analyses.

"The report by Schmitz et al. provides strong reassurance regarding the safety of appropriately supervised weight training in women with a history of breast cancer and lymphedema," Dr. Demark-Wahnefried writes.

"A comprehensive strategy to improve the outcomes in these women should include dietary and exercise interventions aimed at weight management, since overweight, obesity, and weight gain after diagnosis are recognized as significant risk factors for lymphedema as well as for breast-cancer–associated death. Multifactor interventions that promote healthy eating, regular exercise (e.g., aerobic and progressive resistance training), and other lifestyle improvements (e.g., reducing smoking and alcohol use) have the potential to substantially improve overall health and survival among women with this common cancer."

The National Cancer Institute and the National Center for Research Resources supported this study. BSN Medical provided custom-fitted compression garments, and the fitness centers where the weight-lifting sessions took place (YMCA of Philadelphia and Vicinity, Sisters in Shape, and the Family YMCA of Burlington County, NJ) provided discounted membership fees for study participants. The study authors have disclosed no relevant financial relationships. Dr. Demark-Wahnefried has disclosed that she receives honoraria for consulting at the Livestrong Centers for Excellence at Ohio State University and at the University of Pennsylvania.

N Engl J Med. 2009;361:664–673; 710–711.