Breast Cancer Research and Treatment

, Volume 121, Issue 2, pp 421–430 | Cite as

Changes in the Body Image and Relationship Scale following a one-year strength training trial for breast cancer survivors with or at risk for lymphedema

  • Rebecca M. Speck
  • Cynthia R. Gross
  • Julia M. Hormes
  • Rehana L. Ahmed
  • Leslie A. Lytle
  • Wei-Ting Hwang
  • Kathryn H. SchmitzEmail author


The aim of this study was to evaluate the impact of a twice-weekly strength training intervention on perceptions of body image in 234 breast cancer survivors (112 with lymphedema) who participated in the Physical Activity and Lymphedema (PAL) trial. The study population included two hundred and thirty-four women randomly assigned to twice-weekly strength training or control group that completed the 32-item Body Image and Relationships Scale (BIRS) at baseline and 12 months. Percent change in baseline to 12-month BIRS total and subscale scores, upper and lower body strength, and general quality of life (QOL) were compared by intervention status. A series of multiple linear regression models including indicator variables for subgroups based on age, marital status, race, education, BMI, and strength change were used to examine differential intervention impact by subgroup. Strength and QOL variables were assessed as mediators of the intervention effect on BIRS. Results: Baseline BIRS scores were similar across intervention and lymphedema status. Significantly greater improvement in BIRS total score was observed from baseline to 12 months in treatment vs. control participants (12.0 vs. 2.0%; P < 0.0001). A differential impact of the intervention on the Strength and Health subscale was observed for older women (>50 years old) in the treatment group (P = 0.03). Significantly greater improvement was observed in bench and leg press among treatment group when compared to control group participants, regardless of lymphedema. Observed intervention effects were independent of observed strength and QOL changes. Twice-weekly strength training positively impacted self-perceptions of appearance, health, physical strength, sexuality, relationships, and social functioning. Evidence suggests the intervention was beneficial regardless of prior diagnosis of lymphedema. Strength and QOL improvements did not mediate the observed intervention effects.


Breast cancer survivors Body image Strength training Lymphedema 



The authors thank the members of Writers Seminar of The CHOP/PENN Mentored Psychosocial Research Curriculum, supported by a K05 award to Anne E. Kazak, Ph.D. (CA128805), for reading and reviewing prior drafts of this paper.


  1. 1.
    Baron RH, Kelvin JF, Bookbinder M, Cramer L, Borgen PI, Thaler HT (2000) Patients’ sensations after breast cancer surgery. A pilot study. Cancer Pract 8(5):215–222CrossRefPubMedGoogle Scholar
  2. 2.
    Nesvold IL, Dahl AA, Lokkevik E, Marit Mengshoel A, Fossa SD (2008) Arm and shoulder morbidity in breast cancer patients after breast-conserving therapy versus mastectomy. Acta Oncol 47(5):835–842CrossRefPubMedGoogle Scholar
  3. 3.
    Lopez E, Nunez MI, Guerrero MR, del Moral R, de Dios Luna J, del Mar Rodriguez M, Valenzuela MT, Villalobos M, Ruiz de Almodovar JM (2002) Breast cancer acute radiotherapy morbidity evaluated by different scoring systems. Breast Cancer Res Treat 73(2):127–134CrossRefPubMedGoogle Scholar
  4. 4.
    Camidge R, Price A (2002) Radiation recall dermatitis may represent the Koebner phenomenon. J Clin Oncol 20(19):4130 author reply 4130CrossRefPubMedGoogle Scholar
  5. 5.
    Demark-Wahnefried W, Rimer BK, Winer EP (1997) Weight gain in women diagnosed with breast cancer. J Am Diet Assoc 97(5):519–529CrossRefPubMedGoogle Scholar
  6. 6.
    Griffin AM, Butow PN, Coates AS, Childs AM, Ellis PM, Dunn SM, Tattersall MH (1996) On the receiving end. V: patient perceptions of the side effects of cancer chemotherapy in 1993. Ann Oncol 7(2):189–195PubMedGoogle Scholar
  7. 7.
    Ganz P (2005) Breast cancer, menopause, and long-term survivorship: critical issues for the 21st century. Am J Med 118(12B):1365–1415Google Scholar
  8. 8.
    Luskin Biordi D, Warner AM, Knapik GP (2006) Body image. In: Morof Lubkin I, Larsen PD (eds) Chronic illness: impact and interventions, 6th edn. Jones & Bartlett, Sudbury, MA, pp 181–197Google Scholar
  9. 9.
    Carver CS, Pozo-Kaderman C, Price AA, Noriega V, Harris SD, Derhagopian RP, Robinson DS, Moffat FL Jr (1998) Concern about aspects of body image and adjustment to early stage breast cancer. Psychosom Med 60(2):168–174PubMedGoogle Scholar
  10. 10.
    Cousson-Gelie F, Bruchon-Schweitzer M, Dilhuydy JM, Jutand MA (2007) Do anxiety, body image, social support and coping strategies predict survival in breast cancer? A ten-year follow-up study. Psychosomatics 48(3):211–216CrossRefPubMedGoogle Scholar
  11. 11.
    Sandel SL, Judge JO, Landry N, Faria L, Ouellette R, Majczak M (2005) Dance and movement program improves quality-of-life measures in breast cancer survivors. Cancer Nurs 28(4):301–309CrossRefPubMedGoogle Scholar
  12. 12.
    Berglund G, Bolund C, Gustafsson UL, Sjoden PO (1994) One-year follow-up of the ‘Starting Again’ group rehabilitation programme for cancer patients. Eur J Cancer 30A(12):1744–1751CrossRefPubMedGoogle Scholar
  13. 13.
    Burnham TR, Wilcox A (2002) Effects of exercise on physiological and psychological variables in cancer survivors. Med Sci Sports Exerc 34(12):1863–1867CrossRefPubMedGoogle Scholar
  14. 14.
    Courneya KS, Mackey JR, Bell GJ, Jones LW, Field CJ, Fairey AS (2003) Randomized controlled trial of exercise training in postmenopausal breast cancer survivors: cardiopulmonary and quality of life outcomes. J Clin Oncol 21(9):1660–1668CrossRefPubMedGoogle Scholar
  15. 15.
    Daley AJ, Crank H, Saxton JM, Mutrie N, Coleman R, Roalfe A (2007) Randomized trial of exercise therapy in women treated for breast cancer. J Clin Oncol 25(13):1713–1721CrossRefPubMedGoogle Scholar
  16. 16.
    Fillion L, Gagnon P, Leblond F, Gelinas C, Savard J, Dupuis R, Duval K, Larochelle M (2008) A brief intervention for fatigue management in breast cancer survivors. Cancer Nurs 31(2):145–159CrossRefPubMedGoogle Scholar
  17. 17.
    Matthews CE, Wilcox S, Hanby CL, Der Ananian C, Heiney SP, Gebretsadik T, Shintani A (2007) Evaluation of a 12-week home-based walking intervention for breast cancer survivors. Support Care Cancer 15(2):203–211CrossRefPubMedGoogle Scholar
  18. 18.
    Fairey AS, Courneya KS, Field CJ, Bell GJ, Jones LW, Mackey JR (2005) Randomized controlled trial of exercise and blood immune function in postmenopausal breast cancer survivors. J Appl Physiol 98(4):1534–1540CrossRefPubMedGoogle Scholar
  19. 19.
    Mock V, Dow KH, Meares CJ, Grimm PM, Dienemann JA, Haisfield-Wolfe ME, Quitasol W, Mitchell S, Chakravarthy A, Gage I (1997) Effects of exercise on fatigue, physical functioning, and emotional distress during radiation therapy for breast cancer. Oncol Nurs Forum 24(6):991–1000PubMedGoogle Scholar
  20. 20.
    Mock V, Pickett M, Ropka ME, Muscari Lin E, Stewart KJ, Rhodes VA, McDaniel R, Grimm PM, Krumm S, McCorkle R (2004) Fatigue and quality of life outcomes of exercise during cancer treatment. Cancer Pract 9(3):119–127CrossRefGoogle Scholar
  21. 21.
    Schmitz KH, Ahmed RL, Hannan PJ, Yee D (2005) Safety and efficacy of weight training in recent breast cancer survivors to alter body composition, insulin, and insulin-like growth factor axis proteins. Cancer Epidemiol Biomarkers Prev 14(7):1672–1680CrossRefPubMedGoogle Scholar
  22. 22.
    Courneya KS, Segal RJ, Mackey JR, Gelmon K, Reid RD, Friedenreich CM, Ladha AB, Proulx C, Vallance JK, Lane K et al (2007) Effects of aerobic and resistance exercise in breast cancer patients receiving adjuvant chemotherapy: a multicenter randomized controlled trial. J Clin Oncol 25(28):4396–4404CrossRefPubMedGoogle Scholar
  23. 23.
    Ohira T, Schmitz K, Ahmed R, Yee D (2006) Effects of weight training on quality of life in recent breast cancer survivors. Cancer 106:2076–2083CrossRefPubMedGoogle Scholar
  24. 24.
    Ahmed C, Hilton W, Pituch K (2002) Relations of strength training to body image among a sample of female university students. J Strength Cond Res 16(4):645–648CrossRefPubMedGoogle Scholar
  25. 25.
    Cash TF, Novy PL, Grant JR (1994) Why do women exercise? Factor analysis and further validation of the reasons for exercise inventory. Percept Mot Skills 78(2):539–544PubMedGoogle Scholar
  26. 26.
    Schag CA, Ganz PA, Heinrich RL (1991) CAncer rehabilitation evaluation system-short form (CARES-SF). A cancer specific rehabilitation and quality of life instrument. Cancer 68(6):1406–1413CrossRefPubMedGoogle Scholar
  27. 27.
    LL HormesJM, Gross CR, Ahmed-Saucedo RL, Troxel AB, Schmitz KH (2008) The body image and relationships scale (BIRS): development and validation of a measure of body image in female breast cancer survivors. J Clin Oncol 26(8):1269–1274CrossRefGoogle Scholar
  28. 28.
    Schmitz KH, Troxel AB, Cheville A, Grant LL, Bryan CJ, Gross CR, Lytle LA, Ahmed RL (2009) Physical activity and lymphedema (the PAL trial): assessing the safety of progressive strength training in breast cancer survivors. Contemp Clin Trials 30(3):233–245CrossRefPubMedGoogle Scholar
  29. 29.
    Schmitz KH, Ahmed RL, Troxel A, Cheville A, Smith R, Lewis-Grant L, Bryan CJ, Williams-Smith CT, Greene QP (2009) Weight lifting in women with breast-cancer-related lymphedema. N Engl J Med 361(7):664–673CrossRefPubMedGoogle Scholar
  30. 30.
    DS EvansSJW, Royston P (1990) MINIM: minimisation program for allocating patients to treatments in clinical trials, Version 1.5. London Hospital Medical College, LondonGoogle Scholar
  31. 31.
    Pocock SJ, Simon R (1975) Sequential treatment assignment with balancing for prognostic factors in the controlled clinical trial. Biometrics 31(1):103–115CrossRefPubMedGoogle Scholar
  32. 32.
    Rogerino A, Grant LL, Wilcox H 3rd, Schmitz KH (2009) Geographic recruitment of breast cancer survivors into community-based exercise interventions. Med Sci Sports Exerc 41(7):1413–1420CrossRefPubMedGoogle Scholar
  33. 33.
    Ware J Jr, Kosinski M, Keller SD (1996) A 12-item short-form health survey: construction of scales and preliminary tests of reliability and validity. Med Care 34(3):220–233CrossRefPubMedGoogle Scholar
  34. 34.
    Tomich PL, Helgeson VS (2002) Five years later: a cross-sectional comparison of breast cancer survivors with healthy women. Psycho-oncol 11:154–169CrossRefGoogle Scholar
  35. 35.
    Ganz PA, Desmond KA, Belin TR, Meyerowitz BE, Rowland JH (1999) Predictors of sexual health in women after a breast cancer diagnosis. J Clin Oncol 17(8):2371–2380PubMedGoogle Scholar
  36. 36.
    Rowland JH, Desmond KA, Meyerowitz BE, Belin TR, Wyatt GE, Ganz PA (2000) Role of breast reconstructive surgery in physical and emotional outcomes among breast cancer survivors. J Natl Cancer Instit 92(17):1422–1429CrossRefGoogle Scholar
  37. 37.
    Jea FleckS (1997) Designing Resistance Training Programs, 2nd edn. Human Kinetics, Champaign, ILGoogle Scholar
  38. 38.
    Barnard KL, Adams KJ, Swank AM, Mann E, Denny DM (1999) Injuries and muscle soreness during the one repetition maximum assessment in a cardiac rehabilitation population. J Cardiopulm Rehabil 19(1):52–58CrossRefPubMedGoogle Scholar
  39. 39.
    Shaw CE, McCully KK, Posner JD (1995) Injuries during the one repetition maximum assessment in the elderly. J Cardiopulm Rehabil 15(4):283–287CrossRefPubMedGoogle Scholar
  40. 40.
    Sobel M (1982) Asymptotic confidence intervals for indirect effects in structural equation models. Sociol Methodol 13:290–312CrossRefGoogle Scholar
  41. 41.
    Preacher KJ, Hayes AF (2008) Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behav Res Methods 40(3):879–891CrossRefPubMedGoogle Scholar
  42. 42.
    StataCorp L (1996–2008) Stata 10 data analysis and statistical software. In: 10 edn. College Station, TexasGoogle Scholar
  43. 43.
    Hopwood P, Fletcher I, Lee A, Al Ghazal S (2001) A body image scale for use with cancer patients. Eur J Cancer 37(2):189–197CrossRefPubMedGoogle Scholar
  44. 44.
    Ganz PA, Desmond KA, Leeham B, Rowland JH, Meyerowitz BE, Belin TR (2002) Quality of life in long-term, disease-free survivors of breast cancer: a follow-up study. J Natl Cancer Instit 94(1):39–49Google Scholar
  45. 45.
    Warren AG, Brorson H, Borud LJ, Slavin SA (2007) Lymphedema: a comprehensive review. Ann Plast Surg 59(4):464–472CrossRefPubMedGoogle Scholar
  46. 46.
    Velanovich V, Szymanski W (1999) Quality of life of breast cancer patients with lymphedema. Am J Surg 177(3):184–187 discussion 188CrossRefPubMedGoogle Scholar
  47. 47.
    Beaulac SM, McNair LA, Scott TE, LaMorte WW, Kavanah MT (2002) Lymphedema and quality of life in survivors of early-stage breast cancer. Arch Surg 137(11):1253–1257CrossRefPubMedGoogle Scholar
  48. 48.
    Schmitz KH, Holtzman J, Courneya KS, Masse LC, Duval S, Kane R (2005) Controlled physical activity trials in cancer survivors: a systematic review and meta-analysis. Cancer Epidemiol Biomarkers Prev 14(7):1588–1595CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC. 2009

Authors and Affiliations

  • Rebecca M. Speck
    • 1
  • Cynthia R. Gross
    • 2
  • Julia M. Hormes
    • 3
  • Rehana L. Ahmed
    • 2
  • Leslie A. Lytle
    • 2
  • Wei-Ting Hwang
    • 1
  • Kathryn H. Schmitz
    • 4
    Email author
  1. 1.Center for Clinical Epidemiology and BiostatisticsUniversity of Pennsylvania School of MedicinePhiladelphiaUSA
  2. 2.University of MinnesotaMinneapolisUSA
  3. 3.Department of PsychologyUniversity of PennsylvaniaPhiladelphiaUSA
  4. 4.Center for Clinical Epidemiology and BiostatisticsUniversity of Pennsylvania School of MedicinePhiladelphiaUSA

Personalised recommendations