Hanging on to Fitness and a Few Strands of Hair Through Breast Cancer Treatment

I am a Medical Oncologist, a wife, a mother of 4, runner of 12 marathons training to run my 13th with a goal to qualify for Boston when the diagnosis of breast cancer caused a significant detour in my well-planned life. When I asked for guidance on how to continue to stay fit while receiving treatment, I received blank stares and found little data. While I never intended to be in this experiment, I find myself now generating my own data about fitness through the diagnosis and treatment of breast cancer. I am writing this in hopes to help others who find themselves in this same situation.


Training on Chemo: First Month Training Log

Updated: Nov 4, 2019

Although I have been running for about 30 years, initially I had a lot of starting and stopping. There were many reasons for stopping: being a busy college student, being a busy medical student, being a busy resident and then fellow, then pregnancies, and sometimes just plain lack of motivation. When I started running, I had no idea how far, and I really could care less how fast I was running. I did an occasional 5 or 10K "race", but I never "raced". I just did these events to get new t-shirts and to run with a bunch of people. Then I discovered the marathon and the power it had to motivate me to run consistently. Again, initially this was something that I did to stay in shape and I didn’t care how fast I ran. Then discovered the Garmin and how this took the guesswork out of how far and how fast I was running among other things. As a scientist I naturally love data and now this little gadget on my wrist was providing me with more data than I knew what to do with. Initially, the Garmin also turned every run into another chance to be better: run faster, run farther, but I lacked the wisdom to know that making each workout another competition could actually be dangerous. My intuition was that the harder I worked, the better runner I would be. This philosophy had resulted in getting me into and through medical school, residency, and fellowship. It just seemed logical to me that this should work for running too. But I found out the hard way that this approach led to injuries. Ultimately I learned that I needed to have a more balanced approach to training and that rest and recovery were actually a critical components to improving fitness. Then I learned about 2 simple, but almost magical data points I could follow to give me clues as to how my body was handling training: resting heart rate (RHR) and heart rate variability (HRV). RHR is pretty simple, but it is your heart rate at rest, and ideally first thing in the morning. HRV is the time in between heartbeats. Having a bigger difference between heartbeats, or higher HRV is a good thing. This is not telling us about heart health, but it is actually telling us more about our nervous system, specifically how the activity of the sympathetic (fight or flight) and parasympathetic (rest and digest) nervous systems are interacting with each other. Ideally, there should be a balance between these 2 ends of the nervous system spectrum. So for example, my approach of going hard all the time and burning the candle at both ends at home and work leads to an over stimulation of the sympathetic nervous system, and that can show up as a low HRV and that is not good. Trends in HRV over time can indicate how the body is handling the stress, athletically imposes or just plain life. For example, too many days in a row where HRV is lower than average may be an indication that the body needs more rest. First I found apps for my phone that I could use to monitor RHR and HRV. As I continued to follow these, I started noticing things that improved these variables. And it turns out that things like a good nights sleep, and meditation would make these numbers look better. Almost 2 years ago, I discovered a gadget called Whoop which is basically a high tech heart rate monitor worn on the wrist. It is, therefore, able to account for all of the stress my body is encountering throughout the day. That stress may be related to exercise, but it could also be related to just life in general. Ultimately, it sends this information to an app on my phone and gives me a “Recovery Score” in the morning that is calculated based on the stress accumulated over the previous 24 hours, sleep, RHR, and HRV. This score indicates how ready my body was to do a hard workout. I started using this information to guide my workout for the day rather than blindly following my training plan. For example, if I got a recovery score in the red zone, which is an indication that my body was not well recovered, I would either take a rest day or take it very easy. And on the other side of things, I would try to take advantage of the “green recovery” days by potentially pushing a little harder. After using this Whoop gadget and modifying workouts and behaviors according to recovery scores, I stopped getting injured. Long story short, this gadget was a powerful reinforcer of good behavior.

On the morning of April 4th, I took my Whoop off the before I went to the hospital for my surgery. First, I knew that I would need to be naked for surgery, and that would include not wearing fitness trackers, but I felt like it would be pointless to continue wearing this. I was using Whoop to guide my workout and I knew that I would not be working out at all for a while after surgery. Even though I knew that I would not be sidelined due to the surgery forever, it was hard at that moment to even visualize going though hard workouts anytime in the near future knowing the whole treatment journey I was facing. It took a few days, but then I realized that the data collected by Whoop was actually exactly what I needed. Even though I may not be training for a specific athletic event, my body would be going through some serious stress related to the treatment. Managing the stress that I could control, was now going to be critically important. So I put my Whoop tracker back on and I believe that it has been a great tool throughout this process so far. Although chemotherapy is definitely not the kind of stress that will improve my fitness, it seems intuitive to me that balancing this stress with things that will calm my body down, will ultimately put my body in the best state to benefit from this treatment.

The Training

Prior to my breast cancer diagnosis, I found a lot of comfort by following a training plan. I loved the structure it provided and the mini-goals along the way to the big goal. But surgery and then chemotherapy has thrown my ability to follow a training plan completely out the window. Although I have been looking for specific guidance on how to approach running while on chemotherapy, I have not found it yet. My approach has therefore been intuitive and I have been to trying to really tune in to my body and listen to what it needs and completely tune out my ego which would like me to be doing so much more. Although I had to take a break from running and strength training immediately after surgery, I did start I walking on a regular basis starting just a day after surgery. I got back into regular running and strength training ~4-6 days/week about a month after surgery. I got into the habit of going to my favorite local exercise studio, Formula Complete Fitness for classes that included treadmill and strength training and then getting out for a run in the neighborhood during the weekend. The classes provided some structure that I enjoy and the community that I crave even more now. The weekend run outside provided the fresh air that I love and a chance to run a little farther than I do in a typical class at Formula.

How Did it Feel?

Not surprisingly I think, I have discovered that chemotherapy is not performance-enhancing. As mentioned, I have had numerous experiences of coming back to running after injury, pregnancy or laziness and this experience of running while on chemotherapy is different. I know that there was fitness loss due to the break from running that was needed after surgery and then the porta cath placement, but running after chemo started is very different than anything I have experienced. My hemoglobin and hematocrit have dropped due to the chemotherapy so now my heart needs to work harder to pump the oxygenated blood to my muscles since there are fewer red blood cells to carry this oxygen, so this must be part of this different feeling. But I have been anemic in the past after pregnancies and this still feels different. I suspect that some of this may be direct toxicity from the chemotherapy to my all of my cells, not just the unwanted cancer cells this stuff is designed to get rid of. One of the first things I noticed with running was that my heart rate climbed more quickly and to a higher heart rate than I was used to seeing in my pre-treatment state. My perception of effort also did not correspond to the heart rate in ways that it had in the past. I quickly realized that I needed to ignore pace and just keep an eye on my heart rate as this seemed to be the best indicator of how my body was handling the workout. So when I saw the heart rate get too high, I would take a walk break. Regarding strength training, starting at about 6 weeks after surgery, I felt really good. I felt like I quickly came back to my pre-surgery strength and had no limitations. Again, I approached coming back to strength training by listening to my body. If I felt pain, I didn’t do it. So for a while, things like chest press and kettle-bell swings were out. But I gradually worked back into things until I was able to do everything.

What Did the Data Show?

Did I mention that I love data? I could geek out for days talking about the data. But I will spare you all of that and just hit the most interesting highlights. The first interesting data point was on Tuesday March 5th, the day after the biopsy, my HRV was at a record low; my RHR was at an all-time high and my Recovery Score had never been lower. I love it when data makes sense. If HRV and RHR are indicators of stress, they have done their job since I am not sure I can think of a more stressful day than that day I had my biopsy

My HRV of 17 was significantly lower than usual for me.

My RHR of 73 was much higher than my average of 53.

This is a pathetically low recovery score for me. I am not sure I have ever seen this so low for me.

The second interesting observation is that my time in Deep Sleep according to Whoop is significantly longer now compared to my pre-breast cancer diagnosis self. I wonder if this is my body just taking what it needs or as a result of me dialing up things like meditation in my life since diagnosis. Impossible to know for sure, but I am happy about this.

The third observation and maybe not surprising, is that my resting heart rate is higher by about 10 beats per minute now compared to March before all of this started.

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