"You can be better than you were before."

That's the message Dr. Sharon Cowden, a physician with Children's Community Pediatrics, has for her fellow breast cancer survivors.

Dr. Cowden found a lump in her right breast in March 2002. She had surgery to remove it several months later.

The lumpectomy itself went well. What concerned Dr. Cowden was axillary lymph node dissection, the removal of lymph nodes under the arm near the affected breast to see if the cancer has spread.

Lymph nodes are found throughout the body. They act as filters or traps for foreign particles, and are a critical part of the immune system. The removal of nodes can disrupt the flow of lymph, a clear fluid that delivers nutrients to the cells of the body, and removes waste from them. A frequent consequence is lymphedema, a swelling in the arm or leg because the lymph hasn't been drained properly.

"Lymphedema is the consequence I most feared," Dr. Cowden wrote in a 2004 article about her surgery for the magazine of the American Cancer Society. "As a pediatrician, I work 8-12 hours a day. When not in my office, I am busy caring for my home and family. In the summer, I enjoy golfing with friends. How could I continue all these activities if I developed lymphedema after surgery? Prolonged activity causes arm fatigue and will increase the complications of this disorder. I did not want to stop doing the things I loved because of a heavy, swollen arm."

Dr. Cowden didn't develop lymphedema. But in the months following her surgery, she lost flexibility and strength in her right arm. It was painful in the immediate aftermath of surgery to exercise, and she feared an injury might bring on lymphedema.

"The fear of lymphedema affects most aspects of my life," Dr. Cowden wrote in her 2004 article. "In the office, I avoid lifting toddlers and children on my affected arm, which unfortunately is also my dominant arm. Outdoors in the warm weather, I take extra precautions to protect my arm against sunburn or bug bites. And in winter, my family discourages me from activities I used to enjoy, such as shoveling snow."

But Dr. Cowden also chafed at the restrictions on physical activity that her surgery and her fears of lymphedema had imposed. Through a mutual friend she met Janette Poppenberg, a health and fitness specialist certified by the American College of Sports Medicine. Before becoming a private personal trainer, Ms. Poppenberg, whose degree is from Penn State University, was a director of several area health clubs and the director of corporate wellness for Managed Care of America.

Ms. Poppenberg designed a series of exercises for Dr. Cowden that would gently, gradually restore her flexibility and strength without increasing the risk of lymphedema.

Ms. Poppenberg's program worked miracles, from Dr. Cowden's perspective.

"I was just so grateful I could do everything again," Dr. Cowden said. "I could hit a 150-yard drive [in golf] before breast cancer [surgery]. I can hit a 200-yard drive now. You can be better than you were before."

When Dr. Cowden and Ms. Poppenberg were working together in 2002 on Dr. Cowden's rehabilitation, they discussed how they might bring the benefit of Ms. Poppenberg's exercise program to all women who have had breast cancer surgery.

"Wealthy women [who suffer from breast cancer] can do what I did, and hire a personal trainer -- though maybe not as talented a one as Janette," Dr. Cowden said. "We wanted to do something that would help everyone."

Hospitals long have recognized the importance of exercise in the rehabilitation of women who have had breast cancer surgery. But, typically, patients are merely given a sheet of paper with several exercises on it and recommendations for how often they should be performed. Research indicates patients pay little attention to them, Dr. Cowden said.

In 2007, with grants from area health care providers and foundations, Dr. Cowden and Ms. Poppinger produced a DVD incorporating the program, "Strength and Courage: Exercises for Breast Cancer Survivors." WPXI-TV News anchor Peggy Finnegan, a breast cancer survivor, moderates the program and Magee-Womens Hospital's Dr. Adam Brufsky explains how research supports the importance of exercise for these women.

In July 2008, the American Cancer Society recommended that all women who have had breast cancer surgery do stretching exercises. The exercises the American Cancer Society recommends are all on their DVD, Dr. Cowden and Ms. Poppinger said.

Their goal is to have the DVD distributed free of charge to all women who have breast cancer surgeries in Western Pennsylvania hospitals. Dr. Cowden and Ms. Poppenberg also make it available to hospitals outside the area for a nominal charge.

Breast cancer survivors should exercise not just to feel better and to regain flexibility and strength, but to reduce the likelihood of a recurrence of the disease, the women say. According to a study published in the Journal of the American Medical Association in 2005, aerobic exercise can reduce breast cancer recurrence by 50 percent.

The 60-minute DVD consists of five chapters. The first three are devoted to flexibility exercises, the fourth to weight training, the fifth to aerobic exercise.

Dr. Cowden and Ms. Poppenberg also speak regularly at cancer support and health care groups. Last Thursday, they outlined their program for nurses at Magee.

"Our patients really need to know about this," said Janet Troff, director of operations, after their presentation.

More information about the video can be found on the Web at www.strengthandcourage.net.