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Breast Cancer

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Alex Edmondson

on 1 July 2015

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Transcript of Breast Cancer

Accumulation of fluid under the skin. Early signs include tightness, swelling, pain and heaviness
Upper-body morbidity after breast cancer
Jenna, Paul and Alex
Treatment is individualised according to nature of lump, age of patient and staging of tumour (Murtagh 2011).

Optimal management of locally advanced breast cancer is a combined approach that uses chemotherapy, radiotherapy, surgery and or endocrine therapy (Murtagh 2011).
Medical Treatment

Side effects of chemotherapy
Side effects of radiation therapy
Radiation therapy - increased risk of lymphoedema (Erickson et al 2001).

Cording may appear or recur after adjuvant therapy (chemotherapy/radiation therapy) (Lacomba et al 2009).

Chemotherapy-induced neuropathy (CINP). May present with burning paresthesias, pain, sensory ataxia, and sometimes loss of motor function.

Calvary hospital post mastectomy recommendations:
Chemotherapy – Appointments scheduled 1 week prior and 1 week post treatment.
Radiotherapy – patients may lose shoulder ROM so recommend review 4-6 weeks post radiotherapy.

(Calvary Physiotherapy Department, 2011)
Adjuvant treatment Effects
Hormonal Breast Cancer
Accounts for 5 – 10% of breast cancers
BRCA1 and BRCA2 genes
Increased risk of developing breast cancer by 80% or more

1% of the population carries a BRCA1 gene mutation, making them “high risk” at developing breast cancer.
Hereditary Breast Cancer

Types of Breast Cancer
Sensory or motor symptoms, pain, weakness, tightness, poor range of motion, nerve palsies, altered movement patterns or muscle recruitment, numbness, or swelling in the shoulder, arm, and/or breast of the affected side (Hayes et al 2012).

Main postoperative risks following axillary dissection include seroma, wound infection, shoulder stiffness, impaired mobility, axillary web syndrome, and lymphoedema (Lacomba et al 2009)
Breast Cancer
Multiple symptoms is more common than having 1 symptom (Hayes et al 2012).

Prevalence at 4 to 5 years post surgery similar to that observed during 6 months to 3 years post surgery.

At 4 to 5 years up to 56% of women report at least 1 symptom (Hayes et al 2012).
For Physiotherapists

Ideally one assessment pre-surgery.

Check notes, operation record, surgeons post operative protocol, establish level of axillary clearance, presence of drains, expected discharge date.

Review past medical history and areas of pain or numbness. This is commonly over medial aspect of upper arm as a result of division of the intercostal brachial nerve.

Early assessment and treatment post surgery can help correct scapular position which could prevent imbalances and impaired muscle recruitment (Cinar 2008; Lee 2010).
Self-report questionnaires: perceived sensory and size changes, presence and intensity of symptoms.(Hayes et al 2012).

Questionnaires include:
Norman questionnaire, (Norman 2001)
The Lymphedema Breast Cancer Questionnaire (Armer 2003)
The Lymphedema Quality of Life Inventory (Klernas 2010)

Circumferential measurements

Bioimpedance spectroscopy (Cornish 2002).
1. Prevalence
2. Pathophysiology
3. Signs and Symptoms
4. Diagnosis
5. Medical Interventions
6. Surgical Interventions
7. Post operative conditions
8. Physiotherapy assessment
9. Physiotherapy management
10. Discharge Planning
Medical Interventions
For Physiotherapists
Establish existing function.

Shoulder function can be evaluated using questionnaires and clinical assessment (Hayes et al 2012).

Validated questionnaires include:
BREAST-Q (Pusic 2009)
Disability of the Arm, Shoulder and Hand questionnaire (Gummesson, Atroshi, Ekdahl 2003).
Shoulder Assessment
Range assessment: standardized procedures of active and passive ranges using goniometry (Riddle 1987).

Strength and function: dynamometry (Bohannon 1987) and/or maximal or submaximal performance of set tasks using the repetition maximum method (Hall and Brody 2005).

Palpation: especially when establishing myofascial pain and tightness (Hayes et al 2012).

Posture: Visually inspected and where possible when completing tasks (Magarey 2003).

Scar should be examined for healing and mobility, signs of infection or sermoa (Calvary Physiotherapy Department 2011)
Shoulder Assessment
Shoulder surgery and radiation therapy may cause painful scar tissue formation and nerve damage.

Protective posturing may shorten soft tissues of chest well including the pectoral muscles causing a forward depression of the shoulder girdle (Ebaugh, Spinelli, Schmitz 2011).

Impingement of the rotator cuff leading to pain and immobility, can eventually lead to adhesive capsulitis. (Cheville, Tchou 2007).

Shortening of pectorals can also lead to overuse and strained scapular retractors which may lead to myofascial dysfunction in the back and neck muscles (Cheville, Tchou 2007).
Shoulder Dysfunction
Condition Presentation
This can be caused by damage and sclerosis of the lymphatic and/or venous system.

Not always painful but can restrict range of movement.

Cords of tissue extending from axilla down the medial arm, may continue down the forearm to wrist, hand or base of thumb.

Usually evident when the shoulder is abducted.

(Lacomba et al 2009)
Axillary web syndrome 
Useful links

Postmastectomy pain syndrome (PMPS)
Pain beyond post mastectomy healing time frame.
Suspected causes: operative nerve damage, traumatic neuroma or scar on nerve.

Risk factors (Fabro et al 2012):
History of severe and acute pain postoperatively
Younger age at diagnosis
Radiation Treatment to the axilla
Extensive axillary surgery

Signs and symptoms: burning, stabbing, neuropathic (eg, numbness, hyperesthesia, or paraesthesia), or as an "electric shock" at the operative site or ipsilateral arm (Meijuan et al 2013).
Additional Considerations
Edema may result in reduced range of motion (Cheville, Tchou 2007).

Pain control can influence exercise prescription and compliance.

QOL assessments can be used to assess the impact of treatment on functional status (Kroenke 2004).
Psychological Testing
Short Form 36

AQol – Quality of Life

DAS – Depression Anxiety Stress Scale 21

Kessler Psychological Distress Scale (K10)

Monthly to once every 3 months and continuing until 12 months postsurgery then less regular surveillance (Hayes et al 2012).

May modify particularly with lymphoedema as this condition can be fluctuating in nature (Hayes et al 2012).
Lymphoedema Assessment
Signs and Symptoms
Physiotherapy Management
Axillary node dissection
Discharge From Physiotherapy
Scar Management
Shoulder Function
Web Syndrome
Worldwide Breast Cancer Rates
Posture may be affected due to scar tightening, pain or reduced confidence
Physiotherapy management may include:
Posture education
Postural exercises
University of Michigan Comprehensive Cancer Center 2008
WCRFI, 2015
(University of Michigan Comprehensive Cancer Center, 2008)
If not managed correctly, scarring can become hypersensitive or tighten
Initially the patient should be apply gentle pressure around the scar
After the scab has come off the patient should and massage directly over the scar with cream
(Calvary Physiotherapy Department 2011)
Usually occurs within 2-6 weeks post-surgery, resolving by 3 months
Management includes:
Patient education
Fourie & Robb 2009, Calvary Physiotherapy Department 2011
Many patients experience reduced shoulder ROM and strength after mastectomy
Physiotherapy management includes:
Shoulder ROM exercises
Progressive resistance exercises
Compression Garments
Patient education of increased risk, symptoms and best prevention
Avoid injury or infection
Scar massage
Arm exercises
If lymphoedema is suspected refer to a specialist physiotherapist
Complex Lymphoedema Therapy:
Skin care
Manual lymphatic drainage
Compression therapy
(Calvary Physiotherapy Department 2011, Lauridsen et al. 2005, Singh et al. 2013, Lauridsen et al. 2000, Shamley et al. 2005, McNeely et al. 2010, Box et al. 2012, Paramanandam & Roberts 2014)
(Lu et al. 2015, Calvary Physiotherapy Department 2011)
(Australasian Lymphology Association n.d.)
Consider prophylactic use of pressure garments if planning to fly or exercise
Ready to wear garments can be purchased or refer on for custom-made
(Calvary Physiotherapy Department 2011)
Discharge can occur when:
Return of full shoulder range, strength and function has occurred
Lymphoedema education has been given
Any prophylactic compression garments have been fitted
No indication of lymphoedema, or the patient has been referred to a specialist lymphoedema physiotherapist
(Calvary Physiotherapy Department 2011)
Breast cancer in the most common cancer among women in Australia.
Cancer Aus (2012)
Partial irradition
Whole irradition
Cancer Aus (2012)
Exercise may help combat the side effects of adjuvant therapy
Cardiovascular and resistance training improved outcomes in patients undergoing chemotherapy
Exercise and yoga can improve symptoms associated with aromatase inhibitors
(Adamsen et al. 2009)
(Niravath 2013, Lintermans et al. 2014, Nyrop et al. 2013, Irwin et al. 2014, Peppone et al. 2015, Jacobsen et al. 2014)
Majority of adenocarcinomas are hormone sensitive.

Breast cancers are stratified according to their cell differentiation, location, and response to different hormone receptors:

Estrogen receptor (+/-)
Progesterone recepetor (+/-)
Human Epidermal Growth factor receptor 2 (HER2) (+/-)
Triple negative
Lymphoedema Assessment
Accumulation of fluid under the skin.

Early symptoms: tightness or weakness, redness, swelling, pain or heaviness or signs of infection.(Lu et al. 2015)

Approximately 1 in 5 experiencing secondary lymphedema at 6 months post breast surgery (Hayes et al 2012).
Can impact significantly on function, as a result of reduced shoulder range and affected motor skills




Common drug names include:
Endrocrine therapies include:
Antiestrogens (tamoxifen)
Aromatase Inhibitors
Surgical removal of adrenal glands/ovaries
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