Physiotherapy in Breast Cancer: developing clinical practice

Transcription

1 Physiotherapy in Breast Cancer: developing clinical practice Dr Karen Robb Macmillan Cancer Rehabilitation Strategy Development Manager Consultant Physiotherapist Member of Macmillan Consequences of Cancer Treatment Collaborative (CCAT)

2 What I will cover Current challenges in cancer rehabilitation and the changing cancer story An overview of Breast Cancer and the consequences of treatment Evidence-based approaches to physiotherapy including service examples Developing your own services: things to consider.

3 Timing is everything!

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5 The cancer story is changing! Improved diagnosis and treatment are resulting in improved survival plus An aging population Mean In many cases, cancer should be considered more like a chronic illness/condition There is an increased demand for rehabilitation services and survivorship care Self-management is therefore seen as increasingly important There is great interest in healthy lifestyles and preventing future episodes of ill-health.

6 The number of people living with cancer is set to double by 2030 Source: Maddams J, Utley M, Møller H. Projections of cancer prevalence in the United Kingdom, Br J Cancer 2012; 107:

7 Quality of Life survey (DH 2012) The largest survey of cancer survivors in Europe Used EQ-5D to assessed overall quality of life in 4 groups at 4 time points. Headline findings: Overall quality of life was significantly associated with: The presence and number of concurrent long-term conditions Disease status Age (with year olds having the best quality of life) Importantly: Increasing physical activity was associated with improved quality of life as measured by EQ5D!

8 Exercise in Cancer: it is safe and it works ACSM Roundtable (2010) consensus/recommendations: Reviewed evidence and came to consensus on safety and efficacy of exercise testing and prescription in cancer patients. Concluded that there is consistent evidence that exercise is safe both during and after treatment and results in improvements in physical functioning, Qol and cancer related fatigue.

9 Exercise and cancer survival There is preliminary evidence that in addition to functional and quality of life benefits, physical activity performed post-diagnosis may be associated with improved survival. A small number of epidemiological studies involving breast, colorectal and prostate cancer survivors have suggested that risk of cancer recurrence, cancer-specific mortality and all-cause mortality is approximately 40-50% lower in physically active than inactive individuals. However, due to the small body of data and inconsistencies in study results, no firm conclusions can be drawn at this stage about the relationship between physical activity and survival after cancer diagnosis. (BASES 2011).

10 The Recovery Package

11 20 most common cancers (CR-UK 2011)

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13 Breast Cancer: background Breast cancer is not one single disease, there are several types of breast cancer The lifetime risk of developing breast cancer is 1 in 8 in women The biggest risk factors for developing breast cancer are getting older, being female and, for a few, having a significant family history of the disease Just over 80% of breast cancers occur in women who are over the age of 50. Nearly half of all cases are diagnosed in people in the age group More than 8 out of 10 people survive breast cancer beyond five years. (ref: Breast Cancer Care website)

14 Breast Cancer: Treatment Options

15 Potential consequences of cancer treatment amenable to physiotherapy PHYSICAL Reduction in arm ROM and mobility Fatigue Weight gain or loss Decreased CV fitness Decreased muscle mass, strength and endurance Pain Lymphoedema PSYCHOLOGICAL Anxiety Depression Loss of sense of control Fear Altered body image Low self-esteem Diminished emotional well-being Bone health challenges

16 What is cording Tight, painful cord-like structures Often distressing and debilitating Pathophysiology unclear but lymphovenous injury and scar tissue may contribute Linked to the axillary dissection and appear soon after surgery May resolve on their own months BUT can be helped by exercise, stretches and soft tissue mobilisation Example of axillary web syndrome aka cording Ultrasound studies at Barts and by other teams have proven inconclusive. MRI may help understanding. (See: Fourie & Robb (2009) in Physiotherapy 95 : ).

17 LATISSIMUS DORSI RECONSTRUCTION

18 Shoulder kinematics after surgery Analysis of scapulothoracic motion (using Fastrak and EMG recording) in BC patients suggests: Shoulder movement dysfunction is bilateral Scapular deviations and altered muscle control. Muscles anteriorly get short and tight; muscles posteriorly weaken Higher dysfunction: left side and post-mastectomy. Similar to common shoulder conditions e.g. impingement and frozen shoulder. (Shamley et al. 2007, 2009, 2012)

19 The Pulling Through Study (Schmitz et al. 2012) Part of a series in Cancer on a Prospective Surveillance Model for Rehabilitation in Breast Cancer Longitudinal observational cohort study to examine prevalence of sequelae over 6 years of follow-up Women with unilateral BC, <75yrs, randomly selected from cancer registry (n= 287) Data collected via clinical assessment, medical notes, self administered questionnaires from 6mths after diagnosis Information gathered on upper body symptoms and function, fatigue, post-surgical effects, lymphoedema, weight gain Women were only considered to have a specific complication if they reported using the highest 2 levels of the Likert scale

20 The Pulling Through Study (Schmitz et al. 2012) Results: At 6 yrs post diagnosis more than 60% of women experienced 1 or more sequelae amenable to rehabilitation Proportion of women with 3 or more sequelae decreased over time Proportion of women with no sequelae remained stable about 40% from 12mths to 6 yrs Weight-gain was the only complication to increase over time. NB This study was conducted prior to Sentinel lymph node biopsy being widely available in Australia.

21 Clinical implications there is evidence of a sizeable gap between the need versus referral to rehabilitation services during active treatment. In prior studies, the likelihood of referral to PT was lower among minority and socioeconomically disadvantaged patients. Taken together, this evidence lends support for the hypothesis that the proposed prospective surveillance model may particularly benefit those with the fewest resources, and may address this potential health disparity among cancer survivors. (Schmitz et al. 2012)

22 Barts Hospital Physiotherapy Service In and out-patient service Holistic post-operative assessment wound care progressive exercise using standardised patient information posture and advice general supportive care Out-patient follow-up and screening for risk factors for chronic pain/dysfunction Regular monitoring throughout cancer treatment with self-referral in place for known patients Referral to other services as needed eg Clin Psychology, Surgical appliances Referral to appropriate service on discharge e.g. Exercise on referral 6 week physio-led rehabilitation programme (Cancer Transitions) at end of treatment (includes exercise, dietary advice, coping strategies).

23 Barts Hospital Physiotherapy service

24 Cancer Transitions programme First comprehensive evaluation in the UK; 5 year project from scoping work to final report 6 week education and exercise group at completion of Rx Physio-led with support from MDT 3 tiers of evaluation Clinical Audit Health Equity assessment PROMS pre, post, 3,6 and 12mths PROMS cover physical activity, diet, impact of cancer and QoL

25 Feedback from participants This programme should be offered to all cancer patients. It opens your eyes and answers all those painful questions you have in your mind. I did not know what to expect but I m glad I came. This group has been amazing! It has given me the confidence to get back exercising again. It has really made a difference to my well-being.

26 Summary of Results Data from 10 groups (n=107) Clinical Audit revealed a highly rated service that patients would definitely recommend to others Health Equity assessment revealed attendees broadly represent the local population but the programme was not reaching men Some evidence that Cancer Transitions promotes changes in lifestyle particularly physical activity and dietary behaviour. Evidence of improvements in QoL, particularly increases in vitality and function but N.B. no control group Future work needed to: Promote long-term behaviour change Improve accessibility to men and non-english speaking clients Final report unpublished as yet but concludes that Cancer Transitions is worthy of wider roll-out.

27 Improving rehab services Things to consider

28 1. Improve understanding of clinical issues

29 Consequences of treatment

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31 2. Better evaluation of our interventions Whilst the importance of routinely measuring outcomes within the Allied Health Professions is well recognised, it has largely failed to be delivered in practice (Duncan & Murray, 2012). Therapists need to be adept at understanding the intended focus of their interventions and using the most appropriate tools to assess the effectiveness of those interventions (Gilchrist et al. 2009).

32 3. Collaborative R&D

33 4. Influencing commissioners

34 In summary.. Physiotherapy has an important role throughout the breast cancer pathway as part of a wider rehabilitation effort Early intervention and continued surveillance are both important in reducing the impact of consequences of treatment Clinical leadership and strategic vision are vital in developing services which are fit for the future.