Defining the Role of Rehabilitation in Breast Cancer Care Ashley Dew, PT, DPT Ochsner Therapy and Wellness Manager of Program Development Physical Therapist at the Tansey Breast Center
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Primary Role of the Breast Cancer Rehab Specialist Musculoskeletal Cardiopulmonary Integumentary Cancer surgery Reconstruction Chemotherapy Radiation Hormonal therapies Biological therapies Functional deficits
Cancer Treatment Local Effects Pain Weakness Decreased ROM Soft tissue dysfunction Scarring Swelling/edema Risk for lymphedema Functional loss Incontinence Sexual dysfunction Systemic Effects Fatigue Weakness Nausea Osteopenia Sarcopenia Difficulty walking Neuropathy Weight gain/loss
Treatments Have Significant Impacts on Survivors 60% + report 1 or more functional limitations after breast cancer treatment 30% may not be able to return to work On average, patients have 8 complications due to cancer treatment (Stout 2015)
Side Effects Most Commonly Reported in Breast Cancer Treatment Side effects most commonly reported in breast cancer treatment are: Pain Fatigue Peripheral neuropathy UE dysfunction Decreased strength Faulty scapular mechanics Decreased muscle length Decreased shoulder ROM Lymphedema (Stout 2015)
Local and systemic effects Respond to physical and occupational therapy treatment!!!
Patients Should Not be Referred Only When There is a Problem
Best Practice for Breast Cancer Rehabilitation
At Diagnosis Evaluation Our goal is to evaluate each patient at diagnosis Baseline UE measurements Aid in early lymphedema detection Upper Extremity Assessment Strength ROM Posture Lymphedema education Surgical precautions Establish and Exercise program Strength and cardiovascular Fatigue Prevention Energy Conservation Current exercise habits
NOT Just for Post Surgical Range of Motion & NOT Just One Visit after surgery Muscle Weakness Fatigue Tissue length Tissue mobility Return to baseline
Rehab Treatment Re-Evaluation after breast surgery and reconstruction Weekly touch points: improve strength, tissue extensibility and ROM Provide reassurance Through surgical recovery Prepare for radiation simulation and treatment Discuss energy conservation and fatigue prevention
Breast cancer patients treated with manual therapy improve more than those without LJ Waltke, PT, DPT
Rehab Treatment Possible permanent stress to the lymphatic system Changing microcirculation Soft tissue tightness Soft tissue fibrosis Pain Tissue fibrosis Fatigue
Rehab Treatment Chemotherapy Cancer related fatigue Exercise during chemotherapy Reduce fatigue Reduce cardiomyopathy Prevent muscle mass loss ACS recommends 150 min of weekly exercise Combat obesity Rehab cannot directly impact neuropathy, but can improve associated symptoms The only evidence based treatments for fatigue is exercise - LJWaltke
The primary role of the breast cancer therapist is NOT to treat lymphedema.
Breast Cancer Related Lymphedema Incidence 25% Axillary Dissection 7% SLNB 1-3 years after surgery Risk is lifelong (Cemal, 2011) (Ahn 2016) Minimizing Risk Normalize/maximize tissue length Normalize strength Infection risk reduction Maintain/achieve ideal bodyweight Encourage regular exercise
Dispelling Myths Treatment Manual lymphatic therapy Compression bandaging Vasopneumatic compression Exercise There is a 75-93% chance that lymphedema will not develop
Is evidence based, reimbursed medical care Provides low risk, high value outcomes Everyone deserves access to a therapist Refer your patients at diagnosis and think of therapy through survivorship Do not wait until there is a problem to refer to therapy In conclusion
Rehabilitation should be a component of successful cancer care
References Advance News Magazine www.advanceweb.com Expanding Paradigms in Oncology Rehabilitation Vol. 22, Issue 19, page 33 Leslie Waltke, PT, DPT Advance New Magazine www.advanceweb.com Exercise and rehabilitation can prevent cancer-related lymphedema Vol 23, Issue 2, Page 36 Leslie Waltke, PT, DPT Mauk KL 2012, Rehabilitation Nursing: A contemporary approach to practice, Jones & Bartlett Learning, Sudbury. Ahn S, Port ER: Lymphedema Precautions: Time to Abandon Old Practices? J Clin Oncol March 1, 2016 34:655 658 Cemal, Y, Pusic, A, Mehrara BJ (2011) Preventative Measures for lymphedema: Separating Fact from Fiction. J Am Coll Surg 213:543-551. Stout, N.L., Harrington, S., Pfalzer, L., & Fisher, M.I. (2015). Breast cancer rehabilitation: Clinical examination and outcomes assessment. Physical Therapy Faculty Publications, paper 30 Meneses-Echavez, J. (2015). Supervised Exercise reduces cancer-related fatigue: a systemic review. Journal of Physiotherapy, 61(1). 3-9.