February 12, Clinical Update & Interdisciplinary Care: Rehabilitation Following Breast Cancer Surgery. APTA s CSM, Las Vegas, NV, 2009.

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1 CLINICAL UPDATE & INTERDISCIPLINARY CARE: REHABILITAION FOLLOWING BREAST CANCER SURGERY Rebecca G. Stephenson PT, DPT, MS Stephanie Caterson MD Roya Ghazinouri PT, DPT, MS Reg B. Wilcox III, PT, DPT, MS, OCS Daniel W. Ovitt MS, PT Brigham and Women s Hospital Boston, Ma Program Epidemiological Data and Introduction to Breast Cancer Rebecca Stephenson Overview of Surgical Intervention Stephanie Caterson Overview of Adjuvant Treatment Stephanie Caterson Musculoskeletal Impairments & Rehabilitation Considerations following Breast Cancer Surgery Reg B. Wilcox III Break- 10 Minutes Efficacy of Exercise & Therapy Roya Ghazinouri Elements for Designing an Interdisciplinary Model for Rehabilitation Roya Ghazinouri Results from the Breast Cancer Rehabilitations Program at BWH Daniel Ovitt Question & Answers Objectives Demonstrate an understanding of the epidemiological and risk factors of breast cancer. Demonstrate an understanding of the medical and surgical management for breast cancer treatment. Identify common dysfunction following breast cancer surgery and adjuvant treatment. Articulate the efficacy for exercise and therapy following breast cancer surgery. Appreciate the potentially complex patient presentation following breast cancer surgery and the need for an interdisciplinary postoperative rehabilitation plan. This Educational Session is not A course on lymphedema Critical adjunct to the prevention and treatment in physical therapy management Illustrate why abnormal shoulder girdle mechanics occur following surgery for breast cancer. Describe the rehabilitation principles for the shoulder girdle following breast cancer surgery and treatment. Design a comprehensive rehabilitation program for a patient following breast cancer surgery. Epidemiology of Breast Cancer Rebecca G. Stephenson PT, DPT, MS Breast Cancer Statistics Risk Factors Cancer Survivorship What is the Context for us as PT s? What does a diagnosis of breast cancer mean to us? How does that affect the way we practice? What are the needs of the of a breast cancer patient that we need to consider in order to successful treat them? Do we ever find breast cancer in our patients?

2 Finding the Compass Diagnosis Surgery Radiation Chemotherapy Physical Therapy Survivorship Who is Getting Diagnosed with Breast Cancer?? Grandmother, mother, sister, partner, daughter, cousin. Male relative Ourselves? Every TWO Minutes Epidemiology In 2007: 240,000 cases of breast cancer Since 2003, rates have been decreasing Use of mammography Cessation of HRT Women living longer About 41,000 deaths 5 year survival rates (all stages ) 89%, with steady improvement since 1970 s. Pruthi Mayo Clin Proc, Aug 2007; 82(8): Jemal, BCR Estimated US Cancer Cases Men 766,860 Women 678,060 What about Male Breast Cancer? Prostate 29% 26% Breast Lung & bronchus 15% 15%Lung & bronchus Colon & rectum 10% 11%Colon & rectum Urinary bladder 7% 6% Uterine corpus Non-Hodgkin 4% 4% Non-Hodgkin lymphoma lymphoma Melanoma of skin 4% 4% Melanoma of skin Kidney 4% 4% Thyroid Leukemia 3% 3% Ovary 3% Kidney Oral cavity 3% 3% Leukemia Pancreas 2% 21%All Other Sites All Other Sites 19% *Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder. Source: American Cancer Society,

3 Male Breast Cancer Cancer Incidence Rates for Women, Rate Per 100,000 Reported first degree relative with breast cancer Associated with hx of bone fracture Obesity related to risk BMI 30kg/m 2 Physical inactivity Colon and rectum Breast Lung & bronchus Brinton LS et al. J Natl Cancer Inst 2008;100: Uterine Corpus Ovary Non-Hodgkin lymphoma *Age-adjusted to the 2000 US standard population and adjusted for delays in reporting. Source: Surveillance, Epidemiology, and End Results Program, , Division of Cancer Control and Population Sciences, National Cancer Institute, Incidence Increases with Age 2007 Estimated US Cancer Deaths Men 289,550 Women 270,100 SEER median age diagnosis 61y - < 20 y 0.0% % % % % % % % Lung & bronchus 31% Prostate 9% Colon & rectum 9% Pancreas 6% Leukemia 4% Liver & intrahepatic 4% bile duct Esophagus 4% Urinary bladder 3% Non-Hodgkin 3% lymphoma Kidney 3% All other sites 24% ONS=Other nervous system. Source: American Cancer Society, % Lung & bronchus 15% Breast 10%Colon & rectum 6%Pancreas 6% Ovary 4% Leukemia 3% Non-Hodgkin lymphoma 3% Uterine corpus 2% Brain/ONS 2%Liver & intrahepatic bile duct 23% All other sites Cancer Death Rates, for Women, US, Rate Per 100,000 Lung & bronchus Uterus Breast Colon & rectum Stomach Ovary Pancreas *Age-adjusted to the 2000 US standard population. Source: US Mortality Public Use Data Tapes , US Mortality Volumes , National Center for Health Statistics, Centers for Disease Control and Prevention, Five-year Relative Survival (%) During Three Time Periods By Cancer Site Site All sites Breast (female) Colon Leukemia Lung and bronchus Melanoma Non-Hodgkin lymphoma Ovary Pancreas Prostate Rectum survival Urinary rates based bladder on follow up of patients through *5-year relative Recent changes in classification of ovarian cancer have affected survival rates. Source: Surveillance, Epidemiology, and End Results Program, , Division of Cancer Control and Population Sciences, National Cancer Institute, 2006.

4 Incidence Varies by Race Race/Ethnicity Female All Races per 100,000 women White per 100,000 women African American per 100,000 women Asian/Pacific Islander 89.0 per 100,000 women American Indian/Alaska Native 69.8 per 100,000 women Hispanic 89.3 per 100,000 women Cancer Survival*(%) by Site and Race, African Site White American % Difference All Sites Breast (female) Colon Esophagus Leukemia Non-Hodgkin lymphoma Oral cavity Prostate Rectum Urinary bladder Uterine cervix Uterine corpus *5-year relative survival rates based on cancer patients diagnosed from 1996 to 2002 and followed through Source: Surveillance, Epidemiology, and End Results Program, , Division of Cancer Control and Population Sciences, National Cancer Institute, Risk Factors Associated with Breast Cancer Age Family History/ Genetic Influence BRCA 1+2 Estrogen Exposure Early menarche Nulliparity Exogenous hormone use Lifestyle Factors diet, exercise Risk Factors: Age Risk of breast cancer increases with age By age 30 1:1961 By age 40 1:209 By age 50 1:53 By age 60 1:22 By age 70 1:13 By age 80 1:9 SEER Risk Factors: Family History Both age and proximity of affected relative influences risk 75% of women with breast cancer have NO family history Degree Relative Risk 1st 2.5 2nd 1.5 Risk Factors: Family History Factors Influencing the Significance of a Family History: - Age at diagnosis of affected family member - Age and number of unaffected family members - Number of family members with breast cancer - Presence of ovarian cancer - Presence of male breast cancer - Ethnicity Claus et al, Cancer 1994

5 Inherited Susceptibility Genes Responsible for 5-10% of all breast cancers BRCA 1 BRCA 2 Li-Fraumeni Cowden s Disease Ataxia telangectasia BRCA1 and 2 Families Multiple members with cancer, esp. breast and/or ovarian Also: premenopausal breast cancer, bilateral breast cancer, male breast Carriers have 3-7x greater cancer, pancreatic chance of developing breast cancer cancer than usual population Higher prevalence in 50% chance child of an Ashkenazi Jewish affected parent will get the families gene Endogenous Hormones Relative Risk of Breast Cancer by Lifetime Duration of Breastfeeding Increased Risk - Early menarche - Nulliparity - Late first pregnancy - Oral contraceptives (while taking them) - HRT Decreased Risk - Late menarche - Early and repeated pregnancy (after short-term increased incidence) - Early menopause - Prolonged lactation CGHFBC, Lancet 2002 Breast Cancer Risk by Parity and Breastfeeding History Estimated Cumulative Incidence of Breast Cancer in Developed Countries Assuming Parity and Breastfeeding Patterns of Developing Countries CGHFBC, Lancet 2002 CGHFBC, Lancet 2002

6 Exogenous Hormone Use Physical Activity and Breast Cancer Risk OCP: There may be a transient short term increased risk of breast cancer in current OCP users, but no increased risk later in life. HRT: Modest causal relationship exists between HRT use and breast cancer, with risk increasing with time. Chlebowski, JAMA 2003 HRT Placebo Many studies have looked at relationship between physical activity and breast cancer risk Difficult area to study what is exercise? Risk of breast cancer reduced 30-40% in active women Physical Activity and Breast Cancer Risk College Alumni Study: the first study to show a relationship between exercise and breast cancer risk looked at 5398 alumni of US colleges graduating breast cancer cases Exercise assessed from participation in college sports Risk of developing breast cancer 40% lower in women who played college sports Wyshak and Frisch BJC Exercise and Breast Cancer California Teachers Study: prospective study of 110,000 women followed since cases of breast cancer Invasive breast cancer Non-invasive breast cancer Amount of long term Strenuous Exercise, Relative Risk < 0.5h/week vs. > 5h/week 0.80, (95% CI ) 0.69, (95% CI ) Reduced risk was of hormone receptor negative, not hormone receptor positive, cancers Suggests a protective role for long term strenuous exercise. Dallal et al, Arch Int Med 2007 Trends in Overweight* Prevalence (%), Adults 18 and Older, US, Weight and Breast Cancer Risk Mixed relationship between excess body weight and breast cancer risk Slightly lower risk of breast cancer in overweight premenopausal women Weight gain during adulthood may be more important risk factor *Body mass index of 25.0 kg/m 2 or greater. Source: Behavioral Risk Factor Surveillance System, CD-ROM ( , 1998) and Public Use Data Tape (2004, 2005), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 1997, 2000, 2005, Less than 50% 50 to 55% More than 55% State did not participate in survey Many studies show a weak increase in breast cancer in overweight postmenopausal women

7 Impact of Body Mass Index on Breast Cancer Risk in Postmenopausal Women Study N Levels of BMI Compared Nurses Health Study E3N Women s Cohort France Risk of Breast Cancer Heavier vs. Leaner 95,256 > 31 vs. < 20 Trend toward increased risk 94,805 > 30.0 vs Treti 567,333 Very small differences in BMI CPS-II 495,477 > 40 vs Women s Health Initiative 85,917 > 31.1 vs. < 22.6 No increase Small increase (16%) Two fold increase More than two fold increase CPS-II 65,756 > 35 vs. < % increase How do we Define Survivorship?? Cancer Survivorship Cancer Survivors are Increasing Estimated # of Cancer Survivors in U.S. An individual is considered a cancer survivor from the time of diagnosis, through the balance of his or her life. Family members, friends, and caregivers are also impacted by the survivorship experience and are therefore included in this definition National Cancer Institute Number 12,000,000 10,000,000 8,000,000 6,000,000 4,000,000 2,000, Year Cancer Survivors in U.S. by Site of Disease The Challenge of Cancer Survivorship 17% 3% 6% 7% 6% 9% 10% 23% 19% Female Breast Prostate Colorectal Gynecologic Other GU (Bladder & Testis) Hematologic (HD, NHL, Leukemia) Melanoma Lung Other Cancer and cancer treatment has profound implications for individuals and society Physical Psychological Social Vocational Spiritual Economic The challenge in overcoming cancer is not only to find therapies that will prevent or arrest the disease quickly, but also to map the middle ground of survivorship and minimize medical and social hazards Mullen NEJM 1985

8 Goals of Long-Term Follow-up Care Monitor for recurrence, 2 nd breast cancer Maintain patient-clinician relationship Treat for complications of therapy Encourage compliance with ongoing therapy and surveillance recommendations Back to Normal Strategies to help patients to adjust to life after treatment Navigating re-entry Completing the transition What are our roles? Assist with medical and social decisions that may be impacted by history of breast cancer Provide psychosocial support Lifestyle and Breast Cancer: The Bottom Line Exercise Numerous observational studies show active women less likely to develop breast cancer and active survivors less likely to die from breast cancer Small studies show exercise in safe in breast cancer patients Next Step: Randomized trial to see if exercise can improve survival in breast cancer Conclusions The number of breast cancer survivors is growing Care for survivors is as important as care at the time of diagnosis Better understanding and research of the effects of weight, diet, and exercise on breast cancer risk and recurrence is necessary Thank you! Thank You Rebecca G. Stephenson PT, DPT, MS rstephenson1@partners.org

9 Advances in Breast Reconstruction Stephanie A. Caterson, MD Brigham and Women s Hospital Faulkner Hospital Plastic and Reconstructive Surgery Why is Reconstruction Important? Femininity Wholeness Beauty Healing Female Body Image Ideal breast Size/shape are variable Puberty, weight gain/loss, pregnancy, lactation, menopause, gravity Goals Nipples pointed forward Soft consistency Symmetric Sensate No (minimal) scars Venus Breast Reconstruction ,102 breast reconstructions performed 75% implant 18% TRAM 7% DIEP 27% of patients diagnosed with breast cancer undergo reconstruction Range 5 81% Geographic location Patient age Co-morbidities Economic status Lack of referral to a plastic surgeon History of Breast Reconstruction 1895 Vincent Czerny 1960 s Silicone implants Manufactured product, risks with radiation 1970 s Latissimus flap Still usually requires an implant 1979 First pedicled TRAM flap Entire breast mound formed from autologous tissue 1980 s Free TRAM flap 1992 Deep Inferior Epigastric Perforator (DIEP) flap 1993 Superior Gluteal Artery Perforator (SGAP) flap #1 #2 Reconstruction Options Immediate OR Delayed Implant Based OR Autologous Based Tissue Expander / Implant Pedicle TRAM Flap Alloderm TE / Implant Free TRAM Flap Latissimus Flap / Implant DIEP Flap SIEA Flap SGAP Flap IGAP Flap

10 Implant Reconstruction Tissue Expansion / Implant Two shorter operations Multiple office visits Shorter recovery time No loss of other tissues Minimizes scars Risks: Capsular contracture Radiation Leakage / rupture Maintenance surgery Tissue Expansion / Implant Alloderm Breast Reconstruction Placed partially or totally under chest wall muscles Pectoralis major Serratus anterior Rectus abdominus Issues with Muscle spasm Splinting/guarding Shoulder ROM Scarring Chest wall tightness Alloderm Breast Reconstruction Implant Alloderm Reconstruction Minimizes muscle loss Maintains maximal amount of natural breast skin Helps to define natural breast landmarks Inframammary fold Lateral breast curve Pre Op Post Op Three Year Photos courtesy of Karl Breuing, MD

11 Latissimus Flap with Implant More natural tissue = more natural result Usually still need implant Longer initial surgery Decreases risks associated with implant and radiation Latissimus Flap with Implant Lose muscle function Initial shoulder weakness 15-20% Issues with Muscle spasm Ligation of TD nerve Splinting/guarding Shoulder ROM Medial rotation Adduction Shoulder extension Latissimus Flap with Implant Synergistic muscle compensation Teres major Subscapularis Pectoralis major Residual weakness Dominant arm Sports Tennis Golf Skiing Autologous Tissue Reconstruction Abdomen Flaps: Pedicled TRAM (Transverse Rectus Abdominus Myocutaneous) Free TRAM DIEP (Deep Inferior Epigastric Perforator) SIEA (Superficial Inferior Epigastric Artery) Buttock Flaps: SGAP (Superior Gluteal Artery Perforator) IGAP (Inferior Gluteal Artery Perforator) Basic Anatomy Basic Anatomy Internal Mammary Vessels Superior Epigastric Vessels Deep Inferior Epigastric Vessels

12 Pedicled TRAM Flap Pedicled TRAM Flap Benefits All of your own tissue no implant Very natural looking results Ages with the patient Risks Sacrifice entire rectus muscle Abdominal weakness Abdominal hernia Fat necrosis Biomechanics Complete removal of rectus muscle Mesh patch Altered tension of thoracolumbar fascia back pain?? recruitment of obliques? compensation of contralateral rectus Pedicled TRAM Flap Loss of rectus muscle abdominal strength Curl up / sit up Rotation Isokinetic flexion exercise ability More pronounced with bilateral procedure Therapy maneuvers Log roll Trunk stabilization exercises Free TRAM Flap Benefits No implant Very natural looking results Ages with the patient Less fat necrosis better blood supply Risks Sacrifice entire rectus muscle Abdominal weakness Abdominal hernia Risk of microsurgery Introduction of Perforator Flaps Perforator Flap Concepts Pioneered perforator flap breast reconstruction 1989 SIEA 1992 DIEP 1993 SGAP IGAP Robert Allen, MD Blood vessels are dissected out from the muscle Muscle previously considered essential carrier for blood supply Muscle remains in place to continue to perform necessary functions Minimizes donor site morbidity

13 DIEP Flap No implant Benefits Very natural looking results Ages with the patient Minimal abdominal weakness Minimal risk of abdominal hernia Risks Microsurgery 2-3 % flap loss rate Longer operation DIEP Flap Benefits Preserves of abdominal strength 70% rectus abdominus muscle function Lower abdominal hernia rate <1% verses 1-15% in TRAMs Improvement of abdominal contour Decreased post-operative pain Faster recovery Decreased care costs SGAP Flap Superior Gluteal Vessels Benefits No implant Very natural looking results Ages with the patient No abdominal complications Entirely muscle sparing Risks Microsurgery Technically difficult operation Cannot do bilateral in one setting Peri-Operative Course Length of surgery Unilateral DIEP = 6-8 hours Bilateral DIEP = hours Unilateral SGAP = 12 hours Hospital Stay First 24 hours in ICU Stay for 4-5 days total Flap monitoring Transcutaneous Doppler, physical exam Peri-Operative Course Medications Heparin in operating room Aspirin in hospital and for one month Antibiotics Pain Medication Activity Very limited for first 2 weeks No restrictions at 6 weeks No pressure on central chest The Ideal Patient Young Flap ages with you, no implant risks Active Perforator flaps preserve natural function of muscles Healthy Able to tolerate a longer procedure Bilateral reconstruction needed BRCA

14 Perforator Flap Candidates Any Age Dependant on overall health / co-morbidities Suitable body habitus Lower abdominal soft tissue excess Even slender patients usually can donate from the gluteal region Obesity is NOT a contraindication Perforator Flap Contraindications Heavy smoking history Significant cardiopulmonary disease History of blood clots (DVT, PE) Previous surgery that has damaged deep inferior epigastric vessels Allergy to anti-coagulants Heparin, aspirin Perforator Flap Risk Factors DIEP Flap Procedure Prior chest wall radiation Wait 6 months after completion of treatment Diabetes Autoimmune disease Prior procedures to donor area Liposuction or scars Smoking Must abstain 4 weeks pre-op and post-op DIEP Flap Procedure DIEP Flap Procedure

15 DIEP Flap Procedure DIEP Flap Immediate 9 days post op Before and after second stage operation Two months post op Three months post op DIEP Flap Results SGAP Procedure Bilateral immediate DIEP flap SGAP Procedure SGAP Flap Results Left immediate SGAP flap

16 SGAP Flap Results BWH Perforator Protocols Left SGAP flap donor site Peri-Operative Management Under development Clinical Pathway Post-op Order Template Standardized Discharge Instructions Team approach with excellent patient care is #1 priority Peri-Operative Management Physical Therapy Consultation Usually evaluate on POD#1 in ICU Assist with OOB techniques Minimal use of upper extremities Increase activity daily POD#2 = short distance ambulation POD#3 = increased distance, hallway POD#4 = stairs, ROM, limitations review Personalized educational handout for home therapy Peri-Operative Management Things NOT to do: NO PRESSURE ON CENTRAL CHEST Microvascular anastamosis very fragile NO VASOPRESSOR MEDICATION Treat hypotension with IVF/blood, not drugs Do not cover incisions or flap Do not bath or wash flap for first 48 hours No rolling patient for first 48 hours No laboratory blood work needed Peri-Operative Management POD#0 Intensive flap monitoring for first 24 hours Transcutaneous Doppler q15min, then q30min, then q1hour Check for pink color, warmth, capillary refill, swelling Bedrest with HOB elevation, knees flexed Keep room warm (>78 ), Bair Hugger prn Aspirin started in ICU on arrival, then qday Antibiotics, PCA, Heparin SQ Supplemental oxygen to keep sats ~ 100% Pneumatic boots at all times

17 Peri-Operative Management POD#1 Intensive flap monitoring for first 24 hours CBC in AM Incentive spirometry 10 times q 1 hour If flap stable: Advance diet OOB to chair with assistance Transfer to floor after physician / NP OK Flap monitoring now q 2 hours and prn Peri-Operative Management POD#2 Flap monitoring q 2 hours House diet OOB with ambulation Pneumatic boots while in bed DC foley DC PCA, switch to oral pain regiment Heplock IVF Start VNA service arrangements Peri-Operative Management POD#3-4 Flap monitoring q 4 hours Increased ambulation, stairs, ROM, limitations review VNA service arrangements OK to shower with Tegaderm over JP sites Discharge planning PT educational handout JP teaching Discharge Instructions JP measurements and stripping Cannot wear a bra for ~ 4 weeks Do not use anything hot or cold on flap Flap has no sensation, and can be easily burned or damaged Showering OK with Tegaderms at JP sites No driving No heavy lifting No pressure to central chest Must wear seatbelt in car, use small pillow to cushion Continue antibiotics, aspirin (one month), pain medications

18 Questions? Contact Information: Stephanie A. Caterson, MD Oncologic and Radiotherapy Principles in Breast Cancer Stephanie A. Caterson, MD Brigham and Women s Hospital Faulkner Hospital Plastic and Reconstructive Surgery Breast Evaluation Breast Self-Exam Start with development of breast Performed monthly, after menses Annual Professional Breast Exam Digital Mammogram Annually, starting at age 40 Earlier in high risk patients Ultrasound / MRI The First Step Establish a diagnosis BIOPSY Non-invasive or invasive Size Tumor grade Hormone receptor status Estrogen / progesterone HER2/neu oncogene overexpression

19 Treatment Plan Surgery Lumpectomy or Mastectomy Lymph Node Evaluation Sentinel Node verses Full Axillary Dissection Chemotherapy Before or After Surgical Intervention Radiation Usually After Surgical Intervention Hormonal Therapy Timing is Variable! Surgery +/- hormonal therapy Surgery radiation +/- hormonal therapy Surgery chemotherapy radiation +/- hormonal therapy Chemotherapy surgery radiation +/- hormonal therapy Who Gets Surgery? Everyone! This is the mainstay of breast cancer treatment Options of: Mastectomy Breast Conservation (Lumpectomy) All patient with invasive cancer need lymph node evaluation +/- breast reconstruction Surgical Risks Scarring / Adhesions Decreased ROM Weakness Lymphedema risk for infections Neuropathy Chronic pain Who Gets Chemotherapy? Decisions on systemic therapy made based on risk of recurrence after surgery Invasive cancer Lymph nodes positive Large tumors Pre-menopausal patients Aggressive tumors Adjuvant Chemotherapy Reduces risk of recurrence 30% May have differential benefits in ER+/ER- breast cancer Given in cycles, each lasting 2-3 weeks, for weeks total Patients receive an IV infusion on day 1, then spend rest of time at home. Standard medications are used to prevent side effects

20 Standard Adjuvant Chemotherapy Regimens A = doxorubicin (Adriamycin) C = cyclophosphamide (Cytoxan) T = paclitaxel (Taxol) or docetaxel (Taxotere) H = trastuzumab (Herceptin) AC x 4 TC x 4 Dose dense AC + T TAC x 6 AC + TH + H Hormone Sensitive Tumors HER 2 positive Treated with Herceptin for 1 year ER/PR positive Treated with Tamoxifen for 5 years 2 weeks AC AC AC AC T T T T Chemotherapy Side Effects Radiation Common Nausea Hair loss Fatigue/Anemia Mouth sores Low white blood cell count (neutropenia) Infection requires hospitalization Neuropathy especially with taxanes Rare but severe Sepsis Cardiac Damage Secondary leukemia Uses high energy beam to damage cells Both cancer and normal cells effected Reduces the risk of recurrence Total of 60 Gray dose given Divided up over 6 weeks Receive treatment 5 days per week Who Gets Radiation? After breast conservation (lumpectomy): ALL PATIENTS After mastectomy: Large tumors Positive lymph nodes Positive margins Radiation Risks Immediate Skin redness Skin blistering Fatigue Breast tenderness Long Term Increased scarring Poor wound healing Lymphedema Permanent skin changes Telangiectasias Hyperpigmentation Loss of breast volume Increased breast firmness Organ damage

21 Breast Cancer Treatment: Local Management Breast Cancer Treatment: Systemic Therapy TREATMENT Partial mastectomy or mastectomy Breast irradiation LONG-TERM or LATE COMPLICATIONS Lymphedema Brachial plexopathy Radiation pneumonitis Cardiovascular damage Second malignancies Contralateral breast cancer TREATMENT Chemotherapy Adriamycin Cyclophosphamide Taxanes Biologic therapy Trastuzumab Hormonal therapy Tamoxifen Ovarian Suppression Aromatase Inhibitors LONG-TERM or LATE COMPLICATIONS Chronic fatigue Weight gain Neuropathy Cognitive dysfunction Cardiac dysfunction Secondary malignancy Premature ovarian failure, infertility Osteoporosis Vasomotor symptoms Sexual dysfunction Venous thrombosis Endometrial pathology Musculoskeletal Impairments & Rehabilitation Considerations following Breast Cancer Surgery Reg B. Wilcox III, PT, DPT, MS, OCS Clinical Supervisor, Outpatient Services, Department Of Rehabilitation Services, Brigham & Women s Hospital Clinical Instructor, Adjunct Faculty, MGH Institute of Health Professions, Boston, MA Outline / Goals Barriers to Rehabilitation Musculoskeletal Dysfunction Individualized Rehab Program Clinical Pearls Multiple Variables Further research needed Barriers to rehabilitation Absence of robust evidence Interventions are multi-factorial, timevarying How do you measure outcome? Function Vocational ability Community re-integration Interventions & Outcomes are variable Sample size issues Barriers to rehabilitation Dearth of clinicians specializing in care MD, PTs, OTs Lack of emphasis in rehabilitation literature Lack of dedicated programs for patients with Ca Often little to no relationships between MDs and PTs (not an issue at BWH) Patient s financial burdens Patients lack access to services they need Cheville & Tchou. J Surg Oncol 2007; 95:

22 Barriers to rehabilitation Rehab Following Breast Surgery Patient compliance with home program / exercise poor if: No premorbid exercise tendencies Evidence exists that structured physical activity has an impact in mitigating effects of anti-cancer treatments Allow for adequate Healing Minimize / eliminate stiffness Has not been integrated into mainstream cancer care Rehab Following Breast Surgery Rehab Following Breast Surgery Motion to prevent stiffness Do not want to overstress healing tissue Too Much Tissue Stress Not Enough Tissue Stress Rehabilitation Concepts Know the pathology / surgery Respect healing timeframes Walk the tightrope, use teamwork! Make adjustments often! Pathophysiological Targets of Rehab Soft tissue fibrosis Muscle performance deficits Lack of flexibility (ROM) Lymphatic insufficiency Muscle hypertonicity Neural hypersensitivity Maximize Healing, minimize stiffness

23 Breast Cancer Facts 40 % have metastasis in axillary lymph nodes Axillary Lymph Node Dissection 73 % report: Restricted shoulder mobility Tightness Edema Pain numbness Limitations in ADLs Warmuth et al. Cancer 1998; 83: Hack et al. J Clin Oncol 1989; 17: Shoulder Impairments 7-36 % of general population have shoulder related dysfunction Minimal research looking at the efficacy of PT regarding the shoulder following breast cancer surgery Examination/Assessment Initial Pathology Pre existing shoulder function / injuries Surgical Procedure Adjuvant Therapy Patient s Goals Drive Rehab Plan Breast Cancer Surgery What type of surgery Which tissues are compromised Adjuvant Therapy Evaluation R/O Cspine pathology Thoracic kyphosis or cervical lordosis Thoracic ext restrictions (L trap inhib.) Scoliotic curves Muscular bulk, symmetry, atrophy, spasm, tenderness, adaptive shortening Preexisting shoulder dysfunction Prognosis of the UE following surgery and radiation for breast cancer (Lee at al. Breast Cancer Res Treat 2007) What can we pull from the Literature? Systematic Review (5110 to 32 studies) Identify prevalence/severity of UE problems 1-67% shoulder ROM restrictions 0-34% lymphedema 9-68 % shoulder/ue pain 9-28% UE weakness QOL measures high across all studies Irradiated patients higher odds of: Lymphedema & shoulder restrictions