Breast cancer is an increasingly common diagnosis, and many people have family or friends who have or had the disease. It always comes as a surprise. Nine-time Wimbledon singles champion Martina Navratilova cried when her biopsy was positive and said, “I am shocked. This is my 911.” Even with the publicity generated when a celebrity like Navratilova is diagnosed, many women are still not aware of the risk factors, symptoms, and treatment options for breast cancer.

What Is Breast Cancer?

According to the National Cancer Institute, breast cancer is defined as cancer that forms in tissues of the breast, usually the ducts (tubes that carry milk to the nipple) and lobules (glands that make milk). According to the data available, breast cancer is the most common form of cancer in women after skin cancer. Out of all newly diagnosed cases of cancer, a third are breast cancer. The mortality rate is 21% of established cases. It occurs in both men and women, although male breast cancer is rare. Breast cancer is also the number-one cause of death in Hispanics and second-most common cause of death in Caucasians and African-Americans.¹

The risk of developing breast cancer increases with age. It has been shown that the following factors increase risk:^2-6

• Previous history of breast cancer
• Family history of breast cancer diagnosed in mother, sister or male blood relative
• Onset of menses before age 12
• Delivery of first child after age 30
• Use of combination of estrogen-progestin for more than five years
• Exposing the chest wall to radiation (e.g. radiation for Hodgkin disease)
• Obesity increases risk after menopause
• Alcohol consumption
• Physical inactivity
• Genetic alterations like BRCA1, BRCA2 (no more than 10% of all breast cancers)

The staging of breast cancer — the process of finding out whether cancer has spread and if so, how far — is important, as it is a significant factor in determining the treatment and disease state. The purposes of staging are to plan a therapeutic strategy that is most appropriate for the patient, allow for more intelligent prognostication of the disease status of the patient, and permit comparison of therapeutic results obtained from different sources by different means.⁷ According to the American Cancer Society, the TNM system is most commonly used for staging breast cancer. T describes to the tumor size. N details whether the cancer has spread to nearby lymph nodes, and if so, how many. M shows whether the cancer has spread (metastasized) to other organs. The information is then combined into “stage groupings,” labeled with Roman numerals (usually from I to IV). In general, the lower the number, the less the cancer has spread. A higher number means a more serious cancer.

Staging of Breast Cancer8
Stage	Tumor Size	Lymph Node Involvement	Metastasis
Stage I	<2 cm	No	No
Stage II	2 cm to 5 cm	No or in the same side of breast	No
Stage III	>5 cm	Yes, same side of breast	No
Stage IV	Any size	N/A	Yes

Diagnosis and Treatment

Routine physical examinations, annual mammograms, breast self-examinations, and genetic testing help in screening for and diagnosing breast cancer. There is also a Breast Cancer Risk Assessment Tool from the National Cancer Institute that helps woman calculate their risk for developing breast cancer.9 However, breast cancer is often diagnosed after a patient finds a palpable mass in her breast. Diagnosis methods include imaging (mammogram, ultrasound, MRI), ductal lavage (harvesting of cells from the mammary ducts), ductoscopy (endoscopy that assesses early changes in womens’ breast ducts), and biopsy (fine needle aspiration, core needle biopsy, surgical biopsy with tissue analysis).

Signs and Symptoms

• Persistent lump or thickening of breast or armpit area
• Discharge from nipple
• Distorted shape of breast or retracted nipple
• Enlarged, tender lymph nodes
• Changes in color or skin of breast or areola (e.g. dimpling of skin over breast)
• Usually painless (pain may be referred around chest into axilla or neck)
• Unusual rash over breast and nipple
• Unusual prominence of breast veins

Recent Issue

The U.S. Preventive Services Task Force, which issues recommendations for preventive healthcare services, has broken away from the pack of leading medical organizations that recommend routine screening begin at age 40. It now states that routine breast cancer screening for women younger than 50 is not necessary. However, the National Cancer Institute recommends that women 40 and older have mammograms every one to two years. Women who are at higher risk should talk to their physician about having a mammogram before age 40.¹⁰

According to the Centers for Disease Control and Prevention, mammography rates have plateaued since 2002.¹¹ Reasons for this plateau may include access to and availability of services, healthcare norms, fear and ignorance. Furthermore, illegal immigrants may be afraid of being caught and penalized.

There are different interventions available for the treatment of breast cancer, including surgery, chemotherapy, radiation therapy, and hormonal therapy. These depend on the staging of the cancer:⁷

• Lumpectomy involves the removal of a tumor with a small margin of surrounding tissue.
• Modified radical mastectomy removes the entire breast tissue and some of the lymph nodes under the arm.
• Total mastectomy involves removal of the entire breast along with the pectoralis major muscle.
• Chemotherapy is systemic treatment in which the drug travels throughout the body to attack and destroy the cancer cells. Chemotherapy is given in the form of pills, IV or injection. These drugs are strong and damage both cancer cells and normal cells.
• Radiation is administered locally, as brachytherapy or systemically. Local radiation radiates the involved tissue; brachytherapy involves placement of radioactive material into the body near cancer cells; and systemic radiation is administered orally or intravenously.
• Hormonal (anti-estrogen) therapy is effective against hormone-receptor-positive breast cancer. It is different from hormone replacement therapy.
• Women who are at high risk for developing breast cancer may opt for a preventive mastectomy. This is also called a prophylactic or risk-reducing mastectomy. It is the surgical removal of one or both breasts in an effort to prevent or reduce the risk of breast cancer.¹² Data suggests that preventive mastectomy may significantly reduce the chances of developing breast cancer in high-risk women.6 The complications are similar to those of any other surgery.

Treatment Side Effects Relevant to Physical Therapists

Chemotherapy

• Bone marrow suppression and anemia
• Chemotherapy-induced peripheral neuropathy (CIPN)
• Weight loss
• Fatigue
• Decreased immunity
• Increased bleeding

Radiation therapy

• Fatigue

Hormonal therapy

• Hot flashes
• Bone and joint pain
• Heart problems
• Blood clots

What Happens After Breast Surgery?

After surgery, the patient has to cope with the loss of a part of the breast or the entire breast, which can make her feel less feminine. This creates emotional turmoil. Breast reconstruction plays an important role in the psychological recovery of patients. Breast reconstruction rebuilds the breast and is performed by a plastic surgeon. Women who decline to have breast reconstruction may have breast forms or external prosthesis and use specialized bras. There are two types of breast reconstruction: one-stage immediate reconstruction and two-stage delayed reconstruction.

One-stage immediate reconstruction is done during the mastectomy procedure. The surgeon removes the breast and a plastic surgeon immediately places the implant to form the breast contour. Immediate reconstruction saves the additional trauma of a second surgery.

Delayed reconstruction is for women who need radiation therapy after surgery. Two-stage delayed reconstruction is done in two steps: Initially, the tissue expander is put under the chest wall, and it’s periodically injected with a salt-water solution to fill the expander (4 to 6 months) and stretch the chest. Later the expander is removed, and a permanent implant is placed.

The transverse rectus abdominis myocutaneous flap (TRAM) is a common type of breast reconstruction.¹³ This procedure uses skin, muscle tissue and fat tissue from the lower abdomen to reconstruct the breast. It usually does not require an implant as long as there is enough excess skin and fatty tissue in the lower abdomen. There are two types of TRAM: free flap and pedicle flap. In a TRAM pedicle flap, the flap remains attached to the rectus muscle and is tunneled into the breast under the abdomen. It uses the original blood supply of the muscle. In a free TRAM flap, the muscle is cut and is attached to the chest where the blood vessels are reconnected by microsurgery. The blood vessels are either attached to the chest or under the arm. The nipple and areola can also be reconstructed. The surgery is complex and invasive, it leaves a large scar across the abdomen, and the loss of abdominal muscle will cause some weakness in this part of the body. Also, healthy blood vessels are needed for tissues to heal; hence, the procedure is not preferred for women with diabetes, vascular or connective tissue disorder, or history of smoking. Once the procedure has been done, it cannot be repeated.

For the latissimus dorsi muscle flap procedure, a large muscle in the back along with skin and underlying fatty tissue is removed, and the tissues are used to reconstruct the breast. Because the flap is about an inch thick, it usually requires an implant to make the reconstructed breast match the size of the opposite breast.

The newer, deep inferior epigastric perforator (DIEP) flap is another method of breast reconstruction. The DIEP flap procedure, like the TRAM flap procedure, uses skin and fat tissue from the lower abdomen to form the reconstructed breast. But unlike the TRAM flap, the DIEP flap keeps the muscle intact. This speeds recovery and preserves abdominal strength. This type of reconstruction cannot be repeated, and it usually requires two surgeons well trained in microvascular techniques.

The superior gluteal artery perforator (S-GAP) flap procedure uses skin and fatty tissue from the upper part of a buttock to reconstruct the breast. Because no muscle is used, athletic ability after surgery is rarely affected. If the procedure leaves the buttocks different sizes, fat can be removed from the opposite buttock with liposuction. The S-GAP flap procedure also requires a surgeon well versed in microvascular techniques; however, if it is not successful, it can be repeated using tissue from the opposite buttocks.

A new procedure, nipple-sparing mastectomy, preserves the nipple and areola. This is performed on women who have an early stage of cancer or no spread of cancer to or around the nipple. However, complications like a decrease in blood supply to the nipple can actually deform it. There may also be a loss of sensation to the nipple or breast tissue.

Risks associated with reconstruction surgery are —

• Incisional drainage at donor or recipient site
• Scar tissue formation
• Pain, bleeding/hematoma and swelling at surgical site
• Infection at surgical site
• Necrosis of the tissue or muscle flap
• Loss of nipple sensation
• Muscle imbalances of the arm on the involved side
• Side effects of the anesthesia or prescribed pain medications

Hospital stay depends on the type of the surgery. The Breast Cancer Patient Protection Act protects women discharged from the hospital and prohibits insurance companies from limiting the benefits of the stay to less than 48 hours status post-mastectomy and 24 hours status post-lymph node dissection.

Rehabilitation

Many women are not aware of the role of rehabilitation following breast cancer treatment. Breast cancer survivors can face issues such as premature menopause, body image/sexual relationship problems, fatigue, comorbidities as a result of cancer treatments, and a greater risk of psychological distress, depressive episodes and lifestyle disruption.^14,15 The cancer rehabilitation team should include a physician, physical therapist, occupational therapist, nurse, nutritionist and psychologist.

Upper limb dysfunction and decreased quality of life are frequently reported sequelae of early stage breast cancer treatment.¹⁶ Physical therapy helps to improve function post-surgery and prevents lymphedema.^17,18 PTs help address the functional deficits post-surgery, effects of radiation, chemotherapy-induced peripheral neuropathy (CIPN) and lymphedema therapy. Intervention and treatment include upper limb ROM. Strengthening exercises should be introduced to patients preoperatively with instruction to begin shortly after breast cancer surgery.¹⁶ Preoperative assessments enable early diagnosis and recovery of shoulder function in patients with breast cancer.¹⁶ A combined aerobic (e.g., step-up blocks, cycling) and resistance exercise program (e.g., chest press, biceps curls, triceps extension, hip abduction, abdominal crunches) is an effective strategy for improving quality of life, reducing fatigue and social physique anxiety, and improving physical fitness soon after the completion of adjuvant therapy for breast cancer.¹⁴

Physical therapy goals emphasize ROM of the shoulder, strengthening and stretching of shoulder and shoulder girdle musculature, postural correction and patient education. Incisional pain is common post-surgery, which sets off the vicious cycle of spasm of the neck and shoulder musculature, resulting in adhesive capsulitis. Radiation leads to fibrosis of the radiated tissue, leading to tightness of the chest wall and surrounding musculature, which affects shoulder ROM. Impaired ROM and shoulder and shoulder girdle weakness results in faulty postures like rounded shoulders and kyphosis. Exercise can result in a significant and clinically meaningful improvement in shoulder ROM in women with breast cancer.¹⁹ Shoulder exercises can be initiated immediately after surgery.²⁰ Strengthening of the shoulder musculature, especially horizontal adductors of shoulder and serratus anterior, using free weights or resistance bands is important. Isometic exercises in various ranges can also be included in the plan of care. Wand exercises and elbow winging in supine lying, shoulder blade squeeze and side bending in sitting, and chest wall stretch in standing are activities that should be incorporated into treatment.

Post-op considerations for free TRAM include shoulder restrictions to 45 degrees for two weeks. For pedicle TRAM, there are shoulder flexion/abduction limitations to 90 degrees for two weeks. With TRAM flaps, back problems are the most common because patients have decreased core strength and oblique muscle compromise. Decreased shoulder ROM and lymphedema may be present. Absolute restrictions for reconstructive surgery include ROM restrictions for two weeks and no lifting over 5 pounds for 6 weeks. For the latissimus dorsi muscle flap procedure, the shoulder flexion/abduction is restricted to 60 degrees for two weeks. However, the physical therapist should work closely with the surgeon while performing range of motion on the affected shoulder.

There are a few considerations during rehabilitation — ²¹

• Exercise as tolerated with low intensity
• Stop exercising and consult the surgeon if there is —
  • An increase in pain
  • New heaviness in the affected arm
  • Increased swelling
  • Headaches, lightheadedness or visual changes
  • Episodes of impaired balance and falls
  • Onset of neural symptoms, such as tingling or numbness on affected arm

What Is Lymphedema?

Lymphedema is abnormal accumulation of protein-rich fluid in the interstitium, resulting in inflammation and reactive fibrosis of affected tissue. It occurs due to removal of the lymph nodes during surgery and side effects of radiation. Lymphedema may take weeks, months or years to develop. Late-onset lymphedema may occur secondary to weight gain following cancer treatment, infection, or injury of the affected arm.

For patients who underwent mastectomy, all BP readings, IVs or needlesticks should occur only on the uninvolved side. Healthcare professionals should be aware that the chances of lymphedema will increase with infection, with trauma to the arm, with sunburn that stimulates the formation of fluid in the arm, or when the flow of lymph out of the arm is slowed or reduced (as in taking blood pressure). Also, there may be an error in the blood pressure reading on a lymphedemic arm.

Because there is no cure for lymphedema, intervention is focused on preventing occurrences and recurrences. Prolonged building up of fluid can lead to permanent lymphedema. Treatment includes manual lymph drainage, compression bandage, muscle strengthening, pneumatic compression pumps, skin care and education. Manual lymph drainage should be done by a certified professional, as the intensity of the massage strokes is important; excess pressure can lead to lymph vessel spasm. Lymphedema can also lead to decreased grip strength, so gripping exercises and active finger movements are important. Patient education about skin care should be part of the plan of care. To treat the condition, physical therapists have to be certified, which requires aggressive manual training.

Aquatic therapy assists in progressive muscle strengthening. Water depth will result in increased pressure, which can stimulate the lymph nodes. 

Chemotherapy-induced peripheral neuropathy (CIPN) presents with paresthesias/dysaesthesias, burning, numbness and tingling along with weakness in upper extremity musculature. Therefore, appropriate interventions should be chosen during physical therapy. Examples include arm elevation in sagittal planes versus frontal planes due to less neural excursions, rare use of upper limb tension tests, and initiating ROM in a symptom-free range.

Psychological Aspects of Cancer

Breast cancer frequently affects women’s psychological status.²² Although the process of adapting to the disease differs among patients, this condition may lead to depression and anxiety (mostly related to a fear of recurrence), while requiring psychotherapy and medical management.^22,23 Strong predictors of anxiety and depression in patients with breast cancer are poor family relationships and functioning, maladaptive problem and conflict solving, and presence of pain and fatigue.²³ The two disorders influence coping with cancer and promote a negative quality of life.²² One study suggested that 19% of patients were suffering with depression, 2.5% with grade I anxiety, 77% with grade II anxiety, and 19% with grade III anxiety.²² In the same study, quality of life evaluations, difficulty sleeping, emotional status, fatigue and body appearance were related to both depression and anxiety, whereas physical function, role performance, cognitive condition, social position, pain, general health, treatment methods, future anxiety and arm symptoms were negatively affected in patients with depression.²² According to another prospective cohort study, women with lymphedema after surgery had significantly worse emotional well-being and adjustment to life compared with women without lymphedema.²⁴

Breast Cancer in Men

Breast cancer is not very prevalent among men, who have a lifetime risk of 1 in 1,000.25 The prognosis is the same in males and females. Risk factors for men include family history, genetic mutations, aging, Kleinfelter syndrome, conditions affecting the testicles (e.g. undescended testicle, orchiectomy), obesity, liver disease, alcohol consumption and estrogen treatment.

Conclusion

The best way to prevent breast cancer is early detection and risk reduction. Over the last 10 years, there has been a decrease in incidence and death from breast cancer.²⁶ Currently, there are organizations, community outreach programs and support groups available to survivors. As physical therapists, our goal should be to design individualized educational and treatment programs focusing on breast cancer rehabilitation.

Resources

American Cancer Society
Arab American Breast Cancer Education and Referral Program (AMBER)
Living Beyond Breast Cancer
Mammography Facilities
National Breast Cancer Foundation
SHARE: Self-Help for Women With Breast or Ovarian Cancer
Susan G. Komen Breast Cancer Foundation