Breast Cancer

Definition/Description [1]

Mammograms showing a normal breast (left) and a cancerous breast (right)

Cancer is a group of diseases that cause cells in the body to change and grow out of control. Most types of cancer cells eventually form a lump or mass called a tumor.  Most masses are benign; that is, they are not cancerous, do not grow uncontrollably or spread, and are not life-threatening.  Cancers are named after the part of the body where the tumor originates.  Breast cancer begins in breast tissue, which is made up of:

  • Glands for milk production, called lobules,
  • Ducts that connect the lobules to the nipple, and
  • Fatty, connective, and lymphatic tissue


Some breast cancers are called in situ because they are confined within the ducts or lobules where they originated.  However, most breast cancers are invasive, or infiltrating. These cancers started in the lobules or ducts of the breast but have broken through the duct or glandular walls to invade the surrounding tissue of the breast.  In addition to spreading further into breast tissue, breast cancer cells can also metastasize, or spread to one or more sites elsewhere in the body.  This often occurs by way of the lymph system or bloodstream.

  • Regional or local metastasis is cancer that has spread to the lymph nodes, tissues, or organs close to where the cancer started (the primary site).[2]
  • Distant metastasis is cancer that has spread to organs or tissues that are farther away.[2]  The main sites of metastasis for breast cancer include the lungs, liver, and bones.[3]


The seriousness of invasive breast cancer is strongly influenced by the stage of the disease; that is, the extent or spread of the cancer when it is first diagnosed. One system that classifies the extent of the cancer is the TNM classification of tumors.  The TNM staging system uses information on tumor size and how far it has spread within the breast and nearby organs (T), lymph node involvement (N), and the presence or absence of distant metastases (M). Once the T, N, and M are determined, a stage of 0, I, II, III, or IV is assigned, with stage 0 being in situ, stage I being early stage invasive cancer, and stage IV being the most advanced. The TNM staging system is commonly used in clinical settings.

Below is a table outlining the stages of breast cancer according to the TNM staging system.

Breast Cancer Staging[4]

Tumor sizing.jpg

Stage

Definition

0

  • Cancer cells remain inside of breast duct, without invasion into normal breast tissue

I

  • Cancer is 2 cm or less and is confined to the breast (lymph nodes are clear)

II-A

  • No tumor can be found in the breast, but cancer cells are found in the axillary lymph nodes (lymph nodes under the arm) OR
  • The tumor measures 2 cm or smaller and has spread to the axillary lymph nodes OR
  • The tumor is larger than 2 cm but not larger than 5 cm and has not spread to the axillary lymph nodes. 

II-B

  • The tumor is larger than 2 cm but not larger than 5 cm and has spread to the axillary lymph nodes OR
  • The tumor is larger than 5 cm and has not spread to the axillary lymph nodes.

III-A

  • No tumor found in the breast. Cancer found is found in the axillary lymph nodes that are sticking together or to other structures; or cancer may be found in lymph nodes close to the breast bone (sternum) OR
  • The tumor is any size. Cancer has spread to axillary lymph nodes, whcih are sticking together or to other structures or cancer may be found in lymph nodes close to the breast bone (sternum).

III-B

  • The tumor may be any size and has spread to the chest wall and/or skin of the breast AND
  • May have spread to the axillary nodes that are clumped together or sticking to other structures OR
  • Cancer may have spread to lymph nodes near the breast bone (sternum).
Inflammatory breast cancer is considered at least stage III-B.

III-C

  • There may either be no sign of cancer in the breast or a tumor may be any size and have spread to the chest wall and/or the skin of the breast AND
  • The cancer has spread to lymph nodes either above or below the collarbone (clavicle) AND
  • The cancer may have either spread to the axillary lymph nodes or the lymph nodes near the breast bone (sternum).

IV

  • The cancer has spread (metastasized) to other parts of the body.

 


Prevalence

Prevalance is associated with the number of individuals that have already been diagnosed with breast cancer within in a specified time frame. Incidence is associated with the number of individuals that will be newly diagnosed with breast cancer within a specified time frame.[5] The overall statistical trend in female breast cancer has brightened since approximately 2003.  Medical advances in treatment, as well as earlier detection, has led to a decline in death rate and stabilization of the incidence rate.  According to new analysis of breast cancer, overall incidence and mortality rates may be decreasing.[6] Below are statistics based on factors that are generally associated with individuals who are diagnosed with breast cancer. According to the American Cancer Society, in 2008 there was an estimated 2.6 million individuals in the US who had breast cancer or who had a history of breast cancer.[1]

Gender—
  • Women: In 2011, excluding cancers of the skin, breast cancer was the most common cancer among women, accounting for nearly 1 in 3 cancers diagnosed in US women.[1]  Below is a table that has been generated from recently published statistics from the American Cancer Society regarding incidence and death rates of the top 5 cancers that affect women in the United States in 2012.  According to this table, breast cancer has the highest incidence rate and the second highest death rate of all cancers among women.[7]
Top 5 Cancers That Affect Women in the US, Estimates for 2012
Incidence Death
Breast (29%) Lung & bronchus (26%)
Lung & bronchus (14%) Breast (14%)
Colon & rectum (9%) Colon & rectum (9%)
Uterine corpus (6%) Pancreas (7%)
Thyroid (5%) Ovary (6%)

 

  • Men: Breast cancer in men is a rare disease and accounts for approximately 1% of breast cancer cases in the US.  However, like breast cancer in women, the likelihood of being diagnosed with breast cancer in men increases with age.  Also, incidence rates are higher for African American males as opposed to Caucasian males. Risk factors for males include BRCA gene mutations, Klinefelter syndrome, testicular disorders, family history of male or female breast cancer, and obesity.[1]

Age—Breast cancer incidence and death rates generally increase with age. Ninety-five percent of new cases and 97% of breast cancer deaths occurred in women 40 years of age and older. During 2004-2008, women 20-24 years of age had the lowest incidence rate (1.5 cases/100,000 women), while women 75-79 years of age had the highest incidence rate (421.3 cases/100,000 women). Also between 2004-2008, the median age at the time of breast cancer diagnosis was 61 years. This means that 50% of women who developed breast cancer were 61 years of age or younger at the time of diagnosis. Below is a table that estimates the incidence of breast cancer diagnosis and death according to age in 2011.[1]

Estimated New Female Breast Cancer Cases and Deaths by Age, US, 2011*

Age
In Situ Cases
Invasive Cases
Deaths
Under 40
1,780
11,330
1,160
Under 50
14,240
50,430
5,240
50-64
23,360
81,970
11,620
65+
20,050
98,080
22,660
All ages
57,650
230,480
39,520
*Rounded to the nearest 10.

 

Ethnicity—Breast cancer incidence rates are generally higher in non-Hispanic white women compared to all other racial and ethnic groups. Despite higher incidence rates, breast cancer death rates are generally lower among non-Hispanic white women compared to African American women.  African American women have a higher incidence rate before 40 years of age and are more likely to die from breast cancer at every age. It is possible that this trend is seen in African American women because there is a lower rate of combined menopausal hormone use and mammography screening compared to their Caucasian counterparts.The graph below illustrates the incidence and mortality rates among selected ethnicities and races in the Unitest States between 2003-2008. [1]
Incidence and deaths ethnicity.PNG

Characteristics/Clinical Presentation

Breast cancer may be undetectable and asymptomatic in the early stages, however, the most common initial sign of breast cancer is a palpable lump or nodule in the breast.[4][8]  For men, the lump is usually in the center of the breast behind the areola.  For women, the lump is either in the center of the breast behind the areola or outward in the direction of the armpit (upper, outer quadrant).  The mass tends to be firm and irregular if it is malignant versus smooth and rubbery if it is benign.   The lump, in most cases, will not be painful to the touch if it is cancerous.  Other manifestations include a change in breast shape or texture, unusual nipple discharge, retraction or dimpling in of the nipple, local skin dimpling, redness, and/or a local rash or ulceration.  Lymphadenopathy, or enlarged, swollen lymph nodes, may also be an initial finding of breast cancer.  Inflammatory breast cancer (IBC) is characterized by one breast becoming larger than the other with warmth, redness, swelling, itching, pain, skin dimpling, and nipple changes.  Some women also report that IBC looks like a bug bite on their breast, or like a bruise that will not go away. [4]   A mnemonic that is useful in recognizing the physical signs of breast cancer is BREAST: Breast mass, Retraction, Edema, Axillary mass, Scaly nipple, Tender breast. [8]

According to current research, self-awareness is thought to be more effective for detecting breast cancer than a monthly breast self-exam.  Women who detect their own breast cancer usually do so while bathing or getting dressed, therefore, all women should become familiar with the appearance and feel of their breasts.  Any changes that may be detected should be quickly reported to the physician.  The American Cancer Society no longer recommends that all women perform breast self-exams; however, there are potential benefits and women who wish to do so should recieve instruction from a health care provider.[1]

Breast Self Examination Video  

Breast quadrants.jpg

[9]

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Associated Co-morbidities/Secondary Complications

In terms of general health, the presence of 3 or more comorbid conditions in patients with breast cancer (heart disease, diabetes, hypertension, obesity, etc) has been associated with a fourfold higher rate of mortality at three years compared to women with no comorbidities.[4]  In a study published in the Journal of the American Medical Association, the effect of comorbidity on survival rates among African American and Caucasian breast cancer patients was examined.  The study concluded that controlling diabetes and hypertension alone could have a major beneficial impact on African American individuals with breast cancer.  The effect would be to increase the survival rates of African American individuals with breast cancer and to decrease the disparity in survival rates between blacks and whites.[11]


Hodgkin Disease is a chronic, progressive cancer of the lymphatic tissue that is characterized by enlargement of the lymph nodes. It affects males more than females, and occurrence peaks during adolescence and young adulthood, with a second peak occurring in late adulthood. Research indicates that there is an increased risk for breast cancer in individuals who have received radiation therapy for Hodgkin disease. The risk begins to be evident approximately 10-15 years after treatment, and continues to last for at least 20 years. Studies also indicate that women who are younger than 31 years old when treated with radiation for Hodgkin disease are more likely to develop breast cancer than those treated at older ages.[12]
 

While there are not many comorbidities directly correlated to breast cancer, secondary complications can arise from breast cancer and its treatment.  Such complications include decreased quality of life, weight gain, sleep disturbances, poor body image, fatigue, increased risk for osteoporosis, cardiovascular disease, premature menopause, and lymphedema.

Medications

Medications for the treatment of breast cancer most often include chemotherapy drugs and hormone replacement drugs. Chemotherapy medications are many times used in combinations of two or three at a time. Two common groups include anthracyclines and taxanes. Anthracyclines such as, Epirubicin and Doxorubicin, are similar to antibiotics that destroy the cancer cells’ genetic material. Taxanes such as, Paclitaxel and Docetaxel, on the other hand interfere with how the division of the cancer cells.[13]  Paclitaxel and Docetaxel are both categorized as plant alkaloid anticancer drugs. Each are given intravenously and used mostly to treat solid tumors involving breast and ovarian cancers. Toxicities are common in cancer treatment and each drug is not alike. The acute toxicity of Docetaxel is hypersensitivity and a rash and delayed toxicity results in neurotoxicity, fluid retention, neutropenia, alopecia, and bone marrow depression.[14]

Hormone therapies such as the drug Tamoxifen stop the growth, spread, or recurrence of ER-positive tumors by preventing estrogen from reaching the tumors. Tamoxifen is a mixed estrogen antagonist and agonist that blocks  the estrogen activation in the breast and decreases growth factors in the breast tissue. The side-effects are similar to postmenopausal symptoms: hot flashes, nausea, irregular menses, vaginal bleeding and weight gain, as well as slightly increasing a woman's risk for endometrial cancer.[15] Tamoxifen is the most common drug used for premenopausal women to help prevent the recurrence of breast cancer and another drug, Toremifene is the newer estrogen receptor antagonist that is being used in cases of advanced breast cancer.[4][14] Tamoxifen also appears to have a preventive effect in women with a high risk of breast cancer and has now been approved as a chemopreventive agent in this population. [14]

Drug Warning! Cancer patients who receive the targeted therapy bevacizumab (Avastin) in combination with chemotherapy are at increased risk of serious side effects that may lead to death, according to a meta-analysis of 16 clinical trials that was conducted by researchers at Stony Brook University School of Medicine in New York. Fatal events, most commonly hemorrhaging, only occurred in 2.5% of the participants receiving the Avastin treatment compared to those not receiving (1.7% of fatality). The approximated 50% increase in risk occurred in patients also prescribed platinum or taxane chemotherapy agents such as carboplatin and paclitaxel.
The results were published in [Rapura V, Hapani S, Wu S. Treatment-related mortality with bevacizumab in cancer patients: a meta-analysis. JAMA. 2011 Feb 2;305(5):487-94.][16]

Newly FDA Approved Drug

Treatment with eribulin (Halaven™) improved overall survival in women with metastatic breast cancer whose disease progressed despite multiple rounds of prior chemotherapy, according to the results of a phase III clinical trial called EMBRACE. Based on these findings, the FDA approved eribulin last November for women with metastatic disease who have already undergone at least two previous chemotherapy regimens. Eribulin is a laboratory-made form of halichondrin B, a substance derived from a sea sponge. It targets the protein tubulin cells (building blocks of microtubules (narrow, hollow tubes inside a cell), involved in cell division and cell movement), although it binds to tubulin in a different way, interfering with cancer cell division and growth. Women receiving eribulin lived 2.5 months longer than women treated with their physician’s drug of choice and had equal side effects of neutropenia, leucopenia, and peripheral neuropathy.
Study results from [Cortes J. Eribulin monotherapy versus treatment of physician's choice in patients with metastatic breast cancer (EMBRACE): a phase 3 open-label randomized study.The Lancet. 2011 Mar 12;377(9769):914-23.][16]

Diagnostic Tests / Lab Tests / Lab Values

            [[|]]     American College of Radiology Appropriateness Criteria® for Breast Cancer Screening.[17]

Mammogram 

Other than the clinical breast exam or self-breast exam, a mammogram is the most common diagnostic test used to detect for lumps within the breast tissue. A mammogram provides an x-ray picture of the breast tissue. Mammograms are typically suggested for women every year after they turn 40. It is recommended that women who are at a higher risk for breast cancer should talk with their doctors about an appropriate screening plan for them.[18][4]

Ultrasound

An ultrasound may be performed if a lump is suspected, and this test creates a picture of the tissue within the breast. Ultrasounds can help determine if the area in question is a cyst or a solid lump.[18][4]

MRI

MRI may provide a more detailed look at the breast tissue compared to a mammogram or ultrasound. MRIs are move expensive, but may show a lump that the other test did not pick up on previously.[18][4]Women who are at higher risk are recommended to not only receive yearly mammograms, but should also receive a yearly MRI.  Ultimately though women should discuss the appropriate screening process with their doctor.[13]

Biopsy

A biopsy is a procedure that is performed to detect whether the breast tissue that has been removed is cancerous or not. This test gives a definite answer whether cancer is present. A biopsy is suggested if there is an area within the breast that is questionable for cancer.[18][4]

Hormone Receptor Tests

If someone is diagnosed with breast cancer, hormone receptor tests can be used to help develop treatment options. If the cancerous tissue is positive for hormone receptors (estrogen and/or progesterone) then hormone therapy is a recommended form of treatment.[18][4]

HER2/neu Test

HER2 is the human epidermal growth factor receptor-2, which is a protein that can sometimes be found on cancer cells. The cancer cells that contain the HER2/neu protein tend to be more aggressive and may have less favorable prognosis. If this is the case, then a target approach to that specific area will be used as a treatment option.[18][4][14] 
Treatment with trastuzumab (Herceptin®)[19] for 1 year following standard chemotherapy improved disease-free survival in women with HER2-positive early breast cancer. The finding comes from the third analysis of the Herceptin Adjuvant (HERA) trial, a large multicenter study that compared outcomes in patients randomly assigned to receive standard chemotherapy followed by trastuzumab with those in patients randomly assigned to receive chemotherapy alone (the observation group). The 4-year follow-up results were reported in the article [Gianni L. Treatment with trastuzumab for 1 year after adjuvant chemotherapy in patients with HER2-positive early breast cancer: a 4-year follow-up of a randomised controlled trial. Lancet Oncology. 2011. March; 12(3):236-244.] [16]

Causes

There is currently no specific known cause of breast cancer, but there are risk factors that have been associated with those who develop breast cancer. Some of the risk factors are listed below.

Risk Factors for Breast Cancer in Women[20][4][18]

Key Risk Factors

  • Gender
  • Age > 60
  • Early menstrual cycle ( <12 years old) combined with late onset of menopause (>55 years old)
  • Age at first live birth (>35 years old)
  • Previous personal history of breast cancer (Inheritance of the gene mutation BRCA1 or BRCA2, increased chance (80%) of developing breast cancer at a younger age.
  • Two or more first degree relatives with breast or ovarian cancer (mother, sister, daughter, etc.) increases risk 5x
  • Male relative with breast cancer
  • Number of breast biopsies (either positive or negative)
  • At least one breast biopsy with atypical (ductal or lobular) hyperplasia or radial stars


Additional Risk Factors

  • History of benign breast disease
  • Ethnicity (whites: greater incidence; blacks: more deaths; Caucasian women are at greater risk for breast cancer compared to African American women, whereas African American men have twice the risk than Caucasian men.)
  • Late menopause (>50 years old)
  • Nulliparity, infertility; first born child born after age 30 years old
  • Diethylstilbestrol (DES) exposure—DES: synthetic estrogen prescribed during 1940-1971 to prevent miscarriage, premature labor, and other complications in pregnant women.
  • Alcohol use (>2 drinks/day of beer, wine, or hard liquor) increases risk 1.5x; alcohol inhibits the effects of folate which is typically used for cancer prevention
  • Postmenopausal weight gain (20-30lb. more since age 18); obesity allows estrogen to remain even after the onset of menopause due to increased fat storage.
  • High doses of chest radiation before age 30 (ex: Hodgkin’s disease)
  • Environmental exposures (under investigation)
  • High-fat diet
  • Long term use of oral contraceptives before 1975 (high doses, ex. EstrAval) or recent (within the last 5 years) combined with hormone replacement therapy (HRT)
  • High bone density (postmenopausal women); circulating estrogen promotes bone formation


Factors that Reduce Breast Cancer Risk

  • Breastfeeding
  • Participating in moderate or vigorous activity
  • Maintaining a healthy body weight


 The National Cancer Institute "Risk Calculator" 
 

Found at: http://www.cancer.gov/bcrisktool/[21]

Capture.PNG

Systemic Involvement [4][8]

Breast cancer that has metastasized can be manifested in several ways.  Bone is the most frequent site of metastasis in both men and women and symptoms can include back, hip or shoulder pain, and/or pain with weight bearing.  Breast cancer also frequently metastasizes to the central nervous system, especially at the thoracic levels of the spinal cord.  Signs and symptoms that are associated with neurologic involvement include unilateral upper extremity numbness and tingling (cervical/thoracic), leg weakness or paresis (lumbar), or bowel and bladder symptoms (sacral).  Other common sites of metastases are lymph nodes, lung, brain, and liver, as well as the remaining breast tissue.

Neurologic involvement can also be manifested in a paraneoplastic syndrome, which is a term used to describe associated signs and symptoms at a site that is distant from the tumor and/or metastasis.  Paraneoplastic syndromes often present in ways that seem uncorrelated with cancer, and may mimic disorders of the endocrine, metabolic, hematologic, or neuromuscular systems.  Clinical signs and sypmtoms can accompany a relatively limited increase in the size of the cancer and therefore may provide early clues to the presence of cancer.  Stiff-man syndrome is an example of a paraneoplastic syndrome that affects women with breast cancer, and is characterized by progressive symptoms of neuropathy (nerve damage) or myelopathy (spinal cord damage).  Increased muscle tone and rigidity in the spine and lower extremities (especially the ankle dorsiflexors) are commonly experienced.  Information that may be relevant for clinicians can be found here.

Musculoskeletal and integumentary involvement, as they relate to breast cancer prior to treatment, have been previously discussed in the section on Characteristics/Clinical Presentation.

Medical Management (current best evidence)

Treatment for breast cancer depends on the severity and stage of disease that the patient is in at the time. In many cases there is a typical sequence that is followed. Surgery is usually the first step in treatment of breast cancer. The goal of surgery is to remove the cancerous tumor by either removing the entire breast (mastectomy) or removing only the lump and surrounding tissue (lumpectomy). Other forms of surgery such as breast reconstruction and lymph node removal can be done when necessary. After surgery is performed the patient may receive chemotherapy and/or radiation therapy. Chemotherapy is used to destroy the remaining cancer cells that may be left within the body. This form of treatment is applied to the whole body through the blood stream. Chemotherapy can be used with all stages of breast cancer, but is especially recommended for those patients in which the cancer has spread. Radiation therapy is typically used for early stages (can be used in all stages) of breast cancer following a lumpectomy. This form of treatment targets a more specific area unlike chemotherapy. Radiation therapy may also be used following chemotherapy. Once the following treatment options have been completed hormonal therapy may be advised. Hormonal therapy works by decreasing estrogen amounts and blocking its action on the breast cancer cells. The doctor and the patient will discuss each specific case and decide on the best treatment options.[18][13] 

[22] 
[23]
[24] 

 

 

 


Physical Therapy Management

A prospective surveillance model for physical rehabilitation and exercise that can be integrated with disease treatment to create a more comprehensive approach to survivorship health care has been proposed[25]. The goals of the model are to promote surveillance for common physical impairments and functional limitations associated with breast cancer treatment; to provide education to facilitate early identification of impairments; to introduce rehabilitation and exercise intervention when physical impairments are identified; and to promote and support physical activity and exercise behaviors through the trajectory of disease treatment and survivorship.

Upper Extremity Complications Approximately 7 out of 8 individuals who undergo surgery for breast cancer experience recurring shoulder and/or arm problems, among others.  Problems that may persist up to 1 year after surgery include scar tightness, edema in the axilla, and neck-shoulder pain.  Activities that may be limited include lifting, carrying, and reaching.[4]  Physical therapy treatment should be prescribed based on the individual's needs and can include:

  • Soft tissue and joint mobilizations
  • Range of motion and strengthening exercises
  • Functional training
  • Postural assessment
  • Home exercise programs
It is recognized that specific rehabilitation protocols for breast cancer survivors are needed within physical therapy.[4] 


Strength and Mood Disturbances  Muscle weakness and mood disturbances often occur secondary to cancer.  Cantarero-Villanueva et al published a randomized controlled trial in 2011 that examined the effectiveness of an 8-week physical therapy program that focused on core stability exercises and myofascial release/massage on physical (strength) and psychological (mood) outcomes in breast cancer survivors.  Based on their study, the authors concluded that a multimodal program focusing on core stability strengthening and massage reduced fatigue, tension and depression, and increased vigor and strength, both at the end of the study and at a 6-month follow-up.[26]  The protocol that the authors used can be seen in the table below.

Core ex for breast CA.PNG

Lymphedema  Another common problem for breast cancer survivors is lymphedema.  In a review article published in the American Journal of Physical Medicine and Rehabilitation, the current evidence-based treatment for lymphedema includes:

[27]
[28]
[29]
[30]
  • Manual lymph drainage
  • Short-stretch compression bandaging
  • Therapeutic limb exercises
  • Skin care 

This treatment strategy has various names, including decongestive lymphatic therapy, complex decongestive physiotherapy, and complete decongestive therapy.  This treatment is typically performed 5 days per week for a few weeks, depending on patient response in terms of improvement in or resolution of swelling.[31]  Since lymphedema is not a curable condition, it is important for physical therapists to incorporate patient education on prevention of lymphedema into the treatment strategy[4].


Other— This list is not exhaustive, but serves to illustrate the fact that management of the patient with breast cancer is within the scope of the physical therapist.  Other areas that are relevant for physical therapy management include, but are not limited to:[31]

  • Pain
  • Musculoskeletal issues
  • Deconditioning and endurance deficits
  • Fatigue
  • Balance and falls
  • Psychosocial issues


Outcome Measures—

According to an article published in the Physical Therapy Journal, formal work is emerging that uses the ICF classification framework to identify outcome measures that are relevant to specific chronic conditions, such as cancer. This group of measurements is known as a “Core Set”. Although limited in number, ICF “Core Sets” have been developed for patients with breast cancer that provide clinicians with a biopsychosocial view for patient function. Below is a table that lists measures that are often reported in the oncology literature that are more specific to breast cancer. The original article describes these outcomes, and also lists and describes outcomes that are specific to other types of cancers.[32]



Breast Cancer
General Cancer Population
Nervous System

  • MRI* (vertebral metastases or spinal cord compression)
Specific Mental Functions
  • Perceived Cognition Questionnaire
  • Profile of Mood State
  • Functional Assessment of Cancer Therapy-Cognitive Function
Pain

  • Numeric Rating Scale
  • Brief Pain Inventory (pain clinic)
Sensation
  • Modified Total Neuropathy Score
  • Semmes-Weinstein monofilaments
  • Biothesiometer

Cardiovascular System
  • EKG*
  • Heart rate (hospice)
Aerobic Capacity
  • Graded exercise testing

Respiratory System

  • Respiratory rate
  • Pulmonary function tests
Lymphatic System
  • Limb volume: water displacement, infrared optoelectric technology
  • Limb circumference: truncated cone formula
  • National Cancer Institute’s “Common Terminology Criteria for Adverse Events, version 3 (lymphatic, integument, and phlebolymphatic cording scales)”
Musculoskeletal
  • Goniometry
  • Sit-and-reach
  • Computerized posturography

Muscle Function
  • Grip strength

Motor Reflexes
  • DTRs

Mobility

Fatigue
  • Piper Fatigue Scale
  • Functional Assessment of Chronic Illness Therapy-Fatigue
Self-care / Major Life Areas

  • Barthel Index (hospice)
  • General Sickness Impact Profile
* Indicates a test that a physician would perform but is pertinent to a physical therapist


Physiotherapy Intervenes with Lymphatic Drainage[33][34]

To determine the effectiveness of early physiotherapy in reducing the risk of lymphedema, the researchers assessed 120 women who had had breast surgery involving dissection of axillary lymph nodes between May 2005 and June 2007 at Asturias Hospital in Madrid. Two groups were created, the treatment group consisted on manual lymphatic drainage, scar massage, shoulder exercises and patient education and a control group which consisted on only patient education concerning lymphedema prevention and advice on appropriate upper extremity exercises. The control group received only the educational material, which discussed the condition and how to prevent it through shoulder exercises. All patients were followed for a year. A total of 16% of the women developed secondary lymphedema: 25% of those in the control group versus 7% in the intervention group (P=0.01). That translated to a 72% decreased risk of lymphedema (HR 0.28, 95% CI 0.10 to 0.79). By the 12-month follow-up visit, the volume ratio between arms had increased in both groups. In the control group, the affected arm was on average 5.1% greater in volume than the unaffected arm, whereas in the intervention group the affected arm was on average 1.6% greater than the unaffected arm (P=0.0065). In a survival analysis, secondary lymphedema was diagnosed four times earlier in the control group than in the intervention group (HR 0.26, 95% CI 0.09 to 0.79, P=0.01).

Example of a Manual Lymphatic Drainage Post Mastectomy[35]

Lymph.PNG

Support Groups

Support groups provide patients dealing with breast cancer connection to others who may be going through similar situations.  Those within the support groups may also provide information on how to get through or handle this new life situation.  Patients may also provide knowledge to help others as well.[13]

Susan G. Komen for the Cure Website http://ww5.komen.org/BreastCancer/SupportGroups.html [36]

       Listing of online support groups for the patient and their family (The Cancer Community) 

       Patient Navigator contact number : 1-877-GO-KOMEN(1-877-465-6636)

American Cancer Society Website http://www.cancer.org/treatment/supportprogramsservices/app/resource-search[37]

       Finding Local Support: Input Support (Breast) into Program Type search engine




Differential Diagnosis

There are several other conditions that may be associated with breast pain other than breast cancer itself.  Mastodynia, mastitis, benign tumors/cysts, and Paget's disease are some examples of conditions that may cause a patient to present with breast pain resembling breast cancer.

Mastodynia

Mastodynia is an irritation of the upper dorsal intercostal nerve.  This type of breast pain may be associated with ovulatory cycles. [8]

Mastitis

Mastitis occurs in lactating women that is an inflammatory condition.  The breast may become red, swollen, painful, and/or warm.  This is a result of the mammary duct becoming obstructed and clogged.[8]

Benign Tumors/Cysts

These include fibroadenomas, cysts, and calcifications within the breast.  When lumps within the breast are unchanged and have been present for many years this is often times a benign and hormonally induced.  Other benign lumps include, papillomas, fat necrosis, and mammary duct ectasia.  The patient would need to be referred to their doctor to differentiate these conditions.[8]

Paget's Disease 

This is a disease of the breast not to be confused with Paget's disease of the bone.  It is a rare condition of ductal carcinoma which arises from the ducts near the nipple.  Symptoms may include, redness, itching, and flaking of the nipple.[8]

Case Reports & Related Research

Exercise Capacity of a Breast Cancer Survivor: A Case Study[38]

Breast Cancer In a Young Male Without Key Risk-Factors[39]

Breast Cancer Case Study

Breast Cancer–Related Lymphedema: Comparing Direct Costs of a Prospective Surveillance Model and a Traditional Model of Care[40]

          Intervention and supply costs were estimated based on the Medicare 2009 physician fee schedule for 2 groups: (1) a prospective surveillance model group (PSM group) and (2) a traditional model group (TM group). The PSM group comprised all women with breast cancer who were receiving interval prospective surveillance, assuming that one third would develop early-stage Breast cancer-related lymphedema (BCRL). The PSM includes the cost of screening all women plus the cost of intervention for early-stage BCRL. The TM group comprised women referred for BCRL treatment using a traditional model of referral based on late-stage lymphedema. The TM cost includes the direct cost of treating patients with advanced-stage lymphedema. The cost to manage early-stage BCRL per patient per year using a prospective surveillance model is $636.19. The cost to manage late-stage BCRL per patient per year using a traditional model is $3,124.92. There for early intervention for prevention is vital with BCRL.

Factors That Affect Decisions About Physical Activity and Exercise in Survivors of Breast Cancer: A Qualitative Study[41]

         The purposes of this study were: (1) to investigate factors that affected decisions about physical activity and exercise in survivors of breast cancer and (2) to determine whether fear was a factor. Thirty-four breast cancer survivors participated in 8 focus groups and exercise/physical activity participation was influenced by three prominent themes: values and beliefs about exercise, facilitators and barriers that were both similar to those affecting the general population and cancer specific, and lack of or inaccurate information about safe exercise. There for it is a goal of primary care practitioners (Physicians, Physical Therapists, etc.) to educate patients on safe and proper exercise routines.

Effects of Mastectomy on Shoulder and Spinal Kinematics During Bilateral Upper-Limb Movement[42]

          This observational study used a 3-dimensional kinematic analysis to assess overhead glenohumeral movement in the sagittal, scapular, and coronal planes of women with a unilateral mastectomy on the side of their dominant arm (n=29) and nondominant arm (n=24).Women following mastectomy displayed altered patterns of scapular rotation compared with controls in all planes of movement. In particular, the scapula on the mastectomy side rotated upward to a markedly greater extent than that on the nonmastectomy side, and women following mastectomy displayed greater scapular excursion than controls. These findings are not deemed harmful, but the patient post-mastectomy would greatly benefit from activities focused toward scapular strengthening and stabilization.

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