Breast Cancer


Lung, female breast and colorectal cancer account for one-third of the world's cancer incidences.[1] When looking at cancer mortality across the globe female breast cancer is ranked 5th in terms of mortality.[1] However, with the advances in both the diagnostic and treatment approaches for breast cancer survival rate after a diagnosis of breast cancer has significantly improved.[2] The increase in the number of breast cancer survivors has resulted in more research and care being directed toward developing interventions that will help improve the overall quality of life for women who have survived breast cancer.[3] Physiotherapists have an important role in the rehabilitation process during and after a diagnosis of breast cancer, as well as in the care of survivors.

What is Breast Cancer?

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

Breast cancer involves the production of malignant cells in the breast.[4] These cells grow uncontrollably affecting nearby tissue and/or spreading to other parts of the body through a process called metastasis.[4]

However, not all cell growth in breast tissue is malignant.[4] Non-cancerous conditions such as atypical hyperplasia cysts and abscesses, and non-cancerous tumours such as intraductal papillomas can form.[4]

Breast cancers are usually adenocarcinomas.[4] These tumours develop in the following two locations within the breast:[4]

  1. The cells that line the milk ducts (also known as ductal carcinoma)[4]
  2. The milk-producing glands (also known as lobular carcinoma)[4]

Ductal and lobular carcinomas can each be classified as in-situ or invasive (infiltrating).[5] With in-situ, there is no growth into surrounding tissues (the cancer is confined within the ducts or lobules).[5] With invasive, the malignant cells that started in the ducts or glands have begun to invade the surrounding tissue and potentially other parts of the body.[5]

As previously mentioned, metastasis involves the spread to one or more sites elsewhere in the body. This occurs by way of directly affecting an organ or travelling through the lymphatic and/or circulatory systems.[6]

The following terms can be utilized to gage how far the malignant cells have spread:[7]

  • Localized means there is no spread.[7]
  • Regional means there is spread to the lymph nodes, tissues, or organs close to where cancer started (the primary site).[7]
  • Distant (also known as metastatic cancer) means there is spread to organs or tissues that are farther away from the primary site.[7] The main sites of metastasis for breast cancer include bones, lungs, brain, and liver.[8]

Other types of breast cancer are not nearly as common as the adenocarcinomas.[4] They include the following:[4]

  • Inflammatory breast cancer[4]
  • Paget disease of the nipple[4]
  • Triple negative breast cancer[4]


The system commonly used to classify the extent of breast cancer is the AJCC/TNM system.[4][5] The TNM system uses information on tumour 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).[5] Once the T, N, and M are determined through stage grouping, a stage of 0, I, II, III, or IV is assigned.[4][5] The stage number and degree of cancer spread are positively correlated.[4][5]

Click here to review the stages of breast cancer.


Breast cancer can occur in both men and women. However, it is quite rare in men; it accounts for 1% of cancers[9][10][11][12][13][14] and 0.2% of cancer-related deaths in men.[15][16] One in 8 women will develop invasive breast cancer in their lifetime and approximately 1 in 33 will die from it.[17] In 2018, approximately 2.1 million women received a diagnosis of breast cancer.[18] This makes it the most commonly diagnosed cancer and the second leading cause of cancer-related deaths in women.[6] Throughout the decades, the incidence of breast cancer has increased in some countries.[18] The reason for this may be due to a combination of advances in screening and diagnosis, as well as increased rates of obesity and fewer child births per woman.[18]

Survivorship varies across the globe, such that 5-year relative survival was ≥80% in the United States, Canada, and Austria, but <40% in Denmark, Poland, and Algeria.[19] This may be attributed to differences in diagnostics and treatments,[20][21][22][23] as well as a lack of healthcare resources in some countries.[24][25] Verdecchia et al (2008)[26] found that gross domestic product, total national expenditure on health, and the number of computed tomography (CT) scanners per million were correlated with cancer survival. 

Breast cancer-related lymphedema (BCRL) is condition that a woman can develop anytime 3-20 years after treatment.[27] The incidence varies and likely depends on the type of treatment received. For example, 12 months post-treatment 12-26% of women had BCRL.[28][29] Recent evidence suggests that 1 in 5 women will acquire it at some point.[30]

Risk Factors

  • Increased age: Older age has been shown to increase the risk of developing breast cancer.[31][32] Between 2013 and 2015, the probability of a woman developing breast cancer in the United States between birth to 49 years of age was 1 in 51; the probability increased when ≥70 years of age to 1 in 15.[31]
  • Sex (females > males)
  • Personal history of breast cancer
  • Family history of breast cancer: In comparison to women who have do not have a family history of breast cancer, one first-degree relative has been found to lead to a 1.75-fold higher risk and 2 first-degree relatives has been found to lead to a 2.5-fold higher risk of developing breast cancer.[33]
  • Breast cancer associated genes 1 and 2 (BRCA1 and BRCA2) mutations: BRACA1 and BRCA2 are responsible for the suppression of tumours.[34] Furthermore, mutations of these genes have been shown to increase the risk of developing breast cancer.[35]
  • Dense breasts
  • Alcohol consumption: Alcohol has been shown to be a risk factor for the development of breast cancer.[36][37][38][39] 10 g more of alcohol per day may increase the risk by approximately 7.1%.[38]
  • Obesity: Obesity, especially in postmenopausal women, has been found to increase the risk of developing breast cancer.[40] (30 and 31)
  • Cigarette smoking: There is no consensus in the evidence that cigarette smoking increases the risk of developing breast cancer, which may be partly because of the correlation between smoking and alcohol consumption.[41] An analysis[38] found no significant difference between smokers and non-smokers.[38] However, Terry and colleagues (2002)[42] found that those who smoked more and for longer were at a higher risk, especially if they smoked 20 or more cigarettes per day over the course of 40 years or more.[42]
  • Race: Non-hispanic white woman show higher incidence of breast cancer.[43] African-American, Hispanic, Native American, and Asian woman show a higher mortality rate.[43]
  • Menstrual history: A menstrual period that starts early and ends later in life may increase the risk of developing breast cancer.[32]
  • Child birth: Having children after the age of 30 or not having any children at all may increase the risk of developing breast cancer.
  • Endogenous and exogenous estrogens: Exogenous estrogens normally come from oral contraceptives and hormonal replacement therapy.[44] A combined oral contraceptive, one that includes both estrogen and progesterone, may increase the risk of the development of breast cancer, but this increased risk did not remain 10 years after stopping the pill.[41][45] In the UK, the Million Women Study found an increased risk in the development of breast cancer after using estrogen and progesterone combinations in hormone replacement therapy.[46] However, this risk did not remain 2 years after stopping hormone replacement therapy.[47]

See The National Cancer Institute Breast Cancer Risk Assessment Tool

Clinical Presentation

Breast cancer may be asymptomatic and undetectable in its earlier stages. The hallmark signs and symptoms of a ductal carcinoma are a lump in the breast and breast tenderness (not usually pain). The hallmark signs and symptoms of a lobular carcinoma do not involve a lump. There is often a change in breast texture. Therefore, a lobular carcinoma may be harder to detect.[48]

Other signs and symptoms of breast cancer may include the following:[4]

  • Change in breast shape or size[4]
  • Unusual discharge from the nipple[4]
  • Lump in armpit[4]
  • Retraction inwards or inversion of the nipple[4]

Late signs and symptoms of breast cancer may include the following:[4]

  • Bone pain[4]
  • Weight loss[4]
  • Nausea[4]
  • Loss of appetite[4]
  • Jaundice[4]
  • Shortness of breath[4]
  • Cough[4]
  • Headache[4]
  • Double vision[4]
  • Muscle weakness[4]

A useful mnemonic to help remember some of the signs of breast cancer is B.R.E.A.S.T.[49]

Breast Self-Examination

There does not seem to be a consensus on whether or not breast self examinations (BSE) should be carried out by women.[50] In fact, the Canadian Taskforce on Preventive Health Care and the American Cancer Society (ACS) no longer recommend BSE.

Allen et al (2010)[51] commented on the potential benefits and harms of BSE. Some of the benefits included that BSE increase a woman's sense of comfort and autonomy with their health and breasts, the tool is non-invasive, lumps can be palpated, and women become more aware of breast changes over time.[51] Some of the harms included the potential for increased usage of the healthcare system and its resources (more cost, biopsies, etc), as well as higher levels of anxiety depression.[51] Furthermore, women should speak with their physicians to discuss whether the benefits of BSE outweigh the risks for that individual and that they seek clarity on how to perform the examination.
Breast cancer incidence by anatomical site (females).svg.png

In conclusion, it remains important that women become familiar with the appearance and feel of their breasts. Any changes that may be detected can be reported to a physician for further investigation.


  • 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.[52][53]
  • IR thermography: It is a powerful tool that is also non-invasive and non-intrusive easing the analysis, providing safety and comfort to the patients. It can be used in women of different ages and health conditions without any risk[54].
  • Mammography: A mammogram provides an x-ray 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.[52][53]
  • Magnetic Resonance Imaging (MRI): A 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.[52][53]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.[55]
  • 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 or not biopsy is suggested if there is an area within the breast that is questionable for cancer.[52][53] 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.[52][53]
  • 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 a less favourable prognosis. If this is the case, then a targeted approach to that specific area will be used as a treatment option.[52][53][56] 

Factors that May Reduce Breast Cancer Risk

  • Breastfeeding
  • Participating in moderate or vigorous activity
  • Maintaining a healthy body weight [57]

Systemic Involvement

Breast cancer that has metastasized can be manifested in several ways[53][49].

  • 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.
  • Central Nervous System: is another frequent site for metastasizes of breast cancer, 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 tumour 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 symptoms can accompany a relatively limited increase in the size of 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.
    Musculoskeletal and integumentary involvement, as they relate to breast cancer prior to treatment, have been previously discussed in the section on Characteristics/Clinical Presentation.


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.  A retrospective review shows that in comparison to subcutaneous mastectomy with implant procedure, the partial mastectomy with mini latissimus dorsi flap procedure produces significantly superior body image and cosmetic outcomes. It can also be a treatment of choice in selected patients with small breasts and a high tumor/breast ratio[58].


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

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.

Hormonal Therapy

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.[52][55]



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.[55]  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.[56] 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.[62] 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.[53][56] 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. [56]

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.[63] 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 a meta-analysis by Rapura and colleagues (2011).[63]

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.[64]

Physical Therapy Management

After treatment for breast cancer, women may experience any of the following impairments that can be addressed by a physical therapist:

  • Decreased strength of the upper extremity
  • Decreased shoulder mobility
  • Scar tightness (breast and/or axilla)  
  • Upper extremity ache 
  • Lymphedema of the upper extremity
  • Neuropathic pain  
  • Musculoskeletal pain (breast, axilla, and/or neck-shoulder) 
  • Chronic pain  

Karki and colleagues (2005)[65] researched the effects that impairments have on activity limitations and participation restrictions in 96 women at 6- and 12-month follow-ups after an operation for breast cancer. Severity of the impairments were measured using a modified Visual Analogue Scale (VAS).[65] Activity limitations and sleep function were measured using the Behavioural Rate Scale for Patients with Breast Cancer.[65] Results showed increased impairment severity with upper extremity lifting and carrying, as well as sleep disturbances, regardless of the type of operation.[65] While the prevalence decreased at the 12-month follow-up, changes were not statistically significant.[65] Results also show that women experience constant restrictions at home, work, and during leisurely activities, which may also have a negative impact on their social health.[65]

Aerobic exercise, such as walking, cycling, or swimming, has been shown to decrease cancer-related fatigue,[66][67][68] improve quality of life,[69][70] reduce cognitive impairments associated with various cancer therapies,[71] improve cardiovascular outcomes,[72] and improve sleep dysfunction.[73] Research suggests that treadmill exercises provide cardioprotective effects on the Doxorubicin-induced cardiotoxicity.[74] 

Cantarero-Villanueva and colleagues (2011)[75] carried out an 8-week multimodal physiotherapy program, which was comprised of aerobic exercises, core stability exercises, and some recovery with stretching and myofascial release techniques.[75] The researchers found statistically significant improvements in strength, suggesting that core stability exercises should not be ignored in women who have undergone treatment for breast cancer.[75] In fact, chemotherapy has been found to lead to even more muscle atrophy.[76] The protocol that Cantarero-Villanueva and colleagues (2011)[75] followed can be seen in the table below.

Other muscle groups that should be targeted include the rotator cuff, serratus anterior, trapezius, rhomboids, biceps, and pectoralis muscles.[77] Exercises can begin with an elastic bands and be performed 2x/week for 2 sets of 10-15 repetitions.[78] However, it is also important to observe the individual's scapulohumeral rhythm and supplement the exercise program with neuromuscular facilitation exercises if it needs to be corrected.[79][80] This study aimed to analyze the effects of types of surgery and hormone therapy on muscle strength in breast cancer survivors suggested that breast cancer survivors should be encouraged to perform supervised strength training programs for different muscle groups to improve strength[81].

Several forms of manual therapy can be carried out by a physical therapist to address certain impairments. They include the following:

  • Joint mobilization techniques
  • Soft tissue release techniques
  • Neurodynamic techniques

Also see page on Lymphedema for treatment of BCRL.

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.

  1. Mastodynia: is an irritation of the upper dorsal intercostal nerve. This type of breast pain may be associated with ovulatory cycles.
  2. Mastitis: this 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.[49]
  3. 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.[49]
  4. 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.[49]


You can visit some of the websites listed below for more resources.

Download a PDF on Oncology and Breast Cancer


  1. 1.0 1.1 Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: a cancer journal for clinicians. 2018 Sep 12.
  2. Schmitz KH, Speck RM, Rye SA, DiSipio T, Hayes SC. Prevalence of breast cancer treatment sequelae over 6 years of follow‐up: the Pulling Through Study. Cancer. 2012 Apr 15;118(S8):2217-25.
  3. Brown JK, Byers T, Doyle C, et al. Nutrition and physical activity during and after cancer treatment: an American Cancer Society guide for informed choices. CA Cancer J Clin 2003;53:268-91.
  4. 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 4.15 4.16 4.17 4.18 4.19 4.20 4.21 4.22 4.23 4.24 4.25 4.26 4.27 4.28 4.29 4.30 4.31 Canadian Cancer Society. Breast Cancer. Available from: [Accessed 2020 June 23].
  5. 5.0 5.1 5.2 5.3 5.4 5.5 5.6 Ely S, Vioral AN. Breast cancer overview. Plastic Surgical Nursing. 2007 Jul 1;27(3):128-33.
  6. 6.0 6.1 Merkle CJ, Loescher LJ. Biology of cancer. Cancer nursing, principles and practice, 6th edn. Jones and Bartlett, Boston. 2005:3-26.
  7. 7.0 7.1 7.2 7.3 Canadian Cancer Society. Metastatic cancer. Available from: [Accessed 2020 June 23].
  8. Metastatic Breast Cancer Symptoms and Diagnosis. Available from: [Accessed 2020 June 23].
  9. Korde LA, Zujewski JA, Kamin L, Giordano S, Domchek S, Anderson WF, Bartlett JM, Gelmon K, Nahleh Z, Bergh J, Cutuli B. Multidisciplinary meeting on male breast cancer: summary and research recommendations. Journal of Clinical Oncology. 2010 Apr 20;28(12):2114.
  10. Cutuli B. Strategies in treating male breast cancer. Expert opinion on pharmacotherapy. 2007 Feb 1;8(2):193-202.
  11. Gennari R, Curigliano G, Jereczek-Fossa BA, Zurrida S, Renne G, Intra M, Galimberti V, Luini A, Orecchia R, Viale G, Goldhrisch A. Male breast cancer: a special therapeutic problem. Anything new?. International journal of oncology. 2004 Feb 29;24(3):663-70.
  12. Fentiman IS, Fourquet A, Hortobagyi GN. Male breast cancer. The Lancet. 2006 Feb 18;367(9510):595-604.
  13. Yoney A, Kucuk A, Unsal M. Male breast cancer: a retrospective analysis. Cancer/Radiothérapie. 2009 Apr 1;13(2):103-7.
  14. Weiss JR, Moysich KB, Swede H (2005) Epidemiology of male breast cancer. Cancer Epidemiol Biomarkers Prev 14(1):20–26
  15. Burga AM, Fadare O, Lininger RA, Tavassoli FA. Invasive carcinomas of the male breast: a morphologic study of the distribution of histologic subtypes and metastatic patterns in 778 cases. Virchows Archiv. 2006 Nov 1;449(5):507-12.
  16. Darkeh MH, Azavedo E. Male breast cancer clinical features, risk factors, and current diagnostic and therapeutic approaches. International Journal of Clinical Medicine. 2014 Sep 9;2014.
  17. American Cancer Society. Breast cancer facts & figures. American Cancer Society; 2007.
  18. 18.0 18.1 18.2 Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: a cancer journal for clinicians. 2018 Nov;68(6):394-424.
  19. Coleman MP, Quaresma M, Berrino F, Lutz JM, De Angelis R, Capocaccia R, Baili P, Rachet B, Gatta G, Hakulinen T, Micheli A. Cancer survival in five continents: a worldwide population-based study (CONCORD). The lancet oncology. 2008 Aug 1;9(8):730-56.
  20. Gorey KM, Holowaty EJ, Laukkanen E, Fehringer G, Richter NL. An international comparison of cancer survival: advantage of Toronto's poor over the near poor of Detroit. Canadian Journal of Public Health/Revue Canadienne de Sante'e Publique. 1998 Mar 1;89(2):102-4.
  21. Gondos A, Chokunonga E, Brenner H, Parkin DM, Sankila R, Borok MZ, Chirenje ZM, Nyakabau AM, Bassett MT. Cancer survival in a southern African urban population. International Journal of Cancer. 2004 Dec 10;112(5):860-4.
  22. Yu XQ, O'Connell DL, Forman D. Comparison of cancer survival in UK and Australia: rates are higher in Australia for three major sites. British journal of cancer. 2004 Nov;91(9):1663-5.
  23. Gorey KM, Holowaty EJ, Fehringer G, Laukkanen E, Richter NL, Meyer CM. An international comparison of cancer survival: relatively poor areas of Toronto, Ontario and three US metropolitan areas. Journal of Public Health. 2000 Sep 1;22(3):343-8.
  24. Sankaranarayanan R, Black RJ, Swaminathan R, Parkin DM. An overview of cancer survival in developing countries. IARC scientific publications. 1998 Jan 1:135-57.
  25. Sankaranarayanan R, Swaminathan R, Black RJ. Global variations in cancer survival. Cancer: Interdisciplinary International Journal of the American Cancer Society. 1996 Dec 15;78(12):2461-4.
  26. Verdecchia A, Baili P, Quaglia A, Kunkler I, Ciampichini R, Berrino F, Micheli A. Patient survival for all cancers combined as indicator of cancer control in Europe. European journal of public health. 2008 Oct 1;18(5):527-32.
  27. Petrek JA, Senie RT, Peters M, Rosen PP. Lymphedema in a cohort of breast carcinoma survivors 20 years after diagnosis. Cancer. 2001 Sep 15;92(6):1368-77.
  28. Kärki A, Simonen R, Mälkiä E, Selfe J. Impairments, activity limitations and participation restrictions 6 and 12 months after breast cancer operation. Journal of rehabilitation medicine: official journal of the UEMS European Board of Physical and Rehabilitation Medicine. 2005;37(3):180-8.
  29. Fleissig A, Fallowfield LJ, Langridge CI, Johnson L, Newcombe RG, Dixon JM, Kissin M, Mansel RE. Post-operative arm morbidity and quality of life. Results of the ALMANAC randomised trial comparing sentinel node biopsy with standard axillary treatment in the management of patients with early breast cancer. Breast cancer research and treatment. 2006 Feb 1;95(3):279-93.
  30. Ezzo J, Manheimer E, McNeely ML, Howell DM, Weiss R, Johansson KI, Bao T, Bily L, Tuppo CM, Williams AF, Karadibak D. Manual lymphatic drainage for lymphedema following breast cancer treatment. Cochrane database of systematic reviews. 2015(5).
  31. 31.0 31.1 Siegel RL, Miller KD, Jemal A. Cancer statistics, 2019. CA: a cancer journal for clinicians. 2019 Jan;69(1):7-34.
  32. 32.0 32.1 Paley PJ. Screening for the major malignancies affecting women: current guidelines. American journal of obstetrics and gynecology. 2001 Apr 1;184(5):1021-30.
  33. Brewer HR, Jones ME, Schoemaker MJ, Ashworth A, Swerdlow AJ. Family history and risk of breast cancer: an analysis accounting for family structure. Breast cancer research and treatment. 2017 Aug 1;165(1):193-200.
  34. Brewer HR, Jones ME, Schoemaker MJ, Ashworth A, Swerdlow AJ. Family history and risk of breast cancer: an analysis accounting for family structure. Breast cancer research and treatment. 2017 Aug 1;165(1):193-200.
  35. Chen S, Parmigiani G. Meta-analysis of BRCA1 and BRCA2 penetrance. Journal of clinical oncology: official journal of the American Society of Clinical Oncology. 2007 Apr 10;25(11):1329.
  36. Allen NE, Beral V, Casabonne D, Kan SW, Reeves GK, Brown A, Green J. Moderate alcohol intake and cancer incidence in women. Journal of the National Cancer Institute. 2009 Mar 4;101(5):296-305.
  37. Aronson K. Alcohol: a recently identified risk factor for breast cancer. Cmaj. 2003 Apr 29;168(9):1147-8.
  38. 38.0 38.1 38.2 38.3 Collaborative Group on Hormonal Factors in Breast Cancer. Alcohol, tobacco and breast cancer–collaborative reanalysis of individual data from 53 epidemiological studies, including 58 515 women with breast cancer and 95 067 women without the disease. British journal of cancer. 2002 Nov 18;87(11):1234.
  39. Singletary KW, Gapstur SM. Alcohol and breast cancer: review of epidemiologic and experimental evidence and potential mechanisms. Jama. 2001 Nov 7;286(17):2143-51.
  40. Yoo KY, Tajima K, Park SK, Kang D, Kim SU, Hirose K, Takeuchi T, Miura S. Postmenopausal obesity as a breast cancer risk factor according to estrogen and progesterone receptor status (Japan). Cancer letters. 2001 Jun 10;167(1):57-63.
  41. 41.0 41.1 Washbrook E. Risk factors and epidemiology of breast cancer. Women's Health Medicine. 2006 Jan 1;3(1):8-14.
  42. 42.0 42.1 Terry PD, Miller AB, Rohan TE. Cigarette smoking and breast cancer risk: a long latency period?. International journal of cancer. 2002 Aug 20;100(6):723-8.
  43. 43.0 43.1 Fejerman L, Ziv E. Population differences in breast cancer severity. Pharmacogenomics. 2008;9(3):323-333
  44. Sun YS, Zhao Z, Yang ZN, Xu F, Lu HJ, Zhu ZY, Shi W, Jiang J, Yao PP, Zhu HP. Risk factors and preventions of breast cancer. International journal of biological sciences. 2017;13(11):1387.
  45. Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and hormonal contraceptives: collaborative reanalysis of individual data on 53 297 women with breast cancer and 100 239 women without breast cancer from 54 epidemiological studies. The Lancet. 1996 Jun 22;347(9017):1713-27.
  46. Million Women Study Collaborators. Breast cancer and hormone-replacement therapy in the Million Women Study. The Lancet. 2003 Aug 9;362(9382):419-27.
  47. Narod SA. Hormone replacement therapy and the risk of breast cancer. Nature reviews Clinical oncology. 2011 Nov;8(11):669-76.
  48. Winchester DJ, Chang HR, Graves TA, Bland KI, Winchester DP. A comparative analysis of lobular and ductal carcinoma of the breast: presentation, treatment, and outcomes. Journal of the American College of Surgeons. 1998 Apr 1;186(4):416-22.
  49. 49.00 49.01 49.02 49.03 49.04 49.05 49.06 49.07 49.08 49.09 49.10 Goodman C, Snyder T. Differential Diagnosis for Physical Therapists: Screening for Referral. St. Louis, Missouri: Saunders Elsevier, 2007. p784-793.
  50. Smith RA, Saslow D, Sawyer KA, Burke W, Costanza ME, Evans III WP, Foster Jr RS, Hendrick E, Eyre HJ, Sener S. American Cancer Society guidelines for breast cancer screening: update 2003. CA: a cancer journal for clinicians. 2003 May;53(3):141-69.
  51. 51.0 51.1 51.2 Allen TL, Van Groningen BJ, Barksdale DJ, McCarthy R. The breast self-examination controversy: what providers and patients should know. The Journal for Nurse Practitioners. 2010 Jun 1;6(6):444-51.
  52. 52.0 52.1 52.2 52.3 52.4 52.5 52.6 What You Need to Know About Breast Cancer. National Cancer Institute. (accessed 21 February 2010)
  53. 53.0 53.1 53.2 53.3 53.4 53.5 53.6 53.7 Goodman CC, Fuller KS. Pathology: Implications for the Physical Therapist, 3rd Ed. St. Louis, MO: Saunders Elsevier, 2009, pp 1015-1036. (Loe 1b)
  54. Garduño-Ramón MA, Vega-Mancilla SG, Morales-Henández LA, Osornio-Rios RA. Supportive noninvasive tool for the diagnosis of breast cancer using a thermographic camera as sensor. Sensors. 2017 Mar;17(3):497.
  55. 55.0 55.1 55.2 (accessed 21 February 2010).
  56. 56.0 56.1 56.2 56.3 Panus PC, Katzung B, Jobst EE, Tinseley SL, Masters SB, Trevor AJ. Pharmacology for the Physical Therapist. Cancer Chemotherapy. New York: McGraw-Hill Companies, Inc., 2009. p460-477.
  57. Brouckaert O, Van Asten K, Laenen A, Soubry A, Smeets A, Nevelstreen I, Vergote I, Wildiers H, Paridaens R, Van Limbergen E, Weltens C. Body mass index, age at breast cancer diagnosis, and breast cancer subtype: a cross-sectional study. Breast cancer research and treatment. 2018 Feb 1;168(1):189-96.
  58. Ozmen V, Ilgun S, Ozden BC, Ozturk A, Aktepe F, Agacayak F, Elbuken F, Alco G, Ordu C, Iyigun ZE, Emre H. Comparison of breast cancer patients who underwent partial mastectomy (PM) with mini latissimus dorsi flap (MLDF) and subcutaneous mastectomy with implant (M+ I) regarding quality of life (QOL), cosmetic outcome and survival rates. World Journal of Surgical Oncology. 2020 Dec;18(1):1-2.
  59. Nucleusanimation. Breast Cancer Surgery: Lumpectomy, Mastecomy. (accessed 7 April 2010).
  60. Patient Education: Breast Biopsy Surgery. (accessed March 22, 2012).
  61. YouTube. What is a skin-sparing mastectomy? (accessed 15 Mar 2012).
  62. Pariser D. Chemotherapy Power Point Presentation. PT 535 Pharmacology, Bellarmine University. Presented November 5, 2010.
  63. 63.0 63.1 Ranpura V, Hapani S, Wu S. Treatment-related mortality with bevacizumab in cancer patients: a meta-analysis. Jama. 2011 Feb 2;305(5):487-94.
  64. Cortes J, O'Shaughnessy J, Loesch D, Blum JL, Vahdat LT, Petrakova K, Chollet P, Manikas A, Diéras V, Delozier T, Vladimirov V. Eribulin monotherapy versus treatment of physician's choice in patients with metastatic breast cancer (EMBRACE): a phase 3 open-label randomised study. The Lancet. 2011 Mar 12;377(9769):914-23.
  65. 65.0 65.1 65.2 65.3 65.4 65.5 Kärki A, Simonen R, Mälkiä E, Selfe J. Impairments, activity limitations and participation restrictions 6 and 12 months after breast cancer operation. Journal of rehabilitation medicine: official journal of the UEMS European Board of Physical and Rehabilitation Medicine. 2005;37(3):180-8.
  66. Cantarero-Villanueva I, Fernández-Lao C, Cuesta-Vargas AI, Del Moral-Avila R, Fernández-de-las-Peñas C, Arroyo-Morales M. The effectiveness of a deep water aquatic exercise program in cancer-related fatigue in breast cancer survivors: a randomized controlled trial. Archives of physical medicine and rehabilitation. 2013 Feb 1;94(2):221-30.
  67. Carter SJ, Hunter GR, McAuley E, Courneya KS, Anton PM, Rogers LQ. Lower rate-pressure product during submaximal walking: a link to fatigue improvement following a physical activity intervention among breast cancer survivors. Journal of Cancer Survivorship. 2016 Oct 1;10(5):927-34.
  68. Vardar Yağlı N, Şener G, Arıkan H, Sağlam M, İnal İnce D, Savcı S, Çalık Kutukcu E, Altundağ K, Kaya EB, Kutluk T, Özışık Y. Do yoga and aerobic exercise training have impact on functional capacity, fatigue, peripheral muscle strength, and quality of life in breast cancer survivors?. Integrative cancer therapies. 2015 Mar;14(2):125-32.
  69. Burnham TR, Wilcox A. Effects of exercise on physiological and psychological variables in cancer survivors. Medicine and science in sports and exercise. 2002 Dec 1;34(12):1863-7.
  70. McNeely ML, Campbell KL, Rowe BH, Klassen TP, Mackey JR, Courneya KS. Effects of exercise on breast cancer patients and survivors: a systematic review and meta-analysis. Cmaj. 2006 Jul 4;175(1):34-41.
  71. Campbell KL, Kam JW, Neil‐Sztramko SE, Liu Ambrose T, Handy TC, Lim HJ, Hayden S, Hsu L, Kirkham AA, Gotay CC, McKenzie DC. Effect of aerobic exercise on cancer‐associated cognitive impairment: A proof‐of‐concept RCT. Psycho‐oncology. 2018 Jan;27(1):53-60.
  72. Zhang Y, Xu L, Zhang X, Yao Y, Sun Y, Qi L. Effects of different durations of aerobic exercise on the cardiovascular health in untrained women: a meta-analysis and meta-regression.
  73. Roveda E, Vitale JA, Bruno E, Montaruli A, Pasanisi P, Villarini A, Gargano G, Galasso L, Berrino F, Caumo A, Carandente F. Protective effect of aerobic physical activity on sleep behavior in breast cancer survivors. Integrative cancer therapies. 2017 Mar;16(1):21-31.
  74. Yang HL, Hsieh PL, Hung CH, Cheng HC, Chou WC, Chu PM, Chang YC, Tsai KL. Early Moderate Intensity Aerobic Exercise Intervention Prevents Doxorubicin-Caused Cardiac Dysfunction Through Inhibition of Cardiac Fibrosis and Inflammation. Cancers. 2020 May;12(5):1102.
  75. 75.0 75.1 75.2 75.3 75.4 Cantarero-Villanueva I, Fernández-Lao C, del Moral-Avila R, Fernández-de-las-Peñas C, Feriche-Fernández-Castanys MB, Arroyo-Morales M. Effectiveness of core stability exercises and recovery myofascial release massage on fatigue in breast cancer survivors: a randomized controlled clinical trial. Evidence-Based Complementary and Alternative Medicine. 2012 Jan 1;2012.
  76. Clarkson PM, Kaufman SA. Should resistance exercise be recommended during breast cancer treatment?. Medical hypotheses. 2010 Aug 1;75(2):192-5.
  77. Shamley D, Lascurain‐Aguirrebeña I, Oskrochi R. Clinical anatomy of the shoulder after treatment for breast cancer. Clinical Anatomy. 2014 Apr;27(3):467-77.
  78. Giacalone A, Alessandria P, Ruberti E. The physiotherapy intervention for shoulder pain in patients treated for breast cancer: Systematic review. Cureus. 2019 Dec;11(12).
  79. McNeely ML, Campbell K, Ospina M, Rowe BH, Dabbs K, Klassen TP, Mackey J, Courneya K. Exercise interventions for upper‐limb dysfunction due to breast cancer treatment. Cochrane Database of Systematic Reviews. 2010(6).
  80. Galantino ML, Stout NL. Exercise interventions for upper limb dysfunction due to breast cancer treatment. Physical therapy. 2013 Oct 1;93(10):1291-7.
  81. Bertoli J, de Souza Bezerra E, Reis AD, da Costa Barros ÊA, Gobbo LA, Júnior IF. Long-Term Side Effects of Breast Cancer on Force Production Parameters. The Journal of Strength & Conditioning Research. 2020 May 13.