Physical Rehabilitation after Breast Cancer
Breast cancer is ranked as one of the most common types of cancer affecting Singaporean women today. (Singapore Cancer Registry, Interim Report, Trends In Cancer Incidence In Singapore 2004-2008).
Disease free survival after diagnosis and treatment has been reported to be between 63%-74% at 10 years, with overall survival rates of 63-86% (Jacobsen et al, 1995). Therefore, the focus of rehabilitation is to optimise the quality of care and survival, as well as quality of living for women diagnosed with breast cancer.
There are generally two types of mastectomies which are performed, depending on the clinical presentation & histological results; the simple mastectomy, where breast tissue is removed, and the radical mastectomy, where breast tissue and the underlying muscle in the chest is removed (this may be needed if cancer has spread to the chest wall muscles).
The table below illustrates common surgical procedures that may be performed for breast cancer patients.
Table 1: Summary of surgical procedures for breast cancer
Breast biopsy (lumpectomy)
Excision of breast lump
Breast conservation (wide local excision; quadrantectomy; tylectomy; partial mastectomy)
Excision of tumour & surrounding breast tissue to give an adequate surgical margin from cancer cells. Axillary dissection performed in conjunction
Removal of lymph nodes
Excision of all the breast tissue
Modified radial mastectomy (Patey)/MRM
Excision of all the breast tissue, axillary dissection & pectoralis minor muscle
Radial Mastectomy (Halsted)
As for modified radial mastectomy with the excision of pectoralis major muscle
Extended radial mastectomy
As for radial mastectomy with the excision of underlying chest wall(ribs); a split skin graft is required to cover the surgical defect on the chest wall
Breast reconstruction (implants or myocutaneous flap
1. Surgical implant (saline) with/ without prior use of tissue expanders
2. Skin & muscle flap (latissimus dorsi, rectus abdominis) with/without intact blood supply is used to reconstruct the breast, nipple reconstruction/ prosthesis required.
The aim of breast cancer treatment is to eradicate local disease & control the development of further disease, thus enhancing the survival of women diagnosed. However, there are many potential problems that may occur in women who have been treated for breast cancer, such as:
• Decreased shoulder movements & function
• Wound infection & delayed wound healing in the early post-operative period
• Seroma development on the anterior chest or axilla after wound drains are removed
• Lymphedema of the arm &/ or breast
• Neural disorders such as sensory disturbances and nerve entrapment in the arm
• Fibrosis of the skin & muscle of the chest wall after radiotherapy
• Local recurrence or metastatic spread of breast cancer
The degree of difficulty that patients encounter with any of these complications varies with the extent of the disease, surgical procedure, age and co-existing problems.
Physiotherapy in breast cancer
Physiotherapists can therefore play a significant role in the identification, prevention and/or management of the problems mentioned above, and also assist in the support of women before, during & after the treatment and the follow-up period for breast cancer.
Early physiotherapy intervention is essential to an efficient recovery. In most cases, patients are referred to physiotherapy immediately after surgery. After a thorough evaluation is completed, a treatment plan is designed to meet individual needs and goals.
Physiotherapy may include education and advise regarding posture, active/ passive and auto assisted range of motion exercises in helping the patient to regain her preoperative shoulder range & function. In addition appropriate strengthening exercises, massage, prescription of compression or supportive garments, scar mobilization, designing a safe home exercise programme for the individual, and education about lymphedema and its prevention & an awareness of early signs and symptoms are also important roles that the physiotherapists.
Table 2: shows a detailed general physical rehabilitation and management care plan for mastectomy.
Physiotherapy Management Care Plan
Assessment – shoulder ROM, functional questionnaire, limb size
Education – post-operative presentation & Exercises, preliminary lymphedema education
DAILY POST OPERATIVE VISITS
Hand/elbow exercises – start immediately
Shoulder movement- if no axillary dissection has been performed, start immediately post-op & progress within discomfort to full ROM; if axillary dissection has been performed, start at surgeon’s request or when wound drainage is < 100ml/24 hours or there is a marked decrease in drainage over 24 hour period; restricted to < or equal to 100 degrees for first 2 days of movement and gradually increase ROM using a limit of a discomfort rating of 3/10
Lymphedema prevention education progress as appropriate for each patient
DISCHARGE FORM HOSPITAL
Review home programme and limitation of activities initially, re-measure shoulder ROM, functional questionnaire and limb size.
1 MONTH POST-OP
Progress exercises and stretches, advise on functional activity progressions, lymphedema prevention education, re-measure shoulder ROM, functional questionnaire and limb size.
2 MONTHS POST-OP
Assess effects of therapy and modify or progress exercises/ stretches. Advise return to pre-operative function & activity levels.
FOLLOW-UP AT 3,6,12,18,24 MONTHS
Assess progress with measurement of shoulder ROM, functional questionnaire and limb size. Modification of exercises as appropriate.
If you have any concerns or wish to discuss the above matters in more depth, feel free to arrange a consultation with our physiotherapist.