12b - Breast Cancer

Question 1

Incidence breast cancer

Answer 1

• Incidence of 1 in 8 women in Australia

diagnosed before 85yo

Question 2

In‐Situ breast cancer

Answer 2

• Pre‐invasive cancer that has not breached
the epithelial basement membrane
• Marker for the later development of
invasive carcinoma
• Usually asymptomatic
• Common due to breast cancer screening
• Mastectomy is recommended

Question 3

Invasive Breast Cancer

Answer 3

Invasive Ductal (IDC most common) and Lobular

Cancer cells have started to break through
ducts/lobules and invade surrounding areas
with ability to travel through the blood stream
and lymphatic system

Question 4

Usual clinical presentation of breast

cancer

Answer 4

• Most frequently in the upper, outer quadrant
of the breast
• May present as a hard lump ‐ may be
associated with indrawing of the nipple or
discharge. May feel nothing
• May have skin involvement with puckering
skin appearance or frank ulceration and
fixation to the chest wall as the disease
advances locally

Question 5

Types of Surgery Breast Cancer

Answer 5

• Wide local excision (WLE)/lumpectomy
• Axillary dissection or SNB
• Simple Mastectomy
• Modified Radical Mastectomy

Question 6

Where breast drains

Answer 6

axilla

supraclavicular, cervical chain

Question 7

Wide Local Excision

Answer 7

• Removal of the breast lump whilst conserving
the remaining tissue.
• May return for re‐excision 1 week later if
margins not clear

Question 8

Sentinel Node Biopsy

Answer 8

• The first node that the tumour drains to
• Determined by injection of tumor with blue
dye and trace which node turns blue first then
remove it
• If + for tumour cells, further AD done

Question 9

Simple Mastectomy

Answer 9

• Removal of breast but not the lymph nodes (for in situ carcinoma)

Question 10

Modified Radical Mastectomy

Answer 10

• Removal of breast plus axillary lymph nodes

If it is large or multifocal

Question 11

Radical Mastectomy

Answer 11

Removal of breast, axillary nodes and Pectoralis
Major – rarely done

If it has invaded through breastr and into the muscle

Question 12

• Return to activity advice/posture aftter mastectomy

Answer 12

Go back to normal, light activites early - dressing, eating, picking up their phone with that hand

Question 13

Exercises Mastectomy/WLE with AD

Answer 13

• Check op notes
• Level 1 exercises for 1 week plus encourage
light use of arm for normal activity
• Keep arm <90 degrees
• Level 2 exercises commenced after this, so
long as drain removed
• Gradual progression as pain allows

Question 14

Exercises WLE/SNB

Answer 14

• Level 1 exercises for few days plus encourage
light use of arm for normal activity
• Level 2 exercises commenced after this, so
long as drain removed
• Gradual progression as pain allows

Question 15

Posture and Activity Advice mastectomy

Answer 15

• Good posture in standing, sitting and walking
especially mastectomy
• Watch for protective postures – pillow support
• No heavy lifting/repetitive use/sustained
postures

Need yto keep circulation going - every 1/2 hour if doing something like computer or knitting, stop, stretch and move around

Question 16

Why might women have poor posture after mawstectomy

Answer 16

pain

Body image

Question 17

When does lymphoedema occur after mastectomy

Answer 17

• Can develop at any time even years ahead

Question 18

Lymphoedema Prevention Mastectomy

Answer 18

• Avoidable risk factors – factors that challenge
immune system or impede flow of lymph
• Instruct patient to be aware of signs and
symptoms to identify early
• Avoid BP/cannulas/blood taken on the operated
side always (Armer 2013)

Question 19

Possible Post‐op Complications Mastectomy

Answer 19

• Pain
• Seroma
• GH ROM/movement
dysfunction
• Soft tissue
contracture/adhesions
• Numbness/hypersensiti
vity in arm/breast
• AWS/Cording
• Neural tension
• Lymphoedema

Question 20

What is Axillary Web Syndrome/Cording

Answer 20

A visible web of axillary skin overlying
palpable cords of tissue that are made taught
and painful by shoulder abduction

Question 21

Aetiology Axillary Web Syndrome/Cording

Answer 21

• Lymphovenous injury, stasis and
hypercoagulability(tissue injury releases tissue
factor that causes hypercoagulability) as a
consequence of superficial venous stasis,
lymphatic disruption and tissue injury caused
by axillary clearance

Question 22

Risk Factors / Onset axillary cording

Answer 22

• Slimmer women – BMI < 25
• Younger women – Age < 50yo
• Why?? Unknown
• Onset from 2‐8 weeks post‐op

Question 23

Signs of AWS

Answer 23

• Shoulder abduction restricted
• Hardened palpable cords which are painful
but not erythematic
• Cords may extend down medial upper arm,
across cubital fossa into anterior forearm

Question 24

Treatment axillary webbing

Answer 24

• Massage
• Stretches (need to push into some pain)
• LLLT trial – no research but good early results

Question 25

What is neoadjuvant chemo and why is it used

Answer 25

Chemo before the surgery. Used to try and shrink large tumors before surgery

Question 26

What is adjuvant chemo and why is it used

Answer 26

• Adjuvant – can begin quite quickly post‐op
e.g. 2 weeks post‐op. Commonly 6 cycles ‐ 3
weekly

Question 27

Radiotherapy for breast cancer

Answer 27

• All WLE’s, reduces local recurrence
• Mastectomy
• Axilla/SCF if extensive nodal disease
• 50Gy/25f
• Increases risk of lymphoedema

Question 28

Physio role in post operative period mastectomy

Answer 28

• Education
• Movement/strength recovery
• Prevention of adhesions
• Return to activity/exercise
• Lymphoedema/Cording
• Support and monitoring