Breast Surgery - Role of Physiotherapy

Question 1

What types of surgery are associated with breast cancer?

Answer 1

• Mastectomy: Complete removal of all breast tissue
• Breast conversion surgery
• Oncoplastic surgery (breast reconstruction)
• Axillary surgery (removes lymph nodes, indicated when cancer is invasive)

Question 2

Which type of breast cancer surgery requires follow up physio?

Answer 2

• Surgery involving the axilla has greatest affect on morbidity associated with arm & shoulder
• PT usually not indicated if minimal/no axilla involvement

Question 3

What are some of the consequences to the shoulder & arm following axillary surgery?

Answer 3

• Reduced shoulder ROM & function
• Scarring
• Shoulder dysfunction (e.g. scap stability, frozen shoulder)
• Postural changes
• Axillary web syndrome/cording
• Lymphoedema in arm/breast

Question 4

What is axillary web syndrome/cording?

Answer 4

• Tight cord like structures appear in the axilla
• Subjectively- like a tight inelastic band within the arm
• Sometimes palpable down the arm & at the cubital fossa & wrist
  Often worst at about 4-6/52 post surgery

Question 5

What are the risk factors for lymphoedema in breast cancer?

Answer 5

• Axillary surgery
• Other risk factors e.g. high BMI
• Adjuvant treatment

Question 6

What is adjuvant treatment?

Answer 6

Combination of surgery, radiotherapy, chemotherapy and hormone therapy

Question 7

What is adjuvant treatment dependent on?

Answer 7

• Histological type of the cancer (including oestrogen receptor status)
• Size of tumour
• Stage of breast cancer
• Grade of tumour
• Multifocality/multicentricity

Question 8

What is the aim of chemotherapy?

Answer 8

• To eliminate micro metastases
• Individual regimes, dose every 3 weeks for 4-6 cycles
• Usually post surgery, but increasingly pre surgery (neo adjuvant)

Question 9

When is radiotherapy indicated?

Answer 9

• WLE: 95% have radiotherapy
• Mastectomy: 36% if high grade < 50
• Usual course 9 days/ fortnight over 6 weeks

Question 10

What is the aim of hormonal therapy?

Answer 10

• To block oestrogen in receptor positive tumours
• Usually starts after chemo and radiotherapy
• Commonly 5 year course
• Pre-menopausal aim is to eliminate oestrogen production by ovaries

Question 11

What are the common side effects of chemo?

Answer 11

• Nausea and vomiting
• Fatigue
• Hair loss
• Bone marrow suppression (leading to immuno-suppression)
• Taxol-based tend to cause some generalised peripheral oedema
• Effects on skin and nails
• Peripheral neuropathy

Question 12

What are the common side effects of radiotherapy?

Answer 12

• Fatigue
• Skin reaction, burns
• Breast oedema, chronic inflammation, lymphoedema
• Fibrosis leading to tightening of skin and muscles of the chest wall
• Increased risk of UL lymphoedema

Question 13

What are the common side effects of hormonal therapy?

Answer 13

• Some drugs reduce bone density
• Variable – hot flushes, incontinence, vaginal dryness
• Joint pain/inflammation

Question 14

What are the physio goals post breast cancer surgery?

Answer 14

• Regain pre op shoulder ROM & function within 3/12
• Minimise effect of secondary complications on physical recovery (scar contraction, cording, sensory disturbance, weakness)
• Education on lymphoedema
• Manage fatigue
• Establish regular exercise routine to aid recovery of physical fitness

Question 15

What are the common physio interventions post breast cancer surgery?

Answer 15

• Exercise program
• Scar management
• Advice & encouragement to return to activity & exercise
• Education about lymphoedema & monitoring

Question 16

What is physio treatment post breast cancer surgery based on?

Answer 16

Principles of the Physiotherapy Management Care Plan (PCMP)