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*Complex Patient - Physiotherapy > Managment Of Breast Cancer And Lymphoedema > Flashcards

Managment Of Breast Cancer And Lymphoedema Flashcards

1
Q

What is cancer

A
  • cancer refers to any uncontrolled growth of abnormal cells
  • it can arise from any type of cell in the body
  • normal tissue are able to balance the rate of new cell growth and old cell death
  • in cancer, this balance is disrupted resulting in uncontrolled growth or loss of cells ability to undergo cell death (apoptosis)
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2
Q

Types of cancer

A

Four major subtypes of cancer:
• Carcinomas are the most common forms of cancer and arise from epithelial tissue such as the skin and lining of the body cavities and organs
• Sarcomas are found in connective and supportive tissue such as bone, cartilage, nerve, blood vessels, muscle and fat
• Lymphomas arise in the lymph nodes and tissues of the body’s immune system.
• Leukemia are cancers of the immature blood cells that grow in the bone marrow and tend to accumulate in large numbers in the bloodstream

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3
Q

List some common carcinomas

A
  • lung
  • breast
  • colon
  • bladder
  • prostate
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4
Q

Andeno

A

Gland

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5
Q

Chondro

A

Cartilage

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6
Q

Erythro

A

Red blood cells

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7
Q

Hemangio

A

Blood vessels

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8
Q

Hepato

A

Liver

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9
Q

Lipo

A

Fat

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10
Q

Lympho

A

Lymphocytes

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11
Q

Melano

A

Pigment cell

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12
Q

Myelo

A

Bone marrow

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13
Q

Myo

A

Muscle

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14
Q

Osteo

A

Bone

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15
Q

Malignant vs benign

A
  • Tumours can be benign (non-cancerous) or malignant (cancerous)
  • Benign Tumours are unable to spread by invasion or metastasise. Depending on size & location are often left insitu.
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16
Q

Explain metastasis

A

• Metastatic cancer has spread to another part of the body from it’s primary origin
• ~ 90 % of cancer deaths are a result of metastasis
• Majority can not be cured but rather controlled
• All types of cancers have the potential to spread but rare for blood and lymphatic cancers
• Cancer cells can travel through the blood or the lymphatic system until they find a suitable location to settle and re-enter the tissue
• Detection of cancer cells in lymph nodes plays an important role in tumour staging
• Sometimes the metastases can be found before the primary
• Occasionally the primary is unknown (rare)
-Determined by appearance of the cells
• Prognosis is poor
• Usually adenocarcinomas located in the pancreas and lung

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17
Q

What is staging

A
  • A way of grouping cancers for the purposes of prognosis and treatment selection.
  • TNM staging system
  • Tumor size 0-4 (4 being the largest)
  • Nodal involvement 0-3 (3 being most involvement)
  • Metastases 0-1 (1 being metastases present)

Examples:
• T4N2M1- poor prognosis
• T1N0M0- better prognosis

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18
Q

Metastasis and origin location

A
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19
Q

What are the goals of cancer treatment classified as

A
  • curative intent

- palliative intent

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20
Q

What is curative treatment

A
  • A ‘cure’ is when the rate of death for that particular cancer population is the same rate as the general population.
  • However, it can reoccur. Should be considered as prolonged remission instead of a cure
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21
Q

Palatine care

A

• When a curative treatment option is not available
• Focus is on maximising survival time and quality of life
• Does not mean that the patient is going to die in the next 3 months or 6 months.
- Equipment
- Pain Mx

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22
Q

What are 4 treatment options

A
  1. Surgery (gold standard)
  2. Radiotherapy
  3. Chemotherapy
  4. Immunotherapy
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23
Q

What is radiotherapy

A

• Treatment using iodising radiation to cause cell damage or death.
• Delivered via two methods
- External Beam Radiation/Therapy (Teletherapy), usually via a linear accelerator (also Tomotherapy)
- Brachytherapy (Implants/seeding)- direct placement of radioactive source into the region of treatment (“Hot” patients)

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24
Q

What are side effects of radiation

A 
- Mostly site specific:
• Radiation induced diarrhoea
• Nausea and vomiting
• Xerostomia (dry mouth)
• Oral mucositis (painful inflammation and ulceration of the mucous membranes lining the digestive tract)
• Skin reactions/burns/fibrosis

-general side effects
• Fatigue
• Depression
• Loss of ROM • Pain

25
Q

What is chemotherapy

A
  • Using cytotoxic chemical agents to treat cancer
  • Can be used in conjunction with other therapies
  • Currently more than 50 different cytotoxic drugs are used and over 200 protocols with haematology patients alone.
26
Q

What are side effects of chemotherapy

A

• Can cause systemic issues more so than XRT
• Common acute reactions to chemotherapy
-gastrointestinal toxicity (N & V)
-Neutropenia

27
Q

What is gastrointestinal toxicity

A
  • Manifested by Anorexia, Nausea and Vomiting
  • Can occur prior to chemotherapy treatment (anticipatory nausea) and can last for several days post treatment
  • Anti-emetic medication is very important & may be required to complete a physiotherapy session
  • Mouth care and other fact sheets are important (Dietician or Speech are usually involved)
28
Q

What is neutropenia

A
  • Diminished ability to fight infections and at high risk of becoming infected
  • Depending on the severity of the neutropenia you may be required to wear a plastic apron, gloves and a mask (single room & signs)
  • Try and see these patients first
  • Respiratory infection- prophylactic treatment is important in these patients
29
Q

What are precautions to chemotherapy

A

• Chemotherapy can be excreted via all body fluids, especially urine for 48 hours post dose but can be longer
• No safe level of exposure - goal to reduce risk of exposure to As Low As is Reasonably achievable (ALARA)
• Possible exposure routes:
-Inhalation, ingestion, dermal absorption, Mucosal absorption
• Main risk for PT’s is exposure to contaminated urine, faces or vomit. *Sputum is not considered a risk.
• Use cytotoxic precautions for 7-10 days after chemotherapy.
• In case of exposure, remove self from the pt/area immediately and wash the affected area with copious amounts of soapy water for 15 mins.
• Cleanse eyes, mouth or nose that has been splashed with cytotoxic drug or contaminated waste with clean water for 15 mins

30
Q

Where mag pain arise from

A

• A tumour compressing or infiltrating tissue
• Or treatments and diagnostic procedures
• Can last long after treatment has ended
- XRT burns – 2-3/52 post Tx
- Chemo – peripheral neuropathy

31
Q

Presence of pain

A
  • The presence of pain depends mainly on the location of the cancer and the stage of the disease.
  • At any given time, about half of all patients with malignant cancer are experiencing pain.
  • 75% of pain is caused by the illness itself
32
Q

Bone pain

A
  • Most common source of pain
  • Cancer invades the bone
    • tenderness, with constant background pain
    • spontaneous or movement- related exacerbation
    • frequently described as severe
33
Q

Neuropathic pain

A
  • Caused by diseased or damaged Nerves

• Often presents as burning, P&N, sharp shooting

34
Q

Breast anatomy female

A
  • Lobules (milk- producing glands)
  • Ducts (tubes carry milk from lobules to nipple)
  • Stroma (fatty tissue and connective tissue surrounding ducts and lobules)
35
Q

What is the lymphatic system

A
  • Part of body’s defense system
  • Most lymphatic vessels in the breast connect to lymph nodes under the arm (axillary nodes)
  • Some connect to lymph nodes inside the chest (internal mammary nodes) and some to those above the collar bone (supraclavicular nodes)
36
Q

What is a lumpectomy/ WLE

A

• Removes the tumor with a rim of normal tissue (clear margins – 1cm)
• almost always followed by radiation therapy
- decreases the likelihood of the cancer coming back in the breast by more than 50%

37
Q

What is a mastectomy

A
  • Removal of the entire breast including the nipple and areola, leaving the pectoralis major intact
  • With a mastectomy, radiation is usually not necessary
38
Q

What is a sentinel lymph node biopsy

A
  • Sentinel lymph node is the first lymph node to receive drainage from the breast or a tumor in the breast
  • Injection of radiotracer
  • +/- blue dye into the skin
  • A gamma probe used to detect radioactivity in the axilla
  • Only nodes that are hot and/or blue are removed
39
Q

What is axillary clearance

A
  • An important part of staging breast cancer is determining if the lymph nodes under the arm are involved with cancer
  • If nodes are +ve SNB > AC
  • 10 – 40 lymph nodes are removed during an AC
  • Was once standard of care for breast cancer patients
40
Q

What is Physiotherapy involvement in breast cancer

A
  • Shoulder function
  • Prevention of lymphoedema/ Mx
  • Scar Mx
41
Q

Why can shoulder ROM be limited after breast cancer surgery

A
  • Pain (surgery, wound, bruising, drain)
  • Scar tissue
  • Axillary web syndrome (cording)
  • Seroma
42
Q

What is pre op Physiotherapy

A

Gain pre-morbid levels

  • Check sh ROM and function
  • ULmeasures
  • Cancer Council handout – review stage 1 & 2 exercises
  • Education re: role of physio, expectations post op, return to work/activity and Lymphoedema
  • Sh ROM to 90deg only while drain insitu (4-10 days draining less than 100mls/day)
  • Post op exercises – circulation, DBExs, Sitting out of bed and reg Mob
43
Q

What is Physiotherapy day 1 post op

A
  • Review stage 1 & 2 exercises (90 deg if drain insitu)
  • Circ exs, DBExs, SOOB, Mob, Stairs Ax (if req)
  • Review Education
  • Book appt for 2/52 post op
44
Q

What is Physiotherapy outpatient- appointment 2 weeks post surgery

A
  • Review UL measures & Sh ROM
  • Progress Sh ROM exercises (drain removed)
  • Posture retraining & Pec stretch
  • Scar advice & Mx
  • L/O ex’s
  • Cording edu & Mx
45
Q

When are follow ups after surgery

A
  • R/V 1,6 &12 Months for UL measurements and monitoring
    • Seen fortnightly during XRT (incresed risk of L/O)
    • ? More regularly with Sh dysfunction, complex scaring and ongoing cording & L/O
46
Q

What is cording

A

• Can be seen after any axillary surgery
• Presents as a series of tender, cord-like structures that are visible and palpable beneath axillary skin
• Cords can extend down the arm, into forearm
• Cording” is due to disruption of lymphatic vessels during axillary surgery
• Incidence:
-20% after sentinel node biopsy
-44%-72% after axillary clearance
• Develops in early post-operative period (within first 6/12)
• Limits range of motion
• Can present as burning pain

47
Q

What is treatment of cording

A 
The aim of treatment is to either stretch the cords or to break the cords
• Modified stretching
• Deep tissue massage and self massage 
• Reassurance
• Heat
• Strengthening
48
Q

What are contraindications to treatment of cordings

A
  • Reddening of the scars
  • Radiation - manual techniques should not be carried out in an area subjected to radiation until two weeks post
  • Metastasis in the axilla
49
Q

What is lymphoedema

A
  • Lymphoedema can occur as result of lymph nodes being removed from surgery or if they are damaged from radiotherapy.
  • Definition = Reduced lymphatic transport capacity which is overloaded by a normal lymphatic load
  • Lymphoedema is the swelling of one or more parts of the body that occurs when the lymphatic system does not function properly
  • Once the lymphatics are damaged swelling can occur at any time. It may develop gradually or immediately and affect all or part of a limb
  • Can occur weeks, months or years later, triggered by an incident which overloads the lymphatic system
50
Q

Lymph nodes

A
  • All lymph passes through one or more nodes which are largely arranged in regional groups.
  • Macrophages in the nodes break down proteins and fight infections.
  • They are unable to regenerate once removed.
51
Q

What are signs and symptoms of lymphoedema

A
  • Tightness
  • Fullness/constricting feeling
  • Discomfort/pain
  • Persistent/fluctuating swelling
  • Deepening of skin folds
  • Indentations in skin from clothing
52
Q

What is included in assessment of lymphoedema

A

-Detailed history required
-Photos and detailed descriptions
-Surgical history
• When/where was the surgery
• Lymph node status(number removed,number positive)
• Cancerstatus
• Postophealing/complications
• Typeofsx
• XRT/Chemo
• Medical history(contraindications,respiratory problems- COPD, emphysema)
-Swelling
• Onset on swelling
• When is swelling worse? • What reduces oedema?
-Other allied health input
-Work
-Social situation
-Previous musculoskeletal injuries

53
Q

What is visual inspection of lymphoedema

A

• Where is the swelling visible?
• Extent of swelling?
• Where are the scars situated?
-Condition of scar – healed, thickened, mature
• Skin condition
-Radiation fibrosis, fragile, blistered, thickened, nodular skin changes, ulcerations, pigmentation changes

54
Q

What is included in palpation

A

-Texture of the skin and underlying tissue
• Scars (Mobility of the scars, thickened, soft, adhesions, raised)
• Extent of fibrosis
-Consistency of Oedema
• pitting, non pitting, fibrosis

55
Q

What are treatment goals of lymphoedema treatment

A
  • Reduce oedema
  • Improve elasticity of radiated/fibrotic areas
  • Increase shoulder ROM
  • Reduce scarring
56
Q

What’s included in management of lymphoedema

A
  • Skin care and protection
  • Elevation
  • Deep breathing
  • Self Massage
  • Exercises
  • Compression
  • Manual Lymphatic Drainage
57
Q

What are contraindications to management

A
  • Infection to treatment area (cellulitis)
  • Skin breakdown due to radiation (pain and infection control)
  • Current radiation treatment
  • Mets
58
Q

Remember prevention is better than a cure… so educate:

A
  • Skin Care
  • No sunburn or hot baths
  • Avoid Cuts, scratches & bruises to affected arm
  • No needles & blood pressure cuffs
  • Avoid heavy lifting
  • Exercise & UL movement/ elevation
  • Compression: wear for long distance travel and for heavy work…
  • Ongoing Surveillance

*Complex Patient - Physiotherapy (13 decks)

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