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)
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
3
Q
List some common carcinomas
A
- lung
- breast
- colon
- bladder
- prostate
4
Q
Andeno
A
Gland
5
Q
Chondro
A
Cartilage
6
Q
Erythro
A
Red blood cells
7
Q
Hemangio
A
Blood vessels
8
Q
Hepato
A
Liver
9
Q
Lipo
A
Fat
10
Q
Lympho
A
Lymphocytes
11
Q
Melano
A
Pigment cell
12
Q
Myelo
A
Bone marrow
13
Q
Myo
A
Muscle
14
Q
Osteo
A
Bone
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.
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
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
18
Q
Metastasis and origin location
A
19
Q
What are the goals of cancer treatment classified as
A
- curative intent
- palliative intent
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
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
22
Q
What are 4 treatment options
A
- Surgery (gold standard)
- Radiotherapy
- Chemotherapy
- Immunotherapy
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)
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
What is chemotherapy
* 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
What are side effects of chemotherapy
• Can cause systemic issues more so than XRT
• Common acute reactions to chemotherapy
-gastrointestinal toxicity (N & V)
-Neutropenia
27
What is gastrointestinal toxicity
* 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
What is neutropenia
* 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
What are precautions to chemotherapy
• 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
Where mag pain arise from
• 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
Presence of pain
* 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
Bone pain
- Most common source of pain
- Cancer invades the bone
• tenderness, with constant background pain
• spontaneous or movement- related exacerbation
• frequently described as severe
33
Neuropathic pain
- Caused by diseased or damaged Nerves
| • Often presents as burning, P&N, sharp shooting
34
Breast anatomy female
* Lobules (milk- producing glands)
* Ducts (tubes carry milk from lobules to nipple)
* Stroma (fatty tissue and connective tissue surrounding ducts and lobules)
35
What is the lymphatic system
* 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
What is a lumpectomy/ WLE
• 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
What is a mastectomy
* Removal of the entire breast including the nipple and areola, leaving the pectoralis major intact
* With a mastectomy, radiation is usually not necessary
38
What is a sentinel lymph node biopsy
* 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
What is axillary clearance
* 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
What is Physiotherapy involvement in breast cancer
* Shoulder function
* Prevention of lymphoedema/ Mx
* Scar Mx
41
Why can shoulder ROM be limited after breast cancer surgery
* Pain (surgery, wound, bruising, drain)
* Scar tissue
* Axillary web syndrome (cording)
* Seroma
42
What is pre op Physiotherapy
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
What is Physiotherapy day 1 post op
* 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
What is Physiotherapy outpatient- appointment 2 weeks post surgery
* 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
When are follow ups after surgery
- 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
What is cording
• 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
What is treatment of cording
```
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
What are contraindications to treatment of cordings
* 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
What is lymphoedema
* 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
Lymph nodes
* 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
What are signs and symptoms of lymphoedema
* Tightness
* Fullness/constricting feeling
* Discomfort/pain
* Persistent/fluctuating swelling
* Deepening of skin folds
* Indentations in skin from clothing
52
What is included in assessment of lymphoedema
-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
What is visual inspection of lymphoedema
• 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
What is included in palpation
-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
What are treatment goals of lymphoedema treatment
* Reduce oedema
* Improve elasticity of radiated/fibrotic areas
* Increase shoulder ROM
* Reduce scarring
56
What’s included in management of lymphoedema
* Skin care and protection
* Elevation
* Deep breathing
* Self Massage
* Exercises
* Compression
* Manual Lymphatic Drainage
57
What are contraindications to management
* Infection to treatment area (cellulitis)
* Skin breakdown due to radiation (pain and infection control)
* Current radiation treatment
* Mets
58
Remember prevention is better than a cure… so educate:
* 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
