Managment Of Breast Cancer And Lymphoedema Flashcards
What is cancer
- 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)
Types of cancer
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
List some common carcinomas
- lung
- breast
- colon
- bladder
- prostate
Andeno
Gland
Chondro
Cartilage
Erythro
Red blood cells
Hemangio
Blood vessels
Hepato
Liver
Lipo
Fat
Lympho
Lymphocytes
Melano
Pigment cell
Myelo
Bone marrow
Myo
Muscle
Osteo
Bone
Malignant vs benign
- 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.
Explain metastasis
• 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
What is staging
- 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
Metastasis and origin location
What are the goals of cancer treatment classified as
- curative intent
- palliative intent
What is curative treatment
- 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
Palatine care
• 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
What are 4 treatment options
- Surgery (gold standard)
- Radiotherapy
- Chemotherapy
- Immunotherapy
What is radiotherapy
• 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)
What are side effects of radiation
- 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
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.
What are side effects of chemotherapy
• Can cause systemic issues more so than XRT
• Common acute reactions to chemotherapy
-gastrointestinal toxicity (N & V)
-Neutropenia
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)
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
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
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
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
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
Neuropathic pain
- Caused by diseased or damaged Nerves
• Often presents as burning, P&N, sharp shooting
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)
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)
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%
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
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
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
What is Physiotherapy involvement in breast cancer
- Shoulder function
- Prevention of lymphoedema/ Mx
- Scar Mx
Why can shoulder ROM be limited after breast cancer surgery
- Pain (surgery, wound, bruising, drain)
- Scar tissue
- Axillary web syndrome (cording)
- Seroma
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
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
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
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
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
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
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
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
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.
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
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
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
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
What are treatment goals of lymphoedema treatment
- Reduce oedema
- Improve elasticity of radiated/fibrotic areas
- Increase shoulder ROM
- Reduce scarring
What’s included in management of lymphoedema
- Skin care and protection
- Elevation
- Deep breathing
- Self Massage
- Exercises
- Compression
- Manual Lymphatic Drainage
What are contraindications to management
- Infection to treatment area (cellulitis)
- Skin breakdown due to radiation (pain and infection control)
- Current radiation treatment
- Mets
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
