2014 Annual Breast Cancer Rehabilitation

Healthcare Provider Event

A Manual Therapy and Exercise Approach to Breast Cancer Rehabilitation Course

November 7th and 8th, 2014

Mercer University, Atlanta, GA

Sponsored By:

TurningPoint’s Edith Van Riper-Haase Breast Cancer

Rehabiltation Advocacy Fund

thevisualab.com

Presentations are

Available on TurningPoint’s Website:

myturningpoint.org

Click on Course Link

www.oncologypt.org itsthejourney.org

A Manual Therapy and Exercise Approach to Breast Cancer Rehabilitation Course

Overview of the Physical

and Emotional Side

Effects of Breast Cancer

Treatment

Jill Binkley, PT, MSc, FAAOMPT, CLT

This Presentation is available on TurningPoint’s Website:

myturningpoint.org

From Homepage Click on Course Link

Course Themes: Women have a multitude of physical and emotional effects of

breast cancer treatment

Breast cancer rehabilitation has been shown to be effective

in reducing and preventing treatment side effects

Very few breast cancer patients receive rehab care

There is an important role for: Prospective surveillance for treatment side effects to facilitate

early detection and treatment

Manual therapy

Exercise

Coordination of rehabilitation services

Disclosures:

This course is taught by physical therapists and may include clinical content that is not in all attendees’ scope of

practice. Non-physical therapists should refer to their own practice guidelines and state or provincial licensing

board with respect to guide application.

1.Recognize common functional, physical and psychosocial issues affecting patients during and

after breast cancer treatment.

2.Understand the effects of radiation and surgery on the biomechanics of the shoulder complex.

3.Understand the physiology, incidence and risk factors of lymphedema, and be able to implement

an evidence-based approach to lymphedema screening and management, including when referral

to a lymphedema specialist is appropriate.

4.Evaluate and manage the common physical side effects of breast cancer treatment, including

upper extremity dysfunction and cording, using a manual therapy and exercise approach.

5.Understand the role of exercise for breast cancer patients, including therapeutic exercise,

cardiovascular exercise and Pilates.

6.Select and interpret outcome measures relevant to breast cancer patients.

7.Understand the role of rehabilitation for women with metastatic breast cancer.

8.Understand the role of other rehabilitation specialties, including counseling, massage therapy

and nutrition.

9.Understand patient perspectives on the role of rehabilitation for women with breast cancer.

10.Understand how patients with breast cancer can be served in a variety of settings, including

out-patient orthopaedic, hospital and other clinic settings.

Obje

ctives

Breast cancer is life-changing and heart-wrenching.

Leading cause of death in women 35-75.

1 in 8 women in their lifetime will be diagnosed with breast cancer.

Women and their families face staggering physical

and emotional issues during and after treatment.

TurningPoint is a non-profit 501c3 organization whose mission is to improve

quality of life for women with breast cancer by providing, promoting and

advocating for specialized and evidence-based rehabilitation.

Physical Therapy

Massage Therapy

Exercise Programs

Nutrition Counseling

Emotional Counseling

Patient and Community Education Programs

Healthcare Provider Education and Advocacy

www.myturningpoint.org

Care. Compassion. Clinical Excellence.

TurningPoint Breast Cancer Rehabilitation improves

quality of life for women with breast cancer by

providing, promoting and advocating evidence-

based and specialized rehabilitation.

TurningPoint is the only organization in the southeast

that is dedicated solely to providing comprehensive

and specialized rehabilitation for women with breast

cancer.

TurningPoint is a non-profit 501c3 organization.

TurningPoint helps over 400 women each year get

through breast cancer treatment and transition more

quickly and easily back to usual roles and activities.

A financial assistance program and Hispanic Outreach

program help to reduce barriers to care.

Community and healthcare provider

education programs reach thousands

each year

Hispanic Outreach with services in

English and Spanish

Clinical and research partnership with

Grady Hospital in Atlanta to increase

access to breast cancer rehabilitation

care for inner city and minority women

Community Outreach Programs

TurningPoint educates healthcare providers locally

and nationally about breast cancer survivorship

issues and the role of rehabilitation to increase

quality of life.

TurningPoint has worked closely with The American

Cancer Society and hosts annual healthcare

provider education programs to make routine

referral for breast cancer rehabilitation a reality in

United States.

TurningPoint Mission Includes:

Complex Patient Care

Complimentary Education and Patient

Services

Healthcare Provider Education

National Advocacy

Research

Clinical Service Income

(37%)

Corporate, Board and Individual

Donations

(15%)

Fundraising Events

(TP and Community)

(16%)Grants

(26%)

Other

(Course Income, Miscellaneous)

85% of TurningPoint Expenses are Direct Mission Expenses

Brief Overview of Breast Cancer

Treatment

Surgical and Medical Decision-Making

Lumpectomy vs. Mastectomy

Chemotherapy Adjuvent

Post-Surgical Chemotherapy

Hormone Therapy

Targeted Therapy

Radiation

Lumpectomy or Mastectomy ?

Tumor Size

Histological grade

Surgical margins of

lumpectomy

Breast Size

Staging Breast Cancer

Tumor size (T)

Lymph Node Status (N)

Metastases (N)

Lymph Nodes and Breast

Cancer Breast lymph fluid is filtered mainly by nodes in the the armpit, or "axilla“

Since one the main jobs of the lymph nodes is to filter out "bad guys" like cancer cells, this is a logical place to look for breast cancer cells that have escaped the original tumor

The answer to “How far is the horse out of the barn ?” helps to stage breast cancer and plan treatment

Cancer cells may also leave the breast through

the bloodstream and bypass the lymph nodes

Determination of Axillary Node

Status

Axillary Node Dissection

10 – 30 nodes removed usually through same incision as mastectomy, separate incision for lumpectomy

pathological examination to determine if cancer cells

Sentinel Node Biopsy

Less invasive determination of axillary node status

Sentinel Node Biopsy

Radioactive tracer +/- blue dye injected into tumor

Wait 45 min – 6 hours

Scan or geiger counter to determine location of ‘sentinel node(s)’

Small incision to remove SN

If positive further axillary node dissection

If negative assume all nodes are negative and avoid further node removal

Ductal carcinoma in situ (DCIS) - Stage 0

• most common type of non-invasive breast cancer

• starts inside the milk ducts, "non-invasive" because it hasn’t spread beyond the milk

duct into any normal surrounding breast tissue

• not life-threatening, but having DCIS can increase the risk of developing an invasive

breast cancer later on.

• can be treated with lumpectomy - 25% to 30% chance of having a recurrence with no

radiation, radiation reduces the risk of recurrence to about 15%.

Common Types of Breast Cancer

Invasive ductal carcinoma (IDC)

•most common type of breast cancer. (about 80% of all breast cancers)

•cancer begins in milk ducts and has spread to the surrounding breast tissues and can

spread to lymph nodes.

Lobular breast cancer (LCIS and ILC)

•second most common after IDC – 10-15% of breast cancers

•more common in older women

•ILC – more difficult to identify on mammogram, may be felt as thickening, reddening,

can be painful

Inflammatory breast cancer

Inflammatory Breast Cancer

Clinical presentation similar to mastitis

IBC accounts for 1 to 5 percent of all

breast cancer in the U.S.

Younger women compared to non-IBC

breast cancer, slightly higher

occurrence rate in African American

women

Peau d’orange, redness, warmth, ‘rash’

Confirmed by pathology report

Cancer site is the lymphatics of the

breast and chest region

Considered Stage IIIB locally advanced

at diagnosis, very aggressive; Stage IV

with metastases

Simplified Staging of Breast Cancer

Stage I (A, B)

< 2 cm, no positive lymph nodes or other spread (may have micrometastases in lymph nodes)

Stage II (A, B)

2 cm - 5 cm with 1-3 positive lymph nodes or > 5 cm with negative lymph

Stage III (A, B, C)

Larger tumor, lymph node involvement > 3 nodes

Chest wall/skin involvement

Inflammatory breast cancer Stage III, unless metastatic.

Stage IV

Metastatic Breast Cancer

Treatment of Stage 1-3 Breast Cancer

Stage I

Breast conserving surgery or mastectomy, lymph node dissection or sentinel

lymph node sampling

Adjuvant systemic therapy - chemo or hormone therapy depends on size and

grade of tumor

Stage II

Similar to stage I, plus radiation with large tumors and 4 or more lymph nodes

Adjuvant systemic therapy usually recommended

Hormone therapy if ER or PR – positive

Tamoxifen - preventing estrogen from binding to receptors in ER/PR +ve breast cancer

cells

Aromatase inhibitors (femara, arimidex, aromasin) - block estrogen production by blocking the

enzyme aromatase from converting androgens into estrogen – does not stop production of estrogen by

ovaries so only in post-menopausal women

Immunotherapy – Herceptin if elevated HER2/neu

Stage III

Similar to stage II

Other Determinants of Prognosis and

Treatment Options Histological grade – poorly differentiated cancer cells spread more

aggressively

Estrogen and progesterone receptors - if positive - improves prognosis

S-phase fraction – cells dividing more rapidly more aggressive

HER2/neu Human epidermal growth factor Receptor 2 is a growth-promoting hormone increased in 1/3 tumors

– these tumors are more aggressive, treatment with antibody trastuzumab (Herceptin)

Oncotype Testing Tests expression of 21 genes in tumor cells and assists in predicting the likelihood of chemo benefit

as well as recurrence in early-stage breast cancer invasive breast cancer who will be treated with hormone therapy

Typically used in women with early-stage (stage I or II), node-negative, estrogen receptor +ve

Score between 0 and 100 that shows the chance of the breast cancer returning within 10 years of

the original diagnosis.

Recurrence Score is then categorized into one of three groups:

over 31, a high-risk score, this means there's a greater chance that the breast cancer will return

18 or less, a low-risk score

19 to 30 then the recurrence risk is intermediate

Genetic Testing

BRCA1 or BRCA2 gene

increased chance of developing breast and ovarian cancer during their lifetimes

5-10% of women diagnosed with breast cancer will be carriers of one of these mutations.

Local Recurrence of

Breast Cancer

Metastatic Breast Cancer

Common Sites

Lung

Liver

Bone

Brain and CNS

5 Year Survival Rate for Breast Cancer by Stage

Source: ACS 2014

0 100%

I 100%

II 93%

III 72%

IV 22%

Breast Reconstruction Options

Implant – Expander followed by saline or silicone

implant

Autologous Tissue Reconstruction

Latissimus Dorsi Flap with Implant

Transverse Rectus Abdominus Myocutaneous

(TRAM) Flap

Other sites: buttock (superior or inferior gluteal),

the thigh (tensor fascia lata) and the hip region

(iliac or Rubens’ flap)

GAP , Diep Flap

Pectoralis Major

Implant Reconstruction

Implant Reconstruction

Latissimus Dorsi Flap

Transverse Rectus Abdominus

Myocutaneous (TRAM) Flap

Considerations:

• Pedicled flap• flap attached at all times, tunelled from

abdomen to breast region

• Free flap• deep inferior epigastric artery and veins (DIEP)• lower incidence of fat necrosis and calcification

due to blood supply • Only lower portion of muscle/more preserved

Pedicled Tram: First reconstruction to use Transverse

Rectus Abdominus Muscle. Full 1/2 of rectus abdominus

tunneled to chest wall, breast mound with abdominal fat and

skin.

Free Flap TRAM Options: Microvascular surgery using

deep inferior epigastric artery and veins for blood supply. Decreased incidence of fat necrosis and calcification compared to Pedicled TRAM

Free Tram: Portion of rectus abdominus with blood

supply removed and transferred to chest utilizing

microvascular surgery.

Muscle Sparing Free Tram: Free TRAM but very

small (postage stamp) piece of rectus abdominus.

DIEP: Transfer of Deep Inferior Epigastric Artery and

Vein Only with microvascular surgery, fat and skin.

Muscle preserved.

Transverse Rectus Abdominus Myocutaneous

(TRAM) Flap

I-GAP flap: Inferior Gluteal Artery Perforator Flap from the lower

buttock

S-Gap flap: Superior Gluteal Artery Perforator Flap from the upper

buttock

Both use blood vessels, fat and skin from the buttocks

GAP Flap Reconstruction Options

Breast Cancer Survivorship Issues

Common Survivorship Issues

Related To Breast Cancer

Reduced Quality of Life

Shoulder, arm and trunk pain and dysfunction

Lymphedema

Fatigue

Nutritional Issues, including weight gain

Psychosocial Issues – disruption of

relationships, work issues, fear, body image, sexuality

Psychosocial Issues Include:

Fear of Dying

Fear of Prolonged Illness

Lack of ‘Cure’

Loss of Control

Body Image and sexuality

‘Chemopause’

Fear for family members

Abandonment by friends and associates

Relationship issues – partner and children

Cancer-Related Fatigue

What is Cancer Related

Fatigue? No simple definition

Experienced by 30-60% of patients with cancer

Different from other types of fatigue.

One of the most debilitating side effects of treatment.

Overwhelming. Not relieved with rest. Doesn’t go away

immediately when treatment ends

Biggest issue is impact on quality of life.

Impacts every aspect of life, physical,

spiritual, emotional, social

Common Causes of Fatigue

Effect of Chemotherapy and/or

radiation

Anemia

Depression

Nutritional disorders

Sleep Disorders

Pain

Deconditioning

Etiology of Treatment-Related Fatigue

Anemia – chemo and radiation suppress RBC production; cancer, itself, can change production of RBC by bone marrow

Fibrosis - (as a result of radiation therapy) can cause decreased lung function

Cycle - Cardio-respiratory and muscle deconditioning

Decreased Work Capacity

Decreased Level of Activity Due to Fatigue

More Fatigue

Depression Very common

Symptoms include fatigue, persistent sadness, loss

of interest in pleasures in life, difficulty concentrating

Can be difficult to diagnose

Fatigue-depression cycle

Management:

Medication

Education- know what to expect

Counseling

Coping skills- humor, positive reframing

Social support

Osteoporosis

Osteopenia / Osteoporosis(Swenson, Henly 2005)

BC survivors 5x more likely to suffer fracture

Reasons:

Chemotherapy with bone-wasting agents

(Cyclophosphamide and Methotrexate)

Glucocorticoid steroids (Prednisone, Hydrocortisone,

Dexamethasone) > 3 months

Hormonal therapy with aromatase-inhibitors

Primary ovarian therapy (menopause or chemopause)

Lack of physical activity

Other Effects of Chemotherapy

Weight Gain and Breast Cancer

60% of patients report weight gain, 26% weight

loss and 14% no change – cross-sectional study

by Rock et al (1999)

Factors associated with weight gain:

Chemotherapy

African-American ethnicity

Energy intake

Postmenopausal status

Tamoxifen not associated with weight gain

Rock et al, 1999; Saquib, 2007

Presence of signs and symptoms of peripheral nerve

dysfunction

May be somatic or autonomic as a consequence of

damage to the peripheral or autonomic nervous system

caused by administration of chemotherapeutic agents.

The neuropathies are dose dependent.

CIPN is a symmetrical distal polyneuropathy

Affects 50-75% of women who have taxane therapy

Chemotherapy-Induced Peripheral

Neuropathy (CIPN)

CHEMOTHERAPY AGENT INCIDENCE OF CIPN

TAXANESPaciltaxel (Taxol) (ovarian CA,

metastatic BCA)Docetaxel (Taxotere) (BCA)

Abraxane

60%

50%71%

VINCA ALKALOIDS (lymphoma, leukemia , solid tumors)

Vincristine (Onkovin)Vinorelbine

57%25%

PLATINUM COMPOUNDS (lung, ovarian, breast colorectal CA)

Cisplatin (Platinol)Carboplatin (Paraplatin)Oxaliplatin

92%4%74%

Side Effects of Hormone Therapy

Tamoxifen

In breast cancer cells that require estrogen

(ER+) to grow, estrogen binds to and activates

the estrogen receptor in these cells.

Tamoxifen is metabolized into compounds that

also bind to the estrogen receptor but do not

activate it.

Tamoxifen acts like a key broken off in the lock

that prevents any other key from being

inserted, preventing estrogen from binding to

its receptor., and breast cancer cell growth is

blocked.

Pre-menopausal women

Tamoxifen is sold under the trade

names Nolvadex, Istubal, and Valodex.

Side Effects of Tamoxifen

Hot flashes and night sweats, the most common side effect of

tamoxifen, occur in up to 80% of women receiving tamoxifen

The newer antidepressant drugs, such as the selective serotonin

reuptake inhibitors (SSRIs) and the serotonin and norepinephrine

reuptake inhibitors (SNRIs), are some of the most promising non-

hormonal therapies for the treatment of hot flashes.

Some evidence supporting the benefit of acupuncture in the

treatment of hot flashes

Bone: A beneficial side effect of tamoxifen is that it

prevents bone loss by acting as an estrogen

receptor agonist (i.e., mimicking the effects of estrogen) in

this cell type. (exception appears to be that tamoxifen

appears to be associated with bone loss in premenopausal

women who continue to menstruate after adjuvant

chemotherapy.

Endometrial and Uterine cancer: Endometrial changes,

including cancer, and increased risk of uterine cancer.

Cardiovascular and metabolic: Increased risk of blood

clots, especially during and immediately after major

surgery or periods of immobility.

Central nervous system: Reduced cognition, including

memory.

Aromatase Inhibitor Therapy

Aromatase inhibitor therapy is a hormonal therapy used for ER+

breast cancer in post-menopausal women.

Androgens are a group of hormones produced in women by the

ovaries, adrenal glands and by fat (common one is testosterone).

In post-menopausal women, estrogen is primarily synthesized by

aromatization of androgen in fat into estrogen.

Aromatase is an enzyme which converts the androgen turns the

hormone androgen into small amounts of estrogen in the body.

Aromatase inhibitors block the conversion of androgens to estrogen.

The drug names are Arimidex, Aromasin and Femara.

Aromatase Inhibitor-Associated

Musculoskeletal Symptoms(Henry, Giles, Stearns, 2008)

Loss of bone mineral density

Arthralgia (20-36%)

Most common sites are hands, knees and back

Carpal Tunnel Syndrome

Tenosynovitis and Tendonopathies

Bursitis

Exacerbation of osteoarthritis

Less common – rheumatic diseases or RA

Aromatase Inhibitor Side

Effects

Hot Flashes and Night Sweats

Vaginal Dryness

Loss of Sex Drive

Mood Changes

Heart problems, increased blood pressure,

increased cholesterol

Role of Rehabilitation for Women with

Breast Cancer

Early Rehabilitation Program for Women

Post-Mastectomy

Several studies have demonstrated significant improvement in range of motion and function differences in women receiving early post-op physical therapy

The improvement in range of motion

and function persisted at 3 and 6

months

Na, 1999; Cinar, 2008; Box, 2002; Beurskens, 2007, Lacomba, 2010

The efficacy of physiotherapy upon shoulder

function following axillary dissection in breast

cancer, a randomized study. 30 women 2 weeks post-breast cancer surgery and ALND

were randomly allocated to one of two groups:

PT treatment of advice, exercise (ROM and strength) and soft tissue

massage of surgical incision area for a total of 9 treatments

Control group had a flyer with advice and exercises for the arm and

shoulder

Most of the women had mastectomies, a few women in

each group (3 and 4) had breast conserving surgery

Follow up at 3 and 6 months – pain, range of motion,

circumference, grip strength, function

Beurskens CHG et al. BMC Cancer. 2007.

Results and Conclusions

Group receiving PT had significantly better shoulder

ROM, less pain and improved function and quality of

life than the control group

No clinically significant differences found between

groups for circumferential data.

Beurskens CHG et al. BMC Cancer. 2007.

Early Physical Therapy Decreases Risk of Lymphedema in Women with Breast CancerLocomba, MT et al. , British Medical Journal, February, 2010

Results: 1. At 12 month follow -up the incidence of lymphedema was significantly lower in the physical therapy group at 7% (4 women) compared to 25% in the control group (14 women)2. Women in the control group developed lymphedema more quickly after surgery3. The study is the first demonstrate the relationship between axillary cording and subsequent development of lymphedema.

Role of Rehabilitation in

Lymphedema Risk Reduction and

Early Intervention

Early range of motion and exercise

Education re: potential triggers such as infection and inflammation, early detection

Lifestyle and weight management

Evidence Supporting Early Upper Limb

Range of Motion Exercise

24 studies involving 2132 participants:

10 studies examined the effect of early versus delayed implementation

of post operative upper-limb exercise

14 studies examined the effect of structured upper-limb exercise

compared to usual care/comparison

Synopsis of findings:

• Physical therapy based exercise results in a significant and clinically

meaningful improvement in shoulder ROM and restoration of strength

after breast cancer treatment

• There was no evidence of increased risk of lymphedema from exercise at

any time point

Cochrane Systematic Review

McNeeley et al. 2010

Prospective Surveillance Model of Rehabilitation for

Women with Breast Cancer

Kathryn H. Schmitz, PhD, MPH, FACSM; Nicole L. Stout, PT; Kimberly Andrews;

Jill Binkley, PT, MClSc, FAAOMPT, CLT; Robert A. Smith, PhD

Planning and Editorial Committee

American Cancer Society sponsored a meeting of international panel of expert researchers and

clinicians in February, 2011. Stakeholders, including national professional and advocacy organizations,

such as LBBC, were included. Results of the meeting were published in a special supplement of the journal

Cancer

April 15th, 2012.

Prospective Surveillance Model

Incidence of Physical Issues

Early post-op upper body morbidity in 36% of women

undergoing SLNB and 66% of women undergoing

ALND (Langer 2007, McNeely 2012)

At 6 years, 60% of women report 1 or more

moderate to severe physical symptoms related to

breast cancer treatment that are amenable to rehab

intervention (Schmitz, 2012)

20-30% of women develop lymphedema (Hayes, 2012)

Prospective Surveillance Model

There is compelling evidence that rehabilitative and exercise interventions are beneficial.

Evidence is mounting that the physical impairments and functional limitations faced by women with breast cancer could be minimized to become minor issues if caught early and treated appropriately

Prospective surveillance model of care includes pre-operative and early post-operative assessment and ongoing surveillance to detect physical side effects of treatment early

Prospective Surveillance Model for

Rehabilitation for Women with Breast Cancer

Pre-Operative Rehab Assessment

(ROM, Strength, Baseline UE Volume,

Function, Exercise Level ,etc.)

Early Post-Operative Rehab Assessment

(Repeat Pre-Operative Measures)

Ongoing Surveillance

(Timeframe dependent upon risk factors for impairment

and functional issues)

Referral to Rehabilitation and

Exercise Consultation and

Programs as Needed

Ongoing Education

Early Detection of Treatment-

Related Impairments

• Surveillance enables early detection of and

intervention for treatment-related impairments

• GOAL: Decrease severity or prevent

impairment and functional loss at all stages of

disease management

Reduced Barriers to Rehabilitation

A surveillance model that includes all breast cancer

patients potentially addresses several barriers to

rehabilitation:

Reduces the patients burden in identifying ‘is this a

problem?’

Reduced burden on breast cancer oncologists and surgeons

Enhances understanding that impairments related to breast

cancer treatment are normal sequellae rather than a

“complication”

Diminishes time to intervention

Surveillance may potentiate cost benefits

Cancer. Volume 118/Issue 8 -Supplement

April 15, 2012www.canceronlinejournal.comwww.canceronlinejournal.com