Breast Cancer






























General Information


Case no.


2.A Breast Cancer


Authors


Aubree Colorito, PT, DPT, COS-C, Board-Certified Clinical Specialist in Oncologic Physical Therapy


Kathleen L. Ehrhardt, MMS, PA-C, DFAAPA


Judith Schaad, PT, DPT, CWS, CLT-LANA, Board Certified Clinical Specialist in Oncology Physical Therapy


Diagnosis


Right breast cancer


Setting


Outpatient clinic


Learner expectations


☑ Initial evaluation


☐ Re-evaluation


☐ Treatment session


Learner objectives




  1. Understand rationale for the prospective surveillance model for detection of early lymphedema.



  2. Understand significance of gathering key baseline data prior to cancer therapy.



  3. Know risk reduction strategies for patients undergoing lymph node dissection.



































Medical


Chief complaint


Pre-op evaluation prior to mastectomy.


History of present illness


Patient is a 39-year-old female who presents for evaluation prior to right breast mastectomy and sentinel node biopsy for early breast cancer. Stage 2A cT2 cN0 cM0. Surgical procedure is scheduled in 1 week.


Past medical history


Infiltrating ductal carcinoma of the right breast, BRCA 1/2 negative, hypothyroidism, two uncomplicated pregnancies with vaginal deliveries.


Past surgical history


Breast biopsy right breast, appendectomy age 18


Family history


Mother: breast cancer diagnosed at age 49, no residual disease, hypothyroidism.


Father: hypertension, hypercholesterolemia, myocardial infarction at age 62.


Brother: alive and well.


Allergies


No known drug allergies.


Medications


Levothyroxine, Multivitamin


Precautions/Orders


Activity as tolerated.























Social history


Home setup




  • Resides in a multilevel home with husband and children.



  • Three steps + two handrails to enter.



  • Half bathroom is on the first floor.



  • Master bedroom and bathroom are located on the first floor.



  • Children’s bedrooms located on the second floor.



  • Flight of stairs + two handrails to second floor.


Occupation




  • College professor, currently off for summer.


Prior level of function




  • Independent with functional mobility and activities of daily living.



  • Right handed



  • (+) Driver


Recreational activities




  • Swims daily at local health club.



  • Enjoys cooking and spending time with husband and two children aged 12 and 15.





























Imaging/Diagnostic tests


Bilateral screening mammography


Right breast revealing suspicious microcalcifications. BIRADS 4—biopsy should be considered. Left breast without abnormalities.


Diagnostic mammography


Confirms screening mammography results.


Breast biopsy


Infiltrating ductal carcinoma, stage 2A cT2 cN0 cM0.


Hormone receptor tests, HER2 neu test


ER–/PR–/HER2 neu–


Triple negative breast cancer


BRCA testing


BRCA negative


Transvaginal ultrasound


Normal appearance of uterus, tubes, and ovaries.














Medical management


Right breast cancer, BRCA negative, triple negative tumor


Plan for right mastectomy and right sentinel lymph node biopsy in 1 week. Will perform lymph node dissection if sentinel lymph node biopsy positive.












Pause points


Based on the above information, what are the priority




  • Diagnostic tests and measures?



  • Outcome measures?



  • Treatment interventions?





















































































































Physical Therapy Examination


Subjective


“I am nervous about getting lymphedema.”


Objective


Vital signs


Pre-treatment


Post-treatment


Blood pressure (mmHg)


112/70


113/72


Heart rate (beats/min)


87


75


Respiratory rate (breaths/min)


19


15


Pulse oximetry on room air (SpO2)


98%


97


Pain


0/10


0/10


General




  • Patient sitting in examination room, appears anxious.



  • Husband accompanies patient to visit.


Head, ears, eyes, nose, and throat (HEENT)




  • NCAT, neck FROM without lymphadenopathy.


Cardiovascular and pulmonary




  • Normal rate and rhythm



  • Auscultation: clear to adventitious sounds


Musculoskeletal


Range of motion




  • Bilateral upper extremities (BUE): within functional limit (WFL).



  • Bilateral lower extremities (BLE): WFL.



  • All ROM is pain free.


Strength




  • BUE: Grossly 5/5



  • BLE: Grossly 5/5



  • Five Times Sit-to-Stand Test = 11 seconds


Aerobic




  • Able to walk > 250 feet with an RPE 2/10


Flexibility




  • Good appropriate hamstring length as shown by long sit to get out of bed.


Other




  • N/A


Neurological


Balance




  • SLS = 15 seconds on left lower extremity, 20 seconds on RLE.



  • Tandem stance: 25 seconds, mild postural sway, self corrects.


Cognition




  • Alert and oriented x 4



  • Follows 100% of multistep commands.


Coordination




  • Finger-to-nose: intact BUE



  • Heel-to-shin: intact BLE


Cranial nerves




  • II–XII: intact


Reflexes




  • Biceps: 2 + bilaterally



  • Patellar: 2 + bilaterally


Sensation




  • Vibration testing with 128 Hz tuning fork: normal at ulnar styloid and MTP bilaterally.


Tone




  • Normal throughout BUEs and BLEs


Other




  • N/A


Integumentary


Skin integrity




  • BUE and chest wall: intact; negative for irritation, drainage, erythema, and scars


Limb volumes




  • Left upper extremity (LUE): 2.38 L



  • Right upper extremity (RUE): 2.45 L



  • RUE > LUE by 2.9%


Fig. 2.1


Functional status


Bed mobility




  • Supine to/from sit: independent


Transfers




  • Sit to/from stand: independent


Ambulation




  • Ambulated 250 feet independently.



  • Demonstrated normal gait pattern.


Stairs




  • Ascend/descend 12 steps independently with no railing.



  • Demonstrated step-over-step pattern.


Other




  • Health-related quality-of-life outcome measure:


FACT B + 4: Score = 111/148 = 75%



No Image Available!




Fig. 2.1 Standardized evidence-based protocol for facility/health system is to mark off limb at 4-cm intervals. One should start at the wrist and progress along the length of the arm, using a tape measure. Measurements are then recorded using a calibrated tape measure to standardize results. Once circumferential measurements are recorded, they are entered into a formula that calculates the volume of a truncated cone. The result is an approximation of the limb volume. One can then compare the difference between the involved arm volume and the uninvolved as a percentage.

























Assessment


☑ Physical therapist’s


Assessment left blank for learner to develop.


Goals


Patient’s


“I want to do anything I can to prevent getting lymphedema.”


Short term


1.


Goals left blank for learner to develop.


2.


Long term


1.


Goals left blank for learner to develop.


2.














Plan


☐ Physician’s


☑ Physical therapist’s


☐ Other’s


Physical therapist provided home exercise program (HEP)


Fig. 2.2


Physical therapist provided post-op education re: ROM precautions, limiting shoulder flexion to 90 degrees on surgical side until drains removed.


Physical therapist provided education re: rationale and protocol for prospective surveillance for early lymphedema and lymphedema risk reduction practices.



No Image Available!




Fig. 2.2 Example of a pectoralis stretch, which can be provided as part of the home exercise program.






























Bloom’s Taxonomy Level


Case 2.A Questions


Create


1. Synthesizing the medical data and physical examination findings, develop an appropriate physical therapy assessment of the patient.


2. Develop 2 short-term physical therapy goals, including an appropriate timeframe for home care.


3. Develop 2 long-term physical therapy goals, including an appropriate timeframe for home care.


Evaluate


4. Explain the physical therapy findings and plan of care to the medical team.


Analyze


5. Compare and contrast lymphedema incidence after sentinel node biopsy versus axillary lymph node dissection.


6. Compare and contrast interventions for breast cancer–related lymphedema when detected early (subclinical or < 5% change) to when detected visibly or 10% or more change.


Apply


7. Explain the different types of breast cancer receptor testing that should be done on patient’s breast cancer and why testing is beneficial.


Understand


8. Discuss the indications for mastectomy in a patient with early breast cancer


9. Explain the significance of triple negative breast cancer.


10. Explain what it is and the general application of the American Joint Committee on Cancer staging system. Interpret the TMN nomenclature.


Remember


11. What is the most common diagnosed cancer in women and the second most common cause of cancer death in women?


12. Recall the most common histologic type of invasive breast cancer.


13. What is BRCA testing? What are the indications for BRCA testing in men and women?






























Bloom’s Taxonomy Level


Case 2.A Answers


Create


1. Patient is a 39-year-old female who presents for evaluation prior to right breast mastectomy and sentinel node biopsy for early breast cancer—stage 2A cT2 cN0 cM0. The patient demonstrates normal AROM and strength of BUE and BLEs, normal vibration sense of BUEs and BLEs, normal postural stability, and normal functional mobility on even and uneven levels. Baseline UE limb volume difference is 2.9%, involved dominant RUE is greater than nondominant LUE. This difference is likely due to typical increased in size of dominant UE. At this time, patient was provided with HEP, of which she verbalized and demonstrated understanding. Patient will be seen 1-month post-op to reassess her functional status and modify program accordingly. Will continue to follow per Prospective Surveillance Model.


2. Short-term goals:




  • Patient will independently verbalize understanding of rationale for prospective monitoring for early lymphedema and ways to decrease risk of developing lymphedema within one visit.



  • Patient will independently demonstrate post-op HEP within one visit to maintain ROM and strength in BUEs and BLEs.


3. Long-term goals:




  • Patient will follow up with outpatient physical therapist within 4–6 weeks post-op.


Evaluate


4. Patient exhibited baseline arm volume differences with normal functional levels. The baseline arm volume difference is expected in the pre-op setting. Typically, the volume of the dominant arm is 3–5% greater than the nondominant side, due to greater use and muscle hypertrophy. Certain athletes, such as tennis players, may have as much as 10% volume difference at baseline. Baseline information is critical to gather in cancer patients prior to beginning any medical treatments, as they can be used for later comparisons. These data points may be critical to compare later. This is especially true if the patient should receive chemotherapy, as it can cause peripheral neuropathy or breast cancer–related lymphedema. The patient is aware of the risk for lymphedema after lymph node dissection, recommendations to follow that may help reduce her risk, and how to restart upper body activity after breast cancer surgery. The Prospective Surveillance Model of care for breast cancer survivors is the current standard for accredited breast centers. Risk reduction strategies should they arise include:




  • A gradual return to normal activities: avoid overuse and lymph congestion in the early weeks after surgery.



  • Pay close attention to any break in the skin: wash with soap and water, apply antibiotic ointment and cover until healed, inspecting for any signs of infection.



  • Call a physician immediately if any signs of infection are noted in the lymphatic drainage quadrant (arm, chest, lateral and posterior trunk): warmth, redness, pain, swelling, tenderness.



  • Avoid blood pressures and injections/blood draws on the affected arm, and consider a prophylactic compression sleeve and gauntlet for long air flights.


Analyze


5. The risk of developing lymphedema after a sentinel node biopsy is 3–6%. The risk of developing lymphedema after an axillary lymph node dissection is 15–25%.


6. When lymphedema is detected at the subclinical stage (5% relative limb volume change), patients should be fitted with a light (20–30 mmHg) compression sleeve and gauntlet (handpiece) and wear it from wakeup until bedtime, 10–12 hours per day for 4–5 weeks. When relative limb volume differences return to baseline, the patient can reduce wear time of the compressive sleeve and gauntlet to strenuous activities.


In contrast, when lymphedema is detected later (> 10% relative limb volume change), complex decongestive therapy (CDT) is required to reduce swelling. This intervention includes the following components:




  • Phase 1: lymph drainage massage, multilayer compression bandaging 24/7, decongestive exercises, and skin care education. In-person treatments are required three to five times per week.



  • After 4–6 weeks of Phase 1, when the limb volume is decreased and stabilized (often not to baseline level), patient must wear substantial day and night compression garments for the rest of their lives. This is Phase 2, or the maintenance phase.


Apply


7. Breast pathology specimens are tested for estrogen receptor (ER) and progesterone receptors (PR). Patients who are positive for ER, PR, or both are candidates for endocrine therapy in the treatment of their breast cancer. If human epidermal growth factor receptor 2 (HER2) is positive, patients are given HER2-directed therapy.


Understand


8. Mastectomy is recommended for women with early breast cancer when (a) the tumor is large in size compared to the breast; (b) there are diffuse malignant-appearing calcifications on imaging; (c) the patient has a prior history of chest radiation, pregnancy, multicentric disease; or (d) the patient has persistently positive margins. Mastectomy is also a patient-preferred choice in some instances.


9. The significance of triple negative breast cancer is that these tumors do not express ER, PR, and HER2. These types of tumors tend to be more aggressive. There is no targeted therapy available for these patients. Unfortunately, these tumors tend to occur in women younger than 40.


10. The American Joint Commission on Cancer (AJCC) created a rating system to determine the extent of cancer, the location, and subtype. It includes a number and letter and TMN indicators.


Number stages range from stage 1 to stage 4, with 4 being the most advanced. Letters (A–C) add more information to the stage.


Determining the letter assignment is beyond the scope of this discussion.


Invasive breast cancer is indicated by stages 2–4 and is a cancer that has spread from the ducts or lobules into surrounding breast tissue or nearby lymph nodes.


TMN nomenclature provides more details about the cancer.


T: stands for the size of the tumor and extent of spread to nearby tissues.


N: stands for nodes, indicates if the cancer has spread to the nearby lymph nodes and how many nodes are involved.


M: stands for metastasis and indicated Yes (1) or No (0), whether metastasis has been detected elsewhere in the body.


Clinical stage (c) is the rating before any treatment. It is based on the physical exam, biopsy, and imaging results. Pathologic stage (p) or surgical stage is determined by the evaluation of tissue removed at the time of surgery. If drug therapy is given before surgery, then the stage nomenclature will indicate by adding (y) to the TMN stage.


For this patient at the presurgery visit, her stage is 2A: cT2 cN0 cM0. If drug therapy has been administered prior to surgery with the same clinical findings, TNM stage would be 2A: yT2 yN0 yM0.


Remember


11. Breast cancer is the most diagnosed cancer in women as well as the second most common cause of cancer death in women. The most common cause of cancer death in women is lung cancer.


12. Infiltrating ductal carcinoma is the most common histologic type of invasive breast cancer occurring in 76% of patients.


13. Indications for BRCA testing in females include:




  • A personal history of breast cancer diagnosed at younger than 50 years and a second primary breast cancer, one or more relatives with breast cancer, or an unknown or limited family medical history.



  • A personal history of triple-negative breast cancer diagnosed at younger than 60 years.



  • A personal history of ovarian cancer.



  • Two or more of the following: breast cancer; ovarian, fallopian, or primary peritoneal cancer; male breast cancer; or metastatic prostate cancer.


Indications for BRCA testing in males include:




  • A personal history of male breast cancer.



  • A personal history of prostate or pancreatic cancer with two or more relatives with BRCA-associated cancers.


Indications for BRCA testing in females and males include:




  • A personal history of two or more types of cancer.



  • A personal history of breast cancer and Ashkenazi Jewish ancestry.



  • A history of breast cancer at a young age in two or more blood relatives.



  • A relative with a known BRCA1 or BRCA2 mutation.
















Key points


1. It is important to measure and document pre-op circumferences and volumes of both arms. This can help detect breast cancer–related lymphedema at a subclinical, early stage and treat timely. This model of care can effectively prevent the onset of clinical lymphedema, which requires lifelong and costly care that impacts quality of life.


2. Patients seen for a pre-op visit should have baseline multisystem screening of all relevant tests and measures that could be impacted by later treatments, including surgery, radiation, and/or chemotherapy. Examples of side effects of these treatments can include soft-tissue restrictions, weakness, peripheral neuropathy, balance impairments, functional deficits, and pain.


3. It is important to educate patients early and often regarding lifelong risk reduction strategies, which can help avoid the onset of lymphedema, when possible.





























General Information


Case no.


2.B


Authors


Aubree Colorito, PT, DPT, COS-C, Board-Certified Clinical Specialist in Oncologic Physical Therapy


Kathleen L. Ehrhardt, MMS, PA-C, DFAAPA


Judith Schaad, PT, DPT, CWS, CLT-LANA, Board Certified Clinical Specialist in Oncology Physical Therapy


Diagnosis


Right breast cancer, positive sentinel node biopsy s/p right modified radical mastectomy, and lymph node dissection


Setting


Acute care hospital


Learner expectations


☑ Initial evaluation


☐ Re-evaluation


☐ Treatment session


Learner objectives




  1. Understand the differences in surgical procedures and their associated side effects.



  2. Understand the importance of maintaining postoperative protocols during physical therapy assessment and intervention to minimize side effects while maximizing outcomes.



  3. Understand the importance of patient education to improve compliance with a HEP.



































Medical


Chief complaint


s/p right mastectomy and full lymph node dissection yesterday.


History of present illness


Patient is a 39-year-old female who is hospital day 1, post-op day 1 s/p right modified radical mastectomy and lymph node dissection. Triple negative tumor. No reconstruction done due to patient wishes. Patient had sentinel node biopsy during procedure and frozen section was positive for tumor. Patient has been out of bed to bathroom and has ambulated once in the hall with nursing.


Past medical history


Infiltrating ductal carcinoma of the right breast, s/p right mastectomy and lymph node dissection, BRCA 1/2 negative, hypothyroidism, two uncomplicated pregnancies with vaginal deliveries.


Past surgical history


Right mastectomy, lymph node dissection, breast biopsy of right breast, appendectomy at age 18.


Family history


Mother: breast cancer diagnosed at age 49, no residual disease, hypothyroidism


Father: hypertension, hypercholesterolemia, myocardial infarction at age 62


Brother: alive and well.


Allergies


No known drug allergies.


Medications


Levothyroxine, Hydrocodone, Ibuprofen, Docusate sodium, Zolpidem tartrate.


Precautions/Orders


Activity as tolerated, right arm in sling, right axillary drain.


Right upper extremity (RUE) post-op precautions: non–weight-bearing, no flexion > 90 degrees until right axillary drain removed and no lifting.























Social history


Home setup




  • Resides in a multilevel home with husband and children.



  • Three steps plus two handrails to enter.



  • Half bathroom is on the first floor.



  • Master bedroom and bathroom are located on the first floor.



  • Children’s bedrooms are located on the second floor.



  • Flight of stairs plus two handrails to second floor.


Occupation




  • College professor, currently off for summer.


Prior level of function




  • Independent with functional mobility and activities of daily living.



  • Right handed



  • (+) driver


Recreational activities




  • Swims daily at local health club.



  • Enjoys cooking and spending time with husband and two children aged 12 and 15.



























Vital signs


Hospital day 1:


postoperative day 1, ward


Blood pressure (mmHg)


130/82


Heart rate (beats/min)


83


Respiratory rate (breaths/min)


16


Pulse oximetry on room air (SpO2)


94%


Temperature (°F)


98.8

Only gold members can continue reading. Log In or Register to continue

Dec 11, 2021 | Posted by in MANUAL THERAPIST | Comments Off on Breast Cancer
Premium Wordpress Themes by UFO Themes