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:
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.
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.
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.
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.
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:
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.