Breast carcinoma remains one of the most challenging diseases for healthcare practitioners and their patients. The disease’s extensive metastatic capability, combined with intriguing responses to treatment, make breast cancer a compelling enigma for all involved in oncology. Until just a few years ago, breast cancer was the number one cause of cancer death in women in the United States of America and it is now surpassed only by cancer of the lung. Similarly, breast cancer is one of the leading causes of cancer-related deaths in many other countries (see Box 35.1). It was estimated that 234 580 new breast cancer cases would be seen and 40 030 people would die of the disease in the US in 2013 (Siegel et al., 2013). Currently the incidence is 122.3 per 100 000. Breast cancer death rates had been stable for over 50 years but have just recently begun to decrease, and this trend continues. Risk-adjusted incidence rates for breast cancer are lower than conventional incidence rates (Merrill & Sloan, 2012). Individuals with breast cancer are now living for considerably longer periods of time, and survivorship has increased appreciably. Screening for breast cancer in the elderly is also important (Walter & Covinski, 2001). The recognition that breast cancer is a treatable disease has set the stage for numerous clinical trials utilizing various forms of treatment; however, there are sometimes barriers to participation in clinical trials for older patients with breast carcinoma (Trimble et al., 1994; Kemeny et al., 2000). These barriers can range from comorbidities in the patient to investigator bias.

The median survival of patients with metastatic breast cancer is longer than 5 years, a considerable improvement from the past (Henderson, 1995; Francheschi & LaVecchia, 2001; Malik et al., 2013). As many as 10% of those who have metastatic disease will live for more than a decade. During this long interval, symptoms arise that may lead to functional disability. Thus, many geriatric patients with breast cancer will have problems related to both the disease process and its treatment.

Breast cancer in the geriatric patient does not differ greatly from that in younger individuals (Balducci & Yates, 2000; Diab et al., 2000). However, older patients have smaller cancers, more infiltrating lobular types, fewer ductal carcinomas in situ, and tumors are more frequently estrogen-positive (Malik et al., 2013). Also, knowledge of breast cancer in those older than 75 is reduced in terms of understanding symptoms and personal risk (Fentimen, 2013). It is common for clinicians to encounter patients with longstanding indolent disease. Considering treatment, women aged 70 or more who are enrolled in clinical trials are similar to their younger counterparts with regard to response rates, time interval to disease progression, survival and effects of chemotherapy (Christman et al., 1992; Dees et al., 2001). Many elderly patients with breast cancer suffer from intercurrent diseases that not only significantly reduce their life expectancy but also increase their operative risk. However, despite a high percentage of deaths from concomitant diseases, long-term survival of the elderly breast cancer patient is possible and comparable to the general population with breast cancer. Admittedly, there is a paucity of data from randomized trials on the risks and benefits of the newer and increasingly effective treatments in the older cancer patient (Jones et al., 2012).

The clinical relevance of breast cancer to the rehabilitation professional is engendered across the disease process: from detection to primary treatment, through a long period of metastatic disease, should it occur, and culminating in terminal patient care. Many forms of breast cancer are now treated with simple lumpectomy, segmental mastectomy or axillary node dissection. These procedures have not replaced the modified radical mastectomy, which is still necessary in many patients (Fisher et al., 2002). In a modified radical procedure, the breast and the axillary lymphatics are removed but the pectoralis major and minor are preserved. The patient is often discharged from hospital with surgical drains still in place, to be removed at the first clinical visit the following week. Although aggressive manipulation of the shoulder may not be indicated during the first few days, a temporary loss of abduction and forward flexion may be commonly observed.

The percentage of elderly patients undergoing immediate or delayed reconstruction is less than the percentage of younger individuals; however, more elderly patients are opting for breast reconstruction when it is feasible (Francheschi & LaVecchia, 2001). When possible, breast-conserving therapy rather than mastectomy should be offered to the older patient (Fentimen, 2013). Age alone should not be a factor in decision-making; the functional abilities and overall health of the elderly patient should take more importance. More extensive disease, such as a neglected or aggressive tumor that becomes attached to the chest wall or muscles, will naturally require a more extensive surgical approach to result in a definitive cure (Zidak et al., 2012).

The functional disabilities seen following mastectomy or breast-conserving procedures are usually temporary and respond favorably to physical therapy intervention. Elderly patients who do not gain their full range of motion within 6–8 weeks following surgery are not likely to do so (Lauridsen et al., 2005). The reasons for this observation are not entirely clear; a sedentary patient combined with an overly cautious therapist may be contributory factors. The window of opportunity to avoid functional decreases in range and function is not a large one, and an aggressive approach may be warranted (Springer et al., 2010).

Edema of the ipsilateral arm occurs in a significant percentage of cases. The incidence of this complication has declined considerably over the past few decades, largely because of early detection, improved radiation therapy and more limited surgical techniques and, most importantly, early and comprehensive management to effect control. In some cases, edema is severe and neglected, resulting in a grossly enlarged upper extremity with resultant loss of range and function. This is usually preventable with active rehabilitation interventions.

Few cancers can match carcinoma of the breast in terms of metastatic patterns; the disease spreads both lymphatically and hematogenously and the latter process can actually occur well before the primary cancer is detected and initial treatment begun. The skeleton is the most common site of bloodborne spread. Lesions favor the axial skeleton because of Batson’s vertebral plexus of veins; the pelvis, spine, ribs, upper femora, upper humeri and scapulae are most frequently involved. Lesions are most often lytic, but blastic-predominating and mixed patterns may occur. Large lytic lesions in the long bones carry the greatest risk of pathological fracture. The proximal femur is the area of most concern. In bony metastatic disease, pain usually heralds positive radiographs. Occasionally, however, pain may be severe in the absence of both radiographic evidence of the disease and scan positivity.

Differential diagnosis is extremely important. A patient who has no specific cause of pain, especially back or pelvic pain; a history of cancer; is awakened at night; gets no relief with rest; and is not responding/presenting like the typical back or shoulder pain patient should receive further workup. If radiography is negative, a bone scan or MRI may be integral in detecting metastatic bone disease.

Occasionally, axillary metastases and local recurrence in the chest wall produce troubling edema and complex wound care problems. More common are metastases to other organs, following or concomitant to bone metastases. The liver, pleura, lungs, central nervous system and intra-abdominal area can all be involved, with each area producing its particular array of symptoms. Liver metastases cause fatigue, early coffee or strong food intolerance, anorexia, metabolic disturbances and weakness – all rehabilitative problems. Pleural effusions are painful, debilitating and require frequent thoracentesis. Chest tubes may be in place, which limit mobility and function. Lung metastases are of several types. Parenchymal rounded lesions eventually coalesce but do not affect pulmonary function or cause symptoms until a critical amount of lung tissue is compromised. On the other hand, lymphangitic metastases, where the tumor is within the lymphatics of the lung, cause an early and distressing pulmonary syndrome of cough, dyspnea and intense sputum production. Metastases to the brain cause symptoms and signs that are comparable to primary brain tumors. Older individuals may not be diagnosed as readily because of concomitant illnesses and comorbidity.

Metastatic breast carcinoma, the second leading cause of epidural spinal cord compression after lung cancer, is a medical emergency. Sudden or subacute onset of sensory disturbances and motor weakness of the lower extremities in a metastatic breast cancer patient with known spinal disease warrants prompt attention. The pattern and degree of weakness may fluctuate and often the neurological condition improves with treatment, which is less likely in traumatic spinal injury. This presents a dynamic and sometimes frequently changing clinical picture to the healthcare practitioner. Metastases of any type will debilitate the patient. Pain may be one of the major limiting factors in any rehabilitative effort and, therefore, adequate pain control is tantamount to successful rehabilitative intervention. Older patients undergoing chemotherapy will need to be monitored for neutropenic infections, anemia and management of mucositis (Carrera et al., 2005).

It is clear that breast cancer is a complex disease process, resulting in a multiplicity of rehabilitation issues that are important for the clinician. Because patients are living longer with treatable metastatic disease, these issues will continue to pose unique and challenging problems to the clinicians who diagnose and treat them.

The therapeutic treatment of and rehabilitative intervention in the elderly patient with breast cancer needs to be comprehensive and ongoing throughout the disease process. Preoperative physical therapy screening in a sound clinical practice is important, as the information imparted can do much to allay fears and establish a good clinical rapport with the patient. In an elderly patient, the common existence of premorbid functional loss of range of motion in the shoulder, on the operated side, underscores the value of preoperative intervention when possible. If a preoperative visit is not carried out, a physical therapy visit on the day after surgery is desirable. After a modified radical mastectomy or a lumpectomy with axillary node dissection, glenohumeral flexion and abduction should be limited to 90° until the surgical drains have been removed (Chen & Chen, 1999). Because the hospital stay of all patients having this procedure is short, early and consistent intervention assures optimal functional and physical return. The actual timing of exercise after surgery has been studied by several authors and results suggest that the incidence of seroma formation is not increased by waiting a few days after breast surgery before beginning exercises (Schultz et al., 1997; Nay et al., 1999; Shamley et al., 2005).

A scoliotic curvature is common in elderly women and should be a consideration when treating the elderly patient post mastectomy. This curve may be present before surgery; when the curve results from surgery and the weight imbalance that follows, positioning, trunk range of motion and strengthening exercises, and chest wall and breathing exercises may offset any problems.

Various exercises are utilized to regain shoulder range and function; no single program has proved to be superior to another in terms of functional results. Most regimens call for a gradual stretch of the pectoralis major muscle; pulley exercises and wall climbing are often used (Box et al., 2002; Morimoto et al., 2003). External rotation emphasis, slowly bringing the clasped hands behind the head, is another standard approach. Recall that many geriatric patients may already have a functional loss in external rotation before surgery. Complex lymphedema therapy, which involves bandaging, exercises and specialized massage, can be of immense benefit to patients with lymphedema (Moseley et al., 2005). Early monitoring for lymphedema is essential. The fitting of elastic compression garments has become a large part of the care of these individuals. The success of sequential pneumatic intermittent compression devices to decrease or control lymphedema is variable, even among younger patients. More important, perhaps, has been the acceptance of complex lymphedema therapy into mainstream postoperative care. The program is multidimensional and includes manual lymph drainage techniques followed by specific exercise, meticulous skin care and wrapping with elastic material of specific pressure. Complex lymphedema therapy has gained favor in clinical practice as an approach to lymphedema management, and certified lymphedema therapists should be consulted when swelling is an issue (Hwang et al., 1999; Marcus et al., 2012). Lymphedema prevention through patient and family education is paramount.

Older breast cancer patients tend to have more bony and soft tissue disease than their younger counterparts and sometimes an indolent clinical course may be seen where bony metastases predominate (Ratner, 1980). However, even in older women with extensive bony disease, the lesions may be largely asymptomatic. Pain is made worse by activity, particularly weight-bearing. If a patient experiences a pathological fracture and is treated surgically or has the procedure performed prophylactically, aggressive rehabilitative therapy is warranted when the patient can tolerate it. Internal fixation of the femur facilitates nursing care, potentiates ambulatory ability and makes transportation of the patient easier. Ease of transportation is important in facilitating limb positioning during radiation therapy treatment. Early mobilization with cautious weight-bearing needs to be instituted and graduated exercises need to be performed for a maximum functional outcome to be expected. Strength and range of motion can be restored and the complications of a bedridden patient can be avoided.

Orthotic devices to relieve weight-bearing may be tried but extensive bracing should be avoided in the moribund patient, unless used for pain control. Thoracolumbar stabilization with an orthotic device may be required if the spine is heavily involved with tumor and has become unstable. Patients with liver metastases have poor exercise tolerance and this must be respected, while weighing up the difficulties that accompany the immobile patient. Pleural effusions and lung metastases will respond to chest physical therapy intervention. Epidural spinal cord compression is approached assertively, with all rehabilitation techniques pertinent to traumatic spinal cord injury being applicable. The changing weakness patterns, as well as the fairly frequent and sometimes dramatic motor return that is seen, merit intense rehabilitative efforts. The importance of supportive and palliative care for terminally ill geriatric breast cancer patients is integral to total patient care and is most appreciated by those patients who need it. Lastly, the current development of surveillance models for the rehabilitation of women with breast cancer is paramount, in keeping with integrative medicine and the total patient care concept (Gudas, 2012).

Breast cancer rehabilitation in the elderly patient begins with diagnosis, continues through the early postsurgical phase and is both reactive and active. As metastases spread and cause specific symptoms and disabilities, rehabilitation plays a major role in preventing immobility. Palliative and comfort care round out the intervention and, with patients living for an appreciably longer time, the period of rehabilitative care may span decades. Breast cancer in the elderly is a treatable disease and rehabilitation is an integral part of this treatment.