The diagnosis and treatment of breast cancer in women has undergone profound changes in the past century. Although much research and clinical attention has been focused on saving the lives of women with this condition, less focus has been on rehabilitation aspects. This postacute care should be a distinct phase of treatment. The field of physical medicine and rehabilitation has much to offer women who undergo extremely toxic although life-prolonging therapies for breast cancer. The focus of rehabilitation should include improving strength and cardiovascular conditioning, alleviating pain and improving fatigue. With respect to exercise, this can help women to physically recover from treatment and potentially prevent cancer recurrence. Many exciting opportunities will be available for rehabilitation specialists to improve the care of women with breast cancer and to participate in research in the field of oncology rehabilitation.
A historical perspective
Around 2650 BC, early Egyptians documented breast cancer and the treatment, which was cautery of the tumors . Later, in 460 BC, Hippocrates described a case report of breast cancer. He was responsible for naming cancer karkinos , which is the Greek word for crab and described the way tumors seem to have tentacles resembling crabs’ legs . For hundreds of years, despite trying various other treatments, surgery was the only therapy with a chance of being effective. Therefore, according to historian Olson , by the beginning of the 20th century operations for breast cancer outnumbered all other caner surgeries by four to one and the “Halstead mastectomy became the most common major surgical procedure in the world.” Doctors tried many different remedies to save women. However, essentially no effective therapeutic options were available other than severely disfiguring and disabling surgery.
Cancer treatment dramatically improved when chemotherapy and radiation therapy came into use during the middle of the 20th century. However, these therapies also resulted in significant toxicity to healthy tissues and disability in women who survived the disease and the treatments. Nearly all cancer survivors, even now, share the experience of having to recover from not only cancer but also the toxic treatments. Sheed wrote of his experience with radiation treatment for oral cancer in his memoir, In Love with Daylight: A Memoir of Recovery. Sheed noted,
As the radiologist [radiation oncologist] reads off the list of possible side- and after-effects, to run concurrently and forever, it’s awfully hard to remember that this guy is supposed to be on your side. There he is, about to kill off thousands of your favorite cells, adding up to a large tract of the body that brought you this far, and they call this man a healer! Talk about bombing villages to liberate them; talk about napalming whole forests on suspicion. For all anyone knew, I might not even have cancer at this stage. But bomb we must. One can’t be too careful .
Cancer has challenged physicians to save lives without unnecessarily causing pain and disability. This challenge is ongoing, and women who have breast cancer often experience dramatic negative physical effects that may linger for years or even a lifetime. Esophageal cancer survivor, French , wrote about this challenge in her book, A Season in Hell . French succinctly stated the obvious about oncologists, “Simply to treat cancer means they must violate the primary tenet of their code: First, do no harm.”
Another challenge in the cancer community has been the historical secrecy and shame associated with the diagnosis. According to the book Crusade: The Official History of the American Cancer Society:
If the Society would succeed, it first had to take cancer out the closet. In 1913 the disease was not named in polite society. Patients were routinely shielded from knowing that they had a malignancy. The patient’s family might be told, but they were unlikely to discuss this even with their closest friends; it was shameful to have a relative with cancer. The seventh leading cause of death in the United States at that time, responsible for some 75,000 deaths per year, cancer was not mentioned in newspaper obituaries. The standard euphemism was “a long illness.” It ranked in shame with syphilis and other unmentionable afflictions .
Two seminal events happened in 1979, in what the author refers to as “The Tale of Two Bettys.” First Lady Betty Ford and news correspondent Betty Rollin shared with the world their diagnoses of breast cancer and subsequent mastectomies. These admissions and the ensuing media coverage helped pave the way for other women to come forward and tell their stories, and a huge national movement, symbolized by pink ribbons, followed.
Epidemiology
Today breast cancer is the third leading cause of cancer in the world (after lung and gastric cancer) and the most common malignancy in women, accounting for 23% of cancers in women worldwide. In the United States, the numbers are higher, with breast cancer accounting for 32% of all new cancer cases, and just more than 200,000 cases of invasive breast cancer and approximately 60,000 cases of in situ breast cancer diagnosed annually . Worldwide among women from all ethnic classes, and in the United States among women who are of African-American and Hispanic descent, it is the leading cause of cancer mortality. Overall in the United States, it is the second leading cause of cancer deaths (after lung cancer) in women .
The incidence of breast cancer in the United States has been increasing at the rate of 1% to 2% per year. Although it is the most common cause of cancer death in young women, a decrease in mortality in this age group seems to be “attributable to the combination of patient education, earlier diagnosis with mammogram screening, and increased use of systemic adjuvant therapy” . Nevertheless, breast cancer remains a very real threat to women of all ages, with one in nine women developing this disease.
Although mortality statistics are readily available, morbidity statistics associated with breast cancer treatments have not been studied as extensively. Lymphedema of the upper extremity after breast cancer treatment has probably been studied more than any other complication, and yet the statistics on the incidence of this vary from 10% to 30% . However, other physical impairments and disability in breast cancer survivors have also been studied. In a prospective study, Karki and colleagues surveyed 96 breast cancer patients at 6 months and 12 months postsurgery and found that “Impairments and their impact on activities were frequent and constant.” At 6 months, more than half of the respondents experienced limitations in lifting, carry, and reaching, with the most common impairments being axillary scar tightness, axillary edema, and neck–shoulder pain . Another study by Rietman and colleagues retrospectively evaluated 55 women who underwent a modified radical mastectomy or a segmental mastectomy with axillary lymph node dissection. The mean follow-up was 2.7 years after treatment and impairments included pain (60%) and reduced grip-strength (40%). Fehlauer and colleagues evaluated long-term quality of life status in breast cancer survivors related to age at diagnosis and found that physical functioning, role functioning, and sexual functioning were decreased in patients older than 65 years at therapy.
In another study entitled “Functional Limitations in Elderly Female Cancer Survivors,” the researchers found that women who had a history of cancer experienced a decline in physical functioning compared with age-matched peers. For example, 42% of the 1068 5-year survivors in this study reported that they were unable to do heavy household work compared with 31% of the 23,501 participants who never had cancer . Finally, a study examining the impact of rehabilitation services on breast cancer survivors found that only the group that received an early home-based physical therapy intervention experienced a significant benefit in reduced arm morbidity and upper-body disability and improved functional well-being, compared with two other groups studied—women who participated in a group-based exercise and psychosocial intervention and a non-intervention group .
Cancer rehabilitation, like all rehabilitation, involves focusing on physical function while concurrently maximizing psychosocial and vocational function. To best understand the potential morbidity and subsequent disability in women who have a history of breast cancer, reviewing the current treatment regimens and their potential physical side effects is helpful.
Epidemiology
Today breast cancer is the third leading cause of cancer in the world (after lung and gastric cancer) and the most common malignancy in women, accounting for 23% of cancers in women worldwide. In the United States, the numbers are higher, with breast cancer accounting for 32% of all new cancer cases, and just more than 200,000 cases of invasive breast cancer and approximately 60,000 cases of in situ breast cancer diagnosed annually . Worldwide among women from all ethnic classes, and in the United States among women who are of African-American and Hispanic descent, it is the leading cause of cancer mortality. Overall in the United States, it is the second leading cause of cancer deaths (after lung cancer) in women .
The incidence of breast cancer in the United States has been increasing at the rate of 1% to 2% per year. Although it is the most common cause of cancer death in young women, a decrease in mortality in this age group seems to be “attributable to the combination of patient education, earlier diagnosis with mammogram screening, and increased use of systemic adjuvant therapy” . Nevertheless, breast cancer remains a very real threat to women of all ages, with one in nine women developing this disease.
Although mortality statistics are readily available, morbidity statistics associated with breast cancer treatments have not been studied as extensively. Lymphedema of the upper extremity after breast cancer treatment has probably been studied more than any other complication, and yet the statistics on the incidence of this vary from 10% to 30% . However, other physical impairments and disability in breast cancer survivors have also been studied. In a prospective study, Karki and colleagues surveyed 96 breast cancer patients at 6 months and 12 months postsurgery and found that “Impairments and their impact on activities were frequent and constant.” At 6 months, more than half of the respondents experienced limitations in lifting, carry, and reaching, with the most common impairments being axillary scar tightness, axillary edema, and neck–shoulder pain . Another study by Rietman and colleagues retrospectively evaluated 55 women who underwent a modified radical mastectomy or a segmental mastectomy with axillary lymph node dissection. The mean follow-up was 2.7 years after treatment and impairments included pain (60%) and reduced grip-strength (40%). Fehlauer and colleagues evaluated long-term quality of life status in breast cancer survivors related to age at diagnosis and found that physical functioning, role functioning, and sexual functioning were decreased in patients older than 65 years at therapy.
In another study entitled “Functional Limitations in Elderly Female Cancer Survivors,” the researchers found that women who had a history of cancer experienced a decline in physical functioning compared with age-matched peers. For example, 42% of the 1068 5-year survivors in this study reported that they were unable to do heavy household work compared with 31% of the 23,501 participants who never had cancer . Finally, a study examining the impact of rehabilitation services on breast cancer survivors found that only the group that received an early home-based physical therapy intervention experienced a significant benefit in reduced arm morbidity and upper-body disability and improved functional well-being, compared with two other groups studied—women who participated in a group-based exercise and psychosocial intervention and a non-intervention group .
Cancer rehabilitation, like all rehabilitation, involves focusing on physical function while concurrently maximizing psychosocial and vocational function. To best understand the potential morbidity and subsequent disability in women who have a history of breast cancer, reviewing the current treatment regimens and their potential physical side effects is helpful.
Treatment options and their impact on women’s health
Surgery
Surgery, whether it is a localized excision of the malignant cells or tumor (frequently termed breast conservation surgery ) or a partial or complete mastectomy, is often the first treatment. Some women may undergo chemotherapy first and then surgery or, if evidence of distant metastasis (stage IV) is present, they may not undergo surgery at all. If a mastectomy is planned, women may opt to undergo reconstruction at mastectomy, at a later date, or not at all. Several types of reconstructive procedures are available and each influences healing after surgery. Chemotherapy and radiation therapy can also slow healing after surgery. Whether women undergo axillary lymph node dissection or sentinel lymph node biopsy also influences subsequent disability. Women who have a history of breast cancer may also decide to undergo prophylactic mastectomy or oophorectomy, the latter of which is beyond the scope of this article.
Seromas are a frequent complication of breast cancer surgery, with an incidence of 25% to 50% after mastectomy and up to 25% after axillary dissection . In one retrospective analysis of 359 consecutive patients (94% of whom were Hispanic), Gonzalez and colleagues found that seromas occurred in 19.9% of patients who underwent modified radical mastectomy and in 9.2% of patients who underwent breast-conserving surgery.
Axillary lymph node dissection (ALND) is becoming less common because of the advent of sentinel lymph node biopsy (SLNB), which has been shown to reduce postoperative morbidity in the arm and shoulder region in women who have early-stage breast cancer . The presence of metastatic disease in axillary lymph nodes is known to predict recurrence and has important negative prognostic import . Therefore, investigation is ongoing to determine the overall efficacy of SLNB compared with ALND and weighing this against the potential for subsequent arm and shoulder symptoms from SLNB versus ALND. In a recent study in the Journal of Surgical Oncology , Schulze and colleagues evaluated the long-term morbidity of 134 patients with early-stage breast cancer and found that 31 had SLNB only and 103 had SLNB followed by ALND. Participants were followed up from November 1995 through January 2001. In this study, only one patient from each group experienced a local recurrence (3.2% in the SLNB group and 1.0% in the ALND group). The incidence of lymphedema was 15.8% and 19.7% in the SLNB and ALND groups, respectively. No statistically significant differences were seen in arm range of motion between the groups. The measurement of arm strength showed that significantly fewer patients experienced reduced arm strength in the SLNB group. In another study, Rietman and colleagues evaluated 204 patients who had stage I/II breast cancer and a mean age of 55.6 years, finding that patients who underwent SLNB experienced less treatment-related upper extremity morbidity, less perceived disability in activities of daily living, and a better reported quality of life.
Many women choose to undergo breast reconstruction after mastectomy. Implants are considered a less-invasive reconstructive technique and are performed by inserting a silicone or saline implant behind or in front of the pectoral muscle. In some cases the surgeon will use a balloon expander, which is inserted beneath the skin and chest muscle, and will inject a salt-water solution through a valve mechanism to gradually fill the expander over weeks to months. When the skin is sufficiently stretched, saline is let out until the reconstructed breast and natural breast are equal sizes .
Breast reconstruction with the transverse rectus abdominus musculocutaneous (TRAM) flap may need more follow-up surgical procedures than implants or latissimus dorsi flaps . Complications may arise at the donor site level or in the region of the reconstructed breast. Secondary procedures can include liposculpturing, fat necrosis excision, scar revision, and hernia repair. TRAM flaps are similar to deep inferior epigastric perforator (DIEP) flaps; however, theoretically, no muscle is harvested with a DIEP flap. In a retrospective study, Futter and colleagues examined abdominal and back extensor muscle strength, comparing 50 women (23 who had a DIEP flap and 27 who had a free TRAM flap) and 32 nonoperated controls. This study found no statistical difference between the DIEP flap group and controls but that the DIEP group was weaker. They noted a statistical difference between the TRAM and DIEP flap groups, with the former having more significant weakness. In a 2-year analysis of trunk function after TRAM flap, Alderman and colleagues found that breast cancer patients who underwent TRAM reconstructions experienced a less-than-20% long-term deficit in trunk flexion, and no significant difference was seen in patients who receive pedicle versus free TRAM reconstructions.
Chemotherapy
Chemotherapy-related disability may be short-term or long-term, depending on the drugs used and individual patient susceptibility. Neutropenia and gastrointestinal complaints, especially nausea and fatigue, are common during active therapy. Long-term disability (which can vary depending on the regimen used, dosing, interval timing, and individual susceptibility) may include cardiomyopathy and neuropathy. Neuropathy is particularly common with the taxane class of drugs, including paclitaxel and docetaxel. Grade 2 to 3 peripheral neuropathy incidence is believed to be approximately 6% to 10% . For women who have metastatic disease, the taxanes are commonly used for prolonged periods, which may increase their toxicity .
The specific drugs used to treat breast cancer and their potential side effects are beyond the scope of this article. However, currently a trend is occurring toward more aggressive chemotherapy regimens, including dose-dense regimens that seek to reduce the interval between the administration of each dose. The cumulative drug dose remains constant, and essentially the same amount of medication is given over a shorter period. Whether dose densification will ultimately be the optimal way to treat some women who have breast cancer is currently unclear .
Radiation
Radiation therapy combined with other treatments, including surgery and sometimes chemotherapy, can cause significant disability in women who have undergone breast cancer treatment . Long-term disability can be caused by cardiac or pulmonary sequelae, lymphedema, brachial plexopathy, impaired arm/shoulder range of motion, and second malignancies . Blomqvist and colleagues examined range of motion and strength of the arm and shoulder after modified radical mastectomy and radiation therapy and found that of 75 participants, the 30 who underwent radiation experienced significantly reduced range of motion and strength. These authors concluded, “The present analysis indicates that the adjuvant radiotherapy is responsible for most of the reduction of [range of motion] and strength of the shoulder joint in patients operated with mastectomy and axillary dissection” .
Another study examining long-term complications associated with breast conservation surgery followed by radiation found that approximately 10% of the participants experienced a grade 2 or higher late complication, including edema, fat necrosis, skin fibrosis, decreased arm/shoulder range of motion, neuropathy, pneumonitis, and rib fracture .
Endocrine treatment
The decision to use adjuvant therapy for several years after breast cancer treatment depends on many factors, including whether a woman is pre- or postmenopausal and whether her tumor was estrogen receptor–positive or –negative. Traditionally, tamoxifen was the preferred drug, but recent results from randomized controlled trials indicate that aromatase inhibitors (eg, letrozole, anastrozole) have better anticancer efficacy and toxicity profiles for treating breast cancer in women who are postmenopausal, node-negative, and hormone receptor–positive .
The decision to use adjuvant therapy and, if so, what kind is made by the medical oncologist and the patient. However, many women who have breast cancer who present with rehabilitation issues will either take tamoxifen or one of the aromatase inhibitors. Thus, understanding the, listed in Box 1 , is important.
Tamoxifen
Changes in appetite/weight
Changes in menstruation
Decreased libido
Dizziness
Dyspareunia
Fatigue
Headache
Hot flashes
Increased risk for ophthalmologic problems
Increased risk for secondary cancer
Increased risk for thromboembolic events, including stroke
Increased triglycerides
Mood disturbance
Nausea/vomiting
Rash
Vaginal discharge
Aromatase inhibitors
Bone loss
Dizziness
Dyspareunia
Fatigue
Headache
Hot flashes
Loss of libido
Mood disturbance
Myalgias and arthralgias
Nausea/vomiting
Vaginal dryness
This is not a complete list of side effects and ongoing investigations may reveal other issues (eg, cardiovascular side effects are currently unclear).
Rehabilitation interventions
Undoubtedly many patients who have cancer are much healthier in the beginning of treatment than at the end. Of course, this doesn’t minimize the lethal progress of a malignancy that is not treated, but rather acknowledges that the rehabilitation process in cancer treatment is essential for optimal recovery. In the Institute of Medicine report, From Cancer Patient to Cancer Survivor: Lost in Transition , one of the key recommendations was to make survivorship a distinct phase of treatment. The focus on physical and emotional healing is key during this phase and health care professionals can do much to intervene in a positive manner.
Therapeutic exercise
Exercise can certainly help healing in women who have a history of breast cancer, and may in fact assist in preventing cancer recurrence . These factors have led to national media attention and speculation on the value of exercise in cancer. Many studies suggest that exercise is extremely valuable in the survivorship phase of treatment and that it can enhance physiologic outcomes and function and alleviate many disabling symptoms, such as fatigue . These factors also have important quality of life implications . For example, in a cross-sectional study of 40 early-stage breast cancer survivors who reported regular exercise compared with 79 who were sedentary, those who exercised regularly reported higher body esteem and mood than their sedentary counterparts . Additionally, the women who exercised experienced significantly less confusion, fatigue, and depression. In women who have a history of cancer, exercise can affect long-term complications from treatment, such as osteoporosis . Exercise also seems to have a positive benefit in incurable cancer and is one treatment option in palliative care .
Therefore, exercise may affect the quality and quantity of a breast cancer survivor’s life, making it an extremely important part of the survivorship phase of oncology care. In fact, all women should be encouraged to exercise, unless it is contraindicated. However, women tend to exercise less during treatment and may not return to prediagnosis levels of physical activity . To facilitate continuation of exercise, having them use a pedometer and count how many steps a day they are taking may be helpful. Then, using short-term goals to increase the number of steps will help their progress. Ultimately, the number of steps for active, healthy adults should be approximately 10,000 steps per day.
This technique is a simple way for women to begin exercising, but it doesn’t address the specific cardiovascular, strength training, and flexibility exercises that may be particularly beneficial for breast cancer survivors, depending on their specific treatment and physical condition. In a study evaluating 61 patients who had various types of cancer, Midtgaard and colleagues reported that a supervised exercise program encouraged participation and that rates dropped significantly once the program ended. However, participants reported a higher level of exercise after the program ended than their baseline. This study suggests that ongoing supervision for exercise may be necessary to encourage participation, but that even short-term intervention may have some lasting effects. In another study focusing on the effects of a cardiovascular and strength training program, Herrero and colleagues found that this combined program “improves the [quality of life] and the overall physical fitness of breast cancer survivors following even a brief (8-week) exercise program.”
Exercise in women who have undergone breast cancer treatment should be initiated with caution and as much adherence to the current level of research as possible. However, many gaps exist in what experts know and can safely and authoritatively recommend. For example, the ideal time for women to begin upper extremity exercises and how aggressive to be with upper body strength training are unclear. In a review of randomized clinical trials examining this issue, Shamley and colleagues concluded, “This review has identified support for delaying exercises to reduce seroma formation. However, incomplete reporting of trials and faults in study designs resulting in poor internal and external validity have been identified.” In one randomized controlled study evaluating the effect of upper and lower body weight training on the incidence of lymphedema in 45 women who were 4 to 36 months post-treatment, 13 of whom had prevalent lymphedema at baseline, found that the 6-month intervention of exercise did not increase the risk for, or exacerbate the symptoms of, lymphedema .
In the rehabilitation setting, exercise may be important in reducing upper extremity pathology after breast cancer treatment. Physical and occupational therapy can help increase shoulder range of motion, promote upper extremity strength, decrease pain, and reduce swelling, including lymphedema, if that is an issue. Prescribing medications, such as anti-inflammatories, to reduce pain and inflammation, may facilitate therapeutic exercise .
In one randomized controlled study examining the timing of physical therapy after breast cancer surgery, Lauridsen and colleagues found that the optimal time for treatment was 6 to 8 weeks postoperatively. They also noted that physical therapy treatment can be initiated up to 6 months after surgery with similarly good results.
Timing of exercise and how best to perform the exercises are important issues. In a unique study that attempted to evaluate the latter issue, Ferreira de Rezende and colleagues found that the patients who had a very directed physical therapy program consisting of 19 specific exercises were better rehabilitated than the free group who also exercised but did not have such a structured regimen. Although the best way to exercise after breast cancer treatment is extremely important to consider, very few studies have examined this aspect of care, and evidence-based guidelines do not exist.
Reduce pain
The impact of pain on quality of life can be profound. Although the definition of quality of life varies, certain measures are used in research protocols, such as those listed in Box 2 .
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Exercise for Health and Wellness at Midlife and Beyond: Balancing Benefits and Risks
Current and Future Trends in Lymphedema Management: Implications for Women’s Health
Recognizing and Treating Pelvic Pain and Pelvic Floor Dysfunction
The Role of Physical Activity in Bone Health: A New Hypothesis to Reduce Risk of Vertebral Fracture
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