Reviewing a Breast Cancer Rehabilitation Program
By Andrea Tilley
It is widely held that breast cancer surgery and treatment can result in arm morbidity on the affected side such as reduced shoulder range of motion (ROM), pain and lymphedema.1-14 A prospective surveillance model for breast cancer rehabilitation was proposed in a supplement to Cancer journal in April 201218. This demonstrated evidence that there are common physical impairments that arise from breast cancer treatment which are amenable to physiotherapy. Proposed were regular physical assessments and early therapeutic intervention for these impairments in order to optimize physical recovery in the growing survivorship community. The inconsistent delivery of rehabilitation to women with breast cancer in New Brunswick may mirror that in the other provinces. While several communities are fortunate enough to have a hospital-based certified lymphedema therapist, many do not. Often people must travel several hours for therapy and still more are unaware that treatment exists. Organized general breast cancer rehabilitation services are few.
In Saint John, New Brunswick, a program of organized, evidence-based breast cancer rehabilitation is available to all women with breast cancer with the prospective surveillance model in mind. This physiotherapy program has been in operation for five years.
Purpose
This article reports on a review of the discharge summaries of 95 patients who
completed the 12 months of physiotherapy follow-up and to report some of their outcomes. This review could perhaps lead to a more thorough prospective study of women entering the breast cancer rehabilitation program.
Program description
All women scheduled for lumpectomy or mastectomy, are automatically referred to the physiotherapy department for
Outcome Measures
Flow Charting
Breast Cancer Recovery Guide and the follow-up appointment are given. Instructions and reading material are kept to a minimum pre-op as women are of ten overwhelmed with information and emotion at that time.
pre-operative physiotherapy assessment of arm range of motion and volume. (Figure 1) Current activity level is noted. A compression bra (Figure 2) is fitted, to add comfor t and prevent swelling as long as a drain or swelling is present. Immediate post-operative activity guidelines, our
Andrea Tilley, physiotherapist (1992) and CLT (2000) established the first hospital-based lymphedema Treatment Program in the Atlantic Provinces. Andrea, a CLF and ACLN member, participates in national and international lymphedema research, and has presented at national conferences. In 2009, she developed a breast cancer rehabilitation program for Saint John, New Brunswick.
At one week post-op, the patient returns for re-assessment and teaching of shoulder ROM exercises. Cardiovascular activity is recommended to gradually build to 3-5 hours per week. Evidence suggests that this amount of weekly activity will reduce recurrence rates.15 Women are provided with a walking journal (Figure 3). They are encouraged to record the minutes per day that they participate in continuous exercise such as walking (but could include any vigorous aerobic activity such as biking, swimming, aerobic activity).
continued on page 16
As well, depending on how many lymph nodes were removed, education regarding individual likelihood to develop lymphedema (LE) is given, as well as risk reduction techniques for lymphedema. Risk reduction is focused on prevention of infection, achieving full arm ROM and function and maintaining optimal body weight. If required, women will schedule subsequent physiotherapy appointments for
assisted ROM and soft tissue mobilization until they achieve their pre-op ROM. If axillary cording develops, more visits may be required. Once 100% of pre-op ROM is achieved, a six month follow up will be scheduled. Then, if shoulder ROM is maintained, a woman is pain-free, has no LE, and scar tissue is moving well she will be scheduled for the 12 month follow-up. If she shows new physical impairments they will be addressed as previous.
It should be noted that if a woman is found to develop lymphedema, she will be fitted for a compression arm sleeve 20-30 mmHg. If she presents with more than 2cms difference at more than 2 circumferences, she will be offered Complete Decongestive Therapy. Our current criteria for diagnosing LE includes a 1 cm increase at 2 or more arm landmarks or the presence of pitting edema anywhere in the arm, breast or chest wall. At the 12 month follow-up a woman is re-assessed and if there are no impair-
ments she is discharged and a Discharge Summary is completed.
Results
95 discharge summaries were used in the compilation of results for this paper.
A simple Excel spreadsheet was used to enter data from discharge summaries.
The mean age of the 95 women was 64.2 years. 36% had undergone full axillary node dissection (AND) and 58% had undergone sentinel node biopsy (SNB).
6% had no nodes removed.
n 18% of women reported pain at 12 months post-op; however it was only 12% who developed pain over the 12 month period as 6% reported pre-op pain as well.
n Overall, 80% of women regained their pre-op arm ROM. 78% of the AND and 83% of the SNB groups regained full ROM.
n 24% continued to experience scar tissue mobility restriction.
n 48% were getting the recommended 3-5 hrs per week walking or equivalent activity at 12 months post op.
n 21% or 20 of the 95 women developed lymphedema (LE). 15% of SNB had breast LE and 27% of AND had arm LE. Overall, 10 (10%) had breast LE, 8 (8%) had arm LE while 2 (2%) experienced both concurrently. All of the SNB patients who developed LE had it in the breast and 2 of those experienced arm as well.
2
n 22% of women experienced lymphatic cording following surgery. Most were immediate onset, though a few were delayed. Half of those women had cording continue beyond six weeks post-op and one quarter still had evidence of cording at the 12 month follow-up. 6/20 (30%) of the women with cording did not have full ROM at 12 months.
Discussion
n Our rates of failure to regain full ROM were similar in both AND and SNB groups, although developing cording increased that likelihood from 20% to 30%.
n Scar restriction did not appear to affect development of LE as only 4/22 scar restricted women developed LE. The most common type of LE after SNB was breast and after AND was arm.
n Our rates of LE development were higher than typically reported for SNB perhaps because we considered breast LE when most studies do not. Also the criteria for arm LE diagnosis was much more inclusive than is typically seen in studies as any woman with pitting edema in the arm was included.
n Our rate of incidence of cording is lower than that reported in other studies16,17
n Almost half of women were following the recommended activity guidelines at the one year mark.
Limitations
The bias of this study may lean toward more physical impairment as all of these women returned for the scheduled 12 month assessment without incentive or reminder. They
may have been seeking treatment for those impairments. In creating a prospective data base going forward, expanding the discharge summary to include more detailed data on pre-post activity levels, a more thorough reporting of surgery and treatment specifics and weight gain, program adherence and reasons for failing to follow up would allow for more comparison between groups.
We were unable to complete more than 34 assessments with our quality of life tool FACT-B. We had many women upset and others decline due to the very personal nature of some items within. A more appropriate QOL tool should be used in the future.
Conclusion
This program is an example of the proposed “Prospective Surveillance Model for Rehabilitation for Women with Breast Cancer”.18 Currently, a randomized controlled trial is underway led by Dr. K. Campbell in BC comparing
Survivorship Care Plans are gaining approval in Cancer Centers in North America and Canadian Physiotherapists need to get involved.
post-op surveillance and physiotherapy versus standard post-op care without the surveillance.
Survivorship Care Plans are gaining approval in Cancer Centers in North America and Canadian Physiotherapists need to get involved in order to help breast cancer survivors reach their physical potential following treatment. LP
A full set of references as well as the physiotherapy outcome measures chart can be found at www.lymphedemapathways.ca
