Breast Cancer Rehabilitation

1. Breast Cancer Rehabilitation Nancy Hutchison, MDMedical Director for Cancer Rehabilitation and SurvivorshipVirginia Piper Cancer Institute/Sister Kenny Rehabilitation InstituteMinneapolis, MN February 24, 2013

2. Rehabilitation is a Commission on Cancer Requirement for Hospital Cancer Program Accreditation http://www.facs.org/cancer/coc/cocprogramstandards2012.pdf Commission on Cancer Standard E.11 The accredited cancer program must provide the Commission on Cancer a copy of the policy or procedure that ensures access to rehabilitation services and identifies the rehabilitative services that are provided either on-site or by referral.

3. Cancer Rehabilitation is Function Driven Carewith therapies designed to minimizethe functional damage imposed by cancer treatment, to rehabilitate and restore optimal health and wellbeing

4. Physical Medicine and Rehabilitation Specialty has the Model for Cancer Rehabilitation Alfano, C et al. Cancer Survivorship and Cancer Rehabilitation: Revitalizing the Link. Journal of Clinical Oncology. 2012. 30:9. 904-906 Oncology survivorship should utilize “existing models of rehabilitation care …pioneered in the specialty of Physical Medicine and Rehabilitation”

5. Physical Medicine & Rehabilitation MD http://www.allinahealth.org/ahs/rehab.nsf/page/MHCNHutchison0612.pdf/$FILE/MHCNHutchison0612.pdf Copy and paste into your browser, then open the pdf • One of the 24 medical specialties certified by the American Board of Medical Specialties. • 4 year residency: Diagnosis and treatment techniques that are function-oriented and can affect any organ system • Training in neurology, orthopedics, rheumatology, pain management (interventional), neuro-diagnostic tests (EMG), disability, psychology, social services, outcomes assessment and team leadership • The only medical specialty specifically trained to evaluate impairment (loss of function) • Restores optimal function using a holistic, team, patient-focused approach

6. Rehabilitation targets the neuromuscular control of surrounding structures and lymphatic vessels that drain affected areas

7. Side effects of breast cancer treatment improved by rehabilitation • Skin and muscle tightness • Axillary Web Syndrome, axillary cords • Weakness of core and/or shoulder muscles • Lymphedema of chest and/or arm • Excess contractions in reconstruction muscles • Loss of the affected muscle’s position sense • Fatigue • Joint Pain • Neuropathy • Mild cognitive dysfunction (chemobrain): attention, concentration, word finding difficulty, mental fatigue

8. Top 3 recommendations for improving physical health and recovery for breast cancer: before, during and after treatment • Fitness and exercise • improves cancer related fatigue, quality of life, survival, lymphedema, pain • Regain and maintain normal body weight • Reduces risk of lymphedema, improves survival • Clear the life clutter • Improves chemobrain, reduces fatigue, allows time to address nutrition, sleep, relaxation and exercise

9. Top 5 Questions I am asked as a Cancer Rehabilitation Specialist Why do my chest and arm continue to hurt What can I do about neuropathy What can I do about fatigue What can I do about “chemobrain” What can I do to prevent or minimize the impact of lymphedema

10. Why Do My Chest and Arm Continue to Hurt Surgery, radiation, reconstruction affect the function of muscles of the chest wall and core Chemotherapy and hormonal therapies can affect muscle, nerve and joints

11. Main Muscles affected by Breast Surgeries • Pectoralis Major • Rectus Abdominus • LatissimusDorsi • Serratus Anterior

12. Muscles affected by Breast and Chest Radiation • All muscles of the upper chest can be affected by Radiation • Those on the previous slide • Intercostals (rib muscles) • Upper back and shoulder blade muscles

13. Shoulder blade movement is necessary for full range of shoulder motion

14. Shoulder and Scapular Problems of Breast Cancer Survivors Abduction Over a year after mastectomy, axillary dissection, no radiation Flexion -still has severe ROM limitations , chest and arm pain. No lymphedema.

15. After mastectomy, axillary dissection, radiation and latissimus flap reconstruction

16. All breast cancer patients need to work on core muscles • Core muscles hold the body together: upper and lower back, abdominals, pelvic floor, fascia connections • Skeleton is held together by muscles and ligaments • Arms and legs hang off the core. Core muscles stabilize the body so that the arms and legs can move. • Symmetry of movement is achieved by equal balance side to side and front to back • Breathing is achieved through core muscles and is a major factor in core strength, symmetry and flexibility Real Simple Magazine October 2007

17. Axillary Cord/Web • Fibrous post surgical adhesions and/or thrombosedlymphatics • Nerve-like pain • Restricted ROM • Axilla to wrist • Can do skin stretch (don’t do axillary massage until after cancer tx) • If swelling, assess for blood clot or lymphedema

18. Axillary cord in forearm

19. Axillary Cord in Forearm

20. Treatment for Chest and Arm pain Myofascial release Stretching of arm, chest, back and rib cage Work on posture, core, ergonomics Chiropractic/osteopathic techniques if familiar with breast cancer (precaution: bone metastasis must have MD approval) Massage in areas that are not at risk for lymphedema Acupuncture Injections (trigger point, Botox) Muscle relaxants and other pain medications Strengthen the shoulder blade and back muscles New pain should always be assessed for cancer Once cancer has been ruled out, if persistent or unusual, see a PMR doctor to rule out other neuromuscular causes of pain (such as thoracic outlet, carpal tunnel, bursitis, intercostal neuritis, rotator cuff tear, etc)

21. What can I do about chemotherapy-induced peripheral neuropathy • Medications • gabapentin, cymbalta and others • Acupuncture, reflexology • Topical medications: solarcaine, lidoderm patches, compounded gels • Electrical stimulation • Balance treatment in Physical Therapy • Exercise • Supplements?

22. What can I do about cancer related fatigue • Reversal of underlying medical conditions that increase fatigue • Anemia • Low thyroid • Low Vitamin D • Insomnia • Pain • Depression/Anxiety/Distress • Exercise: the only proven treatment • Cognitive Behavioral Therapy • Acupuncture • Medications (controversial)

23. What can I do about mild cognitive impairment of cancer treatment (aka chemobrain) • Rehabilitation techniques developed for mild concussion: • usually done by OT or Speech Therapists under the name: Cognitive Therapy • Organization and Structure • Removal of “brain clutter” and “life clutter” • Life management skills • Linking the above strategies with exercise and time management • Seek professional help, find free resources

24. What can I do to prevent or minimize the impact of lymphedema Cancer treatments can damage lymph nodes and lymph vessels We do not have the means to completely prevent lymphedema when lymphatic tissues have to be removed or damaged by treatment, but we can reduce the risk

26. Breast Cancer Related Lymphedema Transient lymphatic “back up” is common in early treatment Sometimes this progresses and sometimes it resolves People who have early “treatment-related” lymphedema have more risk of developing chronic lymphedema Lymphedema can be of the arm or the chest/breast Chronic lymphedema can be mild, moderate or severe. Severe lymphedema is the most rare in 2013

27. The true incidence of BCRL (arm) is unknown due to inconsistent and inaccurate standards of measurement SLN 7-10%, ALND 20-40% -and depends on many variables of treatment and complications We do not know the incidence of breast/chest lymphedema due difficulty with measurement

28. Time Course BCRL Most BCRL (arm) occurs within 5 years after treatment, approx 80% within 1 year, approx 90% within 5 years. New onset of arm or chest swelling should always be evaluated by a physician before assuming it is lymphedema

29. Prevention of Lymphedema The least treatment necessary to treat the cancer Early detection and early intervention Exercise Weight management Controlling infections (cellulitis) Reasonable efforts to reduce trauma and infection

30. Lymphedema Risk Reduction • Controversy exists regarding risk reduction measures because it is difficult to design studies. • Follow NLN risk reduction guidelines: www.lymphnet.org • When possible avoid trauma to the at risk part • There is no evidence that a prophylactic sleeve on a plane or with exercise prevents lymphedema, • If a patient has lymphedema, a properly fitting sleeve and glove are recommended • Although no scientific study has been done regarding venipuncuture (having blood drawn) and BP cuffs, case reports exist. When an alternative is available, do not use the breast cancer side • There is no evidence that acupuncture, EMG or lymphoscintigraphy (non-venipuncture needles) cause lymphedema Kilbreath, SL (2010). "Effect of air travel on lymphedema risk in women with history of breast cancer". Breast cancer research and treatment.120: 649. Cemal, Y. (2011)Preventative measures for lymphedema: separating fact from fiction. J Am Coll Surg. Oct;213(4):543-51

31. Factors that Contribute to Developing BCRL *ALND *Radiation *Early post op bouts of swelling-this is where we can have an impact by monitoring Lack of activity Obesity Inflammation or infection Genetics Nodal disease status

32. Early Detection of Lymphedema The frontier for lymphedema risk reduction is early detection Early detection allows better chance of reversal or minimizing

33. Bioimpedance Spectroscopy Monitoring for BCRL: accurate and clinically relevant • One study showed 40% of patients had intermittent early bouts of lymphedema detected by BIS • BIS accurately detected lymphedema as much as 10 months before self report or tape measurements if there was a preoperative baseline for BIS • BIS accurately differentiates lymphedema from non-lymphedema • Hayes, S et al.(2008) Lymphedema After Breast Cancer: Incidence, Risk Factors, and Effect on Upper Body Function. J ClinOncol 28, 3536-3542

34. Bioimpedance Spectroscopy (BIS) • BIS is based on the resistance to an imperceptible current passed through the arm. • Impedance is inversely proportion to fluid volume. • As fluid accumulates, impedance or resistance decreases. • BIS represents a direct measure of extra fluid (differentiates fat from fluid)

35. If I don’t have BIS, how do I know if I am developing lymphedema Feeling of aching or heaviness in an area with normal sensation Tendons, veins and bones are less visible Visible swelling in any part of the chest, armpit or arm BCRL occurs on in the chest, arm or upper trunk on the same side as cancer treatment. Swelling in other areas is not BCRL

36. What to do if lymphedema develops Don’t panic but don’t ignore it See a specialist in lymphedema: MD and/or lymphedema therapist Educate yourself-National Lymphedema Network: www.lymphnet.org Make sure you go to the best garment fitter: ask everyone

37. Treatment of Lymphedema • Standard of care is called Complete Decongestive Therapy • Patients should be referred to Certified Lymphedema Therapists who are trained in CDT (see NLN Position Paper on Training of Lymphedema Therapists and listing of certified treatment centers. www.lymphnet.org) • LANA Certification is advanced certification by the Lymphology Association of North America. www.clt-lana.org Mayrovitz HN (2009)The standard of care for lymphedema: current concepts and physiological considerations. Lymphat Res Biol 7,101-8

38. Components of Complete Decongestive Therapy Short stretch compression bandages with foam inserts when needed for fibrosis MLD: (not the same as massage) by Certified Lymphedema Therapists: CLT Lymphatic Exercises: similar to Tai Chi Skin hygiene and moisturizing lotion

39. Sleeves, gauntlets, gloves, chest compression • For less severe or early lymphedema can be used without CDT • Also used after CDT to maintain gains made in therapy

40. Exercise and Lymphedema • Studies show patients with lymphedema and at risk for lymphedema can and should exercise, including weight lifting when done properly • Exercise on a circuit: arm, leg, stretch, cardio • Start low, go slow, drop back if swelling gets worse and work with a professional • Follow NLN exercise guidelines • Schmitz, KH et al. (2009) Weight Lifting in Women with Breast-Cancer–Related Lymphedema N Engl J Med 361:664-73. • Moseley AL et al: (2005) The Effect of Gentle Arm Exercise and Deep Breathing on Secondary Arm Lymphedema. Lymphology38: 136-145 • Schmitz KH. Balancing lymphedema risk: exercise versus deconditioning for breast cancer survivors. Exerc. Sports Sci. Rev. 2009; 38:17-24 • Johansson K, et al. (2005) Low intensity resistance exercise for breast cancer patients with arm lymphedema with or without compression sleeve. Lymphology38,167-80 • Schmitz, (2010) KH et al Weight Lifting for Women at Risk for Breast Cancer Related Lymphedema. JAMA.304(24):2699-705

41. Physical Activity and Cancer Survivorship Brunelli, A. Performance at Preoperative Stair-Climbing Test Is Associated With Prognosis After Pulmonary Resection in Stage I Non Small Cell Lung Cancer. Ann ThoracSurg 2012;93:1796–801 Rock, W. Nutrition and Physical Activity Guidelines for Cancer Survivors. CA Cancer J Clin 2012;00:000-000 “At least 20 prospective observational studies have shown that physically active cancer survivors have a lower risk of cancer recurrences and improved survival compared with those who are inactive.” “ There is accumulating body of data showing a potential association between physical fitness after cancer diagnosis and treatment and survival.”

42. Physical Activity Reduces Mortality Specifically in Breast Cancer • Holick CN, Newcomb PA, Trentham-Dietz A, et al. Physical activity and survival after diagnosis of invasive breast cancer. Cancer Epidemiol Biomarkers Prev 2008;17:379–86. • Irwin ML, Smith AW, McTiernan A, et al. Influence of pre and postdiagnosisphysical activity on mortality in breast cancer survivors: the health, eating, activity, and lifestyle study. J ClinOncol 2008;26:3958–64. • Rock, W. Nutrition and Physical Activity Guidelines for Cancer Survivors. CA Cancer J Clin 2012;00:000-000 “Regular moderate-intensity exercise is known to be associated with a 30-50% reduction in the risk of cancer-specific mortality and all-cause mortality after a diagnosis of early breast cancer”

43. There is no medicine that can do what physical activity can do for cancer patients Fong, D. Physical activity for cancer survivors: meta-analysis of randomised controlled trials. BMJ 2012;344:e70 34 randomized controlled trials Physical activity has positive effects on physiology, body composition, physical functions, psychological outcomes, BMI, peak oxygen consumption, peak power output, and quality of life Exercise, when done properly with appropriately trained professionals, has been demonstrated to be safe at all phases of breast cancer treatment A little activity is better than none

44. What is the best/safest type of exercise to do after cancer treatment • Total body and including • stretching • deep breathing • circuit style (don’t overuse one part of the body especially chest and arms) • Start low, go slow • Drop back if pain or swelling and obtain professional help • The best exercise is something you will do • Just do something • Make small and gradual changes • Keep an activity log • Use a pedometer or activity monitor • Move more, sit less • Make a contract with yourself

45. Find resources • Contact a Commission on Cancer Accredited Cancer Hospital in your area to find out where they refer for cancer rehabilitation. • http://www.facs.org/cancerprogram/index.html • Ask about their Cancer Rehabilitation and/or Survivorship services or programs • www.aapmr.org (America Academy of Physical Medicine and Rehabilitation) • National Lymphedema Network: www.lymphnet.org • Certified Cancer Exercise Trainers-through the American College of Sports Medicine (http://certification.acsm.org/acsm-cancer-exercise-trainer) • LANA Certified lymphedema therapists www.clt-lana.org • Free cleaning http://www.cleaningforareason.org/

46. Thank you Nancy A. Hutchison, MD Medical Director for Cancer Rehabilitation and Survivorship Virginia Piper Cancer Institute Sister Kenny Rehabilitation Institute 800 East 28th Street Minneapolis, MN 44307