Susan Czyzo (Bachelor of Physical Education and Health, Master of Science in Physical Therapy)
The Australian Institute of Health and Welfare estimates 16,084 new cases of breast cancer in Australia in 2016, amounting to 12.3% of all new cancer diagnoses (27% of all new cancers in females) and 6.5% of all deaths from cancer. Although the incidence of breast cancer has tripled in thirty years (1982 to 2012), the likelihood of surviving at least 5 years after diagnosis is currently at 90%. Being labelled a survivor of breast cancer, however, does not automatically translate to a clean bill of health. There are a number of additional health obstacles that many women experience following breast cancer treatment. Fortunately, physiotherapists possess the skills necessary to lessen or even eliminate these obstacles.
Lymphoedema
All women who undergo breast cancer surgery are at risk of developing lymphoedema, which may not appear until months or even years post surgery. Risk is higher for women who have undergone a full axillary lymph node dissection. Radiation treatment may also cause, or if already present, exacerbate lymphoedema. Pain, loss of range of motion and strength in the upper extremity, as well as impaired function are common effects of lymphoedema.
As exercise has shown to be a safe and essential part of lymphoedema management, physiotherapy can play a meaningful role in prevention and treatment. It’s important to be aware that different types of exercise can be beneficial. For example, sustained periods of deep inspiration such as with aerobic exercise help by enhancing venous and lymphatic return. Flexibility training, alternatively, minimizes tightness associated with scarring, a contributor to the blocking of lymphatic flow. Hydrotherapy, with the movement of water exerting a healthy level of compression on the body, is also believed to aid in improving lymphoedema.
In addition to prescribing and supervising a specialized exercise program, kinesiotaping and education on activities or movements that trigger lymphoedema are other ways that physiotherapists can assist with lymphoedema management.
Bone Loss
The rate and magnitude of bone loss caused by cancer treatment is significantly higher than age-related bone loss in the non-cancer population. Chemotherapy-induced premature menopause and anti-estrogen therapies, for example, are believed to contribute to the increased rate and magnitude in this population.
As within the general population, initial management for decreased bone density includes education on the benefits of a lifestyle that includes, among other interventions, regular weight-bearing exercise. Physiotherapists are able to confidently advise these individuals on safe exercise options to maximize bone integrity.
Upper Extremity Dysfunction
Decreased range of motion, rotator cuff strain, adhesive capsulitis, paraesthesia and weakness are all common developments in the upper extremity post breast cancer surgery and/or radiation therapy. Whether appearing independently or in combination, these impairments can severely impact activities of daily living and employment, resulting in functional disability and a decreased quality of life.
Physiotherapy has been shown to be effective in managing post-surgical musculoskeletal symptoms. For example, exercise rehabilitation has shown to result in clinically meaningful improvements in shoulder range of motion.
Fatigue
Fatigue is a frequently reported yet poorly managed symptom reported by cancer patients. It is a complex symptom with various overlapping causes, some of which include anaemia, pain, sleep disturbance, thyroid dysfunction, and mood disorders. Physiotherapists can help their cancer patients manage fatigue through a focused history screening to determine the main contributors; by teaching the importance of planning and pacing their day; by designing a graduated exercise program to increase strength and energy levels; and through GP referral if the cause of their fatigue requires further investigation.
Pain
Another complex symptom with multiple causes reported by cancer patients is pain, often requiring a multi-disciplinary approach to management. A physiotherapist’s role in pain management comes in the form of exercise prescription and acupuncture, both of which have been shown to be effective treatments for pain in this population.
The Importance of Promoting and Prescribing Physical Activity
Engagement in regular physical activity is routinely stressed as a key preventive measure for many chronic health problems and breast cancer is no exception. However, it appears that historically healthcare professionals have been overly conservative with exercise prescription in cancer rehabilitation. The literature reports that many cancer survivors are not meeting standard exercise guidelines. Within breast cancer survivors, strength guidelines in particular are not being met. Today’s guidelines within cancer rehabilitation recommend the following:
Return to normal daily activities as soon as possible after diagnosis as early exercise interventions are showing to be more effective that delayed interventions. Exercise is safe during chemotherapy and radiation treatment and therefore patients should be encouraged to maintain their activity level during treatment as much as possible.
For substantial health benefits, patients should aim for at least 150 minutes of moderate aerobic exercise or 75 minutes of vigorous aerobic exercise per week. Strength training should be completed at least 2x/week. Gradual intensity weight-training is a safe way to improve upper limb strength without increasing the risk of lymphoedema.
Pilates and Breast Cancer
Clinical Pilates exercises taught by a physiotherapist are an excellent starting point for addressing any of the above listed health concerns post breast cancer treatment. With its focus on core engagement, precision and flow of movement, Pilates is an ideal exercise form for developing efficient movement; is safe for painful joints and muscles; and is easily adaptable to fit within pain, fatigue, and energy levels, as well as with upper extremity dysfunction. The focus on posture that Pilates involves also makes it a great option for addressing the postural changes that present post breast-cancer surgery. In addition, the diversity of Pilates allows it to be a challenging exercise option as strength and function improves post treatment.
Special considerations
Be familiar with the common medical treatments for cancer and recognize that they are cancer-specific and are constantly changing. Keep in mind pre-existing health issues and fitness levels.
Adverse effects of cancer treatments may appear months or years after the completion of treatment and may present in multiple body systems.
REFERENCES
Australian Institute of Health and Wellness. (2016). Breast cancer in Australia. Retrieved from http://www.aihw.gov.au/cancer/breast/
Loh, S. Y., & Musa, A. N. (2015). Methods to improve rehabilitation of patients following breast cancer surgery: a review of systematic reviews. Breast Cancer, 7, 81-98. doi: 10.2147/BCTT.S47012
Mc Neely, M. L., Campbell, K., Ospina, M., et al. (2010). Exercise interventions for upper-limb dysfunction due to breast cancer treatment. Cochrane Database of Systematic Reviews.
doi 10.1002/14651858.CD005211.pub2
Runowicz, C. D., Leach, C. R., Henry, N. L., et al. (2015). American Cancer Society/American Society of Clinical Oncology breast cancer survivorship care guideline. Journal of Clinical Oncology.
doi 10.1200/JCO.2015.64.3809
Schmitz, K. H., Courneya, K. S., Matthews, C., et al. (2010). American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Medicine and Science in Sports and Exercise.
doi 10.1249/MSS.0b013e3181e0c112
University Health Network Princess Margaret Cancer Centre. (2015). Clinical Practice Guidelines, Breast Site. Retrieved from http://www.uhn.ca/PrincessMargaret/Health_Professionals/Programs_Departments/Documents/CPG_Breast_BreastCancer.pdf