楊靜蘭　物理治療師 國立臺灣大學醫學院附設醫院復健部物理治療技術科總治療長 國立臺灣大學物理治療學系兼任講師

1. 乳癌病人照護
楊靜蘭
臺大醫院復健部物理治療技術科
台大物理治療學系兼任講師

2. 乳癌病人照護
• Surgical therapy and complications
• Radiotherapy and complications
• Chemotherapy and complications
• Hormonal therapy and complications
• Breast cancer patient
• Post-surgical exercise
• Strengthening exercise
• Lymphedema treatment
• Cancer pain management
• Cancer-related fatigue

3. 乳癌病人照護
• Phases
of
cancer
care
diagnosis
treatment
rehabilita3on
survivorship
recurrent
disease
pain
fatigue
pain
pain

4. Surgical therapy & complications
• Mastectomy
• Lumpectomy (partial mastectomy)
• only the tumor and small section of normal breast tissue
is removed
• Complications: breast fibrosis, breast lymphedema, and
chronic/recurrent breast cellulitis (Newman, 2007)
• Total (simple) mastectomy: removes the whole breast,
but does not remove lymph nodes, for noninvasive cancer
• Modified radical mastectomy: removes the breast, some
lymph nodes under the arm, the lining over the chest
muscle, pectoralis major muscle is spared, for possibility
of cancer cell spreading to the lymph nodes
• Shoulder ROM limitation: mastectomy vs partial
mastectomy: 79% vs 35% (Newman, 2007)

5. Surgical therapy & complications
• Axillary lymph node dissection (ALND)
• Removal of lymph nodes in the armpit, then examine the
nodes to see if cancer cell is present
• Complications
• sensory deficits of intercostobrachial nerve
• Skin adhesion at incision
• Impaired shoulder ROM
• Seroma: collection of serous fluid that accumulates
within the surgical site
• lymphedema, axillary web formation
• Lymphatic mapping/sentinel lymph node biopsy
• Locate, remove and examine the first lymph node draining
the cancerous zone, for axillary staging in breast cancer
• Complications: same as ALND, but <10%

6. Axillary web syndrome
• hypercoagulation and inflammation of the superficial
lymphatic vessel as a result of the ALND
(Ferrandez and Serin, 1996)
• band of scar tissues, cordlike structures coursing from
the surgical bed toward medial arm, the forearm and
occasionally reaching the thumb
• Develop within 2~6-8 weeks after surgery
• significant tightness and limitation of motion, affecting
mainly shoulder abduction
• Physical therapy
• manual lymph-drainage technique in axilla
• progressive active and action-assisted shoulder
exercises

7. Surgical therapy & complications
• Reconstruction
• Latissimus myocutaneous flap
• potential morbidity at the donor site on the back
• weakness for adduction and internal rotation of
the shoulder
• Transverse rectus abdominis myocutaneous
(TRAM) flap
• abdominal weakness
• abdominal bulge or hernia when something
heavy (>20pouns) is lifted
(Cordeiro,
2008)
•

8. Surgical therapy complications
• General
• Wound infections: 1% ~ 20%
• Hematoma: 2% to 10% of cases
• Seroma: Seroma aspiration is necessary in 10%
to 80% of ALND and mastectomy cases
• Chronic incisional pain: 20% to 30% of patients
• Shoulder ROM impairment (2-51%)
• Decreased muscle strength (17-33%)
(Rietman,
2003)

9. Radiation therapy complications
• Skin changes: redness, itching, lasting about 6 weeks
• Shoulder and Arm Complications: 90%
of
women
with
breast
cancer
• impaired shoulder mobility:
• muscular (pectoralis major) and subcutaneous fibrosis
or to vascular injury
• breast fibrosis in 58% stage I-II patients in mid-1980
• axillary radiation vs no axillary radiation: 73% vs 35%
(Sugden, 1998)
• Brachial plexus neuropathy
• rare
complica3on
of
modern
radiotherapy,
irreversible
• nerve
entrapment
by
radia3on
induced
fibrosis,
chronic
oedema,
or
both
• paresthesia
in
the
fingers
or
hands,
hypoesthesia,
hypoalgesia,
disesthesia,
paresis,
hyporeflexia
and
muscular
atrophy
• limb
weakness
may
be
selec3vely
distal,
global
with
more
marked
distal

10. Radiation therapy complications
• Arm lymphoedema
• Fatigue
• Nutrition: loss of appetite and difficulty in digestion
during radiation
• Sometimes related to drop of counts of RBC, WBC,
and platelets during radiation
• Radiation-induced fatigue usually lasts 4-6 weeks
• Pulmonary complications: 0-31% radiation pneumonitis
• Radiation-induced second malignancies: 16~19%
in
breast
cancer
pa3ents,
contralateral
breast
cancer,
skin,
endometrial,
colorectal
and
pancrea3c
cancers

11. Chemotherapy & complications
• Purpose of chemotherapy
• Shrink a tumor prior to surgery
• Decrease chances of recurrence following surgery
• Prevent metastasis
• Cytotoxic: poison frequently dividing cells by preventing
them from dividing

12. Chemotherapy & complications
• Complications
• Hair loss
• Nausea/vomitting: 73
to
82%
(Dibble
2003)
• Pain
• Fatigue: 60%
to
90%
(Feyer
2001)
• Lymphedema
• Neurotoxicity: peripheral neuropathy
• Anthracycline-related long-term cardiac toxicity
• Menopausal symptom
• Secondary leukemia

13. Hormonal therapy & complications
• Estrogen-receptor positive (ER+) /progesterone
-receptor positive cancer: some cancer divide more
frequently in the presence of hormone
• Purpose of hormonal therapy: third line of defense
by blocking one’s own natural hormones
• Complications
• Bone loss
• Menopausal symptom

14. Post-surgical exercise
• beneficial effect of delayed exercise on the
incidence of seroma, no conclusion regarding fluid
drainage and hospital stay, long-term damage to
arm movements (Shamly,
2005)
• early versus delayed implementation of post
-operative exercise
• early exercise was more effective than delayed
exercise in the short term recovery of shoulder
flexion ROM
• however, early exercise also resulted in a
statistically significant increase in wound drainage
volume and duration
(Cochrane review, 2010)

15. Post-surgical exercise
(Harris, 2012)

16. Post-surgical exercise
• Structured exercise programs in the post-operative
period significantly improved shoulder flexion ROM
in the short-term
• Physical therapy treatment yielded additional benefit
for shoulder function post-intervention and at six
-month follow-up
(Cochrane
review,
2010)

17. Strengthening exercise
• Proper and progressive strengthening exercise
• A program of slowly progressive weight lifting did not
result in increased incidence of lymphedema.
• Upper-­‐body
exercises:
seated
row,
chest
press,
lateral
or
front
raises,
bicep
curls,
and
tricep
pushdowns
• Lower-­‐body
exercises: leg
press,
back
extension,
leg
extension,
and
leg
curl
(Schmitz
et
al.,
2009)
• A 6-month intervention of resistance exercise did not
increase the risk for or exacerbate symptoms of
lymphedema. (Ahmed
et
al.,
2006)
• Active resistive exercise with complex decongestive
physiotherapy did not cause additional swelling, and it
significantly reduced proximal arm volume and helped
improve QOL. (Kim
et
al.,
2010)

18. 18
Breast Cancer-related Lymphedema
• Abnormal accumulation of tissue proteins and
swelling
• reduced lymphatic regeneration after surgical
interruption
• radiation induced fibrosis, causing venous and
lymphatic vessel obstruction and lymphocyte
depletion with fatty replacement and local fibrosis
• concomitant use of tamoxifen or chemotherapy
• May accompanied by pain, skin changes,
decreased joint range of motion and recurrent
infections.
• Incidence: 28% (Mortimer, 1996)

19. PT for lymphedema
• Complex physical therapy (Complete decongestive
physiotherapy, decongestive lymphatic therapy)
• Manual lymph drainage
• Compression therapy
• Short-stretch bandage
• Special garment
• Exercise
• Abdominal breathing exercise for clearance of deep
trunk area
• Lymph drainage exercise
• Stretching and flexibility exercise
• Aerobic exercise
• Skin care (healthy advice)

20. 20
Healthy Advices to BCRL Women
• Keeping the lymphedematous arm elevated
• Air travel may not induce or deteriorate lymphedema
• Proper and progressive exercise would be helpful
• Body weight control is necessary (BMI<26)
• Avoid pressure on the involved extremity
• Avoid constrictive clothing
• Avoid strong massage
• Avoid heat
• Avoid vigorous activity
• Keep skin in good condition- moisture lotion
• Avoid infection and injury

21. Lymph drainage exercise

22. Lymph drainage exercise

23. Lymph drainage exercise

24. Physical therapy for cancer pain
• Cancer related pain is often intractable and unremitting,
responding poorly to simple analgesics
• insidious onset and is typically worst at rest or at night
• Description or quality
• Aching, well-localized, stabbing, throbbing, pressure,
often associated with somatic pain in skin, muscle,
bone
• Gnawing, diffuse, cramping, aching, often associated
with visceral pain in organs or viscera
• Sharp, tingling, ringing, shooting, burning, often
associated with neuropathic pain caused by nerve
damage
• Pathophysiology
• Nociceptive/Neuropathic

25. Physical therapy for cancer pain
• Pain related to oncologic emergency
• Bone fracture or impending of weight-bearing bone
• Brain Epidural, leptomeningeal metastases
• Pain related to infection
• Obstructed or perforated viscus (acute abdomen)
• Pain intervention
• Pharmacologic: cornerstone of cancer pain management
• Nonpharmacologic
• Massage
• Heat and/or ice
• Transcutaneous electrical nerve stimulation (TENS)
• Cognitive modalities: Distraction, Relaxation, active
coping training, spiritual care (NCCN CPG, 2010)

26. Physical therapy for cancer pain
• Massage
• Classical massage seems to be an effective adjuvant
treatment for reducing physical discomfort and fatigue,
and improving mood disturbances in women with early
stage breast cancer (Lis3ng
M,
2009)
• An 8-week multidimensional program including
strengthening exercises, and massage as major
components was effective for improving neck and
shoulder pain and reducing widespread pressure
hyperalgesia in breast cancer survivors
(Fernández-­‐Lao
C,
2012)

27. Physical therapy for cancer pain
• Electrophysical agents
• Therapeutic ultrasound applications are absolutely
contraindicated directly over cancerous lesions
• Superficial warming and cooling
• safest,
non-­‐pharmacological
op3ons
for
the
management
of
malignant
pain
that
is
unresponsive
to
medica3on,
regardless
of
the
stage
of
cancer
• Transcutaneous electrical nerve stimulation (TENS)
• limit
the
use
of
TENS
to
the
pallia3ve
stage
only,
as
a
means
of
symptom
control
(hall,
2004)
• insufficient available evidence to determine the
effectiveness of TENS in treating cancer-related
pain (Cochrane
Systema3c
Review,
2012)

28. Postmastectomy pain syndrome
• pain in the anterior aspect of the thorax, axilla, and
/or upper half of the arm after mastectomy for more
than 3 months (Wood, 1970)
• neuropathic – resulting from damaged nerves or
dysfunction of the nervous system
• phantom breast pain
• intercostobrachial neuralgia: PMPS
• pain secondary to the presence of a neuroma – it
includes pain in the surgical scar, thorax, or arm,
which is triggered by percussion (Tinel’s sign)
• pain due to damage to other nerves: medial
pectoral, lateral pectoral, thoracodorsal, and long
thoracic nerves

29. Postmastectomy pain syndrome
• Incidence: 20 to 50%
• Development of axillary hematoma, and
postoperative radiotherapy are possible causes of
PMPS
• use of drugs, such as amitriptyline, venlafaxine, and
capsaicin

30. PT for cancer-related fatigue
• distressing, persistent, subjective sense of tiredness or
exhaustion related to cancer or cancer treatment that is not
proportional to recent activity and interferes with usual
functioning
• Associated with cytotoxic chemotherapy, radiation therapy,
surgery, and biotherapies
• 30% of breast cancer survivors reporting moderate to
severe symptoms of fatigue
• influenced by psychological, physical, and biological factors
• Not a symptom to treat by medication (unless drop of
RBC)
• strongly correlated with psychological distress and
depression coping strategies
• impaired quality of sleep or pain

32. PT for cancer-related fatigue
• Decreased level of activity during adjuvant treatment
cause reduction in the capacity for physical performance
• Physical fitness
• exercise improved cardiorespiratory fitness (Crowley
2003;
Drouin
2002;MacVicar
1989)
• physical performance assessed via timed walking
distances (Campbell
2005;
Mock
1997)
• no evidence that exercise is effective in increasing
strength during adjuvant cancer treatment

33. PT for cancer-related fatigue
• Fatigue
• lower levels of fatigue in cancer patients who exercised
compared to control or comparison groups
• home-based walking programs
• Aerobic exercise was particularly effective, with fatigue
levels approximately 40-50% lower in exercising
subjects
(Ganz
PA,
2007)
• non-significant improvement in fatigue for breast cancer
participants in the exercise intervention groups compared
to control (Campbell
2005;
Drouin
2002;
Mock
1997;
Mock
2004;
Segal
2001
SD;Segal
2001SU)

34. PT for cancer-related fatigue
• Psychosocial interventions
• psycho-educational group intervention focusing on
active coping strategies and physical activity is
beneficial to cancer survivors after breast cancer
treatments (Fillion,
2008)
• self-administered form of stress management
training, peer-modeling video

35. Exercise
for
cancer
patient
• Cancer-related fatigue
• Body Composition
• sarcopenic
obesity
with
evidence
of
reduced
physical
ac3vity
supports
the
need
for
interven3ons
focused
on
exercise,
especially
resistance
training
• non-­‐significant
reduc3on
in
weight
for
par3cipants
in
the
aerobic
exercise
(Cochrane, 2009)
• Nausea:
aerobic
exercise
may
serve
as
a
poten3al
interven3on
for
controlling
or
mi3ga3ng
chemotherapy
induced
nausea
(Winningham 1988)
• Quality of life:
evidence
is
conflic3ng
as
to
whether
exercise
interven3ons
are
effec3ve
in
increasing
cancer-­‐and
cancer
site
-­‐specific
quality
of
life
• Psychological distress outcomes:
anxiety,
mood,
depression:
no
evidence