Jill Binkley, PT, MClSc, FAAOMPT A non-profit organization. Musculoskeletal Dysfunction in Women During and Following Treatment for Breast Cancer Reviewed published breast cancer guidelines & literature identified via MEDLINE(R) Jill Binkley, PT, MClSc, FAAOMPT TurningPoint Women’s Healthcare Breast Cancer Rehabilitation and Wellness Programs A non-profit organization.

Common Rehabilitation Issues Related To Breast Cancer I. Upper Quadrant and Trunk Dysfunction Restricted Shoulder Range of Motion and Pain Chest Wall Pain Donor Site Morbidity Weakness of Upper Extremity and Trunk/CORE II. Lymphedema Upper Extremity Breast Trunk III. Fatigue IV. Weight Gain IV. Psychosocial Issues V. Nutritional Issues Reviewed published breast cancer guidelines & literature identified via MEDLINE(R)

Etiology of Musculoskeletal Problems During and After Breast Cancer Treatment Surgery Mastectomy/ Breast Conserving Surgery (BCS) (Lumpectomy) Axillary Node Dissection (ALND) Donor Sites for Reconstruction Drain Sites Radiation Breast/Chest Wall Axilla Chemotherapy Fatigue Port Site Pain Joint and Muscle Pain Quality of Recovery Advice Women commonly advised to avoid exercise Lack of information regarding maximizing recovery Lack of understanding of role of rehabilitation in breast cancer Reviewed published breast cancer guidelines & literature identified via MEDLINE(R)

Background: Breast Cancer Surgery and Staging of Breast Cancer Management of non-metastatic breast cancer involves surgery +/- adjuvant chemotherapy and/or radiation and is determined by: Size of Tumor Breast Size Tumor pathology and histology Number of positive axillary lymph nodes Surgery Modified Radical Mastectomy Breast Conserving Surgery (BCS) (Lumpectomy) Extent of Lymph Node Involvement Sentinel Node Biopsy +/-Axillary Node Dissection Reviewed published breast cancer guidelines & literature identified via MEDLINE(R)

Determination of Axillary Node Status Axillary Node Dissection 10 – 30 nodes removed same incision as mastectomy, separate for lumpectomy pathological examination Sentinal Lymph Node Biopsy Less invasive determination of axillary node status

Radioactive Tracer +/- Blue Dye Injected at Tumor Site Determination of Axillary Node Status Utilizing Sentinel Lymph Node Biopsy Location of 1st Node from the Tumor Determined by CT Scan and/or Geiger Counter Radioactive Tracer +/- Blue Dye Injected at Tumor Site Full ALND is avoided in women with negative SLNB

Shoulder Restriction and Loss of Function Post Surgery Short Term: Significant loss of shoulder range of motion reported 2-3 months post mastectomy (Gosselink et al, 2003; Reitman, 2003) Long Term: Loss of range of motion reported by 26% of women 1 year post mastectomy; 15% post BCS (Karki et al, 2005; Blomqvist et al, 2004) Nature of Restriction: Flexion and abduction most limited (Blomqvist et al, 2004) Range of motion restriction greater for patients who: Mastectomy versus BCS Received radiation (Blomqvist et al, 2004) Underwent AND versus SNB (Leidenius, 2005) Reviewed published breast cancer guidelines & literature identified via MEDLINE(R)

Post-Surgical Pain Prevalence of Pain 1 Year Post Surgery (Karki et al, 2005) AND versus SNB only (10 month follow-up) Arm-shoulder pain reported by 21% of patients post SLNB 50-60% of patients post ALND (Barranger, 2005) Mastectomy BCS Neck-shoulder pain 42% 37% Upper extremity Pain 26% 15% Breast/Chest Wall Pain 28% 20% Reviewed published breast cancer guidelines & literature identified via MEDLINE(R)

Weakness Post Surgery Significant decrease in strength in shoulder flexion and abduction 15 months post-mastectomy (Blomqvist et al, 2004) EMG abnormalities in upper trapezius and rhomboids with associated reduction in shoulder function post-mastectomy (Shamley, 2007) Reviewed published breast cancer guidelines & literature identified via MEDLINE(R)

Axillary Cording (Web Syndrome) Leidenius et al, 2003; Moskovitz, 2001; Lauridson, 2005 Painful, palpable cords in axilla, across antecubital fossa, in severe cases to base of thumb Tissue sampling demonstrated that cords were lymphatic and venous tissue (Moskovitz) Reviewed published breast cancer guidelines & literature identified via MEDLINE(R)

Axillary Cording (Ledenius, 2003; Lauridson, 2005) Prevalence of 60 – 70 % in post-ALND patients (MRM or BCS) in prospective studies 20% of patients following SLNB Cording is associated with limited ROM Reviewed published breast cancer guidelines & literature identified via MEDLINE(R)

Axillary Cording Reviewed published breast cancer guidelines & literature identified via MEDLINE(R)

Axillary Cording Painful Drain Site Trunkal Cording Reviewed published breast cancer guidelines & literature identified via MEDLINE(R) Bilateral Mastectomy with TRAM reconstruction, Chemotherapy, No radiation

Breast Reconstruction Immediate or Delayed Performed in conjunction with traditional mastectomy or skin sparing Options: Implant Autologous Tissue Reconstruction Latissimus Dorsi Transverse Rectus Abdominus Myocutaneous (TRAM) Other : buttock (superior or inferior gluteal), thigh (tensor fascia lata)

Implant Tissue expander placed under pec major at time of mastectomy Silicone shell gradually expanded with saline Permanent saline or silicone implant once expansion completed and/or following adjuvant treatment Pectoralis Major

Transverse Rectus Abdominus Myocutaneous (TRAM) Flap Abdominal Skin and Fat to Create Breast Mound Portion of TRAM muscle used to provide blood supply Pedicle flap attached at all times, tunnelled from abdomen to breast region Free flap spares more of TRAM muscle, micro vascular surgery to reattach deep inferior epigastric artery and veins

Latissimus Dorsi Flap

Morbidity Following Breast Reconstruction 2 Year Follow Up of 205 Women Post TRAM (n=225) and Implant (n=69) Roth et al, 2007 Back Pain (26%) Breast Pain (12%) Abdominal Pain (16%) Abdominal Tightness (42%) Abdominal pain and tightness significantly more prevalent post TRAM Breast pain more prevalent post implant

Morbidity Following Breast Reconstruction 2 Year Follow Prospective Analysis of Trunk Function Following TRAM versus Implant Reconstruction in 183 Women (Alderman et al, 2006) Significantly lower flexion peak torque in TRAM group – range from 6-19% lower peak torque No significant difference in trunk torque between free and pedicled TRAM reconstructions Study limitations: functional significance of decrease in torque not addressed

Latissimus Dorsi Flap Reconstruction Chest Wall Incision Tightness and Pain Latissimus Dorsi Flap Reconstruction

Tightness, Pain, CORE weakness Donor Site Morbidity Tightness, Pain, CORE weakness TRAM Flap Reconstruction

Effect of Radiation on Connective Tissue (Sassi et al, 2001; Gerber, 1992) Acute effects – inflammation, pigmentation, local pain Long-term effects – fibrosis: Increased turnover of type I collagen increased cross-linking of Type I collagen Reviewed published breast cancer guidelines & literature identified via MEDLINE(R)

Morbidity Related to Radiation (Bentzen & Dische, 2000; Cheville, 2007; Senkus-Konefka, 2006) Progressive loss of shoulder range of motion (1-4 year latent period) * Extent of morbidity is dependent on dose, concomitant systemic therapy, motion impairment pre-radiation Brachial plexopathy (up to 10 year latent period) * Arm lymphedema * Dose-response established Reviewed published breast cancer guidelines & literature identified via MEDLINE(R)