Women Health disorders through life

stages
Breast Cancer And Lymphedema
Learning Outcomes
By the end of this lecture, you will be able to:
Understand the assessment and management of breast cancer.
Assess and manage the lymphedema post mastectomy.
Breast cancer
Anatomy of breast
• https://www.youtube.com/watch?v=aBA14YCV-X0
• Breast cancer arises in the lining cells (epithelium) of the ducts (85%)
or lobules (15%) in the glandular tissue of the breast. Initially, the
cancerous growth is confined to the duct or lobule (“in situ”) where it
generally causes no symptoms and has minimal potential for spread
(metastasis).
• It’s important to understand that most breast lumps are benign and
not cancer (malignant).
• Non-cancerous breast tumors are abnormal growths, but they do not
spread outside of the breast.
• They are not life threatening, but some types of benign breast lumps
can increase a woman's risk of getting breast cancer.
• Any breast lump or change needs to be checked by a health care
professional to determine if it is benign or malignant (cancer) and if it
might affect your future cancer risk.
Incidence of Breast cancer
• In recent years, incidence rates have increased by 0.5% per year.
• Breast cancer is the second leading cause of cancer death in women. (Only
lung cancer kills more women each year.)
• The chance that a woman will die from breast cancer is about 1 in 39
(about 2.6%). Since 2007, breast cancer death rates have been steady in
women younger than 50, but have continued to decrease in older women.
• From 2013 to 2018, the death rate went down by 1% per year.
• These decreases are believed to be the result of finding breast cancer
earlier through screening and increased awareness, as well as better
treatments.
Causes/ Risk
Factors
Causes/ Risk Factors
Activity: Read the given article
and lets discuss breast cancer
screening
Activity
• https://bcrisktool.cancer.gov/calculator.html
Management
Psychosocial
issues related
to breast cancer
Breast cancer related
Lymphedema
Lymphatic System
• The lymphatic system is a network of delicate tubes throughout the body. It
drains fluid (called lymph) that has leaked from the blood vessels into the
tissues and empties it back into the bloodstream via the lymph nodes.

The main roles of the lymphatic system include:

• managing the fluid levels in the body
• reacting to bacteria
• dealing with cancer cells
• dealing with cell products that otherwise would result in disease or disorders
• absorbing some of the fats in our diet from the intestine.
Lymphatic System
Introduction
• Lymphedema is a set of pathologic conditions that are characterized by the
regional accumulation of excessive amounts of interstitial protein-rich fluid.
• These occur as a result of an imbalance between the demand for lymphatic
flow and the capacity of the lymphatic circulation.
• Lymphedema can result from either primary or acquired (secondary)
disorders.
• It can develop in the arm, hand, breast, or torso as a side effect of breast
cancer surgery and/or radiation therapy.
• Lymphedema can appear in some people during the months or even years
after treatment ends.
Types of Lymphoedema

• Lymphedema can be divided into 2 categories primary/ idiopathic and

secondary/ acquired.
• The primary cause of lymphedema happens due to a malformation of
the lymph vessels. Secondary lymphedema is damage that has been
done to normal healthy lymph vessels
Primary/Idiopathic Lymphoedema
• Primary lymphoedema can be idiopathic, intrinsic or spontaneous.
• Idiopathic means there is no known cause
• Intrinsic results from an abnormal lymphatic system
• Spontaneous means the condition has developed on its own without
any interference
Secondary/Acquired Lymphoedema
• Secondary lymphoedema is more common than the primary form.
• Malignant tumours - the presence of cancer tumours can block the flow of lymph fluid
• Surgery (cancer and non-cancer related) – increases the risk of disturbing the function
of lymphatic pathways
• Radiotherapy - destroys cancerous tissue but can also damage healthy lymph nodes
• Infections – contributes to increased swelling in the affected area
• Inflammation – contributes to excess fluid build up in the affected area
• Obesity – increased the pressure on the lymphatic system that could ultimately damage
lymph nodes
• Disease - for example, venous, joint, diabetes
• Trauma - lymphoedema can occur following severe trauma, for example, compound
fractures
Etiology/Causes
Primary Cause Secondary Cause
• Unknown • Filariasis (mosquito bite- parasitic infection)
• Primary or Metastatic Neoplasm (benign or malignant)
• Hereditary • Surgery (lymph node dissection or removal)
• Radiation treatment
• Developmental abnormalities • Chemotherapy
• Severe infection
• Chronic venous insufficiency (CVI)
• Trauma
• Obesity
• Iatrogenic
• Self-induction (artificial,fictitious)
• HIV/AIDS
Cancer
• Lymphoedema following breast cancer surgery is the highest
overlooked cause of secondary lymphoedema.
• Research states approximately 28% of people will acquire
lymphoedema after receiving this treatment.
• The procedure involves removing one or more lymph nodes located
under the arm, leaving fewer lymph nodes to drain all the lymph.
• Continually working under high pressures eventually causes the
remaining lymph nodes to become damaged and lymph leaks into the
lymph vessels.
• Consequently excess fluid builds up in the affected area
• Cancer Research UK discusses the vicious cycle between cancer and
the body’s immune system.
• Cancerous cells are destroyed by the immune system and treatments
for cancer.
• However, the condition can weaken the immune system if lymph
nodes are blocked by cancerous tissue and unable to function
properly.
• A combination of surgery and radiotherapy treatment leads to a
higher risk of acquiring secondary lymphoedema.
• Radiation therapy aims to stop cancer from coming back by using
high-radiation energy to destroy cancerous cells.
• It either occurs before surgery to reduce the size of a tumour, or after
surgery to abolish the remainder of the tumour.
• Lymphoedema can occur as a result of this treatment when the
function of the lymphatic system has been comprised and fluid isn’t
drained away
Prevalence
• The incidence of lymphedema is unknown because it goes
unreported.
• When looking at the primary cause 15% of lymphedema cases are
reported at birth, 75% during adolescence with a ratio of 4:1 females
to males, 10-20% after the age of 35, with 2 % in other syndromes.
• There are around 3 million cases in the US with 30% of those secondary to breast
cancer.
• One study looked at 300 patients with breast cancer a year later the prevalence of
clinically significant lymphedema was 33.5 % and 17.2 % had severe lymphedema.
• The prevalence of lymphedema was 13.4 % in patients treated with surgery only
where as the prevalence was 42.4% in patients treated with surgery and radiotherapy.
• Post treatment lymphedema continues to be a significant problem following breast
cancer therapy.
• Presence of co-morbid conditions and axillary radiation significantly increases the risk
of lymphedema.
• A combination of axillary dissection and axillary radiation should be avoided
whenever feasible to avoid lymphedema.
Impairments and Complications Related to
Breast Cancer Treatment
• Post op pain
• Incisional Pain
• Posterior cervical and shoulder girdle pain
• Postoperative Vascular and Pulmonary Complications  venous stasis
and pulmonary complications
• Lymphedema
• Chest Wall Adhesions
• Decreased Shoulder Mobilit
Impairments and Complications Related to
Breast Cancer Treatment
• Weakness of the Involved Upper Extremity
• Weakness of shoulder
• Decreased grip strength
• Postural Malalignment  rounded shoulders, kyphosis
• Fatigue and decreased endurance
Which Factors Contribute to Impaired Shoulder
Mobility After Breast Cancer Surgery?
• Incisional pain immediately after surgery or associated with delayed wound healing
• Muscle guarding and tenderness of the shoulder and posterior cervical
musculature
• Need for protected shoulder ROM until the surgical drain is removed
• Fibrosis of soft tissues in the axillary region due to adjuvant radiation therapy
• Adherence of scar tissue to the chest wall, causing adhesions
• Temporary or permanent weakness of the muscles of the shoulder girdle
• Rounded shoulders and kyphotic or scoliotic trunk posture associated with age or
incisional pain
• A feeling of heaviness of the upper extremity due to lymphedema
• Decreased use of the hand and arm for functional activitie
Psychological Effects
• Swelling and weight gain impact physical appearance that can affect one’s
perception of how they look, consequently decreasing their self-confidence
• People commonly detach themselves from social events with family and
friends leading to social isolation
• Disturbed sleeping pattern
• Some people may feel they have a lack of support
• Financial concerns as a consequence of treatment cost and potential job
loss/change
• Some cancer survivors that have acquired secondary lymphoedema feel
that it can be a constant reminder of previously having cancer
• For those that experience unilateral lymphoedema, commonly
different sizes of garmets have to be worn on each side of the body
and oversized clothes have to be worn because items such as jeans
dont fit the limbs.
• Psychologically this can largely impact the person because they may
not feel comfortable with the way they look and therefore exclude
themselves from public situations
 Stages of Lymphoedema
Stage Description
0 (Latency) Lymph transport capacity is reduced, no clinical edema is present. Patient may have subjective
complaints.
1 (Reversible) Pitting edema reduces with elevation; Increasing edema with increase in activity, heat, and humidity.
2 (Spontaneously Edema with evidence of fibrosis. Does not resolve overnight; does not regress with elevation,
irreversible) increasingly more difficult to pit. Skin and tissue changes present in severe stage 2.
3 (Lymphostatic Severe non-pitting fibrotic edema with significant increase in connective and in scar tissue. Trophic
elephantiasis) changes are evident (hardening/induration of dermal tissues, skin folds, skin papillomas, and
hyperkeratosis) [3][48][1]
*patient lacking a hugely edematous extremity but with long-standing chronic edema and secondary
tissue changes would still be classified as Stage 3.
Diagnostic Test
• A thorough history must be taken.
• Palpation of the lymph nodes must be done to see if they are swollen or there are any
abnormal changes.
• Measurements for the swelling limbs should also be taken. In diagnosing the diagnostic
tool used is the isotope lymphograph also called lymphoscintigraphy or
lymphangioscintigraphy(LAS) is used to determine abnormal lymph nodes and
lymphatics.
• Other imaging tools are MRI, MR Lymphography techniques, computed tomography (CT),
Perometry, Bioimpedance analysis, Patient-Reported symptom assessments,
ultrasonography(US), and DEXA,etc.
• Progress can be measured by limb circumference and water displacement.
• Clinicians must be reminded that none of the diagnostic tool is perfect in terms of
accuracy.
Medical Management
• Primary lymphedema can be treated with sclerotherapy to seal a
leaky lymph vessels and prevent reflux into the abdomen.
• Radiation therapy and surgical dissections
• Removal of abnormal lymph vessels
• Microsurgeries performed on lymph vessels to amastomose to a vein
or another functional lymph vessel. It has an increased mortality and
morbidity rate and are unsuccessful.
Medications
• Benzopyrones
• Diuretics (inaffective for lymphedema)
Physical Therapy Management
• If treatment for cancer is necessary that should be completed first.
• Physiotherapy can play a major role in the management of
Lymphoedema.
Prevention
• Avoid static, dependent positioning of the lower extremities, such as prolonged sitting or standing.
Avoid sitting with legs crossed.
• When traveling long distances by car, stop periodically and walk around or support an involved upper
extremity on the car’s window ledge or seat back.
• Elevate involved limb(s) and perform repetitive pumping exercises frequently during the day.
• Avoid vigorous, repetitive activities with the involved limb. Avoid carrying heavy loads, such as a
suitcase, a heavy backpack, or shoulder bag. Avoid use of heavy weights when exercising.
• Wear compressive garments while exercising.
• Avoid wearing clothing that restricts circulation, such as sleeves or socks with tight elastic bands. Do
not wear tight jewelry such as rings or watches.
• Monitor diet to maintain an ideal weight and minimize sodium intake.
• Avoid hot environments or use of local heat.
• If possible, avoid having blood pressure taken on an involved upper extremity or injections in either
an involved upper or lower extremity
 Skin Care
• Keep the skin clean and supple; use moisturizers but avoid perfumed lotions.
• Avoid infections; pay immediate attention to a skin abrasion or cut, an insect
bite, a blister, or a burn.
• Protect hands and feet; wear socks or hose, properly fitting shoes, rubber
gloves, oven mitts, etc.
• Avoid contact with harsh detergents and chemicals.
• Use caution when cutting nails.
• Women need to use an electric razor when shaving legs or underarm area.
• Avoid hot baths, whirlpools, and saunas that elevate the body’s core
temperature
Interventions include:
• Elevation
• Manual lymphatic drainage (massage)
• Direct intervention by a therapist
• Self-massage by the patient
• Compression
• Nonelastic or low-stretch bandages or custom-fitted garments
• Intermittent, sequential pneumatic compression pump
• Individualized exercise program  Active ROM (pumping exercises) Flexibility exercises 
Low-intensity resistance exercises  Cardiovascular conditioning
• Skin care and daily living precaution
• Psychological and emotional support
Patient education
• Interdisciplinary patient education involving all aspects of potential
impairments and functional limitations.
• Self-management activities and preparation for participation in a
home program on the first postoperative day
Prevent postoperative pulmonary
complications and thromboemboli.
• Pre- or postoperative instruction in deep breathing, emphasizing
maximal inspirations and effective coughing.
• Active ankle exercises (calf pumping exercises).
Prevent or minimize postoperative
lymphedema
• Elevation of the involved upper extremity on pillows (about 30) while
the patient is in bed or sitting in a chair. Wrapping the involved upper
extremity with bandages or wearing an elastic pressure gradient
sleeve. Pumping exercises of the arm on the side of the surgery. Early
ROM exercises.
• PRECAUTION: Avoid static, dependent positioning of the arm.
Decrease lymphedema if or when it develops
• Manual lymphatic drainage massage.
• Daily regimen of exercises to reduce lymphedema.
• Use of custom-fit elastic compression garment when lymphedema is
stabilized.
• Adherence to precautions for skin care
The principles and technique of MLD
• Slow repetitive movements
• Moves proximally to distally
• Aims to increase lymph drainage without altering capillary function
• Alter interstitial pressures by varying hand movements
• Incorporates breathing techniques (deep diaphragmatic breathing) to
encourage drainage from deep abdominal lymph nodes and vessels
• Up to one hour daily
Designing an exercise plan
Typically, an exercise plan for anyone at risk for or diagnosed with
lymphedema includes some combination of:
• flexibility and stretching exercises
• strength training
• aerobic exercise that uses the upper body, helping with weight loss
and encouraging deep breathing, which in turn helps lymph move
along
Exercise is important, but you have to do it wisely with specific
guidance from someone who knows your situation.
Complex Decongestive Therapy

Phase 1:
• Skin care
• Light manual massage (manual
lymph drainage)
• ROM
• Compression (multi-layered
bandage wrapping, highest level
tolerated 20-60 mm Hg)
Phase 2
• Compression by low-stretch elastic
stocking or sleeve
• Skin care
• Exercise
• Light massage as needed
• Contraindications for compression
includes arterial disease, painful
postphlebitic syndrome, and occult
visceral neoplasia.
Exercise Precautions and Treatment of Breast
Cancer
• Exercise only at a moderate level and never to the point that the affected
arm aches during or after exercise, even if there is no evidence of
lymphedema.
• Monitor upper extremity girth measurements closely.
• Adjust the timing of exercise during cycles of radiation therapy or
chemotherapy.
• With some chemotherapy medications, a patient can develop cardiac
arrhythmia and therefore should not perform aerobic exercises, such as
stationary cycling, for 24 to 48 hours after a chemotherapy session.
• Return to more physically demanding work and recreational activities
gradually after completion of chemotherapy or radiation therapy
 Case Study
• You have been asked to participate in a patient education program at
your community’s cancer society for patients who have undergone
surgery for breast cancer. Your responsibility in this program is to help
these breast cancer survivors prevent physical impairments and
functional limitations associated with their surgery and any related
adjuvant therapies. Outline the components of such a program, and
explain the rationale for the activities you have chosen to include.
The lymphatic drainage exercises
• Preparation for Lymphatic Drainage Exercises
• Set aside approximately 20 to 30 minutes for each exercise session.
• Perform exercises twice daily every day.
• Have needed equipment at hand, such as a foam roll, wedge, or exercise
wand.
• During Lymphatic Drainage Exercises
• Wear compression bandages or a customized compression garment. Precede lymphatic drainage
exercises with total body relaxation activities.
• Follow a specified order of exercises.
• Perform active, repetitive movements slowly, about 1 to 2 seconds per repetition.
• Elevate the involved limb above the heart during distal pumping exercises.
• Combine deep breathing exercises with active movements of the head, neck, trunk, and limbs.
• Initially, perform a low number of repetitions. Increase repetitions gradually to avoid excessive
fatigue.
• Do not exercise to the point where the edematous limb aches.
• Incorporate self-massage into the exercise sequence to further enhance lymph drainage.
Maintain good posture during exercises.
• When strengthening exercises are added to the lymph drainage sequence, use light resistance
and avoid excessive muscle fatigue
• After Lymphatic Drainage Exercises
• If possible, rest with the involved extremity elevated for 30 minutes.
• Set aside time several times per week for low-intensity aerobic exercise
activities, such as walking or bicycling for 30 minutes.
• Carefully check for signs of redness or increased swelling in the edematous
limb, either of which could indicate that the level of exercise was excessive.
• Exercises for lymphatic drainage should follow a particular sequence
to assist lymph flow.
• The central and proximal lymphatic vessels, such as the abdominal, inguinal,
and cervical nodes are cleared first with trunk, pelvic, hip, and cervical
exercises.
• Then, for the most part, exercises proceed distally from shoulders to fingers
or from hips to toes.
• If lymph nodes have been surgically removed (e.g., with a unilateral axillary
node dissection for breast cancer or a bilateral inguinal node dissection for
cancers of the abdominal or pelvic organs), lymph must be channeled to the
remaining nodes in the body.
Palliative Care
Hollistic Needs Assessment (HNA)
• Addressing any physical or everyday concerns
• Direction to local or national support groups
• Information about local Health and Wellbeing Clinics, educational events or self
management courses available
• Referral to appropriate healthcare professionals for support
• Lifestyle advise/changes
• Information or referral to an appropriate physical activity programme
• Information or referral for advice on diet and nutrition
• Referral for psychological support
• Support related to work and finance concerns
• Support for spiritual needs
Resources
• https://youtu.be/M9uhzBQoO98
• https://youtu.be/dT6rAL4-D14
• https://youtu.be/x8k1pLVREEA
• https://youtu.be/grS-Sgfh3vw
• https://youtu.be/f3UAjU2-sAE
• http://www.melbournebreastcancersurgery.com.au/breast-cancer-tre
atment-algorithms.html
• http://your-pt.blogspot.com/2014/04/lymphatic-drainage-exercises.h
tml
• https://rehab.msu.edu/pages/health/Lymph/index.html