Mastectomy

Dr. Joyal Tejpal

• Contents
Lecture- 1: Introduction
• Lecture- 2: Breast cancer:
🡪 Risk factors
🡪 Clinical features
🡪 Investigations
🡪 Stages of breast cancer
🡪 Medical treatment
🡪 Complications
• Role of Physiotherapy
🡪 Lecture- 3: Preoperative assessment and care
🡪 Lecture- 4: Postoperative assessment
🡪 Lecture- 5: Lymphedema assessment (detailed)
🡪 Lecture- 6: Postoperative management (Principles, short term and long term goals)
🡪 Lecture- 7: Exercise program In early stage
🡪 Lecture- 8: Lymphedema management
🡪 Lecture- 9: Later stage management
 Mastectomy
Mastectomy = removal of breast tissue

It can be partial or complete

Most commonly done after breast

carcinoma
Breast cancer
• Breast cancer is the most common
malignancy of females in developed
countries and now a days increasing in
developing country also.

• Incidence is 20% among all cancers

• Breast cancer is an uncontrollable growth
of tissues in the breast.

• The tumor can be either malignant or

benign.

• If tumor is malignant then the cells

surrounding tissues or organs and
metastasize (spread) there.
Risk factors of breast cancer
• Aging 🡪 over 55 yrs

• Family history

• Having H/o breast cancer

• Hormones: greater the level of estrogen in

women’s body, the more susceptible she is to a
breast cancer

• Others:- physical inactivity,

use of OCPs
obesity
Symptoms
• A lump in breast

• Pain in armpits or breast that does not seem to be related

to women’s menses

• Pitting or redness of the skin of breast

• A rash around (or on) nipple

• Swelling in one of the armpit

• An area with thickened tissue in a breast

• One nipple has discharge, sometimes it may contain blood

Investigations
• Mammogram
• Ultrasound
• MRI
• Biopsy
• HER2 test: human epidermal growth
factor receptor-2
Stages of Breast Cancer
Stages of breast cancer

• Stage- 0:
Cancer cells remain inside of breast duct,
without invasion into normal breast tissue

• Stage- 1:
Cancer is 2 cm or less and is confined to
the breast (lymph nodes are clear)
• Stage- 2:

Tumor between 2-5 cm

Lymphnodes are in armpits
No evidence of spread beyond armpit
• Stage -3
Tumor more than 5 cm
Lymph nodes in armpit affected
No evidence of spread beyond armpit
Stage -4

The cancer has spread (metastasized) to

other parts of the body.
Mastectomy Indications:
• Women with 2 or more areas with same
breast.
• Tumor larger than 5 cm
• With certain serious connective tissues
diseases such as scleroderma
Appropriate type of mastectomy and
treatment for breast cancer depend on
several key factors, including
• Age
• General health
• Tumor size, stage, Grade
• Weather lymph nodes are involved or not.
Medical treatment
• Conservative: Chemotherapy
radiotherapy
Surgical treatment of breast cancer falls in
to two broad categories:-
1. Mastectomy:
2. Breast-conservation surgery
Mastectomy
• Involves removing the entire breast

• Types of Mastectomy:-
a) Total
b) Radical / Halsted mastectomy
c) Modified radical Mastectomy
d) Skin sparing mastectomy
e) Nipple sparing/Subcutaneous mastectomy
f) Segmental/ lumpectomy/ breast
conservation surgery
Total or simple Mastectomy
• Removal of the entire breast tissue
including;
- Aereola
- Nipple
- Skin
- Pigmented area but not all lymphnodes
Radical mastectomy
• Includes removal of the breast tissue
along with
- Nipple
- Aereola
- Skin
- Muscles and fascia
- Lymphnodes
Modified radical mastectomy
• Breast tissues removed along with
- Skin
- Aereola
- Nipple
- Lymphnodes but
- Pectoralis major muscle is spared
Segmental mastectomy/lumpectomy/breast
conservation surgery

• Only diseased part along with affected

lymph nodes are removed
Complications
Immediate complications:
• Chest complications
• Circulatory complications
• Pain
• Injury/ Thrombosis of axillary vein
• lymphedema
• Late complications:
- Delayed healing
- Lymphaedema
- Restricted shoulder ROM/ shoulder
dysfunction
- Aerobic deconditioning
 Role of Physiotherapy
• Pre-operative assessment:

- Demographic details

- History: present h/o

medical H/o

surgical H/o

obstetric and gynecological H/o

Investigation H/o (make note on stage of cancer, extent

of the disease)

social H/o
- Objective assessment:

observation: posture

palpation

examination:

🡪 Musculoskeletal assessment: mobility, muscle

strength

🡪 Chest assessment: expansion, PFT etc.

🡪 Functional assessment and exercise capacity

 Preoperative management
• Explain role of physiotherapy following surgery

• Explain breathing exercises and incentive spirometry

to prevent chest complications

• Explain bed mobility

• Ankle-toe movements

• Heel slides

• Upper extremity elevation

Postoperative assessment

🡪 Detailed history of surgery including type of

incision, extent and type of surgery

🡪 Chest assessment: auscultations, expansion

🡪 Examination of surgical site if open

🡪 Severity of pain

🡪 Evaluation of posture and mobility

• Evaluation of functional status on
FIM/Barthel

• Evaluation of Lymphedema

• Later on scar assessment

• Exercise capacity

• Muscle strength and endurance

Assessment of Lymphedema

pathophysiology of lymphedema
Breast cancer related lymphatic
dysfunction:

The type of surgery performed, extent of

axillary nodes removed and the use of radiation
all affect the incidence of lymphedema in a
patient with breast cancer
• Axillary dissection and removal off lymph
nodes interrupt and slow the circulation of
lymph 🡪 lymphedema

• Radiation therapy can cause fibrosis of

tissues in the area of axilla, which obstructs
the lymphatic vessels and contributes to
pooling of lymph in the arm and hand
Examination of lymphedema
• Examination of skin integrity: visual
inspection and palpation of skin

• Pitting or non-pitting edema

🡪 If pitting grades ??
• Girth measurement

• Volumetric measurement

• Bioimpedence measurement

• Stemmer’s sign
• Girth measurement from shoulder to hand
Volumetric measurement
• Immerse the limb in tank of water to
predetermined anatomical landmark and
measure the volume of water displaced
• Use of low-level AC current to measure
the resistance to the flow through the
extracellular fluid in upper extremities

• The higher the resistance to flow, the

more extracellular fluid present
Stemmer’s sign
Inability to peak skin over 2nd metacarpal
indicates positive stemmer’s sign
Post-operative problem list

• Pulmonary complications
• Circulatory complications
• Postoperative pain
• Lymphedema
• Impaired shoulder ROM
• Weakness and impaired functional control of
involved upper extremity
• Postural malallignment
• Fatigue
• Decreased endurance
• Psychological considerations: anxiety,
depression, cosmetic disappearance
Postoperative management goals
Short term goals:-

• To prevent pulmonary complications

• To prevent circulatory complications

• To improve bed mobility and prevent complications of

pressure sores

• To decrease postoperative pain

• To minimize postoperative edema/swelling

Long term goals

•Identify early signs of lymphedema & minimize

the Lymphedema

•To improve shoulder ROM

•To improve voluntary control and functional

movements of muscles surrounding shoulder
complex on involved side

•Prevent postural malalignment

•To improve muscle strength

•To improve exercise tolerance

•To provide psychological counseling and

improve sense of well being

•Provide information about resources for

patient and family support

•Ongoing pt. education

Postoperative management
1. Prepare the patient for postoperative self-
management

🡪 Interdisciplinary pt. education involving all

aspects of potential impairments and
functional limitations

🡪 Self-management activities and preparation

for participation in a home program as
indicated per surgical protocol
2. To prevent chest complications:

- Breathing exercises: diaphragmatic,

segmental

- Incentive spirometry

- ACTs with huffing or coughing if needed

3. To prevent circulatory complications

• ATMs
• Positioning
• Calf stretching
• Bed mobility
4. To improve bed mobility and there by
prevent complications of pressure sores/
deconditioning etc..

- Bed turning
- Transfers
- Early ambulation
5. To relive pain:

🡪 For Incisional pain and neurogenic pain;

In addition to drug therapy;

- Cold packs

- High frequency TENS

- Positioning and posture correction to avid

pain due to muscle spasm
6. Minimize lymphedema/ reduces complication of
lymphedema (Management of lymphedema)

i. Elevation:

ii. Manual lymphatic drainage

iii. Exercises

iv. Compression therapy

v. Risk reducing behavior therapy

• A comprehensive approach to the
management of lymphedema is divided
into two phases:

1. Intensive treatment phase Decongestive

lymphatic therapy
program
2. Long term management

so, from phase 1 to 2 therapist directed

care is replaced by patient directed care
Components of Decongestive lymphatic therapy program

Phase -1:
• Manual lymphatic drainage (MLD)

• Multiple layer compression bandaging

• Skin and nail care

• Exercises

Phase – 2:
• Self-MLD by the patient

• Compression therapy

- Compression garment during the day

- Multiple layer bandaging in the evening/night

• Skin and nail care

Manual lymphatic drainage

• Stroking 🡪 effleurage massage

• Given along with limb elevation

• Clear fluid in proximal compartment first

• Direction of massage is toward specific

lymphnodes (distal-proximal)
Compression therapy

• During phase I; only low stretch bandages

are used🡪 provides low resting pressure
and high working pressure

• Can be worn during day and night (except

bathing)

• Nonwoven padding with foam pads can be

used under the low stretch bandage
• In phase II compression bandage given
during the day time only
• Compression garment has a high resting
pressure and low working pressure

• Used only to maintain limb size during

day, for giving pt. more cosmetic
appearance and ease of wearing cloths
 High resting pressure
low working pressure

Low resting pressure

high working pressure
Upper extremity exercises:

• Active circumduction of involve arm

• Bilateral active movements of arms

• Bilateral hand press

• Shoulder stretches

• Active elbow, forearm, wrist and finger exercises of

involved arm

• Bilateral horizontal arm abduction and adduction

• Overhead wall press

• Finger exercises
Lower extremity exercises:
• Alternate knee to chest exercises

• Bilateral knees to chest

• Posterior pelvic tilts

• External rotation of the hips while lying supine

with both legs elevated and resting on a wedge

or wall

• Active knee flexion of the involved lower

• Active plantar flexion and dorsiflexion and circumduction of

the ankles while lying supine with lower extremities elevated

• Active hip and knee flexion with legs externally rotated and

elevated against a wall

• Active cycling and scissoring movements with legs elevated

• Bilateral knee to chest exercises, followed by partial curl-ups

• Rest with lower extremities elevated

Guidelines 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.

• Wear compression bandages while

exercising
• Combine deep-breathing with active
movements of the head, neck, trunk and
limbs

• After exercises keep involved extremity in

elevation
 Rationale of lymphatic drainage exercises
• Contraction of muscles pump fluids by direct
compression of the collecting lymphatic
vessels.

• Exercise reduces soft tissue and joint

hypomobility that can contribute to static
positioning and lead to lymphostasis.

• Exercise strengthens and prevents atrophy of

muscles of the limbs, which improves the
efficiency of the lymphatic pump.
• Exercise increases heart rate and arterial
pulsations, which in turn contribute to
lymph flow.

• Exercise should be sequenced to clear the

central lymphatic reservoirs before the
peripheral areas.

• Wearing a compression sleeve or

compression bandaging during exercises
enhances lymph flow and protein
resorption more efficiently than exercising
without bandages
Skin care
• Keep the skin clean and supple; use
moisturizers, but avoid perfumed lotions.

• Immediate attention to a skin abrasion or cut,

an insect bite, a blister, or a burn.

• Protect hands and feet; wear socks, properly

fitting shoes, rubber gloves, etc.

• Use protective gloves when in contact with

harsh detergents and chemicals.

• Use caution when cutting nails. Push back

• Use an electric razor when shaving legs or underarms.
If the underarm area is numb, use your eyes to ensure
that good skin integrity was maintained.

• Avoid hot baths, whirlpools, etc., that elevate the

body’s core temperature.

• Seek immediate medical care if infection is suspected.

An infection may present with warmth, redness,
tenderness, or rash on the skin. A fever may or may
not be present.

• Consult your physician immediately if a new onset of

swelling is noted that does not resolve in 1–2 days.
 Later stage management following mastectomy (aims & plans)

• Prevent postural deformities:

🡪 Postural awareness training

- encourage the patient to assume an erect
posture
when sitting or standing to minimize a
rounded
shoulder posture

- Postural exercises with an emphasis on

scapular
retraction exercises
• Prevent muscle tension and guarding in
cervical musculature

🡪 Active ROM of the cervical spine

🡪 Shoulder shrugging and shoulder circle

exercises
Prevent restricted mobility of the upper extremity

• Initially Shoulder motion performed

within protected ROM (up to 900 of
elevation of the arm)
• In progression regain full ROM of
shoulder joint

🡪 Gentle, self-stretching exercises are used

to minimize soft tissue and joint
hypomobility, particularly in proximal
areas of the body that may contribute to
static postures and lymph congestion
 Factors contributing 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

activities
Upper extremity exercises

• Active circumduction of involve arm

• Bilateral active movements of arms

• Bilateral hand press

• Shoulder stretches
• Active elbow, forearm, wrist and finger

exercises of involved arm

• Bilateral horizontal arm abduction and

adduction

• Overhead wall press

• Finger exercises

• Partial curl ups

Regain strength and functional use of the involved extremity

• Initiate resistance exercise following full

postoperative healing

🡪 Both isometric and dynamic resistance training is

given using self-resistance, elastic resistance and
weights or weight machines

🡪 Initially starts with low load, in progression

increase amount of resistance and no. of
repetitions
Sequence of exercises
• Total body relaxation
• Exercises for lymphatic drainage
• Common exercises of upper and lower
extremity
• Cervical ROM
• Scapular exercises
Improve exercise tolerance and sense of well- being

• Activities such as upper extremity ergometry, swimming,

cycling and walking increase circulation and stimulate
lymphatic flow

F = 3 – 5 days
I = When lymphedema is present; conditioning done at
low intensity i.e., 40%-50% of THR &
In progression when lymphedema has been reduced
conditioning done at high intensity i.e., at 80%-95%
T = at least 30 minute/ session
T = interval training to continuous training
Psychological consideration
• All the individuals taking part in rehabilitation
programme should undergo a valid assessment of
anxiety, depression, quality of life and other
relevant psychological factors using an
appropriate assessment tool.
- stress management at home
- stress management at work
- creation of hobbies - time out
- conflict resolution skills
PSYCHOLOGICAL CARE:
- Assist with adjustment
- Promote positive attitude
- Facilitate behavior change
- Identify need for further support
Provide information about resources for
patient and family support and ongoing
patient education
Patient education:
• Postoperatively emphasis on pt. education for reducing
the risk of post opp. Complications, impairments , etc..

Resources:
• American cancer society for family support and ongoing
pt. education(www.cancer.org)
• National breast cancer coalition (
www.nobreastcancer.org)
• National lymphedema network (www.lymphnet.org)
Reference books
• Therapeutic exercise foundations and
techniques, 6th edition- Carolyn Kisner
and Lynn Allen Colby
Sample questions:
1. Management after mastectomy
2. Lymphedema
3. PT management after radical
mastectomy
4. Write in detail on the life style changes
and physiotherapy techniques for
lymphedema post radical mastectomy
“You can help to reduce risk of cancer
by making healthy choices like eating
right, staying active and not smoking.
It's also important to follow
recommended screening guidelines,
which can help detect certain cancers
early.