You are in: eMedicine Specialties > Physical Medicine and Rehabilitation > REHABILITATION PROTOCOLS Cancer and RehabilitationArticle Last Updated: Aug 16, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 11
 
Author: Robert J Kaplan, MD, Associate Professor, Department of Physical Medicine and Rehabilitation, University of Kansas School of Medicine and Medical Center Robert J Kaplan is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, International Spine Intervention Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation Editors: Rajesh R Yadav, MD, Assistant Professor, Section of Physical Medicine and Rehabilitation, MD Anderson Cancer Center, University of Texas at Houston; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain (Tailbone Pain, Coccydynia) Service, University of Medicine and Dentistry of New Jersey, New Jersey Medical School; Kelly L Allen, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Lourdes Regional Rehabilitation Center, Our Lady of Lourdes Medical Center; Robert H Meier III, MD, Director, Amputee Services of America, Presbyterian St Luke's Hospital; Consulting Staff, North Valley Rehabilitation Hospital, Kindred Hospital, and North Suburban Hospital Author and Editor Disclosure Synonyms and related keywords: oncology rehabilitation, physical medicine and rehabilitation, PM&R, cancer medicine, oncology, transverse rectus abdominis muscle flap, TRAM flap, deep inferior epigastric perforator flap, DIEP flap, physical therapy, PT CANCER REHABILITATIONSection 2 of 11
 
Cancer as a disease process reminds us often unexpectedly of our mortality. It frequently compromises our patient's vitality. It is also a burden emotionally and physically on family, friends, significant others, community, and other social resources. Preface and introductionPreface Physical medicine and rehabilitation (PM&R) is the medical specialty principally concerned with impairments, disabilities, and handicaps that arise after acute or chronic illness. According to the 1980 classification of the World Health Organization (WHO), impairment is physiologic dysfunction or loss of anatomic integrity. Disability refers to functional consequences in relation to self-care and mobility imposed by underlying impairments. Handicap may be defined as a physical condition that interferes with a patient's ability to engage in social, educational, recreational, and vocational pursuits. In essence, handicap compromises patient's full integration into personal relationships and family and societal roles. Introduction Cancer is a group of diseases characterized by uncontrolled growth and spread of abnormal cells, which can result in death. Cancer is caused by both external factors (eg, chemicals, radiation, viruses) and internal factors (eg, hormones, immune conditions, inherited mutations). Causal factors may act together or in sequence to initiate or promote carcinogenesis. Ten or more years may pass between carcinogenic exposure or inheritance of a mutation and detectable cancer. Today, cancer is treated with surgery, radiation, chemotherapy, hormones, and/or immunotherapy. Each year, the American Cancer Society estimates the number of new cancer cases and deaths expected in the United States in the current year and compiles the most recent data on cancer incidence, mortality, and survival using data from the National Cancer Institute (NCI) and using mortality data from the National Center for Health Statistics. Incidence and death rates are age standardized to the 2000 standard million population in the United States. In 2005, 1,372,910 new cases of cancer and 570,280 cancer-related deaths were expected in the United States. When deaths are aggregated by age, cancer has surpassed heart disease as the leading cause of death for persons younger than 85 since 1999. When adjusted to delayed reporting, incidences of cancer stabilized in men from 1995 through 2001 but continued to increase by 0.3% per year from 1987 through 2001 in women. The death rate from all cancers combined has decreased by 1.5% per year since 1993 among men and by 0.8% per year since 1992 among women. Mortality rates have also continued to decrease for 3 most common cancers in men (lung and bronchus, colon and rectum, and prostate) and for breast and colorectal cancers in women. Application of existing knowledge about cancer control across all segments of the population has accelerated these declines. The relative 5-year survival rate related to the common cancers and to all cancers combined is currently 64% and has notably improved in both whites and African Americans. Cancer sites for which survival has not improved substantially over the last 25 years include the uterine corpus, uterine cervix, larynx, liver, lung, pancreas, stomach, and esophagus. Neoplastic disease can develop in virtually any organ system. This unregulated growth injures and compromises organ systems that are functioning normally. Cancer-related diseases are often treated with therapeutic modalities that, in themselves, compromise normally functioning organ systems. As a consequence, PM&R practitioners must dynamically respond both to disease progression and to effects of various treatments that may contribute to impairment, disability, and handicap. The rehabilitation approach to the treatment of cancer originated with the National Cancer Act of 1971. This legislation declared cancer rehabilitation as an objective and directed funds to the development of training programs and research projects. In 1972, the NCI sponsored the National Cancer Rehabilitation Planning Conference. This conference identified 4 objectives in rehabilitation of patients with cancer:
In the 1970s, a number of models for cancer rehabilitation were initiated and supported through the NCI cancer-control program. Cancer rehabilitation can be defined as a process that assists the cancer patient to obtain maximal physical, social, psychological, and vocational functioning within the limits created by the disease and its resulting treatment. For excellent patient education resources, visit eMedicine's Cancer and Tumors Center and Women's Health Center. Also, see eMedicine's patient education articles, Bladder Cancer, Brain Cancer, Breast Cancer, Mastectomy, and Ovarian Cancer. Multidisciplinary approach to rehabilitationRehabilitation specialists have proposed several general principles regarding rehabilitation interventions for patients with cancer. Rehabilitation requires an interdisciplinary team approach because of the variety of potential problems patients may face during the course of illness. The availability of professionals from major disciplines is essential to offering comprehensive care. The patient's needs determine the team members involved. Over the last 3 decades, collaboration between PM&R and the specialty of cancer medicine (ie, oncology) has been growing. The healthcare team must develop rehabilitation goals within the limitations of the patient's illness, environment, and social support. Goals must be objective, realistic, and attainable in a reasonable time to demonstrate gains from active participation in therapy and thereby maintain the patient's motivation. Patients, family members, and significant others must be active participants in the rehabilitation process. Patient and family involvement assists in goal setting. Interdisciplinary rehabilitation is the collaborative effort of professional members of the team working with the patient and of an accompanying support network. The rehabilitation team must provide services to patients throughout the course of illness, during all stages. Treatment plans must be individualized to meet each patient's unique and specific needs. Physicians Professional clinicians composing the interdisciplinary team include physicians from several specialties. Primary care physicians, surgeons, radiation oncologists, and medical oncologists make active and concurrent contributions to rehabilitation efforts to manage the disease process. The physiatrist, a specialist in PM&R, treats neuromuscular disease, musculoskeletal disease, and functional deficits, in addition to performing electrodiagnostic procedures (eg, nerve conduction studies [NCS], electromyography [EMG]). The physiatrist also prescribes treatments performed by professionals from other disciplines, such as physical, occupational, and speech therapists. The physiatrist serves as liaison among team members, providing a considerable degree of coordination, especially when rehabilitation and clinical management of the disease are simultaneous. Care coordinator, or case manager The clinical-care coordinator assists in organizing and managing the team. An important aspect of this role is initially evaluating patients referred to the rehabilitation team for consultation. Care coordinators may be nurses, social workers, or professionals in other rehabilitation-related fields. They must be familiar with the functions of team members from other disciplines to assess the patient's needs effectively. Oncology and/or rehabilitation nurse The role of the oncology and/or rehabilitation nurse is pivotal in cancer rehabilitation. The oncology or rehabilitation nurse typically functions as an extension of other members of the team because he or she frequently assists with treatment interventions that the physical, occupational, or speech therapists begins. Such interventions include assisting patients with exercises, mobility on the unit, self-care activities, and speech and swallowing techniques. Because nurses typically have extensive contact with patients and families, they may be most aware of the family's emotional stress and adjustment issues. Nurses sometimes function as counselors, providing substantial emotional support to patients and their families. In addition to active involvement with representatives of most other disciplines participating in the treatment interventions, nurses are responsible for skin care, bowel and bladder management, and patient and family education. Cancer rehabilitation nurses are crucial in promoting the goal of maintaining optimal independent functioning. Social worker The role of the social worker can vary substantially, depending on the medical institution. Social workers often provide counseling to patients and families regarding emotional support, community resources, finances, lifestyle changes, and their participation in treatment. In some settings, social workers lead support groups and actively assist in discharge-planning activities, such as for arranging home-care services and for transfer to other healthcare settings. Psychologist Patients and their families often have a number of psychological and adjustment issues related to the illness, its treatment, and its resulting disabilities. The psychologist assesses and treats patients to help them manage their cancer-related psychological distress. As a member of the rehabilitation team, the psychologist assists other team members when psychological issues, either in patients or their family members, complicate efforts to provide effective therapy. The goal of consulting the psychologist is to maximize the benefit the patient derives from rehabilitation. Physical therapist The role of the physical therapist includes evaluation of the patient's muscle strength, mobility, and joint range of motion (ROM). Treatment interventions the physical therapist provides may include therapeutic exercises to maintain or increase ROM, endurance activities, and mobility training (eg, transfers, gait, stair climbing). Physical therapists can also administer various therapeutic modalities depending on the needs of the individual patient. Examples of modalities that may be beneficial include the application of heat and/or cold, electrical stimulation, hydrotherapy, traction, and massage. Occupational therapist Occupational therapists evaluate patients' ability to carry out tasks related to self-care, including activities of daily living (ADLs), such as dressing, bathing, meal preparation, and homemaking. These professionals also assist patients to increase ability to perform ADLs, including the use of compensatory techniques and adaptive equipment. In addition, occupational therapists evaluate home environments for potential modification, and they provide instruction in driving with adaptive devices. Furthermore, they implement interventions to promote upper-extremity ROM, strength, endurance, and coordination. Dietitian Diet and nutrition are important factors in cancer rehabilitation. A healthy diet and adequate nutrition substantially influence the patient's ability to actively participate in an applied therapy program and are essential for radiation therapy and chemotherapy. The role of the dietitian is to evaluate the patient's current nutritional status and to provide recommendations regarding his or her specific dietary needs. Patients with cancer often require dietary supplements and alternative foods. Dietitians also assist in teaching patients and family members about the importance of appropriate diet in successful rehabilitation. Speech therapist The speech therapist evaluates and treats communication deficits, dysphagia, and cognitive dysfunction in patients with cancer. Speech therapists also train patients in alternative means of speech and communication, including the use of a prosthetic larynx, adaptive communication devices, laryngeal speech, and esophageal speech. The treatment of patients with oral defects or aphasia also falls within the purview of the speech therapist. This therapist also treats swallowing deficits that result from illness or treatment. Vocational counselor Vocational counselors assist patients in adapting to the effect of cancer and its treatment on their employment. Vocational counselors evaluate the patient's suitability for employment and for training, if needed, and they serve as liaison between patients and their employers. Healthcare professionals often overlook the effect of cancer on the patient's vocation as an area requiring possible intervention. Others Although the professionals mentioned above are the most common members of the cancer rehabilitation team, practitioners from many other fields also provide important and valuable advice. These include a chaplain, a dentist, an orthotist, and a prosthetist. In addition, rehabilitation programs benefit from consultative relationships with other care-providing organizations (eg, home healthcare agencies, community hospices). After initial screening, representatives from other disciplines conduct clinical assessments based on the patient's present needs and/or those the care coordinator identifies. Paradigms of cancer rehabilitationDietz (1981) identified 4 categories of cancer rehabilitation that address the scope and course of the illness. A variety of approaches to rehabilitation of the patient with cancer are described below. Preventive interventions Preventive (or "preventative") interventions lessen the effect of expected disabilities and emphasize patient education. Preventive measures also include approaches to improving the patient's physical functioning and general health status. In addition, psychological counseling before treatment can assist with the early identification of adjustment issues to allow for prompt intervention. Restorative interventions Restorative interventions are procedures that attempt to return patients to previous levels of physical, psychological, social, and vocational functioning. Postoperative ROM exercises for patients undergoing mastectomy and reconstructive surgery for head and neck cancer represent this category of interventions. Supportive interventions Supportive rehabilitation is designed to teach patients to accommodate their disabilities and to minimize debilitating changes from ongoing disease. Supportive efforts include teaching patients how to use prosthetic devices after amputation, as well as instructing the patient on use of other devices and procedures that assist in self-management, self-care abilities, and independent functioning. Other supportive efforts include provision of emotional support associated with adjustment issues while the patient is learning to cope with physical lifestyle changes. Palliative interventions During the palliative phase, when increasing disability and advanced disease process may be present, interventions and goals focus on minimizing or eliminating complications and providing comfort and support. Palliative goals include pain control, prevention of contractures and pressure sores, prevention of unnecessary deterioration from inactivity, and psychological support for the patient and family members. Studies in cancer rehabilitationCharacteristics of patients needing rehabilitation Lehman et al in 1978 were among the first authors to investigate the frequency of problems that cancer patients encounter in rehabilitation programs. They screened 805 patients with cancer, as well as psychological and physical problems. A variety of cancers, including leukemia and cancers of the head and neck, breast, respiratory, nervous system, bladder, and bone, had been diagnosed. More than 50% of patients had problems associated with physical medicine, with a substantial portion having problems similar to those of other patients undergoing rehabilitation. Much of the population had evidence of psychological problems. Psychological problems were more prevalent in patients with physical problems than in those without physical involvement. More than 50% of patients with physical involvement had psychological problems, and approximately 29% of patients without physical involvement had psychological difficulties. In patients with cancer of the nervous system, the incidence of psychological problems was higher than that in individuals with cancer at other sites. The investigators concluded that many patients with cancer have coexisting physical-medicine and psychological problems and that many of these patients may benefit from rehabilitation interventions because their problems are similar to those identified in many other patient populations undergoing rehabilitation. Ganz surveyed 500 patients with colorectal, lung, and/or prostate cancer and found that the typical patient had been living with the disease for more than 3 years. More than 80% of the sample reported problems with ambulation and, for more than 50%, the problems were severe. In addition, patients with cancer (41% with colorectal cancer, 69% with lung cancer, and 40% with prostate cancer) reported difficulty with performing ADLs. Physical problems occurred in a relatively functional sample of patients with average Karnofsky performance status (KPS) scores of 80%. More than 40% of each group had no evidence of active disease. Psychosocial problems varied widely among patients who survive longer than 1 year after their cancer was diagnosed. Needs of patients needing rehabilitation Movsas et al (2003) confirmed the findings described above. They examined the rehabilitation needs of patients in a different manner in an acute medical setting. Many patients with cancer had easily remediable but unrecognized rehabilitation problems, such as deconditioning, which indicated the importance of interdisciplinary efforts to preserve patient function. An important finding was that rehabilitation was underused in the population studied. Reasons for underuse may include the failure of the acute care staff to identify functional impairments, lack of appropriate referral for rehabilitation, lack of awareness of rehabilitation services, and lack of knowledge among family members. These barriers can be overcome by providing education and by enlisting the cooperation of the clinical oncology staff, whose background in rehabilitation and functional issues may be limited or underemphasized. Of importance, all practitioners must keep in mind that, after the patient's condition is stabilized and after he or she is discharged from the hospital, PM&R services must be considered on an outpatient or home-based basis to maintain gains and to prevent further deconditioning. At present, the vast majority of patients are never referred for rehabilitation follow-up after discharge. Quality of life VanHarten et al devised a questionnaire to address patients' need to receive professional care related to health problems. Although 258 patients with cancer were invited to participate, only 147 completed the study. The sample consisted of patients with nonmetastatic breast and colon cancer who were living in the community. For all quality-of-life (QOL) factors, patients could indicate whether they felt need for professional care to contend with cancer-related health problems; 26.5% of patients indicated a need for such healthcare. Overall, QOL scores were relatively high. Performance of expected roles and mobility were notable problems in 26% of patients. Other patients reported that fatigue and deconditioning interfered with their functional performance and mobility. Psychological integration of the new situation into personal relations and coping with daily life were also problematic. As a result of their survey, VanHarten et al proposed a community pilot program for patients with cancer. Components of the program included the following:
In a prospective observational study, Van Weert et al (2004) examined 34 patients with cancer-related physical and psychosocial problems. Their 6-week, intensive, multifocal rehabilitation program consisted of 4 components: individual exercise, sports, psychoeducation, and information. Measurements were performed before and after 6 weeks of rehabilitation to assess symptom-limited bicycle ergometry performance, muscle force, and QOL (on the RAND-36 instrument, Rotterdam Symptom Checklist [RSCL], and Multidimensional Fatigue Inventory [MFI]). Statistically significant improvements were found in symptom-limited bicycle ergometry performance, muscle force, and several domains of the QOL instruments (RAND-36, RSCL, and MFI). The rehabilitation program had immediate benefits on physiological variables, QOL, and fatigue. A reliable and valid assessment tool is vital for the rehabilitation team to gauge the patient's status before, during, and after the program, as well as on follow-up evaluation. Such an instrument allows each clinician to determine reasonable short- and long-term goals for the patient. Oncologists were the first practitioners to assess and survey QOL in patients with cancer after the advent of chemotherapy. In the late 1940s, Karnofsky and Buchrenal developed a clinical scale to quantify functional performance in patients with cancer. Since then, a number of programs intended to ensure QOL have been developed, modified, and used. Key elements in any QOL intervention or in ascertaining the patient's overall status in a given clinical situation include the following:
QOL instruments clinicians currently in cancer treatment in rehabilitation include the following:
Purpose and emphasis of rehabilitation The purpose of rehabilitation for patients with cancer is similar to that for patients with other diseases. However, the pathology of the tumor, the anticipated progression of disease, and any associated treatments must be considered carefully when goals are formed. When tumor progression and treatment causes a functional decline or when the disease causes a fluctuation in abilities, rehabilitation assumes a supportive role, and its goals are adjusted to accommodate the patient's persistent anatomic and physiologic limitation. Thorough assessment of impairments, disabilities, and handicaps is paramount before the team proceeds with rehabilitation. Emphasis is initially placed on restoring or maximizing independence with ADLs, mobility, cognition and communication. Issues of survivorship and community reintegration, including return to work, follow. BREAST CANCER AND REHABILITATIONSection 3 of 11
IntroductionBreast cancer can occur in any adult. Incidences have been increasing over the last decades for both premenopausal and postmenopausal women. Although the incidence of breast cancer increases during postmenopausal years, it is the leading cause of cancer death in women younger than 50 years. Age is not a predictor of complications, but it may affect the patient's outcome, ability to cope, and extent of psychological distress. Breast cancer is the most frequent cancer in women, and more than 85% of patients are alive 5 years after diagnosis. For these reasons, more than 700,000 survivors of breast cancer in the United States are alive within 5 years of diagnosis; their total prevalence is over 2 million. Burstein and Weiner (2000) wrote an excellent review of survivorship issues for women with breast cancer. Treatment optionsOverview On initial presentation, clinical and pathologic staging is performed to identify prognostic factors and to determine treatment options. Surgery and/or radiation therapy is used for local control and often successful in early-stage breast cancer. If they are smaller than 5 cm and limited to the breast and axillary nodes, most such cancers may be treated surgically with modified radical mastectomy or breast-conserving surgery. In both cases, the axilla is usually dissected. Disease-free survival rates are equal in patients undergoing mastectomy and breast-conservation surgery. Locally advanced breast cancers are treated with modified radical mastectomy, preceded or followed by chemotherapy. Irradiation of the chest wall is often considered when the risk of chest-wall or nodal recurrence is high, when primary tumors are large or multicentric, or when 4 or more axillary nodes contain metastatic cancer. Systemic therapy (ie, chemotherapy and/or hormonal therapy) is recommended for patients who present with metastatic disease or who have risk factors for metastases. Risk factors for metastatic cancer include age younger than 35 years, positive involvement of the lymph nodes, high-grade histologies, negative estrogen receptors, large tumor, high growth fraction, aneuploid DNA content, and other biologic markers. Chemotherapy may be administered before, during, or after irradiation with parameters of timing and duration depending on the type of chemotherapy. Estrogen and progesterone receptors can be assessed to predict the patient's response to hormonal manipulation. Tamoxifen had been the first-line adjunct hormonal therapy and was started during or after radiation therapy. Hormonal manipulation for the treatment of metastatic breast cancer may include the administration of tamoxifen. However, results of the Arimidex, Tamoxifen, Alone or in Combination (ATAC) trial suggested that an aromatase inhibitor is therapeutically superior and better tolerated than tamoxifen in postmenopausal women with primary breast cancer. Aromatase is expressed in nonovarian tissues, such as muscle and fat in both premenopausal and postmenopausal women. These nonovarian tissues become the dominant sources of estrogen in postmenopausal women. At present, the available aromatase inhibitors belong to 1 of 2 classes. Class I inhibitors irreversibly bind aromatase and have a steroidal structure (eg, exemestane). Class II agents reversibly bind aromatase and are nonsteroidal (eg, anastrozole and letrozole). Because of the specificity of its mode of action, this class of compound is well tolerated and thus lends itself to the management of both early- and advanced-stage disease. In metastatic breast cancer, radiation therapy is often successful in palliating symptoms from painful bony sites, brain metastases, or other metastatic sites causing symptoms or obstruction. Metastatic breast cancer rarely is curable; however, studies are underway investigating efficacy of high-dose chemotherapy followed by peripheral stem-cell rescue of bone marrow to eradicate metastatic cancer. Current issues in breast-cancer management Current issues in breast-cancer management include the following:
Surgery and its acute and chronic morbidityBreast-conserving surgery is increasingly used for many breast cancers because disease-free survival rates are equal for women undergoing either this procedure or non–breast-conserving surgery. Breast-conserving surgery is associated with improved body image and, perhaps, hastened psychological recovery. Breast-conserving surgery refers to removal of the cancer along with a margin of normal breast tissue and axillary dissection. In breast-preservation surgery, wide excision implies the removal of a 1- 2-cm margin of normal tissue, whereas in segmental mastectomy, even more normal breast tissue than this is removed. A relatively uncommon surgical procedure is quadrantectomy. This is a procedure to remove the quadrant of the breast that contains the tumor plus the underlying pectoral fascia. Any increase in the extent of surgery is associated with increased risk of both early and late complications. Most reported surgical complications are associated with axillary dissection. Debate still surrounds issues of whether axillary dissection is necessary and, if so, which parameters should be used to determine its extent. Principles of wound healing directly affect the initiation and appropriate intensity of any rehabilitation program. Wound healing is a dynamic process that lasts months to years. Wounds initially produce inflammation that lasts a few days unless necrosis, infection, or foreign bodies are present. At the edge of an epithelial wound, basal epithelial cells migrate across the defect on fibrin strands. Epithelial cells cover the wound within 48 hours and thereafter begin to differentiate and keratinize. Fibroblasts, from the adventitia of blood vessels, migrate into the wound on fibrin strands on day 3 and begin to synthesize collagen fibers, which begin to appear on day 4. Wound strength is related to the rate of collagen formation. By 3 weeks, most wounds achieve 15% of their ultimate strength. Strength increases at a constant rate for 4 months and then at a lower rate thereafter for more than a year. Pain at the wound site generally limits the amount of stress an individual can place on the wound. Changes in sensation are common; therefore, wounds should be treated gingerly. Because external skin sutures may provide a nidus for infection and cause extra scarring, remove them early. Factors that may impede healing include malnutrition (more common in elderly individuals than in younger patients); deficiencies of vitamin A, vitamin C, and zinc; cigarette smoking; and any conditions that decrease tissue oxygenation. Steroid use, radiation therapy, and some chemotherapy agents impede healing. The administration of doxorubicin (Adriamycin), which commonly used in adjunct chemotherapy programs, should be delayed until 4 weeks after surgery. Early complications after mastectomy include seroma formation (10%), wound infection (7%), and skin-flap necrosis (5%). The fewest wound infections are seen when diagnoses are made by means of fine-needle aspiration. Immediate reconstruction is not associated with an increased rate of complications. Most surgeons agree that a drain must be placed after axillary dissection. The duration of drainage is not standard, but most surgeons agree that the drain can be removed when the volume of fluid draining from the wound decreases to less than 20 mL/day. The presence of a drain or a seroma can lead to infection. If seroma develops after the drain is removed, most surgeons aspirate the seroma only if the patient is uncomfortable. Do not place a drain in a lumpectomy site because cosmesis diminishes. Complications associated with axillary dissection are secondary to nerve, vascular, and lymphatic injury. The most common complaints after axillary dissection are reduced sensation under the right arm and decreased ROM of the shoulder. Sensory deficit improves with time but may never return to normal. No known treatment exists for this adverse effect. Lymphedema can be seen immediately after surgery and results in a small increase in diameter in the upper arm only. Collateral circulation should resolve the edema within several weeks. Chronic lymphedema and its treatment are discussed elsewhere (see the section Management of Lymphedema, below). Injury to the long thoracic nerve results in winging of the scapula. About 30% of patients develop serratus anterior muscle palsy secondary to injury to the long thoracic nerve but appear to recover by 6 months. Injury to the thoracodorsal nerve causes slight weakness in internal rotation and abduction of the shoulder from weakness of the latissimus dorsi muscle. Injury of the medial pectoral nerve results in atrophy of the lateral portion of the pectoralis major muscle. Injury to the intercostobrachial nerve results in reduced sensation along the medial aspect of the arm, and, in some patients, subsequent disabling neuralgia develops. Breast reconstructionIntuition suggests that breast reconstruction offers a woman the opportunity to retain a positive self image, mitigating concern about breast cancer treatment significantly and perhaps even encouraging women to seek earlier diagnosis of breast cancer. However, the psychosocial benefit of reconstruction is only slight when patients who have undergone surgical reconstruction are compared with patients treated with mastectomy alone. Breast-preserving surgery affects body image less than mastectomy and breast reconstructive procedures do. Studies show lower scores for body image in women who have undergone breast reconstruction than in patients who have undergone breast-preserving surgery. This phenomenon may be related to the complicated nature of reconstructive surgery. A cohort analysis of 13,388 women confirmed findings from numerous studies in that breast-augmentation surgery does not increase the risk of breast cancer and does not delay diagnosis. Although breast-reduction surgery is never performed as cancer prophylaxis, it appears to reduce the risk of breast cancer proportionate to the amount of tissue removed. Prophylactic mastectomy has a proven role in reducing the incidence of breast cancer, both among women with a moderate or high-risk family history and among those with proven mutations of BRCA1 or BRCA2. Methods of reconstruction Reconstruction of the breast can be accomplished in several ways at any time after surgery. The type and timing of reconstruction do not affect biologic processes or the detection of breast cancer. For advanced cancers for which irradiation of the chest wall and regional nodes is planned, breast reconstruction should be delayed, but the intention to perform reconstructive surgery does not prevent radiation therapy if unexpected pathologic findings are discovered. The simplest reconstruction consists of placing an expandable saline implant under the pectoralis muscle in the musculofascial layer and stretching the tissues of the chest wall to reduce tightness and firmness of the chest wall. The implant is then replaced with a permanent implant. Saline is instilled into a fill valve at regular intervals over several weeks until the expander is overfilled to 200 mL beyond the volume of the contralateral breast. After the chest wall is stretched to allow for a normal breast contour, a second operation is performed to replace the implant with a shaped prosthesis or to remove the excess fluid and fill valve. Complications include extrusion of the expander, infection, and deflation. Patients complain of chest-wall tightness and asymmetry. The 3 most common of the autologous procedures are the latissimus dorsi muscle flap procedure (performed by using muscles taken from the back), the procedure involving a pedicular transverse rectus abdominus muscle (TRAM flap, sometimes called conventional flap), and the free TRAM flap procedure (sometimes called the microsurgical flap). Both TRAM procedures are performed by using muscle taken from the abdomen. The deep inferior epigastric perforator (DIEP) procedure, and the superior gluteal artery perforator (SGAP) flap procedure are relatively new techniques in which fat and skin without muscle are used for reconstruction. Flap procedures are used to transfer distant tissue with its own blood supply. Muscle and skin can be transplanted from the back (latissimus dorsi flap), abdomen (transabdominal rectus or TRAM flap), or buttocks (gluteus flap), and a microvasculature anastomosis is performed. The TRAM flap has become the flap of choice because of the volume of tissue that can be moved. However, cigarette smoking, diabetes mellitus, and obesity are relative contraindications because of decreased microcirculation. When the irradiated chest wall is reconstructed, the TRAM flap is preferred because of its vascularization. The pedicle TRAM flap procedure requires the entire rectus abdominis muscle for construction of a new breast. The surgeon rotates the muscle, pulls it up through a previously constructed tunnel in the chest, pockets it out, and molds it into a breast. Blood supply from the superior epigastric artery and vein remain intact at their source, and they are pulled up with the muscle. The free TRAM flap procedure requires only a portion of the rectus abdominis muscle. The surgeon fully removes a portion of the muscle from the donor site, with blood supply intact from the deep inferior epigastric vein and artery, and reattaches it to the chest wall to reconstruct the breast. The surgeon then connects the tiny vessels to recipient vessels, most often the thoracodorsal artery and vein in the axilla near the new breast, in a separate microvascular procedure. The free TRAM flap surgery is not performed as often as other procedures in women who choose breast reconstruction after mastectomy (only 5% of reconstructions involve this procedure). However, it is a highly satisfactory option for the right candidates, and, in some cases, it may be the most logical choice. Postprocedural care The patient or her caregiver at home must be able to empty any remaining surgical drains and record amounts of drainage. The surgeon usually orders removal of a drain when it has less than 25 mL of output in 24 hours. Drainage from the incisions should be absent or minimal. However, for the first 2-3 days after drain removal, a small amount of serosanguineous drainage from the exit sites is normal. Abnormal drainage is foul smelling and saturates a 4 X 4-in gauze. After the drain is removed, a small piece of gauze may be placed over the drain exit, but the supportive bra should hold it in place. Tape should not be used on the reconstructed breast. For the first few weeks, showering should replace bathing in a tub. Binding: Instruct patients in the use of a supportive bra without underwires in the hospital, usually a day after surgery. Some patients may desire an abdominal binder in addition to the supportive bra. Smoking: Avoidance of smoking is especially important during the first few weeks of vascular and tissue healing. Also, avoidance of smoking at least 4 weeks before surgery reduces complications, such as flap necrosis and hernia after surgery. Exercise: Encourage women after mastectomy to perform arm abduction and reaching exercises; however, advise patients to avoid these exercises after free TRAM flap surgery. The patient may be limited to lifting no more than 10-lbs. for 4-6 weeks, and the patient should keep her affected arm below the height of her shoulder for 2 weeks. However, encourage use of the arm in front of the body (as in washing the face or eating) to prevent stiffening of the joints. Some patients benefit from physical therapy (PT) to strengthen the abdominal muscle after TRAM flap surgery. If a TRAM flap reconstruction is planned, address rehabilitation issues, and preoperatively counsel the patient about the need for a program to address back and shoulder strengthening. Decreased trunk flexion and extension strength also result from the surgery. PT focuses on strengthening exercises and compensatory movements for most patients, particularly for individuals with chronic spinal pain. Other types of reconstruction are associated with discomfort related both to loss of tissue from their respective areas and to the actual surgical procedure. The latissimus dorsi flap procedure is less complicated than other reconstructive procedures, but an implant is required for adequate cosmesis. The most common complication is seroma formation. No functional loss of shoulder strength is observed. A gluteus maximus flap is both less painful and less morbid than a TRAM flap, but it is more technically demanding. A nipple can be constructed in all types of reconstruction by puckering skin and tattooing an areola, or by grafting skin into a nipple site and tattooing. Avoid grafts on irradiated skin. Shoulder and arm rehabilitationThe goal of arm and shoulder exercises is to enable the patient to return to normal activity after axillary dissection. At 3 or 15 months after surgery, approximately 80% of patients continue to report at least 1 problem. Problems may include swelling (25%), weakness (25%), limited ROM (30%), stiffness (40%), pain (50%), and/or numbness (55%). Increasing numbers of complaints are associated with high levels of psychological distress. In the optimal situation, preoperatively evaluate the patient for strength, ROM, sensation, posture, endurance, and general functional ability. Instruct the patient regarding ROM exercises, postoperative breathing, and initial mobility after surgery. Start shoulder and arm rehabilitation as soon as the surgical incision appears healed and recurrent seroma or infection is absent; remember the principles of wound healing. Early PT to the shoulder after axillary dissection does not increase the incidence of lymphedema. The development of seromas is most prevalent with extensive surgeries. Encourage the patient to begin gradual stretching exercises for all degrees of motion within a few days of surgery. The optimal program starts postoperatively with gentle ROM exercises of the shoulder from 45-90° in patients without reconstruction. PROM should start to 90° of flexion and abduction with external and internal rotation as tolerated. Early mobilization of the glenohumeral joint improves shoulder ROM. Recovery was faster in patients who began shoulder flexion to 40° on day 1 and 90° on day 4 than in those who had a delayed start of ROM exercises. Methods to compensate for nerve injury improve muscle strength and prevent shoulder tightness and discomfort. Patients should begin full shoulder and arm ROM exercises as soon as the surgeon deems them safe, often after the drains are removed. Active and active-assistive exercises can be increased at this stage. Exercises, such as wall climbing, and use of pulley or wand, should be added. After all sutures are removed, exercises more aggressive than these can be incorporated. Physical modalities may be helpful. Use ultrasound with caution, given its potential risks of promoting residual tumor cell growth or metastasis. Include stretching exercises and electrical stimulation as part of the rehabilitation program. Patients treated with mastectomy are more likely than patients receiving breast-conserving surgery to have impaired mobility. Prospective studies demonstrate that patients who receive structured PT achieve arm and shoulder function better than the function of those who do not receive such PT. A home exercise program should be implemented, and follow-up PT assessment should be included. Massaging of scars is usually incorporated into this program around 1 month after surgery. With radiation treatment, ongoing ROM exercises are particularly important to prevent contracture formation. Discuss lymphedema precautions with the patient before surgery, and review her condition within several days of surgery. When resting, the patient should elevate her arm higher than her heart but not over her head. Exercises using the forearm and hand should be performed immediately to help muscular propulsion of blood and lymph fluid from the lower arm. Encourage the patient to squeeze a tennis ball or other soft ball when resting. Advise the patient not to lie on her arm in the ipsilateral decubitus position and to avoid a prone position. Discuss the effects of skin or soft tissue infections on the development of arm edema, the effect of gravity on lymph drainage, the importance of avoiding procedures on the arm that may break the skin, and the type of exercises that can improve muscle tone in the arm. Encourage the patient to be aware of the importance of weight management because edema of the arm is associated with weight gain. Advise the patient to seek medical help immediately if signs of erythema or swelling occur. Many physicians prescribe antibiotics for acute edema. Radiation therapy and its consequencesUse of radiation therapy after breast-preserving surgery is common to reduce the probability of recurrence in the breast and after mastectomy, when the risk of recurrence in the chest wall is high. The breast is treated with tangential techniques that also include irradiation of the underlying muscle, rib, and anterior surface of the lung. After mastectomy, the chest wall is treated with similar techniques, but radiation is delivered after subcutaneous tissue is damaged by production of skin flaps. The supraclavicular, axillary, and sometimes internal mammary nodes are irradiated when the risk of nodal recurrence is high. Direct anterior fields are used to treat increased volumes of rib and lung tissue. The brachial plexus is often in the node fields, but damage is uncommon with standard doses. Irradiation of the axillary nodes is associated with an increased risk of lymphedema; avoid it unless the risk of recurrence in the axillary nodes is clinically significant. Irradiation exaggerates the effects of surgery. Fibrosis secondary to radiation in the treatment field may cause the following effects:
Soft tissue infections, cigarette smoking, and diseases that may impair microcirculation (eg, diabetes, arteriosclerotic vessel disease) increase the probability of fibrosis. Exercise and manual massage may decrease pain and discomfort associated with fibrosis. Ointments to treat dry skin may relieve dryness and itching. Breast edema is an adverse effect unique to breast preservation and related to the extent of axillary dissection, the location and extent of breast surgery, and the size of the breast. Weight gain may aggravate breast edema. Breast edema resolves with time, but weight loss, proper breast support, and avoidance of prone sleeping position may help. Development of late breast edema is uncommon and may represent infection or recurrent cancer. If volumes of lung tissue greater than 10% are included in the radiation fields, the patient may develop cough, shortness of breath, and low-grade fever 4-12 weeks after radiation. The physician must rule out an infectious source. Chemotherapy increases the risk of pneumonitis. Temporary, low-dose steroids may relieve symptoms of radiation pneumonitis, and antibiotics are often added empirically. Acute radiation pneumonitis resolves in 2-3 months and is not predictive of long-term pulmonary insufficiency. About 10% of lung volume must be treated to observe pneumonitis. Always compare chest radiographs with radiation portal images to confirm the etiology of the disease process. Most patients have subclinical effects of the lung. In most patients, the diffusing capacity of carbon monoxide decreases but returns to normal levels by 24 months. However, patients who smoke cigarettes have greater deficit and less recovery than those who do not smoke. Cigarette smoking affects the tolerance of the lung to radiation; therefore, encourage patients to stop smoking. Permanent injury to the lung because of interstitial fibrosis is localized to only the radiation field and can be identified on lung radiographs. Long-term effects of lung fibrosis are related to the volume of irradiated lung and to the patient's pulmonary status before irradiation. Radiation-induced brachial plexopathy is characterized by shoulder discomfort and progressive paresthesias and weakness in the arm and hand. About 1% of patients who receive nodal irradiation with doses greater than 50 Gy and who are usually treated with chemotherapy develop problems. If doses are limited to 50 Gy, symptoms are generally transient. Symptoms develop 3-14 months after irradiation and commonly affect the distribution of the lower plexus. Progressive neurologic dysfunction of the brachial plexus is associated with radiation fibrosis because of large fractions. The prevalence of pain, in addition to paresthesias of the hand and proximal arm weakness, may be increased. Weakness in the distribution of the upper plexus is most common. Associated arm edema secondary to irradiation is often noted. No treatment, other than symptomatic management, is known. However, cancerous infiltration of the brachial plexus can mimic these symptoms and must be ruled out. Women treated with direct fields to the left side of the chest may have increased incidence of arteriosclerotic heart disease and, consequently, of myocardial infarctions. Women often become menopausal as a result of estrogen deprivation; this development may add to incidence of cardiovascular disease. Discuss the benefits of diet, exercise, hypertension treatment, and treatment of cholesterolemia with any patient with breast cancer, but the importance of this step is most obvious in patients treated with irradiation and chemotherapy. Hormonal treatmentTamoxifen or aromatase inhibitors are commonly prescribed for women with hormone receptors positive for estrogen whose cancers are larger than 1 cm. Many premenopausal women receive tamoxifen after chemotherapy, whereas many postmenopausal women with large tumors or positive nodes receive it as single-agent adjunct therapy. Tamoxifen may be prescribed for a minimum of 5 years. In addition to the antitumoral effect, other benefits of tamoxifen may include reduced bone loss and an improved lipid profile. Tamoxifen often exaggerates symptoms of estrogen deprivation, with hot flashes (50-60%), depression (10%), weight gain, and vaginal dryness as common complaints. Examine patients annually because of a possible risk of endometrial carcinoma secondary to tamoxifen. The aromatase inhibitors have equal efficacy and a slightly improved adverse-effect profile. Chemotherapy and its consequencesIn the adjunct setting, chemotherapy is usually administered in 4-6 cycles of 3-4 weeks. Preconceived notions, often incorrect, can affect a woman's attitude toward chemotherapy. The clinician must anticipate these concerns, particularly nausea, hair loss, and lifestyle changes, when introducing the topic of chemotherapy. Immediate effects of chemotherapy include general fatigue, as well as nausea and vomiting, which are effectively countered with medication, including prochlorperazine, lorazepam, ondansetron, and granisetron. Patients often gain weight because food may relieve nausea, and their basic metabolic rate may decrease. Fatigue can be overwhelming and affect exercise and activity levels. Work and family issues may be important during chemotherapy because treatment can last for many months. During therapy, many women have a diminished immune status, which puts them at risk for infection. These periods are short, but some women require increased intervals between chemotherapy cycles or use of growth factors, which are associated with their own adverse effects. Prolongation of chemotherapy may be devastating for many women who have planned for periods of disability for a certain length, who are limited in their sick absences from work, or who must rely on childcare. In general, these women should avoid being around children with the usual childhood diseases (eg, chickenpox). Chemotherapy may render women, generally those in their late 30s or 40s, menopausal. The incidence of premature ovarian failure is about 70%, but it is lower than this in women younger than 30 years. The most common severe late effect of doxorubicin (Adriamycin) chemotherapy is cardiomyopathy, occurring in less than 1% of women with a total cumulative dose of 300 mg/m2. A previously active young woman may become dyspneic on exertion. Appropriate consultations with a cardiologist and staff from cardiac rehabilitation programs may improve the performance status of women made symptomatic by therapy. Another serious adverse effect of chemotherapy is an increased risk of leukemia, which is related to dose and type of alkylating agent (incidence of 0.7% at 10 y); this risk may increase with adjunct radiation. Current data suggest that the risk of leukemia is minimal with regimens containing cyclophosphamide that are used today. Nonetheless, the use of adjuvant chemotherapy clearly benefits women with early breast cancer. A meta-analysis of randomized trials of adjuvant prolonged polychemotherapy in women with early breast cancer demonstrated that, in terms of survival advantage, relatively short regimens of approximately 3-6 months were as effective as the longer chemotherapy regimens. Polychemotherapy provided an absolute improvement of 7-11% in 10-year survival among women younger than 50 years at presentation; for women 50-69 years of age, the absolute improvement in 10-year survival was 2-3%. Anthracycline-containing regimens were slightly more active than the previous standard combination chemotherapy of cyclophosphamide, methotrexate and 5-fluorouracil (CMF), with the former producing a moderate improvement over the latter with respect to the percentage of patients surviving and being disease-free after 5 years. The benefit of anthracycline-containing regimens is particularly evident in premenopausal patients, and increasing evidence suggests that 6 or more cycles of the 3 drug regimens are more effective than the 4 cycles of doxorubicin and cyclophosphamide (ie, Adriamycin and cyclophosphamide [AC]) that has recently become popular. Taxanes, such as paclitaxel, have promising activity in patients with node-positive primary breast cancer. Preliminary results from a large, multicenter study showed that patients treated with AC followed by paclitaxel had a significantly better disease-free survival and overall survival than patients treated with only AC. Moreover, the addition of paclitaxel to AC was well tolerated. Further results from this trial are awaited with interest, particularly because preliminary results from other studies have not yet confirmed these findings. Encourage women to be active and to seek support. Evidence suggests that participating in support groups or having a confidant increase probability of survival. Continuation of regular activities during chemotherapy is beneficial. In 1 study, 41% of women found that treatment was easier than expected. By focusing on delayed benefits of chemotherapy (ie, survival issues), women can cope with short-term adverse psychological effects. In some professions, women are not allowed to continue working during therapy (eg, firefighter, airline pilot), and they are placed on medical disability. The Americans with Disabilities Act (ADA) protects women with breast cancer from workplace discrimination in most settings. The Family Medical Leave Act (FMLA) also requires flexibility in scheduling for patients and family members to accommodate treatments. ExerciseFor the general population, the benefits of exercise on weight and on the cardiovascular system are undisputed. Women with breast cancer who participated in aerobic exercise have improved QOL. Obesity is a minor risk factor for breast cancer; it is associated with additional complications of breast-cancer treatment (eg, lymphedema) and is associated with an increased risk of breast-cancer recurrences. Exercise improves the functional capacity of patients with breast cancer who are receiving adjunct chemotherapy. Weight gain is common during chemotherapy and apparently connected with loss in muscle tissue, which may contribute to reduced functional capacity and a lowered metabolic rate during adjunct chemotherapy. Increased lean body weight is observed in patients who exercise while receiving chemotherapy. In animal models, exercise did not induce metastases and was associated with a decreased number of metastases. Exercise also attenuates cachexia in animals. Management of lymphedemaAny dissection of axillary lymphatics and nodes places a woman at risk for edema of the arm. Axillary surgery and irradiation can lead to lymphedema, which may be caused by direct damage to axillary lymphatics. Fibrosis of the axilla secondary to surgery and/or radiation causes venous and lymphatic obstruction by compressing major vascular trunks and blocking regeneration of lymphatic and venous collaterals. Additional radiation therapy, trauma, and infection are other causative factors. Increase in arm circumference immediately after surgery is common and should resolve within weeks. No standardization exists in the literature as to the type and location of measurement and the implications of such measurement. Most clinicians agree that a difference in circumference of more than 2 cm between the arms has clinical significance. Nonetheless, lymphedema may be classified as 1 of 3 stages. The first stage is where pitting is associated with edema and temporarily reduced with elevation of the arm. In the second stage, the edema does not reverse spontaneously. Protein-rich edema persists and can lead to proliferation of connective tissue. With such changes, fibrosis occurs and brawny edema is seen on clinical evolution. In the last stage, lymphostatic elephantiasis, the patient has enormous volume with cartilage-like hardening of dermal tissue along with papillomatous outgrowths. Late arm edema is associated with the patient's age, the extent of cancer in the axilla, the extent of axillary dissection, and the dose and techniques for irradiation. Nearly 33% of patients older than 55 years and 25% of patients in whom more than 15 nodes are dissected develop a difference of 2 cm or greater in the circumference of their arms at 3 years. By comparison, late breast edema is less common after axillary dissection is performed in conjunction with breast-preservation surgery. Therefore, always consider the presence of an infection or recurrent cancer as a possible causes of late edema. Perform medical assessment to determine the cause of swelling. Rule out or treat infection, venous thrombosis, or cancer recurrence. Prescribe antibiotics if the development of edema is acute. Make serial measurements of both arms with the olecranon as the reference point. Assess shoulder, arm, and hand strength; sensory changes; color; turgor; pulses; and mobility. In rare cases, long-standing lymphedema can lead to lymphangiosarcoma, a highly aggressive tumor with poor survival despite forequarter amputation. Conservative management of lymphedema should include preventive and mechanical modalities as needed. Pharmacologic means include antibiotic prophylaxis to prevent and treat cellulitis and lymphangitis. Drugs such as anticoagulants, hyaluronidase, pyridoxine, benzopyrenes and others have been used but have no proven therapeutic value. Preventive care should emphasize identification of patients at highest risk of lymphedema. Comorbid illnesses such as hypertension, heart disease, diabetes and kidney disease can contribute to edema also. Patients should understand lymphatic drainage, the pathology leading to lymphedema, as well as the signs, symptoms, and complications of lymphedema. Self-care instructions include the following:
Complex lymphedema therapy is used to treat peripheral lymphedema. This therapy consists of manual compression, external compressive bandaging, and specific therapy exercises, including manual and massage techniques. Patients and family members should be taught these techniques. Intermittent pneumatic pressure devices are used in the management of lymphedema. However, such devices may be most effective in low-protein venous edema in which fluid is directly forced back into the blood vessels. With lymphedema, such tissue fluid may simply be displaced into an adjacent region. External compression can place increased proximal demands on the existing intact lymphatic system. Pressures over 45 mm Hg may further damage lymphatic structures. With increased pressures, pain and hematomas are common in the involved site. Patients with severe edema required prolonged compressive bandaging and close follow-up with therapists (typically several times a week for at least 3-4 wk). Afterward, results can be maintained with continued bandaging and use of manual techniques at home. A nonelastic bandage may have to be left on in excess of 12 h/d. After the volume of the limb is stabilized, the use of manual techniques and compression garment (often customized) may be sufficient. With exacerbations of lymphedema, use of a nonelastic bandage may be necessary, along with outpatient PT for close supervision. Compression garments are ideally replaced every 3-4 months because they tend to lose their elasticity. Counsel the patient regarding the permanent nature of the condition and how to prevent its progression. Remember that, with increased interstitial protein level, progressive fibrosis and chronic inflammation can ensue. Although treatment is time-consuming, particularly in its initial phases, it is associated with improved body image and function, which increase QOL. Arm swelling has been associated with increased psychiatric morbidity, as reflected by anxiety, depression, and poor adjustment to breast cancer. Consider psychological intervention when lymphedema is obvious to the casual observer. Investigators in the Netherlands recently reported long-term impairments, disabilities, and QOL-related issues. Pain (60%) and reduction of grip strength (40%) were the most frequent impairments. The prevalence of impaired ROM and edema was 9-16% and 15%, respectively. Mean group scores for QOL differed significantly for physical functioning, vitality, and health perception compared with those for a healthy female group. Radiotherapy and chemotherapy were significant factors in the prediction of impaired ROM. Another group of clinical investigators reported their findings in 105 survivors of breast cancer. The patients were interviewed to obtain data about their health and economic changes in the 5 years after diagnosis and initial treatment. An age- and work-matched group of 105 women without cancer were also interviewed. Key changes in functional status and economic outcomes (eg, changes in market earnings, household income, insurance coverage) were measured. Severity of impairment was compared between the study and control groups. Also tested was the adversity of economic outcomes in relation to the women's impairment, regardless of their breast cancer status. The analysis revealed statistically significant evidence in regard to each of the relationship tested. Survivors of breast cancer were more likely than control subjects to be functionally impaired at 5 years, and women with impairment were most likely to have reduced work effort and have downturns in market earnings, among other outcomes. SYSTEMIC EFFECTS OF CANCER-RELATED DECONDITIONINGSection 4 of 11
Injury to organ systemsCancer syndromes, either as a consequence of tumor-induced organ-system injury or of toxic therapeutic interventions, can produce inactivity in the patient. Fatigue and, in advanced conditions, asthenia, cachexia, and anorexia, compound underlying injuries to organ systems. Effects of inactivity contribute to morbidity and mortality by predisposing organ systems to further pathophysiologic risks. Various deleterious effects of inactivity have been documented in both healthy individuals and patients with cancer. Musculoskeletal effects In healthy individuals on complete bed rest, strength declines at a rate of 1-1.5% per day, or about 10% per week. Muscle torque may decline as much as 24% in lower-extremity muscles after 5 weeks of bed rest. Loss of strength is often greater in the proximal lower extremities than in the upper extremities; this outcome leads to impairments when the patient walks or assumes a sitting or standing posture. Muscle shortening occurs in addition to loss of muscle force. Muscle shortening, in conjunction with changes in periarticular and intra-articular tissues, contributes to joint contractures. If local edema and hemorrhage are present, collagen formation escalates, producing tightness of the soft tissue. In the presence of underlying muscle weakness, as might be seen with a lesion of the lower or upper motor neuron, decreased levels of activity add to weakness already present. In these settings, dynamic muscle imbalance further increases the risk of joint contracture. Urinary calcium excretion increases within 2-3 days of bed rest and continues to increase over 4-7 weeks. This hypercalciuria may result from a loss of muscle pull on bony surfaces and eventually leads to disuse osteoporosis. In young individuals, shift of calcium from bone to the circulatory system is heightened and exceeds maximal urinary excretion, sometimes resulting in hypercalcemia. Underlying skeletal metastatic disease or paraneoplastic production of compounds similar to parathyroid hormone (PTH) may place patients at risk for hypercalcemia. In 1 study of subjects on bed rest, 8 hours of sitting and 4 hours of supine exercise per day were insufficient to diminish hypercalciuria, whereas standing 3 hours per day was helpful. Respiratory effects When a person assumes a recumbent position, the diaphragm moves cephalad because pressure from intra-abdominal contents effectively decreases intrathoracic size. Lying down initially increases in pulmonary blood flow as blood redistributes from the lower extremities; however, within 60-90 minutes, pulmonary blood flow returns to baseline or below the level observed when the patient is sitting. Abdominal-muscle activity predominates over rib-cage motion when the patient is lying down, producing a shallow breathing pattern and increasing the respiratory rate. Reduced activity in diaphragmatic and intercostal muscle contributes to weakness of the respiratory musculature, just as inactivity causes weakness in the musculature of the extremities. Reduced rib-cage motion can lead to tightness of the costovertebral and costochondral joints. As a result of these anatomic changes, functional residual capacity declines, and closing volume (point during expiration where the alveoli close), which changes in position do not affect, may increase beyond functional residual capacity, producing atelectasis. Coughing to clear secretions is more difficult in the supine position than in other positions; therefore, pooling of secretions occurs in the dependent portions of the lungs. In the converse, blood flow is greatest to these same lung portions, leading to a ventilation-perfusion (V/O) mismatch and producing arterial hypoxemia. Several factors increase the risk of respiratory complications in patients with cancer compared with the general population. Coughing or taking deep breaths may be painful for the patient with rib metastases or for the patient who has undergone surgical procedures of the chest and abdomen. Lung involvement because of primary tumor, metastatic disease, malignant pleural effusion, or complications of chemotherapy or radiation further contributes to reduced oxygenation, retained secretions, and the risk of pneumonia. Frequent changes in position may improve secretion clearance and V/O mismatch in patients on bed rest. Encourage patients to take deep breaths at regular intervals and to use incentive spirometers and pulmonary resistive exercises. Stretching and strengthening of the trunk and abdominal muscles can help prevent or treat rib cage tightness and weakness. Urinary effects Voiding in a supine position inhibits effective bladder evacuation. Stasis of urine occurs within the renal pelvis, and this urinary stasis, in conjunction with the hypercalciuria associated with immobilization, predisposes a patient to development of stones in the urinary tract. Retention of urine or use of indwelling catheter increases risk of urinary tract infections. Patients with cancer involving bladder-outlet obstruction (as in prostate cancer), or with impaired bladder emptying caused by involvement of the sacral nerves or spinal cord are at added risk when they are required to void on a bedpan. Prevention of urinary complications involves limiting the use of indwelling catheters as much as possible. If long-term catheter use is required, consider a condom catheter in the male patient or intermittent catheterization in the female patient. Provide a bedside commode for patients with intact spontaneous voiding to allow them to void in a relatively upright position when they can be transferred. Allow patients bathroom privileges as soon as they can move about. GI effects Inactivity results in impaired colonic function. Immobilized subjects have increased adrenergic stimulation, resulting in decreased peristalsis and increased sphincter contraction. Studies using radiopaque markers demonstrate an increase in colonic transit time and decline in mass propulsive waves of the colon in immobilized individuals. Constipation may occur when the patient is receiving opioids for pain control and may result in fecal impaction. Administration of chemotherapy may result in nausea, vomiting, and anorexia. These factors, in combination with the negative nitrogen balance associated with bed rest, may further contribute to cachexia and hypoproteinemia. Early encouragement of patients to use the bathroom or commode and practice of a consistent bowel program, including use of stool softeners and bulk-forming agents, can reduce risks of constipation. Cardiovascular effects Hemodynamic changes associated with compromise within the cardiovascular system begin within a few days of recumbency. Healthy young men lose 300-500 mL of plasma volume within the first week of bed rest. Plasma volume declines more than red cell mass does, increasing blood viscosity, which is thought to contribute to the risk of deep vein thrombosis (DVT). Hypotension in connection with upright positioning has been observed in patients within a week of their beginning a regimen of bed rest. When healthy individuals are elevated to an upright position, venous return declines, decreasing stroke volume and cardiac output. Adrenergic sympathetic stimulation normally occurs, producing increase in the heart rate and vasoconstriction of peripheral and splanchnic blood vessels, maintaining blood pressure. After prolonged recumbency, the circulatory system is unable to produce adequate vasoconstrictive response to changes in posture, leading to fall in blood pressure and tachycardia when the patient rises to a standing position. Stroke volume and cardiac output decline, producing lightheadedness and syncope secondary to inadequate cerebral perfusion. Additional symptoms (eg, burning in the lower extremities, nausea, diaphoresis) have also been documented after recumbency, though clinically significant decreases in blood pressure may not be found in all patients when they assume a standing position. Decreased cardiac efficiency is also affected in response to exercise. Increases in stroke volume in response to exercise are not maintained, and cardiac output declines. In patients with coexisting coronary artery disease, changes on standing may precipitate myocardial ischemia. Maximal oxygen consumption decreases by as much as 15% when healthy individuals exercise in an upright position after 10 days of bed rest. After this postural response is lost, 3-4 weeks may be required to establish normal postural responses. Thrombogenic risks Bed rest, in association with other risk factors, may result in DVT, and risk for thrombosis increases with the length of bed rest. In addition to changes in blood viscosity, mechanical compression of veins may contribute to venous stasis. Patients with cancer, because of associated hypercoagulable states, are predisposed to form venous clots. Several strategies can help prevent and mediate cardiovascular complications, though early mobilization of the patient is the most effective approach. Maintenance of adequate fluid and salt intake is another simple measure for alleviating symptoms associated with cardiovascular symptoms. Dynamic resistance exercises in the supine position assist with maintaining plasma volume. Abdominal strengthening and lower-extremity exercises (eg, ankle pumps) improve venous stasis and can be performed in conjunction with the use of elastic stockings and abdominal binders to maintain blood pressure in orthostatic patients. Use of reclining wheelchairs or tilt tables may help the patient gradually adjust to an upright posture if orthostatic symptoms are a problem. Introduce pharmacotherapy in cases of suspected autonomic neuropathy-related orthostasis. Recommend that the patient begin sitting upright as soon as possible because lack of orthostatic stress significantly contributes to impaired exercise capacity. Nervous effects Balance and coordination decline in patients on bed rest. This decline may increase a patient's risk of falling. Confinement of a patient to a hospital bed can also cause sensory deprivation, which affects perception and cognition. Changes in concentration, sensory distortion, and hallucinations have been documents in both healthy subjects and hospitalized patients. Alterations in intellectual and perceptual testing have also been found in patients on bed rest. Early activity with access to sensory stimulation can help in preventing changes in intellectual or perceptual capacities. Integumentary effects Hospitalized patients are at high risk for pressure ulcers, which have an incidence of 7.7% incidence within 3 weeks of admission. Geriatric patients are at particular risk for pressure ulcers because of the aging-associated loss of subcutaneous tissue, decreased connective tissue elasticity, and decreased secretion levels of sebaceous and sweat glands. Sustained pressure over bony prominences results in ischemic injury, and, because muscle and subcutaneous tissues are more sensitive to injury than the epidermis, the initial appearance of a sore may not reflect the severity of the underlying injury. Several factors contribute to skin breakdown; these include pressure, shearing forces, friction, and moisture. Patients with cancer at increased risk for pressure sores include not only the elderly but also patients with impaired alertness, altered sensation or movement, poor nutrition, and/or incontinence. Prevention involves first the identification of high-risk patients and then intervention with repositioning schedules in a bed or chair, use of support surfaces or beds to reduce pressure, reduction of shearing forces during transfers or repositioning, minimization of skin exposure to moisture, and maintenance of adequate nutrition. Therapeutic exercise to mitigate deconditioningNorwegian clinical investigators recently reviewed the role of therapeutic exercise in the amelioration of cancer-related weakness and fatigue. Interventions included aerobic exercise training (10 studies) and resistance exercise (2 studies). Researchers used a wide range of instruments to assess health-related QOL and physical exercise capacity. The studies indicated promising effects on both physiologic and psychological outcomes. Randomized clinical studies are few, small, and mainly focused on patients with breast cancer. Complete knowledge about the type of physical exercise most beneficial for patients at different stages of the disease progression is still lacking. Future work should identify fewer and more specific endpoints. REHABILITATION FOR HEAD AND NECK CANCERSection 5 of 11
Head and neck cancer: overviewThe American Cancer Society estimates that 9880 new cases of laryngeal cancer (7920 in men and 1960 in women) and 3770 related deaths (of 2960 men and 810 women) in the United States in 2005. An estimated 2500 cases of hypopharyngeal cancer are diagnosed each year. About 60% of larynx cancers start in the glottis. Another 35% develop in the supraglottic region, and the remaining 5% occur in the subglottis. Swallowing and mastication Swallowing and mastication are the most salient deficits that arise as a result of the treatment of cancer of the oropharynx. Swallowing occurs in 3 stages. The first is voluntary, and the other 2 are reflexive. Swallowing starts with voluntary contraction of the mylohyoid muscles, which throw the bolus back onto the posterior pharyngeal wall. The rich sensory innervation, provided by glossopharyngeal nerves, then triggers complex, coordinated movements of the involuntary phases of swallowing. These movements involve the base of the tongue, the soft palate, the larynx, the posterior pillars of the fauces, and the pharynx. Mastication is a complex process resulting from fine and coordinated movements of the mandible at the temporomandibular joint carried out by 4 main muscles originating from the base of the skull, the temporal arch, and the temporal fossa (outer pterygoid, inner pterygoid, masseter, and temporal), and 3 secondary ones on the floor of the mouth (digastric, geniohyoid, and mylohyoid). Therefore, act of chewing is permitted because of the anatomic and functional integrity of active structures (eg, muscles) and passive structures (eg, mandibular lever, teeth, mucosal lining, salivary glands). Treatment modalities As with other cancers, the treatment modalities for head and neck cancers depend on the site, size, and histopathology of the tumor and on evidence of metastasis. The treatment is often defined on a consensus-based system of grading and staging. The combination of radiation therapy with concurrent chemotherapy, primarily platinum based, has curative potential in many patients with advanced squamous cell carcinoma (SCC) of the oropharynx, hypopharynx, and larynx. These treatment regimens are particularly attractive for patients in whom the alternative treatment involves surgical resection of a large portion of the tongue base, oropharynx, hypopharynx, or larynx. The oncologic efficacy of chemoradiation therapy in this population in comparison with radiation therapy alone has been well documented. However, little detailed information is available on the long-term health-related QOL (HRQOL) outcomes after chemoradiation therapy to treat advanced head and neck cancer or on randomized trials comparing chemoradiation therapy with surgery plus radiation therapy. Despite this lack, the presumption persists that posttreatment QOL is generally better with chemoradiation therapy than with surgery plus radiation therapy. Many patient, disease, and treatment factors influence ultimate long-term QOL. Health status outcomes are often globally referred to as QOL outcomes. However, they should precisely be separated into objective and subjective QOL outcomes; that is, functional or performance status outcomes (what an individual can do) and evaluations of the way an individual perceives and reacts to what he or she is capable of doing, respectively. Outcomes Health status outcomes are multidimensional and include several areas or domains. A single healthcare intervention can have positive effects in 1 area and negative effects in another. Circumstances that determine how a person perceives or is affected by performance status (QOL) in a specific area of functioning vary substantially between individuals. These are subject to adaptation over time, and exert a variable influence on overall QOL for different individuals. In addition, the general assumption that nonoperative intervention uniformly leads to superior QOL also fails to account for the potential for a nonfunctioning but anatomically preserved organ. Some health states in which an organ is preserved (eg, chondronecrosis, chronic aspiration) may be less desirable than not having the organ. Furthermore, advances in ablative surgical techniques, surgical reconstruction, and rehabilitation after surgery may help preserve and restore function. Patients treated for head and neck cancer can present with some of the most significant posttreatment morbidity of any group of patients with cancer. Functional deficits can affect nutrition, swallowing, communication, dental health, and the musculoskeletal system. The usual treatment involves surgery and/or radiation, though chemotherapy is most frequently used as a neoadjunct agent. Underlying comorbid illnesses or problems, such as alcohol abuse, poor nutritional status, and cardiopulmonary diseases, are more common in these patients than in others. Extensive surgical treatment can lead to visible deficits and may interfere with socialization and employment. Therefore, functional deficits associated with treatments should be considered with diagnosis of head and neck cancers. In general, treatment selection is the first step in that process because each treatment at each disease site has specific effects on function. Some treatments have been designed with the goal of preserving function. Counseling the patient and family As in other medical and surgical procedures that generate new impairments (eg, amputation), counseling of the patient and family members is important. If possible, facilitate discussion among multidisciplinary team members about procedures planned in the context of potential functional effects and rehabilitation needs. Professionals involved should include the physical therapist, occupational therapist, speech and/or language therapist, dentist and/or maxillofacial prosthodontist, audiologist, physician and surgeon, dietitian, and social worker. In addition, the patient and family members or significant others should be involved. Discuss potential adverse effects or morbidity from each treatment available for the patient's disease site and stage, and identify the patient's preferences for treatment options. After the treatment of choice is determined for a particular patient, address the optimal schedule of interventions by the various rehabilitation team members. If the tumor treatment of choice is a surgical procedure, discuss whether specific parts of the procedure can be modified to facilitate the patient's postoperative function without compromising the possibility of successfully removing the tumor. For example, in patients with oral cancer who undergo surgical treatment, reconstruction may be modified to facilitate postoperative speech and swallowing. When the decision has been made regarding optimum tumor treatment for the patient, each professional on the rehabilitation team should counsel the patient and evaluate the patient's function before treatment, formulating a plan for initiating rehabilitation after treatment. Because the patient can communicate most easily before treatment, pretreatment assessments are critical. Some therapies may be preventive, and they may begin before and continue throughout treatment. For example, the patient who receives radiotherapy and chemotherapy needs oral ROM exercises to maintain movement of the lips, tongue, and jaw. Initiate these exercises before radiation therapy, and advise the patient to continue doing the exercises 4-6 times daily. If possible, these should be performed for 5-10 minutes each time throughout the course of radiation and for at least 3 months thereafter. The physical therapist may likewise need to give the patient shoulder exercises to maintain shoulder ROM if nerves innervating the shoulder are resected in a radical neck dissection. Dental evaluation is important before radiation treatment because dental caries can develop or progress with postradiation xerostomia. Dental extraction, if needed, should be done before radiation treatment. Oral hygiene is essential as a preventive strategy. The dentist and/or maxillofacial prosthodontist may need to take oral impressions before surgery and to be in the operating room during an oral surgical procedure to fit and place a temporary intraoral prosthesis until a permanent prosthesis can be constructed. Immediately after treatment, counsel patients undergoing tumor-removal surgery regarding the functional effects of surgery and the kinds of therapy they need. Patients must realize that they must be active participants in the different components of their rehabilitation program (eg, development of intraoral prosthetics, PT, speech or swallowing therapy). If treatment, radiation, or surgical procedures affects swallowing, evaluate patients with posttreatment videofluorography as soon as they can attempt to swallow. This approach is both cost-effective and efficient. The patient may be able to begin oral intake immediately after undergoing a modified barium swallow study if swallowing is functional or if particular swallowing therapy (eg, postural change, swallowing maneuvers) prove effective. Relying solely on bedside approach to assess swallowing without radiographic study is usually slow because the clinician is tentative about the exact nature of patient's swallowing ability. By using a radiographic study of swallowing, design a therapy and/or rehabilitation program so the patient can return to oral intake as soon as possible. If the patient's ability to |