Breast cancer: overview

Breast cancer occur when cells begin to grow and divided out of control creating a mass of tissue, in one or both breasts, it can also travel to other parts of the body and form new tumors called metastasis.

breast cancer occurs in women and men at any age, but almost entirely in women over the age of 50.

In 2020, breast cancer became the most commonly diagnosed cancer type in the world; there were more than 2.26 million new cases of and almost 685 000 deaths worldwide. Breast cancer was the most common cause of cancer death in women and the fifth most common cause of cancer death overall (WHO , 2022).

Physical therapy intervention has important role in the rehabilitation process during and after the diagnosis , as well as in the care of survivors.

Physical activity habits and physiotherapy intervention after breast cancer helps in the treatment of post-cancer disorders and decrease the number of musculoskeletal disorders (Rangel, J., Tomás, M. T., & Fernandes, B. , 2019).

 causes of breast cancer:

There’re two hypothetical theories for breast cancer initiation and progression: the cancer stem cell theory and the stochastic theory. Although both theories are supported by plenty of data, neither can fully explain the origin of human breast cancer( Sun, Y. et al,  2017).

However, there are several factors that increase risk such as:

• Sex: Women are much more likely to develop breast cancer than men.
• Aging: Getting older increase the risk.
• Genetic mutations: inherited changes to certain genes, such as BRCA1 and BRCA2, are at higher the risk .
• overweight or obese (especially after menopause)
• Personal history of breast cancer
• Family history of breast cancer.
• radiation therapy (Previous treatment).
• sedentary life style increase risk of breast cancer.
• Having the first pregnancy after age 30, can raise the risk.
• never being pregnant or having children.
• Use hormone replacement therapy increase the risk.
• Drinking alcohol increase the risk .

Diagnosis of breast cancer:

• Breast physical exams: check breasts and lymph nodes to feeling if there any abnormalities.
• Biopsy: the only definitive way to make a diagnosis of breast cancer by Removing a sample of breast cells for testing.
• Mammogram: X-ray of the breast, commonly used to screen .
• Ultrasound: produce deep images of structures within the body.

signs of breast cancer:

at earlier stages may be cannot detect or notice any signs and it can vary from person to another,it include:

• change in the breast size and shape.
• change in the breast and nipple texture.
• feel A mass in breast or near underarm
• thickening in breast or near underarm
• Redness of breast or nipple.
• blood or fluid discharge from nipple.

Classification of breast cancer:

• Invasive Breast Carcinoma of No Special Type (NST):This group of breast cancers comprises all tumors without the specific differentiating features that characterize the other categories of breast cancers.
• ductal carcinoma in situ (DCIS)
• mixed invasive NST and special type
• Mixed invasive NST and lobular carcinoma.

Rare morphological variants of invasive carcinoma (NST) include pleomorphic carcinoma, carcinoma with osteoclast-like stromal giant cells, carcinoma with choriocarcinomatous features, and carcinoma with melanotic (Sinn, H. P., & Kreipe, H. , 2013) .

How can dicrease the risk of breast cancer?

There is no sure way to prevent breast cancer. However, regular screening test and regular mammograms can early detect it when it’s small and has not spread, which easier to treat successfully and decrease the risk of deaths , in addition to the lifestyle changes which can reduce the risk of it, these changes include (Mayo Clinic , 2022):

• Maintain a healthy weight.
• be physically active.
• Breast-feeding: might play a role in prevention it.The longer breast-feed, the greater the protective effect.
• Limit postmenopausal hormone therapy: combination hormone therapy may increase the risk of breast cancer.

 Treatment of breast cancer:

There are several treatment options, including surgery, chemotherapy, radiation therapy, hormone therapy, immunotherapy and targeted drug therapy. What’s right depends on many factors, including the location and size of the tumor, the results of lab tests and whether the cancer has spread to other parts of body. healthcare provider will tailor treatment plan according to unique needs. It’s not uncommon to receive a combination of different treatments, too.

 Breast cancer surgery

removing the cancerous portion of breast and an area of normal tissue surrounding the tumor. There are different types of surgery depending on situation, Most patients with breast cancer have surgery to remove the cancer.

Types of Breast cancer surgery (Cleveland Clinic., 2022):

• Lumpectomy (partial mastectomy): removes the tumor and a small margin of healthy tissue around it. Typically, some of the lymph nodes in breast or under arm, are also removed for evaluation. People who have a lumpectomy often have radiation therapy in the weeks following the procedure.
• Mastectomy: Removal of entire breast.
• Sentinel node biopsy: developed to prevent the unnecessary removal of large numbers of lymph nodes that aren’t involved by the cancer. Often, there’s more than one sentinel node identified, but the fewer lymph nodes removed the lower the chance of developing swelling in your arm (lymphedema). A sentinel lymph node biopsy can be done with either a lumpectomy or a mastectomy.
• Axillary lymph node dissection. If, an axillary lymph node dissection may be done to remove multiple lymph nodes are involved by the cancer. This means removing many of the lymph nodes under arm (axilla).
• Modified radical mastectomy.  entire breast is removed in addition to nipple. Nearby lymph nodes in underarm area are also removed, but chest muscles are left intact. Breast reconstruction can often be an option if desired.
• Radical mastectomy.  rarely performed today unless the breast cancer has spread to chest wall muscles, surgeon removes entire breast, nipple, underarm lymph nodes and chest wall muscles. People who undergo this procedure may choose to have breast reconstruction as well.

Chemotherapy :

uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body.

Radiation therapy :

treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing

Hormone therapy :

removes hormones or blocks their action and stops cancer cells from growing. Hormones are substances made by glands in the body and circulated in the bloodstream. Some hormones can cause certain cancers to grow. If tests show that the cancer cells have places where hormones can attach (receptors), drugs, surgery, or radiation therapy is used to reduce the production of hormones or block them from working. The hormone estrogen, which makes some breast cancers grow, is made mainly by the ovaries. Treatment to stop the ovaries from making estrogen is called ovarian ablation.

Immunotherapy :

treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer. This cancer treatment is a type of biologic therapy.

Targeted drug therapy :

treatment that uses drugs or other substances to identify and attack specific cancer cells. This treatment usually cause less harm to normal cells than chemotherapy or radiation therapy do (National Cancer Institute,  2022) .

Physiotherapy role and intervention post Mastectomy surgery:

physiotherapy was effective in the treatment of nociceptive musculoskeletal pain post surgery. It provides for tissue, accessory and neurodynamic joint mobilization plus active exercises with increasing intensity.

neuromuscular proprioceptive facilitation and selective reinforcement exercises are recommended After the sub-acute period to restore the correct scapulohumeral rhythm.

active exercise maintained for 12 months led to an improvement in arthralgia in previously inactive patients.

The most effective treatment for radio-induced neuropathic pain is a supervised and moderate-intensity therapeutic exercise. In addition to improving the pain sensation and shoulder ROM (Giacalone, A., Alessandria, P., & Ruberti, E.  ,  2019).

physiotherapist-delivered early supported exercise intervention with integrated behavioral strategies helped women at risk of shoulder problems following treatment to feel more confident in their ability to mobilize their arm post-surgery. A physiotherapist-delivered early supported exercise intervention with integrated behavioral strategies may address the sense of powerlessness that many women experience during treatment (Boiko, O. et al , 2020).

exercise improves upper quadrant pain severity in women with post-mastectomy pain syndrome (PMPS).

Myofascial release and acupuncture are beneficial for alleviating the pain severity in post-mastectomy pain syndrome (PMPS).

Analysis of data from single trials of complex decongestive therapy (CDT) and neuromuscular taping (NMT) showed a statistically significant effect of these interventions compared to the control conditions (Kannan, P  et al , 2022).

physiotherapy Plan of treatment post masectomy surgery:

restricted arm motion and lymphedema consider tow common complications post breast cancer surgery. so, Early rehabilitation and Motion exercises very important to improve and enhancing tissue extensibility, in addition to facilitate normal movement patterns and promote functional movement to the patient’s previous level of activity

• Several forms of manual therapy may also assist:
• Joint mobilization techniques
• Soft tissue release techniques
• Neurodynamic techniques
• Mobility exercises:
• Arm mobilizations at first or second-day post-op.
• Mobilizations are performed using joint rotations to tolerance, but abduction and flexion are limited to 40°.
• At day 4 post-op flexion and abduction are gradually increased to 45°, this can be increased furthermore by 10-15° per day dependent on the patient’s pain tolerance.

The technique performed by holding the patients arm in 45° flexion or abduction until the drains are removed.

• the (SEWS chart) should be monitored regularly for early warning signs for post-surgical populations. If the patient is feeling fatigued or anemic exercise should be delayed.

The BEAUTY program:

counteract key concerns associated with breast cancer patients such as fatigue, reduced QoL, social anxiety and physical conditioning.

 

All exercise programs should be designed with F.I.T.T principles during and after breast cancer.

FITT Principle

• Warm up: 5-10 minutes to raise heart rate
• Aerobic Exercise: Frequency:
• 3 x 5 times per week.
• Intensity: 50-70% of max. heart rate
• Type: walking cycling aerobic activity
• Time: 30 minutes maintaining as a long-term routine
• Resistance Training: Frequency:
• 2/3 times a week
• Intensity: 12/15 reps of 60 % of 1RM
• Type: Supervised resistance program of major muscle groups
• Time: 6 weeks

Life After Cancer

The role of a physiotherapist is to promote a healthy life style including physical activity and can assist the patient with her plans to return to work by carrying out assessments on the physical capabilities of the patient in relation to the work place (Physiopedia, 2022).

References

Boiko, O., Burgess, C., Fox, R., Ashworth, M., & Gulliford, M. (2020). Risks of use and non-use of antibiotics in primary care: qualitative study of prescribers’ views. BMJ Open, 10(10), e038851. doi: 10.1136/bmjopen-2020-038851

Cleveland Clinic. (2022). Breast Cancer Overview: Causes, Symptoms, Signs, Stages & Types. Retrieved 11 October 2022, from https://my.clevelandclinic.org/health/diseases/3986-breast-cancer

Giacalone, A., Alessandria, P., & Ruberti, E. (2019). The Physiotherapy Intervention for Shoulder Pain in Patients Treated for Breast Cancer: Systematic Review. Cureus. doi: 10.7759/cureus.6416

Kannan, P., Ying, L., Ngai, L., Kiu, M., Yan, M., & Yan, T. (2022). Physiotherapy interventions for the management of post-mastectomy pain syndrome: A meta-analysis. Physiotherapy, 114, e53-e54. doi: 10.1016/j.physio.2021.12.307

Mayo Clinic. (2022). Breast cancer prevention: How to reduce your risk. Retrieved 11 October 2022, from https://www.mayoclinic.org/healthy-lifestyle/womens-health/in-depth/breast-cancer-prevention/art-20044676https://www.mayoclinic.org/healthy-lifestyle/womens-health/in-depth/breast-cancer-prevention/art-20044676

National Cancer Institute. (2022). Breast Cancer Treatment (Adult) (PDQ®)–Patient Version. Retrieved 11 October 2022, from https://www.cancer.gov/types/breast/patient/breast-treatment-pdq#_185

Physiopedia. (2022). Breast Cancer. Retrieved 11 October 2022, from https://www.physio-pedia.com/Breast_Cancer#cite_ref-Leach_2014_41-0

Rangel, J., Tomás, M., & Fernandes, B. (2018). Physical activity and physiotherapy: perception of women breast cancer survivors. Breast Cancer, 26(3), 333-338. doi: 10.1007/s12282-018-0928-7

Sinn, H., & Kreipe, H. (2013). A Brief Overview of the WHO Classification of Breast Tumors, 4th Edition, Focusing on Issues and Updates from the 3rd Edition. Breast Care, 8(2), 149-154. doi: 10.1159/000350774

Sun, Y., Zhao, Z., Yang, Z., Xu, F., Lu, H., & Zhu, Z. et al. (2017). Risk Factors and Preventions of Breast Cancer. International Journal Of Biological Sciences, 13(11), 1387-1397. doi: 10.7150/ijbs.21635

WHO. (2022). Breast cancer – IARC. Retrieved 11 October 2022, from https://www.iarc.who.int/cancer-type/breast-cancer/