The Power of Rehabilitation to Improve Breast Cancer Outcomes
Susannah Haarmann 
The benefits of breast cancer rehab are vast from decreasing treatment side effects, to improving physical and mental health & decreasing recurrence.
Don't believe me? I've got the evidence to prove it... and what I share with you here is just scratching the surface. ;)
Reducing Side Effects
Lymphedema
The reported incidence rate of breast cancer-related lymphedema varies in the literature, but, generally speaking, 33% of breast cancer patients will present with signs and symptoms of lymphedema (Hayes et al, 2008). Education alone can drive down incidence rates to 25%, but, when rehab practitioners implement surveillance with rehab interventions like manual lymphatic drainage, scar tissue massage, and post-op stretches, lymphedema rates showed a drastic reduction to 7%! (Lacomba et al, 2010).
General incidence | Education Alone | Early Intervention |
33% | 25% | 7% |
Is early intervention cost-effective? YES! Prospective surveillance reduces the severity of lymphedema, whereas chronic lymphedema in advanced stages is more difficult and expensive to treat. A study looking at the cost-effectiveness of implementing the prospective surveillance model versus traditional impairment-based care, showed an average cost per patient/per year to be $636.19 for early intervention versus $3,124.92 for later stage interventions (Stout et al, 2012). The authors note that "further analysis of indirect costs and utility is necessary to assess cost-effectiveness" but "a shift in the paradigm of physical therapy toward a prospective surveillance model is warranted."
The authors of a study in the Journal of Cancer Survivorship plainly stated "physical rehabilitation provides a noninvasive and cost-effective intervention for reducing lymphedema-related complications."
Shoulder dysfunction
There are a myriad of reasons why people who have/had breast cancer get shoulder dysfunction: lymphatic cording, capsular contracture, muscle weakness after surgery, postural changes, and more. Let's compare studies looking at the prevalence of shoulder impairment without rehab to those who received pre-operative education and exercise.
Without rehab...
A very valuable research project called "The Pulling Through Study" followed 287 women who did not receive any education or rehab interventions for post-op complications 6 months to 6 years after treatment (Schmitz et al, 2010). Shoulder dysfunction was just one of the complications tracked in this study and they looked at upper body symptoms and function.
- At 6 months, 22.6% of participants reported at least 1 severe symptom of tingling and weakness, pain, stiffness, range of motion, and swelling.
- 25.6% of participants reported poor upper body function.
I would like to note that in the rehab world even mild to moderate symptoms are considered significant and warrant assessment.
With rehab...
Now let's look at a study that provided early intervention to 94 subjects who were evaluated at baseline, given pre-op education and exercise, then evaluated 3 times post-op (1 month, between 3-6 months, and 12 months) (Springer et al, 2010).
- Arm range of motion significantly decreased at 1 month post-op and recovered by 3-6 months.
- Strength with manual muscle testing was impaired at 1 month post-op and returned to baseline strength by 12 months.
- Lymphatic cording with movement restrictions was present in 29% of participants at 1 month post-op. Asymptomatic cording was present in 40% of patients 1-month post-op. Only 5% had minor cording 3-6 months post-op with treatment.
- Less than 10% reported any pain greater than mild at 3-6 months. Later, 1 year out, 3/94 participants reported chest pain, and13.6% reported late onset of shoulder pain, but 92% of them had started radiotherapy by this time.
- Functionally speaking, 42% reported no problem and 50% reported slight difficulty performing hard tasks 1 year out. 98% had no, or slight difficulty performing routine tasks. The authors suggest that upper limb function may deteriorate between 1 and 2 years post-op with radiation treatment and suggest that patients should be monitored.
Not only do these studies speak to the importance of rehabilitation for people who have/had breast cancer, but also the importance of ongoing surveillance!
Improving Survivorship
Quick considerations....
Cognitive changes
People often refer to impairments in executive function, attention, learning, and memory as "chemo-brain," but there are other factors that can be attributed to a cancer-related cognitive impairment such as radiation, surgery, hormone therapy, and post-traumatic stress disorder. The hippocampus of the brain plays an important role in memory and is sensitive to toxic agents such as chemotherapy and radiation. Exercise contributes to neurogenesis in the hippocampus, thus protecting the brain. Exercise may also influence the pre-frontal cortex and inflammatory markers in the body improving cognitive function. A review of the literature suggests that exercise interventions can help in the prevention and rehabilitation of cancer-related cognitive impairment and improve processing speed with early implementation (diagnosis less than 2 years) among breast cancer patients (Zimmer et al, 2016).
Fatigue
1/3 breast cancer patients have prolonged cancer-related fatigue 5-10 years after diagnosis (Bower et al, 2006). Fatigue levels are 40-50% lower in people with cancer who exercise (Mock, 2004).
Sexual Health
Approximately 77% of breast cancer survivors 3 years out qualified for female sexual dysfunction (Raggio et al, 2014). Healthy sexual function is important for many when it comes to self-embodiment, interpersonal relationships, and physical, mental, and emotional health. More research is needed with regard to breast cancer patients, but pelvic floor physical therapy can help with vaginal atrophy, dyspareunia (painful intercourse), and genitourinary symptoms of menopause. Rehab professionals ideally use a biopsychosocial approach to care which considers important factors such as body image, relationships, and reproductive function as it pertains to sexual function and arousal.
Mental health
Cytotoxic therapy is linked to adverse psychiatric effects with the appearance of depressive symptoms being the most common. The presence of depressive symptoms of varying intensity has been shown to be upwards of 76% with signs of depression showing around 27% (Cvetković & Nenadović, 2016). In a 12-week study comparing exercise in breast cancer patients, depression was significantly lower in the supervised exercise group compared to home exercise or control groups (Ergun et al, 2013).
Osteoporosis
Breast cancer survivors have a 68% greater risk of getting osteoporosis and osteopenia compared to cancer-free women. One study showed a 12-month exercise program completely prevented femoral neck bone loss in premenopausal women undergoing breast cancer treatment (Saarto et al, 2012).
Peripheral Neuropathy
People with chemotherapy-induced peripheral neuropathy reported increased psychological distress and falls (Bao, et al 2016). A multi-center random controlled trial with 355 cancer patients showed that a 6-week progressive walking and resistance exercise intervention program of moderate intensity could improve peripheral neuropathy symptoms for patients receiving taxane-, platinum-, or vinca alkaloid-based chemotherapy (Kleckner et al, 2018). If osteoporosis increases fracture risk and peripheral neuropathy could increase fall risk, shouldn't we be screening?
Cardiotoxicity
Cardiovascular disease in breast cancer survivors is the leading cause of non-cancer-related deaths accounting for ~35% of deaths in people 50 years of age and older (Bradshaw et al, 2016). I could say so much more about this, but I'll simply site a prospective cohort study with non-metastatic breast cancer patients which concluded that "Exercise is associated with substantial, graded reductions in the incidence of cardiovascular events in women with non-metastatic breast cancer" (Jones, et al, 2016).
Improved cancer outcomes
Aromatase Inhibitors
Aromatase inhibitors block the enzyme aromatase from producing estrogen and are commonly given to post-menopausal women with ER+ breast cancer, however, 40% of people stopped taking AIs at 2 years due to side effects, and 50% stopped at 5 years (Suskin et al, 2018). Sexual dysfunction and joint arthralgias are two of the most common complaints associated with AIs.
Approximately, 50% of breast cancer survivors taking aromatase inhibitors experience joint pain and stiffness (Yang et al, 2017), but there is something to be done! A 12-month study assessed if supervised resistance training + home-based aerobics would influence joint pain among people taking aromatase inhibitors for breast cancer. I am pleased to announce that joint pain decreased by 29% in the exercise group compared to a 3% increase in symptoms in the control group (Irwin et al, 2015).
Radiotherapy
Radiotherapy requires precision, and in most cases of external beam radiation, the patient must be able to flex and abduct the shoulder in order to get the arm to rest in a cradle for treatment. There have been cases (usually involving lymphatic cording) where the patient is not able to obtain the arm range of motion to get into the cradle. If you are a breast cancer rehab specialist you have likely received an urgent referral to address restoring arm range of motion so that the patient can get the timely treatment they need. We are here to help!
Decreased Recurrence
The Nurses' Health Study assessed nearly 3,000 women with breast cancer prospectively for 30 years and found 50% fewer cancer recurrences when someone exercised greater than 3 hours per week. Is this due to less bioavailability of estrogen with weight loss? Does it have to do with insulin or the anti-inflammatory benefits of moderate exercise?
Is it enough to just tell your patients about the benefits and assume they will carry the motivation or the 'know-how' to get moving? Yes, in some cases; but what if that patient is experiencing peripheral neuropathy leading to pain and impaired balance, altered lab values, joint pain, fatigue, shoulder dysfunction, depression, or they are worried about protecting their surgery after reconstruction? Are the patient's experience and body giving them signals that it is safe to exercise without setbacks or injury?
Guidance...professional guidance is often needed to feel safe. Breast cancer rehab providers are able to objectively show the patient progressive improvements from baseline assessments which adds value to the activity and increases motivation.
The Bottom Line
People who have/had breast cancer are living with side effects from medical treatment that can be constant reminders of their breast cancer journey and inhibit an optimal quality of life.
Breast Cancer Rehab practitioners know how to:
- Provide a pre-op baseline assessment, and give post-op functional guidelines and progressive exercises after mastectomy and reconstruction.
- Perform manual therapy techniques to improve scar tissue and fascial mobility post-op.
- Assess and treat shoulder dysfunction and lymphatic cording.
- Weigh lymphedema risk, take baseline measures, and provide education & exercise interventions to decrease risk.
- Differentially diagnose lymphedema, treat stage 0-1 lymphedema, and refer complex cases to a CLT.
- Differentially diagnose and treat peripheral nerve injuries such as post-mastectomy pain syndrome, brachial plexopathy, scapular dyskinesia, and chemotherapy-induced peripheral neuropathy.
- Identify patients at increased risk for cardiotoxicity, perform a baseline assessment of cardiovascular health, and provide the patient with appropriate education and exercise to improve cardiovascular fitness.
- Assess for chemotherapy-induced peripheral neuropathy, and provide interventions to decrease fall risk & improve functional tasks.
- Identify factors that could be causing fatigue and modify exercise & daily activities to increase vitality.
- Identify patients at risk for osteoporosis and provide evidence-based exercise & nutrition to improve bone health.
- Prescribe exercise in a manner that alleviates strain on joints and improves arthralgias.
- Assess and address painful intercourse and vulvovaginal health in breast cancer patients, referring to a pelvic health provider proficient in treating breast cancer patients if necessary.
If you are a rehab or medical provider:
- who would like to learn how to serve this population with an evidence-based, whole-body approach, check out KickPink training for professionals.
- Check out these resources for professionals too!
If you are someone who has/had breast cancer:
- here is a map of KickPink Practitioners who are skilled in comprehensive breast cancer care, assessment, and treatment.
- please share your experiences going through treatment. Your input through Rant for Recovery will help us with educational initiatives for people during and after breast cancer treatment live with fewer side effects and reminders of breast cancer.
