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Breast Cancer Rehabilitation A Case Study in Prospective Surveillance Nicole L. Stout MPT, CLT-LANA Kaiser Permanente Rockville, Maryland Inherent in cancer treatment… • Known sequelae that have a deleterious impact on function, impacting a majority of patients • An aggregate burden of impairment • Short and long term impact on function • Risk for impairment and recurrent disease – Low risk today ≠ Low risk tomorrow • Patients want and need information to help them stay functional and active Inherent in cancer treatment • Economic burden of cancer morbidity – World-wide cancer morbidity creates the largest economic burden on society • **This does NOT include the cost of treating cancer – 20% > heart disease – Greater than morbidity with HIV/AIDS and TB ACS and LAF The Global Economic Cost of Cancer. Presented at UICC Cancer Congress 2010 http://www.cancer.org/AboutUs/GlobalHealth/globaleconomic-cost-of-cancer-report Why prospective surveillance? • Cancer treatment causes functional deficits • Physical therapists are experts in movement and function and have reliable and valid tools to detect and treat many cancer-related impairments • Surveillance enables early detection of and intervention for treatment-related impairments • Surveillance and intervention will decrease severity or prevent impairment and functional loss at all stages of disease management Is it effective? YES! Stout, NL. Pfalzer, L. Springer, B. Levy, E. McGarvey, C. Danoff, J. Gerber, L. Soballe, P. Breast Cancer Related Lymphedema: Comparing a Prospective Surveillance Model to A Traditional Model of Care. Phys Ther. 2012. Stout NL, Pfalzer L, Levy E, McGarvey C, Springer B, Gerber L, Soballe P. Segmental Limb Volume Changes as a Predictor of the Onset of Lymphedema in Women with Early Breast Cancer. PM&R 2011. Morehead-Gee A, Pfalzer L, Levy E, McGarvey C, Springer B, Soballe P, Gerber L, Stout N. Racial disparities in physical and functional domains in women with early breast cancer. 2011. Springer, B. Levy, E. McGarvey, C. Pfalzer, L. Stout, NL. Gerber, L. Soballe, P. Danoff J. Pre-operative Assessment Enables Early Diagnosis and Recovery of Shoulder Function in Patients with Breast Cancer. Br Ca Res & Treat. 2010. Gerber, L. Stout, NL. McGarvey, C. Soballe, P. Shieh, C. Diao, G. Springer, B. Pfalzer, L. Clinically Significant Fatigue in Women with Primary Breast Cancer. Support Care Cancer. 2010. Stout Gergich, N. Pfalzer, L. McGarvey, C. Springer, B. Gerber, L. Soballe, P. Preoperative assessment enables early diagnosis and successful treatment of lymphedema. Cancer. 2008. A Vision for Prospective Surveillance “The only thing worse than being blind is having sight but having no vision.” - Helen Keller What if we could promote an evidence-based standard of care that improves the quality of life for cancer survivors by reducing the potential for functional decline that is known to be associated with disease treatment? Stout, Binkley, Schmitz et al. Cancer 2012 Clinical Diagnostic Standardization • Pre-operative assessment and prospective surveillance • Subjective assessment • Reliable and valid tools • Sensitive diagnostic threshold Without each of these, we introduce error Pre-operative Assessment Establishing the Baseline • • • • Strength ROM Physical, Recreational and Social activity levels Inter-limb volume measurement – Weight consideration increases/decreases over time – Normal limb variance – 3% to 10% in normal healthy individuals Gebruers 2007 • Weight • Prior history of trauma or surgery • Comorbid conditions Ongoing Surveillance • Regular intervals of post-op follow-up – enable early identification of LE and other physical impairments (Balzarini 2006, Albert 2010, Springer 2010) • Interval follow-up should continue for 1st post-op year, or longer – Progression of lymphedema can occur at any time post treatment (Armer 2010, Johansson 2011, Bar Ad 2009) Cochran Systematic Review McNeeley et al. 2010 24 studies involving 2132 participants – 10 studies examined the effect of early versus delayed implementation of post operative upper-limb exercise – 14 studies examined the effect of structured upper-limb exercise compared to usual care/comparison Synopsis of findings PT based exercise results in a significant and clinically meaningful improvement in shoulder ROM and restoration of strength after breast cancer treatment There was no evidence of increased risk of lymphedema from exercise at any time point Post operative exercises Upper –limb exercise (shoulder ROM and stretching) is helpful in recovering upper-limb movement following BC surgery Starting exercise day 1 to day 3 post op may result in better shoulder movement (WMD: 10.6 degrees ; 95 % CI: 4.51 to 16.6) however there is no long term detriment to ROM if exercise is started more than 7 days post op. Early exercise results in more wound drainage (SMD: 0.31; 95 % CI: 0.14 to 0.49) and requires drains to be in place longer (WMD: 1.15 days; 95% CI: 0.65 to 1.65) than if exercise is delayed by 1 week Post operative exercises Upper limb exercises provided post operatively resulted in better outcomes at 1 year Shoulder flexion ROM at two weeks (MD: 12.92 degrees; 95% CI: 0.69 to 25.16) and at one year (MD: 5.40 degrees; 95% CI: 1.13 to 9.67) Shoulder abduction ROM at two weeks (MD: 9.72 degrees; 95% CI: -8.62 to 28.06) at one month (MD:22.05 degrees; 95% CI: 0.97 to 43.13) and at one year (MD: 7.00 degrees; 95% CI: 1.30 to 12.70) Adjuvant therapy and exercise Adjuvant cancer treatment: Upper limb exercise program versus comparison Exercise programs may benefit*: Shoulder abduction (MD: 11 degrees; 95% CI: 2.38 to 19.62) Upper-extremity strength through resistance exercise (MD: 7.30 kg; 95% CI: 4.42 to 10.18). • *These findings are from single studies. Risk Factor Profile • Treatment-related – Extent of surgery/LN dissection Clark 2005, Paskett 2007, Swenson 2009 – Radiation therapy Paskett 2007, Swenson 2009 – Chemotherapy Paskett 2007, Swenson 2009 – Seroma Swenson 2009 • Lifestyle (modifiable) – Having a BMI >25 (or increasing BMI >25) Soran 2006, Clark 2005, Paskett 2007, Swenson 2009 – Having an infection in the affected arm Soran 2006, – Skin puncture to the affected arm Clark 2005, Early Clinical Presentation Patient’s subjective reports Armer et al 2003 Nurs Research Sequential limb volume measurements, identifying segmental changes in volume Stout et al 2011 PM&R • Early post operative shoulder ROM < 80 degrees ER Stout et al 2012 PMR • Prior surgery or trauma to the UE Springer et al 2010 Br Ca Res and Treat Breast Cancer Diagnosis Physical Therapy Surgery Med. Onc. Rad. Onc. Pre-Operative Multi-Disciplinary Staging and Plan of Care Post Operative Surveillance- 3 month interval follow-up < 3 % change from pre-operative > 3 % change from preoperative Sleeve and Gauntlet 4 weeks daily wear Resume 3 month follow-up surveillance program Reassess Limb Volume Volume Increase Initiate Decongestive Therapy Volume decrease Stout et al Cancer 2008 1 year lymphedema rates Citation Reported Incidence Intervention Stout et al 2008 21% Sub-clinical 0 % Stage I 2 % Stage II* 0 % Stage III Education and Surveillance Monitoring with intervention upon volume change Hayes et al 33 % Stage II/III None Armer et al 48 % Stage II/III None Bar Ad et al 16 % Stage I with 21 % progression rate to Stage II in 1st year None Torres Lacomba 2010 7 % Stage I 2 % Stage II* 0 % Stage III Manual lymph drainage, education and surveillance * Associated with infection (n = 2) or metastatic disease (n = 2) 1 year shoulder morbidity rates Citation Reported Incidence Intervention Springer et al (2010) 4% Prospective surveillance and education. PT if impairment detected Yang et al (2010) 24 % None Devoogdt et al (2009) 45 % Post op 1 visit only and ongoing education Nesvold et al (2008) 12 % - 47 % (SLNB – ALND) Education for post op exercises Box et al (2002) Education only Direct Cost Analysis of PSM Cost of intervention per year Prospective Surveillance Model $636.19 Traditional Model $3124.92 160000 140000 120000 100000 PSM Cost 80000 TM Cost 60000 40000 20000 0 1 5 9 13 17 21 25 29 33 37 41 45 49 Incidence of diagnosis per year Stout et al PTJ 2012 Case Study 42 year old woman diagnosed with Stage IIA L BC • Eastern Cooperative Oncology Group status: 0 • Physical Activity level: – exercises 3-4 times/week including; yoga, weight lifting, running and swimming – golf and hiking recreationally • Social activities; book club, church activities • Employment status: full time clinical research nurse , no significant lifting, carrying or physical exertion. • Right handed • No prior trauma or surgery to the shoulders, elbow wrist/hand, nor neck injuries Pre Operative Assessment How does the evidence guide you in this intervention? • Objective measures? • Outcomes tools? • Patient education? • Post operative follow up? Case Study Immediate post op Presents to PT post operative day 3 s/p L modified radical mastectomy (MRM) with a sentinel lymph node biopsy (SLNB) • A Jackson Pratt (JP) drain is in place, putting out >100 cc’s of fluid/day • Pain at rest = 4/10 She is hesitant and fearful with movement • Pain with reaching at shoulder level = 6/10 and is described as “pulling in the chest wall” Case Study Immediate post op • RED flags? • What is your plan for today? Case Study 10 days post op Returns to PT 10 days post op. The JP drain has been removed, she starts chemotherapy in 2 weeks – She has been trying to move her arms to attempt routine daily activities however has pain with overhead reaching rated at 3/10. – Examination reveals ROM deficits of the LUE at 130 degrees overhead and a pulling sensation from her axilla – Limb volume is not significantly different based on her pre-operative measurement with consideration for her contralateral limb. Case Study 10 days post op • Impairments present? • Can she start back to yoga yet? • Exercise program today? • Outcomes measures? • Education points? Case Study 3 months post op Returns to PT 3 months post op, completed 4 cycles of Adrimycin and Cytoxan and starts Taxol this week • Completing HEP and ADL’s, but still c/o slight limitation in UE use overhead • Working part time, mostly from home • Doing yoga on off-chemo weeks, has not played a round of golf. At the driving range she notices her left arm is weak • Fatigue 5-6/10 on most days following chemo, 3-4/10 in her off-chemo-weeks • Limb volume increase of 5.7% is measured but barely visible . She notes the arm is heavy but 0/10 pain. Case Study 3 months post op Assessment reveals: – Abnormal movement pattern LUE when reaching overhead: notable upper trap overuse – Gross UE strength 4+/5 • Serratus anterior 3+/5, • Middle and Lower trap 4-/5 – L UE resting position: protracted with slight internal rotation at the GH joint Case Study 3 months post op • What if we do nothing here? • What if this patient was not on a prospective surveillance program? Case Study 6 Months post op At 6 months post op she returns for a PT reexamination. Completed radiation therapy 3 days ago. Has been consistent with her UE HEP, however has not continued her aerobic ex program due to fatigue (5/10) Complains of “tightness” in her left chest wall, and restrictions with overhead activities and various yoga postures Case Study 6 months post op • Radiation-related skin changes noted • LUE limb volume is stable with no evidence of lymphedema • AROM of the left UE is 165 degrees overhead and she notes right chest wall pain at 4/10, mostly with far overhead reaching • Scapular recruitment is symmetrical. No strength deficits noted Case Study 6 Months post op • What effect will radiation therapy have on the tissue? How will it impact our exercise recommendations? • Recommendations for improved adherence to exercise program? • Education points? Case Study • Ongoing surveillance visits are conducted at 9 months, 12 months and then at 6 month intervals Implications for Practice • We rely on an impairment-based model for dx. and Rx. of treatment related impairments. • This paradigm is inadequate if for early detection and remediation of common cancer-related impairments. • A shift in the current practice pattern in favor of a surveillance model is necessary and indicated based on the results presented here. • In the absence of a surveillance program, the earliest dx. of impairments will be delayed and promotes late disability from BC treatment More on Prospective Surveillance • APTA Video series on Emerging Models of Care http://www.apta.org/ACO/InnovativeModels/ • American Cancer Society – Supplement to Cancer April 15, 2012 “A Prospective Surveillance Model for Rehabilitation for Women with Breast Cancer.” http://onlinelibrary.wiley.com/doi/10.1002/cncr. v118.8s/issuetoc