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Early Education, Exercise and CDT Following Radiation Therapy for Breast Cancer
By Linda Boyle, PT, DPT, CLT-LANA
OUTLINE FOR CASE PRESENTATIONS
I.
Reason for presenting case
Patients receiving external beam radiation therapy may not be seen by a lymphedema therapist
until late effects of radiation are apparent. Physical changes following external beam radiation
therapy for breast cancer may include osteoporosis/osteopenia, soft tissue fibrosis, muscular
contraction, and cardiopulmonary compromise in the treatment area.1,2
The effects of external beam radiation can lead to the following deficits in the affected
lymphatic quadrant.1
1.
2.
3.
4.
5.
6.
Pain
Range of motion restrictions
Muscular compromise
Exercise restrictions
Functional deficits
Decline in quality of life
Early tissue changes following external beam radiation do not necessarily predict long-term
effects.2
Lymphedema therapists need to be familiar with the early and late effects of external beam
radiation. Affected areas encompass the entrance and exit paths and all deep tissues and organs
therein. Radiation history and treatment area will help direct the therapist in appropriate clinical
intervention.3
The clinical questions in this case.
Would it be prudent to evaluate/assess patients prior their radiation therapy and provide
education concerning possible side effects? Could we intervene to minimize long term
morbidity in these individuals?
II.
Lymphedema Diagnosis
Our patient is a 34 year old right dominant woman diagnosed with left sided breast cancer in
June, 2005. Body Mass Index (BMI) 20. She undergoes post-operative chemotherapy and
radiation therapy extending to the supraclavicular lymph nodes following a lumpectomy with
axillary lymph node dissection and positive lymph nodes 5/12. Early persistent pain free left upper
extremity edema is reported following surgery and with a negative venous doppler study.4 Patient
is scheduled to begin radiation therapy from September until December 2005. Onset of edema is
noted by the patient on the dorsum of the left hand immediately post-operatively, but initially
resolves with elevation. The referral is made to the lymphedema team due to gradually persistent
left hand/wrist/forearm edema and the fact that radiation therapy would soon begin. Initial volume
is 6% greater in the affected left upper extremity and increases to 8% following radiation therapy.5
Tissue texture is slightly spongy in the left hand and wrist in September 2005. By December 2005
the left forearm also feels spongy. Stemmers sign is positive on the left.
The patient attends four sessions of outpatient physical therapy in September 2005 including
manual lymphatic drainage and a home therapeutic exercise program to maintain flexibility and
strength in the neck, thoracic spine, left shoulder, and scapula. A well fitting, compression class
one ready to wear arm sleeve and glove are provided. She is instructed in measuring girth in both
upper extremities. Education concerning fluctuations in body weight common during cancer
therapies is provided. Garments are worn during the day and removed before bed.3 At the end of
the initial four sessions, volume difference in the upper extremities is 5%.
III.
Medical History/ Physical Examination
Prior to diagnosis of breast cancer there is no pertinent past medical/surgical history. The review
of systems is unremarkable. Patient is BRCA1 positive and diagnosed with stage 3 breast cancer.
Cervical and thoracic range of motion is within normal limits and pain free at initial evaluation and
follow-up assessments.
Sensation to light touch is intact throughout except for the left breast incision, left axilla and
proximal humerus due to surgical disruption of the intercostobrachial nerve.6
Initially, palpation of the pectoralis major and minor, subscapularis, upper trapezius and levator
scapulae is unremarkable, but moderate muscle tightness and tenderness are present following
radiation therapy.
Standing posture
September
Normal
Pain
0/10
Supine active range of motion shoulder
Within normal limits
Manual muscle test shoulder and scapula
5/5 throughout
December
Forward shoulder
Scapular abduction/external rotation
Anterior chest wall 5/10
- 5 degrees flexion & extension
4+/5
Range of motion and strength deficits are noted following radiation therapy.7 Special tests on left
shoulder for scapular stability, muscle tendon pathology, impingement, and neurological
pathology were negative.8
II.
Psychosocial Considerations
The patient is an intelligent motivated and appropriately anxious 34 year old woman with breast
cancer.9 She lives with a roommate and has a supportive family that lives locally. Unfortunately, a
quality of life questionnaire is not administered. The patient and her mother attend our first
session and both had many questions concerning the disease of lymphedema. The patient
travels by air frequently for her job as a video producer.10 She is a triathlete before her diagnosis
and has questions concerning exercise and lymphedema.11 She also has a supportive boyfriend.
IV.
Functional Limitations
Our patient reports no functional limitations but notes cancer related fatigue in December 2005 at
5/10 on analogue scale of 0 to 10 (0= absence of fatigue and 10 overwhelming fatigue). She
reported 0/10 fatigue in September 2005. The disabilities of the arm, shoulder and hand (DASH)
was 24/100 upon initial evaluation and 31/100 at the follow up visit in December 2005.12
V.
Degree of Impairment in ADL's
The patient is unable to work or perform her regular aerobic and conditioning exercises during her
radiation sessions due to fatigue. She continues to live in her apartment and is independent in all
aspects of her activities of daily living. Pain is reported in the radiation field due to skin erythema
and disruption. This irritation interferes with patient’s ability to perform regular aerobic
conditioning between October and December 2005.
VI.
VII.
Summary of Pre-treatment goals
a. Educate patient
• Concerning the disease of lymphedema with emphasis on signs and symptoms
• Concerning tissue changes from radiation
• In monitoring bilateral upper extremity volume with respect to body weight
• To perform daily home exercises for flexibility and strengthening of the trunk,
scapulae, and upper extremity throughout her radiation intervention
b. Fit patient with ready to wear garments compression class one (CCI) to wear during
the day while physically active. Garments are removed at night.
c. Assure that the patient and her family contacts the cancer counselors to receive
psychosocial support throughout cancer intervention.
d. Promote open communication and trust between the patient and the lymphedema
team. The patient is encouraged to contact her medical team as questions arise
concerning her care.
Summary of Therapeutic Interventions, Goals and Outcomes
Intervention
Manual lymphatic drainage
Patient education
Garment fitting
Therapeutic exercises
VIII.
Goal
-Facilitate lymphangioactivity prior
to radiation therapy
-Promote relaxation
-Provide knowledge concerning
lymphedema and tissue changes
with radiation
-Minimize volume fluctuations in
the left upper extremity while
undergoing radiation therapy
-Maintain range of motion in the
neck, thoracic spine and left
upper extremity
-Maintain strength in the same
Outcome
-Minimal change in volume
-Positive communication with
patient
-Patient knowledge and home
program allows her to partner in
her care
-Some increase in volume left
upper extremity addressed by
the patient and the
lymphedema therapist
-Mild range of motion deficits
-Mild strength deficits
Results of modified intervention
Patient feels that her need for information was addressed. She also feels supported by the
lymphedema team throughout her cancer interventions.
IX.
Follow-up
The patient continues to consult the lymphedema team for monitoring of her
musculoskeletal, integumentary and volumetric conditions at regular intervals. This patient is
adherent with exercises and use of elastic compression garments. She replaces her compression
garments at least every 6 months.
X.
Conclusions.
What lesson/s can this case teach us?
Objective examination findings are needed to support the use of complete decongestive therapy.
It is our role as lymphedema therapists to remain current with medical evidence and apply it to
our daily lymphedema practices. Specific documentation standards would be helpful to practicing
lymphedema therapists.
Some omissions from data in this case include absence of quality of life and cancer related
fatigue functional tools. Functional tools are administered upon evaluation and at the time of
discharge and must be valid and reliable within the diagnostic group.
Including this information will provide outcome information concerning the efficacy of complete
decongestive therapy.
Discussion/Alternative Suggestions
Early intervention for persons with lymphedema may be helpful towards preventing the
progression of volume increases, tissue changes and musculoskeletal dysfunctions associated
with breast cancer therapies. Perhaps early referral to a lymphedema therapist before radiation
therapy begins would minimize psychological and physical morbidity following radiation therapy.
Baseline data prior to surgery may be ideal.
Further studies would be beneficial.
1
DeVita VT, et al. Cancer: Principles & Practice of Oncology,7th Edition. Philadelphia,
Pa. Lippincott Williams & Wilkins, 2005
2
Pinar B, Radiation-induced DNA damage as a predictor of long-term toxicity in locally
advanced breast cancer patients treated with high-dose hyperfractionated radical
radiotherapy. Radiat Res. 2007Oct;168(4):41522.
3
Foldi M, Foldi E, Kubik S. Textbook of Lymphology, 5th Edition. Munich, Germany.
Urban and Fischer, 2003
4
Ascher E, Salles-Cunha S, Hingorani A. Morbidity and mortality associated with
internal jugular vein thromboses. Vasc Endovascular Surg. 2005 Jul-Aug;39(4):335-9.
5
Armer J.Upper limb swelling following mastectomy: lymphedema or not Oncology
(Williston Park). 2007 Apr; 21(4 Suppl):26-8.
6
Taylor KO. Morbidity associated with axillary surgery for breast cancer.
ANZ J Surg. 2004 May; 74(5):314-7.
7
Cheville AL, Tchou J. Barriers to Rehabilitation Following Surgery for Primary Breast
Cancer. Journ Surg Oncol 2007; 95:409-418.
Magee DJ. Orthopedic Physical Assessment, 3rd Edition. Philadelphia, Pennsylvania. W
B Saunders Company, 1997 (Chapter 5)
8
9
Parker PA, Youssef A, Walker S, Basen-Engquist K, Cohen L, Gritz ER, Wei QX,
Robb GL. Short-term and long-term psychosocial adjustment and quality of life in
women undergoing different surgical procedures for breast cancer.Ann Surg Oncol. 2007
Nov;14(11):3078-89. Epub 2007 Jun 16.
10
National Lymphedema Network, Consensus paper. Air Travel and Lymphedema, May
2006. http://www.lymphnet.org/lymphedemaFAQs/positionPapers.htm
11
Holmes MD,et al. Physical activity and survival after breast cancer diagnosis.JAMA.
2005;293:2479-2486.
12
Hudak P, Amadio P, Bombardier C (1996) Development of an upper extremity
outcome measure: The DASH (disabilities of the arm, shoulder and hand) American
Journal of Industrial Medicine 29, 602-608.