Transcript UM Alumnae Women*s Doctor of Physical Therapy Scholarship

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