Impairments and Complications Related
to Breast Cancer Treatment
The following impairments and complications may occur in association with treatment of breast cancer. Many of these problems are interrelated and must be considered jointly when a comprehensive postoperative rehabilitation program is developed for the patient.
Postoperative Pain
Incisional
pain
A transverse incision across the chest wall is made to remove
the breast tissue and underlying fascia on the chest musculature. The incision
extends into the axilla for lymph node dissection. Postoperatively, the sutured
skin over the breast area may feel tight along the incision. Movement of the
arm pulls on the incision and is uncomfortable for the patient. Healing of the
incision may be delayed as the result of radiation therapy. Delayed wound
healing, in turn, prolongs pain in the area of the incision.
Posterior
cervical and shoulder girdle pain
Pain and muscle spasm may occur in the neck and shoulder region as
a result of muscle guarding. The levator scapulae, teres major and minor, and
infraspinatus often are tender to palpation and can restrict active shoulder
motion. Decreased use of the involved upper extremity after surgery due to pain
sets the stage for the patient to develop a chronic frozen shoulder and
increases the likelihood of lymphedema in the hand and arm.
Postoperative Vascular and Pulmonary
Complications
Decreased activity and extended time in bed
increase venous stasis and the risk of DVT. Risk of pulmonary complications,
such as pneumonia, also is higher because of the patient’s reduced activity
level. Incisional pain may
make the patient reluctant to cough or breathe
deeply, both of which are necessary postoperatively to keep the airways clear
of fluid accumulation.
Lymphedema
As noted previously, patients who undergo any
level of lymph node dissection or whose treatment regimen includes radiation
therapy remain at risk throughout life for developing ipsilateral upper
extremity lymphedema. Lymphedema can occur almost immediately after lymph node
dissection, during the course of radiation therapy, or many months or even
years after treatment has been completed. It is typically evident in the hand
and arm but occasionally develops in the upper chest or back area. In turn,
lymphedema leads to impaired upper extremity function, poor cosmesis, and
emotional distress.
Chest Wall Adhesions
Restrictive scarring of underlying tissues on the chest wall can develop as the result of surgery, radiation fibrosis, or wound infection. Chest wall adhesions can lead to increased risk of postoperative pulmonary complications restricted mobility of the shoulder, postural asymmetry and dysfunction, and discomfort in the neck, shoulder girdle, and upper back.
Decreased Shoulder Mobility
It is well documented that patients may
experience temporary and sometimes long-term loss of shoulder mobility after
surgery or radiation therapy for treatment of breast cancer.
Weakness of the Involved Upper Extremity
Shoulder
weakness
If the long thoracic nerve is traumatized during axillary
dissection and removal of lymph nodes, this results in weakness of the serratus
anterior and compromised stability of the scapula, limiting active flexion and abduct
ion of the arm. Faulty shoulder mechanics and use of substitute motions with
the upper trapezius and levator scapulae during overhead reaching can cause subacromial
impingement and shoulder pain. Shoulderimpingement, in turn, can be a precursor
to a frozen shoulder. If the pectoralis muscles were disturbed, which occurs with
a radical mastectomy for advanced disease, weakness is evident in horizontal
adduction.
Decreased
grip strength
Grip strength is often diminished as the result of lymphedema
and secondary stiffness of the fingers.
Postural Malalignment
The patient may sit or stand with rounded
shoulders and kyphosis because of pain, skin tightness, or psychological reasons.
An increase in thoracic kyphosis associated with aging is commonly seen in the
older patient. This contributes to
faulty shoulder mechanics and eventually restricts active use of the involved
upper extremity. Asymmetry of the trunk and abnormal scapular alignment may occur
as the result of a subtle lateral weight shift, particularly in a
large-breasted woman.
Fatigue and Decreased Endurance
Patients undergoing radiation therapy or chemotherapy often experience debilitating fatigue. Anemia may develop as a result of chemotherapy. Nutritional intake and subsequent energy stores may be diminished, particularly if a patient is experiencing nausea for several days after a cycle of chemotherapy. Fatigue also is associated with depression. As a result, exercise tolerance and endurance during functional activities are markedly reduced.
Psychological Considerations
A patient undergoing treatment for breast
cancer experiences a wide range of emotional and social issues. The needs and
concerns of both the patient and the family must be considered. The patient and
family members must cope with the potentially life-threatening nature of the disease and a difficult treatment
regimen. It is common for a patient to feel anxiety, agitation, anger,
depression, a sense of loss, and significant mood swings during treatment and recovery from breast cancer. In addition to the obvious physical disfigurement and altered body image associated with mastectomy, medicationssuch as immunosuppressants and corticosteroids can affect the emotional state of a patient. Psychological manifestations affect physical well-being and can contribute to general fatigue, the patient’s perception of functional disability, and motivation during treatment.
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