Breast cancer complications

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.