Breast cancer

Breast– a cosmetic organ of the body,used as a food source for infants. It can become life threatening in cases where breast cancer develops.

Breast cancer- Carcinoma developing in the cells of the breast, is known as breast cancer.

When cancer occurs in the breast of women under forty, it is more rapid in its progress than when the patient is older, and also more extensive; remote sympathy likewise takes place more readily in them than in the old, so that the operation succeeds better in the later on this account.

—John Hunter

Breast anatomy-

Breast also known as mammary gland is present in the pectoral region found in both males and females developing after puberty

The structure of breast is divided in skin, parenchyma and stroma

Skin-

Skin covers the gland and following features are seen-

  • Nipple
  • Areola ( Pigmented skin surrounding the base of the nipple)

Parenchyma-

It is composed of tubulo-alveolar gland which secretes milk.

Stroma-

It is a partly fibrous and partly fatty structure that forms the framework of the gland.

  • Fibrous stroma- Anchor the skin and gland to pectoral fascia. (Also known as ligament of cooper)
  • Fatty stroma- Forms the bulk of the gland.

Hormonal physiology

  • Estrogen: Initiates ductal development.
  • Progesterone: Differentiation of epithelium and lobular development (glandular development).
  • Prolactin: Lactogenesis in late pregnancy and postpartum period. It also upregulates hormone receptors and stimulates epithelial development.

Risk factors-

Spread of carcinoma-

  1. Local spread- Spread in pectoral muscles and chest wall.
  2. Lymphatic Spread- 
  1. Blood spread

Stages of breast cancer-

Investigation-

Physical examination-

  • Generally, the first sign is detected as a palpable lump in the breast.
  • Almost half of the lumps appear upside near the armpit.
  • Breast may be tender and there could be a pulling sensation.
  • Second most common sign is fluid discharge from one of the nipples. This discharge can be clear, bloody or colored. (Discharge can be normal in non lactating females when it comes from both breasts)
  • A spontaneous discharge strongly indicates the presence of an underlying mass. Even during pregnancy a bloody discharge is a good indication of breast cancer.
  • Nipple may be elevated and retracted
  • Nipple destruction (paget’s disease).
  • Dimpling of skin
  • Oedema of the arm due to blockage of lymphatic drainage.
  • Local rise of temperature, redness and tenderness are seen in rapidly growing carcinoma.

Management-

Surgical management-

  • Lumpectomy- In a tumor less than 4 cm in size.
  • Simple mastectomy- Entire breast tissue including nipple and areola is removed. Chest muscles are left intact.

In some cases when a few lymph nodes are also removed, known as “extended simple mastectomy”.

  • Radical mastectomy- Also known as Halsted radical mastectomy. In this-

Entire breast, overlying skin and areola, underlying fascia, muscles and lymph nodes in the axilla are removed.

  • Modified radical mastectomy- It is a widely used procedure with minimum loss of muscles of the chest wall. Breast reconstruction can be an option in this type of surgery.
  • Nipple sparing/skin sparing mastectomy- In this surgery skin of breast, nipple and areola are preserved while the breast and tumor is removed.

Complications after mastectomy-

  • Infection around incision
  • DVT
  • Lymphedema

Immediate care-

  • Sponge bath until stitches are removed to maintain hygiene
  • Avoid overhead lifting, strenuous sports and sexual intercourse for 3-6 weeks.
  • Shoulder and arm stretching exercises after removal of drain.
  • Support groups are helpful in dealing with emotional trauma.
  •  For women who choose not to have breast reconstruction , it will be important to find a proper fitting external breast prosthesis made of cloth or HDP foam. 

Prognosis-

The breast area will recover in 3 to 4 weeks without reconstruction and up to 6 weeks with breast reconstruction surgery.

Follow-up treatment –

Radiation therapy-

It involves beaming X-rays at the site of tumor to kill and shrink the size of malignant cells and sterilize surrounding tissues. It is effective in early cases of breast cancer and is often used following a lumpectomy rather than as primary treatment.

Chemotherapy-

Generally, the anticancer cocktail is administered intravenously, in every 3 to 4 weeks for 4 to 24 months. Chemotherapy is systemic treatment so the drugs reach every part of the body but can produce debilitating side effects. 

Physiotherapy management – 

  1. Wound management and prevention of contractures- 
    • low power laser therapy or pulsed short wave or UVA exposure over the wound to promote healing. 
    • Positioning of affected side with shoulder held in 15 to 20 degree flexion-abduction-external rotation and the elbow, wrist and hand free to move (aeroplane splint may be advised till 7th to10th day when sutures are removed. 
    • Relaxed passive movements within pain free range  with at least 5 repetitions twice or thrice a day to retain available range. 
    •  If there are no specific contraindications, active exercises are initiated from the 3rd postoperative day. 
    • TENS in continuous or burst mode for pain relief.

2. Exercise plan for the first postoperative week-

  • Raise the affected arm above the level of the heart for 45 minutes, 2-3 times a day.
  • Exercise the affected arm while it is elevated.
  • Diaphragmatic exercises at least 6 times a day.

3. General guidelines for post operative exercises-

  • Desensitization by rubbing or stroking with hand or soft cloth to relieve burning, tingling, numbness or soreness.
  • Perform exercises after a warm shower to relax muscles.
  • Patients should wear comfortable clothing when doing the exercises.
  • Exercises should be done twice a day until normal range is achieved.

Reference-

  • Pushpal K Mitra ( Textbook of Physiotherapy in Surgical Conditions)
  • K Rajgopal Shenoy and Anitha Shenoy ( Manipal manual of surgery)
  • Norman S. Williams, P. Ronan O’Connelland Andrew W. McCaskie (Bailey & Love’s short practice of surgery)
  • B.D. Chaurasia ( Human anatomy)