Introduction
According to the American Cancer Society, as of January 1, 2019, there were 3,861,520 women living with breast cancer; 807,860 women living with uterine cancer; 283,120 women living with cervical cancer; and 249,320 women living with ovarian cancer. The 5-year survival rates are 91% for breast cancer, 65.8% for cervical cancer, 81.2% for uterine cancer, and 47.6% for ovarian cancer. As women are surviving breast and gynecologic cancers longer, it is perhaps not surprising that the projection for people living with breast and gynecologic cancers is to see these numbers increase. The projection is that by 2030 there will be 4,957,960 living with breast cancer; 1,023,290 living with uterine cancer; 297,580 living with ovarian cancer; and 288,710 living with uterine cervix cancer. Women are also living substantially longer post diagnosis as well. For example, 19% of women are living 20+ years since diagnosed with breast cancer, 29% since diagnosed with ovarian cancer, 49% since diagnosed with cervical cancer, and 22% with uterine cancer. The number of women living with metastatic breast cancer is greater than 150,000. Women are also diagnosed with breast or gynecologic cancer more often later in life. For example, age at prevalence for women diagnosed with breast cancer in the 65–84 age-group was 51% for breast cancer, 47% for ovarian cancer, 39% for uterine cancer, and 56% for uterine corpus.
These statistics illustrate that there are a significant number of women diagnosed with breast and gynecologic cancers, often later in life and living longer post treatments for their cancer. The most common treatments for these types of cancers include a combination of surgery, radiation therapy, chemotherapy, and antihormonal therapy. Whereas these treatments can be very successful in treating the cancer, they can also have an adverse impact on healthy tissues such as muscle, nerve, and connective. The adverse impact on healthy tissues can at times be very close to the onset of the treatment; however, these adverse effects often develop slowly over time leading to a gradual loss of function that can be imperceptible to both the individual and the treatment team. Often the loss of function cannot be directly linked to any one treatment, but rather to a combined effect of several treatments as well the patient’s own precancer state of health, nutritional status, and preexisting diseases such as diabetes mellitus.
Rehabilitation medicine should be an integral part of the care of the person with breast or gynecologic cancer from time of diagnosis, through active treatment and in the survivorship period. Following diagnosis and precancer treatment, physiatrists can assess the patient for any preexisting physical impairments of key body structures that would be subjected to the effects of multimodality cancer treatment. For the person with newly diagnosed breast cancer, this can include shoulder dysfunction, assessment of preexisting peripheral neuropathy, preexisting painful joint conditions affecting the hands, knees, and lower back, and lymphedema. For the person with newly diagnosed gynecologic cancer, this can include assessment of preexisting peripheral neuropathy, preexisting lymphedema of leg, impaired balance, decreased fine motor skills and strength in hands, and history of pelvic floor dysfunction. In addition, an assessment of nutritional status, preexisting cognitive impairment, depression, and anxiety is also very important.
Physiatrists can also provide useful and timely information to medical, surgical, and radiation oncologists with respect to potential impact of cancer treatment on loss of function, which can then in turn be useful in the planning of the cancer treatment. This is based on their knowledge of functional anatomy of the musculoskeletal and nervous systems as well as assessment of functional loss. This information would ideally be discussed at multidisciplinary tumor boards. Another role that physiatrists can have in the planning of cancer treatment is to assess the patient for frailty since frailty can have an adverse impact on a person’s ability to tolerate cancer treatments.
Once these preexisting impairments are identified, a coordinated effort of various team members such as physical therapy, occupational therapy, psychology, and nutrition to minimize them is critical. At times, it is not realistic to address all of these impairments prior to start of treatment since the patient’s focus as well as that of the cancer treatment team is on initiating treatment as soon as possible, therefore prioritization is key. For example, a patient with a preexisting reduction in range of motion of the shoulder would need this limitation to be addressed to help her undergo radiation therapy. Rehabilitative interventions can be continued during active cancer treatment; however, this depends on the patient’s ability to tolerate both cancer treatment and rehabilitative interventions concurrently. Periodic surveillance for subjective and objective evidence of loss of physical function becomes important at times during active treatment as well as during survivorship.
Assessment of Breast and Gynecologic Cancer Patient with a Focus on Physical Impairments and Loss of Function
The physiatrist should approach the assessment of the person with breast or gynecologic cancer by having a good working knowledge of the common physical, cognitive, and psychologic impairments affecting the breast and gynecologic cancer patients and utilizing appropriate clinical assessment tools.
A review of pertinent past medical history and past surgical history can help identify the areas of potential loss of function. For example, preexisting peripheral neuropathy from diabetes may worsen once the patient is treated with chemotherapy, thereby adversely affecting hand function and balance. Another example is a patient with a history of limited shoulder function due to adhesive capsulitis that could potentially lead to a worsening of the condition following treatment of breast cancer with surgery and radiation therapy.
Review of prior imaging studies such as PET/CT scans, bone scans, MRIs, and plain X-rays can help identify the areas with metastatic disease. Results of echocardiograms and pulmonary function studies, if available, can provide information about heart and lung function, respectively. That knowledge can then be used in setting precautions during rehabilitation to minimize the risk of harm for the patient. Review of laboratory studies such as hemoglobin, platelet, and white blood cell counts can yield important information that can be used in generating additional hematological precautions in the rehabilitation prescription. This information as well as review of liver and renal function tests and medications for pertinent drug–drug and drug–disease interactions can be very useful when prescribing medications for the treatment of painful conditions.
The review of systems can serve as a useful “checklist” of areas of potential concern with respect to loss of function post breast and gynecologic cancer treatment. Table 1.1 provides an example of such a checklist as well as possible treatment interventions. In addition to those listed, other areas of interest include symptoms pertaining to the cardiovascular, pulmonary, and nervous systems as well as changes in weight and appetite.
| Impairment | Sample Interventions |
|---|---|
| Fatigue | Medication review |
| Treat underlying anemia and hypothyroidism if present | |
| Treat depression if present | |
| Exercise program | |
| General weakness | Exercise program |
| Obesity | Nutrition referral, exercise |
| Shoulder dysfunction | Physical therapy |
| Nonsteroidal antiinflammatory drugs | |
| Aromatase inhibitor musculoskeletal symptoms | Physical and occupational therapy |
| Nutrition referral if obesity is present | |
| Nonsteroidal antiinflammatory drugs | |
| Injections | |
| Lymphedema | Lymphedema therapy, compression sleeve, compression pump, patient education |
| Nutrition referral if obese | |
| Arm-strengthening exercises | |
| Peripheral neuropathy | Physical therapy |
| Occupational therapy | |
| Medications—duloxetine, pregabalin, gabapentin | |
| Topical medications | |
| Cognitive impairment | Neuropsychological evaluation |
| Occupational and speech therapy | |
| Psychosocial distress | Psychiatry, psychology, social work referral |
| Adverse impact of impairments on work | Physical and occupational therapy |
| Driver training | |
| Ergonomic evaluation, functional capacity evaluation |
It is also important to assess the patient’s level of function in their home, community, and work settings. Pertinent questions about the person’s ability to perform self-care activities such as bathing and dressing and limitations or need for additional assistance are important. Household and community mobility, need for assistive devices for walking, ability to drive, shop for food, and managing finances can all yield important information about functional loss.
If the patient is working, it is important to inquire about the specific tasks involved in their work and any current limitations in their ability to perform their work. For example, a person with breast cancer who works as a hairdresser may have difficulty raising her arm overhead following breast cancer surgery, which can adversely affect her ability to perform her job. Another example is a person with gynecologic cancer that develops lymphedema of the lower extremity as well as peripheral neuropathy, both of which can make it difficult for her to maintain her balance and walk. This in turn can have an adverse effect on her job as a flight attendant for example. It is also important to ask the person about any problems with concentration, memory loss, or difficulty performing activities that require the use of executive functioning skills for either work, school, hobbies, or family life.
Lastly, inquiring about the patient’s ability to function in their various life roles such as spouse or partner, daughter, and/or parent can yield useful information about additional functional limitations. For example, are there difficulties with child rearing due to shoulder or other joint pains or impaired balance associated with neuropathy? Another example, is there sexual dysfunction associated with treatment for gynecologic cancer that included surgery and radiation therapy?
Since exercise is an important part of the lives of many patients with breast and gynecologic cancers, it is useful to inquire about any limitations in the person’s ability to engage in different forms of exercise due to their cancer and cancer treatment. For example, a person may be reluctant to participate due to joint pains or concerns about safely exercising if they have metastatic bone disease.
The physical examination of the breast and gynecologic cancer patients should include a thorough assessment of the nervous and musculoskeletal system that includes inspection, palpation, range of motion, as well as special diagnostic tests of interest. Inspection and palpation of surgical scars can yield useful information about structures that can be a source of pain.
Muscle strength testing of key muscle groups of the upper and lower extremities, testing of muscle stretch reflexes of the upper and lower extremities, as well as sensory testing of the extremities utilizing tests for light touch, pinprick, vibration, proprioception, cold testing, and monofilament testing to name a few can be useful. Assessment for the presence of lymphedema should include obtaining circumferential measurements of the arms or legs as necessary to either establish a baseline level for the patient prior to start of breast or gynecologic cancer treatment, respectively, as well as posttreatment.
Functional examination in the clinic setting can provide useful information about strength, fall risk, as well as presence of frailty. Sample tests include (1) Timed Up and Go Test, (2) sit-to-stand test, (3) balance test, and (4) grip strength. Self-reported outcome measures can also provide useful information about general physical function and fatigue.
Cascade of Disability
Treatments for breast and gynecologic cancers can have significant adverse effects on the individual affected by these cancers. One way to think about this is through a layering of impairments. There are several layers of potential issues affecting the person with breast or gynecologic cancer: (1) aging-related changes; (2) presence of comorbid conditions such as diabetes, cardiac disease, and connective tissue disorders; (3) cancer characteristics such as tumor size and location, lymph node involvement, and presence of metastatic disease; and (4) cancer treatment–related injury to healthy tissues from surgery, chemotherapy, radiation therapy, antihormonal therapies ( Figs. 1.1 and 1.2 ).
