Course

Section 1. Overview of breast cancer (OBC), 6 lectures

OBC 1.1 Statistics
Objective: This lecture outlines breast cancer statistics and their relevance physiotherapists.

Learning outcomes: By the end of this lecture you will be able to:

• Discuss global statistics e.g. prevalence, life time risk, future trends, racial and socioeconomic disparities
• List 5 types of statistics collected by Population Based Cancer Registries (PBCRs)
• Describe 2 factors that have contributed to a recent rise in number of survivors
• Discuss how physiotherapists can plan to meet future BC rehab needs

OBC 1.2 Anatomy
Objective: This lecture outlines anatomy of the breast and the regional lymphatic system.

Learning outcomes: By the end of this lecture you will be able to:

• Discuss the anatomy of the breast
• Describe the anatomy of the superficial and regional lymphatic system.
• List 4 structures that propel lymph fluid through the lymphatic system.
• Discuss how lymph redirects when regional axillary lymph nodes are compromised.
• List 3 soft tissue restrictions (STRs) that may impede lymphatic flow and redirection

OBC 1.3 Understand cancer
Objective: This lecture outlines the common definitions and terms used to explain cancer.

Learning outcomes: By the end of this lecture you will be able to:

• Discuss the W.H.O. definition of cancer
• List the 5 more common types of cancer
• Describe unregulated cell growth
• List the stages of cancer
• Discuss the purposes of staging by the pathologist.
• Discuss in-situ, invasive and metastatic carcinoma, at a cellular level

OBC 1.4 Breast cancer types.
Objective: This lecture outlines 7 common types and the less common types of BC
Learning outcomes: By the end of this lecture you will be able to:

• List the 7 main types of breast cancer
• Discuss “hormone status” and which 2 hormones may fuel breast cancer growth.
• List which group of women are at higher risk for triple negative breast cancer
• Discuss hereditary breast cancer, genetic testing and genetic counselling.
• Discuss the value of breast cancer rehab to patients with metastatic disease.

OBC 1.5 Risk factors
Objective: This lecture outlines breast cancer risk factors.
Learning outcomes: By the end of this lecture you will be able to:

• List 4 risk factors a woman cannot change
• Describe 3 benefits of genetic testing and counseling when family history is a factor
• Discuss a woman’s risk of developing a new cancer in the contralateral breast
• List the 3 features of a healthy diet
• Discuss the dual role physiotherapists play during breast cancer rehab.
• List 3 elements of integrative medicine’s holistic approach to cancer patients.

OBC 1.6 Diagnostic tests and surveillance scans
Objective: This lecture outlines the tests used to screen and diagnose breast cancer and for surveillance during survivorship.
Learning outcomes: By the end of this lecture you will be able to:

• Describe three types of mammography
• List the different tissue types targeted by the Fine Needle and the Core Needle Biopsy
• Describe what T, N and M stand for in the TNM staging system
• List the OncotypeDX low and high recurrence risk scores and their implications for chemotherapy in early breast cancer.
• Discuss 3 survivorship surveillance scans and their purposes.

Section 2. Overview of breast cancer treatment (OBCT) 6 lectures

OBCT 2.1 Surgery
Objectives: This lecture describes the types of breast cancer surgery and the post-operative issues relevant to physiotherapists and breast cancer rehab.
Learning outcomes: By the end of this lecture you will be able to:

• Discuss “The Halsted Procedure” and “The Halsted Theory”
• Describe two types of lymph node surgery and their post-operative physiotherapy.
• Discuss why a patient may select to have a prophylactic double mastectomy and why their lymphedema risk is zero.
• List the tissues removed and the tissues spared in a modified radical mastectomy.
• Discuss the post-op soft tissue restrictions and postures that may impede range of motion and lymph drainage out of the arm.

OBCT 2.2 Reconstruction surgeries
Objective: This lecture discusses the types of breast cancer reconstructions and lists the post-operative issues relevant to physiotherapists during breast cancer rehab.
Learning outcomes: By the end of this lecture you will be able to:

• Discuss “delayed“ and “spontaneous” reconstructions
• List the advantages of “Going flat”
• List the advantages of implant reconstructions.
• Describe the difference between a TRAM and a DIEP Flap reconstruction.
• Discuss when exercise precautions are advised post LAT Flap reconstruction.
• Discuss when implants may be removed and replaced.

OBCT 2.3 Post-operative issues.
Objective: In this lecture, we discuss breast cancer post-op issues and list those issues relevant to physiotherapists during breast cancer rehab.
Learning outcomes: By the end of this lecture you will be able to:

• Discuss when breast cancer patients are at increased risk for DVT.
• Discuss which reconstruction surgery requires seroma exercise precautions.
• Describe how to differentiate between lymphatic congestion and cellulitis
• Discuss lymphatic cording and list 2 physiotherapy treatments
• Discuss the Prospective Surveillance Model of Care for breast cancer rehab.

OBCT 2.4 Chemotherapy
Objective: In this lecture, we discuss the benefits and adverse effects of chemotherapy and hormone therapy and aspects relevant to physiotherapy during breast cancer rehab.
Learning outcomes: By the end of this lecture you will be able to:

• List 6 criteria oncologists consider to estimate recurrence risk
• Describe how chemotherapy kills cancer cells.
• List the adverse effects of chemotherapy
• Describe how Tamoxifen and Aromatase inhibitors reduce recurrence risk
• Discuss the benefits and timing of exercise with chemo and hormone therapy.

OBCT 2.5 Radiation Therapy
Objective: This lecture discusses the uses, types and adverse effects of radiation therapy (RT) and aspects relevant to physiotherapists during breast cancer rehab.
Learning outcomes: By the end of this lecture you will be able to:

• List 3 ways in which radiation therapy is used to treat cancer.
• Describe how Radiation Therapy induces apoptosis (cancer cell death).
• List 2 common, 2 not so common and 2 late adverse effects of radiation therapy
• List 5 patients at higher risk for developing late RT adverse effects
• Discuss skin-self-care that reduces RT’s adverse effects on the skin.

OBCT 2.6 The Breast Cancer Team
Objective: This lecture describes the multidisciplinary team and their clinical expertise to facilitate communication with physiotherapists (both hospital and community based).
Learning outcomes: By the end of this lecture you will be able to:

• Discuss the difference between conventional and alternative oncology.
• List 5 key members of the hospital based cancer team
• Describe the pathologist’s clinical expertise
• Describe the medical oncologist’s clinical expertise
• List the clinical expertise of the hospital and community based physiotherapists.

Section 3. Overview of breast cancer rehab (OBCR) 14 lectures

OBCT 3.1 BC Rehab Assessment
Objective: To review the BC rehab assessment and outcome measures physiotherapists use to design, monitor and evaluate, breast cancer rehab services.
Learning outcomes: By the end of this lecture you will be able to:

• List the assessment questions for breast cancer surgery and reconstruction surgery
• List the assessment questions for radiation therapy
• Learn how to estimate patients risk for developing lymphedema
• Describe the outcome measures for pain, range of motion, fatigue and distress.
• Discuss how scars and soft tissue restrictions adversely affect lymph flow redirection.

OBCT 3.2 Breathing Exercises
Objective: This lecture discusses how breast cancer treatments affect tissues attached to the thorax and the techniques physiotherapists may use to recover good breathing mechanics.
Learning outcomes: By the end of this lecture you will be able to:

• Discuss 3 factors that may adversely influence breathing mechanics.
• List 6 soft tissues attached to the thoracic wall affected by breast cancer treatments
• Explain the link between CO2 and pH.
• Describe how diaphragmatic exercises affect lymph flow.
• List 7 exercises patients can do at home to recover thoracic mobility.

OBCT 3.3 Level 1 Exercises
Objective: This lecture discusses early postoperative or Level 1 Exercises that physiotherapists can consider for breast cancer patients with surgical drains in situ.
Learning outcomes: After this lecture you will be able to

• Discuss future trends in the numbers of new cancer cases
• List 3 aspects of cancer, positively affected by exercise.
• Define a seroma.
• Discuss how Level 1 Exercises balance the benefits of early postoperative exercise with the and risks of delayed healing.
• List 4 Level 1 exercises.

OBCT 3.4 Level 2 Exercises
Objective: This lecture discusses The Level 2 Exercise Series, after the surgical drains are removed during the first 6-8 weeks postop.
Learning outcomes: After this lecture you will be able to

• List 3 of the APTAs CPGs for early postoperative exercise.
• Describe two applications for The Level 2 Exercise Series
• List 3 physical impairments Level 2 Exercises may benefit
• Describe the measures physiotherapist may use to assess and re-assess changes.
• List the 6 exercises in the Level 2 series.

OBCT 3.5 Manual Therapy

Objective: This lecture discusses manual therapy after breast cancer treatment so physiotherapists are aware of specific tissue issues, contraindications and precautions and useful techniques to gain an excellent result.
Learning outcomes: After this lecture you will be able to

• Describe 3 types of soft tissue restrictions after breast cancer treatment
• List 4 surgical scars that may limit flexion
• Describe how skin changes after radiation affect lymph drainage
• Discuss 2 contraindications and 3 precautions for manual therapy when the lymphatic system is compromised.
• List 7 soft tissue techniques to release scars and radiation fibrosis.

OBCT 3.6 Cording
Objective: This lecture discusses cording and the treatments physiotherapists can use to safely release them during in-person and during Telehealth visits.
Learning outcomes: After this lecture you will be able to

• Describe how cording limits shoulder abduction and flexion.
• List 3 benefits of early physiotherapy
• Discuss “bony precautions” for breast cancer patients.
• Describe 2 soft tissue techniques for cording
• List the 4 exercises in The Cording Exercise Sequence

OBCT 3.7 Lymphedema
Objective: This lecture discusses the 2020 APTA’s Clinical Practice Guidelines (CPGs) initial conservative intervention for lymphedema for physiotherapists to guide patients “at risk” for this condition and how to refer for Complete Decongestive Therapy (CDT).
Learning outcomes: After this lecture you will be able to:

• List 3 types of primary and 2 causes of secondary lymphedema
• Describe lymph flow from start to finish.
• Discuss how lymph “redirects” to healthy nodes after breast cancer treatment
• List the first 3 stages of BCRL and their APTA’s CPGs
• Describe, how often “at risk” patients are screened as per the PSM model of care.

OBCT 3.8 Measuring BCRL
Objective: This lecture discusses the low cost, valid and reliable Myotape method for self-measuring breast cancer related lymphedema (BCRL) for physiotherapists and patients to develop consistent technique.
Learning outcomes: After this lecture you will be able to discuss:

• What physiotherapists and patients need to measure
• Where to start taking measurements
• Which five data points to use for arms
• How to use the tape correctly
• How to record the data using the chart.

OBCT 3.9 Compression sleeves

Objective: This lecture on compression therapy discusses the ready-made garments used for the initial conservative intervention for breast cancer related lymphedema (BCRL).
Learning outcomes: After this lecture you will be able to:

• Describe how compression garments affect BCRL.
• Discuss the evidence supporting ready-made garments for sub-clinical BCRL
• List the contraindications and precautions for compression therapy.
• List the 9 steps physiotherapists take when measuring, selecting and ordering CLL 2 ready-made compression arm sleeves e.g. The Bella Lite from JOBST
• Describe 2 donning aids

OBCT 3.10 Self-Care
Objective: This lecture discusses self-care and practices cancer survivors patients can learn to use at home, at work, during exercise and when on holiday.
Learning outcomes: After this lecture you will be able to:

• Describe the glands responsible for the skin’s acid mantle
• Discuss how skin care products negatively and positively affect the acid mantle
• Describe how skin bacteria can cause cellulitis
• List 7 BCRL risk reduction practices that patients can adopt
• Discuss 2 ways patients can avoid over-whelming a compromised lymphatic system.

OBCR 3.11 Self-Manual Lymph Drainage (S-MLD)
Objective: This lecture discusses Self-MLD for patients to do at home and as needed.
Learning outcomes: After this lecture you will be able to:

• Discuss the evidence for MLD and S-MLD
• List the component parts of the initial intervention for early BCRL
• List contraindications and precautions for MLD and S-MLD
• Describe 2 MLD strokes used in S-MLD
• Describe the S-MLD sequence for an arm.

OBCR 3.12 Stretching
Objective: This lecture aims to discuss the adverse effects of cancer treatment on the chest muscles and a cancer specific self-stretching progression.
Learning outcomes: After taking this lecture you will be able to:

• List 3 types of radiation fibrosis
• Discuss why a routine stretching program is best adopted from the beginning and sustained throughout survivorship
• List 3 muscles that are attached to the coracoid process.
• Describe 2 methods of measuring pectoralis minor.
• List the 4 arm positions during the chest prolonged-low-load-stretch-progression

OBCR 3.13 The 12 Week Walking Program
Objective: This lecture reviews this evidenced based 12 Week Walking Program designed for Breast Cancer
Learning outcomes: After taking this lecture you will be able to:

• Define “moderate” and “vigorous” level physical activity as per the guidelines
• List 3 behaviour change techniques (BCTs) used in the 12 Week Walking Program
• List the number of “brisk minutes walked daily” during week 2 and week 10.
• Describe the difference between a pedometer and an accelerometer.
• List 4 “self-monitoring” activities.

OBCR 3.14 Level 3 Exercises
Objective: This lecture aims to review the most recently updated exercise guidelines for physiotherapists as they prescribe fitness and flexibility exercises for breast cancer survivors.
Learning outcomes: After taking this lecture you will be able to:

• List the benefits of exercise and cancer.
• Discuss the link between menopause, body fat, estrogen, prognosis and exercise
• Describe the latest recommendations for aerobic and strength exercises
• List the main barriers to women adopting habitual exercise
• Describe the benefits of isolated and compound exercises
• Describe a home based, compound exercise progression.