The document provides information about mastectomy, breast anatomy, risk factors for breast cancer, ways to minimize risk, breast cancer in men, lymph node involvement, screening methods, self-breast exams, mammography, biopsy procedures, breast cancer surgeries, treatments, rehabilitation issues, and exercises after breast cancer surgery. It defines a mastectomy, lists what is removed, and explains that lymph nodes may also be removed. It also outlines steps for self-breast exams and describes mammography.

1. Mastectomy

2. • What is a mastectomy?
• A mastectomy is a surgery that removes all of the breast
tissue.
• Usually the nipple is removed as well.
• No muscles are removed.
• Lymph nodes from your armpit area can be removed at
the same time.

3. Breast A & P
• Male and female breast
develop at the same rate till
puberty.
• Located between the 2nd &
6th ribs.
• Tail of Spence extends into
the axilla.
• Cooper’s ligaments support
the breast to the chest wall.
• Each breast contains 12-20
lobes.

4. • Personal Health History
• Family Health History
• Certain Genome Changes
• Radiation Therapy to the Chest
• Reproductive and Menstruation History
• Race
• Being Overweight or Obese after Menopause
• Lack of Physical Activity
• Alcohol Use
• Smoking
• Age
Risk Factors

5. • Lose excess weight.
• Be physically active.
• Limit your intake of alcohol.
• Breastfeed your baby.
• Quit smoking.
• Talk to your doctor about the risks and benefits of
hormone replacement therapy (HRT).
• Reduce exposure to chemicals
Minimizing Your Risk

6. Men & Breast Cancer
• Less than 1% of breast cancers happen to men in
Canada; however the number is increasing
• Men over the age of 60 are most often diagnosed with
breast cancer
• Risk factors, diagnosis, staging and treatment are the
same as in women
• Risk factors include: mumps, radiation exposure &
decreased testosterone levels.
• Most common is ductal carcinoma – found in breast
ducts
• Symptoms include a small painless lump, discharge
from nipple, inverted nipple and skin ulceration
• Adverse feelings related to “manhood” and sexuality,
having a “women’s disease”

7. • Some breast cancers spread to the lymph nodes
under a woman's arm.
• Microscopic examination:
• Lymph node involvement = positive
• Lymph node clear of cancer = negative
• Connection between the number of lymph nodes
involved & aggressiveness of cancer's personality.
• Knowing how many lymph nodes are involved will
help identify appropriate treatment.
Lymph Node Involvement

8. Screening
• 1. SBE (self-breast examination)
• 2. Mammography

9. Self Breast Examination
• Self Breast Exams are an important way to find
a breast cancer early.
• Not every cancer can be found this way, but it is
critical to become familiar with your breasts in
order to identify an abnormality
• SBE should be done once a month
approximately 1wk after your menstrual period

10. • Lumps
• most women have lumps or lumpy areas in
the breast that may be the result of
Fibroadenomas or Cysts
• 8 out of 10 lumps removed from the breast
are benign
• Upper/outer area(armpit)- most prominent
lumps/bumps
• Lower half - sandy/pebbly beach
• Underneath nipple - collection of large grains
• Other parts - lumpy bowl of oatmeal
Self Breast Exam cont’d

11. Studies show that regular
breast self-exams,
combined with an annual
exam by a doctor, improves
the chances of detecting
cancer early.

12. – Look in the mirror, shoulders straight
and arms on your hips.
– Look for size, shape, and colour of
breasts, is there any distortion or
swelling present
– Changes to report: dimpling,
puckering, bulging of the skin,
change in nipple position, inverted
nipple, redness, soreness, rash or
swelling.
Steps to a Self Breast Exam:
Step 1

13. – Raise your arms
above your
head and look
for the same
changes.
Step 2

14. • Still standing at the mirror, look for any
discharge/fluid coming from your nipples.
• Changes to report: any fluid coming out of
1 or both nipples (unless you are lactating).
Could be watery, milky, yellow or bloody.
Step 3

15. • Lie down on the bed and
palpate breasts using
pads of a few fingers.
• Use a firm smooth touch
in a circular motion.
• Cover entire breast –
collar bone to top of
stomach, armpit to
sternum.
• Make sure to follow a
pattern so to cover all
area of the breasts.
Step 4

16. Step 5
• Sit or stand and
palpate the breast
in the same manner
as step 4.
• Changes to report:
lumps, bumps,
irregularities

17. Mammography
• Breast imaging technique
• Identifies non-palpable masses and diagnoses palpable
masses
• Procedure takes approximately 15 minutes
• Breast is compressed from top to bottom, and side to
side
• New and old mammograms are compared
• Radiation exposure is equivalent to 1 hour in the sun
• Canadian Cancer Society recommends women to have a
mammogram every 2 years between 50 & 69 years of
age.
• Women at high risk and under 50 should speak with the
HCP

18. EXPERT QUOTE
"The biggest misconception about
mammography is that it picks up every
breast cancer. In fact, mammography
misses at least 10 percent of breast
cancer. So if you feel a lump that
doesn't show up on a mammogram,
bring it to your doctor's attention. Get
it evaluated."
—Susan Orel, M.D.

19. Diagnosis for Breast Cancer
• Procedures for tissue analysis:
– Percutaneous Biopsy
– Fine-Needle Aspiration
– Core Needle Biopsy
– Guided Core Biopsy
– Surgical Biopsy
– Excisional Biopsy
– Incisional Biopsy

20. Needle Biopsy

21. Excisional Biopsy

22. • Surgery
• Chemotherapy
• Radiation
• Adjunctive Therapy
• Alternative Therapy
Treatment

23. Breast Sparing Surgery: Lumpectomy &
Partial Mastectomy

24. Modified Radical Mastectomy

25. Radical Mastectomy-In a radical mastectomy, the entire breast, nipple,
nodes and muscle under the breast is removed. This type of surgery is
rarely completed anymore.

26. Total Mastectomy-A simple or total mastectomy is the removal of all the
breast tissue and skin, including nipple and areola. Lymph nodes and
chest muscles are left undisturbed. Prophylactic mastectomies for
women at high risk for breast cancer are usually simple mastectomies

27. Common Rehabilitation Issues Related To
Breast Cancer
I. Upper Quadrant and Trunk Dysfunction
1. Restricted Shoulder Range of Motion and Pain
2. Chest Wall Pain
3. Weakness of Upper Extremity and Trunk/CORE
II. Lymphedema
1. Upper Extremity
2. Breast
3. Trunk
III. Fatigue
IV. Weight Gain
IV. Psychosocial Issues
V. Nutritional Issues

28. Etiology of Musculoskeletal Problems During and
After Breast Cancer Treatment
• Surgery
– Mastectomy/ Breast Conserving Surgery (BCS) (Lumpectomy)
– Axillary Node Dissection (ALND)
– Donor Sites for Reconstruction
– Drain Sites
• Radiation
– Breast/Chest Wall
– Axilla
• Chemotherapy
– Fatigue
– Port Site Pain
– Joint and Muscle Pain
• Quality of Recovery Advice
– Women commonly advised to avoid exercise
– Lack of information regarding maximizing recovery
– Lack of understanding of role of rehabilitation in breast cancer

29. Shoulder Restriction and Loss of Function
Post Surgery
Short Term:
• Significant loss of shoulder range of motion reported 2-3 months post
mastectomy (Gosselink et al, 2003; Reitman, 2003)
Long Term:
• Loss of range of motion reported by 26% of women 1 year post
mastectomy; 15% post BCS (Karki et al, 2005; Blomqvist et al, 2004)
Nature of Restriction:
• Flexion and abduction most limited (Blomqvist et al, 2004)
• Range of motion restriction greater for patients who:
– Mastectomy versus BCS
– Received radiation (Blomqvist et al, 2004)
– Underwent AND versus SNB (Leidenius, 2005)

30. Post-Surgical Pain
Prevalence of Pain 1 Year Post Surgery (Karki et al, 2005)
Mastectomy BCS(breast
conserving
surgery/
lumpectomy
Neck-shoulder pain 42% 37%
Upper extremity Pain 26% 15%
Breast/Chest Wall Pain 28% 20%

31. Weakness Post Surgery
•
• Significant decrease in strength in
shoulder flexion and abduction 15 months
post-mastectomy (Blomqvist et al, 2004)
• EMG abnormalities in upper trapezius and
rhomboids with associated reduction in
shoulder function post-mastectomy
(Shamley, 2007)

32. Axillary Cording (Web Syndrome)
Leidenius et al, 2003; Moskovitz, 2001; Lauridson, 2005
• Painful, palpable cords in axilla,
across antecubital fossa, in severe
cases to base of thumb
• Tissue sampling demonstrated that
cords were lymphatic and venous
tissue (Moskovitz)

33. Axillary Cording
(Ledenius, 2003; Lauridson, 2005)
• Prevalence of 60 – 70 % in
patients in prospective studies
• 20% of patients following
• Cording is associated with limited
ROM

34. Axillary Cording

35. Axillary Cording
Trunkal Cording
Painful Drain Site
Bilateral Mastectomy with TRAM reconstruction, Chemotherapy, No radiation

36. Implant
• Tissue expander
placed under pec
major at time of
mastectomy
• Silicone shell
gradually expanded
with saline
• Permanent saline or
silicone implant once
expansion completed
and/or following
adjuvant treatment
Pectoralis
Major

37. Breast Reconstruction
• Immediate or Delayed
• Performed in conjunction with
traditional mastectomy or skin sparing
• Options:
– Implant
– Autologous Tissue Reconstruction
• Latissimus Dorsi
• Transverse Rectus Abdominus Myocutaneous (TRAM)
• Other : buttock (superior or inferior gluteal), thigh
(tensor fascia lata)

38. Exercises After Breast
Cancer Surgery
• Many women with breast cancer have some kind of
surgery, even though other kinds of treatment are done,
too. You may have had a:
• Breast biopsy
• Lymph node biopsy or removal
• Breast conservation surgery (lumpectomy)
• Mastectomy
• Breast reconstruction

39. Exercises can help restore
movement.
• No matter what type of surgery you have, it’s important
to do exercises afterward to get the arm and shoulder
moving again.
• Exercises help to decrease side effects of your surgery
and help you get back to your usual activities.

40. • If you’ve had radiation therapy after surgery, exercises
are even more important to help keep your arm and
shoulder flexible.
• Radiation may affect your arm and shoulder long after
treatment is finished.
• Because of this, it’s important to develop a regular habit
of doing exercises to maintain arm and shoulder mobility
after radiation treatments for breast cancer.

41. • Some exercises should not be done until drains and
sutures (stitches) are removed. But some exercises can
be done soon after surgery.
• The exercises that increase your shoulder and arm
motion can usually be started in a few days. Exercises to
help make your arm stronger are added later

42. The week after surgery
• The exercises should be done for the first 3 to 7 days after
surgery. Do not do them until you get the OK from your
doctor.
• Use your affected arm (on the side where your surgery was) as you
normally would when you comb your hair, bathe, get dressed, and
eat.
• Lie down and raise your affected arm above the level of your heart
for 45 minutes. Do this 2 or 3 times a day.
• Put your arm on pillows so that your hand is higher than your wrist
and your elbow is a little higher than your shoulder. This will help
decrease the swelling that may happen after surgery.

43. • Practice deep breathing exercises (using your
diaphragm) at least 6 times a day. Lie down on your
back and take a slow, deep breath.
• Do not sleep on your affected arm or lie on that side

44. General guidelines for these
exercises
• You will feel some tightness in your chest and armpit after surgery.
This is normal, and the tightness will decrease as you do your
exercises.
• Many women have burning, tingling, numbness, or soreness on the
back of the arm and/or on the chest wall. This is because the
surgery can irritate some of your nerves.
• These feelings might increase a few weeks after surgery. But keep
doing your exercises unless you notice unusual swelling or
tenderness. (If this happens, let your doctor know about it right
away.)
• Sometimes rubbing or stroking the area with your hand or a soft
cloth can help make the area less sensitive.

45. • It may be helpful to do the exercises after a warm shower when
muscles are warm and relaxed.
• Wear comfortable, loose clothing when doing the exercises.
• Do the exercises slowly until you feel a gentle stretch. Hold each
stretch at the end of the motion and slowly count to 5. It’s normal
to feel some pulling as you stretch the skin and muscles that have
been shortened because of the surgery.
• Do not bounce or make any jerky movements when doing any of
the exercises. You should not feel pain as you do them, only gentle
stretching.

46. • Do each exercise 5 to 7 times. Try to do each exercise correctly. If
you have trouble with the exercises, talk to your doctor. You may
need to be referred to a physical or occupational therapist.
• Do the exercises twice a day until you get back your normal
flexibility.
• Be sure to take deep breaths, in and out, as you do each exercise.
• The exercises are set up so that you start them lying down, move to
sitting, and finish them standing up.

47. • Wand Exercises This exercise helps increase your ability to move
your shoulders forward
• Lie on your back with your knees bent and your feet flat.
• Do these exercises on a bed or the floor.
• Hold the wand across your belly in both hands with your palms
facing up.
• Lift the wand up over your head as far as you can. Use your
unaffected arm to help lift the wand until you feel a stretch in your
affected arm.
• Hold for 5 seconds.
• Lower arms and repeat 5 to 7 times.

48. • Elbow winging -This exercise helps increase the movement in the
front of your chest and shoulder.
• It may take many weeks of regular exercise before your elbows will
get close to the bed or floor.
• Clasp your hands behind your neck with your elbows pointing
toward the ceiling.
• Move your elbows apart and down toward the bed or floor.
• Repeat 5 to 7 times.

49. • Shoulder blade exercises- This exercise helps increase your
shoulder blade movement.
• Sit in a chair very close to a table with your back against the back of
the chair.
• Place the unaffected arm on the table with your elbow bent and
palm down. Do not move this arm during the exercise.
• Place the affected arm on the table, palm down, with your elbow
straight.
• Without moving your trunk, slide the affected arm forward, toward
the opposite side of the table. You should feel your shoulder blade
move as you do this.
• Relax your arm and repeat 5 to 7 times.

50. • Shoulder blade squeeze
• This exercise also helps increase shoulder blade movement.
• Sit in a chair in front of a mirror. Face straight ahead. Do not rest
against the back of the chair.
• Your arms should be at your sides with your elbows bent.
• Squeeze your shoulder blades together, bringing your elbows behind
you. Keep your shoulders level as you do this. Do not lift your
shoulders up toward your ears.
• Return to the starting position and repeat 5 to 7 times.

51. • Side bends
• This exercise helps increase movement of your trunk and body.
• Sit in a chair and clasp your hands together in front of you. Lift your
arms slowly over your head, straightening your arms.
• When your arms are over your head, bend your trunk to the right
keeping your arms overhead.
• Return to the starting position and bend to the left.
• Repeat 5 to 7 times.

52. • Chest wall stretch
• This exercise helps stretch your chest.
• Stand facing a corner with your toes about 8 to 10 inches from the
corner.
• Bend your elbows and put your forearms on the wall, one on each
side of the corner. Your elbows should be as close to shoulder height
as possible.
• Keep your arms and feet in place and move your chest toward the
corner. You will feel a stretch across your chest and shoulders.
• Return to the starting position and repeat 5 to 7 times.
• The picture shows stretching both sides at the same time, but you
may find it more comfortable to stretch one arm at a time.

53. • Shoulder stretch
• This exercise helps increase your mobility in your shoulder.
• Stand facing the wall with your toes about 8 to 10 inches from the
wall.
• Put your hands on the wall. Use your fingers to "climb the wall,"
reaching as high as you can until you feel a stretch.
• Return to the starting position and repeat 5 to 7 times.
• The picture shows both arms going up at the same time, but you
might find it easier to raise one arm at a time.
• Be sure you keep your shoulders dropped far away from your ears
as you raise your arms.

54. Things to keep in mind after
breast surgery
• Start exercising slowly and increase as you are able. Stop exercising
and talk to your doctor right away if you:
• Get weaker, start losing your balance, or start falling
• Have pain that gets worse
• Have new heaviness, aching, tightness, or other strange sensations
in your arm
• Have unusual swelling or swelling gets worse
• Have headaches, dizziness, blurred vision, new numbness, or
tingling in your arms or chest
• It’s important to exercise to keep your muscles working as well as
possible, but it’s also important to be safe. Talk with your doctor
about the right kind of exercises for your condition, and then set
goals for increasing your level of physical activity.

55. •Thank You