Breast Cancer and Pilates rehabilitation choices

To date in 2023, there have been 20,600 new cases of Breast Cancer recorded in Australia (20,395 females and 205 males). The average age of diagnosis is 62 years old, with one in eight being diagnosed before the age of 85 years old.  

The incidence of Breast Cancer is increasing, due to accurate diagnosis with improved screening and hormonal factors which I will elaborate on below. But pleasingly, the mortality rates are reducing as early detection and treatment options are improving.  

Let us look at the hormonal factors. The more oestrogen in your body, the higher the risk of developing breast cancer. If you start menstruation prior to 12 years old and do not move through menopause until post 55 years old, you are at higher risk. Those women who have never had a pregnancy also present as a higher risk. 75 per cent of breast cancer is in the ages 50 years plus and those most at risk are women who are post-menopausal.  

There is one genetic factor for Breast Cancer. The BRCA 1 and BRCA2 gene predispose a person to Breast Cancer. If there are changes to these genes, cancer cells will proliferate.  

Breast Cancer is categorised into stages.  

Stage One – pre invasive Breast Cancer where abnormal cells are contained inside the milk duct / labule. 

Stage Two – Early-stage Breast Cancer where invasive abnormal cells located in the milk duct and labule invade into surrounding tissues. These cells may or may not spread to the lymph nodes of the axilla.  

Stage Three – large abnormal cell clusters greater than 5cm spreading to the lymph nodes of the axilla and surrounding tissue.  

Stage Four – advanced stage metastatic cancer spreading beyond the breast to bones, liver, lungs, or brain. 

Stage one is treated with small, localised surgery and monitoring. Stages two and three are treated with surgery and radiotherapy. According to the Memorial Sloan Kettering Cancer Centre, the survival rates are listed as Stage 1 = 99%, Stage two = 86%, Stage 3 = 30%. 

Let's look at the several types of Breast Cancer treatment. In the case of a small bundle of contained abnormal cells, a lumpectomy (breast-conserving surgery) is performed with annual bilateral mammograms to monitor. The addition of chemotherapy is dependent on any comorbidities and degree of frailty. Any female greater than 50 years and at higher risk (for example, early onset menstruation, no pregnancies and not yet reached menopause) are advised to have an annual bilateral Breast MRI. Those with the BRCA gene may consider removal of both breasts and a hysterectomy to prevent abnormal cell production.  

A mastectomy is the removal of the whole breast including breast tissue, milk ducts, skin and nipple. Sometimes the axilla lymph nodes are removed also. The surgery will take approximately four hours with a six-week recovery plan. A Radical Mastectomy includes the removal of the breast as well as the chest wall muscles beneath. Chemotherapy is often used in conjunction, to reduce the size of the tumours. 

Side effects of a mastectomy include, 

·       Neural pins and needles across the surgical site 

·       Axilla numbness with nerve damage during removal of lymph nodes 

·       Shoulder joint stiffness especially if Latissimus Dorsi skin flap used in reconstruction 

·       Cording -> tight cord of scar tissue from the axilla along the side of the chest wall 

·       Intercostal pain  

·       Effects of poor basal / lung expansion 

·       Swelling around the armpit (Seroma)  

·       Lymphoedema in the surgical side arm  

·       Changes in balance distribution, particularly if large breasts 

·       Depression around body image 

·       Anxiety around fear of the return of cancer  

Chemotherapy is the systemic administration of chemotherapeutic agents (anti-cancer drugs). In the case of breast cancer, the medications specifically target and inhibit the growth-promoting signals from oestrogen. This therapy is systemic, meaning that it is introduced to the bloodstream and therefore targets cancer at any anatomical location in the body. This allows the targeting of those cancerous cells that escape through the bloodstream and do not show up on scans. Chemotherapy is delivered in an outpatient scenario over a one to six-hour timeframe over three to six months. Common side effects include nausea and vomiting, hair loss, fatigue, diarrhoea or constipation, weight loss, mouth ulcers and infections, skin and nail changes and menopausal symptoms (which may be temporary or permanent). 

Radiotherapy is used for all stages of Breast Cancer and is recommended for lumpectomy. It is a localised treatment where radiation is targeted to damage or kill the cancerous cells. It is delivered daily over a three to six week period.  It can be given from a source outside the body or through a sealed device inserted into the body. Common side effects include itchy burnt skin at the site of the radiotherapy, brachial plexopathy and in extreme cases, pulmonary fibrosis (lung tissue scarring).

Breast reconstruction is common post-surgery. The surgery may be performed at the time of the mastectomy / radical mastectomy or later. The breast can be reformed by using prosthetic implants or skin and muscular flaps from the Latissimus Dorsi muscle or the Transcutaneous Rectus Abdominus.  

Any person going through Breast Cancer and its forms of treatment, are encouraged to, 

·       Stay strong 

·       Keep moving 

·       Relax the mind and body  

·       Follow good nutrition 

When we look at Joseph’s three guiding principles of breath, whole-body health and whole-body commitment, we can relate these to the treatment care plan of the breast cancer client.  

Pilates is an exercise method that can be utilised from the preliminary stages of cancer treatment focusing on breath, ribcage mobility, thoracic mobility, and shoulder joint organisation. Post-surgery, the reconnection of the cylinder of support, mobility of thoracic cage and thoracic spine and breath is imperative. Initially working on fundamentals to assist in regaining shoulder joint range of movement, shoulder girdle function and postural strength and endurance, skeletal stability, then progressing to whole body extensor strength. 

Breast reconstruction involving the Rectus Abdominus will require specific re-education of the Transversus Abdominus, lengthening for the iliopsoas and dissociation of the pelvic-hip complex. Reconstruction involving Latissimus Dorsi will warrant specific extensor strengthening and shoulder organisation.

The Pilates Method allows for slow and controlled return to exercise respecting fatigue and changes in body proportions. The mindfulness of our exercise method allows focus on self, rejuvenation and reduction in depression and anxiety. 

We may need to refer outside our scope of practice to soft tissue release, scar tissue release or shoulder joint of cervico-thoracic adjustments. Any client with Lymphedema will consult a lymphoedema specialist and may need to wear their pressure garment whilst in the studio.  

For those who beat Cancer can seize their new lease on life to better health and wellbeing by continuing with regular Pilates sessions.

Jennifer Guest is a Senior Educator Polestar Pilates Australasia and Senior Physiotherapist Smart Health, South Australia.