Breast cancer is the most common malignancy in female patients. 
- Breast cancer is the most common cancer in American women. As of 2018, 1 in 8 women in the United States will be diagnosed with invasive breast cancer during her lifetime. This risk has been increasing since 1975. 
- Globally, female breast cancer ranks fifth in terms of cancer mortality. 
- From 2014 to 2018, the average age of women found to be diagnosed with breast cancer was 63. 
The treatment of breast cancer is constantly evolving. Fortunately, survival rates are likely to continue to improve due to improvements in individualized treatment and earlier detection .
The increase in the number of breast cancer survivors has led to more research and care towards developing interventions that will help improve the overall quality of life of breast cancer survivors. 
- Physiotherapists play an important role in the rehabilitation process and in the care of survivors during and after a breast cancer diagnosis.
- Physical activity and physical therapy have been shown to reduce the incidence of musculoskeletal disorders after cancer .
- Breast cancer requires an interdisciplinary team to achieve optimal outcomes. The team includes oncology and plastic surgeons, medical oncology, radiation oncology, pathology, physical therapy, radiology, nurses, navigators, and multiple others to discuss each patient and formulate treatment plan. Multiple retrospective studies have demonstrated that breast cancer patient outcomes continue to improve with the increased use of interprofessional teams .
Breast cancer is a malignant tumor originating from breast cells. As with other cancers, there are a variety of factors that increase the risk of breast cancer.
- DNA damage and genetic mutations that lead to breast cancer have been experimentally linked to estrogen exposure.
- Some people inherit DNA and genetic defects such as BRCA1 BRCA2 and P53, among others. Therefore, those with a family history of ovarian or breast cancer have an increased risk of developing breast cancer.
- The immune system normally seeks out cancer cells and cells with damaged DNA and destroys them. Breast cancer may be the result of failure of this effective immune defense and surveillance.
- These are several signaling systems of growth factors and other mediators that interact between stromal cells and epithelial cells. Disruption of these may also lead to breast cancer .
The vast majority of breast cancers are adenocarcinomas (99%). The most common types are:
- Invasive carcinoma not otherwise specified (ductal carcinoma not otherwise specified): 40-75%
- Ductal carcinoma in situ: 20-25% (non-invasive in ducts or lobules)
- Invasive lobular carcinoma: 5-15%
- Grade – “score” of cancer cell appearance and growth pattern: Grade 1 (also sometimes called well-differentiated); Grade 2 (moderately differentiated); Grade 3 high-grade (poorly differentiated).
- Tumor necrosis – if present, this means that dead breast cancer cells are seen in the tissue sample. Tumor necrosis is usually limited to a small area within the sample. Its presence indicates more aggressive breast cancer.
- Vascular or Lymphatic Invasion:- These types of invasion describe whether the cancer cells are evident in the blood vessels and lymph vessels that supply the breast tissue.
- Hormone receptor status: – To test whether breast cancer cells removed during biopsy or surgery have receptors for estrogen or progesterone. When estrogen and progesterone bind to these receptors, they promote cancer growth. The cancer is called hormone receptor positive or Hormone receptor negativity depends on whether they have these receptors . Hormone receptor status determines whether hormone therapy is appropriate.
- HER2 Status:- HER2 is a gene that, when dysfunctional, plays a role in the development of breast cancer. HER2-positive breast cancers tend to grow faster and spread more easily than HER2-negative breast cancers. 
Stage is the most basic way to classify how far a cancer has spread from its point of origin . The phase is the number zero and the Roman numerals I II III or IV (usually followed by A B or C). In general, the higher the number, the more advanced the cancer. For example, the fourth stage. breast cancer cells Has spread far from the breast and lymph nodes. The most common sites are bones, lungs, liver, and brain. This stage is described as “metastatic,” meaning it has spread beyond the area of the body where it was originally found.
Breast tumors are staged using the TNM system published by the American Joint Committee on Cancer/Union for International Cancer Control (UICC): Breast Cancer (Staging).
The TNM system uses information on:
- T: the size of the tumor and how far it has spread in the breast and nearby organs
- N: lymph node involvement
- M: Whether there is distant metastasis
Once TN and M have been determined by stage grouping, stage 0 I II III or IV is assigned. There was a positive correlation between the number of stages and how far the cancer had spread.
Metastasis involves one or more sites that spread to other parts of the body. This occurs by directly affecting organs or by spreading through the lymphatic and/or circulatory system. 
The following terms can be used to classify the extent of malignant cell spread: 
- Localized means there is no spread.
- Regional means spread to lymph node tissue or organs close to where the cancer started (primary site).
- Distant (also called metastatic cancer) is cancer that has spread to organs or tissues that are far from where it started. The main metastatic sites of breast cancer include bone, lung, brain and liver .
Breast cancer is the most common non-cutaneous malignancy in women.
- Six percent of women in affluent North America, Europe and Australia develop invasive breast cancer before age 75, compared with 2 percent in developing regions of Africa and Asia. This difference has been attributed to the risks associated with a Westernized lifestyle, including a high-calorie diet High in fat and protein and lack of exercise
- Survivors varied globally, with 5-year relative survival rates of ≥80% in the United States, Canada, and Austria, but less than 40% in Denmark, Poland, and Algeria.  This may be due to differences in diagnosis and treatment and lack of medical resources in some regions Country
- Breast cancer-related lymphedema (BCRL) is a condition that women can develop at any time for 3-20 years after treatment.  Incidence varies and may depend on the type of treatment received. Recent evidence suggests that one in five women will get it at some point. [twenty one]
- increasing age
- Reproductive lifestyle factors increase unopposed estrogen load
- early menarche
- nulliparous infertility or having few children in the first delivery
- lack of breast feeding
- late menopause
- unopposed estrogen replacement therapy
- Personal history of breast cancer or high-risk breast lesions
- first degree relative with breast cancer
- genetic mutations
- BRCA1 or BRCA2 mutation
- Li Fraumeni syndrome
- Peutz Jegher syndrome
- Cowden syndrome
- ataxia telangiectasia
- thoracic radiation therapy
- alcohol consumption
Factors That May Lower Your Risk of Breast Cancer
- Participating in moderate or vigorous activity
- Maintaining a healthy body weight
- Breast cancer may be asymptomatic and undetectable in its early stages.
- The hallmark signs and symptoms of ductal carcinoma are breast lumps and breast tenderness (usually not pain).
- The hallmark signs and symptoms of lobular carcinoma do not involve a lump. Therefore, lobular carcinoma may be more difficult to detect
- Breast texture often changes. [twenty three]
- Swollen lymph nodes in the armpit or difficulty breathing (metastasis) 
Mammogram showing normal breast (left) and cancerous breast (right)
Mammogram (older ones) and ultrasound (younger ones)
- Breast MRI in Challenging Cases
- US/mammogram guided biopsy
- IR Thermography: It is a powerful tool that is also non-invasive and non-invasive, which simplifies analysis and provides safety and comfort for patients. It can be used in women of different ages and health conditions without any risk .
- Hormone receptor testing If someone is diagnosed with breast cancer, hormone receptor testing can be used to help plan treatment. Hormone therapy is a recommended form of treatment if the cancerous tissue is positive for hormone receptors (estrogen and/or progesterone). 
- HER2/neu test: HER2 is human epidermal growth factor receptor 2, a protein that can sometimes be found on cancer cells. Cancer cells that contain the HER2/neu protein tend to be more aggressive and may have a poorer prognosis. If this is the case, then a targeted approach That specific area will be used as a treatment option. 
Breast cancer that has metastasized can manifest itself in a variety of ways .
- Bone: is the most common site of metastases in both men and women, and symptoms may include posterior hip or shoulder pain and/or weight bearing pain.
- Central nervous system: Another common site of breast cancer metastasis, especially in the thoracic portion of the spinal cord. Signs and symptoms associated with neurologic involvement include unilateral upper extremity numbness and tingling (neck/chest) leg weakness or Paresis (lumbar spine) or bowel and bladder symptoms (sacrum). Other common metastatic sites are lymph nodes, lung, brain and liver, and remaining breast tissue. Nervous system involvement can also present as a paraneoplastic syndrome, a term used to describe associated signs and Symptoms away from tumor and/or metastatic sites.
- Paraneoplastic syndromes often present in ways that do not appear to be cancer-related and may resemble disorders of the endocrine-metabolic hematologic or neuromuscular systems.
See also Oncology Medical Management
Breast cancer often requires surgery as part of treatment. In most early-stage breast cancers, surgery is the first step in treatment.
- The decision to proceed with mastectomy or breast-conserving surgery remains patient and disease driven. Some patients require upfront chemotherapy and/or radiation to downstage the tumor or axillary lymph nodes, such as inflammatory breast cancer.
- Adjuvant radiotherapy after surgery is recommended for almost all patients undergoing breast-conserving therapy, as recurrence rates without breast-conserving therapy are unacceptably high.
- Endocrine therapy is recommended for at least five years for those whose tumors are positive for hormone receptors (i.e., estrogen and progesterone), and is often recommended as preventive treatment in women considered to be at high risk.
- Chemotherapy is also recommended for more aggressive tumors and for tumors that are negative for estrogen, progesterone and HER2neu receptors. 
There are two main types of surgery to remove breast cancer:
- Breast-conserving surgery (also known as lumpectomy, quadrantectomy, partial mastectomy, or segmental mastectomy) is surgery in which only part of the breast that contains cancer is removed. The goal is to remove the cancer along with some surrounding normal tissue. how much mastectomy Depends on the location and size of the tumor and other factors.
- A mastectomy is an operation to remove the entire breast, including all breast tissue and sometimes other nearby tissue. There are several different types of mastectomies. Some women may also have a bilateral mastectomy, which is the removal of both breasts.
To find out if breast cancer has spread to lymph nodes in the underarm (armpit), one or more lymph nodes will be removed and tested in a laboratory. Lymph nodes can be removed as part of surgery to remove breast cancer or as a separate surgery. Two Main Types of Surgery Lymph nodes removed are:
- A sentinel lymph node biopsy (SLNB) is a procedure in which a surgeon removes only the lymph nodes under the arm where the cancer may spread first. Removing only one or a few lymph nodes reduces the risk of side effects of the surgery, such as swelling of the arm, also known as Lymphedema.
- Axillary lymph node dissection (ALND) is a procedure in which the surgeon removes many (usually fewer than 20) lymph nodes under the arm. ALND is not done as often as it used to be, but it may still be the best way to look at the lymph nodes in some cases .
Chemotherapy is used to destroy remaining cancer cells that may remain in the body. This form of treatment is applied throughout the body through the blood. Chemotherapy can be used for all stages of breast cancer but is especially recommended for those whose cancer has spread.
See Chemotherapy Side Effects and Syndromes
Radiation therapy is often used for early-stage (and available at all stages) breast cancer after a lumpectomy. Unlike chemotherapy, this form of treatment targets more specific areas. Radiation therapy can also be used after chemotherapy.
- Almost half of all cancer patients receive radiation therapy as part of their cancer treatment.
See Radiation Side Effects and Syndromes
- Certain types of breast cancer are affected by hormones such as estrogen and progesterone. Breast cancer cells have receptors (proteins) that attach to estrogen and progesterone to help them grow. Treatments that prevent these hormones from attaching to these receptors are called hormonal or endocrine treat.
- Hormone therapy can reach cancer cells almost anywhere in the body, not just the breasts. Recommended for women with hormone receptor positive tumors. It does not help women whose tumors do not have hormone receptors. 
Medicines to treat breast cancer usually include chemotherapy drugs and hormone replacement medicines.
Chemotherapy drugs are used many times in combination of two or three.
- Two common groups include the anthracyclines and taxanes.
- Anthracyclines such as epirubicin and doxorubicin are similar to antibiotics that destroy the genetic material of cancer cells.
- Taxanes such as paclitaxel and docetaxel, on the other hand, interfere with the division of cancer cells. 
- Both paclitaxel and docetaxel belong to plant alkaloid anticancer drugs. Each is administered intravenously and is primarily used to treat solid tumors involving breast and ovarian cancer.
- Tamoxifen stops the growth, spread or recurrence of ER-positive tumors by preventing estrogen from reaching the tumor. Tamoxifen is a mixed estrogen antagonist and agonist that blocks estrogen activation in the breast and reduces growth factors in breast tissue. Tamoxifen is the most common A drug and another drug used in premenopausal women to help prevent breast cancer from coming back
- Toremifene is a novel estrogen receptor antagonist for the treatment of advanced breast cancer. 
Physical Therapy Management
see also Oncology Examination
Women after breast cancer treatment may develop any of the following lesions:
- decreased upper body strength
- Decreased shoulder mobility
- Scar tightness (breast and/or armpits)
- Upper extremity ache
- Lymphedema of the upper extremity
- Neuropathic pain
- Musculoskeletal pain (breast armpits and/or neck and shoulders)
- Chronic pain
Interventions Post Surgery
A physical therapist’s treatment plan should include:
- Movement exercises that improve tissue extensibility and promote normal movement patterns.
- Myofascial release enhances mobility and increases tissue extensibility.    
Several forms of manual therapy may also be helpful:
- Joint mobilization techniques
- Soft tissue release techniques
- Neurodynamic techniques
- Muscle groups that should be targeted include the rotator cuff trapezius anterior, rhomboid biceps, and pectoralis major.  The exercise can start with the elastic band, 2 times a week, and repeat 2 sets of 10-15 times each. 
A Structured Shoulder Problems Prevention Trial (PROSPER) exercise program introduced one week after surgery improved upper extremity function postoperative pain arm symptoms and physical quality of life at 12 months compared to usual care in women at high risk for upper extremity disability After undergoing non-reconstructive surgery. 
- Two common complications are limited arm motion and lymphedema.
- Implement early rehabilitation to promote functional movement to the patient’s previous activity level.
- Arm mobilization is performed on the first or second postoperative day.
- Mobilization is achieved using joint rotation to tolerance, but abduction and flexion are limited to 40°.
- On postoperative day 4, flexion and abduction are gradually increased to 45°, which can be further increased by 10-15° per day depending on the patient’s pain tolerance.
- This technique works by keeping the patient’s arm in 45° flexion or abduction until the drain is removed.
Surface electromyography studies have shown changes in muscle range of motion and onset of each selected shoulder movement in women following breast cancer treatment, suggesting a need to develop a selective therapeutic exercise program to optimize the shoulder neuromuscular Movement of women after breast cancer treatment .
Secondary lymphedema is a common phenomenon after surgery in the breast cancer population and has long-term negative effects on patients’ quality of life. This can be treated with complete decongestant therapy.
- Exercise is increasingly used as a therapeutic tool in breast cancer patients . Recently, it has become apparent that exercise plays a central role in the management and prevention of chronic disease.
- Despite the well-known benefits of exercise, adherence rates among breast cancer survivors are statistically very low.
- There is substantial evidence to support the benefits of physical activity during and after chemotherapy for breast cancer.
- Studies have shown that physical activity and exercise are effective in improving quality of life, cardiorespiratory fitness and physical function in breast cancer patients and survivors .
- Physical activity has been shown to be an appropriate adjunct therapy against long-term chronic disease and has been successful in reducing mortality and improving overall quality of life.
When exercising for the postoperative population, the SEWS chart should be monitored regularly for early warning signs. Exercise should be postponed if the patient is tired or anemic.
BEAUTY (see table R)
- The BEAUTY program aims to eliminate key issues associated with breast cancer patients such as fatigue lower QoL social anxiety and body conditioning. 
- Given the enormous physiological benefits as well as the major psychological benefits, it is important that the physical therapist promotes the benefits of exercise immediately after surgery and ensures that the exercise program can be assessed at home or in the community and is tailored to the individual.
- During and after breast cancer, all exercise programs should be designed according to the F.I.T.T principles.
Exercise adherence after cancer is very low  A number of factors contribute to this, such as lack of services, travel issues cost and personal reasons as well as fatigue are often responsible. Physiotherapists should be aware of barriers to exercise adherence in this specific population (see #obstacle).
FITT Principle After Breast Cancer
- Warm up: 5-10 minutes to raise heart rate
- Aerobic Exercise: Frequency:
- 3 x 5 times a week **Intensity: 50-70% of max intensity. heart rate
- Type: walking cycling aerobic activity
- Time: 30 minutes as a long-term maintenance routine
- Resistance Training: Frequency:
- 2/3 times a week
- Intensity: 12/15 reps of 60% of 1RM
- Type: Supervised resistance program for major muscle groups
- Time: 6 weeks
Aerobic exercise such as walking, cycling or swimming has been shown to reduce cancer-related fatigue    improve quality of life   reduce cognitive impairment associated with various cancer treatments  improve cardiovascular Vascular outcomes  and improved sleep dysfunction.  Research Treadmill exercise is shown to be cardioprotective against doxorubicin-induced cardiotoxicity.  Another study reported the positive effects of a 7-week pedometer exercise program on fatigue quality of life, bone mass, and functional capacity in breast cancer patients Receive chemotherapy.  It can be concluded that a supervised exercise program combining aerobic and resistance training has substantial benefits for fitness bone health and quality of life, especially in overweight or obese breast cancer survivors. 
Below is an 8-week multimodal physical therapy program (cardio core stability exercises and some recovery through stretching and myofascial release techniques). .
Physiotherapy Long-term Management
The role of a physical therapist is to promote a healthy lifestyle, including physical activity and proper nutrition.
- Continuing to exercise continues to foster motivation in the patient, provides the patient with a support group, and promotes social and mental health.
- It can improve patients quality of life.
- It allows patients to have some control over their life stability and daily routine.
- It enables them to restore themselves and become active again in the community .
- Patient education is a key component of the physical therapist’s role.
- Promoting independence and self-management of physical activity is important for successful rehabilitation outcomes.
- Referring to the biopsychosocial model of health, physical therapists should address more than just the physical problems of their patients. All patient needs and concerns require treatment or referral to appropriate professionals.
Life After Cancer
Life after breast cancer treatment means returning to some familiar things and making some new choices.
- The end of treatment does not mark the end of the breast cancer journey.
- Two of the more frustrating and troublesome side effects women face after treatment are fatigue from the cumulative effects of chemotherapy and/or other treatments, and what some women call chemical brain – memory deficits and an inability to concentrate, among other things Psychological changes.
Physiotherapists can help patients plan for returning to work by assessing their physical abilities in the workplace.
- Workplace assessments will also help to achieve this.
- Following a workplace assessment, adjustments to duties can be recommended to patients and employers.
- Knowledge of anatomical kinesiology and ergonomics and agreed workplace adjustments will allow the physical therapist to focus on the treatment of the disease and prevent injury when the patient returns to work.
LymphodemaLYMQOL is a validated lymphedema-specific outcome measure of QOL . It consists of 24 questions covering 4 domains (Symptoms, Body Image, Mood and Functioning). It is measured by a Likert scale of 1-4 Cancer-Related Fatigue BFI (Brief Fatigue Inventory). BFI measures severity and Effects of fatigue over a 24-hour period. 9 item 0-10 numeric scale.  Functional Assessment of Cancer Therapy (FACT-F) The FACT-F measures physical fatigue and its consequences over a 7-day period. It is a 13-item unidimensional scale assessed on a 5-point scale from 0-4.  Shoulder Dysfunction of the arm, shoulder and hand (DASH).  Psychometric outcome measures Hospital Anxiety and Depression Scale (HADS).  European Organization for Research and Treatment of Cancer Quality of Life Breast Cancer – Quality of Life Questionnaire – Core 36 (EORTC QLQ-C36) Development Proposed by Aaronson et al. in 1987.