1 Multidisciplinary care improves quality of life in people with breast cancer

Breast cancer is the most common cancer in women—one in seven women and one in 556 men are at risk over their lifetime (Breast Cancer Network Australia 2024)—and incidence rates are increasing in Australia.

Physiotherapy interventions improve functional outcomes and wellbeing in the breast cancer population (Devoogdt & De Groef 2024).

Physiotherapists can offer a range of treatment options and support during and after breast cancer treatment including management of upper limb dysfunction, manual therapy, range of motion exercises, strength training, exercise therapy, education and management of cancer- related fatigue, pain and lymphoedema (Rees et al 2021, Devoogdt & De Groef 2024).

Because many people with cancer experience anxiety and depression (Tsaras et al 2018) and have an increased risk of social isolation (Nagarajan et al 2020), positive social support and participation in leisure time physical activity are important (Kim et al 2021, Vassilev et al 2023).

Multidisciplinary team care for people with breast cancer has numerous advantages including faster treatment initiation, improved survival rates and adherence to clinical guidelines (Kočo et al 2021, Cancer Australia 2024).

Physiotherapists work closely with medical and radiation oncologists, pathologists, surgeons, GPs, breast care or oncology nurses, the palliative care team and allied health professionals including psychologists, dietitians, exercise physiologists, occupational therapists and social workers.

2 Prehabilitation and postoperative care support recovery from breast cancer surgery

Physiotherapists play a key role in preparing people physically and mentally for surgery, which may involve breast-conserving options (lumpectomy/partial mastectomy) or mastectomy (Devoogdt & De Groef 2024).

Prehabilitation involves individualised exercise programs designed to optimise strength, physical function and upper limb mobility, which can reduce postoperative complications and promote recovery (Denehy & Edbrooke 2022).

After surgery, people often experience side effects including pain, upper limb dysfunction, cording (or axillary web syndrome), lymphoedema and body image concerns (Collins et al 2011, Palesh et al 2018, Lovelace et al 2019, Devoogdt & De Groef 2024).

Approximately 60 per cent of people report upper limb problems such as reduced range of motion and strength (Devoogdt & De Groef 2024).

Postoperative physiotherapy focuses on pain management; wound and seroma care; exercises for range of motion, strength and posture; education; manual therapy; and scar and lymphoedema management (Bruce et al 2021, Rees et al 2021, Devoogdt & De Groef 2024).

Up to 50 per cent of breast cancer survivors may encounter long-term effects such as pain and movement restrictions for three to five years after surgery (Ewertz & Jensen 2011).

Physiotherapy significantly improves physical function and quality of life while helping people regain confidence and independence (Bruce et al 2021, Rees et al 2021).

3 Physiotherapy during breast cancer treatment can mitigate side effects

Treatment for breast cancer often includes chemotherapy, radiation therapy, hormone-blocking therapy and, less often, targeted therapy and immunotherapy.

Each of these therapies has common side effects that physiotherapy can address to minimise their impact on physical, psychological and cognitive function.

Fatigue is the most frequent side effect, resulting in decreased physical activity and a subsequent reduction in muscle mass and strength (Gebruers et al 2019).

Chemotherapy-induced peripheral neuropathy occurs in up to 33 per cent of patients, with altered sensations in feet and/or hands, reduced proprioception and balance disturbances, which may be long- term (Tuğral et al 2023).

Radiation therapy carries a risk of nerve injury, impaired tissue flexibility and lymphatic drainage, fibrosis, chronic pain and breast/arm lymphoedema (Allam et al 2020).

Hormone-blocking therapy is often required for up to ten years, inducing menopause, which contributes to bone mass reduction (Bula et al 2023) and often causes myalgias/arthralgias.

Exercise during treatment is beneficial in attenuating side effects and preventing deconditioning.

Resistance training, either by itself or in combination with cardio, provides the best results (Gebruers et al 2019).

Contraindications to exercise and precautions can be found in the Cancer Exercise Toolkit.

There are also specific exercise considerations during chemotherapy for patients with early breast cancer (van der Leeden et al 2018).

4 Ongoing support after breast cancer treatment is crucial

Ongoing surveillance and proactive treatment of long-term side effects are vital during breast cancer survivorship.

Physical activity, exercise, weight management and rehabilitation strategies can alleviate common challenges (Stout et al 2023).

Breast cancer treatment can cause persisting lymphoedema, chronic pain, body composition changes and cardiovascular problems.

Many survivors experience ongoing fatigue, particularly after chemotherapy.

Exercise is the most effective management strategy and referrals to physiotherapists are recommended for personalised programs (Cormie et al 2018).

Anxiety and depression affect 32.2 and 38.2 per cent of breast cancer survivors respectively (Tsaras et al 2018).

Psychological support and complementary therapies such as yoga and mindfulness can help address these issues.

Mild to moderate aerobic exercise has also been shown to reduce symptoms (Sun et al 2023).

Extended use of endocrine therapies can cause hot flushes, sleep disturbance, weight gain and cognitive fog (Saunders et al 2022).

Many people experience joint pain, stiffness and tendinopathy, affecting their quality of life (Grigorian & Baumrucker 2022).

Non-pharmacological interventions such as exercise, yoga and cognitive behaviour therapy can be beneficial (Cancer Australia 2016).

Over 70 per cent of women face sexual difficulties post-treatment due to body image changes, physical pain and hormonal effects (Panjari et al 2011) and pelvic health physiotherapists can provide crucial support.

5 Physiotherapy plays an important role in advanced breast cancer

Physiotherapy is a safe and effective intervention for advanced breast cancer care, with growing importance as median survival rates increase (Campbell et al 2022).

Exercise can improve physical function and quality of life in patients with metastatic disease.

Research demonstrates that appropriately prescribed and performed exercise does not significantly increase fracture risk for those with bone metastases, while helping to manage pain and maintain mobility (Weller et al 2021).

Cardiotoxicity is a possible side effect of treatments involving radiation therapy, anthracycline-based chemotherapy and trastuzumab.

The risk of delayed cardiovascular disease is noted for patients with radiation for left-sided breast cancer, due to its proximity to the heart.

Symptoms such as shortness of breath, chest pain and peripheral oedema should prompt referral to specialists (Gernaat et al 2017).

Physiotherapists treating patients with a cancer diagnosis should also be very alert to signs of recurrence or metastases (Verhagen et al 2016), including localised bone pain, night pain, night sweats, unexplained weight loss, increased fatigue, nausea and neurological symptoms.

In palliative care, physiotherapists focus on symptom management and functional independence.

Goals are guided by what is important to the person.

Collaboration with a multidisciplinary team ensures holistic care that optimises the person’s quality of life through palliative and end-of-life care (Toohey et al 2023).

>> Read the Clinical Oncology Society of Australia’s position statement on exercise in cancer care here.

>> Dharani Nagarajan APAM is the physiotherapy manager at Access Health and Community in Melbourne. Dharani has completed a Master of Public Health and Pinc and Steel cancer rehabilitation. She is the chair of the Victorian branch of the APA Cancer, Palliative Care and Lymphoedema group and a member of the Clinical Oncology Society of Australia.

>> Germaine Tan MACP is the national chair of the Cancer, Palliative Care and Lymphoedema group and an APA Titled Cancer Physiotherapist with training in oncology, haematology and cancer rehabilitation (PMCC, Pinc and Steel). She was awarded an NHMRC Postgraduate Scholarship in 2023, investigating the impact of cancer rehabilitation timing on patient and health service outcomes.

>> Leah McIntyre APAM is a senior physiotherapist in cancer services at the Mater Hospital Brisbane, with advanced training in lymphoedema, Pinc and Steel cancer rehabilitation and oncology scar therapy. She is a member of the Australasian Lymphology Association and the Queensland chair of the Cancer, Palliative Care and Lymphoedema group.

>> Lizzie Eastwood APAM is the clinical lead oncology physiotherapist at Ramsay Health Plus Hollywood in Perth. She has completed advanced training in lymphoedema, Pinc and Steel cancer rehabilitation and oncology scar therapy. She is a member of the Australasian Lymphology Association and the Western Australian chair of the Cancer, Palliative Care and Lymphoedema group.

>> Kirsty Kirkland APAM is a private practitioner in Adelaide with a focus on cancer rehabilitation and lymphoedema therapy. Kirsty is an accredited decongestive lymphatic therapist and a Pinc and Steel Cancer Rehabilitation Physiotherapist. She is the South Australian chair of the Cancer, Palliative Care and Lymphoedema group.

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CANtreat upper limb and breast lymphoedema