Structural Integration After Breast Cancer Surgery
Jens Nedwal practices structural integration in Wuppertal, Germany. He graduated in 2007 at the Institut für Strukturelle Körpertherapie (Structural Core Therapy Institute) in Nürnberg, Germany. He has worked with oncological patients, particularly post-breast cancer surgery patients, since 2010.
Important innovations over the last years have been translated into new breast cancer diagnosis and treatment strategies that are now being integrated into clinical practice. The progress made in imaging diagnostics, primary and reconstructive breast surgery, radiation therapy, and the development of individualized medical treatment strategies has resulted in new tailored and targeted therapies.
The increasing number of new cases per year calls for an analysis of state of the art therapeutic strategies. This article will provide a short view of current breast cancer treatments. It will also discuss the effects of untreated scar tissue, including fascial tension and loss of sensation. In addition, a client example demonstrating the effectiveness of structural integration in cancer aftercare will be presented.
Breast Cancer Background
Basically, there are two major classes of breast cancer: non-infiltrating and infiltrating. The treatment strategies vary based on type.
Non-infiltrating epithelial tumors are also known as carcinoma in situ, abbreviated as DCIS (ductal carcinoma in situ). Most cases of breast cancer start in the surface cells (epithels) of the ducts, sometimes in the lobules themselves. As long as the breast cancer is confined to the territory of a lobule, it is called a carcinoma in situ and considered early stage, in which state it can remain for years. In this stage, the disease can be cured by almost 90 percent by surgical removal of the tumor, possibly supplemented by radiation therapy (Goodwin, Parker, Ghersi & Wilcken, 2013). In individual cases, a hormone therapy is applied. Chemotherapy, however, is usually not necessary (Thill & Solomayer, 2014). An unknown percentage of these precursors never develop to invasive breast cancer.
Every fifth woman who receives an initial breast cancer diagnosis has a DCIS (Thill & Solomayer, 2014). So far there are no medical ways to predict which DCIS cancers will later become malignant. Because of this, it is recommended that all women with DCIS seek treatment—even though that may mean unnecessary treatment for some women.
There is the large class of so-called infiltrating epithelial tumors, which in turn are divided into different types. These tumors have broken the cell wall of the lobules and grow with very different speed, depending on the cell type, into the surrounding fat tissue of the breast.
Malignant tumors often grow quickly and penetrate aggressively into the surrounding tissue. This penetration is called infiltration or invasion. In addition to being infiltrative, malignant tumors can be destructive, which means they destroy the surrounding tissue. In contrast to benign tumors, malignant tumors usually have no capsule or an incomplete capsule. Malignant tumors often spread along nerves or in lymphatic and blood vessels.
The tumor cells can penetrate into the vessels and be carried away by the blood stream into other parts of the body. They can travel from the blood vessels into the tissue, multiply there, and grow into another tumor. These secondary tumors are called metastases (Kreipe & Friedrichs, 2014).
When the diagnosis has shown that breast cancer is present, surgery is necessary in most cases (Kühn & Kümmel, 2014). For decades, surgical removal of the breast was the standard treatment for breast cancer worldwide; the surgeon typically removed the entire breast (radical mastectomy). In addition to the breast tissue and muscles, the lymph nodes of the armpit were removed. Today, gentler surgical alternatives, called breast-conserving surgeries, are available.
Adjuvant chemotherapy is a continuation of the surgery, where cytostatic drugs attack the cancer cells—and normal tissue. The cytotoxins affect the cell division process in a very special way; they stop the growth of the cells or prevent further proliferation (Bischoff & Janni, 2014). In special cases, chemotherapy before surgery (neo-adjuventive chemotherapy) can be useful.
Chemotherapy reduces tumor size. It can help to make even bigger breast tumors smaller, so a radical mastectomy is not necessary (Bischoff &Janni, 2014). Although chemotherapy delays the date for the surgery, it does not worsen the prognosis.
Side effects of chemotherapy
Despite careful dosing, chemotherapeutic drugs also affect healthy cells, although to a lesser extent. Low blood cell counts, nausea, vomiting, hair loss, heart damage, kidney damage, and liver damage can occur (Bischoff &Janni, 2014). There are still no clinical studies that consider the effect of chemotherapy on the fascial system.
The goal of treatment with ionizing radiation is to destroy possible residual tumor cells or small metastases in the surgical site or in the lymph nodes (Souchon & Friedrichs, 2013). Ionizing radiation attacks the nucleus of the cell. The DNA may be so damaged by the radiation exposure that the cells can no longer divide and multiply. Radiotherapy is always needed if the tumor tissue could not be completely removed and in breast-conserving therapy.
Irradiation of the operated breast is considered essential and is now used more often, because of the increasing use of breast-conserving surgery in recent years. Adjuvant radiation therapy is used to prevent a local recurrence in the immediate area of the operated breast. In general, the radiation starts about three weeks after the surgery, depending on how well the surgical wounds have healed. Irradiation of the breast and lymph nodes takes about six weeks to complete (Souchon & Friedrichs, 2013).
Skin reactions from radiation include redness, dryness, and underlying immovable fascial tissue. Occasionally, radiation can also lead to an increased pigmentation of the exposed areas of the skin. I found that the irradiated tissue is sensitive to mechanical stimuli and requires caution in terms of sliding and gliding during structural treatment.
Scientists have proven that most tumors of the female breast are estrogen-dependent, meaning that the regulation of the growth in these tumors can be influenced by hormones and antihormones (Mundhenke & Schütz, 2014). In other words, if you change the hormonal balance of the woman in a very specific way, there is a chance to prevent the development of metastases or a return of the disease (remission).
Forms of hormone therapy for breast cancer.
1 Previously, the ovaries were surgically removed (ovarectomy). Today, there are drugs to turn off ovary function, called gonadropin-releasing-hormones. These drugs regulate estrogen production in the ovaries.
2 Certain tumor cells have receptors that register the preference for estrogen. Antiestrogens and other medications (so called estrogenrecepting downregulators) block these receptors so the tumor cell is no longer stimulated to grow.
3 An enzyme (a romatase) causes the endogenous formation of estrogens, particularly in fat tissue and in the ovaries. After the onset of menopause, fat tissue is the main endogenous source of estrogen. Aromatase inibitors block the enzyme and the body's production of estrogen.
4 Progesterone, a hormone produced in the ovaries, helps to decrease the blood estrogen level and additionally inhibits the function of the estrogen receptors.
Studies have shown a correlation between high levels of estrogen and high levels of collagen synthesis (Hansen et al., 2008; Talwar, Wong, Svoboda, & Harper, 2006; Claasen et al., 2010). In cases of lower estrogen levels, fascial tension increases over the whole body, especially in scarred areas (Hansen et al., 2008).
Breast-Conserving Surgical Techniques
Through targeted screening measures, breast cancer is increasingly found in early stages when tumors are small. Therefore, breast-conserving surgery is now considered standard treatment for breast cancer. The chances of recovery are just as good, if the tumor is removed with an adequate safety margin and the breast is irradiated afterwards.
A breast-conserving technique is usually possible when a single or multiple small tumors are located in the same quadrant of the breast. Breast-conserving surgery may also be possible for women with large tumors. In some cases, preoperative chemotherapy (neoadjuvant therapy) can shrink the cancer so that the surgeon does not have to amputate the entire breast.
Before the operation, a sentinel lymph node (SLN) is marked with a special process and removed during surgery. During this procedure, the SLN is studied under a microscope to see if cancer cells have spread to the lymph nodes of the armpit. If this is the case, more lymph nodes are removed.
There are three different types of breast-conserving surgical techniques:
1 Only the cancer itself is removed (Lumpectomy)
2 The cancer is removed together with a certain segment of the breast (Segmentectomy)
3 The cancer is removed together with a quadrant of the breast (Quadrantectomy)
By default, radiotherapy is part of a breast-conserving therapy (Witte, 2012).
Modified Radical Mastectomy
A modified radical mastectomy is performed when a breast-preserving approach is not possible because of tumor expansion and the resulting risk of recurrence. Skin-saving forms of mastectomy have not been compared to traditional mastectomy in prospective randomized trials, but in long-term studies and meta-analyses show comparable recurrence rates (Kühn & Kümmel, 2014). The entire mammary tissue, the skin and the nipple-areola-complex and the pectoralis fascia will be removed. The pectoralis musculature is usually maintained. The incision should take into account later reconstruction options.