Breast Cancer

Breast cancer is one of
the most common cancers
that affect women.
The reality is one in eight
will be diagnosed with it
at some point in their lives.
The good news is detection and treatment
have improved.
Now when it’s caught early,
we are able to treat it
more effectively than ever before.
With 3D mammograms,
we can get a clear picture
of your breast.
These pictures give us precise
detail focused images
to help with detection.
The most important thing here,
starting at age 40, making screening
a priority for you and your loved ones.
Know and understand your risk.
Remember, mammograms can save lives.

Routine mammograms are an important
screening tool to catch breast cancers when they're easiest to treat.
On the day of your exam, avoid wearing any deodorant, powder,
lotion or perfume, as these can interfere with your imaging.
Your normal clothes are fine to wear, though two piece outfits make it easier.
You'll have a private area to dress from the waist up, then slip on a simple gown.
We’ll provide a locker for your belongings.
Sutter uses modern digital equipment with low dose
radiation to perform 2D and 3D mammography.
Staff will help you position your breast
on the equipment gently to minimize discomfort.
We take a few images to ensure a full picture,
asking you to hold your breath and stay still for a few seconds each.
Mammogram screenings take about 15 minutesonce the exam starts,
so give yourself about 30 to 45 minutes for the entire appointment.
A radiologist will evaluate your images and compare them to past images
if available.
If you have normal results, we’ll message
you in My Health Online or send them by mail.
If an area needs more imaging, we'll call you about next steps.
Go to My Health Online or call your doctor to book your mammogram, today.
Remember, mammograms save lives.

[MUSIC PLAYING]

Hi, I'm Tiffany De Asis, physical therapist
and certified lymphedema therapist
at Mills-Peninsula Medical Center in San Mateo.
I'm going to show you how to do exercises
to do prior to your breast cancer surgery
to help make you stronger, more flexible,
and help make recovery easier.
First, we're going to do scapular protraction
and retraction.
We're going to do two sets of 10 repetitions.
And what that is, is you are squeezing the shoulder blades
by bringing your shoulder blades back and down
and then going the other direction and around
your shoulders all the way.
And then bring it back, and then around them forward again.
Back stays neutral, and you're just moving from the shoulder
blades.
[MUSIC PLAYING]

Now we're going to do front raises and lateral raises,
two sets of 10 repetitions in each direction.
So you're going to take 2-pound dumbbells.
If you don't have dumbbells at home,
you can use a filled water bottle or a soup can,
something you can grip onto.
You're basically going to take both arms here and lift them up
to about 90 degrees.
OK.
[MUSIC PLAYING]

Just make sure that your shoulders are back
and your shoulders aren't up in your ears.
There you go.
[MUSIC PLAYING]

OK, So for the next exercise, these are the lateral raises.
And your just basically going to do the same thing.
You're just bringing them out to the side
and still at 90 degrees.
If it's too hard to bring your arms
all the way out to the side, you can bring them a little
forward.
[MUSIC PLAYING]
And the same thing, make sure your shoulder
blades are back and down.
[MUSIC PLAYING]

The next exercise we're doing is side-lying
shoulder external rotation with 2-pound weights,
2 sets of 10 repetitions.
You're going to lie on your right side.

And what we're going to do is, you're going to take a towel,
fold it or roll it up, and put it
underneath your elbow for support.
Arm rests kind of right on your stomach there.
You're going to grab onto a 2-pound weight.
And it could be 1 pound.
It could be a water bottle, anything
that has a little bit of resistance there.
And before you lift the arm up, you're
going to squeeze your shoulder blades back, and then lift up.
And again, a comfortable range.
[MUSIC PLAYING]
If it's painful, stop.

Perform these exercises twice a day, or morning and night,
and they will help you to improve your strength
and flexibility to prepare you for surgery.
So now that you've had surgery, I'm
going to show you exercises you can do post-op
to help maintain your range of motion
and decrease pain and tightness.
You can start these exercises once your drains have
been removed and once you've been cleared by your surgeon.
All of these exercises should be pain-free.
So if you feel pain, stop before you feel the pain.
You should move into a stretch and a pull, but not pain.
The first exercise you're going to do is cane shoulder flexion.
You will hold 3 seconds at end range,
and we will do 2 sets of 10 repetitions.
So this exercise, we're going to do using a cane.
You can use the dowel like this.
You can use a golf club, an umbrella, a wrapping paper
tube, anything long that you can have both hands on.
You're going to lie down just like this.
Or if it's too hard for you to lie down.
You're going to elevate, you could put a couple of pillows
under your head if it's too hard for you to lay down just yet.
You can also do these exercises sitting up.
But I think it's a little bit easier at first
to do it lying down.
So you're going to take both hands on the cane,
and you're going to lift the arms overhead.

You want to keep the motion pain-free.
So stop if you feel pain.
[MUSIC PLAYING]

And if it's too hard for you on the surgical side,
you can use the non-surgical side
to help lift the other side if it's too hard for you.

If you have a hard time moving your right arm, which
is the surgical side, you're going
to grab on with both hands.
Keep your elbows straight.
You can relax as much as you want,
or you can have it help along as much as you like,
as long as you're not feeling any pain.
This arm does the work, the non-surgical side.
OK.
Go ahead and lift up, yeah, just like that.
Stop right before you feel that pain.
And then, as you loosen up, as it gets a little bit easier,
the surgical side can assist a little bit more.
[MUSIC PLAYING]

Also too, when you get to the very end,
you can hold for about two, three seconds.
There we go, just that you can and you get a little bit more
of a stretch, and then come back.

The next exercise is cane shoulder abduction.
Hold three seconds at end range, 2 sets of 10 repetitions.
This is going to be that very similar exercise.
We're using the cane as well, except now we're
going to move your arm out to the side.
So if your right side is your surgical side,
you're going to grab on to the cane,
kind of like this with your thumb pointing out.
Your arms are going to be the level of your trunk
or even a little bit above if it's too hard to have it flat.
You're going to use the non-surgical hand to help push
the arm out to the side.
So that one holds on that way.
This one, you can actually-- whatever angle
is easiest for you to push up.
And this arm can stay--
elbow can stay straight, and you can bend this non-surgical side
to help lift up.
And see how it can push it out to the side?
[MUSIC PLAYING]

And again, the surgical side can help as much
as you're comfortable with.
[MUSIC PLAYING]

Now we're going to do a hand-behind-the-head pec
stretch.
Hold 15 to 20 seconds for a nice stretch,
and repeat 2 to 3 times.
You basically want to get your hands behind your head,
but it might be hard, difficult at first.
If that's too difficult for you to come all the way out,
you actually want to bring your arms closer to your--
your elbows closer to your ears.
And you're basically going to slowly bring the arms back
towards the pillow.
And then you might, if this is still hard, you might even
want to bring them in and out, back and forth,
until it feels comfortable and less tight.
And then, when it feels less tight,
then you can hold it at the end.
Once you feel comfortable, hold it 15, 20 seconds.
[MUSIC PLAYING]

Next exercise-- shoulder blade squeezes,
2 sets of 10 repetitions.
It's going to help improve your posture.
It helps stretch the chest and help decrease
some of the pain and the guarding
that you have on your surgical side.
You can do this standing or sitting.
But you're going to squeeze the shoulder blades together
by drawing your shoulder blades back and down.

And the one thing you want to watch for
is to make sure that you're not arching your back.
So your back stays in neutral.
And just isolate for just the shoulder blade.
[MUSIC PLAYING]

And lastly, we will do wall slides,
2 sets of 10 repetitions.
I have two pillowcases here so it makes it easier
to slide up and down the wall.
You can use a towel.
You don't have to use anything, but sometimes your hand
sticks on the wall, which is why I am
having you use the pillowcases.
So one hand here, one hand here, and you're basically
going to slide up a wall and try to increase
some of that range of motion.
And you can lean into it to get a little bit more of a stretch,
and then come right back down.
[MUSIC PLAYING]

Then you can just hold again two to three seconds,
and then come right back.

Pain-free motion-- are only going to the point
where you feel a stretch, but not pain.
And then leaning into it at the end
there gets a little bit more of a stretch,
and you can hold that for two to three seconds.

Perform these exercises once your drains have been removed
and you've been cleared by your surgeon.
Do them twice a day, morning and night,
and they will help to bridge the gap from the time of surgery
until you are able to get in for an appointment
with physical therapy.
And remember, once you get your referral from your doctor,
please schedule your appointment right away so that there
is no delay in care.
[MUSIC PLAYING]

LIZZIE: Hi, my name is Lizzie.
And I'm a clinical coordinator here at Sutter.
We are here today to offer this video class
on cancer-related lymphedema specifically
about understanding and reducing your risk of developing it.
If you have questions, please call your doctor's office.

The content is not intended to be
a substitute for professional medical advice, diagnosis,
or treatment.
Always seek the advice of your physician
or other qualified health provider
with any questions you may have regarding a medical condition.
I want to talk a little bit about this class.
It can be a lot to take in.
We do recommend that you watch and listen to the whole video.
But it is OK to press Pause at any time, take a break,
and come back later.
We have divided it into two parts.
The first part is about lymphedema
so you understand what it is.
The second part includes things that you
can do to reduce your risk of developing it.
For questions about your specific medical care
or lymphedema, contact your surgeon,
your medical oncologist, or your primary care provider.
We have two talented people from our Sutter team
who will be giving you the information about lymphedema.
You can see pictures of them here.
Saskia Thiadens has been an oncology nurse
for over 25 years specializing in lymphedema.
In 1987, she opened the first lymphedema clinic
in the United States and the following year
founded the National Lymphedema Network,
a nonprofit organization.
In 2018, she started a screening and early detection program
for cancer-related lymphedema at California Pacific Medical
Center in San Francisco.
Corinna Lowe received her doctorate of physical therapy
from the University of Washington.
She is a Lymphology Association of North
America-certified lymphedema therapist.
With that being said, I would like to hand this presentation
over to Saskia.
Saskia?
SASKIA THIADENS: Thank you so much, Lizzie,
for this kind introduction.
This webinar is designed to educate and help you
in reducing the risk of developing lymphedema following
your cancer surgery.
Over the past two to three decades,
there has been an increase in interest
in the lymphatic system and lymphedema
in the medical community.
There are now thousands of dedicated certified lymphedema
therapists, screening and education programs
for cancer-related lymphedema in cancer centers
throughout the US.
There's lots of up-to-date and evidence-based research
in clinical diagnostic, genetics,
and psychosocial issues published
in peer-reviewed journals about lymphedema.
This webinar is designed to help you
in understanding the function of the lymphatic system
and how to reduce the risk of lymphedema
following your cancer surgery.
So what is lymphedema?
Lymphedema is swelling caused when your lymphatic system is
blocked or damaged.
It can happen after you've had lymph nodes removed.
For those who want a little more information,
it's actually an accumulation of protein-rich lymphatic fluid
in the connective and supporting tissues within the body
when there is damage to the lymphatic system.
It's mostly seen in arms and legs
but can also occur in the breast, head and neck, abdomen,
and genitalia.
It can develop days, months, or years following your cancer
surgery and is a chronic lifelong condition.
Some people may want to know why they should take this class.
Well, most likely, you're here because your cancer surgeon
or cancer specialist or primary care
physician has recommended it.
If you've been diagnosed with cancer
and will be having surgery, or you have already had surgery,
it is helpful to know about the lymphatic system
and how to reduce your risk of developing lymphedema.
This class may help remind you of signs and symptoms
of lymphedema.
Because like a lot of medical conditions,
it's better if you can catch it early.
If you already have lymphedema, this class
may help you learn how to better manage it as well.
We wanted to give you an overview of lymphedema.
According to the American Cancer Society,
there are nearly 17 million cancer survivors in the US.
1.8 million new cancer patients are diagnosed each year
in the US.
975,000 or almost 1 million of these new cancer patients
are at risk for lymphedema.
And one in three of those, which is about 325,000 people,
will develop it.
Education and awareness with patients, their doctors,
and their lymphedema specialist is an important factor
in preventing lymphedema or preventing
worsening of symptoms if it has already existed.
So we are happy to be here today to help educate and inform you.
Lymphedema can impact the quality of life.
Some patients who develop it say that it can impact ability
to perform everyday activities, which are
called functional limitations.
It can also impact family relationships,
increase levels of depression and anxiety,
and hurt people's self-esteem.
It can cause issues at work, sometimes called
vocational issues.
It can also be a reminder to people
of their cancer experience.
Lymphedema can be a financial issue as well.
Since it also is a lifelong condition again,
the idea is to catch it as early as possible
or to prevent it from getting worse.
So there are a couple of types of lymphedema.
One is called primary.
And you can see this described here on the left.
This happens when people are born with a compromised
lymphatic system.
Lymphedema can happen at birth in these cases,
often in puberty or later in life.
Studies show that there are genetic components
of primary lymphedema, which means that some people may have
a gene passed down from their parents or grandparents
that may makes them more likely to get it.
The second type of lymphedema is in the second column here.
And it's called secondary lymphedema.
In the United States, at least 90% of lymphedema is secondary,
or it happens because of a known cause such as cancer surgery.
The lymph nodes are removed.
It can also happen by being indirectly triggered
by infection or trauma.
The lymphatic system is a vital part of our immune system.
It helps protect and maintain our body fluid
by filtering and draining lymph and waste products away
from each body region and helps the body
fight bacteria and viruses.
It produces cells of the immune system
that are vital in fighting bacteria and viruses.
The lymphatic system consist of lymph vessels, lymph nodes,
and lymphoid organs such as your tonsils, the spleen,
intestinal wall, and bone marrow.
Lymph fluid is collected through lymph capillaries.
It is then transported through lymph vessels to lymph nodes
and empties in the thoracic duct, the largest lymph
vessel in the chest, where it mixes back with the blood.
Essentially, your lymph nodes act as a filtering station.
You can see from this picture that the lymphatic system
is a network of tiny vessels and small, bean-shaped organs
called lymph nodes.
Nodes are located in various areas of the body.
But some of the key lymph nodes following cancer surgery
are in the armpit, which receive fluid from arm, chest, back,
and breast, inguinal nodes, which are in the groin area,
and we see fluid from the leg, lower abdomen,
gluteal fold of the buttock and genitals.
Other areas are in the neck along the windpipe
next to the lungs and in the abdomen or stomach area
and in the pelvis.
We talked about the lymph system.
But now we are going to talk about actual lymph nodes.
The size of a lymph node is about two to 25 millimeter,
which is about the size of a pea or a bean.
We have approximately 400 to 600 nodes in the body.
And 50% are in the abdomen or stomach area.
There are also nodes in the neck region, in the bend of the hip,
and in the armpit.
Their function is to act as a filtering station
and help fight bacteria and toxins.
They produce white blood cells to fight infections and enhance
the body's immune system.
And they help keep fluid volume in the body balanced.
They also recognize and respond to foreign cells,
including cancer cells.
To explain more, I want to talk about the difference
between the flow of lymph fluid and blood.
Lymph runs along the way parallel
to the circulatory system and is a high protein fluid
while our blood circulates or pumps through our body
and is low in protein.
You can see from this picture on the left
that we produce 2.4 liters of lymph fluid a day,
which is equal to about half a gallon of milk per day.
This in comparison to blood, we circulate about 5 liters
of blood per minute, which is equal to about 1
and 1/2 gallons of milk.
So now that we know more about what lymphedema is,
let's talk about why it occurs.
It happens when the lymphatic system is compromised.
And the fluid exceeds the amount of fluid
the lymph system can transport.
So it happens when the lymphatic system can no longer
move normal lymph fluid.
An abnormal amount of protein-rich fluid
collects in the tissue, which makes it show visible swelling.
Left untreated, it becomes stagnant or stops moving.
This decreases oxygen in your tissue, impairs tissue healing,
and increases risk of infection.
Here are the stages of lymphedema.
Stage 0 is not visible.
But the ability for the lymph system to move fluid
has decreased.
Stage 1 is where there is pitting edema.
This means when it is pressed by fingertips,
the area indents and holds the indentation.
Usually, in the morning, it looks normal.
Stage 2 is where it becomes irreversible.
It is characterized by spongy tissue
that when pressed by finger tips bounces back
without any indentation.
And there is visible swelling.
In stage 3, limb is characterized by swelling
that is irreversible.
And the limb is very large.
There are some types of cancer that are more associated
with lymphedema than others.
These are cancers that sometimes require a lymph node removal
and/or radiation.
They're breast cancer, gynecological, melanoma, colon
and rectal, genital, urinary, and head and neck cancers.
What are the risk factors for lymphedema?
For surgical treatment, some risk factors
are removal of a tumor, lymph node removal, the length and/or
location of the surgical incision,
and if a seroma or pocket of fluid develops.
Radiation therapy can cause scarring to the lymphatics
and increase the risk of lymphedema.
And the dose and location of radiation also has an impact.
So how often does lymphedema occur?
More than 50% of cancer patients are at risk for limb lymphedema
with 1 in 3 developing it.
It really is specific for each individual.
If you look at the chart here, you can see on the left
that if you have a cental lymph node removed,
which is anywhere from one to three lymph nodes,
you have a lower risk for developing lymphedema.
The sentinel lymph node is the first lymph node
to which cancer cells are mostly spread from the primary tumor.
In the chart on the right, you will
see that it says that if you have axillary lymph node
removal, which is 10 to 20 lymph nodes,
that your risk of developing lymphedema is higher.
In general, the more lymph nodes you have removed,
the higher your risk for lymphedema.
I mentioned it on the previous slide,
but radiation can also cause scarring
to lymphatics, which can increase
the risk for lymphedema.
Now I'm very happy to introduce and turn over the presentation
to my friend and colleague Corinna Lowe.
Corinna?
CORINNA LOWE: Thank you, Saskia.
You might be wondering when are you at risk of lymphedema
and if there is a time when that risk goes away?
You're at risk of developing lymphedema immediately
after cancer surgery, weeks, months, and years
after cancer treatment.
Once someone is at risk of developing lymphedema,
they're always at risk.
We do know that if someone gets lymphedema,
it usually happens in the first few years after treatment.
Personal risk factors for developing lymphedema
include mobility or the lack of movement, obesity,
and a body mass index of more than 30.
Based on evidence, there are four things
that trigger lymphedema--
infection, injury, restriction like a shirt that is too tight,
and extreme temperature such as a hot tub or sauna.
The lymphatic system is roughly divided
into quarters with each quarter having a drain.
Lymphedema can occur in a section
where the cancer treatment occurred
and where that drain was damaged.
For example, if a person had right breast cancer treatment,
they are at risk of developing lymphedema
in their right breast, right arm, right armpit,
right chest down to their belly button,
and the right side of their back.
If a person had cancer treatment on their right leg,
they're at risk of developing lymphedema in their right foot
and leg, right groin, right lower abdomen,
right lower back, and genitals.

Let's talk about how to reduce your risk of lymphedema.
The goal is to catch or detect lymphedema as soon as possible.
There are screening and early detection programs
for cancer-related lymphedema in cancer centers
throughout the United States.
A certified lymphedema therapist can help with early detection.
One way to reduce your risk of lymphedema
is to keep your skin healthy.
Keeping your skin healthy reduces the risk of infection.
And we know that infection can be a trigger for lymphedema.
What does good skin care mean?
It means using lotion daily, use sunscreen,
wear gloves to avoid skin injuries when gardening,
avoid cutting your cuticles, and wear
well-fitting, closed-toe shoes.
Treat insect bites and cuts aggressively.
You should wash with soap and water.
Use triple antibacterial ointment.
Frequently, patients ask, can my affected arm
be used for blood pressure or a lab draw?
Because every patient's anatomy is different,
your surgeon is the only one who can
answer that question for you.
Constriction is something that is
so tight it could reduce or block
the normal flow of your lymph fluid.
And it is a good idea to avoid doing that on your limb
that is at risk of lymphedema.
You should avoid wearing tight clothes or jewelry
on your at-risk limb.
Another example is a tight watch which
can reduce the normal flow of your lymph fluid.
Talk to your doctor about any questions you have about this.
Exercise can reduce your risk of lymphedema.
Simple movements help drain lymphatic fluid
by moving the skin and the lymphatic vessels
below the skin.
Exercise also uses your muscles like a pump
to move lymphatic fluid.
To start exercising, talk to your doctor about an exercise
program.
Start slow.
Take frequent breaks.
Progress slowly.
Be consistent.
Movement should be pain-free.
Body weight management is another way
to decrease your risk of developing lymphedema.
Weight loss decreases the demand on your lymphatic system.
Consider working with a team to address your relationship
with food, your activity level, and the food you eat.
Consult with a certified lymphedema
therapist to assess your need for a compression sleeve
or stocking and its appropriate fit.
Common times compression garments
are worn in the prevention stage is when exercising or flying.
I am now going to pass the presentation back to Saskia.
Saskia?
SASKIA THIADENS: Let's talk for a minute
about preparing for surgery if you
are to have an axillary or sentinel node dissection.
If your doctor or surgical team instructs you differently,
follow their advice.
In general, it is best to wear a front-opening camisole
with pockets for surgical drain and loose clothing.
Bring a travel pillow, and wear comfortable sneakers
or closed shoes.
And make sure to have a friend or relative drive you
to and from your surgery.
What if you're having a sentinel lymph node
dissection in your groin area?
Well, it's very similar.
But again, if your doctor or surgical team may instruct
you differently.
If this happens, follow their advice.
Wear loose clothing and underwear.
And avoid tight elastic around your waist or panties.
Wear comfortable, well-fitted shoes or sneakers and socks
without tight elastic band.
Also, bring two travel pillows.
And again, make sure to have a friend
or relative drive you to and from your surgery.
Following your surgery, there are some specific breathing
and exercises your doctor may advise
you to recover from surgery and to reduce
the risk of developing lymphedema.
These exercises can be done at home and/or
with a certified lymphedema therapist.
Most important is to rest your body
and allow your lymphatic system to heal.
Be sure to follow whatever instructions your doctor
gives you.
We just have a few more minutes left in this webinar.
So I would like to summarize the ways
you can reduce your risk of developing lymphedema.
The list is practice good skin care.
Avoid constriction.
Treat insect bites and cuts aggressively.
Get daily exercises.
Manage body weight.
Ask your doctor about getting a compression sleeve
or stocking if needed.
Prepare for your surgery.
And follow the instructions that your doctor gives you
after surgery for specific movements you
should do to recover and prevent lymphedema.
Be sure to call your doctor if you experience
a sensation of fullness and heaviness
in the affected limb, your skin feeling
tight, if there is a decreased motion or flexibility
in the arm or leg, difficulty fitting clothing on the arm
or leg, ring, watch, or bracelet tightness,
and swelling in the arm or leg.
Infection and inflammation can be
a trigger for early lymphedema.
And patients should follow the signs of infection closely.
Call your doctor if your skin is warm to the touch,
red or discolored, or is tender and painful.
If you have a fever or have an increase in swelling,
you should also call your doctor.
After you or your doctor have determined you have lymphedema,
and you need treatment, ask for a referral
to a certified lymphedema therapist.
Your doctor should be able to refer you
to a lymphedema therapist who is certified by the Lymphology
Association of North America.
You can see their website address on this slide.
In behalf of Corinna and myself, I
would like to thank you for listening and watching
this webinar.
The slide that follows this one has
a list of resources for you.
As always, for questions about your specific medical care
or lymphedema, contact your surgeon,
your medical oncologist, or your primary care provider.
We wish you all good health, and thank you very much.
If you are interested in getting more information
about lymphedema, you can go to any of these trusted sources.
We have listed the National Lymphedema Network,
the Lymphatic Education & Research
Network, and the Lighthouse Lymphedema Network.
The next link is to a site that described the Lymphedema
Treatment Act, which is a federal bill that
was passed 2019.
It is meant to improve insurance coverage for the medically
necessary and doctor-prescribed compression supplies
that are the cornerstone of lymphedema treatment.
Last but not least, we have a link to a lymphedema blog.
Thank you again.