REPERCUSSIONS OF SYSTEMIC ONCOLOGICAL REHABILITATION IN CHEMOTHERAPY TREATED MASTECTOMIZED PATIENTS

REPERCUSSIONS OF SYSTEMIC ONCOLOGICAL REHABILITATION IN CHEMOTHERAPY TREATED MASTECTOMIZED PATIENTS

Jânia de F. Neves, Ana Paula J. T. Pereira, Eryka N. da Silva, Valeska C. S. de Lyra, Rayara de C. dos S. Evangelista, Isadora B. Lins, Pollyana S. de A. Morais, Ana Cristina N. Marinho

Centro Universitário de João Pessoa – UNIPÊ

OBJECTIVE: Analyze, retrospectively, the repercussions of a systemic cancer rehabilitation protocol in mastectomized women under chemotherapeutic treatment for breast cancer.

METHODOLOGY: The present study was a documentary, descriptive and transverse research, made by information contained in the medical records of mastectomized women attended between February 1st, 2014 and December 15th, 2017 at the Clinic School of Physiotherapy at UNIPÊ. The samples cover the medical records of all women who underwent a mastectomy procedure for breast cancer treatment and were admitted to the School Clinic during the their chemotherapy period. Were included on the study women over 18 years with the following characteristics: a) clinically diagnosed with malignant neoplasm of breast, from any location, relapsed or not; b) have had at least one chemotherapy session, receiving or not another treatment associated with chemotherapy; c) Women submitted to the 20 sessions of the proposed protocol and were evaluated for the variables studied at admission and at the end of the 20th session. Were excluded from research: a) patients with other pathologies that could interfere or aggravate the effects of chemotherapy, such as, cardiac, pulmonary, immunological, metabolic and neurological diseases; b) patients with lymphedema that require specific individual care; c) patients with shoulder dysfunction who needed specialized care for this purpose. The established protocol was carried out individually or for small groups of women. The proposal was composed of a circuit system containing warm-up exercises (performed with moderate intensity walking based on the perception of each woman’s effort), specific aerobic and anaerobic exercises performed for 30 minutes. Aerobic exercises included running machine, exercise bike and trampoline, all of them performed to achieve moderate intensity based on the tolerance limit of each woman. The modified Borg scale was used as parameter. For the strengthening exercises were selected the large muscle groups, such as the musculature of the abdomen, buttocks, upper limbs (maximum load of 1kg). The protocol was finalized with breathing exercises and active muscle stretching. In addition to the proposed exercises, the patients were advised about the importance of water intake, rest, follow-up of the nutritional guidelines they received from the specialists who accompanied them, as well as relaxation strategies and leisure activities. The protocol was performed twice a week, with an average duration of 60 minutes. The extraction of medical record informations was made in two stages. The first stage was composed by recording information for the sample characterization. For this, a form was developed in order to help the identification of the sociodemographic and clinical profile of women. In a second moment, the woman’s perception of fatigue, pain, nausea and sleep was registered in another form by the time of the admission and after the 20th session. A subjective scale ranging from 0 to 10 was used as a parameter, so that 0 means absence of fatigue, pain, nausea and changes in sleep and 10 represents the worst conditions related to these variables based on the individual perception of the participants, with the intermediate scores serving the remaining records. The statistical analysis applied in this work was performed using parameters such as mean and standard deviation for the numerical variables and absolute and percentage frequency for the nominal qualitative variables. A comparison of ordinal qualitative variables was performed on the scale applied for fatigue, pain, nausea and sleep using Wilcoxon’s non-parametric test in paired samples with a significance level of 5% (p<0,05). RESULTS: The present study included 13 women, with mean age of 48.7 ± 9.3 years as samples. Of the total, 53.8% are married, 69.2 are brown or black and 61.5% are Catholic. The mean body mass index (BMI) was 26 ± 3.2. Regarding the primary diagnoses, 92.3% had infiltrating ductal carcinoma. None of the women had metastases during the periods when the protocol was applied. Regarding the surgical treatment, 53.8% of the women performed modified radical mastectomy of the Patey type and 30.8% of the Madden type. When considering chemotherapy, all women (100%) performed the protocol. 76.9% of them had a weekly chemotherapy regimen and the remaining patientes with a 21 days interval between sessions. The latter with an average of 13.7 ± 4.7 sessions. Radiotherapy was used in treatment in 84.6% of the women, with a mean of 22.6 ± 11.3 sessions. About 76.9% use tamoxifen, a selective estrogen receptor modulator, and 30.8% used immunotherapy with trastuzumab. Regarding staging, 76.9% were in stage III (A, B or C). In the study group, fatigue, nausea and sleep disturbances were reported by all women (100%) and pain was present in 92.3% of them during chemotherapy. In order to evaluate the repercussions of the systemic oncologic rehabilitation protocol on fatigue, pain, nausea and sleep disorders, analog scales ranging from 0 to 10 were used, 0 being the absence or alteration of these symptoms and 10 being the worst condition that each woman believes it could be. Being the initial evaluation considered as before the application of the 20 sessions of the protocol and the reevaluation after the application of the 20 sessions of the protocol, the results obtained from the analyzed symptoms are: For fatigue, in the initial evaluation the most frequent score was 8 and in the reevaluation it was 3, with a statistical difference of p < 0.01. Regarding pain, in the initial evaluation the most frequent score was 8 and in the reevaluation was 0, with a statistical difference of p < 0.02. Regarding nausea, the most frequent score was 5 in the initial evaluation and 2 in the reevaluation, with a statistical difference of p < 0.03. Finally, for sleep and its alterations, the most frequent score was 7 in the initial evaluation and in the reevaluation it was 2, with a statistical difference of p < 0.01. The sociodemographic profile found in the present study is similar to the one found on literature. The difference is only in self-reported color, since breast cancer is more prevalent in white women. It is possible that these findings are due to the miscegenation quite common in Brazil, especially in the Brazilian northeast. The mean BMI found in women suggests overweight, considering the parameters of the Brazilian Society of Endocrinology and Metabology. It is known that obesity is a major risk factor for cancer, including breast cancer, particularly postmenopausal. The risk related to overweight and obesity is due to the greater conversion of androstenedione to estrone in adipose tissue, which raises the free estrogen concentration. These women still have lower levels of sex hormone binding globulin. Several authors suggest that this contributes to a greater availability of estrone at the tissue level. At the same time, hyperinsulinemia and increased levels of free IGH-I (insulin-like

growth factor) quite common in obese individuals, increase the risk of cancer by stimulating cell proliferation, changes in the regulation of anabolic processes and cell apoptosis. Additionally, overweight and obese patients tend to have more fatigue, pain and sleep disturbances when compared to non-obese individuals. Fatigue is one of the most important symptoms associated with the treatment of breast cancer. In the literature, the sensation of fatigue is reported from 72% to 95% of patients who undergo chemotherapy or chemotherapy associated with radiotherapy procedures. Similar data was found in the present study in which 100% of women reported fatigue at varying intensities. Although fatigue is considered an adverse effect of the treatment directly, it may be associated with other variables such as the tumor, in addition to associated factors that may aggravate its presence, particularly of metabolic, hematological and nutritional origin. In addition to fatigue, pain is a fairly frequent finding. Painful symptoms can be potentiated throughout the treatment of breast cancer, which corroborates with the results of the present research. Considering the treatment performed by these women, almost all of them were submitted to mastectomy, a procedure in which there are usually reports of postoperative pain and in the first few weeks that follow, either due to the trauma of the surgical procedure or due to neural damage. The painful pictures can still come from neuropathies after chemotherapy, post-radiation and hyperalgesia associated with the use of opioids. Still according to the literature, this pain can be perceived more intensely and incapacitating in the presence of emotional disorders associated to a diagnosis of breast cancer. Nausea and vomiting are reported by about 70% to 80% of oncology patients who do not do adequate antiemetic prophylaxis. Its prevalence in the present study was higher than the findings in the literature. The concern with nausea and vomiting in cancer patients is that they increase the patient’s weakness by interfering in nutritional status and fatigue, with even greater impairments in quality of life. Sleep disorders are reported by about 50% of oncology patients and include mainly insomnia and excessive sleepiness. In the present study, the prevalence of sleep disorders was two times bigger than that one found in the literature, and it was not possible to establish plausible causes for this, since it was not the object of study. The difficulty of evaluating the relationship between sleep disorders and oncological treatment is due to the fact that several factors presented during treatment, but not directly related to it, can interfere with sleep, such as depression, fear, fatigue, nutritional disorders, among others. Recent studies have highlighted that one of the major concerns regarding sleep disorders is that they, in addition to negatively impacting quality of life, contribute to immunosuppression and increase the chances of psychic disorders. The use of exercise and physical activity for cancer patients under treatment and after treatment has been described in the literature, particularly in the last 10 years. Recent studies on its efficacy show levels of evidence A and B, so it becomes increasingly safe to prescribe exercise in cancer rehabilitation. Available research includes studies for various types of cancer, in particular lung, breast, prostate and in patients after bone marrow transplantation. There is no consensus on number of sessions per week, duration of each session, type of exercise used, number of repetitions and load. The protocols are diverse and, in general terms, have positive effects on the control, mainly, of fatigue. Particularly in breast cancer, the studies generate greater controversy. It seems that the use of strenghtening exercises alone or associated with stretching has no effect on fatigue (level of evidence B), but it improves quality of life (level of evidence A). Levels of evidence B suggest that protocols that include stretching, aerobic and strengthening exercises for large muscle groups and relaxation, ranging in intensity from mild, moderate to intense (50% to 80% of maximal heart rate) in the same protocol, by at least 2 times a week and run time between 30 and 60 minutes are more efficient to reduce fatigue, pain and intensity of pain and improve sleep. This type of protocol is beneficial for improving quality of life, with levels of evidence A. The suggested protocol is similar to that prescribed for women in the present study who showed improvement of all these symptoms (p < 0.01, p < 0.02 and p < 0.01, respectively). It is important to highlight that the evidence shows that as of 5 weeks, more expressive results begin to appear. In addition, the persistence of these positive effects in the long term requires that the performance of the exercises be maintained. With regard to the symptoms of nausea, few studies have investigated the effects of physical exercises on the gastrointestinal tract (GIT), either in healthy patients or in cancer patients. In general, high-intensity, long-term exercise increases symptoms of nausea, vomiting, loss of appetite, increased stool frequency. The causes attributed to this are reduced intestinal blood flow, the release of intestinal hormones, dehydration, mechanical stress on the GIT, among others. In contrast, exercises of mild to moderate intensity appear to have a protective effect on GIT. No study investigated explained the causes of improvement of the symptoms of nausea associated to physical exercise, as found in the present study (p < 0.03). CONCLUSION: In view of the symptoms associated with cancer treatment, in particular chemotherapy, several rehabilitation services and centers have been dedicated to thinking about possibilities of care that can bring benefits, with minor risks and side effects. Exercise and physical activity are presented as a therapeutic possibility, so that the most current research has been dedicated to studying how they can be used. In the present study, a structured protocol in a circuit system that included warm-up, moderate-intensity aerobic and muscle-strengthening exercises and stretching and relaxation reduced symptoms of pain, fatigue, nausea, and sleep disturbances. Despite being carried out with a small sample, which translates as one of the main limitations of the research, its results corroborate with findings of studies with level of evidence A and B published in the last 5 years.

Key-Words: Breast Cancer, Exercise, Physiotherapy