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#Breast Cancer and Rehabilitation

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Breast Cancer and Rehabilitation
Introduction

Breast cancer can occur in any adult. Incidences have been increasing over the last decades for both premenopausal and postmenopausal women. Although the incidence of breast cancer increases during postmenopausal years, it is the leading cause of cancer death in women younger than 50 years. Age is not a predictor of complications, but it may affect the patient’s outcome, ability to cope, and extent of psychological distress. Breast cancer is the most frequent cancer in women, and more than 85% of patients are alive 5 years after diagnosis. For these reasons, more than 700,000 survivors of breast cancer in the United States are alive within 5 years of diagnosis; their total prevalence is over 2 million. [17, 18, 19, 20]
Burstein and Winer wrote an excellent review of survivorship issues for women with breast cancer. [21]
Treatment Options

Overview
On initial presentation, clinical and pathologic staging is performed to identify prognostic factors and to determine treatment options.
Surgery and/or radiation therapy is used for local control and often successful in early-stage breast cancer. If they are smaller than 5 cm and limited to the breast and axillary nodes, most such cancers may be treated surgically with modified radical mastectomy or breast-conserving surgery. In both cases, the axilla is usually dissected. Disease-free survival rates are equal in patients undergoing mastectomy and breast-conservation surgery. Locally advanced breast cancers are treated with modified radical mastectomy, preceded or followed by chemotherapy. Irradiation of the chest wall is often considered when the risk of chest-wall or nodal recurrence is high, when primary tumors are large or multicentric, or when 4 or more axillary nodes contain metastatic cancer.
Systemic therapy (ie, chemotherapy and/or hormonal therapy) is recommended for patients who present with metastatic disease or who have risk factors for metastases. Risk factors for metastatic cancer include age younger than 35 years, positive involvement of the lymph nodes, high-grade histologies, negative estrogen receptors, large tumor, high growth fraction, aneuploid DNA content, and other biologic markers. Chemotherapy may be administered before, during, or after irradiation with parameters of timing and duration depending on the type of chemotherapy.
Estrogen and progesterone receptors can be assessed to predict the patient’s response to hormonal manipulation. Tamoxifen had been the first-line adjunct hormonal therapy and was started during or after radiation therapy. Hormonal manipulation for the treatment of metastatic breast cancer may include the administration of tamoxifen. However, results of the Arimidex, Tamoxifen, Alone or in Combination (ATAC) trial suggested that an aromatase inhibitor is therapeutically superior and better tolerated than tamoxifen in postmenopausal women with primary breast cancer. Aromatase is expressed in nonovarian tissues, such as muscle and fat in both premenopausal and postmenopausal women. These nonovarian tissues become the dominant sources of estrogen in postmenopausal women.
At present, the available aromatase inhibitors belong to 1 of 2 classes. Class I inhibitors irreversibly bind aromatase and have a steroidal structure (eg, exemestane). Class II agents reversibly bind aromatase and are nonsteroidal (eg, anastrozole and letrozole). Because of the specificity of its mode of action, this class of compound is well tolerated and thus lends itself to the management of both early- and advanced-stage disease.

In metastatic breast cancer, radiation therapy is often successful in palliating symptoms from painful bony sites, brain metastases, or other metastatic sites causing symptoms or obstruction. Metastatic breast cancer rarely is curable; however, studies are underway investigating efficacy of high-dose chemotherapy followed by peripheral stem-cell rescue of bone marrow to eradicate metastatic cancer.
Current issues in breast-cancer management
Current issues in breast-cancer management include the following:
Necessity for axillary-node dissection and/or breast irradiation after wide excision of breast cancer in patients with a good prognosis (eg, those with small tubular, colloid, or mucinous tumors)
Necessity for whole-breast treatment for intraductal carcinoma
Timing and type of chemotherapy with surgery and radiation
Utility of high-dose chemotherapy with stem-cell rescue in poor-prognosis breast cancer
Treatment of young and old women with breast cancer
Role of estrogen replacement in breast cancer
Surgery and Its Acute and Chronic Morbidity

Breast-conserving surgery is increasingly used for many breast cancers because disease-free survival rates are equal for women undergoing either this procedure or non–breast-conserving surgery. Breast-conserving surgery is associated with improved body image and, perhaps, hastened psychological recovery.
Breast-conserving surgery refers to removal of the cancer along with a margin of normal breast tissue and axillary dissection. In breast-preservation surgery, wide excision implies the removal of a 1- 2-cm margin of normal tissue, whereas in segmental mastectomy, even more normal breast tissue than this is removed.
A relatively uncommon surgical procedure is quadrantectomy. This is a procedure to remove the quadrant of the breast that contains the tumor plus the underlying pectoral fascia. Any increase in the extent of surgery is associated with increased risk of both early and late complications. Most reported surgical complications are associated with axillary dissection. Debate still surrounds issues of whether axillary dissection is necessary and, if so, which parameters should be used to determine its extent.
Principles of wound healing directly affect the initiation and appropriate intensity of any rehabilitation program. Wound healing is a dynamic process that lasts months to years. Wounds initially produce inflammation that lasts a few days unless necrosis, infection, or foreign bodies are present. At the edge of an epithelial wound, basal epithelial cells migrate across the defect on fibrin strands. Epithelial cells cover the wound within 48 hours and thereafter begin to differentiate and keratinize.
Fibroblasts, from the adventitia of blood vessels, migrate into the wound on fibrin strands on day 3 and begin to synthesize collagen fibers, which begin to appear on day 4. Wound strength is related to the rate of collagen formation. By 3 weeks, most wounds achieve 15% of their ultimate strength. Strength increases at a constant rate for 4 months and then at a lower rate thereafter for more than a year. Pain at the wound site generally limits the amount of stress an individual can place on the wound.
Changes in sensation are common; therefore, wounds should be treated gingerly. Because external skin sutures may provide a nidus for infection and cause extra scarring, remove them early. Factors that may impede healing include malnutrition (more common in elderly individuals than in younger patients); deficiencies of vitamin A, vitamin C, and zinc; cigarette smoking; and any conditions that decrease tissue oxygenation. Steroid use, radiation therapy, and some chemotherapy agents impede healing. The administration of doxorubicin (Adriamycin), which commonly used in adjunct chemotherapy programs, should be delayed until 4 weeks after surgery.
Early complications after mastectomy include seroma formation (10%), wound infection (7%), and skin-flap necrosis (5%). The fewest wound infections are seen when diagnoses are made by means of fine-needle aspiration. Immediate reconstruction is not associated with an increased rate of complications. Most surgeons agree that a drain must be placed after axillary dissection. The duration of drainage is not standard, but most surgeons agree that the drain can be removed when the volume of fluid draining from the wound decreases to less than 20 mL/day. The presence of a drain or a seroma can lead to infection. If seroma develops after the drain is removed, most surgeons aspirate the seroma only if the patient is uncomfortable. Do not place a drain in a lumpectomy site because cosmesis diminishes.
Complications associated with axillary dissection are secondary to nerve, vascular, and lymphatic injury. The most common complaints after axillary dissection are reduced sensation under the right arm and decreased ROM of the shoulder. Sensory deficit improves with time but may never return to normal. No known treatment exists for this adverse effect. Lymphedema can be seen immediately after surgery and results in a small increase in diameter in the upper arm only. Collateral circulation should resolve the edema within several weeks.
Chronic lymphedema and its treatment are discussed elsewhere (see the section Management of Lymphedema, below). Injury to the long thoracic nerve results in winging of the scapula. About 30% of patients develop serratus anterior muscle palsy secondary to injury to the long thoracic nerve but appear to recover by 6 months. Injury to the thoracodorsal nerve causes slight weakness in internal rotation and abduction of the shoulder from weakness of the latissimus dorsi muscle. Injury of the medial pectoral nerve results in atrophy of the lateral portion of the pectoralis major muscle. Injury to the intercostobrachial nerve results in reduced sensation along the medial aspect of the arm, and, in some patients, subsequent disabling neuralgia develops.
Breast Reconstruction

Intuition suggests that breast reconstruction offers a woman the opportunity to retain a positive self image, mitigating concern about breast cancer treatment significantly and perhaps even encouraging women to seek earlier diagnosis of breast cancer. However, the psychosocial benefit of reconstruction is only slight when patients who have undergone surgical reconstruction are compared with patients treated with mastectomy alone. Breast-preserving surgery affects body image less than mastectomy and breast reconstructive procedures do. Studies show lower scores for body image in women who have undergone breast reconstruction than in patients who have undergone breast-preserving surgery. This phenomenon may be related to the complicated nature of reconstructive surgery.
A cohort analysis of 13,388 women confirmed findings from numerous studies in that breast-augmentation surgery does not increase the risk of breast cancer and does not delay diagnosis.
Although breast-reduction surgery is never performed as cancer prophylaxis, it appears to reduce the risk of breast cancer proportionate to the amount of tissue removed. Prophylactic mastectomy has a proven role in reducing the incidence of breast cancer, both among women with a moderate or high-risk family history and among those with proven mutations of BRCA1 or BRCA2.
Methods of reconstruction

Reconstruction of the breast can be accomplished in several ways at any time after surgery. The type and timing of reconstruction do not affect biologic processes or the detection of breast cancer. For advanced cancers for which irradiation of the chest wall and regional nodes is planned, breast reconstruction should be delayed, but the intention to perform reconstructive surgery does not prevent radiation therapy if unexpected pathologic findings are discovered.
The simplest reconstruction consists of placing an expandable saline implant under the pectoralis muscle in the musculofascial layer and stretching the tissues of the chest wall to reduce tightness and firmness of the chest wall. The implant is then replaced with a permanent implant. Saline is instilled into a fill valve at regular intervals over several weeks until the expander is overfilled to 200 mL beyond the volume of the contralateral breast. After the chest wall is stretched to allow for a normal breast contour, a second operation is performed to replace the implant with a shaped prosthesis or to remove the excess fluid and fill valve. Complications include extrusion of the expander, infection, and deflation. Patients complain of chest-wall tightness and asymmetry.
The 3 most common of the autologous procedures are the latissimus dorsi muscle flap procedure (performed by using muscles taken from the back), the procedure involving a pedicular transverse rectus abdominis muscle (TRAM flap, sometimes called conventional flap), and the free TRAM flap procedure (sometimes called the microsurgical flap). Both TRAM procedures are performed by using muscle taken from the abdomen. The deep inferior epigastric perforator (DIEP) procedure and the superior gluteal artery perforator (SGAP) flap procedure are relatively new techniques in which fat and skin without muscle are used for reconstruction. See the images below.

 

http://img.medscapestatic.com/pi/meds/ckb/16/ cancer. Transverse rectus abdominis muscle (TRAM) flap.
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http://img.medscapestatic.com/pi/meds/ckb/17/

Breast cancer. Transverse rectus abdominis muscle (TRAM) flap.
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Flap procedures are used to transfer distant tissue with its own blood supply. Muscle and skin can be transplanted from the back (latissimus dorsi flap), abdomen (transabdominal rectus or TRAM flap), or buttocks (gluteus flap), and a microvasculature anastomosis is performed. The TRAM flap has become the flap of choice because of the volume of tissue that can be moved. However, cigarette smoking, diabetes mellitus, and obesity are relative contraindications because of decreased microcirculation. When the irradiated chest wall is reconstructed, the TRAM flap is preferred because of its vascularization.
The pedicle TRAM flap procedure requires the entire rectus abdominis muscle for construction of a new breast. The surgeon rotates the muscle, pulls it up through a previously constructed tunnel in the chest, pockets it out, and molds it into a breast. Blood supply from the superior epigastric artery and vein remain intact at their source, and they are pulled up with the muscle.
The free TRAM flap procedure requires only a portion of the rectus abdominis muscle. The surgeon fully removes a portion of the muscle from the donor site, with blood supply intact from the deep inferior epigastric vein and artery, and reattaches it to the chest wall to reconstruct the breast. The surgeon then connects the tiny vessels to recipient vessels, most often the thoracodorsal artery and vein in the axilla near the new breast, in a separate microvascular procedure.
The free TRAM flap surgery is not performed as often as other procedures in women who choose breast reconstruction after mastectomy (only 5% of reconstructions involve this procedure). However, it is a highly satisfactory option for the right candidates, and, in some cases, it may be the most logical choice.
Postprocedural care

The patient or her caregiver at home must be able to empty any remaining surgical drains and record amounts of drainage. The surgeon usually orders removal of a drain when it has less than 25 mL of output in 24 hours. Drainage from the incisions should be absent or minimal. However, for the first 2-3 days after drain removal, a small amount of serosanguineous drainage from the exit sites is normal. Abnormal drainage is foul smelling and saturates a 4 X 4-in gauze. After the drain is removed, a small piece of gauze may be placed over the drain exit, but the supportive bra should hold it in place. Tape should not be used on the reconstructed breast. For the first few weeks, showering should replace bathing in a tub.
Binding: Instruct patients in the use of a supportive bra without underwires in the hospital, usually a day after surgery. Some patients may desire an abdominal binder in addition to the supportive bra.
Smoking: Avoidance of smoking is especially important during the first few weeks of vascular and tissue healing. Also, avoidance of smoking at least 4 weeks before surgery reduces complications, such as flap necrosis and hernia after surgery.
Exercise: Encourage women after mastectomy to perform arm abduction and reaching exercises; however, advise patients to avoid these exercises after free TRAM flap surgery. The patient may be limited to lifting no more than 10-lbs. for 4-6 weeks, and the patient should keep her affected arm below the height of her shoulder for 2 weeks. However, encourage use of the arm in front of the body (as in washing the face or eating) to prevent stiffening of the joints. Some patients benefit from physical therapy (PT) to strengthen the abdominal muscle after TRAM flap surgery.
If a TRAM flap reconstruction is planned, address rehabilitation issues, and preoperatively counsel the patient about the need for a program to address back and shoulder strengthening. Decreased trunk flexion and extension strength also result from the surgery. PT focuses on strengthening exercises and compensatory movements for most patients, particularly for individuals with chronic spinal pain.
Other types of reconstruction are associated with discomfort related both to loss of tissue from their respective areas and to the actual surgical procedure. The latissimus dorsi flap procedure is less complicated than other reconstructive procedures, but an implant is required for adequate cosmesis. The most common complication is seroma formation. No functional loss of shoulder strength is observed. A gluteus maximus flap is both less painful and less morbid than a TRAM flap, but it is more technically demanding. A nipple can be constructed in all types of reconstruction by puckering skin and tattooing an areola, or by grafting skin into a nipple site and tattooing. Avoid grafts on irradiated skin.
Shoulder and Arm Rehabilitation

The goal of arm and shoulder exercises is to enable the patient to return to normal activity after axillary dissection. At 3 or 15 months after surgery, approximately 80% of patients continue to report at least 1 problem. Problems may include swelling (25%), weakness (25%), limited ROM (30%), stiffness (40%), pain (50%), and/or numbness (55%). Increasing numbers of complaints are associated with high levels of psychological distress. In the optimal situation, preoperatively evaluate the patient for strength, ROM, sensation, posture, endurance, and general functional ability. Instruct the patient regarding ROM exercises, postoperative breathing, and initial mobility after surgery. Start shoulder and arm rehabilitation as soon as the surgical incision appears healed and recurrent seroma or infection is absent; remember the principles of wound healing.
Early PT to the shoulder after axillary dissection does not increase the incidence of lymphedema. The development of seromas is most prevalent with extensive surgeries. Encourage the patient to begin gradual stretching exercises for all degrees of motion within a few days of surgery. The optimal program starts postoperatively with gentle ROM exercises of the shoulder from 45-90° in patients without reconstruction. PROM should start to 90° of flexion and abduction with external and internal rotation as tolerated. Early mobilization of the glenohumeral joint improves shoulder ROM. Recovery was faster in patients who began shoulder flexion to 40° on day 1 and 90° on day 4 than in those who had a delayed start of ROM exercises. Methods to compensate for nerve injury improve muscle strength and prevent shoulder tightness and discomfort.
Patients should begin full shoulder and arm ROM exercises as soon as the surgeon deems them safe, often after the drains are removed. Active and active-assistive exercises can be increased at this stage. Exercises, such as wall climbing, and use of pulley or wand, should be added. After all sutures are removed, exercises more aggressive than these can be incorporated.
Physical modalities may be helpful. Use ultrasound with caution, given its potential risks of promoting residual tumor cell growth or metastasis. Include stretching exercises and electrical stimulation as part of the rehabilitation program. Patients treated with mastectomy are more likely than patients receiving breast-conserving surgery to have impaired mobility. Prospective studies demonstrate that patients who receive structured PT achieve arm and shoulder function better than the function of those who do not receive such PT.
A home exercise program should be implemented, and follow-up PT assessment should be included. Massaging of scars is usually incorporated into this program around 1 month after surgery. With radiation treatment, ongoing ROM exercises are particularly important to prevent contracture formation.
Discuss lymphedema precautions with the patient before surgery, and review her condition within several days of surgery. When resting, the patient should elevate her arm higher than her heart but not over her head. Exercises using the forearm and hand should be performed immediately to help muscular propulsion of blood and lymph fluid from the lower arm. Encourage the patient to squeeze a tennis ball or other soft ball when resting. Advise the patient not to lie on her arm in the ipsilateral decubitus position and to avoid a prone position.
Discuss the effects of skin or soft tissue infections on the development of arm edema, the effect of gravity on lymph drainage, the importance of avoiding procedures on the arm that may break the skin, and the type of exercises that can improve muscle tone in the arm. Encourage the patient to be aware of the importance of weight management because edema of the arm is associated with weight gain. Advise the patient to seek medical help immediately if signs of erythema or swelling occur. Many physicians prescribe antibiotics for acute edema.
Radiation Therapy and Its Consequences

Use of radiation therapy after breast-preserving surgery is common to reduce the probability of recurrence in the breast and after mastectomy, when the risk of recurrence in the chest wall is high. The breast is treated with tangential techniques that also include irradiation of the underlying muscle, rib, and anterior surface of the lung. After mastectomy, the chest wall is treated with similar techniques, but radiation is delivered after subcutaneous tissue is damaged by production of skin flaps. The supraclavicular, axillary, and sometimes internal mammary nodes are irradiated when the risk of nodal recurrence is high. Direct anterior fields are used to treat increased volumes of rib and lung tissue. The brachial plexus is often in the node fields, but damage is uncommon with standard doses. Irradiation of the axillary nodes is associated with an increased risk of lymphedema; avoid it unless the risk of recurrence in the axillary nodes is clinically significant.
Irradiation exaggerates the effects of surgery. Fibrosis secondary to radiation in the treatment field may cause the following effects:
Increased obstruction of arm lymphatics (if in the radiation field)
Increased tightness of the chest wall and pectoralis decreasing shoulder mobility (most prevalent in patients undergoing mastectomy)
Pain in subcutaneous tissues, intercostal muscles, or ribs
Decreased pulmonary reserve (rare unless more than 10% of the lung volume is treated)
Rib fractures (1% risk)
Soft tissue infections, cigarette smoking, and diseases that may impair microcirculation (eg, diabetes, arteriosclerotic vessel disease) increase the probability of fibrosis. Exercise and manual massage may decrease pain and discomfort associated with fibrosis. Ointments to treat dry skin may relieve dryness and itching. Breast edema is an adverse effect unique to breast preservation and related to the extent of axillary dissection, the location and extent of breast surgery, and the size of the breast. Weight gain may aggravate breast edema. Breast edema resolves with time, but weight loss, proper breast support, and avoidance of prone sleeping position may help. Development of late breast edema is uncommon and may represent infection or recurrent cancer.
If volumes of lung tissue greater than 10% are included in the radiation fields, the patient may develop cough, shortness of breath, and low-grade fever 4-12 weeks after radiation. The physician must rule out an infectious source. Chemotherapy increases the risk of pneumonitis. Temporary, low-dose steroids may relieve symptoms of radiation pneumonitis, and antibiotics are often added empirically. Acute radiation pneumonitis resolves in 2-3 months and is not predictive of long-term pulmonary insufficiency. About 10% of lung volume must be treated to observe pneumonitis. Always compare chest radiographs with radiation portal images to confirm the etiology of the disease process.
Most patients have subclinical effects of the lung. In most patients, the diffusing capacity of carbon monoxide decreases but returns to normal levels by 24 months. However, patients who smoke cigarettes have greater deficit and less recovery than those who do not smoke. Cigarette smoking affects the tolerance of the lung to radiation; therefore, encourage patients to stop smoking. Permanent injury to the lung because of interstitial fibrosis is localized to only the radiation field and can be identified on lung radiographs. Long-term effects of lung fibrosis are related to the volume of irradiated lung and to the patient’s pulmonary status before irradiation.
Radiation-induced brachial plexopathy is characterized by shoulder discomfort and progressive paresthesias and weakness in the arm and hand. About 1% of patients who receive nodal irradiation with doses greater than 50 Gy and who are usually treated with chemotherapy develop problems. If doses are limited to 50 Gy, symptoms are generally transient. Symptoms develop 3-14 months after irradiation and commonly affect the distribution of the lower plexus. Progressive neurologic dysfunction of the brachial plexus is associated with radiation fibrosis because of large fractions. The prevalence of pain, in addition to paresthesias of the hand and proximal arm weakness, may be increased. Weakness in the distribution of the upper plexus is most common. Associated arm edema secondary to irradiation is often noted. No treatment, other than symptomatic management, is known. However, cancerous infiltration of the brachial plexus can mimic these symptoms and must be ruled out.
Women treated with direct fields to the left side of the chest may have increased incidence of arteriosclerotic heart disease and, consequently, of myocardial infarctions. Women often become menopausal as a result of estrogen deprivation; this development may add to incidence of cardiovascular disease. Discuss the benefits of diet, exercise, hypertension treatment, and treatment of cholesterolemia with any patient with breast cancer, but the importance of this step is most obvious in patients treated with irradiation and chemotherapy.
Hormonal Treatment

Tamoxifen or aromatase inhibitors are commonly prescribed for women with hormone receptors positive for estrogen whose cancers are larger than 1 cm. Many premenopausal women receive tamoxifen after chemotherapy, whereas many postmenopausal women with large tumors or positive nodes receive it as single-agent adjunct therapy. Tamoxifen may be prescribed for a minimum of 5 years. In addition to the antitumoral effect, other benefits of tamoxifen may include reduced bone loss and an improved lipid profile. Tamoxifen often exaggerates symptoms of estrogen deprivation, with hot flashes (50-60%), depression (10%), weight gain, and vaginal dryness as common complaints. Examine patients annually because of a possible risk of endometrial carcinoma secondary to tamoxifen. The aromatase inhibitors have equal efficacy and a slightly improved adverse-effect profile.
Chemotherapy and Its Consequences

In the adjunct setting, chemotherapy is usually administered in 4-6 cycles of 3-4 weeks. Preconceived notions, often incorrect, can affect a woman’s attitude toward chemotherapy. The clinician must anticipate these concerns, particularly nausea, hair loss, and lifestyle changes, when introducing the topic of chemotherapy. Immediate effects of chemotherapy include general fatigue, as well as nausea and vomiting, which are effectively countered with medication, including prochlorperazine, lorazepam, ondansetron, and granisetron. Patients often gain weight because food may relieve nausea, and their basic metabolic rate may decrease. Fatigue can be overwhelming and affect exercise and activity levels. Work and family issues may be important during chemotherapy because treatment can last for many months.
During therapy, many women have a diminished immune status, which puts them at risk for infection. These periods are short, but some women require increased intervals between chemotherapy cycles or use of growth factors, which are associated with their own adverse effects. Prolongation of chemotherapy may be devastating for many women who have planned for periods of disability for a certain length, who are limited in their sick absences from work, or who must rely on childcare. In general, these women should avoid being around children with the usual childhood diseases (eg, chickenpox).
Chemotherapy may render women, generally those in their late 30s or 40s, menopausal. The incidence of premature ovarian failure is about 70%, but it is lower than this in women younger than 30 years. The most common severe late effect of doxorubicin (Adriamycin) chemotherapy is cardiomyopathy, occurring in less than 1% of women with a total cumulative dose of 300 mg/m2. A previously active young woman may become dyspneic on exertion. Appropriate consultations with a cardiologist and staff from cardiac rehabilitation programs may improve the performance status of women made symptomatic by therapy. Another serious adverse effect of chemotherapy is an increased risk of leukemia, which is related to dose and type of alkylating agent (incidence of 0.7% at 10 y); this risk may increase with adjunct radiation. Current data suggest that the risk of leukemia is minimal with regimens containing cyclophosphamide that are used today.
Nonetheless, the use of adjuvant chemotherapy clearly benefits women with early breast cancer. A meta-analysis of randomized trials of adjuvant prolonged polychemotherapy in women with early breast cancer demonstrated that, in terms of survival advantage, relatively short regimens of approximately 3-6 months were as effective as the longer chemotherapy regimens. Polychemotherapy provided an absolute improvement of 7-11% in 10-year survival among women younger than 50 years at presentation; for women 50-69 years of age, the absolute improvement in 10-year survival was 2-3%.
Anthracycline-containing regimens were slightly more active than the previous standard combination chemotherapy of cyclophosphamide, methotrexate and 5-fluorouracil (CMF), with the former producing a moderate improvement over the latter with respect to the percentage of patients surviving and being disease-free after 5 years. The benefit of anthracycline-containing regimens is particularly evident in premenopausal patients, and increasing evidence suggests that 6 or more cycles of the 3 drug regimens are more effective than the 4 cycles of doxorubicin and cyclophosphamide (ie, Adriamycin and cyclophosphamide [AC]) that has become popular.
Taxanes, such as paclitaxel, have promising activity in patients with node-positive primary breast cancer. Preliminary results from a large, multicenter study showed that patients treated with AC followed by paclitaxel had a significantly better disease-free survival and overall survival than patients treated with only AC. Moreover, the addition of paclitaxel to AC was well tolerated. Further results from this trial are awaited with interest, particularly because preliminary results from other studies have not yet confirmed these findings.
Encourage women to be active and to seek support. Evidence suggests that participating in support groups or having a confidant increase probability of survival. Continuation of regular activities during chemotherapy is beneficial. In 1 study, 41% of women found that treatment was easier than expected. By focusing on delayed benefits of chemotherapy (ie, survival issues), women can cope with short-term adverse psychological effects. In some professions, women are not allowed to continue working during therapy (eg, firefighter, airline pilot), and they are placed on medical disability. The Americans with Disabilities Act (ADA) protects women with breast cancer from workplace discrimination in most settings. The Family Medical Leave Act (FMLA) also requires flexibility in scheduling for patients and family members to accommodate treatments.
Exercise

While there is not a criterion standard when prescribing exercise, an experienced rehabilitation team can prescribe an exercise regimen to optimize each patient’s health. For the general population, the benefits of exercise on weight and on the cardiovascular system are undisputed. Women with breast cancer who participated in aerobic exercise have improved QOL. Obesity is a minor risk factor for breast cancer; it is associated with additional complications of breast-cancer treatment (eg, lymphedema) and is associated with an increased risk of breast-cancer recurrences.
Exercise improves the functional capacity of patients with breast cancer who are receiving adjunct chemotherapy. Weight gain is common during chemotherapy and apparently connected with loss in muscle tissue, which may contribute to reduced functional capacity and a lowered metabolic rate during adjunct chemotherapy. Increased lean body weight is observed in patients who exercise while receiving chemotherapy.
In animal models, exercise did not induce metastases and was associated with a decreased number of metastases. Exercise also attenuates cachexia in animals.[#target3]
Management of Lymphedema

Any dissection of axillary lymphatics and nodes places a woman at risk for edema of the arm. Axillary surgery and irradiation can lead to lymphedema, which may be caused by direct damage to axillary lymphatics. Fibrosis of the axilla secondary to surgery and/or radiation causes venous and lymphatic obstruction by compressing major vascular trunks and blocking regeneration of lymphatic and venous collaterals. Additional radiation therapy, trauma, and infection are other causative factors. Increase in arm circumference immediately after surgery is common and should resolve within weeks. No standardization exists in the literature as to the type and location of measurement and the implications of such measurement. Most clinicians agree that a difference in circumference of more than 2 cm between the arms has clinical significance.
Nonetheless, lymphedema may be classified as 1 of 3 stages. The first stage is where pitting is associated with edema and temporarily reduced with elevation of the arm. In the second stage, the edema does not reverse spontaneously. Protein-rich edema persists and can lead to proliferation of connective tissue. With such changes, fibrosis occurs and brawny edema is seen on clinical evolution. In the last stage, lymphostatic elephantiasis, the patient has enormous volume with cartilage-like hardening of dermal tissue along with papillomatous outgrowths.
Late arm edema is associated with the patient’s age, the extent of cancer in the axilla, the extent of axillary dissection, and the dose and techniques for irradiation. Nearly 33% of patients older than 55 years and 25% of patients in whom more than 15 nodes are dissected develop a difference of 2 cm or greater in the circumference of their arms at 3 years. By comparison, late breast edema is less common after axillary dissection is performed in conjunction with breast-preservation surgery. Therefore, always consider the presence of an infection or recurrent cancer as a possible cause of late edema.
Perform medical assessment to determine the cause of swelling. Rule out or treat infection, venous thrombosis, or cancer recurrence. Prescribe antibiotics if the development of edema is acute. Make serial measurements of both arms with the olecranon as the reference point. Assess shoulder, arm, and hand strength; sensory changes; color; turgor; pulses; and mobility. In rare cases, long-standing lymphedema can lead to lymphangiosarcoma, a highly aggressive tumor with poor survival despite forequarter amputation.
Conservative management of lymphedema should include preventive and mechanical modalities as needed. Pharmacologic means include antibiotic prophylaxis to prevent and treat cellulitis and lymphangitis. Drugs such as anticoagulants, hyaluronidase, pyridoxine, benzopyrenes, and others have been used but have no proven therapeutic value. Preventive care should emphasize identification of patients at highest risk of lymphedema. Comorbid illnesses such as hypertension, heart disease, diabetes and kidney disease can contribute to edema also. Patients should understand lymphatic drainage, the pathology leading to lymphedema, as well as the signs, symptoms, and complications of lymphedema.
Self-care instructions include the following:
Proper nutrition with balanced nutrition and increased protein and lowered salt intake
Weight management
When possible, the arm should be elevated above the level of heart.
Home exercise program includes the following:
ROM exercises
Exercises and techniques to improve venous drainage
The importance of gravitational drainage
Static resistance exercises and positional changes need to be incorporated into daily activities, including positioning for sleep.
Traditionally, no heavy lifting with the involved arm, typically less than 15 lb – However, although weight lifting has generally has been proscribed for women with breast cancer–related lymphedema, in a randomized, controlled trial of twice-weekly progressive weight lifting in 141 breast cancer survivors with stable lymphedema of the arm, Schmitz et al found that, compared with the control group, the weight-lifting group had greater reductions in the self-reported severity of their lymphedema symptoms (P=0.03) and experienced more improvement in upper- and lower-body strength (P< 0.001 for both). [22]
In addition, the incidence of lymphedema exacerbations was lower in the weight-lifting group than in the control patients (14% vs 29%, P=0.04).
Injury and infection should be avoided, as follows:
No venipuncture or finger sticks on the involved side
Skin breaks should be cleaned with mild soap and water, followed by antibacterial ointment use.
Recommend long-sleeved shirts and bug-repellents for prevention of bug bites.
Use of gloves during gardening
Use of an electric razor for shaving
Good nail care, including not cutting the cuticles
Gauze wrapping instead of tape use
Physician should be notified about rashes, erythema, swelling, pain, increased warmth or localized infection. Daily cleaning and lubrication of skin is indicated.
Avoid constrictive pressure on the arm (eg, no blood pressure cuff, no constrictive bands).
Recommend follow-up with the physician on a regular basis and with any sudden change in arm circumference or evidence of infection.
Complex lymphedema therapy is used to treat peripheral lymphedema and typically has 2 phases, acute and maintenance. The acute phase of therapy consists of manual compression, external compressive bandaging, and specific therapy exercises, including manual and massage techniques. Patients and family members should be taught these techniques. The goals for the patient during the maintenance phase are to be able to wear specially fitted pressure gradient garments during the day, with compression bandaging or a compression device at night. Intermittent pneumatic pressure devices are used in the management of lymphedema. However, such devices may be most effective in low-protein venous edema in which fluid is directly forced back into the blood vessels. With lymphedema, such tissue fluid may simply be displaced into an adjacent region.
External compression can place increased proximal demands on the existing intact lymphatic system. Pressures over 45 mm Hg may further damage lymphatic structures. With increased pressures, pain and hematomas are common in the involved site. Patients with severe edema required prolonged compressive bandaging and close follow-up with therapists (typically several times a week for at least 3-4 wk). Afterward, results can be maintained with continued bandaging and use of manual techniques at home.
A nonelastic bandage may have to be left on in excess of 12 h/d. After the volume of the limb is stabilized, the use of manual techniques and compression garment (often customized) may be sufficient. With exacerbations of lymphedema, use of a nonelastic bandage may be necessary, along with outpatient PT for close supervision. Compression garments are ideally replaced every 3-4 months because they tend to lose their elasticity.
Counsel the patient regarding the permanent nature of the condition and how to prevent its progression. Remember that, with increased interstitial protein level, progressive fibrosis and chronic inflammation can ensue. Although treatment is time-consuming, particularly in its initial phases, it is associated with improved body image and function, which increase QOL. Arm swelling has been associated with increased psychiatric morbidity, as reflected by anxiety, depression, and poor adjustment to breast cancer. Consider psychological intervention when lymphedema is obvious to the casual observer.
Investigators in the Netherlands reported long-term impairments, disabilities, and QOL-related issues. Pain (60%) and reduction of grip strength (40%) were the most frequent impairments. The prevalence of impaired ROM and edema was 9-16% and 15%, respectively. Mean group scores for QOL differed significantly for physical functioning, vitality, and health perception compared with those for a healthy female group. Radiotherapy and chemotherapy were significant factors in the prediction of impaired ROM.
Another group of clinical investigators reported their findings in 105 survivors of breast cancer. The patients were interviewed to obtain data about their health and economic changes in the 5 years after diagnosis and initial treatment. An age- and work-matched group of 105 women without cancer were also interviewed. Key changes in functional status and economic outcomes (eg, changes in market earnings, household income, insurance coverage) were measured. Severity of impairment was compared between the study and control groups. Also tested was the adversity of economic outcomes in relation to the women’s impairment, regardless of their breast cancer status.
The analysis revealed statistically significant evidence with regard to each of the relationship tested. Survivors of breast cancer were more likely than control subjects to be functionally impaired at 5 years, and women with impairment were most likely to have reduced work effort and to experience downturns in market earnings, among other outcomes.
Korpan et al reviewed the effects of exercise on breast cancer treatment–related lymphedema. Weight-lifting exercise did not worsen lymphedema when individuals wore a compression garment on the affected limb. Hydrotherapy pool exercise decreased mild-to-moderate lymphedema 29% after 3 months of weekly sessions. [23]
Exercise facilitates lymph drainage via 2 mechanisms. First, exercise compresses lymph vessels with muscle contraction. Second, exercise alternates intrathoracic pressure with respiration. These 2 mechanisms assist lymph drainage from the extremities, into the thoracic duct, and back into circulation.

 

In Medscape

Diminuir a mortalidade por doença cardiovascular: qual a melhor estratégia no Brasil e no mundo?

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Lúcia Helena de Oliveira

As mais de 800 cadeiras no auditório 3 do Transamérica Expocenter, espaço de convenções da capital paulista que sediou entre os dias 15 e 17 de junho o Congresso da Sociedade de Cardiologia do Estado de São Paulo (Socesp), continuaram ocupadas quando, ali, se encerrou a cerimônia abertura. Se, até então, comemorou-se os recordes da 38º edição do evento, tanto na quantidade de trabalhos inscritos quanto na de participantes, o que se viu na sessão seguinte foi um choque de realidade. O encontro científico, claro, traria apresentações sobre novas tecnologias e medicamentos. Mas, ao falar no simpósio intencional  Como enfrentar e vencer a doença cardiovascular, o Dr. Álvaro Avezum Junior, diretor da Divisão de Pesquisa do Instituto Dante Pazzanese, em São Paulo, foi direto ao ponto: “Sem dúvida, avançamos cada vez mais no tratamento da doença cardiovascular já estabelecida, mas sua incidência inabalável nos obriga a encarar que ainda não sabemos atuar na prevenção.”

O Dr. Avezum é um dos quatro cientistas brasileiros, e o único na área da saúde, no grupo dos 3.215 pesquisadores com produção acadêmica de maior impacto no mundo. A listagem, elaborada pela consultoria Thomson Reuters, considera os cientistas cujos trabalhos em 21 campos do conhecimento estão entre os mais citados no período de 2002 a 2012. Segundo o cardiologista, o que está em jogo é a capacidade de o médico influenciar a sociedade na redução da morte por doença cardiovascular.

“E essa capacidade está se mostrando muito aquém do desejável. Até porque precisamos assumir: nós não conhecemos a realidade dos nossos pacientes. Aí é que está”, declarou, abrindo a ferida para continuar a cutucá-la.

“Entre as doenças cardiovasculares, a que se destaca em mortalidade no Brasil e no mundo é o infarto agudo do miocárdio (IAM). E, sejamos honestos, o que precisamos saber para evitar o IAM? Se me disserem que falta avaliar a genética, a presença de infecções ou de inflamações ou, ainda, conhecer mais a fundo a coagulação, direi que para fazer prevenção não precisamos saber de mais nada. O que já sabemos, se fôssemos bons em influenciar as pessoas, evitaríamos 90% dos eventos de IAM. E ponto.”

 Se fôssemos bons em influenciar pessoas, evitaríamos 90% dos eventos de IAM. E ponto. Dr. Álvaro Avezum Jr.

O Dr. Avezum apontou para o INTERHEART, estudo de caso-controle realizado em 52 países, representando todos os continentes habitados, envolvendo 15.152 pacientes que sofreram IAM e outros 14.820 indivíduos no grupo controle[1]. Não importa se mais jovem ou mais velho, se homem ou mulher: em todos os cantos do planeta, nove fatores de risco pesam, de longe, bem mais para a ocorrência do infarto agudo. Eles são, de um lado, a dislipidemia, o  tabagismo, a hipertensão, o diabetes, a obesidade abdominal e os problemas psicossociais, como a depressão, que prejudicam a saúde cardiovascular. Ou, de outro, a carência de três importantes fatores protetores, que são a ingestão rotineira de frutas e vegetais, a atividade física regular e o consumo moderado de álcool. No caso deste, o Dr. Avezum observou, em entrevista ao Medscape, que a bebida reduz o risco só no contexto específico do IAM.

“Em compensação,  aumenta a probabilidade de AVC, tanto isquêmico quanto hemorrágico. Portanto, nenhum especialista em doença cardiovascular deveria aconselhar  o consumo moderado de álcool baseado em evidência”, alerta.

Os fatores de risco no Brasil

Fato é que, ao redor do mundo, o controle desses nove fatores seria capaz de reduzir em 90% a probabilidade do IAM nos homens e em até 94% nas mulheres. E se focarmos o olhar apenas no Brasil? Dr. Avezum, que coordenou o estudo no país, responde: “os achados apontam que, aqui, as dislipidemias são, de longe, o maior fator de risco. Se controlássemos o perfil lipídico do brasileiro, já evitaríamos 57% do total de infartos”. Feitas as contas, considerando que a estimativa nacional é de cerca de 400 mil casos de IAM anualmente, isso significaria em torno de 228 mil episódios a menos.

“Na sequência, em empate técnico, estão a hipertensão e o estresse, porque não se trata de um país tranquilo”, ironizou o Dr. Avezum. “E, finalmente, se  juntarmos o tabagismo e a falta de atividade física, teremos como reduzir em 90% a incidência do IAM nos brasileiros. Logo, olhar para fatores emergentes teria impacto de 10% e, pensar neles, só escamoteia nossa dificuldade de lidar com velhos conhecidos”, opina.

Em sua apresentação, Dr. Avezum reconheceu que o país é bastante heterogêneo, com regiões que alcançam maior sucesso em matéria prevenção do que outras. “Se bem que, por todo canto, o mapa brasileiro continua pontilhado por microrregiões em que a situação é bastante crítica”, disse.

“Fazemos parte das nações que se encaixam no paradoxo do risco, isto é, embora existam países com número bem maior de infartos, temos mais eventos fatais.”

Aliás, oito em cada dez mortes por IAM ocorrem em países de baixa ou média renda, de acordo com o estudo PURE[2], citado pelo Dr. Avezum e do qual ele também é um dos autores. Os países mais favorecidos – no caso, Canadá, Emirados Árabes e Suécia – chegam a ter uma incidência daqueles nove fatores de risco listados no INTERHEART em torno de 30% mais elevada do que o Brasil, que está no grupo das nações renda média. No entanto, temos mais do que o triplo de mortes. Apesar do risco menos presente, temos mais do que o triplo de mortes. Daí o paradoxo.

Não há explicações claras para o fenômeno e, sim, pistas. Muitas delas apontam para a prevenção secundária ineficiente. O Dr. Avezum exemplificou com um dos desdobramentos do estudo PURE América Latina, intitulado Utilização de Medicações Comprovadamente Eficazes em Prevenção Secundária na América do Sul, que está para ser publicado no Global Heart: “o dado mundial, que inclui o Brasil, é de que o controle da hipertensão arterial está em 15%, na melhor das hipóteses”, disse.

“Quando o hipertenso não tem outro fator de risco adicional, oito em cada 100 têm níveis pressóricos controlados, aumentando para pouco mais de 15% quando o indivíduo com hipertensão tem mais de dois desses fatores”, explicou. “Ou seja, generalizando, podemos estimar que apenas um em cada seis casos de hipertensão no planeta está controlado, e é claro que teremos infartos desse jeito.”

Foi sobre esse grupo privilegiado – e restrito –, o de quem recebe  cuidados, que o médico se debruçou ao falar no evento da Socesp. E, de novo contextualizando os achados do trabalho sobre a situação da América do Sul, revelou que na Suécia e no Canadá, 20% dos hipertensos recebem quatro medicamentos: IECAs, bloqueadores dos receptores de angiotensina, antiplaquetários  e estatinas.

“Já no Brasil, na Argentina e no Chile, apenas 5% dos pacientes  tomam essas quatro medicações”, disse. E continuou: “na América do Sul, apenas 18% dos pacientes diagnosticados com doença cardiovascular usam estatina. Já no caso específico de quem sofreu um AVE é ainda pior: menos de 10% usam esse medicamento.”

Diante do cenário que esboçou à plateia do simpósio, Dr. Avezum clamou pela necessidade de se pensar em alternativas “criativas e abrangentes”, lembrando que a responsabilidade não é exclusiva da classe médica, mas do governo, dos hospitais e dos agentes de saúde da família, salientando a importância destes últimos para traçar os famosos roadmaps capazes de mostrar onde estão os nós críticos, até porque esses agentes de saúde cobrem 62% do território nacional. E não só por isso: “o agente  vai até a casa das pessoas, sabe o que realmente acontece lá. Quando o VIGITEL conta que o Brasil tem 27% de adultos hipertensos – referindo-se ao levantamento do Ministério da Saúde, feito por meio de entrevistas por telefone[3]  –  nós, médicos, sabemos que essa não é a verdade. Há uma subnotificação tremenda. Não podemos confiar no que o paciente fala em uma ligação telefônica, muitas vezes com base apenas na impressão que ele tem de si mesmo. A prática clínica mostra que perto de 45% dos brasileiros são hipertensos.”

Ao finalizar a sua parte na sessão, ele lembrou que o Brasil, ao lado da Índia, foi o primeiro signatário do Programa 25×25 da World Heart Federation, comprometendo-se a implantar estratégias para reduzir em 25% a mortalidade por doenças cardiovasculares no país nos próximos sete anos. Para alcançar esse objetivo, segundo o Dr. Avezum, o ideal seria o país eleger uma prioridade na prevenção secundária, aquele fator de risco que, se combatido com afinco nesse período, trará melhores resultados. E, neste ponto, o Dr. John A. Spertus, professor da Escola de Medicina da Universidade de Washington e membro do American College of Cardiology, que também participou da sessão, fez questão de concordar.

“Para um atendimento de qualidade na prevenção secundária, não adianta tentar resolver todos os problemas de uma vez. É preciso começar com um deles, colocar todo o foco nele e acompanhar os resultados a cada instante”.

Na prevenção primária, o Brasil também precisará se esforçar para reduzir o tabagismo de 16% para 11%. Embora a taxa atual seja relativamente boa perto da de outros países, é necessário otimizar a cessação do tabagismo. E, também nesse fator de risco, não faltam os tais nós críticos: “o indivíduo precisa primeiro ser convencido a parar de fumar pelo agente de saúde, que é o enorme obstáculo de sempre. Mas, se o agente então explica que ele pode contar com a ajuda médica para isso, muitas vezes o fumante vai ao posto de saúde  e o médico não está por lá. Ou está, mas não indica o tratamento baseado em evidência.” Vale ressalvar um dos principais motivos dessa conduta, na opinião do grupo de médicos presente na sessão: nas unidades básicas de saúde o médico nem sempre tem acesso às diretrizes e, se tem, mostra tremenda dificuldade para ler, entender e aplicar o que está ali.

“O texto é complexo. Ora, não basta disponibilizar o documento, é preciso facilitar a compreensão dele”, criticou Dr. Avezum. O coordenador da mesa, Dr. José Francisco Kerr Saraiva, professor-titular de Cardiologia da Pontifícia Universidade de Campinas, no interior paulista, fez coro: “Precisamos de guias simples e práticos, com poucas páginas.”

Saber conversar com o leigo

E a corrida de obstáculos continua. Quando o médico do posto de saúde ou até mesmo do consultório particular prescreve o tratamento correto, logo aparece outro problema: a falta de adesão. E não só no caso do tabagismo. O mesmo acontece com a hipertensão, de acordo com os profissionais que discutiram o tema no simpósio.

“No que diz respeito a essa doença, o controle dos níveis pressóricos fica em torno dos 10% dos pacientes e precisa subir para 13% ou 14% para a redução dos tais 25% da mortalidade até 2025. Olhando assim para os números, parece fácil. Mas, infelizmente, a prática no Brasil é outra história”, concluiu Dr. Avezum.

“Insisto que nós médicos somos ruins no discurso da prevenção. Não sabemos explicar para o paciente que ele terá de usar aquele medicamento indefinidamente, e não apenas por trinta ou sessenta dias. Temos uma barreira forte a ser derrubada que é a do diálogo com o leigo.” Para Dr. Ibraim Masciarelli Francisco Pinto, presidente da Socesp, “essa incapacidade do médico de conversar com o paciente o transforma de cúmplice a inimigo. Então, a população passa a acreditar em qualquer site ou notícia fantasiosa.”

Outra barreira é, sem dúvida, a da educação. “Em recente estudo do qual participei, feito com 4.000 crianças na cidade de Campinas, e que ainda não foi publicado, constatamos que 32% delas estão obesas”, revelou o Dr. Saraiva. “Quando começamos a estratificar pela condição social, notamos que aquelas que comem mais, comem pior e são mais inativas são justamente as de família menos favorecidas e com menor acesso a educação de qualidade. Não existe estratégia para reduzir a mortalidade por doença cardiovascular sem desenvolvimento social”, afirmou.

Outro palestrante da sessão que também tocou nesse ponto foi o Dr. Antonio Carlos Palandri Chagas, professor-titular e chefe da disciplina de Cardiologia da Faculdade de Medicina do ABC, na Grande São Paulo, além de professor livre-docente da Faculdade de Medicina da Universidade de São Paulo.

“Esse é um problema até mesmo no país com o maior investimento em saúde do mundo, que são os Estados Unidos”, disse Dr. Chagas, exibindo um estudo publicado em 7 de junho último no JAMA[4]. Os autores acompanharam 17.199 adultos com idade média de 54,4 anos e sem doença cardiovascular estabelecida no período entre 1999 e 2014. Em geral, 20% deles apresentavam um ou mais fatores de risco. Ao longo do tempo, a cessação do tabagismo e o controle da pressão arterial aumentou no grupo de maior renda, o que é um dado excelente. Mas não houve o menor sinal de declínio da presença desses fatores entre aqueles na faixa de pobreza ou até abaixo dela, de acordo com os parâmetros federais americanos. A conclusão do estudo mencionado é clara: os benefícios dos esforços para controlar os fatores de risco por trás das doenças cardiovasculares variam conforme o estrato socioeconômico.

Para o Dr. Chagas, qualquer estratégia deve passar pelos bancos das escolas médicas. “O estudante não é treinado para fazer a translação da Medicina. Sai com o diploma, mas sem a habilidade de passar o conhecimento científico adiante”, observou. “Essa lacuna também acontece em outros países”, disse, exibindo no telão auditório o follow-up de 20 anos do clássico West of Scotland Study[5], que comprovou os benefícios da terapia com estatina para a diminuição dos níveis de LDL-colesterol. “Para surpresa geral, perto de 30 % dos participantes não usavam mais a medicação. E é caso de se perguntar o motivo, já que a Escócia é um país que oferece acesso à saúde, com a consulta paga pelo governo, sendo que o remédio prescrito é disponibilizado pelo próprio médico. A razão da maioria desses indivíduos que abandonaram o tratamento foi a seguinte: eles simplesmente não entenderam a mensagem de que deveriam ou de por que deveriam continuar com o tratamento. E é evidente que, em países com desigualdade social, a preocupação em se fazer entendido deve ser maior. Assim como é proporcionalmente maior a dificuldade do médico para transmitir o que sabe.”

Para o Dr. Chagas, engajar a comunidade em campanhas de prevenção é fundamental. Ele demonstrou preocupação com o futuro relembrando aos presentes o estudo ERICA, publicado no ano passado, que avaliou o risco cardiovascular nos adolescentes brasileiros, acompanhando 73.339 estudantes de 32 escolas de regiões diferentes do país[6]. No Norte e no Nordeste, 8,4% dos meninos (54,6% da amostra) e das meninas (55,4%) eram obesos. No Sul, a prevalência de obesidade entre os jovens ficou em 12,5%. E a prevalência de hipertensão nos estudantes brasileiros obesos foi de 17,8%. No total, considerando os jovens com sobrepeso, 28,4% dos participantes tinham níveis pressóricos elevados.

“Não podemos pensar em estratégias para estancar a mortalidade por doença cardiovascular sem olhar para nossos filhos e netos, desenvolvendo projetos voltados às crianças”. Como exemplo, o médico mostrou imagens da iniciativa Coração de Estudante, da Faculdade de Medicina do ABC, onde leciona, que leva noções de saúde cardiovascular e estilo de vida saudável a crianças entre sete e nove anos da escolas da região.

Compartilhamento de registros médicos

O Dr. John A. Spertus defendeu a necessidade de os profissionais da Medicina registrarem os eventos cardiovasculares e as condutas tomadas milimetricamente, como ocorre em instituições de saúde americanas, incluindo a dele[7]. O National Cardiovascular Data Registry (NCDR), já acumula dados de mais de 60 milhões de pacientes.

“Esse é, ao meu ver, o caminho objetivo e factível para melhorar a qualidade do atendimento em saúde, porque podemos saber quais práticas trazem maiores benefícios conforme o perfil de cada caso”, afirmou.

Segundo o Dr. Spertus faltava essa objetividade antes do NCDR. “Como médicos, nós  sempre presumimos que estamos oferecendo qualidade só porque damos o nosso melhor no tratamento, mas não é bem assim. E, nos Estados Unidos, essa visão mudou quando as companhias de seguro alteraram as regras do jogo. Antes, se o paciente chegava com angina e passava por uma angioplastia, o hospital recebia por isso. Se, por acaso, ocorria uma complicação e ele precisava ficar mais tempo internado, o hospital também recebia por isso. Assim como continuava a receber se o indivíduo mostrava sinais clínicos de que precisava de uma diálise ou qualquer outro tratamento para controlar quaisquer complicações. Mas agora é diferente”, diz ele. “O seguro diz que temos 25 mil dólares, por exemplo, para tratar um evento cardiovascular do instante em que o paciente atravessa a porta do hospital até os 90 dias seguintes. Ou seja, qualquer complicação pesa no bolso da instituição, e isso despertou a necessidade de métricas capazes de dar maior segurança na hora de decidir por uma conduta ou outra. No final, está sendo bom para todos.”

Segundo o Dr. Spertus, mesmo as diretrizes têm seus limites. “A maioria dos pacientes que entra no meu consultório não tem o perfil dos estudos nos quais elas se baseiam. Mas, quando coloco os dados deles no sistema de registro, encontro evidências clínicas geradas da prática diária dos colegas que lidaram pacientes com características semelhantes e posso perceber que, entre duas pessoas com pressão arterial alta, uma com 18 por 8 e outra com 20 por 10,  as chances de sucesso por meio de determinado tratamento são diversas, em vez de olhar para os dois casos como hipertensos simplesmente e generalizar.”

Outro ponto importante, defende ele, é a transparência com os pacientes. “Qualquer cidadão pode consultar o sistema e descobrir se, no meu hospital, a mortalidade por complicações no atendimento de quem deu entrada com IAM, por exemplo, é maior ou menor do que a de outro hospital a poucos quilômetros de distância.”

No entanto, para ele um terceiro aspecto é igualmente importante: “Quando compartilham dados sobre a prática clínica, os médicos se tornam os legítimos comandantes do processo de traçar as estratégias de prevenção. E isso, nos Estados Unidos, é fundamental diante de um cenário em que, nas instituições de saúde, o número de médicos contratados aumentou menos de 50% entre 1970 e 2009, enquanto o número de administradores saltou mais de 300%.”  Uma dor que também aperta o peito dos médicos brasileiros, diga-se.

Dr. Protásio Lemos da Luz, cardiologista professor da Universidade de São Paulo, não tratou de aliviá-la e, da plateia, pediu o microfone para fechar a sessão com um comentário: “Concordo com o Dr. Spertus e com tudo o que foi dito neste simpósio. No entanto, precisamos nos lembrar que, no Brasil, as leis que impactam a incidência das doenças cardiovasculares e de tantos outros males são criadas por políticos que não entendem de saúde e que nunca conversam conosco. O retrato do Brasil de hoje revela a criação indiscriminada de escolas de Medicina, corte de 50% das verbas do Ministério da Saúde e a implementação de  outras políticas públicas com as quais nenhum médico brasileiro concordou. Se não tivermos uma maneira de nos entendermos com o governo, toda essa conversa que acabamos de ter, embora rica, terá sido estéril.”

Surgery patients placed in alternate ICUs have worse outcomes

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Patients staying in non-preferred units often receive less attention from medical teams.

Clinicians are being encouraged to visit patients ’boarding’ in non-preferred intensive care units (ICUs), at the start of their patient rounds rather than the end, to help ensure patients get the appropriate amount of attention they need.

A new study has found that the practice of placing patients in alternative ICUs rather than those they are most suited to, may lead to worse outcomes.

For the study, researchers systematically examined more than 500 routine clinical encounters between caregivers and patients associated with a surgical ICU. They found boarders were far more likely to be visited by caregiver teams at the end of rounds and that caregivers spent about 16 per cent less time on rounds with boarder patients compared to non-boarding patients.
Lead author, Dr Andrew M. Nunn said it is “imperative that critical care providers be aware of this apparent tendency for ICU boarders to receive less attention so that they can develop interventions to correct the discrepancy”.

Future studies will now be undertaken to assess the effectiveness of the new intervention.

Latest ransomware attack targets patients of cosmetic clinic

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After a previous attempt to extort money from the clinic failed, the hackers are now demanding ransoms from the patients.

Patients who attended a Lithuanian cosmetic surgery clinic are being forced to pay ransoms to prevent private photographs and personal data being published online.
An investigation is underway after patient images were made public on Tuesday (May 30) by a hacking group calling themselves ‘Tsar Team’. After a previous attempt to extract a ransom from the clinic itself failed, the group is now demanding ransoms from the clients who attended the clinic from more than 60 countries around the world. Ransoms range from €50 and €2,000, depending on the sensitivity of the data.

The incident comes at a time when healthcare systems are being increasingly targeted by hackers. The UK’s National Health Service was crippled for a number of days last month when its systems were infected with WannaCry ransomware. The attack affected 47 NHS trusts leaving doctors without access to critical online supports. Thousands of computers in 150 countries were affected by the attack.

Last year, data company, Experian, warned that the healthcare sector would be a focal point for hackers in 2017 as medical identity theft remains lucrative and easy for cyber criminals to exploit, with electronic health records likely to be a primary target for attackers.

Nueva técnica inyectable para borrar arrugas superficiales

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El 'blanching' contiene ácidos hialurónicos de reticulación dinámica que consiguen borrar las arrugas finas.

El ‘blanching’ contiene ácidos hialurónicos de reticulación dinámica que consiguen borrar las arrugas finas.

Con el paso del tiempo la piel comienza a sufrir los signos del envejecimiento como son flacidez, sequedad, falta de elasticidad, aparición de arrugas y disminución de la capacidad regenerativa.

El ácido hialurónico es una de las técnicas más extendidas y que se utiliza con éxito desde hace años para combatir algunos de estos signos del paso del tiempo. Esta técnica consiste en la aplicación de este compuesto a través de inyecciones que buscan rellenar pliegues o crear volúmenes con el fin de combatir las arrugas y recuperar el volumen perdido con el paso del tiempo.

La eficacia de esta técnica reside en que tiene una gran capacidad para atraer y retener agua, lo que permite rehidratar la piel y hacer que luzca más tersa, aumentando su grosor y eliminando los surcos. También produce una regeneración de las capas más profundas y superficiales de la piel, porque aumenta la producción de colágeno propio.

El ácido hialurónico se ha inyectado en estos últimos años a niveles medios o profundos en la piel o por debajo de ella, por lo que las arrugas finas como las llamadas patas de gallo y otras arrugas superficiales no eran buenas candidatas al mismo.

En estos meses ha irrumpido en el sector de la medicina estética una nueva técnica, conocida como ‘blanching’, con ácidos hialurónicos de reticulación dinámica que consigue borrar estas arrugas finas.

Este nuevo protocolo, que cuenta con la aprobación de la Food and Drug Administration (FDA), se basa en inyecciones muy superficiales de esta nueva gama de ácidos hialurónicos sin posibilidad de dejar bultos, nódulos, ni coloración azulada, para tratar las arrugas finas estáticas y mejorar sustancialmente las arrugas de expresión.

La técnica ‘blanching’ permite borrar arrugas finas sin afectar la expresión y proporcionando además una hidratación visible en la piel.

Otras zonas de aplicación además de las patas de gallo son los pliegues nasolabiales, las líneas de marioneta, el entrecejo y cualquier arruga fina del rostro. Incluso las marcas de acné.

La técnica ‘blanching’ es un procedimiento que requiere de mucha experiencia y destreza por parte de médico que lo aplica, ya que emplea un plano de infiltración muy superficial, dejando microdepósitos de ácido hialurónico justo en la hendidura de la arruga, sin provocar abultamientos o exceso de producto.

El uso de láser en la intervención de las varices produce menos hematomas y dolor

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Además de una recuperación más rápida.

Además de una recuperación más rápida.

El uso de láser en la intervención de las varices produce menos hematomas y dolor además de que no se originan heridas quirúrgicas, no hay posibilidad de complicación y la recuperación es más rápida así como la incorporación a la actividad cotidiana que puede ser inmediata, ha explicado el especialista del Servicio de Angiología y Cirugía Vascular del Hospital Quirónsalud San José, Jesús Álvarez García.

En esta técnica se elimina la variz a través de un daño térmico a la misma. Esto se hace con una punción, a través de la cual se introduce un catéter dentro de la vena que es la que la daña desde dentro, por lo que, al no haber arrancamiento, las ventajas son múltiples.

Por su parte, la cirugía convencional es un tratamiento efectivo y muy utilizado, aunque es algo agresivo ya que, a través de heridas quirúrgicas se extirpan las venas que funcionan mal. “Esta aproximación a la enfermedad produce cierto dolor y hematomas en el postoperatorio inmediato, además de que precisa de vendajes más duraderos y de una baja laboral algo más prolongada. Por si fuera poco, existe el riesgo de complicación en las heridas”, ha asegurado el Dr. Álvarez García.

La esclerosis es otra forma de eliminación de las varices. En este caso se utilizan inyecciones de un agente químico que busca la inflamación y la lesión de las paredes de la vena y, posteriormente, su reabsorción. Normalmente, se utiliza para vasos de pequeño calibre o telangiectasias, ya que no ha demostrado mejores resultados en vasos de mayor tamaño que las alternativas disponibles.

Como principales ventajas da la posibilidad de llevarla a cabo sin anestesia y en consulta externa, con una recuperación al medio laboral inmediata y con unos resultados estéticos visibles a partir del mes.

“Antes de optar por un determinado tratamiento, es necesario una correcta valoración por un cirujano vascular, ya que diferentes varices precisan de diferentes técnicas”, ha indicado el Dr. Álvarez García y destaca que el resultado del láser es el mismo que el de la cirugía convencional pero con más ventajas.

Aunque las medidas intervencionistas son las únicas que hacen desaparecer las varices, se pueden realizar otras como son las básicas, que tienen como objetivo evitar situaciones en las que se dificulte el drenaje venoso. La elevación de las piernas cuando estamos sentados o tumbados y evitar estar quietos de pie, puesto que el movimiento favorece la contracción de los gemelos y eso mejora la clínica. Además, se debe asociar una hidratación diaria con crema de las piernas.

El experto también se ha referido a el uso de fármacos cuando estamos en los estadios incipientes, “aunque existe cierta evidencia científica, estos medicamentos pueden funcionar de forma distinta en diferentes personas. Son moléculas con un perfil bastante seguro que facilitan un alivio sintomático importante, por lo que, en fases iniciales y de forma accesoria al resto de tratamientos, pueden ser beneficiosos”.

Otra de las medias no intervencionistas son las medias de compresión que aunque son efectivas, dependen en gran medida del uso que se haga de ellas. Su mecanismo de acción se basa en impedir que la sangre venosa se concentre en las piernas, para evitar el edema o hinchazón y la irritación que pueden producir en la piel y en las terminaciones nerviosas.

“Son medidas efectivas pero que en personas con poca tolerancia pueden producir una peor calidad de vida que la cirugía de varices. Tanto las medias como los fármacos no hacen desaparecer las varices”, ha asegurado el especialista del Hospital Quirónsalud San José, que integra el Servicio de Angiología y Cirugía Vascular que dirige el Dr. Luis Riera del Moral.

Grasa corporal y plasma, la alternativa natural que gana terreno al bótox y al ácido hialurónico en la medicina estética

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Pertenecen al grupo de tratamientos de medicina 'antiaging' mínimamente invasivos.

Pertenecen al grupo de tratamientos de medicina ‘antiaging’ mínimamente invasivos.

Los tratamientos de medicina estética basados en infiltraciones de sustancias naturales extraídas del paciente, como su propia grasa localizada o incluso su sangre, están ganando terreno progresivamente al bótox y al ácido hialurónico en el sector de la medicina estética.

De hecho, esta práctica ya se está consolidando en Los Ángeles, Miami y Corea del Sur y, especialmente, entre famosas como Madonna, Giselle Bündchen o Kim Kardashian. Se trata del ‘lipofilling’ facial y del plasma rico en plaquetas.

Ambos pertenecen al grupo de tratamientos de medicina estética ‘antiaging’ que son mínimamente invasivos y cuyos resultados son prácticamente inmediatos, pero no son permanentes, es decir, que al igual que el bótox y ácido hialurónico, su efecto dura aproximadamente seis meses.

“Aunque el bótox y el ácido hialurónico siguen siendo los más demandados en cuanto tratamientos antiarrugas y rellenos faciales, el ‘lipofilling’ y el plasma llaman la atención de los pacientes que no quieren infiltrarse sustancias artificiales y apuestan únicamente por tratamientos naturales. Como es común en este sector, hay un gran número de pacientes que acuden a la consulta porque ven que tal famosa también se lo ha hecho, pero en estos casos hay que actuar con responsabilidad y aconsejarles según criterio médico, teniendo en cuenta edad, estado de la piel y facciones”, ha explicado el director de las Clínicas Diego de León, Miguel de la Peña.

En concreto, el ‘lipofilling’ facial es una de las opciones para rellenar labios con un resultado final “más natural” que con el ácido hialurónico, también para rellenar arrugas, surco nasogeniano, zonas decaídas que pierden volumen como pómulos y mejillas, cicatrices e incluso para eliminar ojeras.

El procedimiento consiste en la pequeña extracción de grasa localizada de una parte concreta del cuerpo como puede ser el abdomen, flancos (más conocidos como michelines) o muslos, la cual se reinyecta en la zona del rostro a rejuvenecer. Para su reinyección, una vez extraídos los adipocitos, estos se centrifugan para separar las células vivas de las muertas. Las vivas son las que se microinyectan en el rostro hasta conseguir el resultado deseado.

Respecto al plasma rico en plaquetas, consiste en la extracción de sangre del paciente de la que se seleccionará el plasma a través de un proceso de centrifugación. El plasma es la parte de nuestra sangre rica en plaquetas y fundamental para la coagulación y reparación de la piel. Las plaquetas provocan el crecimiento y generación de células que reparan y reproducen tejido sano.

A continuación se reinyecta en las zonas de la cara para mejorar luminosidad, arrugas y las partes más deterioradas bien por el paso del tiempo, por el sol y por las sesiones de bronceado mediante rayos en cabina que perjudican y fomentan el envejecimiento de la piel. Este tratamiento se puede aplicar tanto en el rostro como en brazos, palmas de las manos, escote o cuello.