By: Denise Stewart, founder of Breast and Shoulder Rehabilitation and Breast Cancer Occupational Therapist.
Why assess mastectomy scar tissue?
- To help communicate your concerns clearly.
- To help decide the need for specialized breast cancer rehabilitation services.
- To evaluate the effectiveness of protocols used to treat mastectomy scar tissue.
- To reduce chronic pain experiences.
There are frequent reports of a higher rate of arm and shoulder dysfunction and pain experienced by women after mastectomy compared to women after breast conserving surgery. There is a sound research hypothesis or clinical question to this finding:
Does reducing abnormal tight /thick scar tissue at the mastectomy site reduce shoulder and arm dysfunction?
Based on my clinical experience, the answer to this question is YES- if the scar tissue is properly assessed and a suitable rehab program undertaken. Let’s look at assessment first.
Are there medical assessments to evaluate the level or degree of mastectomy scarring?
MRI was used to evaluate a group of women with radiotherapy fibrosis after mastectomy in 1994 and no reliable connection was found between MRI findings and the woman’s scar experience. In 2005, the Vancouver Scar scale was tested by a small group of women (59) with breast cancer scars and was compared to a scar self- assessment rating and a pain scale rating.
The recommendations from this research were:
- The Vancouver scar scale (VSS) is reliable
- There was agreement between the VSS and patient’s self- assessment rating on scar pliability and colour.
- Patient satisfaction was linked with the self- assessment rating of scar pliability and pain, but not with the measures of the VSS.
The Vancouver scar scale was then compared to a Patient and Observer Scar Assessment Scale (POSAS) with a small group of women with breast cancer (line) scars. This research suggested that the POSAS was valid, reliable and more comprehensive: it matched better with patient’s ratings.
The POSAS has a rating scale with 2 parts (free download at http://www.posas.org/downloads/):
- Patient assessment: a self –assessment.
- Observer assessment.
The areas you can rate your scar are:
- pain and itching
- stiffness and thickness
- irregularity and your overall opinion
If you are looking for a way to measure, compare over time or communicate how your mastectomy scar impacts on you or to ask about treatment options, then the POAS scale may be suitable.
Download the scale, rate your scar and use this in your discussion with your breast cancer team member. If the ratings are high in the specific areas of pain, stiffness and irregularity, there are clear reasons for you to request rehabilitation treatment to improve these experiences.
Is there a more specific self- assessment test for mastectomy scar tissue?
The good news is that patient assessment has been recognized as a bench mark to compare new tests to. I am going to suggest that we increase this benchmark – by increasing self-assessment skills. The self- assessment techniques described below have been used in my clinic for many years and are based on detecting mastectomy scar tissue barriers. The important feature of this test is that the mastectomy scar line and the mastectomy chest scar are evaluated:
- Assess the mastectomy chest scar first. Assess the tissue in 4 areas:
a. above the mastectomy (surgical) scar line
b. below the mastectomy (surgical) scar line
c. outside both ends of the mastectomy (surgical) scar line – this will be two separate areas.
- Assess the mastectomy (surgical) scar line next.
The assessment uses a flat hand to assess the stretch of the soft tissues at any direction and at any depth. The assessment will be able to detect where there is a lack of stretch as you will be able to compare to the stretch in other places on your body.
This self- assessment is safe as long as there are no open wounds.
If you like the concept of being able to assess your mastectomy scar tissue using a “hands on” scar tissue barrier approach, then your next step is to contact your specialist rehabilitation provider to get training in the use of this technique at different levels on the mastectomy chest scar area and the mastectomy (surgical) scar line. It is my experience that this type of testing is not general knowledge and does require training and support to learn the technique at deeper levels. Your therapists will also be able to provide barrier release treatments and instruct you in your home treatment program.
Barrier release techniques are not the only treatments that can be used for tight mastectomy scar tissue. Kinesiotape, low level laser, gentle cupping, yoga and stretches are additional treatments used by breast cancer rehabilitation or exercise specialist service providers.
Next Blog: mastectomy and cording (AWS).
Denise Stewart, founder of Breast and Shoulder Rehabilitation and an Occupational Therapist trained in Australia at University of Queensland. Her career started at a major public hospital, providing rehabilitation to people with very serious and chronic illness and injuries.