Mously Le Blanc, M.D., examines cancer patient Sarah Happy.
By Sally Sapega and John Shea
Photos by Daniel Burke
Mously Le Blanc, M.D. ’06, is a detective of sorts. As a cancer rehabilitation specialist – one of only a few in the country – she uses her knowledge of nerves, muscles, and bones to connect the dots between patients’ mysterious symptoms and the cancer treatments they received, often years before.
Take, for example, the 35-year-old patient with a weakness in his right shoulder. He came to see her two months after receiving a Botox injection for neck pain. “He couldn’t raise his arm more than 90 degrees and thought it was connected to the injection,” Le Blanc says. “But the location of the injection site and where he had weakness didn’t add up.”
When the patient removed his shirt for examination, Le Blanc immediately knew the problem. “I asked him if he had been treated for cancer, and he told me he had both surgery and radiation for bilateral tonsillar cancer 13 years earlier.”
How did she know? The muscle tissue in that area had shrunk and looked contracted, tight from the radiation. And the shoulder blade was winging out, as opposed to lying flat as it normally does. “During head and neck surgery or radiation treatment, the spinal accessory nerve – a small nerve that lies near the surface – can be injured,” she explains. “This nerve stimulates the trapezoid muscle, which is a major shoulder stabilizer. Without the working nerve, the shoulder blade doesn’t move correctly and prevents the arm from moving the full range of motion.”
Le Blanc prescribed a rehab program aimed at restoring muscular balance. “We worked on strengthening the compensatory muscles, like the rhomboids and levator scapular, and also stretching out the pectoral muscles,” she says. “After eight weeks, the patient had a full range of motion back on that side.”
Women who undergo treatment for breast cancer can experience similar problems from radiation, which changes the structure of the muscles. “The muscles are no longer soft and tensile. They’re still and fibrotic,” Le Blanc says. “These women can become hunched over due to overactive pectoral muscles from the radiation. They’re scared to move their arms and avoid using that side.” As a result, they lose much of their range of motion.
Six months after one patient had a mastectomy, she couldn’t dress herself and was in significant pain. Anti-inflammatory drugs did not work; neither did physical therapy using just heat and massage. Le Blanc gave her a steroid joint injection and then put her on an aggressive physical therapy plan. As a result, the woman regained her full range of motion and is without pain.
An ultrasound machine can visualize the tendons, ligaments, nerves, and bones that make up the shoulder joint.
“Radiation can affect all the muscles, bones, nerves, and lymphatics in the irradiated area, but the effects can occur years later,” she said. And when they do present, she explains, it is so long since the cancer that primary-care physicians do not consider any connection to the cancer treatment.
“We are now seeing what happened from the 1990s,” Le Blanc says, referring to the cancer treatments of the time. But more recently, as physicians have learned more about the effects of radiation, treatments are changing. Doses have to be low enough to limit the possible side effects. She cites proton therapy as an example; it has the potential to minimize damage to healthy tissue that surrounds tumors.
Because of more successful therapies for cancer, a greater number of people are surviving the disease. There are an estimated 14 million in the United States alone. But as oncologists, reproductive endocrinologists, and cancer rehabilitation specialists now understand, cancer treatments are not without consequences. In the past, survivors have often been left to deal with these long-term effects with little or no guidance. In 2005, however, the Institute of Medicine published a detailed report on the state of cancer survivorship, calling attention to the need cancer survivors have for care plans beyond their immediate treatment – a summary of the treatments they received and the potential for late effects that may take years to manifest, plus tips on follow-up tests and screenings they may need. Subsequently the Commission on Cancer, an organization that accredits cancer centers, responded by requiring all accredited centers to provide such plans to their survivors.
“Survivorship care is ongoing and indefinite,” Le Blanc says. “It may require multiple decades.”
At Penn Medicine, the Abramson Cancer Center developed the first adult cancer survivorship program in the nation in 2001. It provides specialized care, addressing the wide array of physical and mental health problems that cancer survivors and their families experience. About two-thirds of cancer survivors will experience a late effect, either physical or psychosocial, of chemotherapy or radiation that persists or develops more than five years from the time of diagnosis.
In addition, OncoLink, Penn Medicine’s award-winning cancer website, developed the first online program, OncoLife™, to help patients with their physicians to chart out their health-care future after cancer. According to James M. Metz, M.D., G.M.E. 2000, executive director of OncoLink and chair of the Department of Radiation Oncology, “This is the most comprehensive survivorship plan tailored to the individual that’s out there. There’s a lot of available data, but patients are not always getting it from their physicians.” Oncolife, he says, empowers patients to be active participants in their health care. To date, there have been more than 50,000 care plans created using OncoLink’s programs and products.
As progress of this sort continues, Le Blanc will likely treat fewer and fewer patients whose symptoms appear mysterious. But in the meantime, she does not lack for patients. Le Blanc practices at Penn Medicine Rittenhouse, Penn Medicine Radnor, and the Perelman Center for Advanced Medicine, where she is part of the Rena Rowan Breast Center. She is also director of cancer rehabilitation services within Penn Medicine’s Department of Physical Medicine and Rehabilitation. According to Timothy Dillingham, M.D, chair of the department, “she has done a wonderful job at growing the awareness of the importance of exercise and rehabilitation for persons with cancer. As cancer becomes more and more a chronic disease, the holistic approach to survivorship and optimal function takes on greater importance.”
Le Blanc’s first mentor at Penn’s medical school was Andrea L. Cheville, M.D., then a professor of rehab medicine. (She is now at Mayo Clinic’s Cancer Center.) Cheville, says Le Blanc, “had an amazing bedside manner with patients.” Her specialty was lymphedema, a painful swelling of the arm that often results from breast cancer surgery or radiation. Even though Le Blanc fell in love with the specialty very early on, she paid attention to Cheville’s advice to learn all of rehab medicine. “In order to be a great cancer rehab doctor,” Le Blanc explains, “you have to be a great rehab doctor.” What drew her to the field? Dealing with the patients. “Every day, I just left clinical feeling really good.” She did not find rehab a grim setting. Despite the difficult situations the patients had been through, when they were with Le Blanc in rehab, “their defenses were down.” They were able to relax. “They’re so grateful for anything you can do for them.”
For her training, Le Blanc entered a combined program of Columbia University and Cornell University, rotating through several major hospitals. Along the way, she met Michael D. Stubblefield, M.D., then at Memorial Sloan Kettering Cancer Center, whom she considers another of her mentors. He is one of the authors of Cancer Rehabilitation: Principles and Practice (2009). Stubblefield “helped forge the field in physiatry,” Le Blanc says. “I’ve trained with two leaders in the field with different focuses.” Last year, she was one of the co-authors with Stubblefield for a chapter on cancer rehabilitation in Current Diagnosis and Treatment: Physical Medicine & Rehabilitation.
After such training, she believes, you often know “as soon as you walk in the room what the patient’s problem is.” One of the complications from cancer treatment that Le Blanc sees is post-mastectomy pain syndrome. It is frequently misdiagnosed and, as a result, mistreated. This chronic pain can occur after breast cancer surgeries – most prevalent after a lumpectomy – and removal of axillary lymph nodes. Both radiation and direct injury to the sensory nerves in the underarm can cause the symptoms. As Le Blanc explains, “It’s like a stabbing, burning, squeezing that shoots across the chest in a band-like distribution.”
One of her patients, a young breast cancer survivor, was on high-dose narcotics but still was in pain and unable to have anything touch her chest area without severe discomfort. Le Blanc started her on a medication that specifically addressed the nerve pain. “After three weeks, the patient identified her pain as ‘level 2’ and was able to wear a bra and shirt.” But, more important, the patient was finally able to hold her baby close.
Le Blanc can also help patients before treatment, through “a prehabilitation program” to help minimize the risk that the patients will develop some of these complications. “If a patient is not tolerating treatment, it may need to be stopped,” she says. “If it’s better managed, the patient will stay on it.”
Aromatase inhibitors – which are estrogen blockers given to women with hormone responsive cancer to reduce the risk of recurrence – can also cause programs. At least one-third and possibly more of these patients develop symptoms very similar to fibromyalgia, such as diffuse pain, fatigue, and “a foggy brain.” Joint pain associated with these drugs can be especially crippling.
Daily activities, like walking, going down stairs, cooking, and cleaning, are now impossible without significant pain. “These women are often in their 30s or 40s but feel like they aged 20 to 30 years overnight. I hear that all the time,” Le Blanc says. “They go through physical therapy and pain medication, but nothing helps.”
To relieve these symptoms, Le Blanc prescribes a neuropathic pain medication and an anti-inflammatory as needed, in combination with a specific program in physical therapy and occupational therapy. Often, when the women return for a follow-up visit three weeks later, “the difference is amazing.”
As Le Blanc emphasizes, aromatase inhibitors decrease the risk of that the cancer will recur, so it’s very important to stay on the medication. “Creating a plan to help them manage potential side effects can be lifesaving.”
“Oncologists save lives,” she says. “I help facilitate a return to a better quality of life.”