Breast Cancer Treatment&Rehabilitation
August 20, 2013
If you have been diagnosed with breast cancer, you are not alone. According to the American Cancer Society, over 230,000 breast cancer cases in the U.S. will be diagnosed this year. Fortunately, with early detection and treatment, the five-year survival rates for breast cancer are promising with an 88 percent rate for those in stage 1. (Rates vary according to stage of cancer and age when found.)
Effective treatment for breast cancer can include medication, chemotherapy, radiation and surgery. If you have breast cancer or have been told that you are at risk for the development of breast cancer (due to family history or ovarian cancer), your doctor may advise you to have surgery—either lumpectomy or mastectomy—to prevent, treat or control breast cancer.
Breast cancer rehabilitation is for individuals undergoing the following medical management and procedures:
- Surgery (lumpectomy and mastectomy)
- Reconstructive surgery
- Radiation therapy and chemotherapy
About the Speaker
Stephen Grobmyer, MD is a board-certified staff physician and director of Breast Services and Surgical Oncology at Cleveland Clinic. Dr. Grobmyer’s specialty interests include surgical oncology and breast cancer.
Dr. Grobmyer completed his surgical oncology fellowship at Memorial Sloan Kettering Cancer Center, in New York. He completed research fellowships at The University of Pennsylvania, in Philadelphia, and Weill Cornell Medical College, in New York, and surgical residencies at New York Hospital-Cornell Medical Center. Dr. Grobmyer received his medical degree from University of Texas Southwestern Medical School, in Dallas.
Sree Battu, MD is a board-certified associate staff physician in Cleveland Clinic’s Department of Physical Medicine and Rehabilitation. She completed her fellowship in Hospice and Palliative Care at Virginia Commonwealth University Health System, in Richmond, Va. She completed her residency in physical medicine and rehabilitation at University of Texas Health Science Center, in Houston, and her internship at Henry Ford Hospital, in Detroit. Dr. Battu received her medical degree from St. George's University School of Medicine, in Grenada West Indies.
Let’s Chat About Breast Cancer Treatment and Rehabilitation
Moderator: Welcome to our ‘Breast Cancer Treatment and Rehabilitation’ online health chat with Dr. Stephen Grobmyer and Dr. Sree Battu. We are very excited to have both of them here today! First we will begin with a little background.
Sree_Battu,_MD: Welcome to this web chat on breast cancer surgery and rehabilitation. We hope to answer your questions and help provide some direction for your concerns. Breast cancer is a disease that is very complex and it is an encompassing disease process. It can affect your personal, work, family and social life in many different ways. We are aiming to provide education on surgery and rehabilitation to help you understand the process and effects of your treatment. Often times, the process starts with imaging and diagnosis of biopsies. Your medical team will direct you based on these results if surgery, radiation or chemotherapy is the next step. Your rehabilitation team is there to help you with maintaining/ improving how you function as you receive treatments and after treatment is completed.
Breast Self-Examination Signs and Symptoms
Meg: What are the signs of possible breast cancer?
- A lump or thickening in or near the breast or in the underarm that persists through the menstrual cycle
- A mass or lump, which may feel as small as a pea
- A change in the size, shape, or contour of the breast
- A blood-stained or clear fluid discharge from the nipple
- A change in the look or feel of the skin on the breast or nipple (dimpled, puckered, scaly, or inflamed)
- Redness of the skin on the breast or nipple
- An area that is distinctly different from any other area on either breast
- A marble-like hardened area under the skin
Saucie: What causes nipple retraction? Can this indicate cancer?
Stephen_Grobmyer,_MD: Nipple retraction can be a sign of breast cancer particularly if this represents a change in your body. If you have nipple retraction, you should have this examined and worked up by your physician to determine if cancer might be the underlying cause.
shailja_av: I am 23-year-old female. The nipple of my right breast is little painful when I press it even though there is no discharge, no rashes and no lumps. There is nothing—just a little sore when I touch it and it gets a little thick simultaneously. The pain is minimal, and this is happening only on the right side. What is it? This just started four or five days ago.
Sree_Battu,_MD:All females should perform monthly self-breast examinations. Changes in your breasts need further evaluation. You should see your primary care physician who will ask you for additional history, perform a full examination and complete a work up.
Breast Cancer Shoulder Pain
BareShoulder: What can cause shoulder pain in a patient with breast cancer?
Sree_Battu,_MD: You really need an evaluation by a physician for what is causing the pain in your shoulder. Pain in the shoulder can be caused by the joint, joint capsule, muscles, tendons or the nerves. Pain can also occur if the muscles are moving in a way they are not used to—which can happen when the muscle is affected by treatment or surgically changed. There are the usual causes of shoulder pain which all people can develop, such as arthritis, adhesive capsulitis, biceps tendonitis, rotator cuff tears, scapulohumeral dyskinesis, myofascial disease, radiculopathies, neuropathy, etc. Then there are a few neuromusculoskeletal issues that are unique to breast cancer patients, such as tamoxifen-induced arthralgia, radiation fibrosis syndrome, axillary web syndrome, postmastectomy pain syndrome, and breast cancer-related lymphedema. A physical medicine and rehabilitation specialist can help you with evaluation, medication, and can work with a therapist on designing a therapy program.
Does Breast Plastic Surgery Cause Cancer?
penske: Can having work done on your breast, such as reduction, implants or lifts, cause breast cancer or increase your risk for breast cancer?
Stephen_Grobmyer,_MD:I am not aware of any association between breast operations, such as reductions, implants or lifts, and an increase in breast cancer risk. These procedures are not thought to increase the risk of breast cancer.
Breast Cancer Screening Guidelines
Maryann: What are the current screening guidelines for women?
Stephen_Grobmyer,_MD: A great place to start is our latest health guidelines for women at:
- Start yearly screening with mammography at the age of 40 years old, and to continue as long as a woman’s life expectancy is at least 10 more years (meaning they are otherwise in a good state of health).
- Screening every other year is an option for older postmenopausal women. Patients should discuss the pros and cons of this approach with their doctor.
- Careful examination of the breasts remains an important part of the general physical examination.
Women should continue to be familiar with their breasts, and report any changes to their physicians.
Breast Cancer and Genetics
Amy: Is breast cancer inherited?
Moderator: There are several health information articles that answer this question. You may refer to: http://my.clevelandclinic.org/disorders/Breast_Cancer/hic_The_Genetics_of_Breast_Cancer.aspx
Cleveland Clinic is hosting a breast cancer and genetics web chat on October 15 with Stephen Grobmyer, MD and Charis Eng, MD, PhD. Dr. Eng is the Chair and founding Director of the Genomic Medicine Institute of the Cleveland Clinic. Genetic aspects of breast cancer will be discussed in detail.
Breast Cancer Treatment Team
Yolana: Who is involved in treating breast cancer?
Sree_Battu,_MD:There are a variety of medical professionals involved in treating breast cancer. Each patient may meet different health team members depending on their needs. Some physician team members you may see include a radiologist, breast specialist, oncologist, radiation oncologist, breast surgeon, plastic surgeon, physiatrist (physical medicine and rehabilitation physician) and geneticist. You may also benefit from a social worker, physical therapist, occupational therapist, speech therapist, vocational therapist, nutritionist and support groups depending on your needs. You will hear many different things during your care, and this can be confusing. I always recommend that patients use a notebook to write down the names of people they meet, contact information, follow-up information, and advice that they have understood. Sometimes it helps to take a family member or someone you trust with you to your appointments to help remember information and for emotional support.
Lucia: What should I look for in a surgeon for my mastectomy?
Stephen_Grobmyer,_MD: One should look for a surgeon with experience in the management of breast cancer. Additionally, it is important that the surgeon work in collaboration with other specialists (including plastic surgeons, radiation oncologists, rehabilitation specialists, genetics and medical oncologists) who also treat breast cancer as part of a breast cancer program. Seeking care in a nationally accredited breast program would be a good place to start. Accreditation in the United States is done through The National Accreditation Program for Breast Centers (NAPBC). Cleveland Clinic Breast Centers at main campus, Beachwood Family Health and Surgery Center and Cleveland Clinic Florida have received this accreditation.
Lumpectomy vs Mastectomy
LoveMichigan: How do you decide between a lumpectomy and a mastectomy?
Stephen_Grobmyer,_MD: Mastectomy and lumpectomy are operations designed to remove cancer from the breast. Each surgery has its advantages and disadvantages. Each patient should consult her physician and family members in making a decision. Decisions should also be made with consideration of the size of the tumor and the patient's medical history. Lumpectomy is good for patients with smaller tumors, but often is combined with radiation treatments to give the best results. Some patients with larger tumors can also have lumpectomy if they are treated with chemotherapy first. Mastectomy involves removal of the whole breast, and may be required for patients with large tumors or tumors in multiple locations in the breast. Many patients who have mastectomy choose to have breast reconstruction following removal of the breast. Many patients having lumpectomy do not need radiation treatments. Learning about your particular tumor type and stage, and discussing these issues with your surgeon and physician is very important. Seeking a second opinion regarding your case is another approach to educate yourself about your treatment options and the advantages and disadvantages of each approach.
LoveMichigan: After a mastectomy, how long does it take to recover? What about the lumpectomy—how long does it take to recover from this surgery?
Stephen_Grobmyer,_MD: Recovery from breast surgery is variable. Mastectomy recovery depends on what type of mastectomy is done (simple mastectomy vs modified radical mastectomy), and is also affected by the type of breast reconstruction (if performed). Recovery also depends on the general health of a patient—with healthier patients generally recovering faster. Recovery from lumpectomy is generally quicker than mastectomy, but recovery from lumpectomy also depends on the extent of axillary lymph node surgery performed. Recovery following both operations can be accelerated by participation in a rehabilitation program.
Tazzy: What type of reconstruction method do you recommend after mastectomy? My sister had TRAM (transverse rectus abdominis myocutaneous) flap surgery in 2006, and had so many complications with this method that she regrets it. She has recently had surgery to correct the complications and is doing ok at this time.
Stephen_Grobmyer,_MD: I am glad your sister is doing ok at this time. The type of reconstruction offered after a mastectomy depends on several factors. The factors to be considered are the extent of surgery required to remove the tumor, the anatomy and body type of the patient, the need for further medical treatments (including radiation) and patient preference.
Diana53: I am a smoker with breast cancer. I have been told that I cannot have reconstruction after my mastectomy because of this. Why?
Stephen_Grobmyer,_MD: Complication rates (including infections and skin flap breakdown) for breast reconstruction are significantly higher in smokers. It would be best to stop smoking and then discuss options for reconstruction with a breast reconstructive surgeon.
Nancy:Are there things I can do before surgery to make rehabilitation easier?
Sree Battu, MD: I think the best thing you can do is to find out what precautions you will have after your surgery and to plan ahead. You may have restrictions for how far you can move your arms after surgery or how much you can lift after surgery. This will depend on the type of surgery you have and your surgeon’s instructions. You may need help after your surgery from friends or family with basic tasks such as dressing, bathing, meal preparation, house chores, childcare and driving to appointments. You will need to take time off work when your undergo surgery as well. My best advice is to plan ahead and be flexible.
Nancy: Can you describe the rehabilitation process?
Sree_Battu,_MD: The rehabilitation process is a process which primary deals with how your function is affected by disease. How each person is emotionally and physically impacted by disease is different. Learning about what things are important to each patient impacts the rehabilitation plan. The rehabilitation process is an ongoing system of evaluation and treatment for symptoms which impact a person’s function or ability to perform their usual daily activities such as dressing, bathing, hygiene, meal preparation, walking, doing household chores, accounting, planning travel and working. As you go through cancer treatments, your body can be impacted by the treatments. For example, after surgery you can develop swelling, pain due to muscle imbalance and pain from surgery. After radiation you can develop fatigue. After chemotherapy, you can develop numbness in your hands and feet. Not everyone develops symptoms after treatment. A rehabilitation therapist gets a baseline understanding how you physically move by taking physical measurements of strength, range of motion, balance, endurance and sensation testing. Your evaluation will also include questions about what activities you need to do at home and at work as well as quality-of-life measures. How each person is affected by cancer is different and a therapy plan will be made to fit each patient’s needs and wants. Therapists also provide education on how to care for yourself and prevent disability.
SallyM: Does everyone need to go through a rehabilitation process?
Sree_Battu,_MD: I think all breast cancer patients can benefit from some sort of rehabilitation process during or after treatment. Part of the rehabilitation process is education on the prevention of disability, identification and treatment of current issues that can lead to disability, and education on how to monitor for body changes that could lead to disability. Some patients need ongoing help from a therapist for monitoring of function and physical changes—others do not. You can work with your therapist, and discuss how often you may need to see her or him. Also, as you go through different medical treatments (surgery, radiation, chemotherapy and hormone therapy) you may develop different needs. I think knowing that there are rehabilitation services available to help you with a variety of needs is important.
Breast Rehabilitation Physical Therapy
Lucia: What should I look for in a breast rehabilitation physical therapist?
Sree_Battu,_MD: It depends on what your needs are. A general physical therapist that is familiar with cancer patients may be appropriate.
Physical therapists work on improving range of motion, stretching, strengthening, improving endurance, and building exercise programs for you. With breast cancer you need to develop a slow, progressive resistance exercise program in addition to an aerobic exercise program.
If you suspect you have lymphedema you need to be treated by a lymphedema-certified physical or occupational therapist. Lymphedema is not curable, but studies have shown that early, proactive treatment of lymphedema has improved outcomes.
Some early warning sign of lymphedema in the affected arm include:
- numbness or odd sensation
I would also like to mention that occupational therapists and speech therapists familiar with breast cancer also can help depending on your needs. Occupational therapists also treat the shoulder just like physical therapists. They also work on fine motor and gross motors skills if you are having coordination difficulties, energy conservation issues and need help with activities of daily living. Some of them also do cognitive screens. However, if you are having issues with executive functioning, such as difficulty with memory, attention, processing, planning or problem solving you may need an evaluation and treatment from a speech therapist or neuropsychologist.
There are many different types of therapists and they each work on unique issues. If you have many issues and comorbid (coexisting) medical conditions, such as heart, lung or joint disease, you may need a physical medicine and rehabilitation physician to help you with navigating which kind of therapy and therapist would be best for your needs.
Ginger: At what time should I see a physical therapist?
Sree_Battu,_MD: You can see a physical therapist at any point during your cancer diagnosis treatments or after treatment. It is best to start seeing a therapist when you are starting your breast cancer treatments, so that you can have someone who knows your baseline function and can help you with preventing disability, monitoring your body changes, and treating your symptoms as you receive treatment. You and your therapist can also discuss what goals would be appropriate to work on at each stage of your treatment. At times you need to maintain your function, and at other times you will need to improve or restore your function.
Curious1: Can you tell me what energy conservation is?
Sree_Battu,_MD: Energy conservation is the one of the best ways to treat cancer-related fatigue. Research has shown that energy conservation helps with battling fatigue more than nutrition and education alone. Energy conservation is a systematic way of planning your day to take advantage of doing the things you want to do when you are feeling you best and able to enjoy them. Therapists are wonderful at helping you come up with strategies on how to do the things you do on an everyday basis in an efficient and safe manner, which helps you save energy to do the things you want to do.
I would also like to mention that many cancer patients have fatigue, but it is not always cancer-related fatigue. You need to have a full physical evaluation to see if there are other causes for your fatigue which, if treated, can improve your overall function.
Breast Cancer and Exercise
Luv2Workout: As a breast cancer patient how much exercise should I do? How much is too much?
Sree_Battu,_MD: Before starting any kind of exercise program you will need to be cleared by a physician. Particularly with breast cancer, there may be issues with your bones from the spread of cancer or issues with your heart from treatments or a comorbid (coexisting) disease.
The American College of Sports Medicine recommends all cancer survivors participate in:
- Aerobic exercise—consisting of 150 minutes per week of moderate-intensity or 75 minutes per week at high-intensity activity. You can also participate in a combination of both intensities.
- Resistance exercise—involving muscle-strengthening activities of moderate intensity two days per week for each of the major muscle groups.
- Flexibility exercises—Major muscle groups and tendons should be stretched on days when other activities are performed.
Not everyone is able to participate in a program like that recommended by the American College of Sports Medicine. Listening to your body and how you feel after activity is important to managing fatigue. Patients should start with walking on level surfaces at a brisk pace for as long as they can tolerate and build up tolerance. Even if patients walk 10 minutes a day at home, they can still benefit from symptom management. Likewise, some people are able to surpass these recommendations. They can work with a therapist on developing a program that is appropriately challenging for them.
Luv2Workout: Can I lift weights after breast cancer surgery?
Sree_Battu,_MD: Immediately after surgery you should follow your surgeon’s instructions on weight limits and range of motion. In time you can participate in a progressive resistance training program. A physical therapist is key in helping to design a program that is safe for you and your pace. Your therapist will take into account your previous physical fitness and work with you to get you back to that level if possible. After surgery and treatment your muscles may move differently because they are in different places or changed in some way (e.g., radiation can produce a fibrosis of the muscle). It is unsafe to over strain your muscles as this can cause damage. A trained therapist familiar with breast cancer patients and their needs can help slowly develop a program of stretching and strengthening to build your new muscle without straining. Your therapist often can design an exercise program to accommodate a weakened muscle. The strengthening of other muscles that do similar actions can allow you to perform a specific function despite the weakened muscle. This type of slow progressive strengthening program along with education has been shown to help reduce lymphedema symptoms.
Ginny: I am a breast cancer survivor and I have osteoporosis. Do you have any exercises tips for me?
Sree_Battu,_MD: Exercise helps to maintain your bone mineral density. In a large study with more than 500 women with breast cancer who exercise, they found that there is complete prevention of femoral neck bone loss in premenopausal women and but no effect in postmenopausal women. Another study found that when postmenopausal women with breast cancer exercised regularly in addition to taking bisphosphonates (medication for bone mineral density) they were less likely to lose bone mineral density at the femoral neck.
Breast Cancer and Sexuality
StillAWoman: I am worried about how breast cancer will affect my body image and sexuality?
Sree_Battu,_MD: This is a sensitive and important issue you should discuss with your physician team. Your preferences should be known to your team, so they can help guide you with decision making. Breast surgery or radiation to the breast does not physically decrease a woman sexual desire or libido. However, hormone and/or chemotherapy can impair ovarian function which does impact your libido. Depending on the type of breast cancer you have depends on what type of options you have for side effect treatment. Common physical side effects can include pain with intercourse, vaginal dryness and loss of libido. Many women turn to their oncologist, obstetrician/gynecologist (ob/gyn) and/or psychologist to help with sexual functioning and emotions after breast cancer treatment. Common emotional side effects include changes in body image, loss of self esteem and changes in relationships. Rehabilitation therapists and psychologists also can help with some of the cosmetic and emotional issues associated with changes in your body.
Preventing Disability from Breast Cancer
Ginny: What can you do to prevent disability from breast cancer and treatment symptoms?
Sree_Battu,_MD: There are several proactive things you can do to help prevent disability from breast cancer and its treatments. I tell all my patients to do the following:
- Pay attention to your body for signs of swelling, pain, skin changes and fatigue, and seek advice from medical personnel
- Strive to attain an ideal body weight (BMI <30) to decrease the effect of lymphedema
- Eat a heart healthy diet to decrease the chance of cardiac disease
- Exercise (aerobic, resistance and flexibility) in a guided manner to help save bone density and improve symptoms of pain, anxiety, depression and fatigue
- Avoid smoking to help with healing
- Limit your intake of alcohol beverages to help decrease the effects of lymphedema
Breast Cancer Prevention
Summertime: My mother died from breast cancer at the age of 58 years old. Other than getting an annual breast examination and mammography, what are the things I can do to prevent getting this disease? What role does diet play in this disease?
Stephen_Grobmyer,_MD: You should be aware of your entire family history and discuss this with your doctor to determine if referral to a genetic counselor is indicated. A healthy lifestyle is important. Obesity and alcohol consumption are factors that are known to be associated with increased breast cancer risk.
Insurance Coverage of Physical Medicine and Rehabilitation
Ginger: What things are covered by insurance, and what things are out-of-pocket costs?
Sree_Battu,_MD: Most insurance companies pay for physician visits with a physical medicine and rehabilitation specialist. Most insurance companies pay for physical and/or occupational therapy. There are certain ‘cap’ limits with physical therapy and occupational therapy, so you would want to speak to your therapist when making a plan. Some insurance companies pay for lymphedema-certified therapists and therapies; others do not. You can always request an appeal and send additional documentation for this type of therapy. Many times if you do developed lymphedema, insurance companies pay for lymphedema pumps, but they do not always pay for compression garments. Compression garments and short stretch bandages are not ‘durable’ equipment or everlasting, so some insurance companies do not allow you to use your durable medical equipment coverage for these items. Compression garments need to be changed every four to six months because they lose their elasticity.
Lymphedema Treatment Training
Tazzy: How common is lymphedema after breast cancer treatment? What treatment method do you think works best? I am an occupational therapy assistant looking to expand my skills. I will be taking a seven hour continuing education course on breast cancer treatment with lymphedema, and considering going on to become a certified lymphedema therapist. They use a method that involves compression wraps, exercise and decongestive massage treatment and generally frown on compression pumps. Does this sound like a common treatment method that would be used with breast cancer lymphedema?
Sree_Battu,_MD: Unfortunately, there is no consistency in the diagnosis of lymphedema at this time. I have seen reports that range from 10 to 60 percent for how common lymphedema is after surgery from breast cancer. The two most common schools for learning lymphedema management are Dr. Vodder School™ International and the Lymphedema Management LeDuc method. There are some other schools as well which include Földi Clinic, Norton School of Lymphatic Therapy, Klose Training and Consulting, LLC, Lymphedema Therapy Certification Courses and Casley-Smith International. Many therapists gain skills from courses at multiple schools. It is important to know in what situations pumps can be useful and in what situations they are not useful. I have seen patients benefit from all treatment styles.
Moderator: I'm sorry to say that our time is now over. Thank you again, Stephen Grobmyer, MD and Sree Battu, MD, for taking the time to answer our questions today about breast cancer treatment and rehabilitation.
Stephen_Grobmyer,_MD: Thank you for your questions.
Sree_Battu,_MD: What we would like all the participants in this webinar to gain from attending is that you are not going through the journey alone. There are many resources to help you. Rehabilitation is an extra layer of therapeutic and support services that works with your medical team to help you live the life you want to lead. Your medical team focuses on curing or halting your disease process. Your rehabilitation team is there to help you deal with adjusting to medications, changes in your body, and sometimes the temporary or permanent limitations in your body that are the effects of your medical treatment or the disease itself. Your rehabilitation team is here to work hand- in-hand with your medical team. The goal of rehabilitation is to individualize a program that works for you and helps you to attain your functional goals. You and your needs are at the center of this process. The process depends on what is appropriate for your care—which may be prevention of disability, restoration of your function, or improvement of symptoms. Whether you were recently diagnosed with cancer, undergoing active treatment, a cancer survivor with no evidence of disease, or have metastatic disease, a rehabilitation team can help you and your loved ones live with the disease process and your care. The breast cancer rehabilitation process starts a referral to either a specific type of therapist (physical, occupational or speech) or a rehabilitation physician who can help navigate the process.
To make an appointment with Stephen Grobmyer, MD, please call 216.444.7000 or call toll-free at 866.223.8100.
To make an appointment with Sree Battu, MD, please call 216.636.5860 or call toll-free at 866.588.2264.
If you are a cancer patient being seen by a Cleveland Clinic physician, you can also call the Cancer Answer line at 216-444-7923. You can also visit us online at clevelandclinic.org/rehab
For More Information
On Breast Cancer
Being diagnosed with breast cancer raises many questions, and it is important to learn and understand about all of the available treatment options for you in taking control of your health.
If you would like more information you may download our free treatment guide.
Information about the genetic basis for breast cancer and how some cases are inherited can be found at: There are several health information articles that answer this question. You may refer to: http://my.clevelandclinic.org/disorders/Breast_Cancer/hic_The_Genetics_of_Breast_Cancer.aspx. Trying to understand the benefits of genetic testing for breast cancer is important. More information about genetic testing can be found at: http://my.clevelandclinic.org/disorders/Breast_Cancer/hic_What_is_the_Benefit_of_BRCA_Genetic_Testing.aspx
Cleveland Clinic is hosting a breast cancer and genetics web chat on October 15 with Stephen Grobmyer, MD and Charis Eng, MD, PhD. Dr. Eng is the Chair and founding Director of the Genomic Medicine Institute of the Cleveland Clinic. Genetic aspects of breast cancer will be discussed in detail.
On Cleveland Clinic
If you have been diagnosed with breast cancer, Cleveland Clinic physicians, rehabilitation clinicians (occupational, physical and speech therapists), and cancer support services are there to support you with a comprehensive, multidisciplinary approach to rehabilitation. Therapy sessions are customized to meet your individual needs, and are designed specifically to work in conjunction with your ongoing breast cancer treatment regimen or after its completion to produce the best possible outcome.
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