Breast cancer surgery may be associated with debilitating arm and shoulder disability and pain. For example, treatment may affect the lymphatic and musculoskeletal systems of the torso and upper limb. In addition, adverse events after surgery and radiotherapy targeting the axilla are commonly reported, and up to one-third of women experience restricted range of motion in the shoulder, chronic pain, and lymphoedema, limited health-related quality of life (hrQoL), and delayed recovery.  Furthermore, functional impairment and pain-related avoidance of movement may increase the level of disability.[1][2]

According to a study published in the November 11, 2021 edition of The BMJ, debilitating arm and shoulder disability and pain women experience as a side effect of their breast cancer surgery may be can be reduced by following a physiotherapy-led exercise program after their operation. [3]

Research led by the UK-based University of Warwick with the University Hospitals of Coventry and Warwickshire NHS Trust and Baylor College of Medicine showed an improvement in shoulder and arm mobility and reduction in pain amongst women who were recovering after non-reconstructive breast cancer surgery after taking part in the structured PROSPER rehabilitation program.

The PROSPER study was a pragmatic, superiority, multicentre, randomized controlled trial undertaken at 17 National Health Service (NHS) cancer centers.[3]

Alastair Thompson, BSc (Hons), MBChB, MD, FRCS (Ed) Professor and Chief, Section of Breast Surgery, Baylor College of Medicine. Photo Courtesy: ©1998-2021 Baylor College of Medicine®

Non-reconstructive surgery
In non-reconstructive breast cancer surgeries, surgeons aim to remove cancer and often some nodes in the armpit to control cancer. However, this targeted treatment can leave patients with shoulder and arm problems, including chronic pain, restricted movement, and lymphoedema. Past research has shown that as many as one-third of women recovering from breast cancer surgery can struggle to return to everyday tasks such as lifting bags and driving.

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Usual care is to provide an advice leaflet explaining exercises to do after breast cancer surgery. As part of the Prevention of Shoulder Problems Trial (PROSPER), researchers worked with physiotherapists and breast cancer patients to design an exercise program for those at higher risk of developing shoulder problems.

Exercise program
The PROSPER exercise intervention was developed from evidence, clinical experts, and patients; the final intervention consisted of exercise, behavioral strategies, and physical activity. Women were offered a minimum of three face-to-face appointments with a physiotherapist, starting 7 to 10 days postoperatively followed by a prescribed program of stretching and range of motion and resistance exercises.[4]

“After breast cancer surgery, arm and shoulder disability impacts the functioning and quality of life for many women,” noted Alastair Thompson, BSc (Hons), MBChB, MD, FRCS (Ed), professor and section chief of breast surgery in the Michael E. DeBakey Department of Surgery at Baylor College of Medicine and co-associate director for clinical research at the Dan L Duncan Comprehensive Cancer Center.

“Using a physiotherapy-led exercise program introduced a week or so after surgery led to better upper limb function, less pain, and lower costs, up to a year later without any adverse impacts. This randomized trial demonstrates the benefits of early, supported exercise after breast surgery and that it should become standard practice in women treated for breast cancer,” Thomson said.

Professor Julie Bruce,  Ph.D., principal investigator with the Warwick Clinical Trials Unity at the University of Warwick, United Kingdom. Photo Courtesy: Warwick Medical School,  University of Warwick, Coventry CV4 7AL, United Kingdom.

“We know that some women present to physiotherapy services and pain clinics further down the line with shoulder restriction and pain problems, so we wanted to test a rehabilitation program to find out if this could help at an early stage,” explained Julie Bruce,  Ph.D., principal investigator of the trial and professor with the Warwick Clinical Trials Unity at the University of Warwick.

The primary outcome was the Disabilities of the Arm Shoulder and Hand or DASH-score at 12 months. Secondary outcomes included DASH subscales, postoperative pain, complications, and health-related quality of life. Results: 392 women were recruited, 196 randomized to each treatment arm. The mean age was 58.1 years, mean BMI was 30.2. Groups were similar for socioeconomic characteristics at baseline. Of 191 women allocated to exercise intervention, 142/191 (74%) received three or more physiotherapy-led exercise sessions, 38/191 (20%) received up to three sessions, and 11/191 (6%) no treatment.[4]

Patients randomized to exercise had a better arm, shoulder, and hand function compared to usual care at 12 months (mean DASH score 16.4 versus 23.9 respectively; the adjusted mean difference (MD) -7.42; 95% CI -12.34 to -2.50; p=0.003). DASH subscales for activity limitations, participation restriction, and impairment improved over time in women receiving exercise compared to usual care. A lower rate of neuropathic pain at 12 months was reported by the treatment arm (23% control vs 16% exercise).[4]

Based on the outcome of the study, the researchers concluded that early structured postoperative exercise was beneficial on functional and other health-related outcomes at 12 months in women undergoing surgery for breast cancer treatment.

“This is a proven cost-effective program that we know can help women undergoing certain breast cancer procedures,” Bruce said.

“Future research directions could evaluate the application of our preoperative screening criteria for the identification of women at higher risk of developing post-treatment limb related disability who could benefit from this cost-effective exercise program,” she concluded.

The study was funded by the National Institute for Health Research (NIHR), the research partner of the NHS, public health, and social care.

[1] Lee TS, Kilbreath SL, Refshauge KM, Herbert RD, Beith JM. Prognosis of the upper limb following surgery and radiation for breast cancer. Breast Cancer Res Treat. 2008 Jul;110(1):19-37. doi: 10.1007/s10549-007-9710-9. Epub 2007 Sep 26. PMID: 17899373.
[2] Mejdahl MK, Andersen KG, Gärtner R, Kroman N, Kehlet H. Persistent pain and sensory disturbances after treatment for breast cancer: six-year nationwide follow-up study. BMJ. 2013 Apr 11;346:f1865. doi: 10.1136/bmj.f1865. PMID: 23580693.
[3] Bruce J, Mazuquin B, Canaway A, Hossain A, Williamson E, Mistry P, Lall R, Petrou S, Lamb SE, Rees S, Padfield E, Vidya R, Thompson AM; Prevention of Shoulder Problems Trial (PROSPER) Study Group. Exercise versus usual care after non-reconstructive breast cancer surgery (UK PROSPER): multicentre randomised controlled trial and economic evaluation. BMJ. 2021 Nov 10;375:e066542. doi: 10.1136/bmj-2021-066542. PMID: 34759002.
[4] Bruce J, Mazuquin N, Mistry P, Williamson E, Lall R, Vidya R, Withers E, Rees S, Canaway A, Petrou S, Lamb SE, Thompson AM. Prevention of shoulder problems trial (UK-PROSPER): Exercise to prevent shoulder problems in patients undergoing breast cancer treatment. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl): Abstract nr P1-13-04.DOI: 10.1158/1538-7445.SABCS19-P1-13-04 Published February 2020.

Featured Image: Biopsy. A Caucasian woman patient is being operated on. Her nipple is being incised by the surgeon. The male surgeon and an operating room attendant are visible. A surgical biopsy is being performed to determine the exact nature of the solid tumor. Photo Courtesy: © 2020 – 2021 Linda Bartlett/National Cancer Institute on Unsplash.

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