Progressive resistance training to prevent arm lymphedema in the first year after breast cancer surgery: Results of a randomized controlled trial

Early Implementation of Exercise to Facilitate Recovery After Breast Cancer Surgery: A Randomized Clinical Trial

Importance

Recovery of shoulder function following breast cancer surgery is crucial for physical functioning and quality of life. While early implementation of shoulder rehabilitation exercises may enhance recovery, the optimal timing and exercise program remain unclear.

Objective

To investigate whether an early exercise intervention, initiated 1 day postsurgery and continued for 1 month through subsequent visits, could improve shoulder range of motion (ROM) and strength in patients with breast cancer.

Design, Setting, and Participants

A parallel-group, 2-arm randomized clinical trial was conducted between June 2020 and October 2021 at the Breast Cancer Center in Seoul, South Korea. Fifty-six patients (of 119 screened) with early-stage breast cancer who were scheduled for partial or total mastectomy were randomized into a tailored resistance exercise group (n = 28) or a usual care group (n = 28). Data were analyzed from November 2021 to June 2022.

Interventions

The exercise intervention commenced 1 day postsurgery and consisted of 4 supervised exercise education sessions corresponding with surgeon visits and daily home-based exercises for the first postoperative month. Tailored programs, including stretching and strength exercises, were adjusted based on individual shoulder function recovery status.

Main Outcomes and Measures

Primary end points were shoulder ROM and strength at 1 and 6 months postsurgery. Physical activity, body composition, and quality of life were assessed at 6 months.

Results

Of 56 patients randomized (mean [SD] age, 50.3 [6.6] years), 54 completed the trial (96%), with 100% and 97% compliance to supervised and home-based exercise sessions, respectively. At 1 month postsurgery, 19 (67.9%) in the exercise group had fully recovered shoulder strength compared to 1 (3.6%) in the usual care group (P < .001). At 6 months, 22 (78.6%) in the exercise group had fully recovered shoulder ROM and 24 (85.7%) had fully recovered strength compared to 6 (21.4%) and 5 (17.9%), respectively, in the usual care group (P < .001). The exercise group exhibited less loss in muscle mass and improved physical activity and quality of life compared to the usual care group.

Conclusion and Relevance

In this trial, 1-month tailored exercise program, initiated immediately after breast cancer surgery and supplemented with supervised sessions coinciding with surgeon visits, significantly improved shoulder function in patients with breast cancer.

Trial Registration

WHO International Clinical Trials Registry identifier: KCT0006997.

Effects of a lymphedema prevention program based on the theory of knowledge-attitude-practice on postoperative breast cancer patients: A randomized clinical trial

BACKGROUND

Breast cancer-related lymphedema (BCRL) is one of the common postoperative complications that severely affects the functions of the arm and quality of life. Since lymphedema is difficult to treat and prone to recurrence, early prevention of lymphedema is crucial.

METHODS

Patient diagnosed with breast cancer (N = 108) were randomized to the intervention (n = 52) or control group (n = 56). In the intervention group, patients were provided the lymphedema prevention program based on the theory of knowledge-attitude-practice during the perioperative period and the first three chemotherapy sessions (mainly includes health education, seminars, knowledge manuals, sports guidance, peer education, and WeChat group).The limb volume, handgrip strength, arm function, and quality of life were measured in all patients at the baseline, 9 weeks (T1), and 18 weeks (T2) after surgery.

RESULTS

The incidence of lymphedema in the Intervention group was numerically lower than in the control group after implementing the lymphedema prevention program, but the difference was not statistically significant (T1: 1.9% vs. 3.8%, p = 1.000; T2: 3.6% vs. 7.1%, p = 0.744). However, compared with the control group, the intervention group showed there was less deterioration in handgrip strength (T1 [t = -2.512, p < 0.05] and T2 [t = -2.538, p < 0.05]), improved postoperative upper limb dysfunction (T1 [t = 3.087, p < 0.05] and T2 [t = 5.399, p < 0.05]) and less deterioration in quality of life (T1 [p < 0.05] and T2 [p < 0.05]).

CONCLUSION

Although the investigated lymphedema prevention program improved arm function and quality of life, it did not reduce the incidence of lymphedema in postoperative breast cancer patients.

The long-term burden of a symptom cluster and association with longitudinal physical and emotional functioning in breast cancer survivors

BACKGROUND

Fatigue, insomnia and pain are some of the most common and distressing symptoms experienced during breast cancer (BC) treatment and survivorship. The symptoms have been found to impact one another and to form a symptom cluster, and greater severity of the symptoms may be negatively associated with physical and emotional functioning in survivorship. In exploratory analyses from a randomized controlled trial examining the effect of progressive resistance training on the development of lymphedema after BC, we aimed to examine the burden of the symptom cluster fatigue-pain-insomnia, and its prognostic value for long-term symptom severity as well as emotional and physical functioning.

MATERIAL AND METHODS

Latent profile analysis was used to identify groups with similar severity of pain, fatigue and insomnia among 158 patients with BC two weeks after surgery. Mixed effects Tobit regression models were used to estimate fatigue, pain, insomnia, and physical and emotional functioning 20 weeks, 1 year and 3.5 years after surgery.

RESULTS

Two symptom burden groups were identified: 80% of women had a low severity while 20% of women had a high severity of the three symptoms after BC surgery. 3.5 years later, the women with high symptom burden post-surgery still had higher pain, insomnia and fatigue scores than women with low symptom burden. High symptom burden post-surgery was associated with worse physical functioning 3.5 years later, while emotional functioning was only negatively impacted during the first year.

DISCUSSION

These findings warrant larger studies investigating if symptom burden early in BC trajectory can be used for risk stratification for persistent symptoms and diminished physical functioning with the purpose of developing and implementing targeted interventions.

Effects of exercise mode and intensity on patient-reported outcomes in cancer survivors: a four-arm intervention trial

PURPOSE

The aim of this study was to compare the effects of different exercise modes (aerobic, resistance) and intensity prescriptions (standard, polarized, undulating) on patient-reported outcomes (PROs) in cancer survivors.

METHODS

107 breast or prostate cancer survivors (52% females, age 58 ± 10 years, 6-52 weeks after primary therapy) performed one out of four training programs, two sessions/week, over 12 weeks: work rate-matched vigorous intensity aerobic training (AT_Standard, n = 28) and polarized intensity aerobic training (AT_Polarized, n = 26) as well as volume-matched moderate intensity resistance training (RT_Standard, n = 26) and daily undulating intensity resistance training (RT_Undulating, n = 27). Health-related quality of life (HRQoL, EORTC-QLQ-C30) and cancer-related fatigue (CRF, MFI-20) were assessed at baseline, at the end of intervention and after a 12-week follow-up without further prescribed exercise.

RESULTS

Over the intervention period, HRQoL-function-scales of the EORTC-QLQ-C30 improved over time (p = .007), but no group*time interaction was observed (p = .185). Similarly, CRF values of the MFI-20 improved over time (p = .006), but no group*time interaction was observed (p = .663). When including the follow-up period and pooling the AT and the RT groups, HRQoL-function-scales developed differently between groups (p = .022) with further improvements in RT and a decline in AT. For CRF no significant interaction was found, but univariate analyses showed a non-significant trend of more sustainable effects in RT.

CONCLUSIONS

AT and RT with different work rate-/volume-matched intensity prescriptions elicits positive effects on HRQoL and CRF, without one regimen being significantly superior to another over the intervention period. However, RT might result in more sustainable effects compared to AT over a follow-up period without any further exercise prescription.

CLINICAL TRIAL REGISTRATION

The study was registered at clinicaltrials.gov (NCT02883699).

Harms of exercise training in patients with cancer undergoing systemic treatment: a systematic review and meta-analysis of published and unpublished controlled trials

Background

Exercise is recommended for people with cancer. The aim of this study was to evaluate the harms of exercise in patients with cancer undergoing systemic treatment.

Methods

This systematic review and meta-analysis included published and unpublished controlled trials comparing exercise interventions versus controls in adults with cancer scheduled to undergo systemic treatment. The primary outcomes were adverse events, health-care utilization, and treatment tolerability and response. Eleven electronic databases and trial registries were systematically searched with no date or language restrictions. The latest searches were performed on April 26, 2022. The risk of bias was judged using RoB2 and ROBINS-I, and the certainty of evidence for primary outcomes was assessed using GRADE. Data were statistically synthesised using pre-specified random-effect meta-analyses. The protocol for this study was registered in the PROESPERO database (ID: CRD42021266882).

Findings

129 controlled trials including 12,044 participants were eligible. Primary meta-analyses revealed evidence of a higher risk of some harms, including serious adverse events (risk ratio [95% CI]: 1.87 [1.47-2.39], I2 = 0%, n = 1722, k = 10), thromboses (risk ratio [95% CI]: 1.67 [1.11-2.51], I2 = 0%, n = 934, k = 6), and fractures (risk ratio [95% CI]: 3.07 [3.03-3.11], I2 = 0%, n = 203, k = 2) in intervention versus control. In contrast, we found evidence of a lower risk of fever (risk ratio [95% CI]: 0.69 [0.55-0.87], I2 = 0% n = 1109, k = 7) and a higher relative dose intensity of systemic treatment (difference in means [95% CI]: 1.50% [0.14-2.85], I2 = 0% n = 1110, k = 13) in intervention versus control. For all outcomes, we downgraded the certainty of evidence due to imprecision, risk of bias, and indirectness, resulting in very low certainty of evidence.

Interpretation

The harms of exercise in patients with cancer undergoing systemic treatment are uncertain, and there is currently insufficient data on harms to make evidence-based risk-benefits assessments of the application of structured exercise in this population.

Funding

There was no funding for this study.

Effects of an early intervention with Hyperbaric Oxygen Treatment on arm lymphedema and quality of life after breast cancer-an explorative clinical trial

PURPOSE

Lymphedema (LE) is a common complication after breast cancer treatment, which negatively affects the quality of life (QOL). Hyperbaric Oxygen Treatment (HBOT) is an established treatment for radiation-induced tissue injury, but evidence of effect on breast cancer-related LE is inconclusive. We aimed to explore effects of HBOT on early breast cancer-related LE and the implications for QOL.

METHODS

We invited women with breast cancer treated with surgery, axillary dissection and radiotherapy, who had participated in a randomized controlled trial and who presented with LE 1 year after surgery. In a prospective observational study design, change in LE was assessed with perometry, dual-energy X-ray absorptiometry (DXA) and lymphoscintigraphy, and QOL by validated self-report scales. Participants were offered 40 sessions of HBOT on every weekday for 8 weeks and were followed for 6 months.

RESULTS

Out of 50 eligible participants, 20 women accepted participation. Nineteen women initiated and completed treatment and follow-up. None of the objective measures of LE severity showed consistent changes during the study period, but participants reported significant improvements in QOL (physical functioning, fatigue, insomnia and breast and arm symptoms), with improvements peaking at 6-month follow-up.

CONCLUSION

Participants receiving HBOT experienced improved QOL without consistently significant changes in arm mass, volume or lymphatic drainage. These results call for studies into differential effect in patient sub-groups, and a large-scale, randomized placebo-controlled trial with long-term follow-up to assess the effect of HBOT in patients with soft tissue radiation injuries after breast cancer seems warranted.

TRIAL REGISTRATION

Danish Health and Medicines Authority, EUDRACT no. 2015-000,604-25 Ethical committee of the Capitol Region, No. R96-A6604-14-S22.

Effect of progressive resistance exercise using Thera-band on edema volume, upper limb function, and quality of life in patients with breast cancer-related lymphedema

This study aimed to determine the effects of progressive resistive exercise (PRE), including complex decongestive physical therapy (CDPT), on edema volume, handgrip strength, upper extremity function, and quality of life (QoL) in patients with breast cancer-related lymphedema (BCRL). Twenty patients were randomized between the progressive resistance exercise group (PREG) and the self-home resistance exercise group (SREG). Two patients in each group dropped out of the study, leaving 16 patients: n=8 in the exercise group and n=8 in the SREG. First, the PREG and the SREG received CDPT. Subsequently, the patients in the PREG performed PRE, whereas the patients in the SREG performed self-home resistance exercises. Interventions were performed for 50 min, 3 times a week, for 6 weeks. The results showed that, for the edema volume, a significant intergroup variation was absent, whereas the intragroup variation was significant. The inter- and intragroup variations were significant for both handgrip strength and upper extremity function. Regarding QoL, a significant difference was observed in global health status/QoL and role function between the groups. Furthermore, significant differences were observed within the PREG in global health status/QoL; physical, role, and cognitive function; and dyspnea. No significant differences were observed within the SREG. The results collectively suggest that the exercise program was an intervention with a greater potential contribution to reducing edema and enhancing physical function in patients with BCRL.

Rehabilitation interventions for the management of breast cancer-related lymphedema: developing a patient-centered, evidence-based plan of care throughout survivorship

PURPOSE

A work group from the American Physical Therapy Association Academy of Oncologic Physical Therapy developed and published a clinical practice guideline (CPG) to aid clinicians in identifying interventions for individuals with breast cancer-related lymphedema (BCRL). This guideline reviewed the evidence for risk mitigation and volume reduction beginning at cancer diagnosis and continuing through survivorship. Application of CPGs can be challenging due to the variability of clinical settings, heterogeneous patient populations, and range of rehabilitation clinician expertise. The purpose of this paper is to assist these clinicians in implementing the recommendations from the CPG to develop a patient-centered, evidence-based plan of care.

METHODS/RESULTS

This publication presents important considerations for the implementation of recommended rehabilitation interventions across the trajectory of BCRL.

CONCLUSION

Current evidence supports specific interventions to treat or mitigate the risk for the various stages of BCRL. As clinicians implement these recommendations into practice, they also need to address other impairments that may exist in every individual. Continued collaboration between clinicians and researchers is necessary to further develop optimal treatment modalities and parameters.

IMPLICATIONS FOR CANCER SURVIVORS

By implementing evidence-based interventions as outlined in the CPG, clinicians can improve the quality of care for survivors of breast cancer.

Self-managed physical activity in breast cancer survivors: A scoping review

OBJECTIVE

Breast cancer survivors (BCS) experience many issues of rehabilitative concern due to the treatments they have undergone. Given the chronicity of these outcomes, the increasing number of survivors, and the positive results obtained by supervised exercise, professionals should consider offering self-managed physical activity (PA) programs to this population. Our aim was to map the currently available evidence about self-care rehabilitation for BCS.

METHODS

Medline, CINAHL, and Cochrane databases were searched for primary literature. Scoping review methodological frameworks were used to tackle the heterogeneity of the topic. Studies investigating self-managed PA interventions prescribed to adult BCS were included.

RESULTS

One hundred-eight studies were included, with sample sizes ranging from 6 to 692 patients. Information was systematically collected in tables displaying study design, type of PA, duration and recommended frequency, professional leading the study, type of supervision, initial training, strategies used to help patients integrate self-care into their daily lives, and self-managed PA efficacy. Tables were produced for every oncological side effect that BCS might experience: lymphedema, arthralgia, cancer-related fatigue, a decline in physical parameters, treatment-related cardiotoxicity, peripheral neurotoxicity, and a possible decline in the quality of life.

CONCLUSIONS

Self-managed PA has the potential to improve BCS oncological issues. Professionals can adopt many strategies to support patients and empower them with long-lasting self-care competencies. This scoping review provided a comprehensive and easy-to-consult overview of self-managed PA interventions for BCS. We also provided recommendations for future primary studies and secondary synthesis.

Conservative interventions and clinical outcome measures used in the perioperative rehabilitation of breast cancer patients undergoing mastectomy: a scoping review

BACKGROUND

Mastectomy is the first-line treatment approach for more than 90% of breast cancer patients. The numerous physical impairments associated with this surgical procedure negatively impact the patient's quality of life. To date, rehabilitation resources available for breast cancer patients undergoing mastectomy within the institutions affiliated to the Centre intégré universitaire de soins de santé et de services sociaux de la Mauricie-et-du-Centre-du-Québec (CIUSSS-MCQ) are lacking and do not always seem to reflect the particularities of breast cancer care pathways. The purpose of this review was to identify and describe the conservative interventions and the clinical outcome measures used in the perioperative physical rehabilitation of women with breast cancer who are awaiting or have undergone mastectomy. We also aimed to report on the barriers and facilitators to study participation and completion.

METHODS

MEDLINE, CINAHL, and the Cochrane Library were searched from inception to January 2021, and we updated the search on July 11, 2022. We included peer-reviewed English and French literature with quantitative designs, describing conservative interventions and clinical outcome measures used within rehabilitation programs designed for women who were awaiting or had undergone mastectomy. Paired reviewers independently reviewed all citations and articles using a two-phase screening process and independently extracted the data.

RESULTS

Of the 6080 articles identified, 57 met the inclusion criteria. Most interventions were multimodal, which combined exercise with patient education, manual therapy, and/or lymphatic drainage. The most frequently used objective measures of physical function were shoulder range of motion, muscle strength, and signs of lymphedema. In contrast, the primary patient-reported outcome measures were quality of life, shoulder function, and pain. Undergoing another breast surgery, death, and cancer recurrence were the most reported barriers to study completion.

CONCLUSION

This scoping review reports on the heterogeneity and wide range of conservative interventions and clinical outcome measures used in the physical rehabilitation of breast cancer patients who had undergone or were scheduled to undergo mastectomy. Tailoring interventions to breast cancer patients' needs and promoting outpatient rehabilitation interventions appear to be better suited to the particularities of breast cancer care pathways. Further research is needed to better identify barriers and facilitators to study participation and completion.

Visual analysis of global research output of lymphedema based on bibliometrics

Background

Globally, several generations of doctors in the field of lymphedema have created numerous publications. To date, no bibliometric analysis has been performed specifically on these publications. For the further promotion of research on lymphedema and to align with the international research frontiers, it is essential to understand the current state of Lymphedema research output.

Objective

This study aims to statistically and visually analyze the characteristics of publications output, distribution of contributions and development process of lymphedema, enriching the knowledge base of Lymphedema, and then seek potential research topics and collaborators.

Methods

Based on the Web of Science core collection database, we firstly analyzed the quantity and quality of publications in the field of lymphedema, secondly profiled the publishing groups in terms of country, institution, author's publication and cooperation network, and finally sorted out and summarized the hot topics of research.

Results

A total of 8569 papers were retrieved from 1900-2021. The top4 journals with the most publications were LYMPHOLOGY, LYMPHATIC RESEARCH AND BIOLOGY, PLASTIC AND RECONSTRUCTIVE SURGERY and ANNALS OF SURGICAL ONCOLOGY. The top 4 countries with the most publications were USA, Japan, UK, and China. The United States dominates the total number of publications and the international cooperation network. The most productive research institution is Harvard University, and the research institution with the most collaborating institutions is Memorial Sloan Kettering Cancer Center. Mortimer, Peter S contributes the most research in this field. The research achievements of Japanese scholars in this field are of great significance. The top 5 ranked keywords are "Breast Cancer", "Health-Related Quality Of Life", "Lymphscintigraphy", "Lymphovenous Anastomosis", and "Lymphangiogenesis".

Conclusion

More and more scholars are devoted to the research of cancer-related Lymphedema. It is foreseeable that breast cancer-related lymphedema and lymphangiogenesis will remain a focus of future research. Advances in Lymphatic vessel imaging and the development of lymphatic microsurgery will further play a role in the clinical workup of lymphedema. Meanwhile, This study can help researchers identify potential collaborators and partner institutions and contribute to further research.

The Effect of Exercise for the Prevention and Treatment of Cancer-Related Lymphedema: A Systematic Review with Meta-analysis

INTRODUCTION

The purpose of this systematic review and meta-analysis was to evaluate the effects of exercise on (i) the prevention of cancer-related lymphedema (CRL) and (ii) the treatment of CRL, lymphedema-associated symptoms, and other health outcomes among individuals with CRL.

METHODS

An electronic search was undertaken for exercise studies measuring lymphedema and involving individuals at risk of developing or with CRL. The Effective Public Health Practice Project Quality scale was used to assess study quality, and overall quality of evidence was assessed using the Grading of Recommendation, Assessment, Development and Evaluation approach. Meta-analyses were performed to evaluate effects of exercise on CRL incidence, existing CRL status, lymphedema-associated symptoms, and health outcomes.

RESULTS

Twelve studies ( n = 1955; 75% moderate-high quality) and 36 studies ( n = 1741; 58% moderate-high quality) were included in the prevention and treatment aim, respectively. Relative risk of developing CRL for those in the exercise group compared with the nonexercise group was 0.90 (95% confidence interval (CI), 0.72 to 1.13) overall and 0.49 (95% CI, 0.28 to 0.85) for those with five or more lymph nodes removed. For those with CRL in the exercise group, the standardized mean difference (SMD) before to after exercise of CRL was -0.11 (95% CI, -0.22 to 0.01), and compared with usual care postintervention, the SMD was -0.10 (95% CI, -0.24 to 0.04). Improvements after intervention were observed for pain, upper-body function and strength, lower-body strength, fatigue, and quality of life for those in the exercise group (SMD, 0.3-0.8; P < 0.05).

CONCLUSIONS

Findings support the application of exercise guidelines for the wider cancer population to those with or at risk of CRL. This includes promotion of aerobic and resistance exercise, and not just resistance exercise alone, as well as unsupervised exercise guided by symptom response.

Breast cancer-related lymphoedema and resistance exercise: An evidence-based review of guidelines, consensus statements and systematic reviews

AIMS AND OBJECTIVES

Breast cancer-related lymphoedema (BCRL) is a side effect of cancer treatment and can be alleviated by resistance exercise. This systematic, evidence-based review examined the existing best evidence on resistance exercise for BCRL to accurately describe the current status of the field and offer recommendations for clinicians.

METHODS

This review adheres to the PRISMA guidelines. Clinical practice guidelines, consensus documents, systematic reviews and other related evidence-based resources about resistance exercise for BCRL were retrieved through the English databases and guideline websites. The publication data limit was set to December 2020. The following search terms were used: 'breast cancer/breast neoplasm/breast carcinoma/breast tumor/breast malignancy, lymphedema/swelling/edema/lymphoedema, resistance/weight/strength training, best practice/clinical practice/guideline/consensus documents'. The quality of the included studies was evaluated by two authors independently using AGREE II and AMSTAR II tools. Evidence-based recommendations on resistance exercise relevant for BCRL were synthesised and categorised.

RESULTS

Twenty two articles (seven guidelines, four consensus documents and eleven systematic reviews) were included. The overall quality of the eleven eligible guidelines and consensus documents was moderate to high according to the AGREE II criteria. The quality of the eleven systematic reviews was critically low to high according to the AMSTAR criteria. Six clinical topics involving 43 recommendations were identified. Recommendations were categorised by safety of resistance training, effectiveness of resistance training, evaluation prior to resistance exercise, resistance exercise prescription, resistance training outcome index and points for attention.

CONCLUSIONS

This study summarises 43 recommendations for resistance training for BCRL and provides guidance for clinicians. Based on randomised trials and systematic reviews published in recent years, there is an urgent need to update the guidelines and consensus documents in terms of topics, for example effectiveness of resistance training and resistance training outcome index.

Efficacy of resistance training during adjuvant chemotherapy and radiation therapy in cancer care: a systematic review and meta-analysis

PURPOSE

To determine the effect of resistance training during adjuvant chemotherapy and radiation therapy in cancer patients on measures of lean mass and muscle strength. Secondary aims were to analyse the prescription and tolerability of supervised resistance training in this population.

METHODS

EMBASE, Medline, CINAHL, Cochrane Library and Web of Science were searched from inception until 29 March 2021. Eligible randomised controlled trials (RCTs) examining supervised resistance training > 6 weeks duration during adjuvant chemotherapy and/or radiation therapy in cancer patients with objective measurement of muscle strength and/or lean mass were included. The meta-analysis was performed using Revman 5.4.

RESULTS

A total of 1910 participants from 20 articles were included (mean age: 54 years, SD = 10) and the majority were female (76.5%). Resistance training was associated with a significant increase in upper body strength (standardised mean difference (SMD) = 0.57, 95% CI 0.36 to 0.79, I2 = 64%, P < 0.0001), lower body strength (SMD = 0.58, 95% CI 0.18 to 0.98, I2 = 91%, P = 0.005), grip strength (mean difference (MD) = 1.32, 95% CI 0.37 to 2.27, I2 = 0%, P < 0.01) and lean mass (SMD = 0.23, 95% CI 0.03 to 0.42, I2 = 0%, P = 0.02). A P value of < 0.05 was considered statistically significant. The quality of the studies included was moderate to high with low risk of bias as per the PEDro scale.

CONCLUSION

Resistance training is an effective adjunct therapy to improve muscle strength and lean mass in cancer patients undergoing chemotherapy and/or radiation therapy.

PROSPERO REGISTRATION NUMBER

CRD42020180643.

Explore the Application Value of Prospective Monitoring Model in the Nursing Management of Breast Cancer Patients During Perioperative Period

Purpose

To explore the application value of prospective monitoring model in the nursing management of breast cancer patients during perioperative period.

Methods

300 perioperative breast cancer patients admitted to our hospital from January to August 2021 were randomly divided into the control group (n = 150) and the model group (n = 150). Both groups used routine nursing management, and the model group added nursing management based on a prospective monitoring model. The quality of surgical nursing, circumference of the upper limbs, and the scores of disability of arm-shoulder-hand (DASH), exerciseofself-care agencyscale (ESCA), social self-esteem scale (SSES), multidimensional fatigue symptom inventory-short form (MFSI-SF) and functional assessment of cancer therapy-breast cancer (FACT-B) were compared of the two groups.

Results

Postoperatively, the quality of surgical nursing was better in the model group than in the control group (P < 0.05). At 3 months postoperatively, the number of cases of upper limb lymphedema was higher in both groups than before (P < 0.05), but there was no statistical difference between the two groups in the preoperative and 3 months postoperative comparisons (P > 0.05). At 3 months postoperatively, the total DASH score was higher than preoperatively in both groups, but lower in the model group than in the control group (P < 0.05). After nursing, the ESCA and SSES scores of each dimension were higher in both groups than before, and the model group was higher than the control group (P < 0.05). At 3 months postoperatively, the total MFSI-SF score was lower than preoperatively in both groups, and lower in the model group than in the control group (P < 0.05). At 3 months postoperatively, the FACT-B scores of each dimensions were higher in the model group than in the control group (P < 0.05).

Conclusion

The implementation of nursing management based on a prospective monitoring model for breast cancer patients during the perioperative period has important clinical value in improving the quality of surgical nursing and improving postoperative upper limb lymphedema, upper limb function, self-care ability, social self-esteem, cancer-related fatigue symptoms, quality of life, etc.

Resistance Exercise for Breast Cancer Patients? Evidence from the Last Decade

Background

Breast cancer is associated with many therapy-induced side effects that impact patients' lives from diagnosis to long-term survivorship. Physical activity has become an important and proven supportive measure in treating side effects like loss of muscle strength, fatigue, chemotherapy-induced peripheral neuropathy, lymphedema, and loss of quality of life. Resistance training (RT) is an established exercise intervention for breast cancer patients, but the correct type, timing, intensity, and duration of exercise remain unclear. It is necessary to investigate different resistance training interventions and their effects on breast cancer patients by covering all stages of treatment, beginning with prehabilitation, through the period of acute therapy, to long-term survivorship.

Conclusion

Upon evaluation of randomized controlled trials (RCTs) from the past decade, RT was found to be feasible and safe. Furthermore, there is evidence on the impact of RT on muscle strength, CRF and QoL amongst other factors. Studies implementing mixes of aerobic and strength exercises are rather common, but RCTs of RT-only protocols remain scarce. Different strength training protocols at distinct stages of breast cancer treatment have been conducted, but with the complexity of treatments and the variety of training styles, a large field of study remains.

Key Messages

Although the overall data on RT for breast cancer patients has increased, there are many different methodological approaches and testing measures as well as gaps in study documentation. There is still very little of the evidence that would facilitate the compilation of standardized and individualized guidelines.

Progressive resistance exercise training to prevent lower-limb lymphedema after cervical cancer surgery: A feasibility study

Objective

Radical hysterectomy with pelvic lymphadenectomy is the standard surgical treatment for early stage cervical cancer. One of the most common complications after this surgery is lower extremity lymphedema (LLL). Program of progressive resistance exercise training (PRET) is a possible way to prevent LLL for cervical cancer patients postoperatively. Before we start a randomized controlled trial to evaluate the preventive effect of PRET, we conducted this pilot study to assess the feasibility of PRET after cervical cancer surgery.

Methods

The primary purpose of the pilot study was the feasibility of PRET, as well as the satisfaction and adherence to the PRET assessed by a questionnaire. We conducted a single-arm prospective study involving cervical cancer patients who underwent radical hysterectomy with pelvic lymphadenectomy. Participants exercised twice a day for 24 weeks (two weeks of supervised in hospital and then 22 weeks of home-based training) after surgical treatment. All patients were followed up for 12 months. Information that included the limb volume, BMI, perceived difficulty level and adherence rate was collected.

Results

From February to April 2019, a total of 24 patients participated in the study. None of them dropped out. The adherence rate was more than 75% in majority of the patients, the perceived difficulty level of the PRET was high (for the first phase, the fourth phase and the fifth phase, more than half of the participants felt the intensity of the exercise appropriate), and no serious adverse events in the study were observed.

Conclusions

Exercise training was safe and feasible. The preliminary results offered us the possibility to further test the preventive effect of PRET in a full-scale randomized controlled trial.

Interrater Reliability of Dynamic Muscle Testing After Breast Cancer Surgery in Women at High Risk of Lymphedema: To Improve Quality in Clinical Practice

Background: The purpose of this study is to determine the interrater reliability of dynamic muscle tests in the early rehabilitation phase in women after breast cancer surgery with axillary lymph node dissection (ALND) based on the "preventive intervention against lymphedema after breast cancer" (LYCA) randomised controlled trial. Methods: Fifteen women treated with breast cancer surgery including ALND were recruited from participants in the LYCA trial. In this interrater reliability study, women were tested in 4 dynamic muscle tests by 2 physiotherapists at a Capital Hospital in Denmark. Intraclass correlation coefficients (ICCs) with 95% confidence intervals (CIs) was used to assess the relative reliability between raters. A Bland-Altman plot and limits of agreement were calculated to describe the absolute reliability. Results: All 6 subtests displayed high interrater reliability. ICC values were: leg press 0.96 (95% CI = 0.87-0.99), elbow flexion (contralateral) 0.94 (0.83-0.98), elbow flexion (affected arm) 0.93 (0.80-0.98), elbow extension 0.80 (0.41-0.93), shoulder abduction (contralateral) 0.89 (0.68-0.96), and shoulder abduction (affected arm) 0.91 (0.74-0.97). Cumulated interrater reliability for the test battery was very high (ICC = 0.99, 95% CI = 0.990-1.0). The absolute reliability of this study was considered high, and the absence of large shifts between mean and the line of 0 difference suggest no systematic bias that could influence clinical interpretation. Conclusions: The dynamic muscle tests evaluated in this study had high interrater reliability and can be used reliably in women in the postoperative phase after breast cancer surgery with ALND.

Current physical therapy care of patients undergoing breast reconstruction for breast cancer: a survey of practice in the United Kingdom and Brazil

BACKGROUND

In both the United Kingdom (UK) and Brazil, women undergoing mastectomy should be offered breast reconstruction. Patients may benefit from physical therapy to prevent and treat muscular deficits. However, there are uncertainties regarding which physical therapy program to recommend.

OBJECTIVE

The aim was to investigate the clinical practice of physical therapists for patients undergoing breast reconstruction for breast cancer. A secondary aim was to compare physical therapy practice between UK and Brazil.

METHODS

Online survey with physical therapists in both countries. We asked about physical therapists' clinical practice.

RESULTS

181 physical therapists completed the survey, the majority were from Brazil (77%). Respondents reported that only half of women having breast reconstruction were routinely referred to physical therapy postoperatively. Contact with patients varied widely between countries, the mean number of postoperative sessions was 5.7 in the UK and 15.1 in Brazil. The exercise programs were similar for different reconstruction operations. Therapists described a progressive loading structure over time: range of motion (ROM) was restricted to 90° of arm elevation in the first two postoperative weeks; by 2-4 weeks ROM was unrestricted; at 1-3 months muscle strengthening was initiated, and after three months the focus was on sports-specific activities.

CONCLUSION

Only half of patients having a breast reconstruction are routinely referred to physical therapy. Patients in Brazil have more intensive follow-up, with up to three times more face-to-face contact with a physical therapist than in the UK. Current practice broadly follows programs for mastectomy care rather than being specific to reconstruction surgery.

Safety, Precautions, and Modalities in Cancer Rehabilitation: an Updated Review

PURPOSE OF REVIEW

Providing rehabilitation to patients with cancer can be challenging due to the medical complexity associated with the illness and its treatments. This article provides the reader with a summary of frequently encountered medical conditions in the cancer population and associated safety considerations and precautions. An update on treatment modalities commonly used for symptom management is also presented.

RECENT FINDINGS

Cancer and cancer treatments can cause changes in multiple organ systems. Special considerations and precautions are necessary to provide safe and effective rehabilitation. Physical modalities can be used as monotherapy or adjunct to treatment for common cancer-related side effects with recent studies noting benefit with a variety of modalities.

SUMMARY

Detailed assessment of the cancer patient is necessary before implementing a rehabilitation program. Understanding cancer and side effects of treatments, including newer options, are necessary to provide safe care.

The impact of monitoring techniques on progression to chronic breast cancer-related lymphedema: a meta-analysis comparing bioimpedance spectroscopy versus circumferential measurements

BACKGROUND

Chronic breast cancer-related lymphedema (BCRL) is a potentially serious complication following treatment. Monitoring for progression to BCRL may allow for earlier detection and intervention, reducing the rate of progression to chronic BCRL. Therefore, the purpose of this meta-analysis is to evaluate the impact of monitoring techniques on the incidence of chronic BCRL among patients monitored by bioimpedance spectroscopy (BIS) and circumference as compared to background rates.

METHODS

Eligible peer-reviewed studies from PubMed, CINHAL, or Google Scholar that were published in English from 2013 onward and conducted in North America, Europe, or Oceania. Incidence rates abstracted from studies were classified by BCRL monitoring method: background (no standardized BIS or circumference assessments), BIS or circumference. A random-effects model was used to calculate a pooled annualized estimate of BCRL incidence while accounting for clinical and methodological heterogeneity. Subgroup analyses examined differences in duration of follow-up as well as breast and axillary surgery.

RESULTS

50 studies were included, representing over 67,000 women. The annualized incidence of BCRL was 4.9% (95% CI: 4.3-5.5) for background studies (n = 35), 1.5% (95% CI: 0.6-2.4) for BIS-monitored studies (n = 7), and 7.7% (95% CI: 5.6-9.8) for circumference-monitored studies (n = 11). The cumulative BCRL incidence rate in BIS-monitored patients was 3.1% as compared to 12.9% with background monitoring (69% reduction) and 17.0% with circumference-monitored patients (81% reduction).

CONCLUSIONS

Evidence suggests that monitoring with BIS allowing for early intervention significantly reduces the relative risk of chronic BCRL with a 69% and 81% reduction compared to background and circumference, respectively. Circumference monitoring did not appear to provide a benefit with respect to chronic BCRL incidence. Based on these results, BIS should be considered for BCRL screening in order to detect subclinical BCRL and reduce rates of chronic BCRL, particularly in high-risk patients.

Resistance Training in Breast Cancer Survivors: A Systematic Review of Exercise Programs

The aim of this study was to identify the characteristics of resistance training (RT) programs for breast cancer survivors (BCS). A systematic review of the literature was performed using PubMed, Medline, Science Direct, the Cochrane Breast Cancer Specialised Register of the Cochrane Library, the Physiotherapy Evidence Database (PEDro), and Scopus, with the aim of identifying all published studies on RT and BCS from 1 January 1990 to 6 December 2019, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The risk of bias in the studies was assessed using the revised Cochrane Risk of Bias tool (RoB 2.0). Sixteen trials were included for qualitative analysis. More than half of the trials do not adequately report the characteristics that make up the exercise program. The maximal strength was the most frequently monitored manifestation of strength, evaluated mainly as one-repetition maximum (1RM). Resistance training was performed on strength-training machines, twice a week, using a load between 50% and 80% of 1RM. The trials reported significant improvement in muscle strength, fatigue, pain, quality of life, and minor changes in aerobic capacity.

Prospective Surveillance and Risk Reduction of Cancer Treatment-Related Lymphedema: Systematic Review and Meta-Analysis

PROBLEM IDENTIFICATION

Secondary lymphedema is a chronic condition that may result from cancer-related treatments. Evidence is emerging on prospective surveillance and risk reduction.

LITERATURE SEARCH

Databases were systematically searched through April 1, 2019, for comparative studies evaluating interventions aiming to prevent lymphedema in patients with cancer.

DATA EVALUATION

A random-effects model was used to perform meta-analysis, when appropriate.

SYNTHESIS

A total of 26 studies (4,095 patients) were included, with 23 providing data sufficient for meta-analysis. Surveillance programs increased the likelihood of detecting lymphedema. Physiotherapy, exercise programs, and delayed exercise reduced the incidence of lymphedema.

IMPLICATIONS FOR RESEARCH

Future research should standardize (a) evidence-based interventions to reduce the development of lymphedema and increase the likelihood of early detection and (b) outcome measures to build a body of evidence that leads to practice change.

SUPPLEMENTAL MATERIAL CAN BE FOUND AT&NBSP;HTTPS

//onf.ons.org/supplementary-material-systematic-review-cancer-treatment-related-lymphedema.

Interventions for Breast Cancer-Related Lymphedema: Clinical Practice Guideline From the Academy of Oncologic Physical Therapy of APTA

A work group from the American Physical Therapy Association (APTA) Academy of Oncologic Physical Therapy developed a clinical practice guideline to aid clinicians in identifying interventions for people with breast cancer-related lymphedema, targeting volume reduction, beginning at breast cancer diagnosis and continuing through cancer treatments and survivorship. Following a systematic review of published studies and a structured appraisal process, recommendations were developed to guide physical therapists and other health care clinicians in their intervention selection. Overall, clinical practice recommendations were formulated based on the evidence for each intervention and were assigned a grade based on the strength of the evidence. The evidence for each specific intervention was synthesized and appraised by lymphedema stage, when the information was available. In an effort to make recommendations clinically applicable, they were presented by modality throughout the care trajectory. Methodology and research populations varied significantly across studies, and it will be important for future research to use standardized definitions for participant characteristics, diagnostic criteria, and interventions.

Resistance exercise and breast cancer-related lymphedema-a systematic review update and meta-analysis

BACKGROUND

The purpose of this systematic review update and meta-analysis was to analyze resistance exercise (RE) intervention trials in breast cancer survivors (BCS) regarding their effect on breast cancer-related lymphedema (BCRL) status and upper and lower extremity strength.

METHODS

Systematic literature search was conducted utilizing PubMed, MEDLINE, and Embase databases. Any exercise intervention studies-both randomized controlled and uncontrolled-which assessed the effects of RE on BCRL in BCS in at least one intervention group published between 1966 and 31st January 2020 were included. Included articles were analyzed regarding their level of evidence and their methodological quality using respective tools for randomized and nonrandomized trials of the Cochrane collaboration. Meta-analysis for bioimpedance spectroscopy (BIS) values as well as upper and lower extremity strength was conducted.

RESULTS

Altogether, 29 studies were included in the systematic review. Results of six studies with altogether twelve RE intervention groups could be pooled for meta-analysis of the BCRL. A significant reduction of BCRL after RE was seen in BIS values (95% CI - 1.10 [- 2.19, - 0.01] L-Dex score). Furthermore, strength results of six studies could be pooled and meta-analysis showed significant improvements of muscular strength in the upper and lower extremities (95% CI 8.96 [3.42, 14.51] kg and 95% CI 23.42 [11.95, 34.88] kg, respectively).

CONCLUSION

RE does not have a systematic negative effect on BCRL and, on the contrary, potentially decreases it.

Heavy-load resistance exercise during chemotherapy in physically inactive breast cancer survivors at risk for lymphedema: a randomized trial

Background: Due to long-standing concerns that heavy-load lifting could increase the risk of developing lymphedema, breast cancer survivors have been advised to refrain from resistance exercise with heavy loads. This study prospectively evaluated the effect of heavy-load resistance exercise on lymphedema development in women receiving chemotherapy for breast cancer.Material and Methods: Physically inactive women receiving adjuvant chemotherapy for breast cancer (n = 153) were randomized to a HIGH (supervised, multimodal exercise including heavy-load resistance exercise: 85-90% 1 repetition maximum [RM], three sets of 5-8 repetitions) versus LOW (pedometer and one-on-one consultations) 12-week intervention. Outcomes (baseline, 12 and 39 weeks) included lymphedema status (extracellular fluid [bioimpedance spectroscopy] and inter-arm volume % difference [dual-energy X-ray absorptiometry], lymphedema symptoms [numeric rating scale 0-10]), upper-extremity strength (1 RM), and quality of life domains (EORTC- BR23). Linear mixed models were used to evaluate equivalence between groups for lymphedema outcomes (equivalence margins for L-Dex, % difference and symptoms scale: ±5, ±3% and ±1, respectively). Superiority analysis was conducted for muscle strength and quality of life domains.Results: Postintervention equivalence between groups was found for extracellular fluid (0.4; 90% CI -2.5 to 3.2) and symptoms of heaviness (-0.2; -0.6 to 0.2), tightness (-0.1; -0.8 to 0.6) and swelling (0.2; -0.4 to 0.8). Nonequivalence was found for inter-arm volume % difference (-3.5%; -17.3 to 10.3) and pain (-0.7; -1.3 to 0), favoring HIGH. Strength gains were superior in the HIGH versus LOW group (3 kg; 1 to 5, p < .05). Further, clinically relevant reductions in breast (-11; -15 to -7) and arm (-6; -10 to -1) symptoms were found in the HIGH group.Conclusion: Findings suggest that physically inactive breast cancer survivors can benefit from supervised heavy-load resistance exercise during chemotherapy without increasing lymphedema risk. Trial registration: ISRCTN13816000.

Effect of progressive resistance training on persistent pain after axillary dissection in breast cancer: a randomized controlled trial

PURPOSE

Persistent pain is a known challenge among breast cancer survivors. In secondary analyses of a randomized controlled trial, we examined the effect of progressive resistance training on persistent pain in the post-operative year in women treated for breast cancer with axillary lymph node dissection.

METHODS

We randomized 158 women after BC surgery with Axillary Lymph Node Dissection (ALND) (1:1) to usual care or a 1-year, supervised and self-administered, progressive resistance training intervention initiated 3 weeks after surgery. A questionnaire at baseline, 20 weeks and 12 months assessed the intensity and frequency of pain, neuropathic pain and influence of pain on aspects of daily life. We analysed the effect using linear mixed models and multinomial logistic regression models for repeated measures.

RESULTS

A high percentage of participants experienced baseline pain (85% and 83% in the control and intervention groups respectively) and by the 12 month assessment these numbers were more than halved. A high proportion of participants also experienced neuropathic pain (88% and 89% in control and intervention group respectively), a finding that was stable throughout the study period. The effect on intensity of pain indicators favoured the exercise group, although most estimates did not reach statistical significance, with differences being small.

CONCLUSION

For women who had BC surgery with ALND, our progressive resistance training intervention conferred no benefit over usual care in reducing pain. Importantly, it did not increase the risk of pain both in the short and long term rehabilitative phase.