Teaching of Independent Exercises for Prehabilitation in Breast Cancer

Preoperative decreased physical activity is associated with greater postoperative pain: the mediating role of preoperative sleep disturbance

PURPOSE

Engagement in physical activity (PA) is often associated with better sleep quality and less pain severity among patients diagnosed with breast cancer. However, less research has focused on whether patients' PA prior to breast surgery, including their perceived decrease in PA level, is associated with worse preoperative sleep quality, and subsequently, greater postoperative pain. This longitudinal study investigated whether patients' preoperative PA was associated with their postoperative pain. We also explored whether preoperative sleep disturbance partially mediated the relationship between preoperative PA and postoperative pain.

METHODS

Prior to breast surgery, patients self-reported both their overall level of PA and whether they perceived a decrease in their PA since the diagnosis/onset of treatment for cancer. Patients also completed a measure of preoperative sleep disturbance. Two weeks after surgery, patients completed a measure of postoperative surgical-area pain severity.

RESULTS

Our results showed that preoperatively perceiving a decrease in PA level was significantly associated with greater preoperative sleep disturbance and postoperative pain. A mediation analysis revealed that the association between preoperative decreased PA and postoperative pain was partially mediated by preoperative sleep disturbance. Notably, patients' overall preoperative level of PA was not related to preoperative sleep disturbance or postoperative pain.

CONCLUSION

These findings suggest that maintaining, or even increasing, PA after diagnosis/treatment may be more important than the absolute amount of PA that women engage in during the preoperative period. Potentially, some patients with breast cancer may benefit from a preoperative intervention focused on both maintaining PA and bolstering sleep quality.

Method for Incomplete and Imbalanced Data Based on Multivariate Imputation by Chained Equations and Ensemble Learning

The classification analysis of incomplete and imbalanced data is still a challenging task since these issues could negatively impact the training of classifiers, which were also found in our study on the physical fitness assessments of patients. And in fields such as healthcare, there are higher requirements for the accuracy of the generated imputation values. To train a high-performance classifier and pursue high accuracy, we attempted to resolve any potential negative impact by using a novel algorithmic approach based on the combination of multivariate imputation by chained equations and the ensemble learning method (MICEEN), which can solve the two problems simultaneously. We used multivariate imputation by chained equations to generate more accurate imputation values for the training set passed to ensemble learning to build a predictor. On the other hand, missing values were introduced into minority classes and used them to generate new samples belonging to the minority classes in order to balance the distribution of classes. On real-world datasets, we perform extensive experiments to assess our method and compare it to other state-of-the-art approaches. The advantages of the proposed method are demonstrated by experimental results for the benchmark datasets and self-collected datasets of physical fitness assessment of tumor patients with varying missing rates.

Feasibility study of a multimodal prehabilitation programme in women receiving neoadjuvant therapy for breast cancer in a major cancer hospital: a protocol

INTRODUCTION

Neoadjuvant therapy has become a standard treatment for patients with stage II/III HER2 positive and triple negative breast cancer, and in well-selected patients with locally advanced and borderline resectable high risk, luminal B breast cancer. Side effects of neoadjuvant therapy, such as fatigue, cardiotoxicity, neurotoxicity, anxiety, insomnia, vasomotor symptoms, gastrointestinal disturbance as well as a raft of immune-related adverse events, may impact treatment tolerance, long-term outcomes, and quality of life. Providing early supportive care prior to surgery (typically termed 'prehabilitation') may mitigate these side effects and improve quality of life.During our codesign of the intervention, consumers and healthcare professionals expressed desire for a programme that 'packaged' care, was easy to access, and was embedded in their care pathway. We hypothesise that a multimodal supportive care programme including exercise and complementary therapies, underpinned by behavioural change theory will improve self-efficacy, quality of life, readiness for surgery and any additional treatment for women with breast cancer. We seek to explore cardiometabolic, residual cancer burden and surgical outcomes, along with chemotherapy completion (relative dose intensity). This article describes the protocol for a feasibility study of a multimodal prehabilitation programme.

METHODS AND ANALYSIS

This is a prospective, mixed-method, feasibility study of a multi-modal programme in a hospital setting for 20-30 women with breast cancer receiving neoadjuvant therapy. Primary outcomes are recruitment rate, retention rate, adherence and acceptability. Secondary outcomes include patient reported outcome measures (PROMs), surgical outcomes, length of stay, satisfaction with surgery, chemotherapy completion rates, changes in metabolic markers and adverse events. Interviews and focus groups to understand the experience with prehabilitation and different factors that may affect feasibility of the intervention . The output of this study will be a codesigned, evidence-informed intervention assessed for feasibility and acceptability by women with breast cancer and the healthcare professionals that care for them.

ETHICS AND DISSEMINATION

The study received ethics approval from the St Vincents Hospital HREC (HREC/2021/ETH12198). Trial results will be communicated to participants, healthcare professionals, and the public via publication and conferences.

TRIAL REGISTRATION NUMBER

ACTRN12622000584730.

Role of Prehabilitation and Rehabilitation on Functional Recovery and Quality of Life in Thyroid Cancer Patients: A Comprehensive Review

BACKGROUND

This narrative review aims to provide a comprehensive overview of the current prehabilitation and rehabilitation strategies for thyroid cancer survivors to optimize functional outcomes and enhance their quality of life.

METHODS

The review follows the SANRA quality criteria and includes an extensive literature search conducted in PubMed/Medline, Web of Science, and Scopus.

RESULTS

The review emphasizes the role of a comprehensive rehabilitation approach in targeting the different domains that generate disability in thyroid cancer patients. In this context, physical activity, range of motion exercises, myofascial release, joint mobilization, and postural exercises are crucial for improving functional outcomes and reducing treatment-related discomfort and disability. Moreover, tailored rehabilitative management addressing dysphonia and dysphagia might have a positive impact on the quality of life of these patients. Despite these considerations, several barriers still affect the implementation of a multimodal rehabilitative approach in common clinical practice. Thus, sustainable and effective strategies like digital innovation and patient-centered approaches are strongly needed in order to implement the rehabilitative treatment framework of these subjects.

CONCLUSIONS

This narrative review provides valuable insights into the current prehabilitation and rehabilitation strategies to treat thyroid cancer survivors, addressing physical, psychological, and vocational needs to optimize functional outcomes and enhance their quality of life.

Prehabilitation in Patients With Breast Cancer Receiving Neoadjuvant Therapy to Minimize Musculoskeletal Postoperative Complications and Enhance Recovery (PREOPtimize): A Protocol for a Randomized Controlled Trial

OBJECTIVE

The aim of this study is to assess the effects of a prehabilitation program (PREOPtimize), consisting of Nordic Walking and resistance training exercises plus health education among patients with breast cancer, who are receiving neoadjuvant therapy to enhance postoperative functionality of the affected arm. A secondary aim will be to compare the short-term effects of the intervention on other patient-reported outcome measures.

METHODS

This will be an assessor-blind, randomized controlled trial with a parallel group design conducted at a tertiary hospital. A sample of 64 patients with breast cancer scheduled for surgery and undergoing neoadjuvant chemotherapy will be recruited for the trial and randomly allocated to either (1) a prehabilitation program consisting of 2 weekly sessions of 75 minutes of Nordic Walking, muscle strengthening exercises, and health education sessions conducted between the fourth month of treatment and surgery or (2) usual care. Patients in both groups will be assessed at baseline, before surgery, and at 1 and 3 months after surgery. Assessed outcomes include functionality of the affected arm (QuickDash), arm volume, range of motion, handgrip strength, pain, fatigue, functional capacity, physical activity levels, and health-related quality of life. Adherence to the intervention in the prehabilitation group and adverse events will also be recorded.

IMPACT

Prehabilitation for patients affected by breast cancer is rarely implemented in clinical practice. The results obtained with the PREOPtimize trial could show that prehabilitation is a feasible intervention for patients with breast cancer receiving neoadjuvant therapy that might enhance postoperative recovery of upper arm function as well as improve overall physical performance and health-related quality of life.

A systematic review of multimodal prehabilitation in breast cancer

PURPOSE

Breast cancer is the most prevalent malignancy in women. Prehabilitation may offer improvements in physical and psychological wellbeing among participants prior to treatment. This systematic review aimed to determine the efficacy of prehabilitation in participants diagnosed with breast cancer.

METHODS

A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. Studies exploring the impact of prehabilitation in participants with breast cancer were included. Studies were assessed independently according to pre-eligibility criteria, with data extraction and methodological quality assessed in parallel.

RESULTS

3184 records were identified according to our search criteria, and 14 articles were included. Articles comprised of quantitative randomised controlled trials (n = 7), quantitative non-randomised studies (n = 5), a qualitative study (n = 1), and a mixed-method study (n = 1). The majority of selected studies completed exercise programs (n = 4) or had exercise components (n = 2), with two focusing on upper-limb exercise. Five articles reported complementary and alternative therapies (n = 5). Two articles reported smoking cessation (n = 2), with a single study reporting multi-modal prehabilitation (n = 1). Mostly, prehabilitation improved outcomes including physical function, quality of life, and psychosocial variables (P < 0.05). The qualitative data identified preferences for multimodal prehabilitation, compared to unimodal with  an interest in receiving support for longer.

CONCLUSIONS

Prehabilitation for patients with breast cancer is an emerging research area that appears to improve outcomes, however, ensuring that adequate intervention timeframes, follow-up, and population groups should be considered for future investigations.

IMPLICATIONS FOR CANCER SURVIVORS

The implementation of prehabilitation interventions for individuals diagnosed with breast cancer should be utilised by multidisciplinary teams to provide holistic care to patients as it has the potential to improve outcomes across the cancer care trajectory.

Standardization of upper limb exercises to improve radiation therapy for breast cancer, a conceptual literature review

INTRODUCTION

Many patients with breast cancer are left with upper arm mobility dysfunction following surgery. Despite the beneficial effects of upper limb exercises on shoulder dysfunction, radiation therapists still do not widely encourage patients to participate in arm exercises after surgery. This conceptual literature review synthesizes evidence on how patients with breast cancer that participate in upper limb exercises after surgery have improved arm mobility which could result in a more consistent arm position during radiation therapy.

METHODS

A literature search was performed in the PubMed, Athabasca University Library, and Google Scholar databases to identify articles that evaluated the effect of upper limb exercises on patients' arm mobility and range of motion after breast cancer surgery, and the impact of arm position on anatomy during radiation therapy. Sixteen studies were included in the conceptual review synthesis.

RESULTS

The studies were heterogeneous in terms of the utilized exercise methods and the upper limb related outcomes measured. Twelve studies demonstrated that upper arm exercises are an effective intervention in restoring arm mobility and decreasing pain in women with breast cancer. Additionally, four studies showed that differences in arm rotation affect the breast region's anatomy, which could result in set-up errors during radiation therapy.

CONCLUSION

The effectiveness of radiation therapy for breast cancer treatment relies on women to reproduce their shoulder position each day. Any inability to replicate the arm position due to mobility issues can affect the accuracy of the dose delivered and, ultimately, the treatment outcome. Therefore, upper limb exercises should be recommended by radiation therapists to their patients before or during radiation therapy to improve patient comfort and the accuracy of treatment. Additionally, upper limb exercise standards need to be developed for patients with breast cancer and implemented by radiation therapists.

Effects of preoperative personal education on shoulder function and lymphedema in patients with breast cancer: A consort

BACKGROUND

To compare the incidence and severity of ipsilateral shoulder dysfunction and lymphedema of 2 groups of patients needing to undergo unilateral breast cancer surgery, one of which had only received printed education materials and the other group which had received educational materials plus preoperative education.

METHODS

We selected 61 patients who had been diagnosed with unilateral breast cancer and planned to undergo surgery. Before surgery, patients were randomly assigned, either to a control group that only received printed education materials about exercise for shoulder pain relief and lymphatic edema prevention following breast cancer surgery, or to an experimental group that received the printed education material with personal education. Participants were evaluated at 1, 3, 6, and 12 months after the surgery. To evaluate the impairment of shoulder function, we measured the passive shoulder range of motion (ROM), the degree of pain as visual analog scale (VAS), the short version of the disability of arm, shoulder, and hand (short DASH) scores, and the shoulder pain and disability index (SPADI). We checked arm circumferences to evaluate lymphedema.

RESULTS

There was no significant difference in demographic or clinical variables between the control and experimental groups. The experimental group showed significantly less limitation in abduction (P = .042) and forward flexion (P = .039) in the 6 months following surgery. Change in the VAS, short DASH, and SPADI scores were 1.633 (P < .001), 2.167 (P < .001), and 4.1 (P = .003) at 1 month following surgery, respectively. These then decreased with time. These changes started before shoulder ROM and arm circumference changes had occurred, which had started 3 months following surgery.

CONCLUSIONS

Preoperative education might be helpful for the prevention of a shoulder ROM limitation, and we need to focus on pain and disability in patients immediately following breast cancer surgery, and then on ROM and lymphedema.

The effect of nonsupervised physical activity before and after breast cancer surgery on quality of life: Results from a randomized controlled trial (PhysSURG-B)

Background and objective:

The PhysSURG-B trial of prehabilitation before breast cancer surgery randomized patients to a nonsupervised physical activity or a control group. The effects of the intervention on short- and long-term quality of life (QoL) were examined, with a subgroup analysis of patients receiving adjuvant chemotherapy.

Methods:

Female patients planned for surgery were randomly assigned to either an intervention of 30 min of self-administered physical aerobic activity daily 2 weeks before and 4 weeks after surgery or control. QoL was assessed with questionnaires at baseline, 4 weeks and 12 months postoperatively using the instruments FACT-B, RAND-36, and EQ-VAS.

Results:

Of 354 included participants at 12 months after surgery, 287 were available for analysis. FACT- B scores at 4 weeks and 12 months showed no differences between intervention compared to control, odds ratio (OR) of 0.975 (95% confidence interval (CI) 0.636–1.495) and 0.883 (95% CI 0.581–1.342), respectively. There was no difference in EQ-VAS comparing intervention to control at 4 weeks and 12 months, respectively, OR 1.163 (95% CI 0.760–1.779) and 0.817 (95% CI 0.559–1.300). RAND-36 domains “role limitations due to physical health” and “pain” showed a decrease at 4 weeks in both groups, returning toward baseline at 12 months follow-up. The subgroup who received adjuvant chemotherapy had significantly lower QoL measured using FACT-B at 12 months compared to patients not receiving chemotherapy (OR 0.475; 95% CI 0.300–0.753).

Conclusions:

An intervention of non-supervised physical activity before and after surgery for breast cancer showed no effect on short or long-term QoL, compared to control.

Trial registration:

ClinicalTrials.gov registration number: NCT 02560662.

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.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01927-3.

The Impact of Therapeutic Exercises on the Quality of Life and Shoulder Range of Motion in Women After a Mastectomy, an RCT

Breast cancer ranks highest in incidence and mortality among females and second among both genders. Lebanon has the second highest rate of breast cancer worldwide for those 35-39 years old and the highest for those 40-49. Mastectomy often results in deceased shoulder and arm mobility and decreased quality of life. The objective of this study was to assess the effect of an educational program of therapeutic exercises on the quality of life and functional ability in women after a mastectomy. Sixty women undergoing a mastectomy were randomly assigned to either an intervention or control group. The intervention group received extensive pre-surgery education as well as training on therapeutic exercises. Follow-up phone calls to the intervention group were made to ensure that the exercises were being done. Both groups were visited at home at two and four weeks to obtain the outcome variables. The Breast Cancer Patient Version was used to assess quality of life, and the "Goniometer" was used to assess the range of motion of the affected shoulder. At two and four weeks after surgery, women in the intervention group had significant improvements in their shoulder range of motion: flexion, extension, and abduction were significantly different between the control and intervention group at p = 0.04-0.00. For quality of life, physical, psychological, psychological, social, and spiritual well-being were significantly higher for the intervention group at both two and four weeks after surgery, p < 0.001. In a middle-income country, one-to-one education provided by a nurse, which included demonstrations, back demonstrations, and weekly phone calls had a positive impact on women's shoulder range of motion and quality of life. NCT04184102.

State of Rehabilitation Research in the Head and Neck Cancer Population: Functional Impact vs. Impairment-Focused Outcomes

PURPOSE OF REVIEW

Management of head and neck cancer (HNC) typically involves a morbid combination of surgery, radiation, and systemic therapy. As the number of HNC survivors grows, there is growing interest in rehabilitation strategies to manage HNC-related comorbidity. In this review, we summarize the current state of HNC rehabilitation research.

RECENT FINDINGS

We have organized our review using the World Health Organization's International Classification of Function (ICF) model of impairment, activity, and participation. Specifically, we describe the current research on rehabilitation strategies to prevent and treat impairments including dysphagia, xerostomia, dysgeusia, dysosmia, odynophagia, trismus, first bite syndrome, dysarthria, dysphonia, lymphedema, shoulder syndrome, cervicalgia, cervical dystonia and dropped head syndrome, deconditioning, and fatigue. We also discuss the broader impact of HNC-related impairment by exploring the state of rehabilitation literature on activity, participation, psychosocial distress, and suicidality in HNC survivors. We demonstrate that research in HNC rehabilitation continues to focus primarily on impairment-driven interventions. There remains a dearth of HNC rehabilitation studies directly examining the impact of rehabilitation interventions on outcomes related to activity and participation. More high-quality interventional studies and reviews are needed to guide prevention and treatment of functional loss in HNC survivors.

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.

Translating 2019 ACSM Cancer Exercise Recommendations for a Physiatric Practice: Derived Recommendations from an International Expert Panel

In 2018, the American College of Sports Medicine (ACSM) reconvened an international, multi-disciplinary group of professionals to review pertinent published literature on exercise for people with cancer. The 2018 roundtable resulted in the publication of three articles in 2019. The three articles serve as an important update to the original ACSM Roundtable on Cancer, which convened in 2010. Although the focus of the three 2019 articles is on exercise, which is only one part of comprehensive cancer rehabilitation, the evidence presented in the 2019 ACSM articles has direct implications for physiatrists and other rehabilitation professionals who care for people with cancer. As such, the narrative review presented here has two primary objectives. First, we summarize the evidence within the three ACSM articles and interpret it within a familiar rehabilitation framework, namely the Dietz model of Cancer Rehabilitation, in order to facilitate implementation broadly within rehabilitation practice. Second, via expert consensus, we have tabulated relevant exercise recommendations for specific cancer populations at different points in the cancer care continuum and translated them into text, tables, and figures for ease of reference. Notably, the authors of this article are members of the Cancer Rehabilitation Physician Consortium (CRPC), a group of physicians who subspecialize in cancer rehabilitation medicine (CRM).

Multimedia in preoperative patient education for adults undergoing cancer surgery: A systematic review

PURPOSE

The purpose of this systematic review was to determine whether adequate research evidence exists to support utilizing multimedia technology in the preoperative education of adult cancer patients.

METHODS

A systematic search of Medline, CINAHL, Web of Science, and PsycINFO databases from 2010 through September 24, 2020, was performed. The review included quantitative studies that examined whether education delivered by multimedia impacted levels of anxiety, knowledge acquisition, satisfaction, and compliance. The research quality was evaluated using the Joanna Briggs Institute Critical Appraisal Tool specific to the study design.

RESULTS

The database search identified 529 scientific articles, of these nine studies met the eligibility criteria (n = 5 randomized controlled trials; n = 4 quasi-experimental studies). The education interventions included a variety of researcher-developed, multimedia modalities, consisting of video (n = 7), a computer program (n = 1), and a tablet application (n = 1). The methodological rigor varied among these studies. Multimedia patient education resulted in decreased anxiety and improved knowledge acquisition within groups; however, there was no significant difference when compared to traditional methods. Patients were also similarly satisfied and compliant with both education methods.

CONCLUSIONS

In all studies, the healthcare provider played a prominent role in both multimedia and traditional interventions, revealing the strong influence of the interpersonal connection in the delivery of preoperative education. Future research is needed to investigate whether more interactive technology could improve patient outcomes.

Effect of physical activity levels on oncological breast surgery recovery: a prospective cohort study

After breast cancer (BC) surgery, women may experience a physical decline. The effect of physical activity (PA) on the course of recovery after BC surgery has not yet been thoroughly examined. To analyze the impact of physical activity performed by women undergoing breast cancer surgery on measures of function, range of motion, and self-efficacy. A prospective study was carried out in 157 patients who underwent surgery for BC between October 2018 and April 2019, divided into four groups according to the intensity of PA with 6 months follow-up. 50 sedentary patients and 107 active patients were enrolled; the mean age was 52.6. Women who performed physical activity, moderate to vigorous, demonstrated lower function disabilities (QuickDASH 2.22) compared with inactivity or light physical activity (QuickDASH 7.0, p < 0.001), with better shoulder flexion (159.0° vs. 150.7°, p = 0.007) and abduction (159.5° vs. 152.2°, p = 0.008). Higher PA levels, displayed in higher self-efficacy reports (9.5 vs. 8.8, p = 0.002), and return to prior job status (0.005). The PA level does not influence pain at one, three and 6 months postoperatively (p = 0.278, p = 0.304 and p = 0.304 respectively). High PA levels increase the risk of axillary web syndrome (p = 0.041), although, it reduces the incidence of chronic pain (p = 0.007). Women who practice physical activity recover better from BC surgery than sedentary women. The higher the intensity and frequency of training, the better the results. Vigorous activity cause axillary web syndrome, despite, it has a beneficial effect on lowering the rate of chronic pain.

Prehabilitation is the Gateway to Better Functional Outcomes for Individuals with Cancer

Prehabilitation is a clinical model that introduces components of rehabilitation to patients prior to undergoing intensive medical interventions, such as surgery, in order to optimize function and improve tolerability to the intervention. Cancer care introduces a continuum of sequential or concurrent intensive anti-neoplastic medical interventions that are known to be detrimental to a patient's function. Prehabilitation evidence has grown across several areas of oncology care delivery demonstrating that a multi-modal rehabilitative intervention, delivered prior to oncology-direct therapies, leads to better functional outcomes and improves important endpoints associated with surgery and cancer treatment. This commentary article provides a brief history of the emergence of prehabilitation in cancer care delivery, reviews the current evidence base and guidelines for prehabilitation, and offers insights for future implementation of this model as a standard in oncology care. A prehabilitation program is an optimal starting point for most patients undergoing anti-neoplastic therapy as it serves as a gateway to improving functional outcomes throughout the cancer continuum. Future research in prehabilitation should aim to reach beyond measuring functional outcomes and to explore the impact of this model on important disease treatment endpoints such as tumor response to oncology-directed treatment, impact on treatment-related toxicities, and disease progression.

Feasibility of Prehabilitation Prior to Breast Cancer Surgery: A Mixed-Methods Study

Background

Breast cancer surgery results in numerous acute and long-term adverse outcomes; the degree to which these can be mitigated or prevented through prehabilitation is unknown.

Methods

We conducted a longitudinal, single-arm, mixed-methods study to examine the feasibility of prehabilitation in 22 women undergoing breast cancer surgery. All participants received an individualized exercise prescription including upper quadrant-specific resistance and mobility training and aerobic exercise for the duration of their surgical wait time. Feasibility was assessed by recruitment, adherence, attrition, and intervention-related adverse event rates. An exploratory investigation of intervention efficacy was conducted via a 6-min walk test, upper-quadrant strength and range of motion, volumetric chances associated with lymphedema, and participant-reported quality of life, fatigue, pain, and disability. Outcome assessments were conducted at baseline, prior to surgery, and at six and 12 weeks after surgery. Semi-structured interviews with a subset of participants (n = 5) and health-care providers (H; n = 2) were conducted to provide further insights about intervention feasibility. Qualitative data were analyzed using a hybrid inductive and deductive thematic analysis approach.

Results

Recruitment and attrition rates were 62 and 36%, respectively. Average prehabilitation duration was 31 days (range = 7–69 days). Seventy six percent of participants complied with at least 70% of their prehabilitation prescription. There was a clinically significant increase in the 6-min walk distance from baseline to the preoperative assessment (57 m, 95% CI = −7.52, 121.7). The interviews revealed that the intervention was favorably received by participants and HCPs and included suggestions that prehabilitation (i) should be offered to all surgical candidates, (ii) is an avenue to regain control in the preoperative period, (iii) is a facilitator of postoperative recovery, and (iv) is an opportunity to provide education regarding postoperative rehabilitation protocols. A preference for multimodal prehabilitation (including dietetic and psychological counseling) was also highlighted.

Conclusion

Our findings suggest that surgical prehabilitation in women with breast cancer is feasible. Data are hampered by study sample size and lack of a control group. Thus, randomized controlled trials to examine prehabilitation efficacy in people with breast cancer, especially interventions employing a multimodal strategy, are warranted.

Pain Management in Breast Surgery: Recommendations of a Multidisciplinary Expert Panel-The American Society of Breast Surgeons

Opioid overdose accounted for more than 47,000 deaths in the United States in 2018. The risk of new persistent opioid use following breast cancer surgery is significant, with up to 10% of patients continuing to fill opioid prescriptions one year after surgery. Over prescription of opioids is far too common. A recent study suggested that up to 80% of patients receiving a prescription for opioids post-operatively do not need them (either do not fill the prescription or do not use the medication). In order to address this important issue, The American Society of Breast Surgeons empaneled an inter-disciplinary committee to develop a consensus statement on pain control for patients undergoing breast surgery. Representatives were nominated by the American College of Surgeons, the Society of Surgical Oncology, The American Society of Plastic Surgeons, and The American Society of Anesthesiologists. A broad literature review followed by a more focused review was performed by the inter-disciplinary panel which was comprised of 14 experts in the fields of breast surgery, anesthesiology, plastic surgery, rehabilitation medicine, and addiction medicine. Through a process of multiple revisions, a consensus was developed, resulting in the outline for decreased opioid use in patients undergoing breast surgery presented in this manuscript. The final document was reviewed and approved by the Board of Directors of the American Society of Breast Surgeons.

The influence of mastectomy and reconstruction on residual upper limb function in breast cancer survivors

PURPOSE

Breast cancer survivorship is common (90% of women survive 5 or more years), but many women are not able to return to full function and well-being after treatment due to functional limitations, persistent pain, and inability to perform daily activities. Since each surgical reconstructive option (e.g., autologous tissue flaps versus implants) can impact shoulder and arm function differently, it is important to understand how shoulder and upper limb strength, mobility, and function are influenced by the type of surgical intervention. Efforts can then focus on prehabiliation strategies to prevent the onset of limitations and on developing rehabilitation protocols that directly target shortcomings.

METHODS

The current paper presents a review summarizing how shoulder and upper limb function may be affected by surgical mastectomy and breast reconstruction.

RESULTS

Mastectomy and breast reconstruction with implants or autologous tissues present different functional outcomes for patients. Each surgical procedure is associated with unique sequelae derived from the tissues and procedures associated with each surgery. Characterizing the specific functional outcomes associated with each surgical approach will promote the development of targeted rehabilitation strategies that can be implemented into a multidisciplinary treatment planning pathway for breast cancer patients.

CONCLUSIONS

Surgical treatments for breast cancer, including mastectomy and breast reconstruction, can have negative effects. Focused efforts are needed to better understand treatment-specific effects so that targeted rehabilitation can be developed to improve patient function, QoL, and ability to return to work and life activities post-breast cancer.

The Role and Scope of Prehabilitation in Cancer Care

OBJECTIVES

To recognize cancer prehabilitation as a pretreatment regimen to increase functional status for patients requiring cancer treatment. This article presents current evidence addressing the efficacy and benefits of prehabilitation regimens in different cancer survivor populations.

DATA SOURCES

Studies and case reports in the PubMed database.

CONCLUSION

Cancer prehabilitation may improve outcomes. Prehabilitation may include targeted or whole-body exercise, nutrition, education, psychologic counseling, and smoking cessation. Opportunities exist to further improve access to and delivery of multimodal prehabilitation, and nurses play a critical role in connecting patients to these services.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses who are knowledgeable of cancer treatment-related effects are poised to assess survivors for existing impairments, advocate for prehabilitation for existing and potential morbidities, and monitor functional status over time. As patient educators, they are key to informing cancer survivors about the role of prehabilitation.

Prehabilitation for adults diagnosed with cancer: A systematic review of long-term physical function, nutrition and patient-reported outcomes

OBJECTIVE

Prehabilitation is increasingly being used to mitigate treatment-related complications and enhance recovery. An individual's state of health at diagnosis, including obesity, physical fitness and comorbidities, are influencing factors for the occurrence of adverse effects. This review explores whether prehabilitation works in improving health outcomes at or beyond the initial 30 days post-treatment and considers the utility of prehabilitation before cancer treatment.

METHODS

A database search was conducted for articles published with prehabilitation as a pre-cancer treatment intervention between 2009 and 2017. Studies with no 30 days post-treatment data were excluded. Outcomes post-prehabilitation were extracted for physical function, nutrition and patient-reported outcomes.

RESULTS

Sixteen randomised controlled trials with a combined 2017 participants and six observational studies with 289 participants were included. Prehabilitation interventions provided multi-modality components including exercise, nutrition and psychoeducational aspects. Prehabilitation improved gait, cardiopulmonary function, urinary continence, lung function and mood 30 days post-treatment but was not consistent across studies.

CONCLUSION

When combined with rehabilitation, greater benefits were seen in 30-day gait and physical functioning compared to prehabilitation alone. Large-scale randomised studies are required to translate what is already known from feasibility studies to improve overall health and increase long-term cancer patient outcomes.

The effect of preoperative exercise on upper extremity recovery following breast cancer surgery: a systematic review

Prehabilitation benefits among patients undergoing various oncological surgeries have been demonstrated. However, the effects of presurgical exercise and fitness on postoperative ipsilateral upper extremity recovery outcomes in patients with breast cancer surgery are less evident. A systematic review was performed to assess the effects of preoperative exercise and fitness on postmastectomy recovery. Systematic literature search was performed in 12 electronic databases. Study eligibility was accessed using the PICOS (Participants, Interventions, Comparison, Outcome and Study Design) criteria. Six eligible studies were found: three cohort-control and three prospective observational studies. One randomized-controlled trial showed that prehabilitation was beneficial in shoulder range of motion (ROM) and upper extremity functional recovery. One cohort-control study demonstrated that preoperative exercises reduced postoperative pain without increasing the risk of developing a seroma. A prospective cohort study showed that preoperatively active individuals had a significantly better chance of feeling recovered physically at 3 weeks after surgery. Baseline ipsilateral grip strength, shoulder flexion, and abduction ROM were reliable predictors of shoulder flexion and abduction ROM and grip strength improvements at 1 month following breast cancer surgery. One study showed that preoperative conditioning alone without postoperative rehabilitation was insufficient to aid recovery. Implementing exercise program and optimizing preoperative fitness, especially shoulder ROM, before breast cancer surgery in conjunction with individualized rehabilitation program may benefit postmastectomy ipsilateral upper extremity recovery.

A Multidisciplinary Preoperative Teaching Session for Women Awaiting Breast Cancer Surgery: A Quality Improvement Initiative

Purpose:

Most of the breast cancer diagnoses are recommended for breast surgery. Unfortunately, many patients report preoperative anxiety, which can affect postoperative recovery. Preoperative teaching sessions have been shown to reduce anxiety and improve recovery for the patients with breast cancer. To better support the patients at our cancer center, a multidisciplinary preoperative teaching session was developed and delivered as a quality improvement initiative.

Methods:

Participants scheduled for breast surgery were invited to attend a group-delivered preoperative teaching session, either for breast-conserving surgery or mastectomy. The sessions were presented by a nurse, occupational therapist, and physiotherapist. Data were collected through a researcher-developed 2-item questionnaire administered before and after sessions to compare self-reported anxiety and knowledge levels, along with qualitative feedback.

Results:

A total of 94 participants attended the preoperative sessions, piloted over a year. The majority were scheduled for breast-conserving surgery. Wilcoxon signed rank tests showed that after session, self-reported levels of anxiety decreased, whereas levels of knowledge increased. Most participants found the session to be very helpful and would recommend it to other patients/families awaiting surgery.

Conclusions:

Patients awaiting surgery for breast cancer may be better supported through a multidisciplinary group teaching session by decreasing anxiety and improving knowledge related to the procedure. Future directions could explore the effect of specific session elements on anxiety, knowledge, and postoperative complications using psychometrically sound instruments and additional time points.

Implications for cancer survivors:

Standardization of these preoperative teaching sessions may enhance breast cancer care, reduce postoperative complications, and improve patient recovery.

The Case for Prehabilitation Prior to Breast Cancer Treatment

Cancer rehabilitation in breast cancer survivors is well established, and there are many studies that focus on interventions to treat impairments as well as therapeutic exercise. However, very little is known about the role of prehabilitation for people with breast cancer. In this narrative review, we describe contemporary clinical management of breast cancer and associated treatment-related morbidity and mortality considerations. Knowing the common short- and long-term sequelae, as well as less frequent but serious sequelae, informs our rationale for multimodal breast cancer prehabilitation. We suggest 5 core components that may help to mitigate short- and long-term sequelae that align with consensus opinion of prehabilitation experts: total body exercise; locoregional exercise pertinent to treatment-related deficits; nutritional optimization; stress reduction/psychosocial support; and smoking cessation. In each of these categories, we review the literature and discuss how they may affect outcomes for women with breast cancer.