Effect of breast reconstruction modality on the development of postmastectomy shoulder morbidity

Factors affecting upper limb functional recovery after mastectomy with immediate breast reconstruction: a prospective study

BACKGROUND

Little is known about the differences in postoperative shoulder function following two common approaches for immediate breast reconstruction (IBR): abdominal-based breast reconstruction and implant-based breast reconstruction (ABR and IMBR). It was hypothesized that postoperative upper limb function would differ between the ABR and IMBR due to incomplete detachment of the pectoral muscles.

PURPOSE

This study aimed to investigate the factors for shoulder function recovery post-IBR and compare recovery outcomes between ABR and IMBR.

METHODS

This single-center prospective follow-up study included 60 patients who underwent IBR for 4 months postoperatively. Patients were invited to complete functional measurements 1 and 4 months postoperatively. The primary outcome was improvement in upper limb disability based on the Q-DASH score. Secondary outcomes were functional shoulder recovery markers: shoulder flexibility, strength, movement accuracy, scapular alignment, body schema accuracy, and neuropathic pain. Repeated-measures analyzes of variance and linear regression were performed.

RESULTS

Within-group differences were found for most variables (p < .05) except for neuropathic pain (p = .929). However, there was no overall main group effect (p > .05). Multivariate regression analysis established significant models for ABR and IMBR (R2 = 0.430, p = .002 and R2 = 0.442, p < .001, respectively). However, the variables included in the model showed between-group differences.

CONCLUSION

Postoperative shoulder function was comparable between the two IBR approaches. However, different factors were associated with improved upper limb disability between ABR and IMBR. Acute rehabilitation focused on resolving muscle tightness and pain may help mitigate upper limb disabilities following IBR.Trial registration number: KCT 0006501.

Postmastectomy Functional Impairments

PURPOSE OF REVIEW

This narrative review aims to offer a thorough summary of functional impairments commonly encountered by breast cancer survivors following mastectomy. Its objective is to discuss the factors influencing these impairments and explore diverse strategies for managing them.

RECENT FINDINGS

Postmastectomy functional impairments can be grouped into three categories: neuromuscular, musculoskeletal, and lymphovascular. Neuromuscular issues include postmastectomy pain syndrome (PMPS) and phantom breast syndrome (PBS). Musculoskeletal problems encompass myofascial pain syndrome and adhesive capsulitis. Lymphovascular dysfunctions include lymphedema and axillary web syndrome (AWS). Factors such as age, surgical techniques, and adjuvant therapies influence the development of these functional impairments. Managing functional impairments requires a comprehensive approach involving physical therapy, pharmacologic therapy, exercise, and surgical treatment when indicated. It is important to identify the risk factors associated with these conditions to tailor interventions accordingly. The impact of breast reconstruction on these impairments remains uncertain, with mixed results reported in the literature.

Risk factors for long-term arm morbidities following breast cancer treatments: A systematic review

PURPOSE

To examine the risk factors for arm morbidity following breast cancer treatments, taking a broad view of all types of physical morbidity, including prolonged pain, lymphedema, decreased range of motion, and functional limitations.

METHODS

A systematic literature review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. Studies exploring the risk factors for prolonged arm morbidity following breast cancer surgery and treatments were included. The studies were assessed independently according to pre-eligibility criteria, following data extraction and methodological quality assessment.

RESULTS

1,242 articles were identified. After removing duplicates, the full texts of 1,153 articles were examined. Sixty-nine of these articles met the criteria and were included in the review. These 69 articles identified 29 risk factors for arm morbidity following treatments for breast cancer. The risk of bias was evaluated using NIH study quality assessment tools. The studies reviewed were published between 2001 and 2021 and included a total of 22,886 patients who were followed up for between three months and 10 years.

CONCLUSIONS

The main risk factors for long-term morbidity are removal of lymph nodes from the axilla, body mass index >30, having undergone a mastectomy, the stage of the disease, radiation therapy, chemotherapy, infection and trauma to the affected arm after surgery. An understanding of the risk factors for prolonged arm morbidity after surgery can help doctors and therapists in making personalized decisions about the need and timing of rehabilitation treatments.

The Use of Wearable Activity Monitors to Measure Upper Limb Physical Activity After Axillary Lymph Node Dissection and Sentinel Lymph Node Biopsy

BACKGROUND

We suspect that morbidity from both sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND) has been inadequately evaluated to date. Current methodologies are subjective and susceptible to bias. Objective assessment using wearable activity monitors (WAMs) would allow quantitative analysis of recovery by measuring physical activity (PA) and could provide evidence for axillary de-escalation.

PATIENTS AND METHODS

A prospective, single center, observational study was conducted from February 2020 to May 2022. Consecutive patients undergoing breast and/or reconstructive surgery and axillary surgeries were identified from the operating schedules. Patients wore WAMs for an average of 3 days prior to surgery and up to 2 weeks following surgery. In total, 56 patients with breast cancer were recruited, of whom 35 underwent SLNB and 21 ALND.

RESULTS

Patients who underwent ALND experienced significantly worse PA compared with those who underwent SLNB in week 2 (median 66.4% versus 72.7%, p = 0.015). Subgroup analysis revealed significantly lower PA in simple mastectomy (Mx)-ALND versus Mx-SLNB (median 90.3% versus 70.5%, p = 0.015) in week 2. The PA for SLNB did not return to baseline at 2 weeks after surgery.

CONCLUSIONS

Compared with SLNB, ALND results in a lower PA level in week 2. The findings also indicate that SLNB has a protracted effect on PA levels, which extend to 2 weeks postoperatively. Monitoring recovery objectively following breast cancer surgery provides patients and surgeons with more information regarding the predicted outcomes of their surgery, which can drive the development of a personalized rehabilitation program.

Impact of Axillary Lymph Node Dissection and Sentinel Lymph Node Biopsy on Upper Limb Morbidity in Breast Cancer Patients: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the impact of axillary lymph node dissection (ALND) and sentinel lymph node biopsy (SLNB) on upper limb (UL) morbidity in breast cancer patients.

BACKGROUND

Axillary de-escalation is motivated by a desire to reduce harm of ALND. Understanding the impact of axillary surgery and disparities in operative procedures on postoperative arm morbidity would better direct resources to the point of need and cement the need for de-escalation strategies.

METHODS

Embase, MEDLINE, CINAHL, and PsychINFO were searched from 1990 until March 2020. Included studies were randomized-controlled and observational studies focusing on UL morbidities, in breast surgery patients. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The prevalence of UL morbidity comparing SLNB and ALND at <12 months, 12 to 24 months, and beyond 24 months were analyzed.

RESULTS

Sixty-seven studies were included. All studies reported a higher rate of lymphedema and pain after ALND compared with SLNB. The difference in lymphedema and pain prevalence between SLNB and ALND was 13.7% (95% confidence interval: 10.5-16.8, P <0.005) and 24.2% (95% confidence interval: 12.1-36.3, P <0.005), respectively. Pooled estimates for prevalence of reduced strength and range of motion after SLNB and ALND were 15.2% versus 30.9% and 17.1% versus 29.8%, respectively. Type of axillary surgery, greater body mass index, and radiotherapy were some of the predictors for UL morbidities.

CONCLUSIONS

Prevalence of lymphedema after ALND was higher than previously estimated. ALND patients experienced greater rates of lymphedema, pain, reduced strength, and range of motion compared with SLNB. The findings support the continued drive to de-escalate axillary surgery.

Implant-based versus Autologous Reconstruction after Mastectomy for Breast Cancer: A Systematic Review and Meta-analysis

For women undergoing breast reconstruction after mastectomy, the comparative benefits and harms of implant-based reconstruction (IBR) and autologous reconstruction (AR) are not well known. We performed a systematic review with meta-analysis of IBR versus AR after mastectomy for breast cancer.

Methods

We searched Medline, Embase, Cochrane CENTRAL, CINAHL, and ClinicalTrials.gov for studies from inception to March 23, 2021. We assessed the risk of bias of individual studies and strength of evidence (SoE) of our findings using standard methods.

Results

We screened 15,936 citations and included 40 studies (two randomized controlled trials and 38 adjusted nonrandomized comparative studies). Compared with patients who undergo IBR, those who undergo AR experience clinically significant better sexual well-being [summary adjusted mean difference (adjMD) 5.8, 95% CI 3.4-8.2; three studies] and satisfaction with breasts (summary adjMD 8.1, 95% CI 6.1-10.1; three studies) (moderate SoE for both outcomes). AR was associated with a greater risk of venous thromboembolism (moderate SoE), but IBR was associated with a greater risk of reconstructive failure (moderate SoE) and seroma (low SoE) in long-term follow-up (1.5-4 years). Other outcomes were comparable between groups, or the evidence was insufficient to merit conclusions.

Conclusions

Most evidence regarding IBR versus AR is of low or moderate SoE. AR is probably associated with better sexual well-being and satisfaction with breasts and lower risks of seroma and long-term reconstructive failure but a higher risk of thromboembolic events. New high-quality research is needed to address the important research gaps.

A comprehensive approach to risk factors for upper arm morbidities following breast cancer treatment: a prospective study

BACKGROUND

Breast cancer surgery frequently causes deficiencies in shoulder functioning. The study pourpode is to identify risk factors for prolonged pain, reduction in function, and decrease in range of motion (ROM) in BC patients.

METHODS

A prospective cohort study was designed in a private hospital; between October 2018 and April 2019 with a follow-up of 6 months. Patients following BC surgery, were divided by arm morbidities, and the different risk facrors were evaluated using univariate analysis and logistic regression.

RESULTS

A total of 157 patients were included in the study. Risk factors for functional disabilities included; pain levels during hospitalization NPRS 1.2 (±0.8) compared to patients with no disabilities 0.5 ± 0.7 (p = .006), the size of tumors more than 1.4 ± 0.8 cm. compared with no morbidities 0.8 ± 0.9 cm. (p = .046), and breast reconstructions (p = .030). Risk factors for prolonged pain includes mastectomy (p = .006), breast reconstruction (p = .011), more than three dissected lymph nodes (p = .002), the presence of preoperative pain (p < .001), in-hospital pain (p < .001), axillary web syndrome (p < .001) and lymphedema (p < .001). Risk factors for decreased ROM were more than three dissected lymph nodes (p = .027), radiation (p = .018), and the size of dissected tissue (p = .035). Postoperative physical therapy appears to reduce the incidence of prolonged pain (p = .013) and regular physical activity may reduce long term functional disabilities (p = .021).

CONCLUSIONS

Upper arm morbidity following BC treatments affect up to 70% of the patients. Identifying the different risk and beneficial factors may improve awareness among physicians to refer patients to early rehabilitation programs and thus avoid chronic morbidity and improve the course of recovery.

TRIAL REGISTRATION

The study was registered in Clinical trial with the ID number: NCT03389204 .

Patient Perspective on Post-Breast Reconstruction Exercise and Physical Therapy

Background

Breast reconstruction may result in significant functional compromise and pain. Postoperative exercise and physical therapy can mitigate these morbidities, but it is infrequently recommended by healthcare providers. This study asked how many breast reconstruction patients are instructed to perform postoperative at-home exercises or physical therapy, how many reported following through with these instructions, and what timeline they were given for these activities.

Methods

A 16-question multiple-choice anonymous online survey was distributed to a private breast cancer survivor Facebook group (Diep C. Foundation).

Results

A total of 150 breast reconstruction patients responded to our survey. The majority of respondents in our sample were not provided with specific instructions regarding postoperative at-home exercises (N = 70, 54.3%) or physical therapy (N = 77, 63.6%). Approximately 13 of 59 respondents (22%) who had been instructed to participate in postoperative at-home exercises were directed to begin at 2-3 weeks. Approximately 15 of 44 respondents (34.1%) who had been instructed to participate in physical therapy were directed to begin these at 4-5 weeks.

Conclusions

To the best of our knowledge, this is the first study of how often postoperative at-home exercises and physical therapy are recommended to breast reconstruction patients. Despite robust evidence of these activities' benefits, most women are not instructed to participate in postoperative at-home exercises or physical therapy. This is likely to impede breast reconstruction patients' recovery and delay their return to activities of daily living. More studies are needed of how to actively engage breast reconstruction patients in postoperative at-home exercises and physical therapy.

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.

Physical side-effects following breast reconstructive surgery impact physical activity and function

PURPOSE

To investigate the incidence and severity of physical side-effects experienced by women following breast reconstructive surgery and the effect of these side-effects on physical activity and function.

METHODS

Two hundred and thirty-one Australian women (55 years SD 6.5) who had previously had breast reconstruction surgery retrospectively self-reported the incidence and severity of eight physical side-effects and the perceived effect of these side effects on six physical functions, at three time points after their surgery. The frequency of the combined incidence/severity scores and their impact at the three time points were tabulated and compared using Chi-squared tests. A general linear regression was used to identify characteristics associated with moderate-very high (≥ 5/10) combined incidence/severity scores.

RESULTS

At 6 months following surgery, approximately 50% of respondents reported moderate to very high incidence/severity scores for physical side-effects across multiple body regions, which were perceived to limit their physical function and activity levels. The highest incidence/severity scores were associated with the following: (i) pre-existing physical problems before surgery, (ii) post-operative complications (seroma, infection, necrosis), and (iii) autologous rather than implant-based reconstructions.

CONCLUSION

A large percentage of women reported moderate to severe physical side-effects across multiple body regions following breast reconstructive surgery. These side-effects were perceived to negatively impact both physical function and activity. Early intervention, education and treatment are recommended to alleviate these issues and minimise their negative impact.