Oncology Section Task Force on Breast Cancer Outcomes: Clinical Measures of Upper Extremity Function:

Community-based outpatient rehabilitation for the treatment of breast cancer-related upper extremity disability: an evaluation of practice-based evidence

PURPOSE

To evaluate the impact and acceptability of outpatient physical or occupational therapy (PT/OT) for breast cancer survivors (BCS) with varying levels of upper extremity disability (UED).

METHODS

We retrospectively extracted patient and therapy characteristics, UED measured by quick-disabilities of the arm, shoulder and hand (QuickDASH, 0-100 pts.), and patient-rated acceptability (1-item, 0-10 pts) from rehabilitation charts of BCS who completed cancer-specialized PT/OT provided by a single national institution in 2019. We summarized characteristics and acceptability using descriptive statistics, then used established parameters to group BCS by baseline UED severity: high- (QuickDASH > 31.5), moderate- (QuickDASH = 18.5-31.5), or low-UED (QuickDASH = 13-18.5). To evaluate within-group pre-to-post QuickDASH change, we used paired samples t test (p < 0.01), then calculated the proportion who achieved the minimally clinical important difference (MCID, 15.9 points). To compare between-groups difference in QuickDASH improvement, we used Kruskal-Wallis test and Chi-squared test.

RESULTS

Patients (N = 417) were 59.89 ± 12.06 years old, 99% female, and attended approximately 10 PT/OT sessions (IQR = 6.0-16.0). Most had high baseline UED (62%), followed by moderate (25%) or low UED (13%). For each severity group, mean pre-to-post change in QuickDASH was significant: high-UED (M∆ = 25.13 ± 20.33, d = 1.24, p < 0.01), moderate-UED (M∆ = 11.36 ± 11.9, d = 0.95, p < 0.01), and low-UED (M∆ = 4.84 ± 9.15, d = 0.53, p < 0.01). Most with high UED achieved the MCID (n = 176, 68.2%). In the moderate- and low-UED groups 44% (n = 46) and 4% (n = 2) achieved the MCID, respectively. Acceptability was high (n = 167, Median = 10).

CONCLUSION

Outpatient cancer rehabilitation is associated with significant improvement in UED for BCS and was acceptable to patients regardless of UED severity at baseline.

Exercise versus usual care after non-reconstructive breast cancer surgery (UK PROSPER): multicentre randomised controlled trial and economic evaluation

OBJECTIVE

To evaluate whether a structured exercise programme improved functional and health related quality of life outcomes compared with usual care for women at high risk of upper limb disability after breast cancer surgery.

DESIGN

Multicentre, pragmatic, superiority, randomised controlled trial with economic evaluation.

SETTING

17 UK National Health Service cancer centres.

PARTICIPANTS

392 women undergoing breast cancer surgery, at risk of postoperative upper limb morbidity, randomised (1:1) to usual care with structured exercise (n=196) or usual care alone (n=196).

INTERVENTIONS

Usual care (information leaflets) only or usual care plus a physiotherapy led exercise programme, incorporating stretching, strengthening, physical activity, and behavioural change techniques to support adherence to exercise, introduced at 7-10 days postoperatively, with two further appointments at one and three months.

MAIN OUTCOME MEASURES

Disability of Arm, Hand and Shoulder (DASH) questionnaire at 12 months, analysed by intention to treat. Secondary outcomes included DASH subscales, pain, complications, health related quality of life, and resource use, from a health and personal social services perspective.

RESULTS

Between 26 January 2016 and 31 July 2017, 951 patients were screened and 392 (mean age 58.1 years) were randomly allocated, with 382 (97%) eligible for intention to treat analysis. 181 (95%) of 191 participants allocated to exercise attended at least one appointment. Upper limb function improved after exercise compared with usual care (mean DASH 16.3 (SD 17.6) for exercise (n=132); 23.7 (22.9) usual care (n=138); adjusted mean difference 7.81, 95% confidence interval 3.17 to 12.44; P=0.001). Secondary outcomes favoured exercise over usual care, with lower pain intensity at 12 months (adjusted mean difference on numerical rating scale -0.68, -1.23 to -0.12; P=0.02) and fewer arm disability symptoms at 12 months (adjusted mean difference on Functional Assessment of Cancer Therapy-Breast+4 (FACT-B+4) -2.02, -3.11 to -0.93; P=0.001). No increase in complications, lymphoedema, or adverse events was noted in participants allocated to exercise. Exercise accrued lower costs per patient (on average -£387 (€457; $533) (95% confidence interval -£2491 to £1718; 2015 pricing) and was cost effective compared with usual care.

CONCLUSIONS

The PROSPER exercise programme was clinically effective and cost effective and reduced upper limb disability one year after breast cancer treatment in patients at risk of treatment related postoperative complications.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN35358984.

Low-Intensity Resistance Training and Compression Garment in the Management of Breast Cancer-Related Lymphedema: Single-Blinded Randomized Controlled Trial

There is limited evidence regarding the combined effect of exercise and compression garment on breast cancer-related lymphedema (BCRL). Therefore, we investigate the effect of low-intensity resistance training alone or in combination with a compression garment on lymphedema volume, self-reported lymphedema symptoms, and shoulder mobility and function. A total of 60 women with unilateral BCRL were randomly assigned to low-intensity resistance exercises (Rex group, n = 30) or exercises and compression garment (Rex-Com-group, n = 30). Both groups take part in exercises program consisted of 10-12 repetitions at 50 to 60% of one repetition maximum (IRM), three times weekly, for 8 weeks. The primary outcome was lymphedema volume determined by percentage reduction of excess limb volume (ELV). Secondary outcomes were lymphedema symptoms (pain, heaviness, and tightness) and shoulder mobility and function using the disabilities of the arm, shoulder, and hand (DASH) questionnaire. All measurements were standardized and performed before (week 0, W0), after the intervention (week 8, W8), and at follow-up (week 12, W12). A significant reduction in percentage of ELV (p < 0.01), pain severity (p < 0.05), a sensation of heaviness (p < 0.05) and tightness (p < 0.001), and improvement in shoulder range of motion (p < 0.05) and function on DASH scores (p < 0.05) were observed at W8 and W12 in both groups. However, no between-group differences were observed over time. These findings suggest that low-intensity resistance training, irrespective of garment use, can effectively reduce limb volume and lymphedema symptoms, and increase shoulder mobility and function.

A quantitative comparison of arm activity between survivors of breast cancer and healthy controls: use of accelerometry

PURPOSE

Survivors of breast cancer (BC) on the non-dominant side have more persistent deficits than those with cancer on the dominant limb. What is not known is whether those with BC use their involved upper limbs more, less, or at the same level as women without BC. Accelerometer use offers a quantifiable method to measure activity levels of upper limbs. The purpose of this study was to quantify the activity levels of the non-dominant involved limb among survivors of BC and compare these values to their dominant limb, as well as the non-dominant limb of a control group.

METHODS

Participants (n = 30) were women with unilateral BC on the non-dominant limb, diagnosed between 6 and 24 months prior to data collection, and a matched healthy group of women as controls. Participants completed the following questionnaires: medical and demographics, Brief Fatigue Inventory, Brief Pain Inventory - Short form, Disabilities of the Arm, Shoulder and Hand (DASH), and Beck Depression Index. Participants wore an accelerometer on each wrist during waking hours for 7 days. Arm activity was measured using vector magnitude activity counts extracted from the accelerometers.

RESULTS

There were no significant differences in total vector magnitude activity counts between groups for either limb. Within group dominant to non-dominant comparison was significantly different (p ≤ 0.001). No significant difference in pain was present but significant differences for fatigue (p = 0.002), depression (p = 0.004), and DASH scores (p = 0.035) were present.

CONCLUSIONS

Women with non-dominant BC use their involved limb similar to healthy controls but less than their dominant limb.

A user's survey of the clinical application and content validity of the DASH (Disabilities of the Arm, Shoulder and Hand) outcome measure

STUDY DESIGN

Survey.

PURPOSE OF THE STUDY

To elicit feedback on the clinical use and content validity of the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure from frontline users of the instrument.

METHODS

A cross-sectional survey was administered to registered DASH users and inquired about how the DASH was being used and to identify the informational value of items of the DASH (content validity).

RESULTS

About 172 completed the survey. One or both of the DASH and/or QuickDASH were consistently (89.5%) being used. About 90% were using it in adults (21-65 years), and at least 70% were using it across the entire extremity, and to a lesser extent, 10% reported using it in isolated neck injuries. Most respondents (66.9%-75.8%) were using the DASH in musculoskeletal (MSK) disorders, with some applying it for other more unique or non-MSK conditions (2.5%-16.6%). All but 1 of the 30 DASH items had at least 10% endorsement as being informative, and 4 items were identified as being problematic by greater than 20%.

CONCLUSIONS

The DASH is being used as intended (whole extremity and MSK conditions), and in addition, it is being used in different body regions and diverse conditions.

LEVEL OF EVIDENCE

Not applicable (descriptive survey).

Time course of upper limb function and return-to-work post-radiotherapy in young adults with breast cancer: a pilot randomized control trial on effects of targeted exercise program

PURPOSE

Breast cancer (BC) diagnosis in young adults (YA) is rising, and both disease and treatments are aggressive in this population. Evidence supports the use of physical activity in reducing shoulder dysfunction, which is common among BC survivors. A pilot randomized clinical trial was performed to determine the effectiveness of a 12-week post-radiation exercise program in minimizing upper extremity dysfunction in YA with BC.

METHODS

Participants were randomized to either an exercise arm or a control arm receiving standard care. Data was collected over six time points using: the Disability of Arm, Shoulder, and Hand (DASH); the Metabolic Equivalent of Task-hours per week (MET-hours/week), and a post hoc questionnaire on return to work.

RESULTS

In total, 59 young women participated in the study (n = 29 exercise; n = 30 control). No statistically significant differences were found in overall DASH results between groups; however, those who underwent total mastectomy had residual upper limb dysfunction (p < 0.05). Both groups returned to pre-diagnosis activity levels by 18 months. Final evaluation showed that 86% of the women returned to work, and 89% resumed prior work activities with a decrease of 8.5 h/week.

CONCLUSION

Although the short-term targeted exercise program had no effect on long-term upper limb function post-radiation, timing and program specificity may require consideration of tissue healing post-radiation and surgery type. The majority of participants returned to work, however not returning to pre-diagnosis work hours.

IMPLICATIONS FOR CANCER SURVIVORS

Exercise interventions alone may not reverse the long-term sequelae of breast cancer treatment and allow young adult patients to return to work.