Quality of Life Interventions in Breast Cancer Survivors: State of the Art in Targeted Rehabilitation Strategies

Is the Absence of Manual Lymphatic Drainage-Based Treatment in Lymphedema after Breast Cancer Harmful? A Randomized Crossover Study

(1) Background: Manual lymphatic drainage (MLD), included within the complex decongestive therapy, as a therapy for the treatment of lymphedema has raised controversy about its benefits for lymphedema after breast cancer. The aim of this research is to test the effects of MLD on lymphedema after breast cancer during the treatment maintenance phase. (2) Methods: A randomized, single-blinded, controlled crossover trial was conducted to analyze the effects of a manual lymphatic drainage intervention compared to a control group without MLD intervention for the treatment of lymphedema. Arm volume measured by circumference measurement, subcutaneous tissue thickness measured by ultrasound, and the sensation of pain, heaviness, and swelling were evaluated as outcome measures. (3) Results: For the control group, an increase in volume was found in some of the circumference and subcutaneous tissue thickness measurements, in addition to a worsening of arm pain, swelling and heaviness. (4) Conclusion: The absence of treatment based on MLD in lymphedema after breast cancer worsens volume measurements, as well as arm heaviness. Therefore, it would be advisable to carry out this type of therapy as part of the maintenance treatment for lymphedema in breast cancer.

Impact of cancer diagnosis and treatment: a qualitative analysis of strains, resources and coping strategies among elderly patients in a rural setting in Ghana

BACKGROUND

Rurality is fraught with numerous difficulties including a lack of advanced health facilities to provide health services, and an absence of specialist cancer services, and qualified personnel, among others. These factors exacerbate the challenges of elderly patients diagnosed with cancer and further pose limitations to activities/instrumental activities of daily living. Yet, there is limited scholarship on the strains that affect elderly patients diagnosed with cancer and the resources that helps them to overcome them. This study explores the strains, resources, and coping strategies of elderly patients diagnosed with cancer and undergoing treatment in rural Ghana.

METHODS

An exploratory, descriptive qualitative design was adopted. Purposive sampling was used to recruit 20 individuals to participate in in-depth interviews. The collected data was analysed inductively using Collaizi's framework. QSR NVivo-12 was used in managing the data.

RESULTS

The results were grouped into two main categories, namely: strains and resources. Within the category of strains, three main themes with their corresponding sub-themes emerged: cancer-related strains (systemic side effects from treatment, altered physical appearance and body image, and experience of pain), elderly strains (altered functional ability, limited social interactions and participation, psycho-emotional reactions, limited/restricted economic participation, and financial strains), and health system strains (negative attitude and insensitive communication, delay in diagnosis, lack of geriatric oncology care, lack of community-based specialist cancer centre and long travel distance to access care, and limited availability of essential cancer medicines and other radiations services). Four types of resources were available to cancer patients: personal resources, family resources, community resources, and healthcare systems resources.

CONCLUSION

In conclusion, elderly patients diagnosed with cancer experience physical, economic, psychological, and emotional strains that threaten their health and well-being. However, they are able to leverage family, community, and health system-related resources to navigate through the strains. There is, therefore, a need to expand advanced health facilities with geriatric oncology units and specialists to improve access to cancer care in rural areas. The government needs to assist elderly persons with costs associated with their diagnosis and treatment through the expansion of the National Health Insurance Scheme to include this as part of the benefits package.

Proposing and evaluating a model of depression, stress, resilience and spirituality in relation to pain in women with breast cancer: Investigating the mediating role of mindfulness

BACKGROUND

Pain experience is one of the most common symptoms of women with breast cancer receiving chemotherapy. It may cause physical and psychological problems and interfere with the treatment process.

AIMS

This study aimed to examine the relationship between depression, stress, resilience and spirituality on the pain symptoms of breast cancer patients during chemotherapy and explore the potential mediating role of mindfulness in this association.

METHOD

Two hundred and forty women with breast cancer receiving chemotherapy from Shiraz University Hospital, were selected and evaluated by a purposive sampling method. The research instruments were Perceived Stress Scale, Beck Depression Questionnaire-2, Mindfulness, Resilience, Spirituality and Pain Questionnaires. The obtained data was analyzed by SPSS software and MPLUS using Spearman correlation coefficient and path analysis.

RESULTS

Based on the findings of direct path analysis, depression, stress, and spirituality showed a significant relationship with mindfulness, but resilience had no significant relationship with mindfulness (p < 0.01). Furthermore, depression, stress, resilience, and mindfulness showed a significant relationship with pain, while spirituality had no significant relationship with pain (p < 0.01). Finally, indirect path analysis revealed mindfulness is a significant mediator of stress and pain (p < 0.05).

CONCLUSIONS

The present study suggested a model can be useful in better understanding of the psychological components affecting pain in breast cancer patients, after and during their treatments. It also provided an effective framework to develop and investigate pain-focused and non-pharmacological interventions.

The Role of Emotion-Related Abilities in the Quality of Life of Breast Cancer Survivors: A Systematic Review

Breast cancer survivors have to deal with notable challenges even after successful treatment, such as body image issues, depression and anxiety, the stress related to changes in lifestyle, and the continual challenges inherent to health management. The literature suggests that emotional abilities, such as emotional intelligence, emotion management, mood repair, and coping play a fundamental role in such challenges. We performed a systematic review to systematize the evidence available on the role of emotional abilities in quality of life and health management in breast cancer survivors. The search was performed on three scientific databases (Pubmed, Scopus, and PsycINFO) and, after applying exclusion criteria, yielded 33 studies, mainly of a cross-sectional nature. The results clearly support the hypothesis that emotional abilities play multiple important roles in breast cancer survivors' quality of life. Specifically, the review highlighted that coping/emotional management plays multiple roles in breast cancer survivors' well-being and health management, affecting vitality and general adjustment to cancer positivity and promoting benefit findings related to the cancer experience; however, rare negative results exist in the literature. This review highlights the relevance of emotional abilities to promoting quality of life in breast cancer survivors. Future review efforts may explore other breast cancer survivors' emotional abilities, aiming at assessing available instruments and proposing tailored psychological interventions.

A pilot study of cognitive behavioural therapy integrated with activity pacing for fatigued breast cancer patients undergoing chemotherapy in Ethiopia

Background

Fatigue is a common symptom in breast cancer patients, and it is one of the major factors that influence the quality of life (QoL). Cognitive behavioural therapy (CBT) has been recommended to manage cancer-related fatigue. In this study, CBT will be integrated with activity pacing (AP), which can help breast cancer patients achieve a balance between activity and rest. Therefore, this pilot study aimed to investigate the acceptability, feasibility, and efficacy of the CBT-AP intervention.

Methods

A total of 10 fatigued breast cancer patients undergoing chemotherapy were included in the study. The acceptability and feasibility of the study were measured by the patient recruitment rate, attrition rate, intervention fidelity, intervention compliance, and therapist’s and participant’s evaluations of the intervention. The outcomes were measured at baseline and at 6 weeks of intervention.

Results

The pre–post study suggested that CBT-AP was found to be acceptable and feasible for fatigued breast cancer patients undergoing chemotherapy. Among 27 eligible participants, 10 (37.03%) participants accepted our invitation to participate in the study. One participant dropped out from the intervention because of serious illness, and the dropout rate was 10%.

Both the intervention fidelity and intervention compliance were found to be satisfactory.

Fatigue severity [Brief Fatigue Inventory (BFI)] was reduced in 77.77% of participants from baseline to 6 weeks of intervention. The global health status/QoL scale and physical, emotional, and social functioning scales were improved from baseline to 6 weeks of intervention. All symptom scales, except constipation, diarrhea, and financial difficulties, were decreased after the intervention. Depression [Public Health Questionnaire (PHQ)-9] was reduced in 55.55% of participants.

Conclusion

This study suggested that CBT-AP is an acceptable, feasible, and potentially efficacious intervention to reduce fatigue and improve the QoL of breast cancer patients. The efficacy of a CBT-AP programme is going to be investigated in subsequent larger randomized clinical trials.

Axillary Web Syndrome in Breast Cancer Women: What Is the Optimal Rehabilitation Strategy after Surgery? A Systematic Review

Background: Axillary web syndrome (AWS) is one of the most prevalent and underrecognized disorders affecting breast cancer (BC) women. However, the optimal therapeutic strategy to manage AWS is far from being fully characterized. Therefore, this systematic review aims to provide a broad overview of the available rehabilitation treatments in this burdensome condition. Methods: On 13 January 2022, PubMed, Scopus, Web of Science, Cochrane, and PEDro were systematically searched for clinical studies assessing rehabilitation interventions in post-surgical BC women with AWS. The outcomes analyzed were pain, AWS clinical resolution, upper limb function, and health-related quality of life (HR-QoL). Results: The search identified 1115 records, of which 11 studies were included. A total of 174 patients were assessed (ages ranging from 37 and 66 years old). The interventions included manual lymphatic drainage, manual therapy, stretching, resistance training, mobilization techniques, and Kinesio tape. Positive improvements were reported in terms of pain relief (in 7 studies), AWS clinical resolution (in 9 studies), upper limb function (in 10 studies), and HR-QoL (in 2 studies). Conclusions: Our findings suggest that rehabilitation might be considered an effective therapeutic strategy in AWS patients. Further RCTs are needed to characterize the optimal rehabilitative interventions.

Effects of intensive physiotherapy on Quality of Life (QoL) after pancreatic cancer resection: a randomized controlled trial

BACKGROUND

Patients have significantly lower QoL scores after pancreatic resection due to cancer in the physical and psychological domains compared to healthy controls or other cancer patients. Intensified physiotherapy or physical training can increase QoL by reducing fatigue levels and improving physical functioning. However, data on the long-term effects of intensive or supervised physiotherapy is lacking. The aim of this exploratory study is the assessment of QoL in the intervention group, using various QoL questionnaires in their validated German translations and gather data on its feasibility in the context of chemotherapy with a follow-up of 12 months (and develop concepts to improve QoL after pancreatic cancer resection).

METHODS

Fifty-six patients (mean age: 66.4 ± 9.9 years) were randomized in this study to intervention (cohort A, n = 28) or control group (cohort B, n = 28). Intervention of intensified physiotherapy program consisted of endurance and muscle force exercises using cycle ergometer. In the control group physiotherapy was limited to the duration of the hospital stay and was scheduled for 20 min on 5 days per week. The clinical visits took place 2 days preoperatively, 1 week, 3 months, 6 months and 12 months postoperatively. Both groups attended the follow-up program. QoL was evaluated using the Short Physical Performance Battery (SPPB), Short Form-8 Health Survey (SF-8) and the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and pancreatic cancer-specific module QLQ-PAN26 questionnaires. The course of QoL was evaluated using a repeated measures ANOVA and a per protocol design.

RESULTS

Of the initial 56 randomized patients, 34 finished the 12 months follow-up period. There were no adverse events due to the intervention and 80% of patients in the intervention group where adherent. There was no significant influence on physical performance as measured by SPPB and SF-8 questionnaire. However, after 6 months patients in the intervention group regained their prior physical condition, whereas the control group did not. Intensive physiotherapy significantly influenced various factors of QoL measured with the C30 questionnaire positively, such as physical functioning (p = 0.018), role functioning (p = 0.036), and appetite loss (p = 0.037), even after 6 months. No negative effects in patients undergoing chemotherapy compared to those without chemotherapy was observed.

CONCLUSION

This first randomized controlled study with a 12-month follow-up shows that supervised physiotherapy or prescribed home-based exercise after pancreatic cancer resection is safe and feasible and should be proposed and started as soon as possible to improve certain aspects of QoL.

TRIAL REGISTRATION

German Clinical Trials Register (No: DRKS00006786 ); Date of registration: 01/10/2014.

Pathological examination of breast cancer samples before and after neoadjuvant therapy: recommendations from the Italian Group for the Study of Breast Pathology - Italian Society of Pathology (GIPaM-SIAPeC)

Neoadjuvant therapy (NAT) in breast cancer is administered to downstage the tumor, de-escalate surgery, and provide prognostic information that can be used to tailor subsequent adjuvant therapy. In this respect, the pathological evaluation of both pre-NAT biopsies and post-NAT surgical specimens is crucial to precisely assess the treatment response. With the increasing possibilities of NAT protocols and the rising number of eligible patients, it has become extremely important to standardize the pathological response assessment. Here, we provide an update on the recommendations of the Italian Group for the Study of Breast Pathology - the Italian Society of Pathology (GIPaM-SIAPeC) for the analysis of breast cancer samples before and after NAT.

Efficacy of Antiresorptive Drugs on Bone Mineral Density in Post-Menopausal Women With Early Breast Cancer Receiving Adjuvant Aromatase Inhibitors: A Systematic Review of Randomized Controlled Trials

Background

Cancer treatment-induced bone loss (CTIBL) is a frequent complication of breast cancer therapies affecting both disability and health-related quality of life (HRQoL). To date, there is still a lack of consensus about the most effective approach that would improve bone health and HRQoL. Therefore, the aim of this systematic review of randomized controlled trials (RCTs) was to summarize the evidence on the effects of antiresorptive drugs on CTIBL in patients with early breast cancer.

Methods

PubMed, Scopus, and Web of Science databases were systematically searched up to April 30, 2021 to identify RCTs satisfying the following PICO model: P) Participants: postmenopausal women with early breast cancer receiving adjuvant aromatase inhibitors (AI), age >18 years; I) Intervention: antiresorptive drugs (i.e. bisphosphonates and/or denosumab); C) Comparator: any comparator; O) Outcome: bone mineral density (BMD) modifications. Moreover, a quality assessment was performed according to the Jadad scale.

Results

Out of the initial 2415 records, 21 papers (15 studies) were included in the data synthesis. According to the Jadad scale, 6 studies obtained a score of 5, 1 study obtained a score of 4, 13 studies obtained a score of 3, and 1 study with score 1. Although both bisphosphonates and denosumab showed to increase BMD, only denosumab showed significant advantages on fractures.

Conclusions

Bone health management in patients with early breast cancer receiving adjuvant AIs remains challenging, and the optimal therapeutic approach is not standardized. Further studies are needed to investigate CTIBL, focusing on both the need for antiresorptive drugs and their duration based on individual patients’ characteristics.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero, identifier CRD42021267107.

The non-fatal burden of cancer in Belgium, 2004-2019: a nationwide registry-based study

BACKGROUND

The importance of assessing and monitoring the health status of a population has grown in the last decades. Consistent and high quality data on the morbidity and mortality impact of a disease represent the key element for this assessment. Being increasingly used in global and national burden of diseases (BoD) studies, the Disability-Adjusted Life Year (DALY) is an indicator that combines healthy life years lost due to living with disease (Years Lived with Disability; YLD) and due to dying prematurely (Years of Life Lost; YLL). As a step towards a comprehensive national burden of disease study, this study aims to estimate the non-fatal burden of cancer in Belgium using national data.

METHODS

We estimated the Belgian cancer burden from 2004 to 2019 in terms of YLD, using national population-based cancer registry data and international disease models. We developed a microsimulation model to translate incidence- into prevalence-based estimates, and used expert elicitation to integrate the long-term impact of increased disability due to surgical treatment.

RESULTS

The age-standardized non-fatal burden of cancer increased from 2004 to 2019 by 6 and 3% respectively for incidence- and prevalence-based YLDs. In 2019, in Belgium, breast cancer had the highest morbidity impact among women, followed by colorectal and non-melanoma skin cancer. Among men, prostate cancer had the highest morbidity impact, followed by colorectal and non-melanoma skin cancer. Between 2004 and 2019, non-melanoma skin cancer significantly increased for both sexes in terms of age-standardized incidence-based YLD per 100,000, from 49 to 111 for men and from 15 to 44 for women. Important decreases were seen for colorectal cancer for both sexes in terms of age-standardized incidence-based YLD per 100,000, from 105 to 84 for men and from 66 to 58 for women.

CONCLUSIONS

Breast and prostate cancers represent the greatest proportion of cancer morbidity, while for both sexes the morbidity burden of skin cancer has shown an important increase from 2004 onwards. Integrating the current study in the Belgian national burden of disease study will allow monitoring of the burden of cancer over time, highlighting new trends and assessing the impact of public health policies.

Adapted Physical Activity for Breast Cancer Patients Treated with Neoadjuvant Chemotherapy and Trastuzumab Against HER2 (APACAN2): A Protocol for a Feasibility Study

Background

The standard care for HER2-positive breast cancer is chemotherapy plus a HER2-directed therapy. This can lead to treatment-induced cardiotoxicity. On the other hand, the practice of physical activity is known to improve cardiac function; thus HER2-positive breast cancer patients could draw particular benefit from physical activity during treatment. However, at the time of diagnosis for breast cancer, the majority of patients are insufficiently active according to physical activity recommendations of World Health Organisation, and it is difficult to remain or become active during the treatment. There is a lack of data in the literature on the optimal program to propose to patients to encourage them to be active during treatment. The aim of our study is to assess the feasibility of a home-based physical activity program during neoadjuvant chemotherapy and trastuzumab for HER2-positive breast cancer.

Methods

The APACAN2 study is a single-centre, non-randomized interventional trial. Patients with HER2-positive breast cancer treated with anthracycline-based neoadjuvant chemotherapy and trastuzumab are eligible for enrolment. The supervised home-based physical activity program takes place during neoadjuvant chemotherapy (NACT). It combines aerobic and strengthening exercises. The primary endpoint is the proportion of patients reaching the international physical activity recommendations, i.e. 150 minutes of moderate-intensity activity per week at the end of NACT. The study started in April 2018 and seventy patients are expected to be recruited.

Discussion

In the literature, the majority of studies on practice of physical activity in breast cancer focus on adjuvant chemotherapy or on the period after the end of treatment. To the best of our knowledge, the APACAN2 study is the first to evaluate a home-based physical activity program during neoadjuvant chemotherapy for HER2-positive breast cancer.

Trial Registration Number

Clinicaltrials.gov: NCT02963363, registered on July 11, 2016. Identifier with the French National Agency for the Safety of Medicines and Health Products N°ID RCB 2016-A01344-47, registered in August 2016. Protocol: version 8, 24 February 2021.

Physical Therapies for Psychosomatic Symptoms and Quality of Life Induced by Aromatase Inhibitors in Breast Cancer Patients: A Systematic Review and Meta-Analysis

Objective

To evaluate the effects of Physical Therapies (PTs) on improvement in psychosomatic symptoms and quality of life (QOL) in breast cancer patients.

Data Sources

Seven databases (MEDLINE, EMBASE, Cochrane CENTRAL, China National Knowledge Infrastructure, Wangfang, VIP, and China Biology Medicine disc databases) were systematically searched from the database inception through May 18, 2021.

Study Selection

Randomized controlled trials (RCTs) which compared acupuncture or exercise with a sham control or usual care for the treatment of aromatase inhibitors (AIs)-related psychosomatic symptoms and QOL.

Data Extraction and Synthesis

Data were screened and extracted independently using predesigned forms. The quality of RCTs was assessed with the Cochrane Handbook for Systematic Reviews of Interventions. The effect size was calculated via random-effects modeling. The quality of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation approach.

Main Outcomes and Measures

The score of pain was measured with BPI scale and Western Ontario and the McMaster Universities Index (WOMAC) scale. Emotional state was measured with Pittsburgh Sleep Quality Index (PSQI), Hospital Anxiety and Depression Scale (HADS-A), and Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-Fatigue). The QOL score was measured by self-reported measurements, including the Functional Assessment of Cancer Therapy-General (FACT-G) scale and 36-Item Short Form Survey (SF-36) scale.

Results

Eleven RCTs (with 830 patients) were included in the systematic review, and data from 10 RCTs (with 798 patients) were used in the meta-analysis. Results showed acupuncture significantly reduced worst pain scores (P < 0.00001, I² = 83.5%) [SMD = −0.81, 95% CI (−1.51, −0.11)], but the effect of exercise therapies was not significant in overall change in worst pain scores (P =0.006, I² = 72.3%) [SMD = −0.30, 95% CI (−0.76, 0.16)]. Both acupuncture and exercise resulted in little to no difference in overall change in HADS-A subscale (P = 0.026<0.05, I² = 79.8%) [WMD = −0.21, 95% CI (−3.44, 3.03)], PSQI subscale (P = 0.488, I² = 0%) [WMD = 0.98, 95% CI (−0.57, 2.53)], and FACIT-Fatigue subscale (P = 0.022<0.05, I² = 81.0%) [WMD = 1.6, 95% CI (−5.75, 8.94)]. Exercise (compared with usual care) was associated with improving overall change in health-related QOL (subscales of SF-36 tool) (P = 0, I² = 72.1%) [WMD = 7.97, 95% CI (5.68, 10.25)] and cancer-specific QOL (subscales of FACT-G tool) (P = 0.304, I² = 16%) [WMD = 1.16, 95% CI (0.34, 1.97)].

Conclusions and Relevance

This systematic review and meta-analysis suggested that based on moderate-level evidence, acupuncture was associated with significant reductions in pain intensity, and exercise might improve QOL in breast cancer patients treated with AIs. However, in psychosomatic symptoms such as anxiety, sleep disturbance, and fatigue, acupuncture and exercise training did not result in significant improvements.

Longitudinal Assessment of Physical Activity, Fitness, Body Composition, Immunological Biomarkers, and Psychological Parameters During the First Year After Diagnosis in Women With Non-Metastatic Breast Cancer: The BEGYN Study Protocol

Background

Moderate physical activity is associated with an improved prognosis and psychosocial outcome in breast cancer patients. Although exercise and physical activity are associated with multiple physiological and psychological effects, many of the underlying mechanisms remain obscure. The BEGYN study (Influence of physical activity in breast cancer patients on physiological and psychological parameters and on biomarkers) aims at identifying potential associations between the extent of physical activity, fitness, body composition, immunological biomarkers, psycho-emotional parameters, and the course of treatment during the first year after diagnosis of breast cancer.

Methods

The prospective observational BEGYN study will include 110 non-metastatic breast cancer patients. The patients will be assessed during a base line visit prior to the initiation of the antineoplastic therapy and after 3, 6, 9 and 12 months. The physical activity will be measured using a fitness tracker and a self-assessment diary during the entire study. Each visit will include the assessment of (i) cardiorespiratory fitness measured by spiroergometry, (ii) body composition, (iii) psycho-emotional parameters (quality of life, mental health, fatigue, depression, distress, anxiety, well-being), and (iv) extensive blood tests including routine laboratory, vitamin D, selenium and immunologically relevant biomarkers (e.g., leukocyte subpopulations and cytokine profiles).

Discussion

Whereas most studies investigating the influence of physical activity in breast cancer patients focus on specific activities for three months or less, the BEGYN study will quantify the daily physical activity and cardiorespiratory fitness of breast cancer patients based on objective measurements in the context of the oncological therapy for 12 months after diagnosis. The study will reveal potential associations between exercise, immune status and physical as well as psycho-emotional outcome and the clinical course of the disease. Moreover, complementary therapies such as Vit D and Selenium supplementation and parameters investigating the motivation of the patients are part of the study. Due to this holistic approach, the BEGYN study will guide towards confirmatory studies on the role of physical activity in breast cancer patients to develop individualized counselling regarding the recommended type and extent of exercise.

Trial Registration

This study has been registered at the German Clinical Trials Register DRKS00024829.