Rehabilitation in Women with Breast Cancer

Effects of physical exercise on rehabilitation of cancer patients undergoing radiotherapy

Background

According to the World Health Organization and American Cancer Society, cancer survivors should involve in mild-to-moderate intensity exercises and consume vegetarian diet. These lifestyle alterations show improvement in cancer recurrence, risk reduction, and quality of life (QOL).

Objective

The purpose of this study was to study the effect of physical activity on health/behavioural changes among adult cancer survivors.

Materials and Methods

The study is randomized controlled trial which included 100 patients (Group A - Exercise group - 50 patients and Group B - Control group - 50 patients). Assessment of cardiopulmonary fitness, endurance, and QOL was done.

Results

Significant improvement in pulse rate, SpO2 and endurance, mental health, and social dimension was found in exercising group with no significant improvement in spiritual dimension.

Conclusion

Remodelling the lifestyle by diet adjustment, strength training, and exercises alters the incidence and prognosis of cancer.

Scoping 'sex' and 'gender' in rehabilitation: (mis)representations and effects

BACKGROUND

Researchers have highlighted a large-scale global unmet need for rehabilitation. While sex and gender have been shown to interact with each other and with other social and structural factors to influence health and wellbeing, less is known about how sex and gender shape rehabilitation participation and outcomes within health systems.

METHODS

Using an intersectional approach, we examine literature that explores the relationship between sex and/or gender and rehabilitation access, use, adherence, outcomes, and caregiving. Following a comprehensive search, 65 documents met the inclusion criteria for this scoping review of published literature. Articles were coded for rehabilitation-related themes and categorized by type of rehabilitation, setting, and age of participants, to explore how existing literature aligned with documented global rehabilitation needs. Responding to a common conflation of sex and gender in the existing literature and a frequent misrepresentation of sex and gender as binary, the researchers also developed a schema to determine whether existing literature accurately represented sex and gender.

RESULTS

The literature generally described worse rehabilitation access, use, adherence, and outcomes and a higher caregiving burden for conditions with rehabilitation needs among women than men. It also highlighted the interacting effects of social and structural factors like socioeconomic status, racial or ethnic identity, lack of referral, and inadequate insurance on rehabilitation participation and outcomes. However, existing literature on gender and rehabilitation has focused disproportionately on a few types of rehabilitation among adults in high-income country contexts and does not correspond with global geographic or condition-based rehabilitation needs. Furthermore, no articles were determined to have provided an apt depiction of sex and gender.

CONCLUSION

This review highlights a gap in global knowledge about the relationship between sex and/or gender and rehabilitation participation and outcomes within health systems. Future research should rely on social science and intersectional approaches to elucidate how gender and other social norms, roles, and structures influence a gender disparity in rehabilitation participation and outcomes. Health systems should prioritize person-centered, gender-responsive care, which involves delivering services that are responsive to the complex social norms, roles, and structures that intersect to shape gender inequitable rehabilitation participation and outcomes in diverse contexts.

Use of rehabilitation pathways in women with breast cancer in the first 12 months of the disease: a retrospective study

Background

Breast cancer (BC) presents important physical and psychological challenges that should be appropriately addressed through continuous, integrated and individualized rehabilitation programs after treatment. In this study, we aimed to collect more information on the rehabilitation patterns and utilization of healthcare services by women with BC.

Methods

We retrospectively analyzed data from two archives of the Lazio Regional Health System Database to assess rehabilitation patterns in women diagnosed with BC in the Lazio region (Italy) in 2008.

Results

A total of 5538 women diagnosed with BC were considered in the present study. Most patients (81.7%) received outpatient rehabilitative care, consisting mainly of pathology-related interventions and, more rarely, disability-related interventions (mainly motor rehabilitation and rarely cognitive or psychological therapy). Few patients followed an inpatient (1.3%) or an intensive outpatient rehabilitation program (1.0%).

Conclusion

Most patients do not receive adequate rehabilitation care during the first year after diagnosis. More information and better rehabilitation services should be provided to help patients with BC access rehabilitation programs. The study also suggests the importance of psychosocial and cognitive interventions, which is a major unmet need in women with BC.

Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction in a Patient with a History of Toxic Epidermal Necrosis

Breast reconstruction is a procedure that is in increased demand due to high incidence of breast cancer. To provide high-quality esthetic and functional results, each patient should be properly managed. Patients with comorbid conditions have become more common and account for higher difficulty in perioperative patient management. Despite the ongoing diversification of comorbidities in patients undergoing breast reconstruction, it is the patient’s right to receive this final stage in rehabilitation after a mastectomy. We present a clinical vignette of a patient with a severe comorbid hypersensitivity disorder undergoing breast reconstruction with the deep inferior epigastric artery perforator flap. Despite early postoperative complications, our brigade managed to maintain flap viability without the use of surgical or pharmacological assistance in a patient with a history of toxic epidermal necrosis syndrome.

Optimizing post-acute care in breast cancer survivors: a rehabilitation perspective

Breast cancer (BC) is the most common malignancy and a leading cause of morbidity and mortality in women worldwide. Therapeutic advances and improved survival rates of women with BC have implications for long-term impact on disability, psychological function and quality of life (QoL), which may be amenable to rehabilitation. The focus of rehabilitation is on managing disability, reducing sequelae and symptoms, and enhancing participation and societal reintegration, to achieve the highest possible independence and the best QoL. Rehabilitation interventions should be considered early for maintaining functional capacity and reducing the risk of losing important abilities or independence and should be individualized depending on disease phase, functional deficits, personal requirements and specific goals. A number of interventions have been trialled to support rehabilitation input for women with BC, which include physical therapy, psychological interventions (psychotherapy, cognitive behavioral training) and others. Multidisciplinary rehabilitation and uni-disciplinary interventions such as physical therapy have been shown to be beneficial in reducing disability, and improving participation and QoL. There is a need for comprehensive assessment of health domains in BC patients using a standardized framework and a common language for describing the impact of disease at different levels, using the International Classification of Functioning, Disability and Health core sets. This will provide more detailed information on the needs of these patients, so more efficient and targeted rehabilitation interventions can be provided.

Shoulder impairment before breast cancer surgery

OBJECTIVE

To compare pre- and post-operative shoulder active range of motion (AROM) values from female breast cancer survivors to population norm values for shoulder AROM; and to compare shoulder AROM differences pre- and post-surgery between female African American and White breast cancer survivors (BCA).

STUDY DESIGN

This pilot study used a convenience sample and longitudinal design measuring participants 2 times (T0 = baseline, after biopsy but within 2 weeks before BCA surgery; T1 = 2nd postoperative week).

BACKGROUND

The U.S. has the largest BCA survivor population in history and yet the mortality burden remains highest among AA BCA survivors. AAs may also have greater burden of physical and functional side effects compared to whites and the general population.

METHODS AND MEASURES

The data were collected from a convenience sample (n = 33; nAA = 9, nW = 24) and included data on shoulder AROM, medical chart review for pre- and co-morbid conditions, and self-reported demographics and medical history. We used t-tests to compare sample AROM means to population norms. We then compared our sample across 2 timepoints (T0 = pre-surgery; T1 = 2 weeks post-surgery) using independent samples t-tests and repeated measures analysis of variance (p < .05) to compare AA to White sub-samples AROM means.

RESULTS

African Americans had significantly less shoulder abduction (at T0) and flexion (at T1) than whites. However, 100% had significantly reduced AROM for all movements at T0 (prior to surgery but after biopsy) when compared to population norms.

CONCLUSIONS

The significant reduction in shoulder AROM after biopsy but before surgery points to a possible unmet need for early physical therapy intervention. Further research using randomized controlled trial design is recommended.

Cancer prehabilitation: an opportunity to decrease treatment-related morbidity, increase cancer treatment options, and improve physical and psychological health outcomes

Cancer prehabilitation, a process on the continuum of care that occurs between the time of cancer diagnosis and the beginning of acute treatment, includes physical and psychological assessments that establish a baseline functional level, identifies impairments, and provides targeted interventions that improve a patient's health to reduce the incidence and the severity of current and future impairments. There is a growing body of scientific evidence that supports preparing newly diagnosed cancer patients for and optimizing their health before starting acute treatments. This is the first review of cancer prehabilitation, and the purpose was to describe early studies in the noncancer population and then the historical focus in cancer patients on aerobic conditioning and building strength and stamina through an appropriate exercise regimen. More recent research shows that opportunities exist to use other unimodal or multimodal prehabilitation interventions to decrease morbidity, improve physical and psychological health outcomes, increase the number of potential treatment options, decrease hospital readmissions, and reduce both direct and indirect healthcare costs attributed to cancer. Future research may demonstrate increased compliance with acute cancer treatment protocols and, therefore, improved survival outcomes. New studies suggest that a multimodal approach that incorporates both physical and psychological prehabilitation interventions may be more effective than a unimodal approach that addresses just one or the other. In an impairment-driven cancer rehabilitation model, identifying current and anticipating future impairments are the critical first steps in improving healthcare outcomes and decreasing costs. More research is urgently needed to evaluate the most effective prehabilitation interventions, and combinations thereof, for survivors of all types of cancer.

CanWell: meeting the psychosocial and exercise needs of cancer survivors by translating evidence into practice

BACKGROUND

As more evidence emerges to support the incorporation of exercise for cancer survivors to positively affect physical, emotional, and social health, it is imperative that health-care providers use current knowledge to develop evidence-based exercise programs for these patients. Our purpose is to describe the development, implementation, and effectiveness of the CanWell program, an evidence-based, community and partnership-based, exercise, and education program for all people with cancer.

METHODS

Exercise and cancer research was reviewed, summarized, and utilized to develop CanWell. A 12-week, supervised, community-based, exercise, and education program established in collaboration between an acute care hospital, academic center, and a not-for-profit YMCA facility. CanWell participants completed physical and health-related quality of life measures prior to initiating the program and repeated them at 6 and 12 weeks.

RESULTS

Following the exercise program, participants reported significant improvements in health-related quality of life, recorded distance ambulated during a 6-min walk test, and total minutes on a treadmill recorded using the standardized exponential exercise protocol treadmill test. Furthermore, no increases in disease burden were identified using the Edmonton Symptom Assessment System. In addition, no exercise related injuries were reported by CanWell participants.

CONCLUSIONS

As the body of evidence supporting the incorporation of exercise as a standard of care for cancer survivors, it is imperative that care providers use current knowledge to provide opportunities for their patients to exercise in effective exercise programs. CanWell is an example on how collaboration between hospital, university, and community institutions can be used to move research into practice and meet the needs of cancer survivors.

Effect of comprehensive rehabilitation on the upper limb function in patients after mastectomy

Introduction: Breast cancer is the most common cancer in Poland, in Europe and the US. Women after breast cancer treatment suffer from various motor dysfunctions. The most frequent is upper limb dysfunction on the operated side caused by lymphedema and limitations in the shoulder complex mobility. Physical therapy and psychotherapy have a significant beneficial effect on the quality of life of these women. The aim of the study was to assess the effect of comprehensive rehabilitation on the upper limb function and incidence of lymphedema, sensory dysfunctions and pain on the operated side.

Material and methods: The experimental group included 19 patients with diagnosed breast cancer. All of them underwent a standard surgical intervention - radical mastectomy according to Patey’s method followed up by outpatient rehabilitation according to a designed plan. The control group consisted of 16 women who underwent the same treatment but did not take part in the designed rehabilitation program. During the examinations the following parameters were measured: motion range of the shoulder complex, hand-grip strength and occurrence of lymphedema, pain and sensory dysfunctions.

Results: Women in the experimental group improved the upper limb mobility on the operated side and hand-grip strength, and rated lower their level of pain intensity.

Conclusions: The outcomes confirmed the necessity to implement early rehabilitation program as a follow-up treatment for patients after mastectomy. Comprehensive rehabilitation leads to reduced pain intensity and improved upper limb function on the operated side and has a beneficial effect on the general physical fitness of women.

Multidisciplinary rehabilitation for follow-up of women treated for breast cancer

BACKGROUND

Breast cancer is the most common malignancy in women worldwide. Multidisciplinary rehabilitation aims to improve outcomes for women but the evidence base for its effectiveness is yet to be established.

OBJECTIVES

To assess the effects of organised multidisciplinary rehabilitation during follow-up in women treated for breast cancer.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, CINAHL, AMED, PEDro and LILACS in December 2011.

SELECTION CRITERIA

Randomised and controlled clinical trials (RCTs, CCTs, respectively) that compared multidisciplinary rehabilitation with some form of control intervention (such as a lower level or different type of intervention, minimal intervention, waiting list controls or no treatment, interventions given in different settings).

DATA COLLECTION AND ANALYSIS

The type of data retrieved did not allow for quantitative synthesis and therefore a narrative synthesis was provided. The methodological quality of the included studies was evaluated by three authors using the risk of bias tool.

MAIN RESULTS

Two RCTs, including 262 participants, met the inclusion criteria. Both trials scored poorly for methodological quality. There was 'low level' evidence that multidisciplinary rehabilitation produced short-term gains at the levels of impairment (that is range of shoulder movement), psychosocial adjustment and quality of life after breast cancer treatment (up to 12 months). No evidence was available for the longer-term functional outcomes for caregivers or the cost effectiveness of these programmes. It was not possible to suggest the most appropriate frequency and duration of therapy or choice of one type of intervention over another.

AUTHORS' CONCLUSIONS

There was 'low level' evidence that multidisciplinary rehabilitation can improve the outcomes of people with breast cancer in terms of functional ability, psychosocial adjustment and participation in social activities. There was no evidence available on functional gain at the level of activity. This review highlights the limitations of RCTs in rehabilitation settings and the need for high-quality trial-based research in this area. Regular evaluation and assessment of breast cancer survivors for rehabilitation is recommended.

Factors associated with long-term functional outcomes and psychological sequelae in women after breast cancer

The objective of this study was to examine factors impacting long-term functional outcomes and psychological sequelae in survivors of breast cancer (BC). A clinical assessment and structured interview assessed the impact of BC on participants' (n=85) current activity and restriction in participation, using validated questionnaires: Functional Independence Measure (FIM), Perceived Impact Problem Profile (PIPP) and Depression Anxiety Stress Scale (DASS). Participants showed good functional recovery (median motor FIM score=78). Three-quarters (74%) reported pain, 32% reported upper limb weakness, 31% pain limiting shoulder movement and 29% lymphoedema. One third (32%) reported greatest impact on psychological wellbeing. A substantial number of participants reported high levels of depression (22%), anxiety and stress (19% each). Factors associated with poorer current level of functioning and wellbeing included: younger participants, recent diagnoses, aggressive tumour types, receiving chemotherapy, shoulder limitation due to pain, and lymphoedema. BC survivors require long-term management of psychological sequelae impacting activity and participation.

Developing a rehabilitation model of breast cancer patients through literature review and hospital rehabilitation programs

PURPOSE

This study aimed to develop a rehabilitation model of breast cancer patients through review of literature and available online hospital rehabilitation programs.

METHODS

Electronic searches of the literature related to rehabilitation programs of breast cancer patients in Cumulative Index to Nursing & Allied Health Literature, PubMed Clinical Queries, and Academic Search were carried out. In addition, hospital websites were reviewed for their rehabilitation programs, which in turn were reviewed and analyzed regarding their contents.

RESULTS

The four dimensions, 12 categories, and concepts related to rehabilitation of breast cancer patients were uncovered. The four dimensions were concerns and problems, types of rehabilitation, activities, and quality of life. The 12 categories consisted of 2 categories in concerns and problems, 4 categories in types of rehabilitation, 4 categories in activities, and 2 categories in quality of life. A rehabilitation model for breast cancer patients was constructed that was grounded in the four dimensions, 12 categories, and concepts.

CONCLUSION

Rehabilitation of breast cancer patients deserves special attention to achieve optimal quality of life. Health care professionals need to be educated about rehabilitation as an effective intervention.