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Clinical practice guidelines for breast cancer rehabilitation: Syntheses of guideline recommendations and qualitative appraisals
Abstract
Despite strides in early detection and management of breast cancer, the primary treatments for this disease continue to result in physical impairments for some of the nearly 3 million people diagnosed annually. Over the past decade, evidence-based clinical practice guidelines (CPGs) have been developed with goals of preventing and ameliorating these impairments. However, translation of these guidelines into clinical practice needs to be accelerated.
Relevant health science databases (2001-2011) were searched to identify CPGs on breast cancer rehabilitation for the following impairments: upper extremity restrictions, lymphedema, pain, fatigue, chemotherapy-induced peripheral neuropathy, treatment-related cardiotoxicity, bone health, and weight management.
Recommendations from 19 relevant CPGs were first summarized by impairment within tables; commonalities across guidelines, within each impairment, were then synthesized within the article. The CPGs were rated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II); wide variability was noted in rigor of development, clarity of presentation, and stakeholder involvement. The most rigorous and comprehensive of those rated was the adult cancer pain guideline from the Scottish Intercollegiate Guidelines Network.
Based on a large body of evidence published in recent years, including randomized trials and systematic reviews, there is an urgent need for updating the guidelines on upper extremity musculoskeletal impairments and lymphedema. Furthermore, additional research is needed to provide an evidence base for developing rehabilitation guidelines on management of other impairments identified in the prospective surveillance model, eg, arthralgia.
... Currently, in Canada, several interventions, including medical, pharmacological [10] or psychosocial [11], are recommended to treat physical pain and thus reduce patients' psychological symptoms [10]. However, recently, increasing numbers of oncology patients are combining complementary/alternative medicine (CAM) with their conventional therapies in Canada [12,13]. ...
... Currently, in Canada, several interventions, including medical, pharmacological [10] or psychosocial [11], are recommended to treat physical pain and thus reduce patients' psychological symptoms [10]. However, recently, increasing numbers of oncology patients are combining complementary/alternative medicine (CAM) with their conventional therapies in Canada [12,13]. ...
... Currently, pharmacotherapy is the most prescribed treatment for pain in breast cancer patients in Canada [10]. Indeed, pharmacology follows a sequential order, modeling the analgesic scale of the World Health Organization (WHO) [31]. ...
Aim: In Canada, osteopathic medicine, a well-known branch of complementary/alternative medicine, has received minimal attention for pain management within oncology. Purpose: This review reports both the existing literature and patient experience surrounding the application of osteopathy as an effective treatment for pain in breast cancer patients. Results: Both the literature and this case study support, to some degree, the benefits of osteopathy as pain management for breast cancer patients. Conclusion: Due to contradictory reported findings, more studies would be required to make firm conclusions, especially within a Canadian context. However, a lack of standardization of osteopathic procedures and collaboration between osteopaths and traditional healthcare professionals are challenges in including osteopathy as a standard service offered to breast cancer patients.
... Pain education and exercise have been suggested as effective in reducing postoperative pain [8]. Despite compelling evidence supporting the effectiveness of early rehabilitation in addressing lymphedema and showing improved outcomes in pain levels, ROM, and functional disability scores [9,10], there is still reluctance among surgeons to refer patients to physical therapy [11]. ...
... However, it is noteworthy that there was an average delay of 24 months between symptom onset and consultation with the PMR department. This delay is concerning, especially considering that early rehabilitation is recognized as the standard clinical practice [3,9,10,[17][18][19]. It underscores the need to improve the referral pathway within our hospital to ensure timely access to rehabilitation services. ...
... Rights reserved. treatment; however, there is a lack of evidence supporting their use in this population [28]. ...
... Due to the variability in symptoms among patients with PBSPS, personalizing rehabilitation programs is important. Customized physical therapy regimens and therapeutic exercise plans play a major role in addressing the specific needs of each patient, resulting in notable improvements in patient outcomes [28]. Research has demonstrated that engaging in physical therapy after surgical intervention can lead to improved upper extremity function and a higher quality of life within 3 to 6 months after treatment, compared to patients who only receive exercise-related information [29]. ...
Purpose of Review
Post-breast surgery pain syndrome (PBSPS) is a clinical diagnosis referring to chronic pain following breast cancer surgery. PBSPS affects approximately 25 to 60% of women who undergo breast surgery and can have a substantial impact on quality of life and overall functional ability. We aim to describe and analyze the latest findings in the medical literature regarding clinical patients, preventive efforts, and current and novel treatment techniques of PBSPS.
Recent Findings
Early and multidisciplinary interventions, including pharmacologic, interventional, physical, and psychological therapies, have demonstrated promising results in alleviating PBSPS symptoms. Timely and appropriate diagnosis with a tailored treatment plan is crucial for minimizing the impact of PBSPS and promoting optimal recovery in affected individuals.
Summary
As society becomes increasingly aware of the impact of PBSPS in the lives of breast cancer survivors, there is a compelling need for further research seeking to enhance patients’ overall well-being and quality of life.
... The AGREEII Instrument is a useful tool used world wide for evaluating the quality of guidelines. Howe ver, it has some limitations; especially regarding the assignment of scores, as there are no clear definitions for different scores (36). Hence, at times scoring may be influenced by subjectivity (37). ...
... A clinimetric appraisal of the AGREE II tool was beyond the scope of this review. The AGREEII tool focuses on methodological issues related to the guide line development process and reporting, and which is explicitly insufficient to ensure that recommendations are valid and appropriate (36,37). The tool itself cannot appraise the quality of evidence supporting the recom mendations. ...
Purpose:
To systematically evaluate evidence from published systematic reviews for the effectiveness of rehabilitation interventions in adults with burn injury.
Materials and methods:
A comprehensive literature review conducted using medical and health science electronic databases up to 31 July 2022. Two independent reviewers selected studies, extracted data, and assessed methodological study quality using A Measurement Tool to Assess Systematic Reviews (AMSTAR-2), and the certainty of evidence for reported outcomes using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool.
Results:
Twenty-one systematic reviews evaluated five categories of interventions: physical, psychological, technology-aided modalities, educational and occupational programs, complementary and alternative medicine. Outcomes included fitness level, hand function, oedema, pain, pruritus, psychological state, quality of life, range of motion, return to work, strength, scar characteristics, level of impairment and burn knowledge. The methodological quality was rated as "critically low" for all reviews. Quality of evidence for the effectiveness of evaluated interventions ranged from "moderate to very low."
Conclusions:
Beneficial effects of inhaled aromatherapy and extracorporeal shockwave therapy on pain reduction; inhaled or massage aromatherapy, music therapy on anxiety were reported. Safety of interventions was not evaluated, due to the lack of adverse event reporting in primary studies and the included reviews.
... In the patients who initiated PT during or after RT, there was a median of 179 days between surgery and PT. One potential way to address ROM limitations early without increasing the risk of post-operative complications could be to begin gentle PT one to three weeks postoperatively, after initial wound healing is complete, with oversight by a physical therapist and input and support from members of the multidisciplinary breast oncology team [27]. These gentle PT interventions could include passive and active mobilization, stretching, resistance training, and scar tissue massage to enhance tissue extensibility, improve circulation, and assist with restoring normal movement patterns, with the degree of intensity of PT determined based on wound healing [27][28][29]. ...
... One potential way to address ROM limitations early without increasing the risk of post-operative complications could be to begin gentle PT one to three weeks postoperatively, after initial wound healing is complete, with oversight by a physical therapist and input and support from members of the multidisciplinary breast oncology team [27]. These gentle PT interventions could include passive and active mobilization, stretching, resistance training, and scar tissue massage to enhance tissue extensibility, improve circulation, and assist with restoring normal movement patterns, with the degree of intensity of PT determined based on wound healing [27][28][29]. ...
Purpose
Establishing optimal timing of physical therapy (PT) during multimodal breast cancer treatment can be challenging. We hypothesized patients initiating PT post-surgery and pre-radiation therapy (RT) would experience greater gains in functionality compared to PT initiated during/after RT.
Methods
A retrospective review was performed for patients receiving multimodality breast cancer treatment and PT between 1/2015-8/2021. Three cohorts were established: patients who received no RT, PT initiated before RT (pre-RT), and PT during/after RT (d/a-RT). The primary endpoint was percent change in ipsilateral shoulder ROM between first and last PT visits. Associations between range of motion (ROM) across groups and baseline characteristics were evaluated with analysis of variance testing.
Results
Thirty-seven patients were identified, median age of 47 years. The no-RT cohort exhibited the greatest mean percent improvement in ROM with PT (74%) versus pre-RT (59%) and d/a-RT (20%). The no RT and pre-RT groups demonstrated greater improvements in ROM compared to patients receiving PT d/a-RT (no RT 74% vs d/a-RT 20%, p = 0.006; pre-RT 59% vs d/a-RT 20%, p = 0.045). There was no difference in ROM gains between the no-RT and pre-RT groups (p = 0.528). Lower baseline ROM was associated with smaller improvements in ROM after PT (p = 0.008). When adjusting for baseline ROM, the no-RT cohort remained associated with ROM improvement compared to the d/a-RT group (p = 0.024). There was no difference in ROM change between no-RT and pre-RT cohorts.
Conclusion
PT improves shoulder ROM in patients undergoing multimodality breast cancer treatment; however, early initiation of PT before starting RT may maximize ROM gains.
... There is a very limited number of guidelines from international societies regarding cancer patients and TENS usage [41,42]. The recommendations from the American Cancer Society state that cancer-related pain can be alleviated by TENS [42]. ...
... There is a very limited number of guidelines from international societies regarding cancer patients and TENS usage [41,42]. The recommendations from the American Cancer Society state that cancer-related pain can be alleviated by TENS [42]. ...
Transcutaneous electrical nerve stimulation (TENS) is the usage of a mild electrical current through electrodes that stimulate nerves. Patients with malignancies experience pain and chemotherapy-induced peripheral neuropathy. A systematic review was performed to find research evaluating the effect of TENS on these two common symptoms decreasing the quality of life in cancer patients. PubMed, the Cochrane Central Register of Controlled Trials and EMBASE were searched. Original studies, namely randomized controlled trials, quasi-randomized controlled trials and controlled clinical trials, published between April 2007 and May 2020, were considered. The quality of the selected studies was assessed. Seven papers were incorporated in a qualitative synthesis, with 260 patients in total. The studies varied in terms of design, populations, endpoints, quality, treatment duration, procedures and follow-up period. Based on the results, no strict recommendations concerning TENS usage in the cancer patient population could be issued. However, the existing evidence allows us to state that TENS is a safe procedure that may be self-administered by the patients with malignancy in an attempt to relieve different types of pain. There is a need for multi-center, randomized clinical trials with a good methodological design and adequate sample size.
... Timing on when to initiate PT has also been studied. Most studies focus on implementing PT early in the postoperative period, with clinical practice guidelines recommending starting gentle range of motion exercises the day after surgery to reduce shoulder dysfunction and pain [60]. Active stretching, followed by strengthening, can then be introduced over the next 6-8 weeks [60]. ...
... Most studies focus on implementing PT early in the postoperative period, with clinical practice guidelines recommending starting gentle range of motion exercises the day after surgery to reduce shoulder dysfunction and pain [60]. Active stretching, followed by strengthening, can then be introduced over the next 6-8 weeks [60]. Several studies however, do report an increase in complications when starting PT too soon after ALND, with Schultz et al. suggesting that a delay of one week can help reduce the incidence of postoperative seromas [61]. ...
Fortunately, with advances in screening and management, the prognosis of breast cancer has substantially improved. However, as patients with breast cancer are living much longer, consequences of management are becoming increasingly apparent, particularly persistent pain after breast cancer surgery. This pain disorder, referred to as Post-Mastectomy Pain Syndrome (PMPS) is common and typically presents as pain with neuropathic features around the surgical incision. This pain disorder is associated with negative effects on the patient’s social and psychological well-being as well as increased healthcare expenditures. Despite the common occurrence of this disorder, it is vastly under-recognized with a lack of preventative and treatment options. This chapter aims to outline the management of persistent breast surgery pain. The pathophysiology and etiology will be reviewed, followed by tools that clinicians can implement in order to appropriately diagnose neuropathic pain. Pertinent risk factors that are commonly seen in practice will be outlined, followed by non-pharmacological, pharmacological, and interventional therapeutic options that can be offered.
... A meta-analysis of randomized controlled trials has shown that postoperative physical therapy has beneficial effects on BC sequelae and thus can improve shoulder function, reduce lymphedema risk, and improve the quality of life [12]. Among all kinds of therapy modalities [13][14][15], active exercises and stretching have been proven to be much more effective in the treatment of upper limb dysfunction than other modalities [16,17], and accordingly, active exercises and stretching are recommended by clinical guidelines [18]. Active exercises have important physiological benefits in maintaining the blood and lymphatic flow to joints and soft tissues, which can prevent the shortening and weakness of the surrounding muscles and connective tissues that may occur following immobilization after surgery [15,19]. ...
... In the Clinical Practice Guidelines for Breast Cancer Rehabilitation, it is recommended that postoperative physical therapy should begin the first day following surgery, gentle ROM exercise should be initiated in the first week after surgery, and the resistive exercises can be started with light weights within 4-6 weeks after surgery. Active stretching exercises can be initiated 1 week after surgery, or when the drain has been removed, and they should be continued for 6 to 8 weeks or until full ROM is achieved in the affected upper extremity [18]. According to the guidelines, we designed a timeline initiating active shoulder exercises 1 week after surgery and PRT 4 weeks after surgery as the control condition for this study. ...
Introduction
Due to advancements in treatment, the survival of breast cancer (BC) patients has significantly improved. Improving the postoperative quality of life has become a widespread concern for patients and doctors. At present, the staged rehabilitation training program for postoperative BC patients has been recognized. However, there is not yet a consensus about the optimal time to initiate rehabilitation training. We designed this study to investigate the optimal intervention times for postoperative BC patients to begin different stages of rehabilitation.
Design
This is a randomized controlled trial. Female participants with BC who are scheduled to undergo mastectomy, including unilateral total breast or breast-conserving surgery plus axillary lymph node dissection, will be enrolled in this study. The intervention includes the following: 200 participants will be allocated using a 1:1:1:1 ratio to the A, B, C, and D groups, which have four different rehabilitation timelines for four phases of rehabilitation exercises. A therapist will evaluate the patient’s overall health and then adjust the training intensity before initiating training. The assessments include upper limb mobility, grip, limb circumference, postoperative drainage volume (PDV), and pain. The training will last for 12 weeks, and patients will undergo follow-up twice within 6 weeks after discharge. Outcomes include the following: Constant-Murley Score (CMS) is the primary parameter. European Organization Research and Treatment of Cancer Quality of Life Questionnaire-BR23 (EORTC QLQ-BR23), SF-36, range of motion (ROM), strength, grip, circumference, PDV, and pain are the secondary parameters. All enrolled subjects will be assessed at 1 day, 3 days, 1 week, and 2, 3, 6, 9, 12, and 18 weeks after the surgery.
Discussion
This is a randomized controlled trial to evaluate the effect of different rehabilitation training timelines to prevent shoulder dysfunction among postoperative patients with BC. If the results are confirmed, this study will establish an optimal timeline for postoperative BC rehabilitation.
Trial registration
ClinicalTrials.gov NCT03658265 . Registered on September 2018.
... Accessing a physiotherapist with experience in managing breast cancer-related upper limb impairments can be difficult, due to the low numbers of physiotherapists within this specialty [17]. Provision of a preoperative review and postoperative follow-up care for up to 1 year after surgery with long-term ongoing surveillance is recommended to optimize physical and functional well-being after breast cancer surgery [5,18,19]. Although access to physiotherapy services for breast cancer surgery varies between and within nations, it rarely meets these recommendations [20][21][22]. ...
... Throughout the "rehabilitation" section of the interview, participants reported a desire for increased access to physiotherapy services, both before and after surgery, and at later stages of treatment. Alongside clinical practice guidelines, other research with patient populations also supports these recommendations for routine preoperative and follow-up physiotherapy services [18,65,66]. Many participants had extensive breast surgery and axillary clearance (Table 2), which are risk factors for the development of lymphedema [67] and arm and shoulder impairments [68], indicating that this sample had substantial rehabilitation needs from the time of surgery onward. ...
Background:
Physiotherapy-led home rehabilitation after breast cancer surgery can protect against the development of upper limb dysfunction and other disabling post consequences of surgery. A variety of barriers can limit physical rehabilitation outcomes, and patients may benefit from more support during this time. MHealth systems can assist patients during rehabilitation through providing exercise support, biofeedback and information. Before designing mHealth systems for a specific population, developers must first engage with users to understand their experiences and needs.
Objective:
The aim of this study was, firstly, to explore patients' rehabilitation experiences and unmet needs during home rehabilitation after breast cancer surgery and, secondly, to understand their experiences of mHealth technology and the requirements they desire from an mHealth system.
Methods:
This was the first stage of a user-centered design process for an mHealth system. We interviewed ten breast cancer survivors under the two main topics of 'Rehabilitation' and 'Technology' and performed a thematic analysis on the interview data.
Results:
Discussions on rehabilitation focused on acute and long-term consequences of surgery; unmet needs and lack of support; self-driven rehabilitation; and visions for high quality rehabilitation. Regarding technology, participants reported a lack of mHealth for this clinical context and using non-cancer specific applications and wearables. Participants requested an mHealth tool from a reliable source which provides exercise support.
Conclusions:
There are unmet needs surrounding access to physiotherapy, information and support during home rehabilitation after breast cancer surgery which could be addressed with an mHealth system. Breast cancer survivors are open to using an mHealth system and require that it comes from a reliable source and focuses on supporting exercise performance.
Clinicaltrial:
... Besides this, there are measures of lymphedema control for patients with breast cancer, with measurements at four circumference points: metacarpophalangeal joint, fist, 10 cm away from the lateral epicondyle and 12 cm in proximity to the lateral epicondyle regarding the superior limbs from each female patient, in a pre-/post-format. Differences larger than 2 cm at any point represent a statistical difference and, therefore, a lymphedema [25]. ...
Background
Physical activity has been shown to benefit patients undergoing adjuvant cancer therapy. Although exercise interventions may be applied in several settings, most trials have focused on specialized facilities for their interventions. While these approaches benefit the access for individuals living near exercise centers, it hampers the assessment of real-world effectiveness. Therefore, evaluating the feasibility and implementation of home-based models of exercise training, especially in low-to-middle-income settings, may inform future physical activity trials and programs. In this article, we present the protocol for the BENEFIT CA trial, which aims to assess the implementation of a remote exercise intervention for patients with breast cancer or prostate cancer, primarily quantifying adherence to an exercise program.
Methods
This is a 12-week study, utilizing a non-randomized, single-arm design to assess the feasibility of a home-based exercise training. The intervention is remotely guided, and participants also receive an educational component about cancer and exercise. The study aims to recruit 40 patients diagnosed with breast cancer and 40 patients diagnosed with prostate cancer, all of whom undergoing active hormonal treatment. The primary outcome is the level of adherence, indicated as the proportion of performed exercise episodes. Secondary outcomes include recruitment rates, fatigue, quality of life, and functional capacity. Adverse events will be monitored throughout the study. Because this is a feasibility trial, the statistical analysis plan is based on descriptive statistics, which encompasses an intention-to-treat analysis and a plan for handling missing data.
Discussion
This is a low-cost feasibility study to orient the design of a wide-range, pragmatic phase 3 trial based on remote exercise intervention. With this study, we aim to better understand the adherence and implementation strategies regarding home-based exercise for the proposed population and, in the near future, move forward to a randomized clinical trial. In addition, this trial may contribute to engage patients with cancer in exercise programs throughout their treatment and beyond.
Trial registration
This trial has been approved by the Hospital de Clínicas de Porto Alegre Ethics Committee/IRB (48,869,621.9.0000.5327), and it is registered at Clinicaltrials.gov (NCT05258526), registered on February 25, 2022, prior to the beginning of the study.
... Consistent with principle of neuropathic pain therapy, a multimodal strategy should be considered in pain management after breast cancer procedure, including non-pharmacological and pharmacological intervention. 20 Physical rehabilitation is commonly recommended in breast cancer survivors at early postoperative phase, 21 providing not only pain relief, but also improving shoulder motion, lymphedema, fatigue, physical functioning, anxiety, and sleep disorder. 22 Oral medication may be required for those who need long-term control of symptoms, as one third of patients reported ongoing moderate to severe pain. ...
Purpose:
Post-mastectomy pain syndrome is a common yet debilitating neuropathic complication after breast cancer procedures, resulting in significantly reduced quality of life. Recently, emerging evidence has supported the therapeutic effect of magnesium administration in chronic pain. However, the role of magnesium supplementation in development of chronic pain after breast cancer surgery remains less known. The aim of this study was to evaluate therapeutic effect of magnesium supplementation on persistent pain after breast cancer procedure.
Patients and methods:
This was a randomized, double-blind, placebo-controlled clinical trial. A total of 109 patients who underwent breast cancer procedure received magnesium-L-threonate (n = 48) or placebo (n = 61) for 12 weeks. Chronic pain incidence, short form of the McGill Pain Questionnaire (SF-MPQ), Generalized Anxiety Disorder Scale (GAD-7), Patient Health Questionnaire-9 (PHQ-9), Pittsburgh Sleep Quality Index (PSQI), and Telephone Interview for Cognitive Status (TICS) were evaluated at 3- and 6-month follow-up.
Results:
About 31% (15 out of 48) of patients reported chronic pain after magnesium supplementation, and 26% (16 out of 61) of the control group at 6-month follow-up respectively. Total scores of SF-MPQ were significantly increased in the control group 6 months after surgical intervention (mean difference, 1.475; 95% CI, -2.730 to -0.2211), but NOT in the magnesium treated group (mean difference, 1.250; 95% CI, -2.775 to 0.2748). No significant differences were found between two cohorts on SF-MPQ, GAD-7, PHQ-9, PSQI, or TICS at each timepoint.
Conclusion:
Oral supplementation of magnesium-L-threonate did not effectively prevent the development of persistent pain in breast cancer survivors, nor provide sufficient pain relief over placebo. We did not observe improvement of pain, mood, sleep disorder, or cognitive function after 12-week magnesium supplementation. Future study may focus on magnesium combined with other effective anti-neuropathic pain treatment.
... Patient education is an important component of BCRL prevention. Given the benefits of early BCRL treatment and in light of evidence that patient-reported arm symptoms (e.g., clothing or jewelry tightness, arm heaviness) may be prodromal [45][46][47], all breast cancer patients should know the importance of contacting their healthcare providers immediately should such symptoms arise [48][49][50]. Since cellulitis may act as a trigger for BCRL, patients should also be cautioned to avoid infections [49]. ...
Purpose
Breast cancer-related lymphedema (BCRL) represents a lifelong risk for breast cancer survivors and once acquired becomes a lifelong burden. This review summarizes current BCRL prevention and treatment strategies.
Findings
Risk factors for BCRL have been extensively studied and their identification has affected breast cancer treatment practice, with sentinel lymph node removal now standard of care for patients with early stage breast cancer without sentinel lymph node metastases. Early surveillance and timely management aim to reduce BCRL incidence and progression, and are further facilitated by patient education, which many breast cancer survivors report not having adequately received. Surgical approaches to BCRL prevention include axillary reverse mapping, lymphatic microsurgical preventative healing (LYMPHA) and Simplified LYMPHA (SLYMPHA). Complete decongestive therapy (CDT) remains the standard of care for patients with BCRL. Among CDT components, facilitating manual lymphatic drainage (MLD) using indocyanine green fluorescence lymphography has been proposed. Intermittent pneumatic compression, nonpneumatic active compression devices, and low-level laser therapy appear promising in lymphedema management. Reconstructive microsurgical techniques such as lymphovenous anastomosis and vascular lymph node transfer are growing surgical considerations for patients as well as liposuction-based procedures for addressing fatty fibrosis formation from chronic lymphedema. Long-term self-management adherence remains problematic, and lack of diagnosis and measurement consensus precludes a comparison of outcomes. Currently, no pharmacological approaches have proven successful.
Conclusion
Progress in prevention and treatment of BCRL continues, requiring advances in early diagnosis, patient education, expert consensus and novel treatments designed for lymphatic rehabilitation following insults.
... C ancer-related fatigue (CRF) is a symptom commonly experienced by patients during the course of cancer and its treatment (1). It is described as a distressing permanent feeling of tiredness or exhaustion concerned to cancer that is not related to recent activity and interferes with common functioning (2). It can be defined in terms of perceived energy, mental capacity, and psychological situation (3,4). ...
... We considered 80% or more as the minimal acceptable adherence level for both UBE and compression therapy, a standard commonly used for adherence. 31 The majority of studies either did not report adherence to the UBE program or rates were unclear. Moreover, none of the studies reported details on the type of compression used during exercise sessions, a factor that may influence response. ...
Purpose
This systematic review aimed to examine the benefit of combined upper body exercise and compression therapy for breast cancer related lymphedema.
Method
Electronic searches were performed in Medline, EMBASE, CINAHL, SPORTDiscus, and PEDRO. We included randomized and controlled clinical trials that examined the effect of upper body exercise with use of compression therapy on arm lymphedema. Where data were available, effect sizes were calculated. Risk of bias was assessed using the Cochrane risk-of-bias tool. The quality of evidence was rated using Grading of Recommendations Assessment, Development and Evaluation (GRADE).
Results
Of 444 studies, 11 met all inclusion criteria. Two cross-over trials examined single bouts of upper body exercise with or without compression, three intervention trials examined non-resisted upper body exercise and compression, and six intervention trials examined upper body resistance exercise and compression. Only two studies reported statistically significant benefit from the combined intervention for arm lymphedema volume. Seven studies provided adequate data to allow for calculation of effect size; however, heterogeneity precluded pooling of data. The quality of evidence was moderate in intervention trials comparing combined upper body exercise and compression to standard care ( n = 1) or to exercise alone ( n = 1). For all other trials the grade of evidence was low, with quality ratings downgraded due to small sample sizes and/or high or unclear risk of bias.
Conclusions
No clear conclusions could be made regarding the benefit of combined upper body exercise and compression for breast cancer related lymphedema. Further high-quality trials are warranted.
... /fpsyt. . emergence of further evidence in this evolving domain of research (54,55). ...
Introduction
Evidence suggests that family-center collaborative care is useful for individuals identified with chronic mental illness. Clinical practice guidelines offer specific recommendations primarily based on to be had studies and are beneficial in informing evidence-based practice and guiding destiny studies.
Objective
Identify current scientific practice guidelines including family-center collaborative care suggestions for individuals with Bipolar Mood Disorder, Schizophrenia, and Major Depressive Disorder and analyze the selection of guidelines for their methodological quality.
Methods
A systematic search was conducted on seven electronic databases (G-I-N), (NICE), (MOH), (SIGN), (WHO), (NIH) and (APA) and additional sources. Three referees independently reviewed articles and selected guidelines for inclusion criteria. Subsequently, 18 trained appraisers independently assessed all 15 guidelines using AGREE II.
Results
The mean scores for domains and overall quality were computed. For the overall assessment of the guidelines, 60% reached the quality threshold with domain scores of 60%. The overall average quality rating for these guidelines was 58/29%.
Conclusion
The applicability of the guidelines needs to be improved in order to improve their relevance and clinical utilization. As individuals with chronic mental illnesses progress through their disease course, families and health care providers play a crucial role in helping them. The analysis of research knowledge on effective rehabilitation techniques, including the involvement of families in treatment, can be enhanced by using well-developed and appropriate methods.
... Surgery, chemotherapy, radiotherapy, and hormonal therapy for breast cancer lead to many consequences, such as inflammation and tissue adherence, causing pain and altering the patients' quality of life (QoL) [3,4]. The more frequent rehabilitation problems in women with breast cancer are as follows [5][6][7][8][9]: ...
Purpose
To evaluate the effects of a protocol treatment based on inelastic adhesive tape with cetylated fatty acids (CFAs) esters in breast cancer survivors with chronic neck pain.
Methods
In this observational study, patients have been visited for chronic neck pain using numeric rating scale (NRS) for pain assessment, Neck Disability Index (NDI) for disability caused by neck pain, and range of movement (ROM) measures for cervical mobility. Scales have been performed at T0, after 15 days of treatment (T1) and successively after 15 days of stop treatment (T2). Patients have been treated with an inelastic adhesive tape with CFA esters (Cetilar® Tape, Pharmanutra Spa, Italy) positioned, 8 h/day for 15 days, on specific anatomic sites (upper trapezius, paravertebral cervical muscles, sub-occipitals, and/or levator scapulae muscles).
Results
Forty-five patients were included in the study. A statistically significant reduction in pain has been reported from T0 to T1 and maintained at T2 ( p < 0.05); a statistically significant improvement in the mobility of the cervical spine, as evidenced by ROMs, and in disability, as resulted by Neck Disability Index, have been reported from T0 to T1 and maintained at T2; moreover, ROM at T0 correlates inversely and statistically significantly with NRS and all NDI variables at T0, similarly at T1 and T2 ( p < 0.001).
Conclusions
CFA ester taping is a simple, effective, and side-effect-free treatment in order to reduce pain and improve cervical mobility in breast cancer survivors with chronic neck pain.
... Besides this, there are measures of lymphedema control for the breast cancer patients, with measurements at four circumference points: metacarpophalangeal joint, fist, 10cm away from the lateral epicondyle and 12cm in proximity to the lateral epicondyle regarding the superior limbs from each female patient, at the beginning and at the end of the intervention. Differences larger than 2cm at any point represent a statistical difference and, therefore, a lymphedema (24). ...
Background Physical activity promotes benefits regarding adjuvant cancer therapy. Although exercise interventions may be applied in several settings, most trials involve participants going to specific facilities to engage in interventions. However, such approaches tend to restrict the access to people living nearby exercise centers, also reducing the assessment of real-world effectiveness. Therefore, evaluating the feasibility and implementation of home-based models of exercise training, especially in low-to-middle income settings, may inform future physical activity trials and programs. We herein present the protocol for the BENEFIT CA trial, with its’ goal to assess the implementation of a remote exercise intervention for patients with breast cancer or prostate cancer, primarily aiming to quantify adherence to an exercise program. Methods This study consists of a 12-week non-randomized, single arm, feasibility trial assessing a home-based exercise training, remotely guided, without a restricted follow-up, as well as an educational component, about cancer and exercise. Forty patients diagnosed with breast cancer and 40 patients diagnosed with prostate cancer, both being under active hormonal treatment, are being recruited. The primary outcome is the level of adherence, indicated as the proportion of performed exercise episodes. Secondary outcomes are related to recruitment rates, fatigue and quality of life scores, and functional capacity assessments. Throughout the study, adverse events will be accounted for. Because this is a feasibility trial, the statistical analysis plan is based on descriptive statistics, which encompasses an intention-to-treat analysis and a plan for handling missing data. Discussion This is a low cost feasibility study to orient the design of a wide range, pragmatic phase-three trial based on remote exercise intervention. With this study, we aim to better understand the adherence and implementation strategies regarding home-based exercise for the proposed population and, in the near future, move forward to a randomized clinical trial. In addition, this trial may contribute to engage patients with cancer to exercise programs throughout their treatment and beyond. Trial registration: this trial has been approved by the Hospital de Clínicas de Porto Alegre Ethics Committee/IRB (48869621.9.0000.5327) and registered at the Clinicaltrials.gov (NCT05258526), registered on 25 February of 2022, prior to the beginning of the study, prior to the beginning of the study. Keywords: feasibility; home-based; physical activity; exercise; cancer.
... PF muscle training) to treat PF dysfunction should be integrated into existing breast cancer physiotherapy treatments. Women with breast cancer may access physiotherapy to manage other side effects of cancer treatment such as lymphoedema, cancer-related pain and fatigue, scar tissue, limited shoulder range of movement and body deconditioning after cancer treatment [32]. In this study, the majority of participants wanted to access treatment for PF dysfunction after primary cancer treatment when other side effects of cancer treatment generally develop, as they tend to access physiotherapy services at this point in their cancer recovery. ...
Purpose
To explore the experiences of women with breast cancer and pelvic floor (PF) dysfunction and the perceived enablers and barriers to uptake of treatment for PF dysfunction during their recovery.
Method
Purposive sampling was used to recruit 30 women with a past diagnosis of breast cancer and PF dysfunction. Semi-structured interviews were conducted, and data were analysed inductively to identify new concepts in the experiences of PF dysfunction in women with breast cancer and deductively according to the capability, opportunity, motivation and behaviour (COM-B) framework to identify the enablers and barriers to the uptake of treatment for PF dysfunction in women with breast cancer.
Results
Participants were aged between 31 and 88 years, diagnosed with stages I–IV breast cancer and experienced either urinary incontinence ( n = 24/30, 80%), faecal incontinence ( n = 6/30, 20%) or sexual dysfunction ( n = 20/30, 67%). They were either resigned to or bothered by their PF dysfunction; bother was exacerbated by embarrassment from experiencing PF symptoms in public. Barriers to accessing treatment for PF dysfunction included a lack of awareness about PF dysfunction following breast cancer treatments and health care professionals not focussing on the management of PF symptoms during cancer treatment. An enabler was their motivation to resume their normal pre-cancer lives.
Conclusion
Participants in this study reported that there needs to be more awareness about PF dysfunction in women undergoing treatment for breast cancer. They would like to receive information about PF dysfunction prior to starting cancer treatment, be screened for PF dysfunction during cancer treatment and be offered therapies for their PF dysfunction after primary cancer treatment. Therefore, a greater focus on managing PF symptoms by clinicians may be warranted in women with breast cancer.
... We undertook a literature review to identify systematic reviews and clinical trials investigating the effectiveness and potential adverse effects from exercise interventions for breast cancer patients. We also reviewed national and international breast cancer clinical guidelines [62][63][64] and the types of exercises reported to be prescribed within the UK survey of physiotherapy and oncology departments. 61 We considered the content, timing, duration and setting of delivery of exercises. ...
Background
Upper limb problems are common after breast cancer treatment.
Objectives
To investigate the clinical effectiveness and cost-effectiveness of a structured exercise programme compared with usual care on upper limb function, health-related outcomes and costs in women undergoing breast cancer surgery.
Design
This was a two-arm, pragmatic, randomised controlled trial with embedded qualitative research, process evaluation and parallel economic analysis; the unit of randomisation was the individual (allocated ratio 1 : 1).
Setting
Breast cancer centres, secondary care.
Participants
Women aged ≥ 18 years who had been diagnosed with breast cancer and were at higher risk of developing shoulder problems. Women were screened to identify their risk status.
Interventions
All participants received usual-care information leaflets. Those randomised to exercise were referred to physiotherapy for an early, structured exercise programme (three to six face-to-face appointments that included strengthening, physical activity and behavioural change strategies).
Main outcome measures
The primary outcome was upper limb function at 12 months as assessed using the Disabilities of Arm, Hand and Shoulder questionnaire. Secondary outcomes were function (Disabilities of Arm, Hand and Shoulder questionnaire subscales), pain, complications (e.g. wound-related complications, lymphoedema), health-related quality of life (e.g. EuroQol-5 Dimensions, five-level version; Short Form questionnaire-12 items), physical activity and health service resource use. The economic evaluation was expressed in terms of incremental cost per quality-adjusted life-year and incremental net monetary benefit gained from an NHS and Personal Social Services perspective. Participants and physiotherapists were not blinded to group assignment, but data collectors were blinded.
Results
Between 2016 and 2017, we randomised 392 participants from 17 breast cancer centres across England: 196 (50%) to the usual-care group and 196 (50%) to the exercise group. Ten participants (10/392; 3%) were withdrawn at randomisation and 32 (8%) did not provide complete baseline data. A total of 175 participants (89%) from each treatment group provided baseline data. Participants’ mean age was 58.1 years (standard deviation 12.1 years; range 28–88 years). Most participants had undergone axillary node clearance surgery (327/392; 83%) and 317 (81%) had received radiotherapy. Uptake of the exercise treatment was high, with 181 out of 196 (92%) participants attending at least one physiotherapy appointment. Compliance with exercise was good: 143 out of 196 (73%) participants completed three or more physiotherapy sessions. At 12 months, 274 out of 392 (70%) participants returned questionnaires. Improvement in arm function was greater in the exercise group [mean Disabilities of Arm, Hand and Shoulder questionnaire score of 16.3 (standard deviation 17.6)] than in the usual-care group [mean Disabilities of Arm, Hand and Shoulder questionnaire score of 23.7 (standard deviation 22.9)] at 12 months for intention-to-treat (adjusted mean difference Disabilities of Arm, Hand and Shoulder questionnaire score of –7.81, 95% confidence interval –12.44 to –3.17; p = 0.001) and complier-average causal effect analyses (adjusted mean difference –8.74, 95% confidence interval –13.71 to –3.77; p ≤ 0.001). At 12 months, pain scores were lower and physical health-related quality of life was higher in the exercise group than in the usual-care group (Short Form questionnaire-12 items, mean difference 4.39, 95% confidence interval 1.74 to 7.04; p = 0.001). We found no differences in the rate of adverse events or lymphoedema over 12 months. The qualitative findings suggested that women found the exercise programme beneficial and enjoyable. Exercise accrued lower costs (–£387, 95% CI –£2491 to £1718) and generated more quality-adjusted life years (0.029, 95% CI 0.001 to 0.056) than usual care over 12 months. The cost-effectiveness analysis indicated that exercise was more cost-effective and that the results were robust to sensitivity analyses. Exercise was relatively cheap to implement (£129 per participant) and associated with lower health-care costs than usual care and improved health-related quality of life. Benefits may accrue beyond the end of the trial.
Limitations
Postal follow-up was lower than estimated; however, the study was adequately powered. No serious adverse events directly related to the intervention were reported.
Conclusions
This trial provided robust evidence that referral for early, supported exercise after breast cancer surgery improved shoulder function in those at risk of shoulder problems and was associated with lower health-care costs than usual care and improved health-related quality of life.
Future work
Future work should focus on the implementation of exercise programmes in clinical practice for those at highest risk of shoulder problems.
Trial registration
This trial is registered as ISRCTN35358984.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 26, No. 15. See the NIHR Journals Library website for further project information.
... These improved outcomes have called health professionals' attention to those long-term side effects faced by breast cancer survivors either related to the disease or to their treatment [4][5][6]. As an example, a substantial fraction of breast cancer survivors does experience long-term side effects that include fatigue, lymphedema, peripheral neuropathy, neurocognitive dysfunction, and persistent pain, as well as an increased risk of developing cardiovascular disease, metabolic disturbances, and compromised mental health (e.g., depression and anxiety) [7][8][9][10][11][12][13]. All these aspects negatively affect quality of life of breast cancer survivors. ...
Background
Most cancer patients, under active treatment or not, are sedentary, despite increasing scientific and clinical understanding of the benefits of exercise and physical activity, such as improving quality of life, limiting disease symptoms, decreasing cancer recurrence, and increasing overall survival. Studies have shown that both supervised exercise and unsupervised physical activity programs have low adherence and limited long-term benefits among cancer survivors. Therefore, interventions focused on increasing physical activity levels have clinical and psychological relevance. The present study will examine the feasibility and efficacy of an intervention that combines supervised group exercise with active lifestyle recommendations, analyzing its clinical, psychological, physiological, functional, and immunological effects in breast cancer survivors.
Methods
Women aged 35–75 years who have completed chemotherapy, radiotherapy, and surgery for breast cancer will be recruited from the Cancer Institute of the State of Sao Paulo (ICESP) and take part in a 16-week, parallel-group, randomized, and controlled trial. They will receive a booklet with recommendations for achieving a physically active lifestyle by increasing overall daily movement and undertaking at least 150 min/week of structured exercise. Then, they will be randomized into two groups: the supervised group will take part in two canoeing group exercise sessions every week, and the unsupervised group will increase their overall physical activity level by any means, such as active commuting, daily activities, or home-based exercise. Primary outcome includes aerobic capacity. Secondary outcomes are physical activity, physical functioning, self-reported quality of life, fatigue, presence of lymphedema, body composition, immune function, adherence to physical activity guidelines, and perceptions of self-image.
Discussion
Results should contribute to advance knowledge on the impact of a supervised group exercise intervention to improve aspects related to health, physical functioning, and quality of life in female breast cancer survivors.
Trial registration
Brazilian Registry of Clinical Trials Number: RBR-3fw9xf. Retrospectively Registered on 27 December 2018. Items from the World Health Organization Trial Registration Data Set can be accessed on http://www.ensaiosclinicos.gov.br/rg/RBR-3fw9xf/ .
... Adjuvant cancer therapy has been reported to have a relationship with PMPS in many studies. It has been found that surgery induced injury is aggravated by radiation therapy 23 .Gartner et al. 13 in his study on post mastectomy pain showed that radiation treatmenthas a significant association risk , but this is not related to the extent of the field of radiation and not related to severity as well. The same study also reported non independent relation of chemotherapy with pain. ...
Post mastectomy pain syndrome is one of the most common complications after axillary surgery for breast cancer. PMPS is considered a neuropathic pain and is thought to be caused by a variety of pre-operative, intraoperative and postoperative risk factors. In this study all post operative patients for breast cancer were interviewed at follow-up visits for symptoms of pain according to DN4 neuropathic pain score questionnaire and VAS scale for pain intensity. A total of 97 patients were included according to inclusion criteria. Among them 24(24.74%) patients were having PMPS and 73(77.06%) were having no PMPS. Among risk factors, ALND was found to be the most important risk factor for development of PMPS. In most patients the pain was mild in intensity according to VAS scale. And site of the pain was mostly found to be ipsilateral chest wall and axilla and majority of patients pin responded to simple NSAIDS and Arm exercises. Keywords: Breast cancer, mastectomy, pain
... A primary finding of this study was that adherence to daytime compression was less than optimal. At present, compression garments are the mainstay of lymphedema self-management [10] , and are generally recommended for use during all waking hours [23,24] . Poor adherence to BCRL self-care practices has been associated with increased arm volume and progression of BCRL to more advanced stages [12] , supporting the importance of good adherence. ...
Aim: The objective of this follow-up study was to explore the barriers and facilitators to use of daytime compression among women with breast cancer related lymphedema who previously took part in a trial examining the efficacy of night compression.
Methods: We used a multi-methods approach involving a survey and subsequent focus group sessions. The survey questions were developed based on clinical experience and findings from the literature. Questions were framed to align with the Theoretical Domains Framework. For the focus group data, we applied an interpretive description qualitative methodology to understand participants’ experiences and views on use of daytime compression. Qualitative findings were mapped to the Theoretical Domains Framework.
Results: Questionnaires were completed by 48 of 52 participants. Only 15 participants (31%) reported adhering to wearing the garment for greater than 12 h each day. Better adherence was positively associated with perceived control of lymphedema (r = 0.304; 95%CI: 0.051-0.564 ; P = 0.021). Survey findings suggest that participants have good knowledge about the rationale for, and the benefits of, wearing the compression sleeve. Twenty-three survey respondents took part in one of the five subsequent focus group sessions. Five key themes were identified representing the primary barriers to regular use of daytime compression: discomfort, negative emotions, interference with function, social situations and visibility, and use of alternative management strategies.
Conclusion: The findings suggest less than optimal adherence to daytime compression sleeve use. Further research is needed to explore the relative benefit of daytime compression, optimal wear times, and implementable strategies to improve adherence.
... 5,[9][10][11][12][13][14][15][16] Exercise has been shown to improve the physical function of breast cancer survivors and quality of life in several high quality studies. 6,8,9,12,15,[17][18][19][20][21] Exercise has been shown to be beneficial in symptom management for patients receiving adjuvant therapy such as chemotherapy and/or radiotherapy. [22][23][24][25][26] Furthermore, upper body exercise, including resistance exercise, is safe for women at risk for or with lymphedema following breast cancer. ...
Purpose: To examine the effects of a group exercise program on shoulder pain, disability, range of motion, and strength. Method: This was an observational study of twenty-six patients who had undergone breast cancer surgery and were receiving physiotherapy intervention. The intervention was a supervised 8-week exercise group program. The primary outcome measure was shoulder pain and disability index (SPADI). Secondary outcome measures were shoulder range of motion of flexion and abduction and strength of shoulder flexion and abduction. Results: The average age of patients referred to the group was 56-years (range of 29 to 71 years). The average time since surgery was 6-9 months (range of 2 to 16 months). The exercise group intervention resulted in small reductions in SPADI scores (pConclusion: An 8-week group exercise program can be effectively implemented in the clinic without any seen side effects. There were improvements in shoulder range of motion and strength, and a reduction in pain and disability although not clinically significant. This pilot study assists clinicians with incorporating an exercise program for patients in breast cancer rehabilitation.
... Pain education and exercise have been suggested as effective in reducing postoperative pain [12,13]. Although there is evidence regarding the effectiveness of early PT [14], surgeons still refrain from referring to PT as it may lead to increased bleeding, seroma (fluid accumulation in the tissue) [15], and lymphedema (chronic edema) [16,17]. It is arising the discussion when it is the right time to start PT and exercises [18,19]. ...
Background
Morbidity of the shoulders after breast cancer (BC) surgery is a common side effect that includes; persistent pain, function limitation, and decreased range of motion (ROM). This study examines the effect of early physical therapy (PT) and patient's education on these morbidities.
Methods
A prospective, randomized clinical trial was conducted at a single medical center from October 2018 until April 2019. Women scheduled for breast cancer surgery were divided into intervention or control as standard care. The intervention included a PT treatment that included exercise instructions from the first postoperative day. Pain levels, upper limb function, ROM, and complications were measured.
Results
The study includes 157 women (mean age, 52.2 ± 12.9). Early PT reduced pain levels at the first month (NPRS 1.5 ± 1.2) and six months (NPRS 0.5 ± 0.8), compared with control (NPRS 2.1 ± 1.4, 1.0 ± 1.2), p = 0.019 and p = 0.011, respectively. Subdivision of the sample into small and extensive surgeries revealed additional positive effect for the intervention six months postoperatively on functional disabilities, p = 0.004 and p = 0.032 respectively. No complications attributable to the intervention were recorded.
Conclusions
Early PT and patient education reduces pain levels, and may improve function disabilities, without causing postoperative complications, although a larger study is needed to achieve unequivocal results.
... While evaluating pain, the emotional status should be assessed carefully. 13,14 Furthermore, emotional distress management is recommended as a routine part of cancer care. 15 Jacobson first described progressive muscle relaxation exercises (PRE) in 1938. ...
Background Aromatase inhibitors (AI) have positive effects on disease-free life in patients with Breast Cancer (BC); on the other hand, their side effects especially arthralgia can be observed in many of patients. This study aimed to evaluate the effectiveness of Progressive Relaxation Exercises (PRE) on the common side effects of AI in patients with BC. Methods A total of 44 patients receiving AI were allocated to the study and control groups in this randomized controlled, single-blind trial. The study group (n=22) performed a combined (one-day supervised, and 3 days home-based) PRE program 4 days/week, for six weeks. The control group (n=22) was given advice about relaxation in daily life. Data was collected initially and after 6 weeks of the intervention. Pain, quality of life (QoL) and emotional status (ES) were assessed using the Brief Pain Inventory (BPI), Functional Assessment of Chronic Illness Therapy (FACT) and Hospital Anxiety and Depression (HAD) scales, respectively. Results Pain was significantly reduced within the study group in Pain Severity (p=0.001) and Pain Interference (p=0.01) sub-scores. Pain was also reduced between the groups as compared using the Pain Severity (p=0.00) and Patient Pain Experience (p=0.003) sub-scores; QoL and ES remained with no significant difference either within the groups or between the groups (p>0.05). Conclusion The results of this study showed that PRE significantly decreased pain scores in BC patients receiving AI. Although the reduction in pain is a valuable data even in the 6-week period in those cases, the long-term effects of relaxation techniques need to be followed.
... There remains, however, an unmet need in the cancer population, and only a limited number of survivors receive the appropriate rehabilitation intervention that they need (40,41). Furthermore, despite acknowledging rehabilitation as an integral component of the management of cancer patients, rehabilitation-specific guidelines for many cancer groups are limited, and many general cancer guidelines do not incorporate recommendations for specific rehabilitation interventions (42)(43)(44). ...
Objective:
To evaluate existing evidence from published systematic reviews for the effectiveness of rehabilitation interventions in patients with lymphoma.
Data sources:
A comprehensive literature search was conducted using medical/health science databases up to 1 October 2020. Bibliographies of pertinent articles, journals and grey literature were searched.
Data extraction and synthesis:
Two reviewers independently selected and reviewed potential reviews for methodological quality and graded the quality of evidence for outcomes using validated tools. Any discrepancies were resolved by final group consensus.
Results:
Twelve systematic reviews (n = 101 studies, 87,132 patients with lymphoma) evaluated 3 broad categories of rehabilitation interventions (physical modalities, nutrition and complementary medicine). Most reviews were of moderate-to-low methodological quality. The findings suggest: moderate-quality evidence for exercise programmes for improved fatigue and sleep disturbance; low-quality evidence for exercise therapy alone and qigong/tai chi for improved symptoms and overall quality of life, and an inverse association between sunlight/ultraviolet radiation exposure and incidence of non-Hodgkin's lymphoma; and very low-quality evidence for beneficial effects of yoga for sleep disturbances. Association between physical activity and lymphoma risk is not indistinct.
Conclusion:
Despite a range of rehabilitative modalities used for patients with lymphoma, high-quality evidence for many is sparse. Beneficial effects of exercise programmes were noted for fatigue, psychological symptoms and QoL. More research with robust study design is required to determine the effective rehabilitation approaches.
... Perioperative nerve blocks and pharmacotherapy such as opioids and pregabalin have been reported to be effective in the prevention and management of PPMP [3,9]. In addition, clinical practice guidelines for breast cancer recommend postoperative rehabilitation, including exercise and physical activity, for pain and improvement of upper limb dysfunction [10]. However, many patients with breast cancer still have pain and dysfunction in their upper limb despite the efficacy of perioperative nerve blocks, pharmacotherapy, and postoperative physiotherapy [9,11,12]. ...
Purpose
Central sensitization (CS)-related symptoms and pain catastrophizing contribute to persistent post-mastectomy pain (PPMP). Pain neuroscience education (PNE) is effective in reducing CS-related symptoms and pain catastrophizing in patients with chronic pain. However, to date, no intervention study of PNE has been conducted to patients with PPMP. This study was aimed to examine whether PNE is more effective than biomedical education (BME) for PPMP.
Methods
In this retrospective case-control study, 118 patients were included. We intervened different patients at different times as follows: (1) a BME group (n = 58) of patients who received BME combined with physiotherapy and (2) a PNE group (n = 60) of patients who received PNE combined with physiotherapy. One year after surgery, we assessed pain intensity and interference (brief pain inventory [BPI]), CS-related symptoms (central sensitization inventory [CSI]), and pain catastrophizing (pain catastrophizing scale [PCS]). Propensity score matching was used to reduce or minimize selection bias and confounding biases and to make the number of cases in both groups match 1:1.
Results
Propensity score matching generated the BME group (n = 51) and the PNE group (n = 51). The BPI score, CSI score, and PCS score were statistically significantly lower in the PNE group than in the BME group (all, p < 0.05). The effect sizes for the BPI intensity (r = 0.31) were moderate.
Conclusions
PNE resulted in a better outcome of pain management with less functional disability and CS-related symptoms compared to BME after breast surgery.
... Esses dados podem ter ocorrido pela longinquidade entre iniciar a reabilitação e a alta pós-operatória, isto porque iniciar brevemente a reabilitação para pacientes mastectomizadas é fundamental para a efetividade do tratamento de amplitude de movimento do ombro. A literatura afirma que uma intervenção deve começar o mais cedo possível, sendo defendido o início da reabilitação pós-cirurgia entre quatro a seis semanas (HARRIS et al., 2012). Assim, como no serviço público, o tempo de marcação de uma consulta até o momento de atendimento é um dos principais fatores de insatisfação dos usuários (BRITO; JESUS; FERNANDES, 2012), a entrega de cartilhas ou manuais instrutivos para realização de exercícios físicos domiciliares pode ser uma estratégia para o início oportuno da reabilitação física. ...
Introdução: A realização de exercícios físicos domiciliares é umametodologia segura e eficiente. Entretanto, poucos estudos abordamidosas com câncer de mama mastectomizadas. Objetivo: Verificaro impacto de 12 semanas de um programa de exercícios físicosdomiciliares na amplitude de movimento do ombro de idosas sobreviventes de câncer de mama em tratamento. Métodos: Ensaio clínico randomizado, com idosas mastectomizadas (n=33), 18 idosas para Grupo Controle e 15 para o Grupo Intervenção, realizado de abril anovembro de 2015. Foi ofertado ao Grupo Intervenção um manualde exercícios físicos e DVD previamente desenvolvido. Para o estudo,foram analisados os dados referentes ao teste “Alcançar as Costas”da bateria Senior Fitness Test. As idosas foram avaliadas no inícioda pesquisa e ao término da 12ª semana. Foi realizada análise estatísticadescritiva através do programa estatístico STATA versão 12,com nível de significância de <0,05. Resultados: Após 12 semanas,foram observadas melhora significativa da flexibilidade no grupo deexercícios físicos domiciliares, de acordo com o teste “Alcançar asCostas” da Senior Fitness Test, medido em centímetros (-7.93 ± 11.54a 0.533 ± 7.9, p <0,02), e tendência de piora do Grupo Controle (-12.5± 9.16 a -18.33 ± 9.12, p <0,06). Além disso, alterações referentesà classificação da flexibilidade das idosas de acordo com a idadeforam observadas com ganhos para o Grupo Intervenção (p<0.01).Conclusão: A realização de um programa de exercícios físicos domiciliaresparece ser sensível para a melhora da amplitude de movimentode idosas mastectomizadas em tratamento de hormonioterapia.
... Several authors have reported on the safety and importance of performing exercises, also identifying that they are not associated with the occurrence of certain complications, such as seroma and dehiscence [18][19][20]. Recommendations to perform active exercises in the 1st POD are given according to the Clinical practice guidelines for breast cancer rehabilitation [21] and the systematic review carried out by De Groef et al. [16]. ...
PurposeThe goal of this study is to evaluate the influence of shoulder exercises with restricted amplitude movement (RAM) or free amplitude movement (FAM) performed from the first postoperative day (1st POD) on the incidence of surgical wound complications (SWC) in breast cancer.Methods
This study comprises a randomized clinical trial with an intention-to-treat analysis including 465 women aged 18 to 79, who underwent curative surgery for breast cancer. Participants were submitted to perform free amplitude movement (FAM) or restricted amplitude movement (RAM) shoulder exercises, until the 30th postoperative day. The outcome measures were the SWC: seroma, dehiscence, necrosis, infection, hematoma and bruise.Results461 participants completed the follow-up. Thirty days after surgery, 63.8% of the women presented some surgical wound complication, with necrosis (39.3%) and seroma (30.8%) as the most frequent. No statistically significant differences in SWC according to postoperative amplitude shoulder exercise (FAM vs RAM), even after a stratified analysis by type of surgery (segmentectomy vs mastectomy) or axillary approach (axillary lymphadenectomy versus sentinel lymph node biopsy) were observed.ConclusionFAM exercises do not increase the incidence of postoperative wound complications compared to RAM exercises.Trial registration: NCT03796845
Background
Rehabilitation professionals (RPs) play a major role in identifying, managing, and treating upper-body issues in individuals following breast cancer surgery. Varying definitions of postoperative arm morbidity in the literature have hampered development of standardized surveillance programs for people undergoing breast cancer surgery within clinical care. Our objective was to explore RPs' practices in defining the presence of arm morbidity after breast cancer surgery.
Methods
This qualitative study used semistructured focus group interviews with 29 RPs from 5 health authorities in British Columbia, Canada. Transcripts were analyzed using content analysis.
Results
Two categories captured RPs' overarching lack of consensus in defining the presence of postoperative arm morbidity: (1) Complex concerns, complex considerations ; and (2) Many ways of measuring arm morbidity . Varying perspectives exist as to which upper-body issues and functional criteria constitute arm morbidity, as well as which characteristics to consider in identifying who is at risk of developing arm morbidity. In tandem, there is currently no gold standard outcome measure or standardized assessment to identify arm morbidity.
Conclusion
Because of the complex interaction between different breast cancer treatments and various environmental and personal factors, there is currently a lack of consensus among RPs about how to define and assess arm morbidity. Our findings demonstrate the presence of arm morbidity is challenging to characterize, given its multifaceted presentation, inconsistent approaches to risk stratification across clinical settings and geographical regions the RPs worked, and numerous ways of measuring arm morbidity.
Objective:
To investigate whether advancing the initiation of rehabilitation training compared to the time recommended by the guidelines after breast cancer (BC) surgery is beneficial to the recovery of shoulder function and quality of life.
Design:
Prospective, observational, single center, randomized controlled trial SETTING: The study was conducted between September 2018 and December 2019, with a 12-week supervised intervention and 6-week home-exercise period concluding in May 2020.
Participants:
Two hundred BC patients received axillary lymph node dissection.
Interventions:
Participants were recruited and randomly allocated into 4 groups (A, B, C, and D). Group A started range of motion (ROM) training at 7 days postoperative and progressive resistance training (PRT) at 4 weeks postoperative; Group B started ROM training at 7 days postoperative and PRT at 3 weeks postoperative; Group C started ROM training at 3 days postoperative and PRT at 4 weeks postoperative; and Group D started ROM training at 3 days postoperative and PRT at 3 weeks postoperative.
Main outcome measures:
The primary outcome measure was Constant-Murley Score. Secondary outcome measures included ROM, shoulder strength, grip, EORTC QLQ-BR23, and SF-36. Incidence of adverse reactions (drainage and pain) and complications (ecchymosis, subcutaneous hematoma, lymphedema) were also assessed.
Results:
Participants who started ROM training at 3 days postoperative obtained more benefits in mobility, shoulder function, and EORTC QLQ-BR23 score, while patients who started PRT at 3 weeks postoperative saw improvements in shoulder strength and SF-36. Incidence of adverse reactions and complications were low in all four groups, with no significant differences among the four groups.
Conclusion:
Advancing ROM training initiation to 3 days postoperative or PRT to 3 weeks postoperative can better restore shoulder function after BC surgery and lead to faster quality of life improvement.
Background: Quality of life issues is a crucial burden in breast cancer (BC) survivors with relevant implications in terms of survivorship and health-care costs. The increasing long-term survival of these patients provides new challenges, with translational research now focusing on innovative and tailored approaches to improve their complex management. In this scenario, several emerging biomarkers have the potential to improve the clinical rehabilitative management of patients with BC. However, to date, guidelines supporting biomarker implementation in this area are still lacking. Therefore, the aim of this systematic review was to summarize the currently available biomarkers that might be potentially integrated into rehabilitation practice to promote a precision medicine approach to BC survivorship issues.
Methods: On 9th March 2022, PubMed, Scopus, Web of Science, Cochrane, and PEDro were systematically searched for randomized controlled trials (RCTs) assessing rehabilitation interventions in BC patients. Molecular biomarker modifications induced by physical exercise have been assessed through the review of the study protocols and published results. The Jadad scale was used to assess the quality of the studies included.
Results: Out of 2,224 records, 22 studies were included in the present systematic review. Exercise therapy showed significant results in 15 RCTs, in terms of metabolic biomarkers, including glycemic and insulin profile, and lipid profile ( p ≤ 0.05). Similarly, 12 studies underlined significant effects in inflammation and immune response biomarkers, including TNF-α, IL-6, IL-10, C-reactive protein, leptin, and adiponectin ( p ≤ 0.05). On the other hand, cardiac biomarkers were assessed in three studies without reporting significant differences after exercise therapy (p = NS). The quality assessment identified 19 RCTs as high-quality studies and three RCTs of low quality.
Conclusion: Our findings reveal significant biochemical perturbations in key molecules induced by physical exercise in patients with BC, suggesting room for the implementation of actionable biomarkers. Future research might clarify the role of biomarkers on treatment effectiveness monitoring, to optimize rehabilitative strategies tailored to patient’s needs.
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.
Cancer-related fatigue is a common symptom in patients with cancer, which is experienced by 70% to 100% of these patients and brings some impairment of physical and mental performance, hinders their working or carrying out regular daily activities, and hence results in a substantial reduction of the quality of life. Physical exercise has consistently been identified as a central element of rehabilitation for many chronic diseases like cancer, and increasing evidence supports the contention that physical activity is a valuable intervention that can be utilized in conjunction with conventional therapies during CRF treatment. Objective: The aim of this study was to assess the impact of a program of physical exercise on fatigue levels and physical performance of cancer patients. Method: A consecutive series of 44 adult patients with neoplastic disease (solid or hematological), with a medical diagnosis of fatigue, who were enrolled in an oncological treatment, with the ability to walk and willing to enter a rehabilitation program of exercise for at least 4 consecutive months. The exercise program was performed two times per week, each session lasting one hour and consisting of aerobic, resistance, and flexibility exercises. The protocol was divided into aerobic exercise and resistance training combined with aerobic exercise. The patients were evaluated with two assessments: one prior to their beginning the exercise program and other at the end of the four-month program. In both assessments the patients completed the Revised Piper Fatigue Scale and the six-minute walk test. The primary outcome of change over baseline and after 16 weeks in PFS-R score and six-minute walk test were compared using a two sample two-sided t-test for both groups. Alpha level was set at p < 0.05. Results: After 16 weeks, the patients who participated in the aerobic or the combined exercise program reported significantly higher levels of physical functioning (6-minute walking test, p = 0.0009 and p = 0.001, respectively) and significantly lower fatigue (PFS-R, p = 0.003 and p = 0.002, respectively) than at the beginning the exercise program. Conclusion: The results of patients who underwent aerobic or aerobic + anaerobic exercise showed statistically significant improvement of physical performance and of fatigue. Data from this study corroborates with the literature showing that exercise programs with aerobic or resistance exercises are an effective strategy for the treatment of fatigue. The results of this study confirm that physical exercise could be useful in rehabilitation of cancer survivors, especially for fatigued patients.
Management of all patients with lymphedema begins with nonsurgical management. Lymphedema physical therapy using complete decongestive therapy (CDT) is the mainstay of lymphedema management and consists of two phases: the reduction phase and the maintenance phase. The reduction phase involves either the use of low-stretch bandages or a specialized reduction garment, complemented by manual lymphatic drainage (MLD), to achieve an intensive volume decrease, with adjunctive exercises and skin care. This is followed by a maintenance phase to retain the reduction achieved, which consists primarily of compression garment use with adjunctive use of MLD or a sequential gradient pump. Optimized conservative therapy reduces the rate of disease progression and the risk of cellulitis by reducing the lymphatic fluid stasis and thereby lowering the inflammation. Patients are encouraged to maintain a normal body mass index, exercise, and engage in all activities that do not provoke swelling.Although CDT is an important component of the postoperative management of patients that have undergone surgery for lymphedema, there is increasing emphasis on its role as part of a prehabilitation process to optimize patients before surgery. In this chapter, we describe the techniques and approach for the nonsurgical management of lymphedema.KeywordsComplete/complex decongestive therapy (CDT)ReductionMaintenanceManual lymphatic drainage (MLD)Compression garmentLow-stretch bandagingPneumatic compression device (PCD)Prehabilitation
Significance:
Lymphoedema is a common, distressing and debilitating condition with various aetiologies. Effective diagnosis, assessment and management rely on evidence-based clinical practice guidelines ("guidelines"). This study aims to describe and compare international guidelines on lymphoedema diagnosis, assessment and management. Recent Advances: The review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and registered on the International Prospective Register of Systematic Reviews (PROSPERO). Systematic searches of electronic literature databases and the web were completed in December 2020 for lymphoedema guidelines published in English since 2000. Quality was assessed using the AGREE-II reporting checklist. Synthesis took a narrative approach to compare guideline recommendations and associated levels of evidence.
Critical issues:
This systematic review of 1564 articles and 159 web pages yielded 14 guidelines. All guidelines were from high-income countries. Ten focused exclusively on lymphoedema, and four on cancer. Most (n=13) guidelines recommended an integrated medical, psychological assessment and physical examination, with a limb volume measurement of >10% in the affected limb compared, confirming a lymphoedema diagnosis. Recommended management involved Complex Decongestive Therapy (CDT) followed by self-management using skincare, self-lymphatic drainage massage, exercise and compression.
Future directions:
The underlying aetiology of lymphoedema appeared to make little difference to guideline recommendations regarding care. High-quality guidelines are available to guide lymphoedema care. However, their suitability for low resource settings is unclear.
Purpose
To investigate the access to physical rehabilitation for a range of adverse physical effects following different types of breast cancer surgery.
Methods
Online survey of 632 Australian women (mean age = 59.8 years, SD = 9.6) grouped according to their breast cancer surgery, (i) breast-conserving surgery (BCS; n = 228), (ii) mastectomy (MAST; n = 208), (iii) breast reconstruction (BRS; n = 196), who retrospectively reported whether they received any physical rehabilitation for 6 adverse physical effects. Fisher's exact tests were used to compare the frequency of respondents who received physical rehabilitation for each adverse physical effect among the 3 groups. The percentage of the entire cohort of respondents (n = 632) who had lymph nodes removed, postoperative complications, or preexisting musculoskeletal issues who received physical rehabilitation was also tabulated.
Results
No significant difference was found among the 3 groups in the percentage of respondents who received physical rehabilitation for most adverse physical effects (scar: P = .27; shoulder: P = .11; torso: P = .76; physical discomfort disturbing sleep: P = .74), except lymphedema ( P = .001) and breast support issues ( P = .01), which were significantly less for the BRS and BCS groups. Less than 50% of respondents following all types of breast cancer surgery received physical rehabilitation for issues associated with scars, the torso, and physical discomfort disturbing sleep, whereas more than 70% received physical rehabilitation for shoulder issues and lymphedema.
Conclusion
Access to physical rehabilitation was similar following the different types of breast cancer surgery; however, gaps were identified for adverse physical effects associated with scars, torso, and physical discomfort disturbing sleep, where access was less than that for shoulder issues and lymphedema.
Minimally invasive surgery (MIS) is a set of techniques that enable surgeons to operate on a patient with reduced trauma thereby improving recovery time and limited scarring. Surgery is a complicated task, requiring skilled surgeons operating with tools that extend their dexterity and reach to the region of interest. Within the past 5 years there have been great strides in innovation in applications of computer assistance and robotics to minimally invasive surgery, building upon the initial uptake in the field roughly 3 decades ago. Robotic and minimally invasive surgery have introduced new benefits and challenges to the operating room, the latter of which are being identified and addressed. The benefits of MIS have begun to be revealed within the past two decades, as less trauma to the patient means shorter recovery times, less pain, scarring, and a lower infection rate. This essay presents three different areas of MIS in which computer assistance and technology are innovating. It also describes how each example can apply in practice.
Real-time in-situ histology promises to offer surgeons the ability to make quick decisions about various pathologies resolving inherent impasses for intraoperative surgical resections of tumours. Clinically identifying the right resection margins, or differentiating between normal and abnormal tissue all contribute to improved clinical outcomes for patients undergoing surgery. As such, it is believed that having real-time ability to delineate between various tissue types at specific morphological time-points can allow for characterisation of the tissue itself and facilitate optimal resection to improve clinical outcomes
Minimally invasive surgical intervention includes various surgical approaches ranging from laparoscopic, endoscopic and robotic surgery that requires, dexterity, stereoscopy and precision being advantageous for safety and improved recovery times over traditional open surgical approaches. Neurosurgery is one such specialty that has embraced the minimally invasive approach through micro-neurosurgery over several decades, however the specialty is yet to fully adopt robotic surgery in the United Kingdom, which necessitates advanced judgement of depth. Scene depth estimation is also necessary for augmented reality to aid 3D perceptual registration of preoperative models unto organs intraoperatively.
There has been a paradigm shift in the management of lymphedema with a better understanding of the functioning of lymphatics with the introduction of “lymphosome concept” and with the recent advances in super-microsurgical techniques. The most frequently used intraoperative imaging modality now is indo cyanine green lymphangiography. In endemic countries, any patient with lymphedema without prior history of trauma or, oncosurgical or radiotherapy interventions must undergo Alere filariasis test strip. Patients in early stages of disease can benefit from complex decongestive therapy and physiologic surgical procedures such as lymphovenous anastomosis or vascularized lymph node transfers. However, in advanced disease, excisions or debulking through radical reduction with preservation of perforators will be required. The localized adipose tissue deposits in lymphedema can be removed by liposuction. At present, there is still no cure for lymphedema, but emerging research in tissue engineering, lymphangiogenic growth factors, and immunomodulatory therapy may provide better management options for lymphedema in future.
The goal of the study was to explore the influence of single-nucleotide polymorphisms of the COMT gene on the formation and features of pain syndrome, the level of anxiety, and the need for narcotic analgesics in patients with breast cancer. Materials and methods. The intensity of pain and opioid consumption in the postoperative period were evaluated in 58 patients who met the inclusion criteria of the study and were operated for breast cancer. The frequency of chronic pain syndrome after mastectomy was studied in the same group of patients after a year by using short pain questionnaires, McGill Pain Questionnaire and PainDetect. The anxiety level was assessed by using the HADS questionnaire. Genotyping was performed for single-nucleotide polymorphisms, rs4680, rs740603, rs2097603 = rs2070577, rs4633, of the COMT gene localized in the 22q11.21 region in the studied group of patients. The relationship between the carrier of different genotypes and the intensity of acute and chronic pain, the severity of the pain rating index for sensory and affective characteristics, the presence of a neuropathic component of pain, and the severity of anxiety were studied in the entire sample. The use of narcotic analgesics was evaluated in the postoperative period (IU/day and IU/course) and for the relief of chronic pain. Results. It is shown that the intensity of postoperative pain and the severity of anxiety do not depend on the presence of a mutant allele for the studied polymorphisms of the COMT gene, while the postoperative consumption of opioids in patients with the rs4680 missense mutation in the exon of this gene is significantly less. The dependence of the intensity of chronic pain syndrome and the severity of anxiety on the presence of a mutant allele for the polymorphic locus rs4680 localized in the exon of the COMT gene was established. No significant relationship was observed between the mutant alleles and the use of opioids for chronic pain relief after mastectomy. Conclusion. Genotyping for the COMT gene polymorphisms can be useful for choosing the optimal tactics of pain management in patients with breast cancer.
Introduction
Digital home rehabilitation systems require accurate segmentation methods to provide appropriate feedback on repetition counting and exercise technique. Current segmentation methods are not suitable for clinical use; they are not highly accurate or require multiple sensors, which creates usability problems. We propose a model for accurately segmenting inertial measurement unit data for shoulder rehabilitation exercises. This study aims to use inertial measurement unit data to train and test a machine learning segmentation model for single- and multiple-inertial measurement unit systems and to identify the optimal single-sensor location.
Methods
A focus group of specialist physiotherapists selected the exercises, which were performed by participants wearing inertial measurement units on the wrist, arm and scapula. We applied a novel machine learning based segmentation technique involving a convolutional classifier and Finite State Machine to the inertial measurement unit data. An accuracy score was calculated for each possible single- or multiple-sensor system.
Results
The wrist inertial measurement unit was chosen as the optimal single-sensor location for future system development (mean overall accuracy 0.871). Flexion and abduction based exercises mostly could be segmented with high accuracy, but scapular movement exercises had poor accuracy.
Conclusion
A wrist-worn single inertial measurement unit system can accurately segment shoulder exercise repetitions; however, accuracy varies depending on characteristics of the exercise.
Lymphedema of the extremities related to oncologic therapies such as cancer surgery, radiation therapy, and chemotherapy is a major long-term cause of morbidity for cancer patients. Both nonsurgical and surgical management strategies have been developed. The goals of these therapies are to achieve volume reduction of the affected extremity, a reduction in patient symptoms, and a reduction in associated morbidities such as recurrent soft-tissue infections. In this article, we review both nonsurgical and surgical management strategies. Traditional surgical therapy has focused on more ablative techniques such as the Charles procedure and suction-assisted lipectomy/liposuction. However, newer more physiologic surgical methods such as lymphovenous anastomoses and vascularized lymph node transfers have become a more common treatment modality for the management of this complex problem.
Objectives
Breast cancer survivors experience a wide spectrum of physical sequelae from cancer treatment. National and international guidelines recommend that rehabilitation is offered from the point of diagnosis. However, there is a lack of data on the translation of these recommendations into clinical care. The objective of this study was to explore the experiences of breast cancer survivors, rehabilitation professionals and breast surgeons on current rehabilitation services including preferences for care delivery, specific ways to promote early detection and timely management of upper body issues and attitudes towards self-managed surveillance and rehabilitation.
Design
Qualitative focus groups. Breast cancer survivors completed a questionnaire about rehabilitation services received and experience of upper body issues. These quantitative data were collected to provide context for the qualitative data and increase transferability. Transcripts were analysed using content analysis.
Setting
Five geographically distinct health authorities in British Columbia, Canada.
Participants
Eleven focus groups were conducted with 35 breast cancer survivors, 29 rehabilitation professionals and 5 breast surgeons.
Results
Three categories captured participants’ concern and wish for improved care: (1) cut the cancer out and goodbye ; (2) you have to look out for yourself and (3) in a perfect world . All breast cancer survivors reported chronic upper body issues (mean 4.5 unique issues). Breast cancer survivors expressed worry and uncertainty in their solo management of the rehabilitation. The current services were reported to not enable early detection and timely management. Suggestions included reorganising the timing of patient education and improving the quality of and access to rehabilitation services by elevating the knowledge among healthcare professionals and providing multimodal self-management resources.
Conclusions
The results revealed a gap between oncology guidelines and the current clinical reality. The rehabilitation services were reported in need of revamping to increase equity of care. Multiple upper body issues were reported by many breast cancer survivors.
While the number of cancer patients is increasing with the arrival of the super-aging society, the age-adjusted mortality rate of cancer decreases due to medical advances, and the number of cancer survivors is growing rapidly.
Cardiovascular disease (CVD) is one of the most important causes of death among cancer survivors. In recent years, the number of cancer patients with CVD risk factors has increased. Also, the emergence of new drugs has led to the emergence of a new condition called cancer treatment-related cardiovascular disease (CTRCD).
Cardio-oncology (onco-cardiology) is a new multidisciplinary field with the common goal of completing cancer treatment and improving the prognosis of cancer patients and survivors, including the prevention, diagnosis, and treatment of CTRCD.
Cardio-oncology rehabilitation (CORE) is a new concept that aims to reduce the risk of CVD and improve cardiopulmonary fitness in cancer survivors by providing exercise prescriptions and cardiac rehabilitation in addition to so-called cancer rehabilitation during and after cancer treatment.
This review provides an overview of the theoretical background, feasibility, challenges, and opportunities of CORE, including a series of recent white papers and scientific statements released by the American Heart Association.
Cancer survivors are often highly motivated to seek information about food choices, physical activity, dietary supplement use, and complementary nutritional therapies to improve their treatment outcomes, quality of life, and survival. To address these concerns, the American Cancer Society (ACS) convened a group of experts in nutrition, physical activity, and cancer to evaluate the scientific evidence and best clinical practices related to optimal nutrition and physical activity after the diagnosis of cancer. This report summarizes their findings and is intended to present health care providers with the best possible information on which to help cancer survivors and their families make informed choices related to nutrition and physical activity. The report discusses nutrition and physical activity issues during the phases of cancer treatment and recovery, living after recovery from treatment, and living with advanced cancer; selected nutritional and physical activity issues such as body weight, food choices, and complementary and alternative nutritional options; and selected issues related to breast, colorectal, lung, prostate, head and neck, and upper gastrointestinal cancers. In addition, handouts containing commonly asked questions and answers and a resource list are provided for survivors and families. Tables that grade the scientific evidence for benefit versus harm related to nutrition and physical activity for breast, colorectal, lung, and prostate cancers are also included for this growing body of knowledge to provide guidance for informed decision making and to identify areas for future research.
Neuropathy is a common, often debilitating complication of cancer and its treatment. Effective management of this disorder depends on early diagnosis and an understanding of its underlying causes in the individual patient. In January 2009, NCCN gathered a multidisciplinary group to review the literature and discuss intervention strategies currently available to patients as well as areas that require research efforts. The task force, which comprised experts in anesthesiology, medical oncology, neurology, neuro-oncology, neurophysiology, nursing, pain management, and rehabilitation, was charged with the goal of outlining recommendations for the possible prevention, diagnosis, and management of neuropathy. This report documents the proceedings of this meeting with a general background on neuropathy and neuropathy in oncology, followed by discussions on challenges and research issues, evaluation criteria, and management of different symptoms associated with this disorder.
Bone health and maintenance of bone integrity are important components of comprehensive cancer care in both early and late stages of disease. Risk factors for osteoporosis are increased in patients with cancer, including women with chemotherapy-induced ovarian failure, those treated with aromatase inhibitors for breast cancer, men receiving androgen-deprivation therapy for prostate cancer, and patients undergoing glucocorticoid therapy. The skeleton is a common site of metastatic cancer recurrence, and skeletal-related events are the cause of significant morbidity. The National Comprehensive Cancer Network (NCCN) convened a multidisciplinary task force on Bone Health in Cancer Care to discuss the progress made in identifying effective screening and therapeutic options for management of treatment-related bone loss; understanding the factors that result in bone metastases; managing skeletal metastases; and evolving strategies to reduce bone recurrences. This report summarizes presentations made at the meeting.
Radiation therapy has a major role in the management of breast cancers. However, there is no consensus on how to irradiate and on volume definitions, and there are strong differences in strategies according to different centers and physicians. New treatment protocols and techniques have been used with the principal purpose of decreasing lung and heart toxicity and adapting radiation treatment to patients' anatomy. There is evidence that indicates internal mammary chain radiotherapy should be used carefully and that high quality techniques should be used for decreasing the dose delivered to the heart. This review of the literature presents the state of the art on breast cancer radiotherapy, with special focus on the indications, techniques, and potential toxicity.
Overview Pain, defined as "a sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage,"(1) is one of the most common symptoms associated with cancer. Cancer pain or cancer-related pain is distinct from pain experienced by patients without malignancies. Pain occurs in approximately one quarter of patients with newly diagnosed malignancies, one third of patients undergoing treatment, and three quarters of patients with advanced disease,(2-4) and is one of the symptoms patients fear most. Unrelieved pain denies patients comfort and greatly affects their activities, motivation, interactions with family and friends, and overall quality of life. The importance of relieving pain and availability of effective therapies make it imperative that physicians and nurses caring for these patients be adept at the assessment and treatment of cancer pain.(5-7) This requires familiarity with the pathogenesis of cancer pain; pain assessment techniques; common barriers to the delivery of appropriate analgesia; and pertinent pharmacologic, anesthetic, neurosurgical, and behavioral approaches to the treatment of cancer pain. The most widely accepted algorithm for the treatment of cancer pain was developed by the WHO.(8,9) It suggests that patients with pain be started on acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID). If this is not sufficient, patients should be escalated to a weak opioid, such as codeine, and then to a strong opioid, such as morphine. Although this algorithm has served as an excellent teaching tool, the management of cancer pain is considerably more complex than this 3-tiered "cancer pain ladder"...
Impairments in upper-body function (UBF) are common following breast cancer. However, the relationship between arm morbidity and quality of life (QoL) remains unclear. This investigation uses longitudinal data to describe UBF in a population-based sample of women with breast cancer and examines its relationship with QoL.
Australian women (n=287) with unilateral breast cancer were assessed at three-monthly intervals, from six- to 18-months post-surgery (PS). Strength, endurance and flexibility were used to assess objective UBF, while the Disability of the Arm, Shoulder and Hand questionnaire and the Functional Assessment of Cancer Therapy-Breast questionnaire were used to assess self-reported UBF and QoL, respectively.
Although mean UBF improved over time, up to 41% of women revealed declines in UBF between six- and 18-months PS. Older age, lower socioeconomic position, treatment on the dominant side, mastectomy, more extensive lymph node removal and having lymphoedema each increased odds of declines in UBF by at least two-fold (p<0.05). Lower baseline and declines in perceived UBF between six- and 18-months PS were each associated with poorer QoL at 18-months PS (p<0.05).
Significant upper-body morbidity is experienced by many following breast cancer treatment, persisting longer term, and adversely influencing the QoL of breast cancer survivors.
We undertook research to improve the AGREE instrument, a tool used to evaluate guidelines. We tested a new seven-point scale, evaluated the usefulness of the original items in the instrument, investigated evidence to support shorter, tailored versions of the tool, and identified areas for improvement.
We report on one component of a larger study that used a mixed design with four factors (user type, clinical topic, guideline and condition). For the analysis reported in this article, we asked participants to read a guideline and use the AGREE items to evaluate it based on a seven-point scale, to complete three outcome measures related to adoption of the guideline, and to provide feedback on the instrument's usefulness and how to improve it.
Guideline developers gave lower-quality ratings than did clinicians or policy-makers. Five of six domains were significant predictors of participants' outcome measures (p < 0.05). All domains and items were rated as useful by stakeholders (mean scores > 4.0) with no significant differences by user type (p > 0.05). Internal consistency ranged between 0.64 and 0.89. Inter-rater reliability was satisfactory. We received feedback on how to improve the instrument.
Quality ratings of the AGREE domains were significant predictors of outcome measures associated with guideline adoption: guideline endorsements, overall intentions to use guidelines, and overall quality of guidelines. All AGREE items were assessed as useful in determining whether a participant would use a guideline. No clusters of items were found more useful by some users than others. The measurement properties of the seven-point scale were promising. These data contributed to the refinements and release of the AGREE II.
We established a program of research to improve the development, reporting and evaluation of practice guidelines. We assessed the construct validity of the items and user's manual in the beta version of the AGREE II.
We designed guideline excerpts reflecting high-and low-quality guideline content for 21 of the 23 items in the tool. We designed two study packages so that one low-quality and one high-quality version of each item were randomly assigned to each package. We randomly assigned 30 participants to one of the two packages. Participants reviewed and rated the guideline content according to the instructions of the user's manual and completed a survey assessing the manual.
In all cases, content designed to be of high quality was rated higher than low-quality content; in 18 of 21 cases, the differences were significant (p < 0.05). The manual was rated by participants as appropriate, easy to use, and helpful in differentiating guidelines of varying quality, with all scores above the mid-point of the seven-point scale. Considerable feedback was offered on how the items and manual of the beta-AGREE II could be improved.
The validity of the items was established and the user's manual was rated as highly useful by users. We used these results and those of our study presented in part 1 to modify the items and user's manual. We recommend AGREE II (available at www.agreetrust.org) as the revised standard for guideline development, reporting and evaluation.
Breast-cancer-related lymphedema affects approximately 25% of breast cancer (BC) survivors and may impact use of the upper limb during activity. The purpose of this study is to compare upper extremity (UE) impairment and activity between women with and without lymphedema after BC treatment.
144 women post BC treatment completed demographic, symptom, and Disability of Arm-Shoulder-Hand (DASH) questionnaires. Objective measures included Purdue pegboard, finger-tapper, Semmes-Weinstein monofilaments, vibration perception threshold, strength, range of motion (ROM), and volume.
Women with lymphedema had more lymph nodes removed (p < .001), more UE symptoms (p < .001), higher BMI (p = .041), and higher DASH scores (greater limitation) (p < .001). For all participants there was less strength (elbow flexion, wrist flexion, grip), less shoulder ROM, and decreased sensation at the medial upper arm (p < .05) in the affected UE. These differences were greater in women with lymphedema, particularly in shoulder abduction ROM (p < .05). Women with lymphedema had bilaterally less elbow flexion strength and shoulder ROM (p < .05). Past diagnosis of lymphedema, grip strength, shoulder abduction ROM, and number of comorbidities contributed to the variance in DASH scores (R (2) of 0.463, p < .001).
UE impairments are found in women following treatment for BC. Women with lymphedema have greater UE impairment and limitation in activities than women without. Many of these impairments are amenable to prevention measures or treatment, so early detection by health care providers is essential.
To determine the effectiveness of early physiotherapy in reducing the risk of secondary lymphoedema after surgery for breast cancer.
Randomised, single blinded, clinical trial.
University hospital in Alcalá de Henares, Madrid, Spain.
120 women who had breast surgery involving dissection of axillary lymph nodes between May 2005 and June 2007.
The early physiotherapy group was treated by a physiotherapist with a physiotherapy programme including manual lymph drainage, massage of scar tissue, and progressive active and action assisted shoulder exercises. This group also received an educational strategy. The control group received the educational strategy only.
Incidence of clinically significant secondary lymphoedema (>2 cm increase in arm circumference measured at two adjacent points compared with the non-affected arm).
116 women completed the one year follow-up. Of these, 18 developed secondary lymphoedema (16%): 14 in the control group (25%) and four in the intervention group (7%). The difference was significant (P=0.01); risk ratio 0.28 (95% confidence interval 0.10 to 0.79). A survival analysis showed a significant difference, with secondary lymphoedema being diagnosed four times earlier in the control group than in the intervention group (intervention/control, hazard ratio 0.26, 95% confidence interval 0.09 to 0.79).
Early physiotherapy could be an effective intervention in the prevention of secondary lymphoedema in women for at least one year after surgery for breast cancer involving dissection of axillary lymph nodes.
Current controlled trials ISRCTN95870846.
Mammographic screening alone will miss a certain fraction of malignancies, as evidenced by retrospective reviews of mammograms following a subsequent screening. Mammographic breast density is a marker for increased breast cancer risk and is associated with a higher risk of interval breast cancer, i.e. cancer detected between screening tests. The purpose of this review is to estimate risks and benefits of supplemental breast ultrasound in women with negative mammographic screening with dense breast tissue.
A systematic search and review of studies involving mammography and breast ultrasound for screening of breast cancer was conducted. The search was performed for the period 1/2000-8/2008 within the data source of PubMed, DARE, and Cochrane databases. Inclusion and exclusion criteria were determined prospectively, and the Oxford evidence classification system for diagnostic studies was used for evidence level. The parameters biopsy rate, positive predictive value (PPV) for biopsy, cancer yield for breast ultrasound alone, and carcinoma detection rate by breast density were extracted or constructed.
The systematic search identified no randomized controlled trials or systematic reviews, six cohort studies of intermediate level of evidence (3b) were found. Only two of the studies included adequate follow-up of subjects with negative or benign findings. Supplemental breast ultrasound after negative mammographic screening permitted diagnosis of primarily invasive carcinomas in 0.32% of women in breast density type categories 2-4 of the American College of Radiology (ACR); mean tumor size for those identified was 9.9 mm, 90% with negative lymph node status. Most detected cancers occurred in mammographically dense breast ACR types 3 and 4. Biopsy rates were in the range 2.3%-4.7%, with PPV of 8.4-13.7% for those biopsied due to positive ultrasound, or about one third of the PPV of biopsies due to mammography. Limitations: The study populations included wide age ranges, and the application to women age 50-69 years as proposed for mammographic screening could result in less striking benefit. Further validation studies should employ a uniform assessment system such as BI-RADS and report not only PPV, but also negative predictive value, sensitivity and specificity.
Supplemental breast ultrasound in the population of women with mammographically dense breast tissue (ACR 3 and 4) permits detection of small, otherwise occult, breast cancers. Potential adverse impacts for women in this intermediate risk group are associated with an increased biopsy rate.
Weight lifting has generally been proscribed for women with breast-cancer-related lymphedema, preventing them from obtaining the well-established health benefits of weight lifting, including increases in bone density.
We performed a randomized, controlled trial of twice-weekly progressive weight lifting involving 141 breast-cancer survivors with stable lymphedema of the arm. The primary outcome was the change in arm and hand swelling at 1 year, as measured through displaced water volume of the affected and unaffected limbs. Secondary outcomes included the incidence of exacerbations of lymphedema, number and severity of lymphedema symptoms, and muscle strength. Participants were required to wear a well-fitted compression garment while weight lifting.
The proportion of women who had an increase of 5% or more in limb swelling was similar in the weight-lifting group (11%) and the control group (12%) (cumulative incidence ratio, 1.00; 95% confidence interval, 0.88 to 1.13). As compared with the control group, the weight-lifting group had greater improvements in self-reported severity of lymphedema symptoms (P=0.03) and upper- and lower-body strength (P<0.001 for both comparisons) and a lower incidence of lymphedema exacerbations as assessed by a certified lymphedema specialist (14% vs. 29%, P=0.04). There were no serious adverse events related to the intervention.
In breast-cancer survivors with lymphedema, slowly progressive weight lifting had no significant effect on limb swelling and resulted in a decreased incidence of exacerbations of lymphedema, reduced symptoms, and increased strength. (ClinicalTrials.gov number, NCT00194363.)
Purpose
To update the 2002 American Society of Clinical Oncology guideline on pharmacologic interventions for breast cancer (BC) risk reduction.
Methods
A literature search identified relevant randomized trials published since 2002. Primary outcome of interest was BC incidence (invasive and noninvasive). Secondary outcomes included BC mortality, adverse events, and net health benefits. An expert panel reviewed the literature and developed updated consensus guidelines.
Results
Seventeen articles met inclusion criteria. In premenopausal women, tamoxifen for 5 years reduces the risk of BC for at least 10 years, particularly estrogen receptor (ER) –positive invasive tumors. Women ≤ 50 years of age experience fewer serious side effects. Vascular and vasomotor events do not persist post-treatment across all ages. In postmenopausal women, raloxifene and tamoxifen reduce the risk of ER-positive invasive BC with equal efficacy. Raloxifene is associated with a lower risk of thromboembolic disease, benign uterine conditions, and cataracts than tamoxifen in postmenopausal women. No evidence exists establishing whether a reduction in BC risk from either agent translates into reduced BC mortality.
Recommendations
In women at increased risk for BC, tamoxifen (20 mg/d for 5 years) may be offered to reduce the risk of invasive ER-positive BC, with benefits for at least 10 years. In postmenopausal women, raloxifene (60 mg/d for 5 years) may also be considered. Use of aromatase inhibitors, fenretinide, or other selective estrogen receptor modulators to lower BC risk is not recommended outside of a clinical trial. Discussion of risks and benefits of preventive agents by health providers is critical to patient decision making.
Learning Objectives
Analyze the clinical trial data for the treatment of breast cancer. Evaluate the risk of cardiotoxicity associated with the use of trastuzumab. Design and conduct a practical approach to managing patients with trastuzumab-associated cardiotoxicity.
This article is available for continuing medical education credit at CME.TheOncologist.com.
Bone health and maintenance of bone integrity are important components of comprehensive cancer care in both early and late stages of disease. Risk factors for osteoporosis are increased in patients with cancer, including women with chemotherapy-induced ovarian failure, those treated with aromatase inhibitors for breast cancer, men receiving androgen-deprivation therapy for prostate cancer, and patients undergoing glucocorticoid therapy. The skeleton is a common site of metastatic cancer recurrence, and skeletal-related events are the cause of significant morbidity. The National Comprehensive Cancer Network (NCCN) convened a multidisciplinary task force on Bone Health in Cancer Care to discuss the progress made in identifying effective screening and therapeutic options for management of treatment-related bone loss; understanding the factors that result in bone metastases; managing skeletal metastases; and evolving strategies to reduce bone recurrences. This report summarizes presentations made at the meeting.
Objective:
To provide information and recommendations for women and their physicians when making decisions about the management of lymphedema related to breast cancer.
Options:
Compression garments, pneumatic compression pumps, massage and physical therapies, other physical therapy modalities, pharmaceutical treatments.
Outcomes:
Symptom control, quality of life, cosmetic results.
Evidence:
Systematic review of English-language literature retrieved primarily from MEDLINE (1966 to April 2000) and CANCERLIT (1985 to April 2000). Nonsystematic review of breast cancer literature published to October 2000.
Recommendations:
Pre- and postoperative measurements of both arms are useful in the assessment and diagnosis of lymphedema. Circumferential measurements should be taken at 4 points: the metacarpal-phalangeal joints, the wrists, 10 cm distal to the lateral epicondyles and 15 cm proximal to the lateral epicondyles. Clinicians should elicit symptoms of heaviness, tightness or swelling in the affected arm. A difference of more than 2.0 cm at any of the 4 measurement points may warrant treatment of the lymphedema, provided that tumour involvement of the axilla or brachial plexus, infection and axillary vein thrombosis have been ruled out. Practitioners may want to encourage long-term and consistent use of compression garments by women with lymphedema. One randomized trial has demonstrated a trend in favour of pneumatic compression pumps compared with no treatment. Further randomized trials are required to determine whether pneumatic compression provides additional benefit over compression garments alone. Complex physical therapy, also called complex decongestive physiotherapy, requires further evaluation in randomized trials. In one randomized trial no difference in outcomes was detected between compression garments plus manual lymph drainage versus compression garments alone. Clinical experience supports encouraging patients to consider some practical advice regarding skin care, exercise and body weight. [A patient version of these guidelines appears in Appendix 2.]
Validation:
An initial draft of this document was developed by a task force sponsored by the BC Cancer Agency. It was updated and revised substantially by a writing committee and then submitted for further review, revision and approval by the Steering Committee for Clinical Practice Guidelines for the Care and Treatment of Breast Cancer.
Sponsor:
The steering committee was convened by Health Canada. COMPLETION DATE: October 2000.
The purpose of this article is to provide evidence-based clinical practice guidelines for choosing the most effective rehabilitation strategies and the most appropriate hand and arm care for women who have undergone axillary dissection in managing breast cancer. With this goal in mind, an interdisciplinary task force, comprising physical therapists, medical and radiation oncologists, surgeons, and women living with breast cancer, was set up by the Breast Tumour Group of the British Columbia Cancer Agency in February 1997. The 12 clinical practice guidelines that evolved were developed by categorizing relevant peer-reviewed studies (1966-June 2000), using Sackett's1 rules of evidence. These guidelines addressed four areas: Upper extremity rehabilitation, hand and arm care, electrotherapy modalities, and the need for further research. Because much of breast cancer research has focused on evaluating interventions aimed at decreasing the significant mortality of this disease, the authors recognized the need to develop practice guidelines and to call for further research aimed at reducing the physical morbidity of breast cancer and its treatments.
Background: International interest in clinical practice guidelines has never been greater but many published guidelines do not meet the basic quality requirements. There have been renewed calls for validated criteria to assess the quality of guidelines. Objective: To develop and validate an international instrument for assessing the quality of the process and reporting of clinical practice guideline development. Methods: The instrument was developed through a multi-staged process of item generation, selection and scaling, field testing, and refinement procedures. 100 guidelines selected from 11 participating countries were evaluated independently by 194 appraisers with the instrument. Following refinement the instrument was further field tested on three guidelines per country by a new set of 70 appraisers. Results: The final version of the instrument contained 23 items grouped into six quality domains with a 4 point Likert scale to score each item (scope and purpose, stakeholder involvement, rigour of development, clarity and presentation, applicability, editorial independence). 95% of appraisers found the instrument useful for assessing guidelines. Reliability was acceptable for most domains (Cronbach's alpha 0.64-0.88). Guidelines produced as part of an established guideline programme had significantly higher scores on editorial independence and, after the publication of a national policy, had significantly higher quality scores on rigour of development (p<0.005). Guidelines with technical documentation had higher scores on that domain (p<0.0001). Conclusions: This is the first time an appraisal instrument for clinical practice guidelines has been developed and tested internationally. The instrument is sensitive to differences in important aspects of guidelines and can be used consistently and easily by a wide range of professionals from different backgrounds. The adoption of common standards should improve the consistency and quality of the reporting of guideline development worldwide and provide a framework to encourage international comparison of clinical practice guidelines.
Objective: To help health care professionals develop optimal strategies for managing the chronic pain caused by breast cancer. Outcomes: Pain relief, absence of adverse effects, good quality of life.
BACKGROUND
The incidence of breast cancer (BC)-related lymphedema (LE) ranges from 7% to 47%. Successful management of LE relies on early diagnosis using sensitive measurement techniques. In the current study, the authors demonstrated the effectiveness of a surveillance program that included preoperative limb volume measurement and interval postoperative follow-up to detect and treat subclinical LE.METHODSLE was identified in 43 of 196 women who participated in a prospective BC morbidity trial. Limb volume was measured preoperatively and at 3-month intervals after surgery. If an increase >3% in upper limb (UL) volume developed compared with the preoperative volume, then a diagnosis of LE was made, and a compression garment intervention was prescribed for 4 weeks. Upon reduction of LE, garment wear was continued only during strenuous activity, with symptoms of heaviness, or with visible swelling. Women returned to the 3-month interval surveillance pathway. Statistical analysis was a repeated-measures analysis of variance by time and limb (P ≤ .001) comparing the LE cohort with an age-matched control group.RESULTSThe time to onset of LE averaged 6.9 months postoperatively. The mean (±standard deviation) affected limb volume increase was 83 mL (±119 mL; 6.5% ± 9.9%) at LE onset (P = .005) compared with baseline. After the intervention, a statistically significant mean 48 mL (±103 mL; 4.1% ± 8.8%) volume decrease was realized (P < .0001). The mean duration of the intervention was 4.4 weeks (±2.9 weeks). Volume reduction was maintained at an average follow-up of 4.8 months (±4.1 months) after the intervention.CONCLUSIONSA short trial of compression garments effectively treated subclinical LE. Cancer 2008. Published 2008 by the American Cancer Society.
The current model of care for individuals with breast cancer focuses on treatment of the disease, followed by ongoing surveillance to detect recurrence. This approach lacks attention to patients' physical and functional well-being. Breast cancer treatment sequelae can lead to physical impairments and functional limitations. Common impairments include pain, fatigue, upper-extremity dysfunction, lymphedema, weakness, joint arthralgia, neuropathy, weight gain, cardiovascular effects, and osteoporosis. Evidence supports prospective surveillance for early identification and treatment as a means to prevent or mitigate many of these concerns. This article proposes a prospective surveillance model for physical rehabilitation and exercise that can be integrated with disease treatment to create a more comprehensive approach to survivorship health care. The goals of the model are to promote surveillance for common physical impairments and functional limitations associated with breast cancer treatment; to provide education to facilitate early identification of impairments; to introduce rehabilitation and exercise intervention when physical impairments are identified; and to promote and support physical activity and exercise behaviors through the trajectory of disease treatment and survivorship.
The model is the result of a multidisciplinary meeting of research and clinical experts in breast cancer survivorship and representatives of relevant professional and advocacy organizations.
The proposed model identifies time points during breast cancer care for assessment of and education about physical impairments. Ultimately, implementation of the model may influence incidence and severity of breast cancer treatment-related physical impairments. As such, the model seeks to optimize function during and after treatment and positively influence a growing survivorship community.
Background: International interest in clinical practice guidelines has never been greater but many
published guidelines do not meet the basic quality requirements. There have been renewed calls for
validated criteria to assess the quality of guidelines.
Objective: To develop and validate an international instrument for assessing the quality of the process
and reporting of clinical practice guideline development.
Methods: The instrument was developed through a multi-staged process of item generation, selection
and scaling, field testing, and refinement procedures. 100 guidelines selected from 11 participating
countries were evaluated independently by 194 appraisers with the instrument. Following refinement
the instrument was further field tested on three guidelines per country by a new set of 70 appraisers.
Results: The final version of the instrument contained 23 items grouped into six quality domains with
a 4 point Likert scale to score each item (scope and purpose, stakeholder involvement, rigour of development,
clarity and presentation, applicability, editorial independence). 95% of appraisers found the
instrument useful for assessing guidelines. Reliability was acceptable for most domains (Cronbach’s
alpha 0.64–0.88). Guidelines produced as part of an established guideline programme had
significantly higher scores on editorial independence and, after the publication of a national policy,
had significantly higher quality scores on rigour of development (p<0.005). Guidelines with technical
documentation had higher scores on that domain (p<0.0001).
Conclusions: This is the first time an appraisal instrument for clinical practice guidelines has been
developed and tested internationally. The instrument is sensitive to differences in important aspects of
guidelines and can be used consistently and easily by a wide range of professionals from different
backgrounds. The adoption of common standards should improve the consistency and quality of the
reporting of guideline development worldwide and provide a framework to encourage international
comparison of clinical practice guidelines.
To appraise primary open-angle glaucoma (POAG) practice guidelines critically and to compare these guidelines' major recommendations.
Evaluation of clinical practice guidelines and their development process.
Glaucoma fellowship-trained ophthalmologists.
The POAG clinical practice guidelines published by the American Academy of Ophthalmology (AAO), European Glaucoma Society (EGS), and South East Asia Glaucoma Interest Group (SEAGIG) were evaluated by independent reviewers using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument.
Domain scores using the AGREE instrument.
Critical appraisal using the AGREE instrument demonstrated that the AAO guidelines scored favorably (>60%) in the domains of scope and purpose, rigor of development, and clarity and presentation, while scoring unfavorably (<60%) in the domains of stakeholder involvement, applicability, and editorial independence. The Terminology and Guidelines for Glaucoma and the Asia Pacific Glaucoma Guidelines respectively developed by EGS and SEAGIG scored favorably in the domains of scope and purpose and clarity and presentation, but scored unfavorably in the domains of stakeholder involvement, applicability, and editorial independence. The major recommendations regarding diagnosis and management of POAG were similar among the 3 guidelines, although the level of detail varied considerably.
Although the clinical practice guidelines from the AAO, SEAGIG, and EGS have contributed to developing evidence-based guidelines for glaucoma management, there is variability in the quality of the guideline development process and how it is reported as evaluated by a standardized instrument. The adoption of common standards in developing clinical practice guidelines in ophthalmology should improve their consistency and quality.
Proprietary or commercial disclosure may be found after the references.
To assess the quality of clinical practice guidelines providing recommendations on the frequency of mammography screening in asymptomatic, average-risk women 40-49 years of age.
We searched the National Guideline Clearinghouse and MEDLINE for guidelines published from 2005 to 2010. Five independent assessors rated the quality of each guideline and its underlying evidence review using the Appraisal of Guidelines for Research and Evaluation (AGREE) and Assessment of Multiple Systematic Reviews (AMSTAR) instruments, respectively.
Eleven guidelines were appraised. Ten referenced an underlying evidence review; two referenced the same review. Three reviews were rated good, one was moderate, and five were rated poor quality. On overall assessment of the quality of the guidelines, two were strongly recommended, two were recommended with provisos, and seven were either not recommended or the assessors were unsure whether to recommend it. Most guidelines clearly presented their recommendations, but the rigor of development, applicability, and stakeholder involvement varied. Seven guidelines recommended mammography screening as part of a periodic health examination and four recommended individualized screening in the target population. The latter four guidelines were based on good-quality reviews and three were recommended by the assessors.
Guideline users need to be aware of the variability in quality and identify the high-quality guidelines that meet their needs.
The findings support the use of compression garments and compression bandaging for reducing lymphedema volume in upper and lower extremity cancer-related lymphedema. Specific to breast cancer, a statistically significant, clinically small beneficial effect was found from the addition of manual lymph drainage massage to compression therapy for upper extremity lymphedema volume.
The global burden of cancer continues to increase largely because of the aging and growth of the world population alongside an increasing adoption of cancer-causing behaviors, particularly smoking, in economically developing countries. Based on the GLOBOCAN 2008 estimates, about 12.7 million cancer cases and 7.6 million cancer deaths are estimated to have occurred in 2008; of these, 56% of the cases and 64% of the deaths occurred in the economically developing world. Breast cancer is the most frequently diagnosed cancer and the leading cause of cancer death among females, accounting for 23% of the total cancer cases and 14% of the cancer deaths. Lung cancer is the leading cancer site in males, comprising 17% of the total new cancer cases and 23% of the total cancer deaths. Breast cancer is now also the leading cause of cancer death among females in economically developing countries, a shift from the previous decade during which the most common cause of cancer death was cervical cancer. Further, the mortality burden for lung cancer among females in developing countries is as high as the burden for cervical cancer, with each accounting for 11% of the total female cancer deaths. Although overall cancer incidence rates in the developing world are half those seen in the developed world in both sexes, the overall cancer mortality rates are generally similar. Cancer survival tends to be poorer in developing countries, most likely because of a combination of a late stage at diagnosis and limited access to timely and standard treatment. A substantial proportion of the worldwide burden of cancer could be prevented through the application of existing cancer control knowledge and by implementing programs for tobacco control, vaccination (for liver and cervical cancers), and early detection and treatment, as well as public health campaigns promoting physical activity and a healthier dietary intake. Clinicians, public health professionals, and policy makers can play an active role in accelerating the application of such interventions globally.
Treatment options for patients with breast cancer have progressively improved over the past 40 years, from an era of no chemotherapy to the introduction of taxanes, hormonal therapy, and biologic therapy. These advances have resulted in substantial, 15%-20% improvements in clinical outcomes. However, progress has yet to be made to improve the prognosis in many breast cancer patients, and research is currently under way to test new tools, or new applications of older tools, to advance breast cancer management. Chemotherapy clearly remains a cornerstone of adjuvant breast cancer treatment, because breast cancer can be very sensitive to the currently available agents. Meanwhile, the era of a one-size-fits-all approach to breast cancer management is over, and the maximum potential of chemotherapy should now be reached by targeting specific populations. Effective biomarkers are therefore needed to optimize chemotherapy, define more selective populations, and clearly tailor treatment. This paper discusses recent data, including new trials that are more fully incorporating current knowledge with respect to molecular markers and the underlying biology of breast cancer.
These guidelines propose a treatment algorithm in which patients are evaluated regularly for fatigue using a brief screening instrument and are treated as indicated by their fatigue level. Management of fatigue begins with primary oncology team members who perform the initial screening and either provide basic education and counseling or expand the initial screening to a more focused evaluation for moderate or higher levels of fatigue. At this point, the patient is assessed for current disease and treatment status and undergoes a review of body systems and an in-depth fatigue evaluation. In addition, the patient is assessed for the presence of treatable factors known to contribute to fatigue. If any of these conditions are present, they should be treated according to practice guidelines, with referral to other care professionals as appropriate, and the patient's fatigue should be reevaluated regularly. If none of the factors are present or if the fatigue is unresolved, appropriate fatigue management and treatment strategies are selected based on the patient's clinical status (e.g., undergoing active cancer treatment, posttreatment, at the end of life). Management of fatigue is cause-specific when conditions known to cause fatigue can be identified and treated. When specific causes of fatigue cannot be identified and corrected, the fatigue can still be treated with nonpharmacologic and pharmacologic interventions. Nonpharmacologic interventions may include a moderate exercise program to improve functional capacity and activity tolerance, psychosocial programs to manage stress and increase support, energy conservation to maintain energy, and nutritional and sleep interventions for patients with disturbances in eating or sleeping. Pharmacologic therapy may include drugs, such as antidepressants for depression or erythropoietin for anemia. A few clinical reports suggest the need for further research on the use of psychostimulants as potential treatment modalities for managing fatigue. Effective management of cancer-related fatigue involves an informed and supportive oncology care team that assesses patients' fatigue levels regularly, counsels and educates patients regarding strategies for coping with fatigue,216 and refers patients with unresolved fatigue to institutional experts.45 The oncology care team must recognize the many patient-, provider-, and system-related behaviors that can impede effective fatigue management. Using available resources and evidence-based guidelines to reduce barriers increases benefits to patients experiencing fatigue. 217,218
Nodal staging in breast cancer is a key predictor of prognosis and directs subsequent adjuvant therapy. This article addresses current modalities of nodal staging in breast cancer but focuses on promising non-invasive alternatives for staging the axilla.
Upper-limb dysfunction is a commonly reported side effect of treatment for breast cancer and may include decreased shoulder range of motion (the range through which a joint can be moved) (ROM) and strength, pain and lymphedema.
To review randomized controlled trials (RCTs) evaluating the effectiveness of exercise interventions in preventing, minimi sing, or improving upper-limb dysfunction due to breast cancer treatment.
We searched the Specialised Register of the Cochrane Breast Cancer Group, MEDLINE, EMBASE, CINAHL, and LILACS (to August 2008); contacted experts, handsearched reference lists, conference proceedings, clinical practice guidelines and other unpublished literature sources.
RCTs evaluating the effectiveness and safety of exercise for upper-limb dysfunction.
Two authors independently performed the data abstraction. Investigators were contacted for missing data.
We included 24 studies involving 2132 participants. Ten of the 24 were considered of adequate methodological quality.Ten studies examined the effect of early versus delayed implementation of post-operative exercise. Implementing early exercise was more effective than delayed exercise in the short term recovery of shoulder flexion ROM (Weighted Mean Difference (WMD): 10.6 degrees; 95% Confidence Interval (CI): 4.51 to 16.6); however, early exercise also resulted in a statistically significant increase in wound drainage volume (Standardized Mean Difference (SMD) 0.31; 95% CI: 0.13 to 0.49) and duration (WMD: 1.15 days; 95% CI: 0.65 to 1.65).Fourteen studies examined the effect of structured exercise compared to usual care/comparison. Of these, six were post-operative, three during adjuvant treatment and five following cancer treatment. Structured exercise programs in the post-operative period significantly improved shoulder flexion ROM in the short-term (WMD: 12.92 degrees; 95% CI: 0.69 to 25.16). Physical therapy treatment yielded additional benefit for shoulder function post-intervention (SMD: 0.77; 95% CI: 0.33 to 1.21) and at six-month follow-up (SMD: 0.75; 95% CI: 0.32 to 1.19). There was no evidence of increased risk of lymphedema from exercise at any time point.
Exercise can result in a significant and clinically meaningful improvement in shoulder ROM in women with breast cancer. In the post-operative period, consideration should be given to early implementation of exercises, although this approach may need to be carefully weighed against the potential for increases in wound drainage volume and duration. High quality research studies that closely monitor exercise prescription factors (e.g. intensity), and address persistent upper-limb dysfunction are needed.
Cancer may be associated with many symptoms, but pain is the one most feared by patients. Pain is experienced by one-third of patients receiving treatment for cancer and about two-thirds of those with advanced cancers. To aid in providing quality care and pain relief for cancer patients, Cancer Care Ontario's Cancer-related Pain Management Guideline Panel conducted a systematic review of guidelines to provide evidence-based and consensus recommendations for the management of cancer-related pain to guide the practice of healthcare providers.
Published and unpublished cancer-related pain management guidelines were sought by conducting an Internet search, which included health organizations and the National Guidelines Clearinghouse, the Guideline International Network, and the McMillan Group. Also, MEDLINE searches were conducted for guidelines published between the years 2000 and May 2006.
Twenty-five guidelines were found and the quality of each guideline was evaluated using the Appraisal of Guideline Research and Evaluation Instrument and the utility of the guideline for recommendations was assessed. Using these 2 criteria, 8 relevant and high-quality pain guidelines were identified. From these guidelines, the Panel articulated core principles of the management of cancer pain and selected or adapted specific recommendations through consensus to become a part of the cancer-related pain guide for practice.
The domains on which recommendations were drafted include: assessment of pain; assessors of pain; time and frequency of assessment; components of pain assessment; assessment of pain in special populations; plan of care; pharmacologic intervention; nonpharmacologic intervention; documentation; education; and outcome measures of cancer-pain management.
Guidelines are increasingly used to direct clinical practice, with the expectation that they improve clinical outcomes and minimize health care expenditure. Several national guidelines for vaginal birth after cesarean section (VBAC) have been released or updated recently, and their range has created dilemmas for clinicians and women. The purpose of this study was to summarize the recommendations of existing guidelines and assess their quality using a standardized and validated instrument to determine which guidelines, if any, are best able to guide clinical practice.
English language guidelines on VBAC were purposively selected from national and professional organizations in the United Kingdom, United States, Canada, New Zealand, and Australia. The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was applied to each guideline, and each was analyzed to determine the range and level of evidence on which it was based and the recommendations made.
Six guidelines published or updated between 2004 and 2007 were examined. Only two of the six guidelines scored well overall using the AGREE instrument, and the evidence used demonstrated great variety. Most guidelines cited expert opinion and consensus as evidence for some recommendations. Reported success rates for VBAC ranged from 30 to 85 percent, and reported rates of uterine rupture ranged from 0 to 2.8 percent.
VBAC guidelines are characterized by quasi-experimental evidence and consensus-based recommendations, which lead to wide variability in recommendations and undermine their usefulness in clinical practice.
