Integrated Rehabilitation for Breast Cancer Survivors

Andrea L. Cheville, MD, MSCE1; Sarah A. McLaughlin, MD2; Tufia Haddad, MD3; Kathleen D. Lyons, OTR/L, ScD4; Robin Newman, OTR/L, OTD5; Kathryn J. Ruddy, MD, MPH3. American Journal of Physical Medicine & Rehabilitation Articles 2018

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Integrated Rehabilitation for Breast Cancer Survivors 

Andrea L. Cheville, MD, MSCE1; Sarah A. McLaughlin, MD2; Tufia Haddad, MD3;  Kathleen D. Lyons, OTR/L, ScD4; Robin Newman, OTR/L, OTD5;  Kathryn J. Ruddy, MD, MPH3. American Journal of Physical Medicine & Rehabilitation Articles 2018

The physical and psychological side effects of breast cancer therapies can have substantial impact on survivors’ physical and social functioning.  Roughly half of the more than 3 million Americans alive with a history of breast cancer report adverse, function-degrading sequelae related to their oncologic treatments.  Care delivery models for the timely delivery of rehabilitation services have been proposed yet limitedly vetted or implemented.  These include the prospective surveillance model, procedure-linked referrals, survivorship care plans and risk stratification.   Patients’ capacity to engage in the rehabilitative process varies over the course of cancer therapy and into survivorship.  Perioperative attention generally focuses on managing premorbid impairments and normalizing shoulder function.  In contrast, during chemo- and radiation therapies, symptom control, constructive coping, and role preservation may become more salient. Risk-stratified, individualized screening and prevention activities for specific impairments have become increasingly feasible through predictive models and analytics.  Impairments’ severity deleterious impact can be mitigated, as has been established for lymphedema, shoulder dysfunction, chemotherapy-induced peripheral neuropathy, cognitive dysfunction, fatigue, and sexual side effects.  Integrated rehabilitative programs, often following the completion of cancer treatment, are available in some countries outside of the  United States and may offer survivors vital vocation- and avocation-directed services.

Main findings

This paper provides an excellent overview of many facets of rehabilitation. The presence of a single impairment, arm lymphedema, was found to increase overall healthcare utilization by 30% up to 10 years after the completion of BC treatment.

Current and proposed models of rehabilitation care delivery 

Prospective surveillance (PSM):

  • The PSM has been associated with improved outcomes including reduced incidence of lymphedema and shoulder contractures.
  • The lack of a comparator usual care group has impeded estimation of effects attributable to the model.
  • Concerns have been raised regarding the PSMs high human resource requirements, as well as the fact that BC survivors at low risk of impairments may not derive benefit from such frequent, clinic-based assessments
  • A less resource-intensive iteration of the PSM has been suggested that, rather than clinic-based assessments, would rely on patient-reported outcomes (PROs) and/or physical examinations performed by primary care and oncologic providers during routine follow up appointments.
  • PRO-based screening is theoretically possible for any BC-related impairment, although no PROs have yet been validated or consistently implemented for this purpose, so the approach remains largely theoretical.

Treatment/diagnosis linked

  • Certain cancer distribution and histological characteristics require more aggressive and protracted treatments which are more likely to engender impairments. For example, patients undergoing axillary node dissection generally require more prescriptive and extensive rehabilitation than patients undergoing sentinel node biopsy.

Survivorship care plans

  • Individualized survivorship care plans (SCPs) are intended to help patients and caregivers navigate the period following definitive BC treatment and to promote communication between patients’ oncology and primary care providers.
  • Lack of evidence demonstrating that SCPs improve outcomes. This is likely because the SCP document is created at a single point in time and remains static; whereas, the side effects of cancer treatment are dynamic and evolve over time.

Web resources

  • Web-based, tailored interventions may encourage BC engagement with impairment screening and interventions, and adoption of wellness behaviors. By leveraging the relatively low cost and broad reach of the internet, survivors may be alerted to potential adverse late effects, directed to local resources, and encouraged to make healthy lifestyle choices.
  • Although promising, this approach has a limited evidence base.

Treatment phase-specific rehabilitation needs


  • Prior to the initiation of BC treatments has received increasing attention based on anecdotal reports of benefit and reduced perioperative morbidity with prehabilitation before resection of non-breast cancers.
  • The prehabilitation literature is challenging to synthesize as interventions have included aerobic training, psychosocial approaches18, and discrete upper quadrant range of motion activities.
  • The increasing use of neoadjuvant chemotherapy as initial BC treatment offers an opportunity to integrate gentle conditioning activities during chemotherapy.

Peri- and post-operative:

  • Contemporary perioperative literature demonstrates that patients with improved exercise capacity tolerate anesthesia better and have fewer surgical complications.
  • Early postoperative referral for individualized rehabilitation therapy is warranted in patients with axillary cording, limited shoulder abduction, or completing radiation after a full axillary dissection.

Adjuvant chemotherapy:

  • Rehabilitation needs are dependent on the specific treatments received and each person’s individual susceptibility to the side effects of those drugs.
  • Enhanced physical activity is the most effective means of reducing fatigue.
  • Elderly patients and those with pre-morbid balance deficits who develop CIPN may be at increased risk for falls. The comprehensive geriatric assessment has been advocated as means of screening for fall risk, however brief gait testing or verbal queries often suffice to identify at risk individuals.
  • Diverse forms of exercise including resistive, aerobic, and high intensity interval training have been shown to improve outcomes, including fatigue, mood, cardiovascular fitness and overall QoL, among patients receiving adjuvant chemotherapy for breast cancer.
  • Patients’ exercise preferences should be proactively solicited as they begin adjuvant treatment with support provided to maintain activity.

Radiation therapy

  • Patients negotiating the demands of external beam radiation may have limited time and energy to devote to the rehabilitation process.
  • Indications for therapy include progressive loss of shoulder range of movement, axillary quadrant pain and fatigue.
  • Radiation fibrosis doesn’t begin until months following radiation.

The article then goes onto discuss how to identify who may benefit from rehabilitation including risk prediction, post treatment/ long term survivorship, metastatic disease and patient reported outcomes.

It reviews the prevention and treatment of specific impairments including lymphoedema, chemotherapy indices peripheral neuropathy, contracture/ cording / shoulder pathology, upper quadrant pain, cognitive dysfunction, fatigue, sexual dysfunction and cardiovascular effects.