Upper extremity disability and quality of life after breast cancer treatment in the Greater Plains Collaborative clinical research network

Elizabeth A. Chrischilles1,2,8 · Danielle Riley1 · Elena Letuchy1 · Linda Koehler3 · Joan Neuner4 · Cheryl Jernigan5 · Brian Gryzlak1 · Neil Segal1,5 · Bradley McDowell2 · Brian Smith1,2 · Sonia L. Sugg2,6 · Jane M. Armer7 · Ingrid M. Lizarraga2,6. Breast Cancer Research and Treatment. March 2019

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Upper extremity disability and quality of life after breast cancer treatment in the Greater Plains Collaborative clinical research network

Elizabeth A. Chrischilles1,2,8  · Danielle Riley1 · Elena Letuchy1 · Linda Koehler3 · Joan Neuner4 · Cheryl Jernigan5 · Brian Gryzlak1 · Neil Segal1,5 · Bradley McDowell2 · Brian Smith1,2 · Sonia L. Sugg2,6 · Jane M. Armer7 · Ingrid M. Lizarraga2,6. Breast Cancer Research and Treatment. March 2019

Purpose Chronic upper extremity disability (UED) is common after breast cancer treatment but under-identified and undertreated. Although UED has been linked to quality of life (QoL), the role of UED as mediator between contemporary treatment practices and QoL has not been quantified. This investigation describes UED in a contemporary sample of breast cancer patients and examines its relationship with personal and treatment factors and QoL.

Methods Eight hundred and thirty-three women diagnosed at eight medical institutions during 2013–2014 with microscopically confirmed ductal carcinoma in situ or invasive stage I–III breast cancer were surveyed an average of 22 months after diagnosis. UED was measured with a modified QuickDASH and QoL with the FACT-B. The questionnaire also collected treatments, sociodemographic information, comorbidity, body mass index, and a 3-item health literacy screener.

Results Women who received post-mastectomy radiation and chemotherapy experienced significantly worse UED and QoL. Women who had lower income, lower health literacy and prior diabetes, arthritis or shoulder diagnoses had worse UED. Patients with worse UED reported significantly worse QoL. Income and health literacy were independently associated with QoL after adjustment for UED but treatment and prior conditions were not, indicating mediation by UED. UED mediated 52–79% of the effect of mastectomy-based treatments on QoL as compared with unilateral mastectomy without radiation. UED and QoL did not differ by type of axillary surgery or post-mastectomy reconstruction.

Conclusions A large portion of the treatment effect on QoL is mediated by UED. Rehabilitation practices that prevent and alleviate UED are likely to improve QoL for breast cancer survivors.

Main findings

  • A total of 1,986 patients were invited and 1235 (62.2%) responded to a mailed questionnaire.
  • The measurements were via QuicDASH which is a short-form of the Disabilities of Arm, Shoulder, and Hand Questionnaire and also the Functional Assessment of Cancer Therapy for breast cancer (FACT-B) [29] was used to measure QOL. Higher FACT-B scores reflect better QoL.
  • Treatment including post-mastectomy radiation was strongly associated with upper extremity disability (UED) as well as worse QoL, regardless of whether one or both breasts were removed, whereas treatment with lumpectomy and radiation was associated with comparable UED and QoL to that exhibited by patients who received unilateral mastectomy without radiation. The higher rates of chemotherapy in the post-mastectomy radiation treatment groups may be contributing to these differences, but also radiation after lumpectomy differs greatly from post-mastectomy radiation in its extent. Standard whole breast radiation involves two fields targeting the breast only, often including a boost to the tumour bed, whereas modern post-mastectomy radiation treatment includes treatment to the chest wall, infra- and supraclavicular area, posterior axilla and internal mammary nodes, with much greater potential for muscle and soft tissue fibrosis and loss of function.
  • Early physical therapy intervention, such as early mobility, range of motion exercises, manual therapy, lymphedema education, and/or scar management, have demonstrated a lower incidence in the arm and shoulder morbidity and better QoL in patients following surgery for breast cancer.
  • Early diagnosis and treatment for lymphedema through a breast cancer rehabilitation surveillance program has been able to potentially reverse and reduce the risk of chronic lymphedema onset and analyses project the cost-effectiveness of such a model. A supervised physical therapy program consisting of aerobic and resistance exercises improved cardiorespiratory fitness, strength, and QoL in women with early-stage breast cancer.
  • Since QoL can predict survival in women with breast cancer, it is important to consider interventions, such as physical therapy, that address UED which can improve QoL and potentially survival. Other rehabilitation interventions may also include arm, shoulder, and neck range of motion and stretching, strengthening, postural education, counselling, and occupational therapy.