An active 72-year-old woman, Claire Mitchell had always enjoyed cooking. However, after breast cancer surgery she found that she had less freedom of movement and reaching jars on high shelves became quite painful. Her plight is common.
A new Cochrane review finds that exercise programs help patients recover shoulder movement and minimize loss of arm or shoulder function after breast cancer surgery.
Many breast cancer survivors develop pain, shoulder stiffness and arm swelling after treatment. These problems often persist for years. Physicians usually prescribe arm and shoulder exercises after surgery to prevent pain and stiffness in those areas on the side of the cancer. However, the best type of exercise or how soon it should begin have been debated.
“There has been some concern that too much aggressive movement soon after surgery might cause pain, delay healing, and increase the risk of arm swelling,” said lead review author Margaret McNeely, an assistant professor of physical therapy at the University of Alberta and clinical researcher at the Cross Cancer Institute, in Canada.
McNeely’s team examined 24 research studies comprising 2,132 women with a confirmed breast cancer diagnosis and who had undergone surgery such as a radical mastectomy, modified radical mastectomy, or a local wide excision or lumpectomy. They had also all had surgery removing lymph nodes from the axilla, or armpit, to determine the extent of the cancer.
Specially designed programs included range-of-motion movements for the shoulders and stretching exercises.
The review showed that starting exercise early after surgery — within the first to third day —might result in better shoulder movement in the early weeks following surgery.
However, “starting exercise that soon after surgery may cause more wound drainage and require drains to remain in place longer than if exercise is delayed by about one week,” McNeely said. Early exercise lengthened wound-healing time by about one day.
The review was published by The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.
Fourteen studies compared the effect of structured exercise to usual care, in which women received an exercise pamphlet or no exercise instruction at all.
Of these, structured programs including physical therapy regimens in the early postoperative period led to a significant improvement in shoulder range of motion over the short and long term.
One problem that can affect women after breast surgery is lymphedema, which is swelling caused by fluid buildup. This swelling begins in the underarm area but can affect the entire arm, usually on the side of the breast surgery, and can be uncomfortable or even painful.
Several persistent complications can greatly diminish a patient’s quality of life, said Douglas Blayney, M.D., medical director at the University of Michigan’s Comprehensive Cancer Center.
Blayney said that although current surgical treatment is attempting to move away from disturbing the axilla, more women, especially younger women, are choosing mastectomy over breast conserving surgery. Mastectomy has a higher incidence of swelling and limited shoulder motion. There is a trend now toward increasing use of radiation therapy to the axilla and this approach also might increase the risk of swelling, he said.
“Combined, these trends in primary treatment of breast cancer make this review highly relevant,” said Blayney, who has no affiliation with the review. Nevertheless, he noted that making suitable exercise programs widely available to breast cancer patients in a timely manner would be a challenge.
He said optimal breast cancer care now involves a team with a wide range of health specialists: surgeons, radiation oncologists, medical oncologists, reconstructive surgeons and others. “This review demonstrates that early involvement of a new team member who manages exercise or physical therapy is also useful for the best outcome,” he said.
Blayney added that he finds few things as disheartening as seeing a breast cancer survivor in long-term follow-up who is cured yet burdened with a “frozen” shoulder or daily use of a lymphedema sleeve, an elastic compression garment worn over the arm to help move fluid and reduce swelling.
“Implementation of modern primary treatment strategies — including early intervention with suitable exercises — should reduce the incidence of these heartbreaking complications,” Blayney said.
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