BACKGROUND AND PURPOSE:

• Bruce et al. (BMJ, 2021) assessed whether a structured exercise program improved functional and health related quality of life outcomes compared with usual care for women after breast cancer surgery

METHODS:

• Multicenter, pragmatic, superiority, randomized controlled trial with economic evaluation
• Participants
  • Women undergoing breast cancer surgery
  • High risk for postoperative upper limb morbidity
    • Planned axillary node
    • Planned radiotherapy to the axilla or supraclavicular fossa
    • BMI ≥30
    • Existing shoulder problems
    • Subsequent axillary surgery after sentinel lymph node biopsy
    • Planned axillary or supraclavicular radiotherapy within six weeks of primary surgery
• Interventions
  • Usual care (information leaflets) only
  • Usual care plus a physiotherapy led exercise program
    • Stretching | Strengthening | Physical activity | Behavioral change techniques to support adherence to exercise
    • Introduced at 7 to 10 days postoperatively | 2 more appointments at 1 and 3 months
• Study design
  • Randomized 1:1 to an intervention group
  • Analysis by intention to treat
• Primary outcome
  • Disability of Arm, Hand and Shoulder (DASH) questionnaire at 12 months (0 score for no disability to 100 for most severe disability)
• Secondary outcomes
  • DASH subscales
  • Pain using Numerical rating scale (Moderate to severe pain 4 to 10)
  • Complications
  • Health related quality of life using Functional Assessment of Cancer Therapy-Breast+4 (FACT-B+4), a validated quality of life tool designed to assess the impact of arm morbidity on patients following breast cancer surgery
  • Resource use (healthcare and social services)

RESULTS:

• 382 participants
  • Mean age: 58.1 years
  • Exercise group: 191 participants | 95% attended ≥1 appointment
• Upper limb function mean DASH score improved after exercise compared with usual care
  • Exercise: 16.3
  • Usual care: 23.7
  • Adjusted mean difference (aMD): 7.81 (95% CI, 3.17 to 12.44); P=0.001
• Secondary outcomes were better with exercise over usual care
  • Lower pain intensity at 12 months
    • Numerical rating scale aMD: −0.68 (95% CI,−1.23 to −0.12); P=0.02
  • Fewer arm disability symptoms at 12 months
    •  FACT-B+4 aMD: −2.02 (95% CI, −3.11 to −0.93); P=0.001
• No differences in complications, lymphoedema, or adverse events
• Exercise was cost effective, compared to usual care

CONCLUSION:

• An exercise program, implemented 7 to 10 days post-breast cancer surgery, improved upper limb function and reduced pain in patients at risk of treatment related postoperative complications
• Exercise was also cost effective
• The authors state

Early, structured exercise was safe, and women had better arm function and health related quality of life, with less pain and limb related disability over one year compared with usual care

The PROSPER exercise programme was clinically impactful and cost effective

This trial provides the best quality evidence to date in support of early exercise for women at high risk of shoulder problems after breast cancer treatment

Learn More – Primary Sources:

Exercise versus usual care after non-reconstructive breast cancer surgery (UK PROSPER): multicentre randomised controlled trial and economic evaluation

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