Rehabilitation of breast cancer patients
3-page executive summary
Breast cancer is the leading cause of cancer in women worldwide. In 2007 in Norway 2761 new instances of breast cancer were diagnosed. In all 33889 women living in Norway have once been diagnosed with breast cancer. The breast cancer survival rate has increased, due to improvements in early diagnostic procedures fol-lowed by more tailored and/or more aggressive therapies. More patients are long-term survivors and live with the long-term side effects of the disease and treatment. Rehabilitation medicine is based on a holistic approach to medical care, using the combined expertise of multiple caregivers. Different rehabilitation programmes have been developed to treat the side effects occurring after the treatment of breast cancer. Although rehabilitation of breast cancer patients has been a priority during the last years, there still a need for evidence on which types of interventions are the most effectual.
The Central Norway Regional Health Authority requested the Norwegian Knowledge Centre for the Health Service (NOKC) to perform a systematic review (SR) on the rehabilitation of breast cancer patients.
To investigate whether such programmes are effective we need to know the follow-ing:
i) the efficacy of single treatments for rehabilitation of breast cancer pa-tients
ii) whether the combination of different treatments, e.g. a rehabilitation programme, is better than a single treatment
iii) what type of combinations are most effective
A group of experts in areas related both to generic medical rehabilitation and to more specific breast cancer treatment was organized to evaluate the existing litera-ture. Systematic searches in relevant databases were carried out. These databases were: Cochrane Library, The Centre for Reviews and Dissemination databases, Med-line, Embase, Cinahl, PsycINFO, AMED and PEDro until September 2008. Selec-tions of relevant studies were conducted by two separate reviewers. Data were re-trieved from included studies by one person and checked by another person.
Study design: Randomised controlled trials (RCTs).
Population: Female breast cancer patient who have undergone surgery, and may or may not have undergone irradiation, chemotherapy, or hormonal therapy.
Intervention: Physical exercise, physiotherapy, psychosocial interventions, nutri-tional therapy, complementary therapy or complex interventions.
Outcomes: somatic, psychological, and social outcomes.
We summarised results from 46 RCTs (54 publications). Seven studies addressed physiotherapy; 11 studies (15 publications) evaluated different types of exercise; 18 studies (22 publications) evaluated different psychosocial interventions. Two studies evaluate nutrition and five studies evaluate different complementary interventions. Three studies evaluate a complex rehabilitation programme. Ten of the included studies were of high quality (most on physical activity), while the remaining 36 stud-ies were of moderate quality. Due to variations in intervention and outcome meas-urements it was not possible to perform meta-analyses. We divided the studies ac-cording to when the intervention was given, either during primary cancer treatment (chemotherapy or radio therapy) or after primary cancer treatment (could include hormonal therapy).
Breast cancer patients received physiotherapy for treating lymphedema and to im-prove shoulder motility. Three studies evaluated manual lymph drainage (MLD) as an additional treatment for lymphedema; the studies do not show significant benefit of MLD. One study showed a decrease in lymphedema with complex decongestive therapy (lymph drainage, compression bandage, evaluation, medical exercise and skin care) compared to standard physiotherapy. Three studies showed that effect of physiotherapy do not seem to be influenced by the timing of interventions. Six stud-ies are done after Axillary lymph node dissection (ALND) and not by sentinel lymph node biopsy (SLNB), while one study was done in a mixed population with both ALND and SLNB surgery.
Quality of life (QoL) is an outcome in ten studies. Four studies showed that physical activity after primary cancer treatment may improve QoL (short term). Three stud-ies showed that physical activity after primary treatment may reduce fatigue. A physical activity intervention during primary cancer treatment showed varied result, and more studies are needed in order to give any conclusion of effect. We did not find any significant effect on mood outcomes after physical activity interventions. Three studies showed that early physical activity was not associated with aggravated lymphedema (including weight training).
We included 18 randomised controlled trials under the heading psychosocial inter-ventions. We divided the psychosocial interventions into three categories; psy-choeducation , cognitive behavioural therapy , and social and emotional support interventions. Six RCTs examined the effect of psychoeducational information. There were inconsistencies from the interventions examined. Seven RCTs examined the effect of Cognitive Behavioral Therapy (CBT); one of these studies was of high quality. Four studies found an improvement in QoL when the intervention was given after primary cancer treatment. There were inconsistencies from the interventions examined the effect of CBT during cancer treatment. Five studies have addressed social and emotional support interventions during breast cancer treatment, but the impact of these interventions on patients’ quality of life, wellbeing, and functioning is still unclear.
We identified two randomized controlled trials on nutritional interventions for breast cancer survivors after primary cancer treatment. The effect of nutritional in-tervention after cancer treatment is unclear.
Five randomized controlled trials examined the effect of complementary interven-tions in the rehabilitation of breast cancer patients. Altogether these results suggest that a complementary intervention during cancer treatment may have some effect on moods. Outcomes were addressed only in a few studies, so it was difficult to con-clude about the effect.
Three randomised controlled trials investigated the effect of a complex rehabilita-tion programme for breast cancer patients. These three studies showed different re-sults. The results therefore indicate that a complex intervention after cancer treat-ment still has unclear effect on QoL and moods. This was addressed in three studies with different results.
Although these studies report some positive outcomes, due to the small number of studies and the heterogeneity of interventions, it is not possible to draw generic in-ferences about the key elements of rehabilitation interventions of breast cancer pa-tients. These interventions could still be useful for breast cancer patients, but we lack high quality research on the issue.
However, this review does underline some promising results.
• There is some evidence that physical activity after breast cancer treatment improved quality of life and reduced fatigue.
• There is some evidence that CBT intervention after breast cancer treatment increased overall QoL.
• There are some promising results that physical activity is not associated with aggravated lymphedema.
Further research is needed on the time, mode and intensity on these interventions. Single studies in this review are showing promising, but insufficiently documented effects on important questions in rehabilitation of breast cancer patients. There is insufficient evidence to show whether physiotherapy or MLD was more beneficial than standard care for lymphedema or shoulder function. There is insufficient evi-dence to define optimal psychoeducational or social and emotional support inter-ventions from this review. There is also insufficient evidence from these studies to determine the most beneficial nutrition or complementary interventions.
FURTHER RESEARCH IS NEEDED
There is need for further research on the effect of rehabilitation interventions among breast cancer patients. Few of the studies in the present review include patients go-ing through new long-term medical treatments regiments for breast cancer; new studies should address this. Additional research might profitably assess whether some interventions are more effective for certain subgroups of breast cancer pa-tients.