BC treatments are a common cause for prolonged arm morbidity . Since lymphedema has been studied in great depth in literature, this study examines the other long term arm morbidities that affect the lives of women recovering from BC, in a broad view.
Six months after surgery, the most common complaint reported by 40% of patients was the pain. The results of this study found, like many studies before us, that the extension of surgery has a role in predicting prolonged pain, as mastectomy surgeries cause more pain than lumpectomy [2, 29]. Nevertheless, contrary to expectations, when examining whether a relationship between the amount of tissue removed and the risk of developing prolonged pain exists, we found no significance.
From this cohort, it was found that during hospitalization, even very low pain levels i.e., 0.5 NPRS and above, can affect long-term recovery. Similar results were found in several studies [30,31,32], demonstrating that the severity of acute postoperative pain and inadequate pain management were associated with an increased likelihood of persistent pain, although the reported pain levels were higher than in our cohort of patients. Nevertheless, in the case of acute pain, it is difficult to isolate the causes, since higher pain scores during hospitalization may be caused by larger surgeries, axillary drains and emotional factors . Legeby et al. found similar results, as patients undergoing extensive surgeries such as immediate breast reconstructions and ALND were at a higher risk for increased pain during hospitalization, and found it to be a predictor of chronic pain . There is an agreement in the literature regarding the role of ALND as a risk factor for chronic pain , as well as for the development of lymphedema . Lymphedema was found in this study consistently to other studies, as an additional risk factor for chronic pain [36, 37]. Moreover, the results of this study indicates that even the dissection of 3–4 lymph nodes, has an adverse effect on prolonged pain and decreased ROM, compared to the removal of only 1–2 lymph nodes. Hack et al., demonstrate that the greater the number of lymph node dissected greater the morbidities, including infections, restriction of movements lymphedema and more , while, our study analyses all types of oncological treatment of BC and not confined only to surgery.
Miaskowski et al. found that the presence and number of surgical drains placed in the armpit or breast cause moderate pain 6 months after the operation . Our results adds that more than 20 cc of accumulated daily drain secretions increases the risk of prolonged pain.
Moreover, in concurrent to prior literature [2, 4, 39] it was found that preoperative pain may be another important risk factor for prolonged pain, nonetheless, there is difficulty in determining the cause, as there may be other related factors such as neoadjuvant chemotherapy or the tumor itself . AWS was found significantly associated with prolonged pain, comparable to previous reports, finding that the tendon that extends from the armpit toward the arm causes pain and limitation in function .
Unlike previous studies, some of which reported young age as a risk factor for prolonged pain and some reported older age [2, 33, 36], we didn’t find association between age and prolonged pain. Similar results were obtained regarding BMI, which contrasting to what was reported in the previous literature [2, 41], was not found to be a risk factor of prolonged pain.
In addition, no associations were found in this cohort between oncology treatments and long-term arm morbidity including pain, decreased function, or ROM, unlike previous studies, which found that radiation therapy [2, 42] and chemotherapy [32, 35] as predictive factors.
A decrease in ROM is the second common complaint in the sample, reported by a third of the participants. Three risk factors were found to be associated with decreased ranges including radiation therapy, which was previously found to causes prolonged pain [2, 40]. Nevertheless, regarding the effect of radiation on ROM reduction, there is conflicting evidence, while some authors demonstrated an associations [43, 44], others did not find significant results [38, 45]. This study results did find radiation to have an adverse effect on shoulder ROM. The number of lymph nodes removed was found to be associated with a decrease in ROM, the results suggest that even removal of 3–4 lymph nodes may result in movement restrictions. Our results examining in more depth, the results of previous researchers such as Kootstra how found that 7 years after BC surgery, 40% of the women after SLNB and 70% out of women after ALND had arm impairments . The third factor that might affect ROM, is the size of breast tissue dissected, as the mastectomy procedure of large breast tissue was found in our results to be a potential cause of limitation in ROM. Many studies in the past, have found that extensive surgeries adversely affect ROM, relative to conservative surgeries , nonetheless to the best of our knowledge the amount of tissue removed has not been examined. In addition, contrary to previous reports, we did not find any significant associations between neoadjuvant treatments and a decrease in ROM .
The results of our analysis suggest that pain higher than NPRS 0.5 during hospitalization is a potential risk factor not only for prolonged pain but also for long-term disability. The association between pain and function disability were previously explored by Bosompra et al. who found that pain intensity and swelling of the arm are related to functional disability , nevertheless to the best of our knowledge the potential association of functional decline to pain during hospitalization was examined in this study for the first time.
In concurrent with previous literature that demonstrated that breast reconstruction surgery, whether it is a tissue expander, implant-based reconstruction, or autologous reconstruction causes functional limitation , our data that evaluated mainly implant-based reconstruction suggests that in a small percentage of patients, the effect will last for more than 6 months.
The size of the tumor removed might be another risk factor, as in our sample, patients that had tumors larger than 1 cm reported more functional disabilities, and to the best of our knowledge, no previous studies have reported a similar association.
Two beneficial factors were examined; postoperative physical therapy treatment and consistent physical activity. Previous studies found that postoperative physical therapy is effective in improving functional use of the affected arm [22, 49], our results suggest that in addition, postoperative physical therapy may reduce the incidence of prolonged pain.
The benefits of physical activity were explored in depth in various aspects of research, finding multiple benefits for women with BC, which include a reduction in mortality, in the recurrence of the disease to the relief of the symptoms of oncological treatments [50, 51]. Our results consistent with pervious authors , demonstrating that physical active BC patients are less likely to have functional limitations.
Once risk factors for any arm morbidity have been identified for prolonged pain, ROM and function decline, patients with risk factors can be used to pre-identified, and offered a comprehensive rehabilitation approach, which includes early start of physical therapy and physical activity can improve fatigue during chemotherapy , improve ROM, quality of life, muscle strength and arm function [54, 55]. Therefore services such as the chemotherapy 54 prospective surveillance care model, that offers long-term multidisciplinary follow-up and treatments tailored to each morbidity, are necessary to provide optimal service for those coping with BC .
Limitations and strengths
The limitations of the study are in the nature of a prospective cohort, which may indicate connections but cannot determine the extent of the influence of the various factors. For this purpose, randomized controlled research is needed, with a longer follow-up can shed definitive results.
In addition, the self-report method of diagnosis in lymphedema and AWS (chosen because of the geographical distance), instead of volume measurement and clinical diagnosis might not provide the precise prevalence of these diseases.
The strengths of the study are in the broad examination of different risk factors that may affect recovery and, in an attempt, to bind the risk factors into models that were intended to predict risk for each morbidity separately (prolonged pain, functional limitation, and limitation in ROM).