Exercise After Breast Cancer Surgery Improves Shoulder Function, Quality of Life

Aerobic exercise benefits patients with breast cancer | Image Credit: SEVENNINE_79 - stock.adobe.com

Research published in JAMA Surgery found patients with breast cancer who participated in a tailored exercise program immediately after breast cancer surgery improved shoulder function after 1 month.¹

Acute discomfort and chronic complications are popular adverse outcomes patients with breast cancer face following surgery. Oftentimes, restricted shoulder range of motion (ROM) is a major adverse effect that has been known to disrupt patient quality of life (QOL) and prolong the recovery period.

Exercise has been recommended for patients with breast cancer following surgery to improve joint stiffness, muscle atrophy, shoulder function, and overall QOL. This coincides with the link between physical activity and a reduced risk of breast cancer development.² Once a patient receives a diagnosis, exercise has also been found to decrease the risk of recurrence and help with adverse effects like fatigue, pain, depression, and lymphedema.

In a parallel-group, 2 arm randomized clinical trial, women aged 19 through 70 years old were enrolled from the Breast Cancer Center in the Republic of Korea between June 2020 through October 2021.¹ Women were required to have a confirmed diagnosis of stage IV or lower breast cancer and were scheduled for a partial or total mastectomy.

The primary end point of the study was to assess shoulder ROM and strength across 6 different time points: the day before surgery, the day after surgery, 1 week post-operation, 2 weeks post-operation, 1 month post-operation, and 6 months post-operation. Outcomes were measured using shoulder passive ROM, shoulder strength, peak muscle force, and shoulder function measurements. Secondary outcomes were measured using shoulder pain and disability, surgical complications, and body composition.

A total of 56 patients, with an average age of 50.3, were randomized in the study. They were assigned either the exercise group or the usual care group in a 1:1 ratio.

Patients assigned to the exercise group completed tailored home-based stretching and resistance exercises for 4 supervised sessions on postoperative days 1 to 2, 7 to 10, 14 to 20, and 21 to 30, coinciding with surgeon visits. Throughout all 4 sessions, expert exercise specialists performed shoulder ROM and strength assessments under supervision for 20 to 30 minutes.

Patients with breast cancer assigned to the usual care group received an information booklet about breast care, breast cancer treatment, daily activities like post-operative wound care, nutrition, exercises, and self-examinations. This group did not receive any personalized exercise education or training following surgery.

Overall, 96.7% of participants completed the study in its entirety, with a 100% compliance rate for supervised sessions and a 97% compliance rate for home-based exercise sessions.

Results of the primary outcome assessments found 67.9% of patients in the exercise group had a full recovery in shoulder strength just 1 month after surgery, while 3.6% encompassed the usual care group (P < .001). After 6 months, 78.6% of patients had fully recovered shoulder ROM, while only 21.4% in the usual care group experienced improvement (P < .001). There were 85.7% of patients at the 6-month mark in the exercise group that had a full recovery, but the usual care group consisted of 17.9% of patients (P < .001).

Secondary outcome results found both groups had the highest shoulder pain score, disability, and total Shoulder Pain and Disability Index following 1-week post-operation and slowly decreased from that point onwards. After 1 month, the most frequent adverse effect was seroma, followed by hematoma, and then axillary web syndrome.

Interestingly, the exercise group reported increased physical activity after surgery, but the control group reported decreased physical activity and did not change by the 1-month or 6-month follow-up. Patient QOL was at the lowest in both groups 1 month post-operation but showed improvements by the 6-month period. However, the exercise group had greater improvement in patient QOL compared with the usual care group.

Similarly, a scoping research review found moderate to vigorous physical activity could benefit cognitive function in patients who survived breast cancer that have endured chemotherapy treatment, and developed cancer-related cognitive impairment.³ The review suggested high-intensity exercise because it allows skeletal muscles to be an endocrine organ capable of improving systemic health of the organism. The improvement of patient cognitive function has also increased QOL following high-intensity exercise.

According to the University of California San Francisco Health, at least 20 minutes of aerobic exercise at either moderate or high intensity can benefit patients with breast cancer.⁴ Aerobic exercises are defined as any continuous movements using your legs, arms, or both. Some examples of this form of workout include walking, jogging/running, bicycling, swimming, using a treadmill, or other type of aerobic equipment.

Activities that provide aerobic movement include dog walking, golfing, gardening, housework, yard work, or running around at work or after children. While these activities can offer the body physical movement, they should not be relied on for aerobic exercise completely.

Study limitations included the single-center sample size, with authors noting that caution should be exerted when generalizing findings to broader populations and other medical centers.¹ The study neglected to provide the usual care group with any in-person post-operation exercise education, so patient experience may have influenced their efforts, causing room for bias.

By tailoring exercise routines to the patient, the risk of other adverse effects may be minimized while improving shoulder function and other health parameters through early intervention post-operation. Despite the short and long-term improvements in shoulder ROM and strength, future studies must consider multicenter and multinational landscapes to test the validity of combined home-based and supervised exercise routines.

References

1. Min J, Kim JY, Ryu J, et al. Early implementation of exercise to facilitate recovery after breast cancer surgery: a randomized clinical trial. JAMA Surgery. 2024;1-9. doi:10.1001/jamasurg.2024.1633

2. DePolo J, Schmitz K. Exercise. breastcancer.org. Accessed June 4, 2024. https://www.breastcancer.org/managing-life/exercise

3. Santoro C. Physical activity, aerobic exercise programs show promise in combating CRCI in breast cancer survivors. AJMC. February 9, 2024. Accessed June 4, 2024. https://www.ajmc.com/view/physical-activity-aerobic-exercise-programs-show-promise-in-combating-crci-in-breast-cancer-survivors

4. Breast cancer self-care and recovery: exercise program. ucsfhealth.org. Accessed June 4, 2024. https://www.ucsfhealth.org/education/breast-cancer-self-care-and-recovery-exercise-program