Systematic review
Rehabilitation of breast cancer patients
Systematic review
|Updated
The aim of this overview is to explore literature to assess the efficacy of single treatments and combination of treatments (e.g. rehabilitation programs) with respect to improvements in physical functionality and psychological well-being.
Key message
Breast cancer is the leading cause of cancer in women world wide. Although recent advances in therapy have improved survival rates, they are associated with significant side effects. The Central Norway Regional Health Authority requested that the Norwegian Knowledge Centre for the Health Services (NOKC) perform a systematic review (SR) on rehabilitation of breast cancer patients.
The aim of this overview is to explore literature to assess the efficacy of single treatments and combination of treatments (e.g. rehabilitation programs) with respect to improvements in physical functionality and psychological well-being.
Results
We included 46 randomised controlled trials of moderate or high quality. Seven studies addressed physiotherapy, 11 studies investigated different types of physical activity, 18 studies examined different psychosocial interventions. Two studies addressed nutrition, and five studies address complementary interventions as rehabilitation. Three studies evaluated a complex rehabilitation program. Due to variation in interventions and outcomes it was not possible to perform meta-analyses. The studies on physical activity after primary cancer treatment showed effect on improving quality of life (QoL) and reducing fatigue. It was difficult to conclude about the studies on physical activity during primary treatment due to inconsistency. Three studies showed that early physical activity was not associated with aggravated lymphedema. Four studies showed that cognitive behaviour therapy (CBT) intervention after primary cancer treatment will increase overall QoL. More documentation is needed for the interventions of physiotherapy, psychoeducation, social and emotional support, nutrition, complementary and complex interventions.
Conclusions
There is limited documentation for the efficacy of different rehabilitation interventions for breast cancer patients. The documentation from this review indicates that physical activity after primary cancer treatment may increase QoL and reduce fatigue. Patients might also have some benefits on QoL from CBT interventions. More documentation is needed for the effect of interventions of physiotherapy, psychoeducation, and social and emotional support. There is still a critical need for further research focusing on rehabilitation interventions throughout and after treatment among breast cancer patients.
Summary
Background
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 followed 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.
Mandate
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 following:
i) the efficacy of single treatments for rehabilitation of breast cancer patients
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
Method
A group of experts in areas related both to generic medical rehabilitation and to more specific breast cancer treatment was organised to evaluate the existing literature. Systematic searches in relevant databases were carried out. These databases were: Cochrane Library, The Centre for Reviews and Dissemination databases, Medline, Embase, Cinahl, PsycINFO, AMED and PEDro until September 2008. Selections of relevant studies were conducted by two separate reviewers. Data were retrieved from included studies by one person and checked by another person.
Inclusion criteria:
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, nutritional therapy, complementary therapy or complex interventions.
Outcomes: somatic, psychological, and social outcomes.
Results
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 studies were of moderate quality. Due to variations in intervention and outcome measurements it was not possible to perform meta-analyses. We divided the studies according to when the intervention was given, either during primary cancer treatment (chemotherapy or radio therapy) or after primary cancer treatment (could include hormonal therapy).
Physiotherapy
Breast cancer patients received physiotherapy for treating lymphedema and to improve 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 studies 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.
Physical activity
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 studies 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).
Psychosocial interventions
We included 18 randomised controlled trials under the heading psychosocial interventions. We divided the psychosocial interventions into three categories; psychoeducation, 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, well-being, and functioning is still unclear.
Nutrition
We identified two randomised controlled trials on nutritional interventions for breast cancer survivors after primary cancer treatment. The effect of nutritional intervention after cancer treatment is unclear.
Complementary interventions
Five randomised controlled trials examined the effect of complementary interventions 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 conclude about the effect.
Complex intervention
Three randomised controlled trials investigated the effect of a complex rehabilitation programme for breast cancer patients. These three studies showed different results. The results therefore indicate that a complex intervention after cancer treatment still has unclear effect on QoL and moods. This was addressed in three studies with different results.
Conclusion
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 inferences about the key elements of rehabilitation interventions of breast cancer patients. 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 evidence to define optimal psychoeducational or social and emotional support interventions from this review. There is also insufficient evidence from these studies to determine the most beneficial nutrition or complementary interventions.
Further research 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 going 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 patients.