Arm/shoulder problems in breast cancer survivors are associated with reduced health and poorer physical quality of life.

BACKGROUND: Except for lymphedema, the consequences of arm/shoulder problems (ASPs), at long-term in breast cancer survivors (BCSs) have hardly been studied. We examined demography, lifestyle, quality of life (QoL) and somatic morbidity in BCSs with and without ASPs. We also compared the associations of restricted shoulder abduction and lymphedema with QoL. METHODS: We used a cross-sectional case-control design. A sample of 256 BCSs all with lymph node metastases were examined at a mean of 4.1 (SD 0.9) years post-surgery. Based on objective examinations and self-rating the sample were separated into 81 BCSs (32%) with definite ASP (ASP+ group) and 175 (68%) with minimal or no ASP (ASP- group). The self-rating contained among other schedules the Short Form-36 (SF-36) and the Kwan's arm/shoulder problem scale (KAPS). RESULTS: In univariate analysis ASP+ was associated with not being employed, having had mastectomy, longer follow-up time, radiotherapy to axilla, poorer self-rated health and physical condition, minimal physical activity, increased body mass index, regularly intake of analgesics, and poorer physical QoL. Multivariate analysis showed that mastectomy, longer follow-up time, minimal physical activity and poorer physical QoL were associated with belonging to ASP+ group. All domains of the SF-36 were significantly associated with having impaired shoulder abduction (> or = 25 degrees difference) while none of the associations with lymphedema were significant. DISCUSSION: In BCSs, at four years after treatment, having ASP was associated with mastectomy, minimal physical activity and poorer physical QoL. Poor physical QoL is strongly associated with reduced shoulder abduction rather than with lymphedema.

Kwan's arm problem scale: psychometric examination in a sample of stage II breast cancer survivors.

Arm/shoulder problems and lymphedema are common in patients treated for breast cancer. The Kwan's arm problem scale (KAPS) is a 13 items self-rating form developed for examination of such problems. Since no such testing has been done, we wanted to examine the psychometric properties of the KAPS. At a median of 47 months (range 32-87 months) post-surgery, 256 stage II breast cancer survivors filled in the KAPS. Findings from physical examination of arm/shoulder function, assessment of lymphedema, and established measures of quality of life (QOL), mental distress and fatigue were used to study convergent and discriminant validity. Factor structure and internal consistency were tested in split-half samples. The total KAPS as well as its two subscales showed high internal consistency (alpha > or = 0.92). A two factor solution explained 70% of the variance in the total KAPS score. Convergent validity was shown as the total KAPS score explained 32.5% of the variance in abduction of the ipsilateral shoulder. Discriminant validity was shown as the total KAPS score explained only 6.7% of the variance in abduction of the contralateral shoulder. Concurrent validity was confirmed since the total KAPS explained 54.8% of the variance in arm symptom subscale of breast cancer-specific QOL. Area under the curve was 0.80 for problems of using the arm at a cut-off of the total KAPS score of 21.5. The results show that the KAPS has good psychometric properties supported by high reliability and considerable convergent and discriminant validity.

Arm and shoulder morbidity in breast cancer patients after breast-conserving therapy versus mastectomy.

INTRODUCTION: The objective of this study was to compare the prevalence of late effects in the arm and shoulder in patients with breast cancer stage II who had radical modified mastectomy (RM) or breast-conserving therapy (BCT) followed by loco-regional adjuvant radiotherapy with or without chemotherapy/anti-oestrogen. MATERIAL AND METHODS: All patients had axillary lymph node dissection. At a median of 47 months (range 32-87) post-surgery, 263 women (RM: n=186, BCT: n=77) were seen during an outpatient visit and had their arm and shoulder function and the presence of lymphedema assessed by a clinical examination, interview and self-rating. Volume calculation was used to measure lymphedema. RESULTS: In the RM group 20% had developed arm lymphedema versus 8% in the BCT group (p=0.02). In multivariate analysis lymphedema was associated with a higher number of metastatic axillary lymph nodes [OR1.14, p=0.02], RM [OR 2.75, p=0.04] and increasing body mass index (BMI) [OR 1.11, p<0.01]. In the RM group 24% had a restricted range of motion in shoulder flexion compared to 7% in the BCT group (p<0.01). Shoulder pain was reported by 32% in the RM group and by 12% in the BCT group (p=0.001). Increasing observation time, RM, and increasing BMI were significantly associated with impaired arm/shoulder function. DISCUSSION: Arm/shoulder problems including lymphedema were significantly more common after RM compared to BCT in irradiated breast cancer patients who have undergone axillary lymph node dissection. The performance of BCT should be encouraged when appropriate, to ensure a low prevalence of arm/shoulder morbidity including lymphedema.

Arm/shoulder problems and insomnia symptoms in breast cancer survivors: cross-sectional, controlled and longitudinal observations.

OBJECTIVE: In breast cancer survivors (BCSs) the relation between insomnia symptoms and arm/shoulder problems has hardly been investigated. In cross-sectional and longitudinal designs we examined this association in BCSs and in comparison to age-matched controls from the general population. METHODS: Our cross-sectional sample consisted of 337 BCSs stage II/III studied in 2004 at a median of 3.9 years after surgery combined with adjuvant radiotherapy and cytostatics/hormones. In 2007 248 (74%) BCSs were re-examined (median 2.5 years later). The responses of the 2004 sample were compared to those of 1685 controls. RESULTS: Thirty percent of BCSs reported insomnia symptoms in 2004, and arm/shoulder problems were significantly associated with insomnia, as were established variables in bivariate analyses. In 2004 only regular use of hypnotics remained associated with insomnia in multivariate analysis. In bivariate analysis arm/shoulder pain and restricted mobility in 2004 were significant predictors of insomnia in 2007. Only insomnia in 2004 was a significant predictor in multivariate analysis. In bivariate analyses BCSs and controls had several common factors associated with insomnia, but only regular use of hypnotics was common in multivariate analysis. CONCLUSIONS: Arm/shoulder problems are factors to consider in BCSs with insomnia, particularly arm/shoulder pain. Factors associated with insomnia in BCSs and general population controls are partially overlapping.

The relation between arm/shoulder problems and quality of life in breast cancer survivors: a cross-sectional and longitudinal study.

BACKGROUND: This cross-sectional and longitudinal study of breast cancer survivors (BCSs) examines the associations between arm/shoulder problems (ASPs), which consist of pain, restricted mobility and lymphedema, and different aspects of quality of life (QoL). METHODS: BCSs who had breast surgery, axillary lymph node dissection and radiotherapy (n = 255) were examined in 2004 (mean 4.1 years post-surgery) and a sub-sample (n = 187) was re-examined in 2007. ASPs was rated clinically in 2004 and by self-report (EORTC BR23) in 2004 and 2007. QoL was self-reported with The Short Form-36 (SF-36) and The Impact of Cancer scale (IOC). RESULTS: In 2004 BCSs with ASPs showed significantly poorer mean scores in most SF-36 domains compared to those without. No group differences were observed for positive IOC domains, while BCSs with ASPs showed significantly poorer mean scores in the negative ones. BCSs with clinically defined movement restriction showed significantly poorer SF-36 and negative IOC mean scores than those with clinically defined lymphedema. The longitudinal sub-study of self-rated pain, restricted mobility and lymphedema showed significant changes over time only for negative IOC domains in the pain group. Self-rated restricted mobility and lymphedema were significantly associated with most SF-36 domains both in 2004 and 2007, while few were associated with pain. Self-rated pain and restricted mobility showed significant associations with negative IOC domains. IMPLICATIONS FOR CANCER SURVIVORS: Not only lymphedema, but pain and restricted mobility in the arm/shoulder are significantly associated with poor QoL in BCSs at long-term. These problems should be diagnosed and treated in order to improve QoL.

A study of body image in long-term breast cancer survivors.

BACKGROUND: In this controlled postdiagnosis study, the authors examined various aspects of body image of breast cancer survivors in cross-sectional and longitudinal designs. METHODS: In 2004 and 2007 the Body Image Scale (BIS) was completed by the same 248 disease-free women who had been treated for stage II and III breast cancer between 1998 and 2002. "Poorer" body image was defined as greater than the 70th percentile (N=76 women) of the BIS scores in contrast to "better" body image (N=172 women). Breast cancer survivors were examined clinically in 2004, and their BIS scores were compared with the scores from an age-matched group of women from the general population. RESULTS: In this cross-sectional study, poorer body image in 2004 was associated significantly with modified radical mastectomy, undergoing or planning to undergo breast-reconstructive surgery, a change in clothing, poor physical and mental health, chronic fatigue, and reduced quality of life (QoL). In univariate analyses, most of these factors and manually planned radiotherapy were significant predictors of poorer body image in 2007. In multivariate analyses, manually planned radiotherapy, poor physical QoL and high BIS score in 2004 remained independent predictors of a poorer body image in 2007. Body image ratings were relatively stable from 2004 to 2007. Twenty-one percent of breast cancer survivors reported body image dissatisfaction, similar to the proportion of dissatisfaction in controls. CONCLUSIONS: In this cross-sectional analysis, body image in breast cancer survivors was associated with the types of surgery and radiotherapy and with mental distress, reduced health, and impaired QoL. Body image ratings were relatively stable over time, and the antecedent body image score was a strong predictor of body image at follow-up. Body image in breast cancer survivors differed very little from that in controls.

[Lymphedema after surgical treatment of cervical and vulvar cancer]. / Lymfødem etter operativ behandling av cancer i cervix uteri og vulva.

BACKGROUND: Lack of information after surgery for cervical cancer to women who are at risk of developing lymphoedema can lead to delay in diagnosis and treatment of this side effect. MATERIAL AND METHODS: Former patients with cervical cancer and vulvar cancer were asked whether they remembered having been counselled about lymphoedema post-operatively and whether they were satisfied with the information received. 83 out of 92 returned a mailed questionnaire assessing the standard of the information given before discharge. RESULTS: 30% of the patients were satisfied with the information given. About 30% reported that they had received neither written nor oral information about lymphoedema. 18 women stated the importance of oral information. 20% had symptoms of lymphoedema of the lower limbs. INTERPRETATION: The study confirms the importance of patient education given verbally before discharge. Health personnel with extensive knowledge and experience in the area should give this information.