Racial disparity in breast cancer survivorship: themes from a series of four national healthcare provider live virtual forums.

PURPOSE: Significant disparity exists in the diagnosis, treatment, and survivorship outcomes among Black breast cancer (BC) survivors. Black BC survivors have more significant survivorship issues and a greater burden of illness than White counterparts. Barriers to rehabilitation exist for all BC survivors but are magnified in Black BC survivors. The purpose of this qualitative research was to document patient, clinician, and researchers' perceptions surrounding contributing factors, lived experiences, and potential solutions to racial disparity in BC survivorship. METHODS: A narrative approach was utilized to identify themes from a series of four virtual healthcare provider forums that explored lived personal and professional experiences, issues, and potential solutions surrounding racial disparity in BC survivorship. Forums included perspectives of patients, healthcare providers, researchers, and stakeholders in the BC field. An independent thematic analysis was performed by the investigators, all of whom have emic perspectives with respect to race and/or BC. RESULTS: Three main themes were identified related to racial disparity in BC survivorship: (1) societal and cultural contributing factors, (2) contribution of healthcare providers and systems, and (3) models of care and research considerations. CONCLUSIONS: The findings provide compelling documentation of lived personal and professional experiences of racial disparity in BC survivorship. Potential solutions exist and must be enacted immediately to ensure equitable survivorship outcomes for Black individuals following a BC diagnosis. IMPLICATIONS FOR CANCER SURVIVORS: Increased awareness related to racial disparity in BC survivorship among survivors, healthcare providers, and researchers will contribute to health equity and improved outcomes for Black individuals.

Update to the Canadian clinical practice guideline for best-practice management of breast cancer-related lymphedema: study protocol.

BACKGROUND: One of the more frequent complications following treatment for breast cancer, lymphedema is a substantial swelling of the arm, breast and chest wall that occurs on the side where lymph nodes were removed. The aim of this work is to update recommendations on the prevention, diagnosis and management of lymphedema related to breast cancer. METHODS: We present the protocol for an update of the 2001 clinical practice guideline on lymphedema from the Steering Committee for Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. We will use a patient-oriented research approach with a focus on self-management and the positive health model to inform the updated guideline development. The methods proposed will be undertaken with consideration of the standards outlined in the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. The literature will be appraised by evaluating existing guidelines from other countries, the evidence from systematic reviews and meta-analyses and direct evidence from clinical studies. We will manage competing interests according to Guidelines International Network principles. Recommendations will be presented using an actionable statement format and will be linked to the level of evidence along with any relevant considerations used in formulation. A draft of the guideline will be produced by the steering committee then sent out to international experts and stakeholder groups for feedback. INTERPRETATION: The primary benefit of this clinical guideline will be to improve the quality of care of women with breast cancer-related lymphedema. Findings will be disseminated at national and international conferences and through webinars and educational videos hosted on the websites of the supporting organizations.

An infrared 3D scanning device as a novel limb volume measurement tool in breast cancer patients.

BACKGROUND: Lymphedema is a common complication of breast cancer treatment that affects one in five breast cancer survivors, yet there is no reliable method to detect lymphedema in the subclinical range. The objective of this study was to determine the feasibility and reliability of using an infrared 3D scanning device (ISD) as a peri-operative limb volume measurement tool. METHODS: Fifteen patients were analyzed based on inclusion criteria. Peri-operative measurements were obtained using tape measure and an ISD. Volumes were calculated using a standard algorithm for tape measure and a custom algorithm for ISD measurements. Linear regression models were used to assess ISD and tape measurement volume and circumference correlation. One-way ANOVA was used to compare change in percent difference at set time points post-operatively (2-3 weeks, 4-6 weeks, and 7-12 weeks) for both ISD and tape measure. t tests for unequal variances with the Bonferroni correction were performed among these groups. RESULTS: There is a positive linear correlation (R2 = 0.8518) between absolute volume measurements by the ISD and tape measure. Analyses over 2-10 weeks post-operatively showed that the ISD was able to detect volume changes in both the unaffected and the affected arm. Furthermore, the affected arm tended to have a greater increase in volume in the majority of patients, indicating these patients could be at risk for lymphedema. CONCLUSIONS: Technology utilizing infrared 3D scanners can reliably measure limb volume pre- and post-treatment similarly to tape measure in a small sample of patients. Further research using 3D scanning technology with a longer follow up is warranted.

Assessing Arm Volume in People During and After Treatment for Breast Cancer: Reliability and Convergent Validity of the LymphaTech System.

BACKGROUND: There are challenges related to the accurate and efficient measurement of lymphedema in people with breast cancer. The LymphaTech 3D Imaging System (LymphaTech, Atlanta, GA, USA) is a mobile, noninvasive platform that provides limb geometry measurements. OBJECTIVE: The objective of this study was to estimate the reliability and validity of the LymphaTech for measuring arm volume in the context of women seeking care in a specialty breast cancer rehabilitation clinic. DESIGN: This was a cross-sectional reliability and convergent validity study. METHODS: People who had stage I to IV breast cancer with lymphedema or were at risk for it were included. Arm volume was measured in 66 participants using the LymphaTech and perometer methods. Test-retest reliability for a single measure, limb volume difference, and agreement between methods was analyzed for 30 participants. A method-comparison analysis was also used to assess convergent validity between methods. RESULTS: Both LymphaTech and perometer methods displayed intraclass correlation coefficients (ICCs) of ≥0.99. The standard errors of measurement for the LymphaTech and length-matched perometer measurements were nearly identical. Similar intraclass correlation coefficients (0.97) and standard errors of measurement (38.0-40.7 mL) were obtained for the between-limb volume difference for both methods. The convergent validity analyses demonstrated no systematic difference between methods. LIMITATIONS: The sample size was not based on a formal sample size calculation. LymphaTech measurements included interrater variance, and perometer measurements contained intrarater variance. CONCLUSIONS: The LymphaTech had excellent test-retest reliability, and convergent validity was supported. This technology is efficient and portable and has a potential role in prospective surveillance and management of lymphedema in clinical, research, and home settings.

Estimating the Reliability and Validity of the Upper Extremity Functional Index in Women After Breast Cancer Surgery.

BACKGROUND: Activity limitations as well as impairments such as pain, numbness, limitation of shoulder range of motion, and weakness are common and well documented during and after treatment for breast cancer. There is limited information regarding the measurement properties of patient-reported outcome measures of upper extremity activity limitation in this population. This study examined the reliability and validity of the Upper Extremity Functional Index (UEFI) in patients after surgery for breast cancer. PATIENTS AND METHODS: Measures of function, shoulder flexion range of motion, and pain were obtained for 53 women before and 2 weeks after surgery for breast cancer. To estimate UEFI test-retest reliability, a convenience sample of 20 patients was assessed on a second occasion within 48 hours of their 2-week postsurgery assessment. Convergent and discriminant construct validation methods were applied by examining correlations between UEFI scores and change scores with those of the shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), Functional Assessment of Cancer Therapy-Breast (FACT-B) +4 items, shoulder flexion range, and pain. RESULTS: UEFI test-retest reliability was estimated to be 0.87 (95% confidence interval, 0.69, 0.94), and the standard error of measurement was 4.8 (95% confidence interval, 3.7, 7.1) scale points. The 90% confidence interval for a given UEFI score was ±7.9 and minimal detectable change at 90% confidence (MDC90) was ±11.1 points. UEFI correlations with the QuickDASH (cross-sectional -0.79 and longitudinal -0.62) were greater than with the FACT-B+4 and impairment measures. CONCLUSION: These results support and guide the use of the UEFI in patients after breast cancer surgery.

Implementing the Prospective Surveillance Model (PSM) of Rehabilitation for Breast Cancer Patients with 1-Year Postoperative Follow-up, a Prospective, Observational Study.

BACKGROUND: The Prospective Surveillance Model (PSM) of rehabilitation for patients with breast cancer aims for early identification, treatment, and support of physical impairments postoperatively. The purpose of this study was to describe the incidence of impairments during the first postoperative year and the differences between the patients requiring rehabilitation intervention versus those not requiring intervention. METHODS: A total of 120 patients were enrolled. Impairment measures included: pain, range of motion, and self-reported measures of function using the Upper Extremity Functional Index (UEFI) and Quick Disability of the Arm, Shoulder and Hand (QuickDASH) questionnaires. These measures were performed at designated intervals during the first postoperative year. All patients received exercise and education, and patients with identified impairments underwent individualized rehabilitation intervention. Clinical factors associated with need for intervention were determined using univariate analysis. RESULTS: Thirty-six patients required rehabilitation intervention. There were no statistically significant differences between intervention and no-intervention groups for body mass index, breast surgery type, reconstruction type, or radiotherapy. Statistically significant differences were found between intervention and no-intervention groups in early postoperative UEFI, QuickDASH, pain scores, age, number of lymph nodes removed [9.3 (intervention) vs. 5.6 (no-intervention)], axillary surgery type, chemotherapy, and breast cancer stage. CONCLUSIONS: Survivorship practitioners should have heightened awareness for rehabilitation intervention in patients with greater axillary surgery and burden of disease. Patients with more activity restriction and lower levels of function in the early postoperative period may benefit from rehabilitation intervention. Future studies should focus on implementing a screening tool to identify patients in need of rehabilitation referral.

A prospective surveillance model for rehabilitation for women with breast cancer.

BACKGROUND: The current model of care for individuals with breast cancer focuses on treatment of the disease, followed by ongoing surveillance to detect recurrence. This approach lacks attention to patients' physical and functional well-being. Breast cancer treatment sequelae can lead to physical impairments and functional limitations. Common impairments include pain, fatigue, upper-extremity dysfunction, lymphedema, weakness, joint arthralgia, neuropathy, weight gain, cardiovascular effects, and osteoporosis. Evidence supports prospective surveillance for early identification and treatment as a means to prevent or mitigate many of these concerns. This article proposes a prospective surveillance model for physical rehabilitation and exercise that can be integrated with disease treatment to create a more comprehensive approach to survivorship health care. The goals of the model are to promote surveillance for common physical impairments and functional limitations associated with breast cancer treatment; to provide education to facilitate early identification of impairments; to introduce rehabilitation and exercise intervention when physical impairments are identified; and to promote and support physical activity and exercise behaviors through the trajectory of disease treatment and survivorship. METHODS: The model is the result of a multidisciplinary meeting of research and clinical experts in breast cancer survivorship and representatives of relevant professional and advocacy organizations. RESULTS/CONCLUSIONS: The proposed model identifies time points during breast cancer care for assessment of and education about physical impairments. Ultimately, implementation of the model may influence incidence and severity of breast cancer treatment-related physical impairments. As such, the model seeks to optimize function during and after treatment and positively influence a growing survivorship community.

Patient perspectives on breast cancer treatment side effects and the prospective surveillance model for physical rehabilitation for women with breast cancer.

Women's experience of breast cancer is complex, affecting all aspects of life during and after treatment. Patients' perspectives about common impairments and functional limitations secondary to breast cancer treatment, including upper extremity motion restriction, lymphedema, fatigue, weight gain, pain, and chemotherapy-induced peripheral neuropathy, are addressed. Women often report being uninformed regarding these side effects and surprised that they do not always disappear after treatment, but remain part of their lives. Breast cancer patients express strong, unmet needs for education, information, and intervention for these side effects. Evidence suggests that rehabilitation and exercise are effective in preventing and managing many physical side effects of breast cancer treatment. Nevertheless, few women are referred to rehabilitation during or after treatment, and fewer receive baseline assessments of impairment and function to facilitate early detection of impairment and functional limitations. The prospective surveillance model of rehabilitation will serve the needs of women with breast cancer by providing education and information about treatment side effects, reducing the incidence and burden of side effects through early identification and treatment, and enhancing access to timely rehabilitation. Integration of exercise as a component of the model benefits patients at every phase of survivorship, by addressing individual concerns about exercise during and after treatment and highlighting the important contribution of exercise to overall health and survival. The prospective surveillance model of rehabilitation can meet the evident and often expressed needs of survivors for information, guidance, and intervention--thus addressing, and potentially improving, overall quality of life for individuals diagnosed with and treated for breast cancer.

A prospective model of care for breast cancer rehabilitation: postoperative and postreconstructive issues.

Appropriate and timely rehabilitation is vital in the recovery from breast cancer surgeries, including breast conserving surgery, mastectomy, axillary lymph node dissection (ALND), and breast reconstruction. This article describes the incidence, prevalence, risk factors and time course for early postoperative effects and the role of prospective surveillance as a rehabilitation strategy to prevent and mitigate them. The most common early postoperative effects include wound issues such as cellulitis, flap necrosis, abscess, dehiscence, hematoma, and seroma. Appropriate treatment is necessary to avoid delay in wound healing that may increase the risk of long-term morbidity, unduly postpone systemic and radiation therapy, and delay rehabilitation. The presence of upper quarter dysfunction (UQD), defined as restricted upper quarter mobility, pain, lymphedema, and impaired sensation and strength, has been reported in over half of survivors after treatment for breast cancer. Moreover, evidence suggests that survivors who undergo breast reconstruction may be at higher risk of UQD. Ensuring the survivor's optimum functioning in the early postoperative time period is critical in the overall recovery from breast cancer. The formal collection of objective measures along with patient-reported outcome measures is recommended for the early detection of postoperative morbidity. Prospective surveillance, including preoperative assessment and structured surveillance, allows for early identification and timely rehabilitation. Early evidence supports a prospective approach to address and minimize postoperative effects.

A prospective model of care for breast cancer rehabilitation: function.

A significant proportion of adult breast cancer survivors experience deficits in function and restriction in participation in life roles that may remain many years after diagnosis. Function is a complex construct that takes into account the interactions between an individual, their health condition, and the social and personal context in which they live. Research to date on limitations in activities of daily living, upper extremity function, and functional capacity in breast cancer survivors illustrates the need for prospective measurement of function using measures that are sensitive to the unique issues of breast cancer survivors and the need for the development of effective rehabilitation interventions to improve function. Limitations in function have a significant impact on quality of life, but less is known about the implications on return to work and survival, as well as the impact of other comorbidities and aging on the function limitations in breast cancer survivors. This review provides a rationale for the integration of measures of function into breast cancer care to more fully appreciate the functional limitations associated with breast cancer diagnosis and treatment and to aid in the development of better rehabilitation care for breast cancer survivors.

Stakeholder perspectives on dissemination and implementation of a prospective surveillance model of rehabilitation for breast cancer treatment.

The prospective surveillance model proposes a paradigm shift in the delivery of care for patients with breast cancer. The model is based on clinical research and clinical practice experience that was reviewed and discussed at a multidisciplinary meeting. The model identifies critical physical sequelae of treatment as well as timeframes for identification of and surveillance for these issues. Although the model of ongoing assessment for physical impairment and early rehabilitative intervention creates a framework for care, broad support and active dissemination among a variety of stakeholders will be required to transform patient care. Translating research findings to transform practice often occurs on a protracted timeline. The authors sought participation from a variety of stakeholder representatives throughout the process of creating this model in an effort to ensure that it reflects the realities of the patient experience and care delivery, to incorporate their input regarding the construct and viability of the model, and to potentiate effective and efficient strategies for implementation. This article summarizes comments from stakeholder representatives concerning the prospective surveillance model for rehabilitation for women treated for breast cancer. Concerns addressed include the scope of impairments included in the model, the potential creation of barriers to exercise and participation in community exercise programs, and cost and feasibility issues. Stakeholder disseminations strategies are also presented. Overall, there is recognition by the stakeholder group that this model calls attention to important unmet needs and defines a crucial opportunity to improve care for breast cancer survivors.