This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
An exercise programme improved women’s recovery and upper limb movements after breast cancer surgery. Research found that the programme, introduced 7 to 10 days after surgery, was also safe and cost-effective to deliver.
Many women develop problems in their shoulder, arm or hand (upper limb) after having surgery or radiotherapy for breast cancer. This can make everyday tasks, such as getting dressed, writing or lifting everyday objects, difficult. For some women, the problems can go on for years.
Researchers, patients and clinical experts developed an exercise programme to help prevent upper limb problems after breast cancer surgery. The team tested the programme in women who had surgery to remove the cancer (but not to rebuild the breast - non-reconstructive surgery). Women in the study were at higher risk of developing problems because, for example, of the type of surgery they were due to have, or because they already had shoulder problems.
The study found that women who received the exercise programme as well as information leaflets had fewer upper limb problems than those only given leaflets. Women in the exercise group felt reassured by the physiotherapist, had better quality of life, and reported less pain and arm symptoms than those only receiving leaflets.
The team hopes that UK guidance will be updated to recommend the exercise programme after non-reconstructive breast cancer surgery. Training on the content and how to prescribe the programme is available for free online via a structured course for healthcare professionals (for instance physiotherapists and breast cancer nurses).
What’s the issue?
Women with breast cancer might need surgery to remove all or part of their breast and some or all of their lymph nodes (glands that fight infection and remove excess fluid). They may also receive radiotherapy to kill cancer cells in the armpit. These treatments are effective against breast cancer but can affect the joints, bones and muscles of the upper limb (hands, arms or shoulders).
As many as 1 in 3 women who have surgery or radiotherapy for breast cancer have upper limb problems. They may have reduced shoulder movement, long-term pain or lymphoedema (arm swelling). These problems can make it difficult to get dressed, open jars, and lift everyday objects. They limit quality of life and delay recovery.
Women who have all the lymph nodes under their arm removed, or radiotherapy to the armpit or collarbone area, are at increased risk of shoulder problems. Also, women with restricted shoulder movement or who are overweight before their surgery, are at high risk of developing upper limb problems after treatment.
UK guidance recommends slowly introducing exercises after breast cancer surgery, and seeing a physiotherapist if problems develop. There is little research on when to start exercise and how intense it should be. Women usually receive a leaflet describing exercises they can do after surgery.
This research team worked with patients and clinical experts to co-develop a structured exercise programme, to be delivered by physiotherapists working in collaboration with cancer units. It included tailored stretches and strengthening exercises, and behavioural change techniques to help people continue to exercise (such as goal-setting and keeping an exercise diary). The programme also encouraged general physical activity and return to usual activities.
The research team assessed whether the programme improved shoulder, arm and hand function in women at high risk of upper limb problems. They looked at pain, quality of life, and arm swelling, and compared the costs with usual care (information leaflets).
The study included 392 women with breast cancer from 17 NHS cancer centres across the UK. All were scheduled to have non-reconstructive breast cancer surgery. Their average age was 58 years, and they were all at risk of upper limb problems.
After surgery, half the women (196) received usual care (information leaflets containing advice about recovery from surgery and recommending exercises). The other half received usual care plus the structured exercise programme. The programme consisted of 3 face-to-face sessions with a physiotherapist, which took place 7 to 10 days after surgery, and a further session at 1 month and again at 3 months. Women could request additional sessions with the physiotherapist if needed.
Participants filled out questionnaires before surgery about their arm, hand and shoulder problems, and their quality of life. 6 weeks after surgery, they filled out questionnaires about side-effects from surgery. All participants were invited to fill out questionnaires again at 6 months and at 1 year after their surgery.
After 1 year, compared with women receiving usual care (leaflets only), those who received the exercise programme:
- had improved upper limb function
- had lower pain scores
- had better physical health-related quality of life
- felt more confident to return to their usual activities and to physical activity
- had no extra complications following surgery, such as an increase in wound healing time, neuropathic pain, wound infections or arm swelling.
During the trial, the team interviewed 10 participants from each group, and 11 physiotherapists. Soon after surgery, all participants described how they were afraid to move their upper body and felt unable to follow the exercises in the usual care leaflet. However, those in the exercise group were reassured by the physiotherapist about doing exercise.
Participants in the exercise group felt more cared for. They benefitted from the programme and enjoyed it. They appreciated being involved in selecting exercises and doing something themselves to help their recovery. This helped restore a sense of control. One participant said: “It was more than the exercise. I think it was because you were doing something, because so much of… cancer care is being done to you… It was just quite nice to have something proactive for you to do rather than just turn up and have the drugs.”
Physiotherapists found delivering the intervention rewarding. They felt they were providing high-quality care. One said: “We did have extra time for these patients … so it was nice to be able to treat them properly… That sounds awful but we don’t [usually] get the time to do it.”
The exercise was cheap to deliver, and cost £129 per participant. This included training and delivery of the exercise programme. The programme was cost-effective, with lower costs overall than usual care. It saved an average of £387 per patient through a reduction in broader healthcare costs (such as attendance at pain clinics) and informal care.
Why is this important?
This is the first UK study to show the benefits of an exercise programme for up to 1 year after breast cancer surgery. It was cost-effective, safe, improved quality of life and reduced upper limb problems in women at high risk.
Women engaged with the programme. Most (92%) of those in the exercise group attended at least 1 appointment with a physiotherapist, and 3 in 4 (73%) attended 3 or more sessions. Women who attended 3 or more sessions showed the most improvement in upper limb function.
The researchers noted that most women who stopped taking part, did so in the first 6 months, when many were receiving cancer treatment such as chemotherapy and radiotherapy. They could be fatigued or afraid of being physically active, especially at this early stage. Physiotherapists can reassure people that it is safe to exercise. They can motivate women to stick with the exercise programme and give them feedback on how they are doing. Further research could explore how best to encourage women to keep going with the programme.
Working with patients and physiotherapists to develop the exercise programme and its manual helped the research team pick up general points that can be applied more widely. For instance, women preferred photos showing real women doing the exercises (rather than cartoons or men, as used in many hospital leaflets). They also preferred the term ‘physiotherapy’ to ‘exercise’, with some saying the word ‘exercise’ was a barrier. The researchers suggest that these points could be used in usual care leaflets provided by hospitals.
Physiotherapists and breast cancer nurses can be trained to deliver the exercise programme. Training is available through FutureLearn and is freely available in the UK and internationally.
The researchers hope their study will be included in UK guidance on breast cancer. It provides evidence that exercise can be started early to improve recovery after surgery. Further research could explore whether having physiotherapists within the cancer team would help implement the programme. Women may need support to keep going with the programme in the long-term. The team would like to see whether the benefits of the programme persisted, or even increased, after the trial ended.
Some of the centres in the study have continued to refer women for physiotherapy after surgery. The researchers say this shows that clinicians can see the benefits of supporting women to do exercises after breast cancer surgery. But guidelines would need to change for more hospitals to offer this programme after breast cancer surgery.
You may be interested to read
This Alert is based on: Bruce J, and others. Exercise to prevent shoulder problems after breast cancer surgery: the PROSPER RCT. Health Technology Assessment 2022;26:15.
Paper on this study focusing on upper limb function, pain and cost: Bruce J, and others. Exercise versus usual care after non-reconstructive breast cancer surgery (UK PROSPER): multicentre randomised controlled trial and economic evaluation. BMJ 2021;375:e066542.
Paper on this study focusing on the participants’ experience of the exercise programme: Rees S, and others. Role of physiotherapy in supporting recovery from breast cancer treatment: a qualitative study embedded within the UK PROSPER trial. BMJ Open 2021;11:e040116.
The physiotherapist manual and trial related materials to accompany the exercise programme: Prevention of Shoulder Problems trial (PROSPER): Physiotherapist Manual.
Funding: This study was funded by the NIHR Health Technology Assessment Programme. Funding was also received from the NIHR Research Capability Funding via University Hospitals Coventry and Warwickshire NHS Trust and the NIHR Applied Research Collaboration Oxford and Thames Valley at Oxford Health NHS Foundation Trust.
Conflicts of Interest: The study authors declare no conflicts of interest.
Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.