Nicole L. Stout

Upper-Body Morbidity After Breast Cancer* Incidence and Evidence for Evaluation, Prevention, and Management Within a Prospective Surveillance Model of Care

The purpose of this paper is to review the incidence of upper‐body morbidity (arm and breast symptoms, impairments, and lymphedema), methods for diagnosis, and prevention and treatment strategies. It was also the purpose to highlight the evidence base for integration of prospective surveillance for upper‐body morbidity within standard clinical care of women with breast cancer. Between 10% and 64% of women report upper‐body symptoms between 6 months and 3 years after breast cancer, and approximately 20% develop lymphedema. Symptoms remain common into longer‐term survivorship, and although lymphedema may be transient for some, those who present with mild lymphedema are at increased risk of developing moderate to severe lymphedema. The etiology of morbidity seems to be multifactorial, with the most consistent risk factors being those associated with extent of treatment. However, known risk factors cannot reliably distinguish between those who will and will not develop upper‐body morbidity. Upper‐body morbidity may be treatable with physical therapy. There is also evidence in support of integrating regular surveillance for upper‐body morbidity into the routine care provided to women with breast cancer, with early diagnosis potentially contributing to more effective management and prevention of progression of these conditions. Cancer 2012;118(8 suppl).

Practical clinical interventions for diet, physical activity, and weight control in cancer survivors

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Breast Cancer–Related Lymphedema: Comparing Direct Costs of a Prospective Surveillance Model and a Traditional Model of Care

Secondary prevention involves monitoring and screening to prevent negative sequelae from chronic diseases such as cancer. Breast cancer treatment sequelae, such as lymphedema, may occur early or late and often negatively affect function. Secondary prevention through prospective physical therapy surveillance aids in early identification and treatment of breast cancer–related lymphedema (BCRL). Early intervention may reduce the need for intensive rehabilitation and may be cost saving. This perspective article compares a prospective surveillance model with a traditional model of impairment-based care and examines direct treatment costs associated with each program. Intervention and supply costs were estimated based on the Medicare 2009 physician fee schedule for 2 groups: (1) a prospective surveillance model group (PSM group) and (2) a traditional model group (TM group). The PSM group comprised all women with breast cancer who were receiving interval prospective surveillance, assuming that one third would develop early-stage BCRL. The prospective surveillance model includes the cost of screening all women plus the cost of intervention for early-stage BCRL. The TM group comprised women referred for BCRL treatment using a traditional model of referral based on late-stage lymphedema. The traditional model cost includes the direct cost of treating patients with advanced-stage lymphedema. The cost to manage early-stage BCRL per patient per year using a prospective surveillance model is

Recent progress in the treatment and prevention of cancer-related lymphedema.

636.19. The cost to manage late-stage BCRL per patient per year using a traditional model is

Integrating a prospective surveillance model for rehabilitation into breast cancer survivorship care

3,124.92. The prospective surveillance model is emerging as the standard of care in breast cancer treatment and is a potential cost-saving mechanism for BCRL treatment. Further analysis of indirect costs and utility is necessary to assess cost-effectiveness. A shift in the paradigm of physical therapy toward a prospective surveillance model is warranted.

Segmental Limb Volume Change as a Predictor of the Onset of Lymphedema in Women With Early Breast Cancer

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Prospective evaluation of physical rehabilitation needs in breast cancer survivors: a call to action.

At some point during or after treatment, breast cancer may be considered a chronic illness, presenting many choices for managing the disease, its adverse treatment‐related effects, other medical comorbidities as well as the biobehavioral burden of having a life‐threatening disease, even for individuals with potentially curable breast cancer. Health care models, such as the chronic care model, the medical home, and the shared care model, provide a context for building survivorship health care models. Goals and characteristics of recently proposed shared care models for cancer survivorship health care delivery closely align with the goals and concepts of the prospective surveillance model (PSM) proposed elsewhere in this supplement to the journal Cancer. Given these similarities, along with the growth and expansion of survivorship care models and impending mandates for delivery, there is merit to considering how implementation of the PSM can be integrated with models of survivorship care delivery. The PSM model will likely face many similar challenges and barriers that have impeded widespread dissemination of other survivorship models of care. There exist opportunities to integrate lessons learned as well as to align efforts to achieve greater impact on the shared goal of improving health outcomes for breast cancer survivors. Cancer 2012;118(8 suppl):.

Surgical Prehabilitation in Patients with Cancer: State-of-the-Science and Recommendations for Future Research from a Panel of Subject Matter Experts

To demonstrate that segmental changes along the upper extremity occur before the onset of breast cancer–related lymphedema (BCRL). These changes may be subclinical in nature and may be predictive of the onset of chronic lymphedema.

A qualitative assessment of upper quarter dysfunction reported by physical therapists treated for breast cancer or treating breast cancer sequelae

For most women in developed countries, breast cancer has become a survivable chronic disease. Improved survival has been achieved through steady improvements in early detection and therapy and has contributed to a growing population of breast cancer survivors. However, the natural emphasis on improved survival overshadows the reality that breast cancer survivors face a cascade of post-treatment challenges, principally surveillance for recurrence, but also near-term and longterm, treatment-related medical and psychological sequelae. One set of these sequelae includes physical impairments, such as fatigue, pain, postsurgical and persistent upper-quadrant issues, chemotherapy-induced peripheral neuropathy, lymphedema, cardiotoxic effects of chemotherapy and radiotherapy, weight gain, bone health challenges, and arthralgias. It is known that these impairments, many of which are amenable to rehabilitative and exercise interventions, lead to limitations and restrictions in the performance of common daily activities, including occupational and home activities. There are multiple barriers to addressing physical impairments secondary to treatment. One barrier is the fractured delivery of health care: Surgery, radiation, chemotherapy, and survivorship follow-up all may occur in separate health care systems. Other barriers are lack of established relationships between the oncology, general surgery, and plastic surgery professions and the rehabilitation and exercise professions, like what exists between the orthopedic surgery and rehabilitation professions. Furthermore, patients and their health care providers may have a sense that these sequelae are ‘‘expected’’ and normal and that they simply need to be tolerated. There is a general lack of understanding of the role that rehabilitation and exercise can have in ameliorating commonly experienced physical impairments after breast cancer. Even when all treatment occurs in the same health system, and even when that health system has electronic medical records, the referral

Racial disparities in physical and functional domains in women with breast cancer

This review by a 10-member panel of experts in surgical prehabilitation addresses processes that may improve oncologic care. Surgical prehabilitation is the process on the continuum of care that occurs between the time of cancer diagnosis and the beginning of surgical treatment. The panel focused on the current state-of-the-science and recommended future research that would help to identify the elements that enhance preoperative physical, nutritional, and psychological health in anticipation of surgery, mitigate the burden of disease, facilitate the return of patient health status to baseline values, decrease postoperative morbidity, and reduce health care costs.