Exercise superior to usual care at reducing upper limb disability after breast cancer surgery

An early, structured, progressive exercise is safe and effective for women at high risk of developing shoulder and upper limb problems following nonreconstructive breast cancer surgery, evidence from the UK PROSPER study shows.

“The PROSPER exercise programme improved upper limb function at 1 year after breast cancer surgery and was cost-effective compared with usual National Health Service (NHS) care,” the researchers said. “Our manualized exercise intervention is suitable for wider implementation in clinical practice.”

A multicentre, pragmatic, superiority, randomized controlled trial with economic evaluation was conducted at 17 NHS cancer centres in the UK. A total of 392 women (mean age 58.1 years) undergoing breast surgery were randomized to usual care with structured exercise (n=196) or usual care alone (n=196). Of these, 382 (97 percent) were eligible for intention-to-treat analysis (n=191 for each cohort).

The intervention included usual care plus a physiotherapy-led exercise programme, incorporating stretching, strengthening, physical activity, and behavioural change techniques to support adherence to exercise, introduced at 7–10 days postoperatively, with two further appointments at 1 and 3 months. On the other hand, usual care only included information leaflets.

Of the patients assigned to exercise, 181 (95 percent) attended at least one appointment. Upper limb function improved in women after exercise compared with usual care alone (mean Disability of Arm, Hand, and Shoulder [DASH] for exercise, 16.3; mean DASH for usual care, 23.7; adjusted mean difference, 7.81, 95 percent confidence interval [CI], 3.17–12.44; p=0.001). [BMJ 2021;375:e066542]

Secondary outcomes (DASH subscales, pain, complications, health-related quality of life, and resource use) were also better with exercise over usual care, with lower pain intensity at 12 months (adjusted mean difference on numerical rating scale, –0.68, 95 percent CI, –1.23 to –0.12; p=0.02) and fewer arm disability symptoms at 12 months (adjusted mean difference on Functional Assessment of Cancer Therapy-Breast+4, –2.02, 95 percent CI, –3.11 to –0.93; p=0.001).

Of note, women in the exercise group showed no increase in complications, lymphoedema, or adverse events. In addition, the intervention accrued lower costs per patient (on average, –£387, 95 percent CI, –£2,491 to £1,718; 2015 pricing) and was more cost-effective than usual care.

“The PROSPER structured exercise programme introduced at 1 week postoperatively was safe to deliver, clinically impactful, and cost-effective, providing the best quality evidence to date in support of prescription of early exercise for women at high risk of shoulder problems and upper limb morbidity after nonreconstructive breast cancer treatment,” the researchers said.

Earlier systematic reviews reported a lack of high-quality evidence on the timing, safety, and optimal content of postoperative exercise after nonreconstructive breast cancer surgery. [Cochrane Database Syst Rev 2010;6:CD005211; Arch Phys Med Rehabil 2015;96:1140-1153]

A 2019 analysis also reported low-quality evidence for the effectiveness of early rehabilitation on upper limb function up to 6 months postoperatively. [Clin Rehabil 2019;33:1876-1886]

“We aimed to fill this gap by investigating the efficacy of early structured rehabilitation on functional and health-related outcomes over 1 year,” the researchers said.

“Future research directions could evaluate application of our preoperative screening criteria for the identification of women at higher risk of developing post-treatment limb-related disability who could benefit from this cost-effective exercise programme,” they noted.