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ORIGINAL ARTICLE
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A descriptive study on prevalence of arm/shoulder problems and its impact on quality of life in breast cancer survivors


 Department of General Surgery, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi, India

Date of Submission06-Jan-2019
Date of Decision13-Jan-2020
Date of Acceptance16-Feb-2020

Correspondence Address:
Priyansh Jariwala,
Department of General Surgery, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijc.IJC_22_19

  Abstract 


Background: Surgery for breast cancer and adjuvant radiotherapy are frequently associated with impairment of arm/shoulder function and development of lymphedema. However, most of the studies in Indian breast cancer survivors (BCSs) have focused on the development of lymphedema even though restriction of shoulder movement and pain are even more prevalent and adversely affect the quality of life (QOL). Hence, this study was conducted with the objectives to (1) study the prevalence of arm/shoulder problems (ASPs) including restricted shoulder mobility (ROM), lymphedema and arm/shoulder pain (2) assessment of the QOL in BCSs (3) to study the impact of ASPs on QOL.
Methods: This descriptive study was conducted on BCSs at an academic center in Delhi These patients underwent a mastectomy and axillary lymph node dissection with adjuvant therapies and were within 6 months to 5 years of follow-up. Assessment of ASPs was done using Kwan's arm problem scale (KAPS), and survivors with scores of more than 21.5 were considered to have significant ASPs. Assessment of shoulder movements was done by using a goniometer, lymphedema by measuring arm circumference at multiple points and arm/shoulder pain by using a numerical pain rating scale (NPRS). QOL was assessed using short form (SF-36) questionnaire.
Results: A total of 212 BCSs were studied with a mean duration of follow-up of 2.7 years (range = 6 months - 60 months). The prevalence of ASPs was 49% on KAPS. Prevalence of ROM, lymphedema, and arm/shoulder pain was found to be 51%, 27%, and 12% respectively. Patients with ASPs had poorer QOL scores on SF-36, significantly affecting both physical and mental component summary score. Among ASPs, worst scores were reported for limb swelling.
Conclusion: There is a high prevalence of ASPs in BCSs. Survivorship care plans should appropriately address these issues.


Keywords: Arm and shoulder problems, breast cancer survivors, quality of life
Key Message: Breast cancer survivors face several survivorship issues which adversely affect their quality of life. Well organized follow-up care plans should be made an integral part of basic cancer management to tackle these issues.



How to cite this URL:
Jariwala P, Kaur N. A descriptive study on prevalence of arm/shoulder problems and its impact on quality of life in breast cancer survivors. Indian J Cancer [Epub ahead of print] [cited 2020 Oct 20]. Available from: https://www.indianjcancer.com/preprintarticle.asp?id=297017





  Introduction Top


Survivorship care following treatment for breast cancer is assuming increasing importance in the last few decades in view of enhanced survival rates. The average 5-year survival rate for women with breast cancer is 90% in the west, and the average 10-year survival rate is 83%.[1] Consequently, the population of long-term survivors is increasing, emphasizing the need for knowledge on long-term sequelae of treatment. India too has a growing population of survivors even though mortality rates remain high (5-year survival of 66.1%), as compared to their western counterparts.[2]

Arm/shoulder problems (ASPs) constitute one of the most prevalent long-term sequelae, adversely affecting the quality of life (QOL) of breast cancer survivors (BCSs). ASPs are defined as lymphedema (LE), restricted shoulder mobility (ROM) and/or arm/shoulder pain. Nesvold et al. reported the prevalence of arm/shoulder pain to be 30–40%, LE 10–15%, and restricted arm mobility 15–30% in BCS.[3] Multiple studies, in general, have reported a higher rate of ASPs in BCSs undergoing mastectomy, axillary lymph node dissection (ALND) and radiotherapy as compared to those who undergo breast conservation surgery, sentinel lymph node biopsy, and no radiotherapy.[4],[5] Additionally, women who gain weight after treatment or have a high body mass index prior to diagnosis are at greater risk for developing LE.[6],[7]

QOL is increasingly being used as a primary outcome measure in studies to evaluate the effectiveness of treatment, especially in cancer patients. Nesvold et al. reported a significant correlation of low physical QOL in BCSs with ASPs.[4] Many authors have shown that functional upper limb impairment in BCSs is significantly correlated with decreased QOL score on multiple scales.[8],[9]

However, there are only a few studies reported in Indian BCSs, who have primarily studied LE and its effect on QOL. Hardly any data are reported about shoulder pain or ROM, which are even more prevalent in Indian patients who undergo more radical treatments due to delayed presentation and advanced stage at diagnosis and are further disadvantaged due to lack of well-organized follow-up care plans. Hence, we planned this study with the objectives (1) to study the prevalence of ASPs including ROM, LE, and arm/shoulder pain, (2) to assess QOL in BCSs, and (3) to study the impact of ASPs on QOL.


  Material and Methods Top


This cross-sectional descriptive study was carried out in the department of surgery, at an academic center in Delhi, from November 2014 to April 2018.

All BCSs who had undergone mastectomy/lumpectomy with axillary lymph node dissection and had 6 months to 5 years follow-up since surgery were included. Exclusion criteria were (1) pre-existing shoulder pain or limb deformity, (2) metastatic or recurrent disease, (3) breast reconstruction after mastectomy, (4) patients older than 70 years of age, and (5) patients who refused consent. Clearance from the institutional ethics committee was obtained. After taking informed consent from the patients, demographic and clinical details, as noted in their clinical records, were entered in a predesigned pro forma.

ASPs were assessed by using Kwan's arm problem scale (KAPS), and a score of more than 21.5 was considered to be significant. KAPS has been validated for assessment in BCSs and is shown to have good psychometric properties.[10] It includes 13 items consisting of two subscales. Problem subscale (8 items) and activity of daily life (ADL) subscale (5 items) with Likert style rating from 1 to 5 for every item. Problem scale includes eight items: swollen arm; arm pain; shoulder pain; stiff arm; stiff shoulder; use of arm; numbness; and move the arm. ADL scale includes five items: brush hair; pull sweater; fasten bra; back zipper; and reach over head. For the purpose of analysis, an item score of 1,2 was taken as a mild problem, 3 as moderate, and 4,5 as severe problem.

Assessment of shoulder movements (flexion and abduction) was done by using a goniometer. A restriction of more than a 15-degree movement on the operated side as compared to the normal side was considered significant.[11] Assessment of LE was done by measuring the circumference of the limb at 5 points (11.5 and 21 cm above and 7.5, 14, and 24 cm below the olecranon process). A difference of more than 3 cm was considered clinically significant, and the difference of more than 5 cm was considered severe LE.[12] Arm/shoulder pain was assessed using a numerical pain rating scale (NPRS), and scoring of more than 3 was considered clinically significant.[13]

QOL assessment was done using an SF-36 questionnaire. It is commonly used as a generic measure of QOL and contains eight individual scales, which are also scored as two summary scales: SF-36 physical (PCS) and mental (MCS) component summary scales.[14]

Statistical analysis

All data were analyzed with SPSS v20.0 software. Simple descriptive statistics were used for prevalence estimates and KAPS scores. Scoring of SF-36 was done as per specified guidelines. Statistical significance was assessed by using the Chi-square test and a value of P < 0.05 was taken as statistically significant.


  Results Top


A total of 243 BCSs who came for a follow-up visit were evaluated. Eighteen BCSs were excluded as the data collected was incomplete, eight were excluded as they were receiving treatment for osteoarthritis involving multiple joints and five were excluded as they had recurrent/metastatic disease. Results are based on the analysis of information on the remaining 212 BCSs.

Sociodemographic and clinical profile

The mean (standard deviation (SD)) age of the BCSs was 50 ± 13.7 years (range = 26 -76 years). Most of them were married (86%), unemployed (88%), and Hindus (53%). One hundred seventy-four patients (82%) underwent a modified radical mastectomy while rest 38 patients (18%) underwent a lumpectomy. Levels 1 and 2 ALND was performed in 157 patients (74%) and level 3 ALND in 55 patients (26%). The mean (SD) duration of follow-up was 2.7 ± 1.6 years (range = 6 months - 60 months). The majority of them had stage 3 disease (57%). Out of 212 BCSs, 121 patients (57%) received five-field conventional external beam radiotherapy, while 34 patients (16%) received four-field radiotherapy. 186 BCSs (88%) received chemotherapy and 21 BCSs (43%) received hormonal therapy. Details of sociodemographic and clinical characteristics are given in [Table 1].
Table 1: Sociodemographic and clinical parameters of breast cancer survivors (BCSs)

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Prevalence of ASPs

The prevalence of ASPs as assessed by the KAPS score of >21.5 was seen in 104 BCSs, that is, 49% of our patient population [Table 2]. Mean scores of all the items in BCSs with ASPs were in mild to moderate range, that is, 2.5–3.0 [Table 3]. The highest mean score of 3.0 was seen for swelling of the arm, while the stiffness of arm/shoulder had a mean score of 2.9. Arm and shoulder pain had mean scores of 2.6 and 2.7, respectively. On activities of daily life scale of KAPS, most affected functions were reaching over head and pulling up sweater. On further analysis of KAPS, 16% BCSs complained of severe problems of swelling in the arm, 14% and 10% BCSs had a severe problem of the stiffness of shoulder and arm, respectively. While severe scores in the shoulder and arm pain were reported by 8% and 4%, respectively [Table 4].
Table 2: Prevalence of ASPs in BCSs

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Table 3: Mean scores of KAPS items

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Table 4: Distribution of KAPS scoring in BCSs

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Clinically significant ROM, defined as > 15-degree reduction was noted in 108 BCSs (51% of patients). All these 108 BCSs had a restriction in abduction movement while only 82 (39%) BCSs had limited flexion mobility. Restriction of > 10-degree shoulder movement was seen in 137 (65%) BCSs. Severe shoulder restriction (>25°) was observed in 51 (24%) BCSs. LE was present in 57 BCSs (27%), out of which 25 BCSs (12%) had severe LE. Arm/shoulder pain noted as an NRS score of more than 3 was present in 25 BCSs (12%). Details of ASPs in BCSs are given in [Table 2].

Correlation of ASPs with sociodemographic and clinical factors

No significant correlation was observed between epidemiological factors such as age, level of education, socioeconomic status, or clinical factors such as tumor size, grade, or nodal status, with the development of ASPs in our patient population (P > 0.05). The effects of adjuvant treatments such as radiotherapy and chemotherapy could not be evaluated since the majority of these patients received both. All the patients in the current study were advised arm/shoulder physiotherapy in the immediate postoperative period by refereeing them to the physiotherapy clinic. However, their adherence to the same was not evaluated in further follow-up visits.

ASPs and QOL

Scores of all domains of SF-36 were lower in BCSs with ASPs when compared to those without ASPs. On comparing SF-36 scores between these two groups, a statistically significant difference was observed in scores of physical component summary (PCS), physical functioning (PF), role-playing (RP), bodily pain (BP), general health (GH), and vitality (VT) domains. [Table 5] provides a detailed analysis of SF-36 scores in BCSs with ASPs.
Table 5: Quality of life (QOL) in BCSs

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  Discussion Top


Risk factors and pathophysiology

ASPs present significant morbidity for women who have undergone curative treatment for breast cancer. Although they have a detrimental effect on upper extremity function and health-related QOL, their significance is undervalued by treating physicians. It was reported that over 60% of women who suffered from ASPs did not discuss their problem with a health care provider.[15] Common reasons for this under reporting could be the beliefs that symptoms were normal, would diminish over a period of time or would decrease if they restrict certain activities. There is also a general lack of awareness regarding available treatment options. Another report highlighted the fact that out of 90% of breast cancer patients who would have benefitted from some rehabilitation intervention, only 30% received appropriate treatment.[16] So, it is important for both patients as well as treating physicians to understand what should be appropriate measures in terms of arm/shoulder impairments and functional limitations.

ASPs in BCSs

Almost half of our patient population (49%) had significant ASPs. Similar results were also published by Kwan et al. who originally described Kwan's arm problem scale.[17] Nesvold and coworkers, who validated the use of KAPS, found that 47% of their patient population had a score of >21.5 on KAPS.[3] All the BCSs in our study underwent at least level I and II ALND and over 70% received radiotherapy, which explains the high prevalence of ASPs. Further, none of them were monitored for the development of shoulder morbidities or adherence to shoulder exercises during their follow-up visits.

The most prevalent ASP in our study was the restriction of shoulder motion (51%). In literature, different criteria for defining ROM have been used and have provided different results. Tengrup et al. used criteria of >15° difference between two arms as significant restriction and reported a rate of 49%, which is almost similar to our results.[11] Nesvold and coworkers used the criteria of >25° restriction and reported a prevalence rate of 33%.[3] Kuehn et al. reported a prevalence rate of 45.5% when the criteria of movement restriction were 10°.[18] Since the 51% rate of significant ROM most closely matches the rate of significant problems on Kwan's arm problem scale (49%), we believe a criteria of > 15° restriction of movement is the most appropriate measure for further studies.

Out of 108 patients with ROM, all had a restriction in abduction, while 82 patients also had a restriction in a shoulder flexion movement. A similar difference between the two movements was also noted by Kuehn and coworkers.[18] These restrictions have been attributed to the impaired shoulder girdle-resting alignment, restricted shoulder girdle movement due to pain and protective posturing and scar tissue formation on the anterior chest wall. In addition, weakness of muscles due to neurapraxia and altered motor control as well as the development of LE further compromise the shoulder functions.[19]

LE was the second most prevalent ASP with a prevalence rate of 27% in our study. Deo and coworkers used similar criteria to define LE and reported a rate of 33.5%.[12] Similar higher rates like 35.9% and 41.1% have been reported by Li Zou et al. and Pillai et al.[20],[21] In all these studies, patients underwent radical treatment in form of mastectomy and ALND.

However, when other methods are used for the assessment of LED, there is a wide variation in reported prevalence. Studies that have used questionnaires have reported a higher incidence of LE 42% and 54%, respectively.[22],[23] Hayes and coworkers had reported a 33% rate of LE by using bioelectrical impedance spectroscopy (BIS).[24] Methods like infrared perometry and BIS provide early and accurate detection of LE but are costly, large, and complex to use instruments.[24],[25] Whereas measurement of arm circumference is a simple method and applicable in clinical practice and can be done easily by using a simple measuring tape.

The prevalence of clinically significant arm/shoulder pain was 12%. It has not been independently reported much and is generally described as a component of post-mastectomy pain syndrome (PMPS). “International Association for Study of Pain” (IASP) defines PMPS as chronic pain in the anterior aspect of thorax, axilla, and/or upper half of the arm, beginning after mastectomy or quadrantectomy and persisting for more than 3 months after the surgery. It is typically neuropathic pain which is described as burning sensations or tenderness with paroxysms of lancinating, shock-like pain.[26] It is also described by some women as dysesthesia with different degrees of discomfort. Sagen et al. reported that pain (36%) and the sensation of heaviness (21%) in the upper limb were present up to 5 years after surgery.[27]

QOL in BCSs with ASPs

It is reported that BCSs with ASPs have significantly decreased QOL scores. This can be explained to multiple factors related to ASPs. Decreased upper limb function negatively impacts a woman's ability to care for her family or return to work. Pain has a negative effect on mood, daily activities, sleep, cognitive functions, and socio-relation in life.[28] Physical symptoms associated with LE, such as heaviness, tingling, pain, and restriction of shoulder movements affect normal daily routine and result in poor physical functioning scores.[29] Women with LE have also been shown to experience emotional disturbances such as stress, anger, sadness, etc.

In our study, too, we observed that all the domains of SF-36 with 2 summary scores (PCS and MCS) had a lower mean score in BCSs with ASPs. Significant deterioration was noted in PCS, PF, RP, BP, GH, and VT domains. A similar trend was reported in the study by Nesvold, where all the domains of SF-36 were significantly lower in BCSs with ASPs except MCS.[3] ASPs are mainly associated with a physical disability and, hence, a poor physical QOL is seen. However, physical disability is also likely to affect a survivor's psychological well-being and, hence, lower scores of MCS was also found in this study.


  Strengths and Limitations Top


This is probably the first study to evaluate the prevalence of ASPs and its impact on QOL in Indian BCSs. The impact of individual parameters of ASPs was studied in detail along with their effect on QOL.

However, pretreatment assessment of arm/shoulder morbidity was lacking. SF-36 questionnaire is a generic tool and includes multiple questions not directly related to breast cancer. Our patients found it difficult to provide accurate answers to the SF-36 questionnaire too.


  Conclusion Top


BCSs have a high prevalence of ASPs, likely attributable to the advanced stage of presentation, radical surgical treatment, and poor postoperative follow-up care. ASPs adversely affect the QOL of patients. Survivorship care plans should appropriately address these issues.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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