University of Exeter: Arm and shoulder disability and pain after breast cancer surgery reduced by exercise

Researchers led nationally by the University of Warwick with University Hospitals of Coventry and Warwickshire NHS Trust, and involving the University of Exeter, saw an improvement in shoulder and arm mobility and reduction in pain amongst women who were recovering after non-reconstructive breast cancer surgery after taking part in the structured PROSPER rehabilitation programme.

Published in The BMJ, the study authors are calling for wider adoption of the PROSPER programme in cancer services to improve the wellbeing of women recovering from breast cancer surgery. The study was funded by the National Institute for Health Research (NIHR), the research partner of the NHS, public health and social care.

Now, University of Exeter researchers, who were involved in the study, have developed a free-to-access Futurelearn course, aimed at health professionals, to teach them how to deliver the PROSPER programme to their patients as part of routine care. Funded by the University of Exeter and led by Professor Sallie Lamb, the course is open to registration, launches on November 29, and aims to swiftly roll out the PROSPER programme to benefit patients.

In non-reconstructive breast cancer surgeries, which includes women having mastectomy and surgery to the axilla (armpit), surgeons aim to remove the cancer and often some nodes in the armpit to control the cancer. This targeted treatment can leave patients with shoulder and arm problems, including chronic pain, restricted movement and arm swelling (known as lymphoedema). Past research has shown that as many as one third women recovering from breast cancer surgery can struggle to return to everyday tasks such as lifting bags and driving.

Usual care is to give an advice leaflet explaining exercises to do after breast cancer surgery. As part of the Prevention of Shoulder Problems Trial (PROSPER), researchers led from the University of Warwick worked with physiotherapists and breast cancer patients to design an exercise programme for those at higher risk of developing shoulder problems. The PROSPER exercise programme consists of an assessment with a physiotherapist at one week after their surgery, and followed by a prescribed programme of stretching, range of motion and resistance exercises.

In what is the largest trial in this patient group to date, they recruited 392 women undergoing non-reconstructive breast cancer surgery who were at higher risk of developing shoulder or arm complications. Half were randomly assigned to take part in the PROSPER rehabilitation programme, and half to receive usual care (advice leaflets only). 17 UK National Health Service cancer centres recruited to the trial, including at University Hospitals of Coventry and Warwickshire NHS Trust which was the top recruiter for the trial.

Participants were asked to complete questionnaires on their arm function, pain and overall quality of life over a 12 month period. After 12 months, women in the exercise group reported fewer arm disability symptoms, lower pain intensity, and better physical quality of life than those in the usual care group.

Professor Julie Bruce of Warwick Clinical Trials Unit at the University of Warwick, and principal investigator on the PROSPER trial, said: “We know that some women present to physiotherapy services and pain clinics further down the line with shoulder restriction and pain problems, so we wanted to test a rehabilitation programme to find out if this could help at an early stage.

“We hope these results will encourage NHS Trusts to consider offering this service to women having non-reconstructive breast cancer surgery. This would mean training physiotherapists in the PROSPER rehabilitation programme. This is a proven cost-effective programme that we know can help women undergoing certain breast cancer procedures, and it could be offered on the NHS.”

Professor Sallie Lamb, of the University of Exeter, said: “We’re delighted to translate this body of research into a free training resource – I’d encourage health professionals working in the field to sign up. We now know PROSPER works – let’s ensure it reaches those who need it.

Breast cancer is the commonest cancer in the UK, with over 50,000 women newly diagnosed with breast cancer each year. Thanks to screening programmes and new treatments that allow doctors to act earlier, women now survive for longer after their cancer treatment. This also means a greater number of women seeking treatment for arm and shoulder problems following their surgery.

Co-author Professor Alastair Thompson, professor and section chief of breast surgery at Baylor College of Medicine’s Dan L Duncan Comprehensive Cancer Center, said: “After breast cancer surgery, arm and shoulder disability impacts the functioning and quality of life for many women. Using a physiotherapy led exercise program introduced a week or so after surgery, led to better upper limb function, less pain and lower costs, up to a year later without any adverse impacts. This randomized trial demonstrates the benefits of early, supported exercise after breast surgery should become standard practice in women treated for breast cancer.”