A systematic review of multi-modal prehabilitation in breast cancer

Author/Year

Purpose

Sample size/mean age (SD, years), gender

Participants (Cancer type, cancer stage, treatment)

Response Rate (reasons for declining); attrition/ adherence

Design

Time Points

Data Collection Tools

Baima et al. 2017

USA [37]

Explore the feasibility of an independent home shoulder exercise program to improve ipsilateral shoulder pain and abduction ROM after BC surgery.

Sample size: 

n =60 (Group 1: n=36; Group 2: n=24).

Age: 

35-81 years (median not reported).

Gender:

Female: n=59

Male: n=1.

Type:

Not reported.

Stage: 

Not reported.

Treatment: 

Surgery (not specified).

Response rate:

n=64 recruited, n=60 consented; n=45 completed study (accessibility of study staff at follow-up appointments, delayed surgical treatment due to prolonged CT, disease worsening).

Attrition/adherence: 

76% chose to exercise; n=29 (85%) performed exercises 3≥ per week.

Prospective, cohort observational study.

T1: 1-4 weeks prior to surgery.

T2: 3 months post-surgery.

Subjective data collection:

Pain scale (0-10).

Objective data collection:

ROM (0 to 180°); chart documentation of postoperative seroma formation.

Brahmbhatt et al. 2020

Canada [38]

Determine the feasibility and acceptability of an individualised, home-based prehabilitation intervention prior to BC surgery.

Sample size:

n=28.

Age:

Mean age 54 ± 10.98 years.

Gender:

Female: n=28.

Type: 

Not reported.

Stage: Not reported.

Treatments: 

Unilateral lumpectomy with SLNB: n=12 (54.55%);

Unilateral mastectomy with SLNB: n=2 (9.09%); 

Unilateral mastectomy with ALND: n=1 (4.55%);

Bilateral mastectomy with SLNB: n=4 (18.18%); 

Bilateral mastectomy with SLNB and insertion of tissue expanders: n=1 (4.55%),

Bilateral mastectomy with immediate autologous reconstruction: n=1 (4.55%).

Response rate:

n=45 approached, n=28 consented (62%)

• n=28 consented (travel/ distance (n=3), extremely anxious (n=2), travelling (n=1), already active (n=1), not interested (n=5), no reason provided (n=5)

• n=22 completed baseline: could not contact (n=4), withdrew consent (n=1), change in treatment plan (n=1))

• n=18 completed T1 (lost to follow-up (n=2), travelling (n=1), not interested (n=1))

• n=15 completed T2: lost to follow-up (n=2), family commitments (n=1)

• n=14 completed T3: illness (n=1)

Attrition/adherence:

Overall attrition rate was 36%

17 participants submitted exercise logs

Adherence to: minimum aerobic exercise prescription: 142.22 ± 82.66%; minimum resistance training prescription: 114.44 ± 38.26%; n=13 (76%) participants completed >70% prescribed exercise; n=2 participants completed <70% prescribed exercise in some sessions; n=2 participants completed <70% of prescribed exercise.

Prospective, single-arm, feasibility study with an emergent, embedded mixed-methods design.

Baseline: lasted 30 ± 16.59 days.

T1: 1 week prior to surgery.

T2: 6 weeks post-surgery.

T3: 12 weeks post-surgery.

Subjective data collection

Quantitative: DASH; FACT-F; SF-36, GLTEQ-LSI, WHODAS 2.0, BPI.

Qualitative: Semi-structured interviews with open ended questions.

Objective data collection:

6MWT; upper-extremity strength (handgrip dynamometry); manual muscle testing (digital handheld dynamometer); WC; BMI; lean body mass; BF%; fat mass; clinical disease related data.

Heiman et al. 2021

Sweden [39]

Evaluate whether an intervention consisting of recommended physical activity before and after surgery improved physical recovery at 4 weeks after BC surgery.

Sample size: 

n=400 (I: n=200; C: n=200).

Age:

I: 30-84 years; median age 61 (IQR 52-68) years

C: 38-89 years; median age 63 (IQR 54-71) years.

Gender:

Female n=400.

Type:

Not reported.

Stage:

Not reported.

Treatments:

Breast-conserving surgery: I: n=147; C: n=154; 

Bilateral surgery: I: n=3; C: n=7

Mastectomy: I: n=36; C: n=43; Bilateral surgery: I: n=6; C: n=4; Direct reconstruction: I: n=2; C: n=4

Missing: I: n=17; C: n=3.

Response rate:

n=997 approached (n=288 met exclusion criteria, n=309 declined to participate), n=400 consented, n=370 completed primary endpoint, n=368 analysed (I: n=179, C: n=189)

Withdrew consent at preop phase: I: n=17, C: n=3

Withdrew consent at postop phase: I: n=3, C: n=7

Withdrew consent at analysis phase: I: n=1, C: n=1.

Attrition/adherence: 

n=318 (85.9%) (I: n=149 (82.8%), C: n=169 (88.9%)) returned baseline and 4-week questionnaires

n=151 (83.9%) intervention group returned physical activity diary.

Randomised, controlled, multicentre open label trial.

Baseline: preoperative

T1: 4 weeks postoperative.

T2: 12 months post-operative.

Subjective data collection:

SGPALS (AUDIT-C).

Objective data collection:

ASA physical status grade, use of drainage, antibiotic and thromboembolic prophylaxis, duration of hospital stay, complications, reoperations, and readmissions were retrieved from medical records.

Knoerl et al. 2022

USA [40]

Explore the impact of exercise and mind-body prehabilitation interventions on changes in quality of life and cancer treatment–related symptoms in women with newly diagnosed BC.

Sample size:

n=49 (Exercise: n=27; Mind-Body: n=22).

Age:

Exercise: 53.3 ± 9.6. years

Mind-Body: 53.4 ± 8.0 years.

Gender:

Female n=49.

Type:

Not reported.

Stage:

Stage 1: Exercise: n=10; Mind-Body: n=9

Stage 2: Exercise: n=9; Mind-Body: n=9

Stage 3: Exercise: n=6; Mind-Body: n=1

Unknown: Exercise: n=1; Mind-Body: n=1.

Treatments:

Planning to undergo BC surgery

Response rate:

n=49 consented, n=47 completed T1, n=46 completed T2, n=35 completed T3.

Attrition/adherence:

Participants in Exercise group increased physical activity by 203 minutes per week, participants in Mind-Body group completed 23 minutes.

n=14 (66.7%) participants in Mind-body group returned diary; engaged with the intervention on 69% of pre-surgery days. 

Randomised controlled trial.

T1: at enrolment.

T2: post.

intervention/ immediately prior to surgery.

T3: one-month post-surgery.

Subjective data

EORTC QLQ C-30; HADS; PSS.

Objective data

7-Day PAR.

Larson et al.

2000

USA [41]

Evaluate the feasibility and potential immunological benefit of a presurgical psychosocial intervention for BC patients.

Sample size:

n=41 (I: n=23; C: n=18).

Age:

29-80 years; mean 56 ± 13 years.

Gender:

Female: n=41.

Type:

Not reported.

Stage:

Reported by n=28 (68%) of participants:

Stage 1: n=17 (60.7%) 

Stage 2: n=8 (28.6%)

Stage 3: n=2 (7.1%)

Stage 4: n=1 (3.6%).

Treatments:

All were awaiting either surgery, or surgery plus RT or CT

Response rate:

n=41 consented, n=2 participants dropped out of control after T1.

Attrition/adherence:

Not reported.

Randomised controlled trial.

T1: within one week of diagnosis and prior to the intervention.

T2: following the intervention but within 1-3 days.

prior to surgery

T3: 1-week post-surgery.

Subjective data:

CES-D, DES-IV, IES, LOT, SF-36.

Objective data:

NK cell activity and IFN-γ production.

Sato et al.

2014

Japan [42]

Investigate the effectiveness of a perioperative education program for improving upper arm dysfunction in patients with BC.

Sample size:

n=162 (I: n=96, C: n=66).

Age:

ALND:

I: 52.9 ± 10.1 years.

C: 52.1 ±12.9 years.

SLNB:

I: 54.3 ±10.6 years.

C: 53.7 ± 9.5 years.

Gender:

Not specified.

Type:

Not reported.

Stage:

ALND: 

Stage 0: I: n=0, C: n=6.7%

Stage 1: I: n=7.7%, C: n=20%

Stage 2: I: n=43.6%, C: n=50%

Stage 3: I: n=41%, C: n=23.3%

Stage 4: I: n=7.7%, C: n=0

SLNB:

Stage 0: I: n=25.5%, C: n=44.8%

Stage 1: I: n=54.9%, C: n=48.3%

Stage 2: I: n=17.6%, C: n=6.9%

Stage 3: I: n=2%, C: n=0

Stage 4: I: n=0, C: n=0.

Treatments:

Total Mastectomy: 

ALND: I: n=56.4%, C: n=36.7%; SLNB: I: n=21.6%, C: n=24.1%

Partial Mastectomy:

ALND: I: n=43.6%, C: n=63.3%; SLNB: I: n=78.4%, C: n=75.9%

Adjuvant CT: ALND: I: n=79.5%, C: n=86.7%; SLNB: I: n=11.8%, C: n=24.1%

Adjuvant RT: ALND: I: n=69.2%, C: n=83.3%; SLNB: I: n=58.8%, C: n=51.7%

Adjuvant hormone therapy: ALND: I: n=82.1%, C: n=63.3%; SLNB: I: n=80.4%, C: n=75.9%.

Response rate:

n=162 enrolled, n=49. analysed:

ALND: I: n=39, C: n=30

SLNB: I: n=51, C: n=29

T1:

• I: n=3 dropped out (n=2 lost to follow-up, n=1 changed hospital)

• C: n=5 dropped out (n=2 lost to follow-up, n=2 changed hospital, n=1 lost interest)

T2:

• I: n=3 dropped out (n=1 lost to follow-up, n=1 lost interest, n=1 lack of time)

• C: n=2 dropped out (n=1 lost to follow-up, n=1 lack of time)

Attrition/adherence:

Not reported.

Controlled trial (allocated according to participant wishes).

Baseline: pre-surgery.

T1: 1-week post-surgery.

T2: 1-month post-surgery.

T3: 3 months post-surgery.

Subjective data:

SPOFIA; DASH.

Objective data:

Arm girth; shoulder ROM; Grip strength (dynamometer).

Springer et al. 2010 

USA [43]

Determine the extent and time course of upper limb dysfunction in subjects seen pre-operatively and followed prospectively using a novel physical therapy surveillance model post-BC and treatment.

Sample size: 

n=94.

Age:

Mean age 53.39 ± 11.8.

Gender:

Female: n=94.

Type:

DCIS: n=11 (11.70%)

IDC: n=44 (46.81%)

DCIS and IDC: n=31 (32.98%)

Other: n=8 (6.51%).

Stage:

Stage 0: n=11

Stage 1: n=40

Stage 2: n=30

Stage 3: n=13.

Treatments:

BCT: n=41 (43.62%)

MRM: n=50 (53.19%)

Simple mastectomy: n=3 (3.19%)

ALND: n=66 (70.21%)

SLNB: n=20 (21.28%).

CT: n=57 (60.64%)

RT: n=64 (68.9%)

Hormone therapy: n=67 (71.28%),

Response rate:

n=200 enrolled, n=94 (47%) included in analysis.

Attrition/adherence:

Not reported.

Prospective observational cohort study.

T1: pre-surgery.

T2: 1-month post-surgery.

T3: 3-6 months post-surgery.

T4: 12-months post-surgery.

Subjective data: 

ULDQ.

Objective data: 

Shoulder ROM and strength; upper limb volume and girth.

Tamaki et al. 2017

Japan [44]

Compare the effects of aromatherapy on mood, quality of life, and physical symptoms in patients with BC.

Sample size:

n=162 (I: n=110; C: n=52).

Age:

I: 52 ± 11.3 years

C: 55 ± 13.5 years.

Gender:

Not specified.

Type:

DCIS: I: n=10, C: n=12

IDC: I: n=78, C: n=82

ILC: I: n=10, C: n=0

Others: I: n=2, C: n=6.

Stage:

Stage 0: I: n=10%, C: n=12%

Stage 1: I: n=50%, C: n=47%

Stage 2: I: n=35%, C: n=37%

Stage 3: I: n=5%, C: n=4%.

Treatments:

Mastectomy: I: n=32%, C: n=39%.

Response rate:

n=249 approached, n=162 consented.

Attrition/adherence:

I: n=8 did not complete questionnaires, C: n=1 did not complete questionnaires.

Pilot randomised controlled trial (2:1 randomisation).

Baseline: at time of hospitalisation.

T1: day of surgery.

T2: one day post-surgery.

Subjective data: 

EORTC QLQ-C30.

Objective data: 

Hypnotics, vital signs: blood pressure, heart rate, adverse events.

Tanaka et al. 2021

Japan [45]

Assess the effects of Yokukansan on BC patients undergoing a practical or total mastectomy breast surgery.

Sample size:

n=100 (I: n=50, C: n=50).

Age:

I: 49 ± 6.2 years

C: 48 ± 5.7 years.

Gender:

Female: n=91.

Type:

Not reported.

Stage:

Not reported.

Treatments:

Partial resection: I: n=22, C: n=21

Total mastectomy: I: n=21, C: n=27.

Response rate:

n=100 consented, n=77 analysed (I: n=35, C: n=42)

T1:

• I: n=3 excluded (n=1 protocol violation, n=2 refusal of study participation)

T2:

• I: n=7 excluded (n=7 positive sentinel lymph node)

• C: n=6 excluded (n=5 positive sentinel lymph node, n=1 inhaled steroid for treatment of bronchospasm

T3:

• I: n=5 excluded (n=5 incomplete answers to questionnaires)

• C: n=2 excluded (n=2 incomplete answers to questionnaires)

Attrition/adherence:

Not reported.

Single-blind randomised controlled trial.

T1: One day pre-surgery.

T2: immediately prior to surgery.

T3: one day post-surgery.

Subjective data

VAS; HADS; STAI; QoR-15.

Objective data

sAA.

Thomsen et al. 2009 

Denmark [46]

Explore how women smokers with newly diagnosed BC experienced brief preoperative smoking cessation intervention in relation to BC surgery.

Sample size:

n=11.

Age:

Median age = 50 (range 40 – 72).

Gender: 

Female: n=11.

Type:

Not reported.

Stage: 

Not reported.

Treatments: 

Unresolved at time of interview: n=2.

Radiation therapy: n=3.

Endocrine therapy: n=1

CT: n=1

RT + CT: n=1

RT + CT + endocrine therapy: n=3.

Response rate:

Not reported.

Attrition/adherence:

Not reported.

Qualitative, descriptive study.

T1: 3-8 weeks after surgery.

Subjective data collection:

Semi-structured interviews, initiated with: ‘‘Please tell me how you experienced being counselled to stop smoking before your BC surgery.’’

Thomsen et al. 2010

Denmark [47]

Examine if a brief smoking cessation intervention encouraging patients to stop smoking from two days before to ten days after BC surgery would reduce the frequency of postoperative clinical complications requiring treatment.

Sample size: 

n=130 (I: n=65, C: n=65).

Age: 

I: 57.5 (35-79) years

C: 56.5 (36-82) years.

Gender:

Female: n=130.

Type:

Not reported.

Stage:

Not reported.

Treatments:

BCS without axillary resection: I: n=27 (47%), C: 32 (52%)

BCS with axillary dissection: I: n=14 (24%), C: n=10 (16%)

Mastectomy without axillary dissection: I: n=7 (12%), C: n=11 (18%)

Mastectomy with axillary: I: n=9 (15%), C: n=9 (14%)

Axillary dissection not complete: I: n=1 (2%), C: n=0.

Response rate:

n=347 approached (n=217 excluded), n= 130 consented, n=113 analysed (I: n=55, C: n=58)

Allocation:

• I: n=7 excluded (n=6 withdrew prior to receiving intervention, n=1 incorrect inclusion)

• C: n=3 excluded (n=3 withdrew)

Follow up:

• I: n=3 lost to follow-up (n=3 withdrew)

• C: n= 4 lost to follow-up (n= 3 withdrew, n=1 death)

Attrition/adherence:

Not reported

Single-blind randomised controlled multicentre trial.

Baseline: at inclusion

T1: 2-10 days prior to surgery.

T2: 10 days post-surgery.

T3: 30 days post-surgery.

T4: 3 months post-surgery.

T5: 6 months post-surgery.

T6: 12 months post-surgery.

Subjective data:

Smoking cessation.

Objective data:

Postoperative complications, length of hospital stay, requirement of secondary surgery, hospital readmission due to complication of primary surgery; exhaled carbon monoxide.

Tian et al. 2020

China [48]

Determine the influence of comprehensive nursing on the prognosis of BC patients, aiming to provide a better theoretical reference for future clinical nursing interventions with BC patients.

Sample size: 

n=168 (I: n=98, C: n=70).

Age: 

I: 42.3 ± 6.6 years

C: 43.2 ± 7.5 years.

Gender: 

Not specified.

Type:

Not reported.

Stage:

Stage I-II: I: n=78 (79.59%), C: n=51 (72.86%)

Stage III-IV: I: n=20 (20.41%), C: n=19 (27.14%).

Treatments: 

Not reported.

Response rate:

n=168 consented.

Attrition/adherence:

Not reported.

Controlled trial.

T1: before treatment.

T2: after treatment.

Subjective data:

MMSE; QOL; SAS; SDS; VAS; therapeutic effects; adverse reactions; nursing satisfaction.

Objective data:

RECIST.

Wu et al. 2021

UK [49]

Assess the feasibility of multimodal prehabilitation as part of the BC treatment pathway.

Sample size: 

n =61.

Age:

Median age = 63 (range 30 – 86) years.

Gender:

Female: n=61.

Type:

Not reported.

Stage: 

Not reported.

Treatments: 

Surgery (not specified).

Response rate:

n=75 approached, n=61 (81.3%) consented, n=27 completed study, n=24 (32%) completed all results, n=20 nonparticipating patients consented to C

Reasons for nonparticipation: surgery within 2 weeks (n=14), full time commitments (n=12), transportation difficulties (n=8).

Attrition/adherence:

n=12 attended 1-3 session, n=12 attended ≥4 sessions

Prospective, cohort observational study.

Baseline: pre-operative.

T1: 6 weeks post-surgery.

Subjective data collection:

SF-12, HADS, SPADI.

Objective data collection:

Usage of healthcare resources (length of stay and complications).

Zgâia et al. 2016

Romania [50]

Investigate the effects of pre-operative relaxing technique and psychological counselling on the post-operative intensity of acute pain, analgesic consumption and psychological symptoms, for patients scheduled for MRM for BC.

Sample size: 

n=102 (I: n=58, C: n=44).

Age: 

I: 52.25 ± 12.23 years

C: 59.04 ± 10.75 years.

Gender: 

Not specified.

Type:

Not reported.

Stage: 

Not reported.

Treatments:

MRM: n=102.

Response rate:

n=115 approached (n=13 excluded; n=7 refused to participate, n=4 met exclusion criteria, n=2 had surgery postponed), 102 consented

Assigned: I: n=58, C: n=44.

Attrition/adherence:

n=6 in I refused intervention and were assigned to C.

Prospective, randomised, open-labelled, controlled trial (allocation ratio 1:1).

Post-operative pain: 

T1: 0 hours post-surgery.

T2: 2 hours post-surgery.

T3: 8 hours post-surgery.

T4: 12 hours post-surgery.

T5: 24 hours post-surgery.

T6: every 6 hours on the first day post-surgery.

Post-operative psychological symptoms: 

T1: every 6 hours in the 48 hours post-surgery.

Subjective data:

Pain intensity and intensity of psychological symptoms using NRS.

Objective data: 

Height, weight, BMI, consumption of analgesic drugs.

1. Qualitative

Item number of check list

S1.

S2.

1.1.

1.2.

1.3.

1.4.

1.5. 

Thomsen et al. 2009 [46]

Y

Y

Y

Y

Y

Y

Y

Item number check list key*: S1. Are there clear research questions, S2. Do the collected data allow to address the research questions, 1.1. Is the qualitative approach appropriate to answer the research question, 1.2. Are the qualitative data collection methods adequate to address the research question, 1.3. Are the findings adequately derived from the data, 1.4. Is the interpretation of results sufficiently substantiated by data, 1.5. Is there coherence between qualitative data sources, collection, analysis and interpretation.

2. Quantitative Randomised Controlled Trials

Item number of check list

S1.

S2.

2.1.

2.2.

2.3.

2.4.

2.5.

Heiman et al. 2021 [39]

Y

Y

Y

Y

Y

N

N

Knoerl et al. 2022 [40]

Y

Y

Y

Y

Y

U

Y

Larson et al. 2000 [41]

Y

Y

U

Y

Y

U

Y

Tamaki et al. 2017 [44]

Y

Y

Y

Y

Y

U

Y

Tanaka et al. 2021 [45]

Y

Y

Y

Y

Y

Y

U

Thomsen et al. 2010 [47]

Y

Y

Y

Y

Y

Y

U

Zgâia et al. 2016 [50]

Y

Y

Y

Y

Y

Y

Y

S1. Are there clear research questions, S2. Do the collected data allow to address the research questions, 2.1. Is randomisation appropriately performed, 2.2. Are the groups comparable at baseline, 2.3. Are there complete outcome data, 2.4. Are outcome assessors blinded to the intervention provided, 2.5. Did the participants adhere to the assigned intervention. 

3. Quantitative Non-Randomised

Item number of check list

S1.

S2.

3.1.

3.2.

3.3.

3.4.

3.5.

Baima et al. 2017 [37]

Y

Y

Y

Y

Y

U

Y

Sato et al. 2014 [42]

Y

Y

Y

Y

Y

U

Y

Springer et al. 2010 [43]

Y

Y

Y

Y

Y

U

Y

Tian et al. 2020 [48]

Y

Y

Y

Y

Y

U

Y

Wu et al. 2021 [49]

Y

Y

Y

Y

Y

U

Y

S1. Are there clear research questions, S2. Do the collected data allow to address the research questions, 3.1. Are the participants representative of the target population, 3.2. Are measurements appropriate regarding both the outcome and intervention (or exposure), 3.3. Are there complete outcome data, 3.4. Are the confounders accounted for in the study design and analysis, 3.5. During the study period, is the intervention administered (or exposure occurred) as intended. 

5. Mixed Method

Item number of check list

S1.

S2.

5.1.

5.2.

5.3.

5.4.

5.5.

Brahmbhatt et al. 2020 [38]

Y

Y

Y

Y

Y

Y

Y

S1. Are there clear research questions, S2. Do the collected data allow to address the research questions, 5.1. Is there an adequate rationale for using a mixed methods design to address the research question, 5.2. Are the different components of the study effectively integrated to answer the research question, 5.3. Are the outputs of the integration of qualitative and quantitative components adequately interpreted, 5.4. Are divergences and inconsistencies between quantitative and qualitative results adequately addressed, 5.5. Do the different components of the study adhere to the quality criteria of each tradition of the methods involved. 

Yes (Y)

Unclear (U)

No (N)

Author/Year

Purpose

Intervention

Baima et al. 2017

USA [37]

Explore the feasibility of an independent home shoulder exercise program to improve ipsilateral shoulder pain and abduction ROM after BC surgery.

Group 1 (in person teaching): Received an information sheet with exercises, video links and instruction with physical demonstration performed by the research team. The first exercise (Codman’s exercise) involves leaning over and tracing circles with the affected arm. The second exercise (scapular squeezes), involves standing with the arms above the head and pulling the elbows back and in. The third exercise (reach for the pillow) involves raising one arm above the head to reach pillows behind the head while lying supine.

Group 2 (video-only): Received the instruction sheet only, with a link to the video as well as the recommended number of repetitions. The subjects were instructed to do the exercises daily before surgery and to stop at the time of surgery. They were restricted from any upper arm exercise above 90° of abduction while drains were in. They could resume the same exercises as desired after surgery and after all drains were removed.

Brahmbhatt et al. 2020

Canada [38]

Determine the feasibility and acceptability of an individualised, home based prehabilitation intervention prior to BC surgery.

Intervention: Comprised of individually tailored, home-based exercise programs. Exercise prescriptions were developed and delivered by a RKin and consisted of aerobic exercise 3-5 days/ week for 30–40 min per session, before and upper quadrant-specific resistance training 2-3 days per week. Aerobic exercise prescriptions typically included brisk walking at an intensity of four-six on a 10-point RPE scale. Upper quadrant-specific resistance training consisted of two to three sets of 10-12 repetitions per exercise, with each session incorporating up to eight exercises (standing rows, shoulder external rotation, front raise, lateral raise, bicep curls, triceps extensions, wall push-ups, and chest press). Intervention also included stretching and mobility exercises which reflected standard postoperative rehabilitation. Participants were also provided with resistance bands and an exercise manual to facilitate home-based exercise. The RKin communicated with the participants on a weekly basis via phone calls or emails to support program compliance and appropriate progression and address any barriers to exercise (including questions about appropriate exercise completion) that may have prevented ongoing participation.

Heiman et al. 2021

Sweden [39]

Evaluate whether an intervention consisting of recommended physical activity before and after surgery improved physical recovery at 4 weeks after BC surgery.

Intervention: Recommended physical activity (add 30 min medium intensity aerobic activity daily) before and 4 weeks after surgery and completed questionnaires to track physical recovery.

Control: Standard care. 

Knoerl et al. 2022

USA [40]

Explore the impact of exercise and mind-body prehabilitation interventions on changes in quality of life and cancer treatment–related symptoms in women with newly diagnosed BC.

Intervention: Participants were asked to attend two 60-90 min supervised exercise sessions with a certified trainer per week. Exercise intervention included both aerobic and resistance exercise training. Target exercise goals included 40 min of strength training and 180 min moderate intensity aerobic training each week. 

Control: The mind-body control participants were given a book and asked to listen to an associated guided imagery audio guide twice a day. 

Larson et al. 2000

USA [41]

Evaluate the feasibility and potential immunological benefit of a presurgical psychosocial intervention for BC patients.

Intervention: Participants attended two 90-minute treatment or “intervention” sessions. Both sessions included psychosocial support including discussion about emotional impacts of initial diagnosis and impending surgery, identification of problems/difficulties warranting further attention, education about the impact of stressful life events on health, developing individually tailored problem-solving strategies before and an introduction to progressive muscle relaxation exercises. Both sessions concluded with participant debriefing and completion of a feedback questionnaire.

Control: Standard care.

Sato et al. 2014

Japan [42]

Investigate the effectiveness of a perioperative education program for improving upper arm dysfunction in patients with BC.

Intervention: Received pre-operative education regarding the mechanism and causes of symptom development; post-op they were taught techniques to prevent/improve impairment, including monitoring symptoms, exercises and massage techniques; individual support provided between 1 and 3 months to enhance symptom management.

Control: Standard care.

Springer et al. 2010 

USA [43]

Determine the extent and time course of upper limb dysfunction in subjects seen pre-operatively and followed prospectively using a novel physical therapy surveillance model post-BC and treatment.

Intervention: Participants were instructed in a post-operative upper limb ROM exercise program and educated regarding upper limb lymphedema precautions and physical exercise initiation and progression. The exercise program was reviewed 1-month post-surgery, and individualised home program instructions provided as needed. 

Tamaki et al. 2017

Japan [44]

Compare the effects of aromatherapy on mood, quality of life, and physical symptoms in patients with BC.

Intervention: Participants had aroma oil placed at the bedside from 9pm of the day before surgery day until 6am of the surgery day. The aromatherapy consisted of the choice of three kinds of aroma oil, including ylang-ylang, orange or lavender. 

 Control: Standard care. 

Tanaka et al. 2021

Japan [45]

Assess the effects of Yokukansan on BC patients undergoing a practical or total mastectomy breast surgery.

Intervention: Received two 2.5 g doses of the medication (Yokukansan) before sleeping the night before surgery and 2 hours before induced anaesthesia. 

 Control: did not receive the medication 

Thomsen et al. 2009 

Denmark [46]

Explore how women smokers with newly diagnosed BC experienced brief preoperative smoking cessation intervention in relation to BC surgery.

Intervention: Smoking intervention took place three to seven days before surgery and consisted of one counselling session lasting 45–90 min with trained smoking cessation counsellors. The principles of motivational interviewing inspired the intervention. Content entailed that the risks of smoking and the health benefits of smoking cessation in relation to surgery and in the long-term were discussed with participants. Qualitative interviews were conducted by a single author 3-8 weeks after surgery, with interviews lasting from 35 to 100 min. 

Thomsen et al. 2010

Denmark [47]

Examine if a brief smoking cessation intervention encouraging patients to stop smoking from two days before to ten days after BC surgery would reduce the frequency of postoperative clinical complications requiring treatment.

Intervention: Smoking intervention took place three to seven days before surgery and consisted of one counselling session lasting 45–90 min with trained smoking cessation counsellors. Additionally, NRT was offered for the recommended perioperative smoking cessation period.

Control: Standard care. 

Tian et al. 2020

China [48]

Determine the influence of comprehensive nursing on the prognosis of BC patients, aiming to provide a better theoretical reference for future clinical nursing interventions with BC patients.

Intervention: Comprehensive Nursing Intervention: Medical staff engaged in hospital education for participants and their families to improve their correct understanding of BC diseases and described successful cases to enhance the confidence of participants and families. They also strictly required participants to eat a healthy diet and gave effective guidance to participants and their families. Health care staff strictly required participants to exercise their upper limbs and provided professional guidance to ensure a balanced diet. They also urged participants to engage in appropriate outdoor exercise and to keep an optimistic attitude. If the participants had adverse reactions, they were appeased right away, and certain methods were adopted to improve participants’ discomfort and prognosis. 

Control: Conventional Nursing Mode: Nurse instructed participants in the rational administration of the drug, explained the disease to participants, performed assigned tasks, including infusions, vital sign monitoring, gave appropriate psychological counselling, life guidance, and other nursing interventions.

Wu et al. 2021

UK [49]

Assess the feasibility of multimodal prehabilitation as part of the BC treatment pathway.

Intervention: Received four types of intervention (supervised exercise, nutrition, smoking cessation, and psychosocial support:

• Supervised exercise consisted of two circuits (circuit one: sit-to-stand, horizontal row, calf raises and chest press; circuit two: deadlift, pullover, knee extension, shoulder press) which were both performed three times a session, with each exercise repeated 8-12 times. 

• Nutritional advice consisted of the consumption of adequate amounts of protein and consider the nutrient density of the foods they consume.

• Smoking cessation provided participants with necessary therapies and advice to help them quit smoking, including NRT, patches, and gum.

• Psychological support was assigned if participants identified with raised anxiety and/or depression scores. Participants had at least one session with their counsellor as part of their program.

Control: Standard care. 

Zgâia et al. 2016

Romania [50]

Investigate the effects of pre-operative relaxing technique and psychological counselling on the post-operative intensity of acute pain, analgesic consumption and psychological symptoms, for patients scheduled for MRM for BC.

Intervention: Received 50 minutes of relaxation technique in the morning of the surgery. This included 25 minutes of a short clinical semi-structured interview regarding history of the disease and treatment of the participants, offering supplementary information regarding the surgery and its complications, and 25 minutes of autogenous training exercise known as “autogenous training” or “Schultz relaxation method” combining visual imagery and suggestions to experience relaxation and peace.

Control: Did not receive any psychological intervention before surgery.

Author/Year

Study Outcomes

Physical Function Assessments

Clinical Assessments

Patient reported outcome measurement

Findings

Baima et al. 2017

USA [37]

Primary outcome: 11-point pain scale (0–10), ROM (0 to 180°), and chart documentation of postoperative seroma formation.

11-point pain scale (0–10), ROM (0 to 180°).

Chart documentation of postoperative seroma formation.

Not assessed. 

Data failed to provide strong evidence of a difference in exercise compliance between in-person teaching versus video teaching. (75 %, 24/32 vs. 77 %, 10/13, OR = 1.03).

Sixty-six percent of participants (20/30) lost greater than 10° shoulder abduction ROM at 1-month post-surgery.

29 % of participants (9/31) had worse shoulder pain than baseline at 1-month post-surgery (24 %, 6/25 exercisers, and 50 %, 3/6 non-exercisers).

Fifteen percent of participants (4/27) had pain worse than baseline at 3 months post-surgery (8 %, 2/25 exercisers, and 100 %, 2/2 non-exercisers).

Strength data did not show significance.

Brahmbhatt et al. 2020

Canada [38]

Primary and secondary outcomes not clearly reported.

Quantitative feasibility outcomes, qualitative assessment of feasibility, and participant experience.

6MWT; upper-extremity strength (handgrip dynamometry); manual muscle testing (digital handheld dynamometer); WC, BMI, lean body mass, BF%, and fat mass.

Clinical disease related data collected from chart review.

DASH; BPI; FACT-F; SF-36 v2; GLTEQ-LSI; WHODAS 2.0.

The 6MWT distance increased from baseline to the preoperative assessment by 57.10 ± 24.0 m (95% CI = 7.52, 121.7).

Small decrease in 6MWT distance from the preoperative assessment to the 6-week postoperative assessment (-5.51 ± 27.6 m [-79.74, 68.7]), scores remained greater than at baseline.

Increase in 6MWT distance of 62.90 ± 24.00 m (1.81, 127.60) from baseline to the last study assessment.

An increase in DASH scores of 16.18 ± 4.96 (2.74, 29.63) points was observed between the preoperative and 6-week postoperative assessment, indicating a clinically important increase in upper-quadrant disability (MCID of 15 points).

Overall worsening in fatigue levels from baseline to the 12-week postoperative assessment, demonstrated by a reduction of 4.63 ± 3.34 (-13.7, 4.41) points in FACT-F scores which have an MCID of three points.

SF-36 questionnaire consistently worsened over the study period with a decrease of 5.90 ± 2.17 (-11.75, -0.05) points from the first to the last assessment.

SF-36 mental component score worsened from baseline to the preoperative assessment but then improved by 4.36 ± 2.25 (-1.72, 10.44) points from the pre- to 6-week postoperative assessment.

GLTEQ-LSI scores increased over the study period from 22.8 ± 5.30 at baseline to 33.8 ± 6.12 at the last study assessment.

Qualitative subthemes: 

Intervention feasibility: appropriateness of the intervention, barriers and facilitators to participation.

Participants’ experiences: intervention design preferences, multimodal care, need for an exercise professional, perceived benefit, health behaviour change, regaining control, prehabilitation as education. 

Heiman et al. 2021

Sweden [39]

Primary outcome: physical recovery at 4 weeks after surgery, measured using self-administered questionnaires. 

Secondary outcomes: self-reported mental recovery at 4 weeks after surgery.

Not assessed.

Medical records were accessed to obtain surgical information.

SGPALS; AUDIT-C.

There was no significant difference in favour of the intervention for the primary outcome physical recovery (RR = 1.03, 95%; CI = 0.95-1.13). 

There was also no difference for mental recovery (RR = 1.05, 0.93-1.17) nor in mean Comprehensive Complication Index score (4.2 (range 0–57.5) versus 4.7 (0–58.3)) between I and C.

64.1% in I did not report any change in physical activity level; 66/0% in C. 

Knoerl et al. 2022

USA [40]

The impact of exercise and mind-body prehabilitation intervention on changes in quality of life and cancer treatment-related symptoms. 

7–Day PAR.

Clinical chart and diagnosis.

EORTC QLQ C-30; PSS; HADS.

Significant improvements in exercise amount for I: 203 ± 129 min/week, compared to C: 23 ± 76 min/week (P < 0.0001). 

Mind-body group participants experienced significant improvements in cognitive functioning in comparison to exercise group participants between T1 and T3.

Difference in average change: -9.61, P = 0.04, d = 0.31. 

Both groups experienced improvement in anxiety (exercise: average change = -1.18, P = 0.03, d = 0.34, mind-body: average change = -1.69, P = 0.006, d = 0.43) and perceived stress (Stress improvement: Exercise: average change = -2.33, P = 0.04, d = 0.30, mind-body: average change = -2.59, P = 0.05, d = 0.29). 

Improvements were seen in the mind-body group for insomnia (average change = -10.03, P = 0.04, d = 0.30) and cognitive function (average change = 13.16, P = 0.0003, d = 0.67). 

Both groups experienced a significant decline in role functioning (exercise: average change = -11.10, P = 0.005, d = 0.43; mind-body: average change = -11.31, P = 0.009, d = 0.40) over time. 

No significant changes (P > 0.05) in physical function, fatigue, or pain. 

Larson et al. 2000

USA [41]

Evaluate whether BC patients who participated in the psychosocial intervention would have improved immune function, as measured by an increase in both NK cell activity and IFN-γ production, and whether responses to psychological (i.e., self-report) measures would mirror these immune system shifts.

Immune function via NK cell activity and IFN-γ production

Not assessed. 

CES-D, DES-IV, IES, LOT, SF-36.

Analysis of NK cell activity did not yield any significant differences between the control and the experimental groups. Results did not support the idea that the presurgical psychosocial intervention in any way influenced the NK cell response.

IFN-γ levels decreased substantially over time in C but not for I, suggesting that the intervention may have been successful in reducing immunosuppression prior to surgery. However, this finding is clouded by no significant difference in IFN-γ levels at the baseline timepoint. 

Participants in I showed a decrease in feelings of cancer-related disgust over time, whereas control participants experienced an exacerbation of those same feelings.

Sato et al. 2014

Japan [42]

Evaluate provision of perioperative exercise program vs standard care, evaluate the subjective perception of post-operative functional impairment and disability of the arm and shoulder, in combination with objective measurements of measured arm girth, shoulder ROM, and grip strength.

Arm girth; shoulder ROM; grip strength.

Medical records provided notes on type of surgery, level of ALND, and adjuvant treatment. 

SPOFIA; DASH.

SPOFIA and grip strength were significantly improved in the I who underwent ALND; no significant improvement in the I who underwent SLNB. 

No significant differences in arm girth, shoulder ROM, or DASH were seen between groups with ALND. Significant differences in change in SPOFIA score over time were noted between the ALND I and C groups (F value = 3.34; P = 0.02). 

A significant difference over time in the difference in mean grip strength was seen between normal and affected sides in both I and C groups (F value = 2.77; P = 0.04), indicating significantly improved grip strength over time in the ALND I group compared to the ALND C group. 

No significant differences in arm girth, shoulder ROM, grip strength, SPOFIA, or DASH were identified between SLNB groups. 

Springer et al. 2010 

USA [43]

Primary outcome: the extent and time course of upper limb dysfunction in subjects seen pre-operatively and followed prospectively using a novel physical therapy surveillance model post-BC and treatment. 

Secondary outcomes: determine if pain is a factor in recovery and assess self-report of functional task difficulty 12 months post-surgery using ULDQ. 

Shoulder ROM (flexion, abduction, internal rotation, and external rotation) and strength; upper limb volume and girth. 

Not assessed. 

ULDQ. 

Shoulder abduction, external rotation, flexion, and composite ROM decreased from baseline to 1 month (P < 0.0001), improved from 1 month to 3-6 months (P < 0.0001), and improved further from 3-6 to 12 months (P < 0.0001). 

Internal rotation ROM had a significant decrease from baseline to 1 month (P < 0.04), and a significant improvement from 1 and 3-6 months to 12 months (P < 0.03). 

Shoulder strength had a significant decrease at 1 month (P < 0.001). 

Greater pain at 1 month than baseline (P < 0.001). 

Shoulder abduction, flexion, external rotation, and composite ROM significantly correlated with all subcategories of the ULDQ (P < 0.02); internal rotation did not. 

Significant difference in limb volume found between sub-clinical lymphedema and no lymphedema subgroups at 12 months (P < 0.045). 

Tamaki et al. 2017

Japan [44]

Primary endpoint: QOL, which was assessed EORTC QLQ-C30. 

Secondary endpoints: necessity of hypnotics, vital signs (blood pressure and heart rate), adverse events, and patient perception of the experience. 

Vital signs (blood pressure and heart rate). 

Not assessed. 

EORTC QLQ-C30; use of hypnotics; patient experience

No statistically significant differences between groups in the EORTC QLC-C-30 at the surgery day. Differences in physical functioning and role functioning detected for post-operation day 1 but did not reach statistical significance (P = 0.08 and 0.09, respectively). 

No effects of aromatherapy were observed for blood pressure, heart rate, and the rate of hypnotic using (all P > 0.05). 

Patient experience was positive (participants were relaxed, comfortable, and enjoyable). 

Tanaka et al. 2021

Japan [45]

Primary outcome: changes in sAA as an objective measure of anxiety. 

Secondary outcomes: subjective measures of anxiety through HADS, STAI, QoR-15, and VAS for pain intensity. 

sAA levels were monitored pre- and post-surgery as an anxiety indicator. 

Clinical charts and BC diagnosis

HADS (HADS-A and HADS-D); STAI (STAI-S and STAI-T); QoR-15; VAS for pain intensity

Difference in HADS-A: I: -2.77, 95% CI [-1.48- -4.06], P < 0.001, and C: -1.43 [-0.25- -2.61], P = 0.011. 

Difference in STAI-T: I: mean -4.23 [-6.95- -1.51], P = 0.0004: and C: 0.12 [-2.36- -2.60], P = 0.92. 

sAA scores significantly lower in I group at T2: I: 0.88 (0.42); C: 1.14 ± 0.49: F [2, 150] = 3.76; P = 0.03; gη² = 0.017. 

No significant differences in HADS-D, STAI-S, and VAS scores between groups. 

Thomsen et al. 2009

Denmark [46]

Qualitative experiences related to the prehabilaition smoking intervention. 

Not assessed.

Not assessed.

Not assessed.

Reflecting upon smoking and health

Participants used metaphors such as ‘‘the final push,’’ ‘‘a kick’’ and ‘‘a wake-up call’’ to describe their experience of being offered brief preoperative smoking intervention. Major motivation for wanting to stop smoking was the risk of postoperative wound healing complications.

“‘It’s a combination. Being told you have cancer. Of course, BC hasn’t got anything to do with smoking. That’s more lung cancer but you begin to think in other directions. How much at risk are you of getting other types of cancer? And that’s why I thought: No, I’ve already got asthma, so I have to quit. And being offered smoking intervention before surgery gave me the last push.’’

Escaping the social stigma of being a smoker

Described by the participants as increasingly awkward due to restrictive smoking policies and disapproval of smoking.

‘‘Shortly before [being offered the smoking intervention] I told her [my daughter] that I had cancer, she said to me oh mum will you please stop smoking. You know I’d like to and I’ve wanted to and I have also tried twice. Just don’t ask me to do it now. Right now, I can’t face it with the cancer and all that. But you know I came to a point, yes, because I think it’s easier to be a non-smoker.”

Heightened awareness of being addicted to smoking

Some participants experienced that the smoking intervention motivated smoking cessation for a short period before or immediately after surgery; however, they quickly resumed their habit, or alternatively, attempted but were unable to stop smoking at all.

Specifically, anxiety peaked in the days prior to surgery and to getting the results of surgery. Brief preoperative smoking intervention in this context did not sustain abstinence in these participants.

‘‘Absolutely, I’m never going to smoke another cigarette, ever again. But going through the hospital system and all the waiting and pressure and worrying. Then you start to think: If I smoke just one cigarette here and another one there, it won’t harm anything, because you need it.’’

Enacting a duty of responsibility

The participants who stopped smoking experienced doing so as an enactment of a duty of responsibility towards themselves and those nearest to them.

‘‘I want to be well again and live a healthy life. The most important thing is to be able to be here for my kids and not to pollute them with my smoking.’’

Thomsen et al. 2010

Denmark [47]

Primary objective: Postoperative complications, defined as death or postoperative morbidity requiring treatment within 30 days after surgery (including seroma requiring aspiration). 

Secondary objectives: self-reported smoking cessation (two days before to ten days after surgery), exhaled carbon monoxide, and long-term continuous smoking cessation. 

Not assessed.

Patients’ charts examined for clinical complications. 

The Fagerström Test for Nicotine Dependency Score; smoking diary; telephone interviews for long-term cessation. 

Brief smoking intervention increased self-reported perioperative smoking cessation without having any clinical impact on postoperative complications.

Significantly more I participants (16/57; 28%) than C participants (7/62; 11%) reported continuous abstinence from two days before to ten days after surgery (RR = 2.49; 95% CI 1.10-5.60). 

At 12 months, groups did not differ in smoking cessation (I: 7/55, 13%; C: 5/58, 9%; RR = 1.48; 95% CI 0.50-4.38). 

Median carbon monoxide levels on day of surgery were significantly different: I: 2 ppm (range: 0-33); C: 4ppm (range 0-36); p-0.04). 

Carbon monoxide levels did not differ significantly between groups after ten days: I: 5 ppm (range: 0-43); C: 6.5 ppm (range: 0-52); P = 0.14. 

Postoperative complications (I: 52%; C: 64%; P = 0.35) and wound complications (I: 44%; C: 47%; P = 1.00) within 30 days did not differ. 

Tian et al. 2020

China [48]

Primary outcomes: observe the clinical curative effect of the two groups, and compare the therapeutic effects, adverse reactions, nursing satisfaction, VAS pain, psychological state SAS and SDS, and QOL of the two groups.

Secondary outcomes: compare the MMSE of the groups. 

Target lesions evaluated according to RECIST.

Pain evaluated according to VAS scores.

Not assessed. 

QOL; SAS; SDS; MMSE.

Curative effect: No difference in total effective rate between the two groups (P = 0.400). 

No differences in the adverse reactions in the two groups (P > 0.05). 

Number of participants who were very satisfied with nursing in I was higher than C (P < 0.05). 

VAS scores in I after treatment (2.45 ± 1.26) were significantly lower (P < 0.05) than C scores (3.73 ± 1.39). 

SAS and SDS scores significantly lower in I than C after treatment, and scores significantly lower in both groups after treatment than baseline (all P < 0.05). 

MMSE scores in I significantly higher than in C after treatment (P < 0.05). 

QOL scores in I higher than in C (P < 0.05). 

No differences in participant survival in the two groups (P > 0.05).

Wu et al. 2021

UK [49]

Feasibility was determined by the multimodal prehabilitation compliance. 

Not assessed.

Length of inpatient stay, hospital readmissions and complications. 

SF-12; HADS; SPADI. 

Anxiety scores (HADS) were significantly lower after surgery in both groups participating in prehabilitation (1-3 sessions: P = 0.028; ≥4 sessions: P = 0.045). The remaining outcomes analysed did not demonstrate significant changes (P > 0.05).

Median length of stay was 2 days/1night for both prehabilitation cohorts. No 30-day complications requiring further hospitalisation and no hospital readmissions recorded. 

Zgâia et al. 2016

Romania [50]

Primary outcome: Postoperative pain intensity.

Secondary outcomes: presence and intensity of psychological symptoms; analgesic consumption (Opioids, Paracetamol, NSAIDs).

Not assessed.

Not assessed.

NRS (for pain intensity); NRS (for intensity of psychological symptoms). 

Pain intensity significantly lower in I than C immediately after waking, at T2, T3, T4, and T5 after surgery (P < 0.05). I recorded maximum pain intensity 4/10 NRS. C recorded maximum pain intensity 8/10 NRS. Difference between mean scores of groups approximately 5/10 NRS immediately after waking (I: 1.5/10; C: 6/10), and a difference of 3/10 NRS 2 hours post-surgery (I: 1/10; C: 4/10).

Amount of post-surgery intravenous opioid used (ampoules of 100 mg tramadol) and NSAIDs (ampoules of 100 mg ketoprofen) significantly lower in I compared to C, both on the first and the second day after surgery (both P < 0.001). Amount of intravenous paracetamol (bottles of 1g paracetamol) similar in both groups. 

Higher frequency of psychological postoperative symptoms in C compared to I during evaluation period. 

Differences statistically significant at 6 (P < 0.001), 12 (P = 0.011), 24 (P = 0.021), 30 (P = 0.006), and 48 (P = 0.021) hours after surgery, and not at 42 hours (P = 0.537). At 48 hours, intensity of psychological symptoms lower in I compared to C.