Access to physical rehabilitation education and treatment for women following breast cancer surgery was found to be similar irrespective of the type of breast cancer surgery, except for lymphedema and breast support issues. Substantial variation was found in the access to physical rehabilitation depending on each specific physical side-effect. Because most respondents did not receive any form of physical rehabilitation education or treatment as part of their standard care, we deem that physical rehabilitation is a gap in care following all types of breast cancer surgery. The implications of this are discussed below.
Consistent with previous research, physical rehabilitation was found to be underutilized by women after breast cancer surgery [17, 28, 42]. The percentage of respondents who received any form of physical rehabilitation education or treatment for shoulder issues was similar to previous research . No previous research, however, had measured access to any form of physical rehabilitation for the other physical side-effects.
The significantly lower percentage of the BRS group (25%) who received any form of physical rehabilitation for lymphedema compared to the MAST (86%) and BCS (85%) groups was attributed to previous research that reported the risk of lymphedema to be lower after breast reconstructive surgery [43, 44] compared to mastectomy and breast conserving surgery. Decreased risk, however, does not mean that women cannot develop lymphedema after breast reconstructive surgery. It is therefore concerning that only 17% of the BRS group who had an immediate breast reconstruction (n = 58) received any education or treatment for lymphedema (Table 3), even though 67.2% of these women also had lymph nodes removed. Only a third of the entire cohort who had lymph nodes removed (n = 497) received any information about lymphedema as part of their standard care (Table 5), yet the need for lymphedema education/treatment by these women is evident by the equivalent percentage who sourced their own lymphedema education/treatment (Table 4). Lymphedema has high economic cost to both the health system and individuals and negatively impacts long-term health and quality of life [24, 46–49]. Considering early intervention is vital to effectively manage lymphedema [17, 19, 24, 45] and providing education to allow for early intervention has a relatively low cost, the gap in care for lymphedema must urgently be filled, particularly given the increasing number of women who are electing to have an immediate breast reconstruction surgery [50, 51].
Contrary to our hypothesis, the only other significant difference in the access to physical rehabilitation for women following different types of breast cancer surgery was for breast support issues (Table 2). The significantly lower percentage of the BCS group (~ 50%) who received any form of education/treatment for breast support issues compared to the MAST (~ 85%) and BRS group (~ 66%) and the significantly lower percentage of the BRS group who had an immediate breast reconstruction (~ 50%) compared to those who had a delayed breast reconstruction (~ 75%) does not align with need for education/treatment for breast support issues. Approximately 60% of women experience breast support issues of a moderate-to-very high incidence and severity 12-months after all types of breast cancer surgery [14, 18, 52]. Importantly, breast support issues are perceived to be the third highest barrier to physical activity after breast cancer surgery [53–55] (Table 3). The need for education/treatment for breast support issues is supported by the nearly two-fold number of respondents who sourced their own education/treatment for breast support issues compared to that provided by standard care. It is also concerning for the BCS group because 97% also had radiation treatment, which is assocated with scarring and breast edema, which are known to exacerbate breast support issues [20, 49, 56–59]. Although the underlying mechanisms of breast support issues experienced by women varies according to the different types of breast cancer surgery [14, 52], the need for education and guidance on how to find a comfortable, supportive, correctly fitted bra (and prosthesis) is an essential component of any physical rehabilitation program following all types of breast cancer surgery.
Women who have a higher risk of developing more severe and frequent physical side-effects following breast cancer surgery are especially in need of physical rehabilitation education and treatment [15–19]. Pain, mobility, and strength issues associated with scars and the shoulder are likely sequelae of seromas and delayed healing of surgical scars secondary to infection or tissue necrosis. Yet, less than a third of the respondents who had post-operative complications (n = 272) received any form of physical rehabilitation as part of their standard care for their shoulder or scar issues to help them to prepare for or manage these side-effects (Table 4). The same scenario occurred for respondents who had pre-existing physical problems in their shoulder or torso region, with less than 40% receiving any physical rehabilitation for their shoulder as part of their standard care. The equivalent percentage (~ 40%) who sourced their own treatment for these issues is evidence of the need these women have for physical rehabilitation to manage these side-effects. Pre-operative questioning for any pre-existing physical problems and greater follow-up of women who experience post-operative complications is required to ensure that the women who are at greater risk of developing more frequent and severe physical side-effects have access to physical rehabilitation as part of their standard post-operative care. This could limit the duration, progression, and impact of these physical side effects on physical activity, sport, and daily tasks.
Consistent with our second hypothesis, the content of the physical rehabilitation provided to women following all types of breast cancer surgery varied according to each side-effect and was less for scar, torso and breast support issues, and physical discomfort disturbing sleep compared to shoulder issues and lymphedema. Of concern, less than 50% of respondents received any form of physical rehabilitation education/treatment for scar or torso issues and only 25% received any guidance on how to get into a safe and comfortable position to enable good sleep after their surgery (Table 2). Again, the need for physical rehabilitation for these issues was evident by high percentage of women who independently sourced relevant information about physical rehabilitation education/treatment for scar, torso, and sleep issues compared to the percentage who received it standard care (Table 5). Scar issues that have an moderate to very high incidence and severity affect over 30% of women 6 months following all types of breast cancer surgery and can limit shoulder and torso range of motion and cause bra discomfort on underlying scars [14, 52]. Over 40% of women report difficulty finding a sleeping position in order to get a good night’s sleep at 6 months post-surgery . Guidance on how to get physically comfortable to enable good sleep is vital to promote tissue healing, and mental and physical health. Good sleep also limits fatigue, which is a known barrier to physical activity . It is therefore vital that physical rehabilitation education and treatment programs for women following breast cancer surgery include all of the commonly reported physical side-effects, particularly because women report a lack of awareness and knowledge of how to manage these side-effects makes them more distressing and debilitating [60–62].
The content of physical rehabilitation education and treatment following autologous breast reconstructions was also lacking in relation to donor site issues because only one in two respondents received any physical rehabilitation for their donor site. Yet pain and decreased mobility and muscle strength in the region of the donor site of a moderate to very high incidence and severity has been reported by 20% of women 6-months after autologous breast reconstruction surgery . Strategies to maximize the physical recovery of the donor site should also be fundamental content included in the physical rehabilitation education and treatment provided to women following autologous breast reconstructions.
A limitation of the study is that no time limit was placed on the time since surgery (mean 6.7 ± 6.0 years (range: 0–46 years). It is therefore possible that the physical rehabilitation following surgery over this period may have changed, just as surgical techniques have changed. Although this study provides insight into the access to physical rehabilitation following different types of breast cancer surgery and which physical side-effects are commonly included, it does not provide any detail on the quality or patient perceptions of this education and treatment. The quality and patient perceptions of education and treatment delivered in the form of a pamphlet are likely to differ compared to follow-up sessions with a health professional, where exercises are demonstrated, checked, and progressed. Further research is therefore recommended to investigate the content of physical rehabilitation education and treatment both quantitatively and qualitatively, received by women following all types of breast cancer surgery.