Delayed versus immediate exercises following surgery

for breast cancer: a systematic review (Structured

abstract)
Centre for Reviews and Dissemination
Database of Abstracts of Reviews of Effects 2015 Issue 2
Copyright 2015 University of York. Published by John Wiley & Sons, Ltd.
Original article:Shamley D R, Barker K, Simonite V, Beardshaw A. Delayed versus immediate
exercises following surgery for breast cancer: a systematic review. Breast Cancer Research and
Treatment.2005;90(3):263271. Links

CRD summary
This review compared the effects of delayed and early exercise after breast
cancer surgery. The authors concluded that delayed exercise reduces the
risk of seroma formation, but differences between studies made it
impossible to adequately assess the effects on other outcomes. This was a
wellconducted review and the authors' conclusions are likely to be reliable.

Authors' objectives
To compare the effects of delayed versus early exercise after surgery for
breast cancer in terms of risk of seroma formation, fluid loss, hospital stay
and loss of arm movement.

Searching
The Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL,
AMED, PEDro, REHABDATA and ProQuest Medical Library were searched
from 1960 to June 2002 without any language restrictions; the search terms
were reported. The reference lists of relevant reports were checked.

Study selection: study designs

Randomised controlled trials (RCTs) were eligible for inclusion.

Study selection: specific interventions

Studies that compared early versus delayed shoulder mobilisation or
exercise were eligible for inclusion. In the included studies, delayed

exercise started 3 to 14 days after early exercise, where stated.

Study selection: participants

Studies of women who had had surgery for primary breast cancer were
eligible for inclusion. The included studies differed in the extent of surgery
the women had received (from lumpectomy with axillary dissection to
radical mastectomy). One study included women who had received pre
operative chemotherapy and radiotherapy.

Study selection: outcomes

Studies that assessed range of motion of the shoulder, wound
complications, volume of fluid drained, or incidence of seroma formation
were eligible for inclusion. The review also assessed length of hospital stay.

Study selection: how were decisions on the relevance of

primary studies made?
Three independent reviewers, blinded to authors and publications, selected
studies. Any disagreements were resolved by consensus.

Validity assessment
Studies were assessed for many aspects of validity: power calculations,
sample size, randomisation methods, allocation concealment, blinding,
validity of the methods used to assess the outcomes, statistical analysis,
baseline comparability of the treatment groups, description of the
interventions, and losses to followup reported with reasons. Two
independent reviewers assessed validity using a standardised form, and
any disagreements were resolved by consensus.

Data extraction
Two independent reviewers extracted the data using a standardised form,
and any disagreements were resolved by consensus. Where necessary,
authors were contacted for further information about missing data. The
number of patients with each outcome of interest was extracted for each
treatment.

Methods of synthesis: how were the studies combined?

Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were

calculated for dichotomous data using fixedeffect and randomeffects

metaanalyses. Pooled weighted mean differences (WMDs) with 95% CIs
were calculated for continuous data. Funnel plots were used to examine
the potential for publication bias.

Methods of synthesis: how were differences between studies

investigated?
Statistical heterogeneity was assessed using the chisquared test and
potential sources of differences among the studies were discussed.

Results of the review

Twelve RCTs (n=1,127) were included in the review, of which six (n=540)
were included in the metaanalyses.
In terms of study quality, most of the studies did not report power
calculations, allocation concealment, validity of the outcome measures,
blinding of the outcome assessment, or randomisation methods. Other
methodological flaws included insufficient information justifying the use of
parametric statistical tests, inadequate reporting of exclusion criteria, a and
lack of reporting baseline comparability of the treatment groups.
Seroma formation (5 studies).
Seroma formation was significantly reduced with delayed compared with
early exercises, 27% versus 46%; the OR when using a fixedeffect model
was 0.41 (95% CI: 0.20, 0.95, P=0.00001; the upper limit of the 95% CI
was reported as 0.5 in the review abstract). No significant statistical
heterogeneity was found (P=0.15). The results were similar when using the
randomeffects model (OR 0.40, 95% CI: 0.22, 0.73, P=0.003).
Drainage volume (6 studies).
There was no significant difference between treatments for drainage
volume (WMD 175 mL, 95% CI: 397, 47, P=0.12). Significant statistical
heterogeneity was found (P<0.00001).
Hospital stay (5 studies).
There was no significant difference between treatments in length of hospital
stay (WMD 0.63 days, 95% CI: 1.91, 0.66, P=0.3). Significant statistical
heterogeneity was found (P=0.0015).

It was not possible to conduct a metaanalysis for treatment effects on

range of shoulder motion because there was too much variability among
studies in the methods used to measure this outcome.
Owing to the small number of studies, it was not possible to draw firm
conclusions about publication bias from the funnel plots.

Authors' conclusions
There was evidence that delayed exercises reduce the risk of seroma
formation, but differences between the studies made it impossible to draw
conclusions about the effects of delayed exercise on fluid drainage,
hospital stay or arm movement.

CRD commentary
The review addressed a clear question that was defined in terms of the
participants, intervention, outcomes and study design. Several relevant
databases were searched without language restriction and attempts were
made to locate unpublished studies, thus minimising the potential for
language and publication bias. At least two reviewers independently
selected studies, assessed validity and extracted the data, thus reducing
the potential for reviewer bias and errors. Validity was comprehensively
assessed using specified criteria, the results of the assessment were
reported, and adequate information about the primary studies was given.
Sources of clinical heterogeneity among the studies were discussed and
statistical heterogeneity was assessed. The use of a metaanalysis to pool
studies assessing seroma appeared appropriate, although studies differed
in the extent of surgical treatment. The finding of significant heterogeneity
for metaanalyses of outcomes other than seroma suggests, as the authors
correctly stated, that metaanalysis was not an appropriate method for
summarising the effect size of treatment for these outcomes. This was a
wellconducted review and the authors' conclusions are likely to be reliable.

Implications of the review for practice and research

Practice: The authors did not state any implications for practice.
Research: The authors stated that future studies should clearly define
distinctive protocols for each treatment, take prognostic factors into account
in study design, use an adequate sample size, and adhere to the
Consolidated Standards of Reporting Trials (CONSORT) recommendations
for methods and reporting.

Record status
This record is a structured abstract written by CRD reviewers. The original
has met a set of quality criteria. Since September 1996 abstracts have
been sent to authors for comment. Additional factual information is
incorporated into the record. Noted as [A:....].

CRD database number

DARE12005003856

Index terms
Medical Subject Headings (MeSH)
[Subject indexing assigned by NLM]
xillary ExclusionA Successful Technique for Reducing
Seroma Formation after Mastectomy and Axillary
Dissection
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DOI: 10.4236/abcr.2013.21001
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Natalie Chand, Anna M. G. Aertssen, Gavin T. Royle

Affiliation(s)
Southampton
Salisbury

University
District

Hospital,
Hospital,

Southampton,
Salisbury,

UK.
UK.

Southampton University Hospital, Southampton, UK.

ABSTRACT
Introduction: A seroma is the commonest complication of breast cancer surgery, and although its
consequences most often cause no more than discomfort and anxiety, more important sequelae
include flap necrosis and wound breakdown. Infection developing within seroma increases
morbidity and often results in the need for re-admission, re-imaging, drainage and antibiotic
usage. Numerous methods to reduce post-mastectomy seroma formation have been tried with no
consistent success. Methods: 24 consecutive patients undergoing mastectomy and axillary
clearance were recruited before and after a departmental change in practice. At the point of skin
closure, patients either underwent axillary exclusion or not. Total drain outputs were recorded by
community district nursing staff for all patients. At the first post-operative visit, the presence and
severity of seroma was recorded. Results: 24 patients were included (study group 14, control
group 10). Age, size of tumour, and number of positive lymph nodes and laterality were
comparable between groups. Mean drain output for the entire group was 471 ml (3 - 1030 ml)

over 5.21 days. The control group had a drain output of 763.5 ml (95%CI 674.2 - 852.8) while the
study group had a mean drainage of 262.2 ml (95%CI 161.9 - 362.5), a reduction of over 65%, p
< 0.001. 15 (62.5%) out of 24 patients developed seroma. 42.9% of the study group and 90% of
the control group developed seroma, p < 0.01. Conclusion: Seromas are a common complication
following mastectomy and axillary clearance. Our technique of axillary exclusion has resulted in
significantly reduced drainage volumes and fewer seromas.

KEYWORDS
Breast Cancer; Lymphocele; Seroma; Mastectomy; Axilla

Cancer Journal:
January/February 2004 - Volume 10 - Issue 1 - p 4248
Original Article

Prospective Trial of Complete Decongestive Therapy for Upper

Extremity Lymphedema After Breast Cancer Therapy
Mondry, Tammy E. PT, CLT-LANAa; Riffenburgh, Robert H. PhDb; Johnstone, Peter A. S. MD, MAa,c

Abstract
PURPOSE: Lymphedema is a well-described complication of therapy for breast cancer. Patients who
present with lymphedema may experience pain and body image issues and are at increased risk for
developing cellulitis. Complete decongestive therapy (CDT) is a four-component therapy for
lymphedema. Data regarding CDT as an intervention in the immediate after the diagnosis period and
prolonged follow-up are limited; we prospectively analyzed results of CDT in this cohort of patients.
MATERIALS AND METHODS: Twenty patients were enrolled in CDT immediately after their diagnosis
of lymphedema. The Functional Assessment of Cancer Therapy quality of life (QoL) measure and a
visual analogue scale for pain were completed before, on the 10th day of, and on the last day of
treatment. Each patient underwent a daily 60- to 90-minute treatment session, 5 days per week for 2
4 weeks. Treatment consisted of skin and nail care, manual lymphatic drainage, a multilayer
compression bandage, and therapeutic exercise. Edema of the affected limb was reassessed weekly.
On reaching a measurement plateau, the patient was discharged from active treatment and began a
maintenance phase. The patient was reassessed for girth, volume, and body weight at 3 months.
These measurements plus the QoL and pain measures were also reassessed at 6 months and 1 year
after treatment.
RESULTS: Patients completed 24 weeks of treatment (median, 2 weeks). Those classed as severe
decreased from 7 to 1. Median girth reduced 1.5 cm and median volume reduced 138 mL. Decreasing
girth correlated significantly with decreasing visual analogue scale scores for pain, but not with
increasing QoL. Increasing grade correlated significantly with girth reduction and volume reduction.
Compliance with the treatment regimen at home decreased with time on the program. During followup, girth and volume reverted slightly but stabilized at about 1 cm and 100 mL below baseline,
respectively. Although the increase in QoL was not significant, it was noted that during the entire
treatment and follow-up period, QoL consistently increased, ending about 5% above baseline, and
pain scores gradually decreased, ending with 54% (and median) of patients at 0 pain.
CONCLUSIONS: CDT is effective in treating lymphedema. Success in girth reduction contributes to
less pain. Grade is a useful indicator of severity; class is not. Increased number of treatment sessions
provides marked improvements in girth, volume, and weight but result in poorer compliance. Longer
latency more successfully reduces girth, volume, and pain and increases QoL. QoL and pain are
improved by treatment and continue to improve after treatment has ended.

ournal of Women's Health Physical Therapy:

Spring 2006 - Volume 30 - Issue 1 - p 510
Research Report

The Effects of Complete Decongestive Physical Therapy Treatment

On Edema Reduction, Quality of Life, and Functional Ability of
Persons with Upper Extremity Lymphedema
O'Neill, Jennifer MPT1; Beatus, Joseph PhD, PT2

Abstract
Background:: There is paucity of clinical data regarding the effect of Complete Decongestive
Therapy (CDT) on edema reduction, and quality of life changes that accompany the increase in
lymphedema.
Purpose:: The basis of our study was to investigate the effectiveness of CDP treatment on edema
reduction, functional ability, quality of life, pain level, and grip strength.
Methods:: Limb volumes, grip strength, pain, quality of life, and functional ability were recorded pre
and posttreatment. Data were analyzed with repeated measures ANOVA.
Results:: The results of the study demonstrated statistically significant reduction in edema and pain,
and an increase in mean grip strength and quality of life. No statistically significant change was noted
in functional ability.
Conclusions:: In a clinical sample of postmastectomy patients with axillary node dissection, CDT
treatment seems to reduce edema, improve quality of life, decrease pain, and increase grip strength.
These findings from a small consecutive sample should serve as an impetus for further studies.

rm and shoulder morbidity in breast cancer patients after

breast-conserving therapy versus mastectomy
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DOI:
10.1080/02841860801961257
Inger-Lise Nesvolda*, Alv A. Dahlb, Erik Lkkevikc, Anne Marit Mengshoeld & Sophie D. Fossb
pages 835-842
Publishing models and article dates explained

Received: 13 Jun 2007

Published online: 08 Jul 2009

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Abstract
Introduction. The objective of this study was to compare the prevalence of late effects in the arm and
shoulder in patients with breast cancer stage II who had radical modified mastectomy (RM) or breastconserving therapy (BCT) followed by loco-regional adjuvant radiotherapy with or without
chemotherapy/anti-oestrogen. Material and methods. All patients had axillary lymph node dissection.

At a median of 47 months (range 3287) post-surgery, 263 women (RM: n=186, BCT: n=77) were
seen during an outpatient visit and had their arm and shoulder function and the presence of
lymphedema assessed by a clinical examination, interview and self-rating. Volume calculation was
used to measure lymphedema. Results. In the RM group 20% had developed arm lymphedema
versus 8% in the BCT group (p=0.02). In multivariate analysis lymphedema was associated with a
higher number of metastatic axillary lymph nodes [OR1.14, p=0.02], RM [OR 2.75, p=0.04] and
increasing body mass index (BMI) [OR 1.11, p<0.01]. In the RM group 24% had a restricted range of
motion in shoulder flexion compared to 7% in the BCT group (p<0.01). Shoulder pain was reported by
32% in the RM group and by 12% in the BCT group (p=0.001). Increasing observation time, RM, and
increasing BMI were significantly associated with impaired arm/shoulder
function. Discussion. Arm/shoulder problems including lymphedema were significantly more common
after RM compared to BCT in irradiated breast cancer patients who have undergone axillary lymph
node dissection. The performance of BCT should be encouraged when appropriate, to ensure a low
prevalence of arm/shoulder morbidity including lymphedem