The Breast 21 (2012) 314e320

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The Breast
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Original article

Factors associated with long-term functional outcomes and psychological

sequelae in women after breast cancer
Fary Khan a, b, *, Bhasker Amatya b, Julie F. Pallant c, Ishani Rajapaksa b
a
Department of Medicine, Dentistry & Health Sciences, University of Melbourne, Grattan Street, Parkville, VIC 3050, Australia
b
Department of Rehabilitation Medicine, RoyalMelbourne Hospital, 34-54 Poplar Road Parkville, Melbourne VIC 3052, Australia
c
Rural Health Academic Centre, University of Melbourne, 49 Graham St, Shepparton, VIC 3632, Australia

a r t i c l e i n f o a b s t r a c t

Article history: The objective of this study was to examine factors impacting long-term functional outcomes and
Received 6 October 2011 psychological sequelae in survivors of breast cancer (BC). A clinical assessment and structured interview
Received in revised form assessed the impact of BC on participants’ (n ¼ 85) current activity and restriction in participation, using
23 January 2012
validated questionnaires: Functional Independence Measure (FIM), Perceived Impact Problem Profile
Accepted 24 January 2012
(PIPP) and Depression Anxiety Stress Scale (DASS). Participants showed good functional recovery
(median motor FIM score ¼ 78). Three-quarters (74%) reported pain, 32% reported upper limb weakness,
Keywords:
31% pain limiting shoulder movement and 29% lymphoedema. One third (32%) reported greatest impact
Breast cancer
Rehabilitation
on psychological wellbeing. A substantial number of participants reported high levels of depression
Disability (22%), anxiety and stress (19% each). Factors associated with poorer current level of functioning and
Participation wellbeing included: younger participants, recent diagnoses, aggressive tumour types, receiving
Functional Independence Measure chemotherapy, shoulder limitation due to pain, and lymphoedema. BC survivors require long-term
Depression Anxiety Stress Scale management of psychological sequelae impacting activity and participation.
Ó 2012 Elsevier Ltd. All rights reserved.

Introduction Recovery and treatment options after BC can be challenging.

Breast cancer (BC) is the most common malignancy in women
worldwide, comprising up to 16% of all cancers in women.1 The
incidence for BC is on the rise; and varies (age standardized rates)
with higher incidence rate (99 per 100,000 population) in North
America, moderate in South America, west Asia and eastern Europe,
and lowest in Africa.1 In Australia, 1 in 9 women will develop BC by
2015, with the projected population of women with BC expected to
increase to 15,400.2 The BC survival rates vary from 80% in devel-
oped countries (United States, Japan, Sweden), to 40e60% in low and
middle income countries (Russia, India, China). Several risk factors
for BC, both modifiable and non-modifiable, have been docu-
mented.3,4 As 21% of deaths from BC across the world are linked to
modifiable risk factors (physical inactivity, obesity, alcohol use)5;
comprehensive BC control incorporates prevention, early detection,
diagnosis and treatment,6 rehabilitation and palliative care.1
* Corresponding author. Department of Rehabilitation Medicine, Royal Mel-
bourne Hospital, 34-54 Poplar Road Parkville, Melbourne VIC 3052, Australia.
Tel.: þ61 3 83872000; fax: þ61 3 83872506.
E-mail addresses: fary.khan@mh.org.au (F. Khan), bhasker.amatya@mh.org.au
(B. Amatya), jfpallant@gmail.com (J.F. Pallant), ishani.rajapaksa@mh.org.au
(I. Rajapaksa).
Although the majority of patients make a good functional recovery,
the impact of BC on activities of daily living, work, social activities
and quality of life (QoL) can be considerable and prolonged.
Treatment options such as surgery, radio/chemotherapy are dis-
cussed elsewhere.7 Common complications from these treatment
modalities may include: wound sepsis, seroma formation, pain
(post surgical pain, phantom pain, post-mastectomy pain
syndrome, and musculoskeletal pain)8; decreased shoulder range
of movement, lymphoedema; and psychosocial dysfunction. The
triad of fatigue, mood disorders and cognitive complaints have
been reported.9,10 Radiation treatment can worsen shoulder joint
contractures, radiation induced brachial plexopathy, oedema upper
limb, and wound breakdown. After BC treatment, a range of
psychological sequalae can also occur (e.g., anxiety, depression,
sexual dysfunction and/or body dysmorphism).9 As disease prog-
resses other concerns may include: bone metastases, tumour
infiltration causing plexopathy and/or radiation induced
plexopathy.7
Women after BC treatment can present to rehabilitation settings
with a range of difficulties which may be physical, emotional,
psychosocial and/or environmental. Multidisciplinary rehabilita-
tion encompasses the framework and common language for
describing the impact of disease at different levels, advocated by

0960-9776/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.breast.2012.01.013
 F. Khan et al. / The Breast 21 (2012) 314e320
WHO, using the International Classification of Functioning,
Disability and Health (ICF).11 For example, in women after BC
treatment: ‘impairments’ are problems with body (anatomical)
structures or function (physiological) (lymphoedema, pain,
decreased shoulder range of movement); ’activity limitation’
(disability) are difficulties faced by a person executing everyday
tasks (mobility or self-care); ’restriction in participation’ relates to
problems experienced by a person which limits involvement in
societal participation and life situations (employment, family life,
social reintegration); ‘contextual factors’ are: ‘environmental’
which make up the physical, social and attitudinal environment in
which a person lives their life; and ‘personal’ (gender, race, coping
style, social, educational background) which may affect the
person’s experience of living with their condition.
The ICF provides a framework to account for contextual factors
when measuring disability and participation. For example, lym-
phoedema or post-mastectomy pain may lead to difficulty lifting,
carrying, reaching due to axillary scarring and oedema, and neck
shoulder pain,12 impacting mobility and self care ability. These
disabilities can limit participation which means it can impact on
return to work, driving, family and intimate relationships.
With advances in medical care and increased life expectancy,
issues related to health, wellbeing and participation become
increasingly important. Patients in the community continue to
improve over many months, however in the transition period
various adjustment issues may surface (self-worth, self-image),
coping with new demands associated with increased care needs,
inability to return to driving and work, financial constraints,
marital stress and restriction in participation. At present, no
systematic reviews address long-term outcomes in BC patients or
comparisons of different methods of treatment in these persons in
Australia. The objective of this study therefore was to examine
factors associated with residual disability and restriction in
participation over a longer-term, including functional outcomes
and psychosocial sequelae in BC survivors in an Australian
community cohort.
Methods
Participants and setting
This study was part of a prospective rehabilitation outcomes
research programme for BC survivors at the Royal Melbourne
Hospital (RMH), a tertiary referral centre in Victoria, Australia; and
approved by its Ethics committee. The RMH BC programme
provides acute surgical/oncological and rehabilitative care for
inpatients and in ambulatory settings to minimize activity limita-
tion and enhance participation.
Participants in this study were recruited from the 298
consecutive patients admitted to RMH for acute care between
2007 and 2011; with the ICD Code ((C50) for BC (main diagnosis)
incorporating all 9 sub-codes that localize the breast tumour
(C50.1-C50.9)), (first admission only). The RMH Access Database
was used for cross-indexing of diseases from the Patient Admin-
istrator System (HOMER) of Hospital Information Systems,
Department of Health Victoria, Australia. The source of these
patients was a pool of persons residing in the community, referred
to the RMH from public and private medical clinics across greater
Melbourne in Victoria. All participants were aged >18 years and
fulfilled standard diagnostic criteria for BC as defined by the
American Joint Committee on Cancer,13 currently disease free and
assessed by a surgeon/oncologist at the RMH. These participants
resided in the community (area of greater Melbourne <60 km
radius), and had known limitations in their status (including
mobility) at admission and discharge from RMH.
315
Data collection
At the time of recruitment 143 patients listed on the RMH
Database were eligible for this study due to entry criteria. All
were invited by mail to participate in the study and the 85
who consented were recruited for the project (flow chart
Fig. 1). All interviews and assessments (45 min each) were
conducted by two trained physicians and one research
assistant.
Measurement
The International Classification of Functioning, Disability and
Health11 was used as a conceptual basis for choice of best outcomes
for measurement. It provides a broader framework and describes
the impact of disease at the level of impairment, limitation in
activity and participation; incorporating contextual (environment
and personal) factors which may act as barriers or facilitators in
these persons.11
BC related measures
Information extracted from the medical record included:
disease related data, surgical procedures, pathology, treatments
received, and signs and symptoms at admission and discharge from
RMH.
Measures of impairment
The Medical Research Council (MRC)14 scale graded muscle
power (0 ¼ no contraction, 5 ¼ normal power).
A single item Visual Analogue Pain scale15 was used to assess
pain (score range 1e10).
Limb girth serial measurements were taken for lymphoedema.
Lymphoedema was defined as an increase of 10% in the involved
arm circumference compared with the opposite side (measured
10 cm above and below the elbow fold).16
Measures of activity and functioning
Functional Independence Measure (FIM)17 assessed function
(activity) and need for assistance (physician assessed). The FIM
motor section has 13 items that assess level of function in four
subscales: Self-care, Transfers, Locomotion and Sphincter control.
Each item is rated on a scale of 1e7 (1 ¼ total assistance, 5 ¼ needs
supervision, 6 ¼ modified independence, 7 ¼ independent). A low
score reflects burden of care in each area measured. FIM has good
reported reliability and validity.17,18
Measures for participation and quality of life
The Depression Anxiety Stress Scale- 21 (DASS)19 consists of
three 7-item self-report scales, to measure the negative
emotional states of depression, anxiety and stress. Participants
rated the extent to which they experienced each state over the
past week on a 4-point Likert rating scale. Subscale scores were
derived by totalling the scores, and multiplying by two to ensure
consistent interpretation with the longer DASS 42-item version.
The scores for each domain range from 0 to 42, with higher
scores indicating more dysfunction. It has good internal
consistency.19
The Perceived Impact of Problem Profile (PIPP),20 a 23-item
scale with five subscales (Mobility, Self-care, Relationships,
Participation and Psychological Wellbeing), assessed the impact
associated with a health condition. For each item, respondents
were asked to rate ‘how much impact has your current health
problems had on (item of function or activity) using a 6-point scale
(‘no impact’ and ‘extreme impact’), with high scores indicating
greater impact.20
316 F. Khan et al. / The Breast 21 (2012) 314e320
Fig. 1. Flow chart of recruitment process.
Statistical analysis
A series of analyses were conducted to describe the current level of
function and wellbeing of participants and to identify those factors
associated with scores on the FIM, PIPP and DASS subscales. Given the
skewed distributions, continuous predictor variables (age, time since
diagnosis) were split at the median to form approximately equal
groups for comparison. Non-parametric analyses (ManneWhitney U
tests) were used to compare scores across groups. Although
a substantial number of univariate analyses were conducted,
increasing the likelihood of a Type 1 error, it was decided to report all
p values above .05 as significant. This was consistent with the
descriptive nature of the study to ensure all potentially important
predictors of the long-term sequelae of BC were identified.
Results
Sample characteristics
The participant’s (n ¼ 85) ages ranged from 33 to 80 yrs
(median (Md) ¼ 57years, IQR ¼ 47.4e63.9), time since diagnosis
from <1 year to 24 years (Md ¼ 2.2 years, IQR ¼ 1.4e4.9).
Majority were tertiary educated (n ¼ 43, 51%) and married
(n ¼ 53, 62%). Over half of the sample had
BloomeRichardsoneElston (BRE) tumour Grade 3 (n ¼ 45, 54%),
were estrogen-receptor positive (n ¼ 70, 85%) and with lymph
node involvement (n ¼ 56, 66%). More than a third (n ¼ 31, 37%)
had breast conservation surgery (lumpectomy) with axillary
clearance (Table 1).
Current symptoms
Three quarter of the sample reported some degree of breast
related pain (n ¼ 63, 75%), with 39% (n ¼ 24) rating the pain as  5
on a 10 point scale, and describing it as sharp (n ¼ 12, 19%), aching
(n ¼ 12, 19%) or dull (n ¼ 11, 18%).Phantom breast sensation (n ¼ 13,
15%) and phantom breast pain (n ¼ 5, 6%) were noted. Almost one
third reported limited shoulder movement (n ¼ 28, 33%), with 31%
(n ¼ 26) indicating shoulder limitation due to pain; lymphoedema
(n ¼ 25, 29%), and upper limb weakness of affected side (n ¼ 36,
42%) on MRC motor scale (Table 1).
 F. Khan et al. / The Breast 21 (2012) 314e320 317

Table 1 Table 1 (continued )

Socio-demographic characteristics of participants (n ¼ 85).
n, (%) (unless
n, (%) (unless stated different)
stated different) 4 (Active movement against gravity/resistance, 29 (34.1%)
Demographic factors no full power)
Age (years) [Md, IQR] 57 (47.4e63.9) 5 (Normal power) 49 (57.6%)
Sex Female 85 (100%) Overall mean (SD) 4.5 (0.8)
Marital status
IQR ¼ Interquartile range; Md ¼ median; MRC ¼ Medical Research Council; n ¼ total
Married/Partner 53 (62.4%)
number; ROM ¼ Range of Motion; SD ¼ standard deviation.
Divorced/Separated 18 (21.2%)
Single 12 (14.1%)
Widowed 2 (2.4%)
Living with Current level of functioning, participation and psychological
Alone 17 (20.0%)
wellbeing
Partner 39 (45.9%)
Family 29 (34.1%)
Education Although participants reported minimal change to their physical
Primary 2 (2.4%) functioning as indicated by high FIM motor scores (Md ¼ 78,
Secondary 37 (43.5%) IQR ¼ 78 to 78), a substantial number reported high levels of
Tertiary 43 (50.6%)
depression (22%), anxiety and stress (19% each) (measured by
Other 3 (3.5%)
Smokers 13 (15.3%) DASS), compared with only 13% in an Australian normative sample.
Consumes alcohol 46 (54.1%) One third (n ¼ 27, 32%) women reported highest impact on the
Have Children 65 (76.5%) psychological wellbeing PIPP subscale (scores of 3 on the six-
With 2 child 54 (63.5%)
point scale), and substantial impact on the PIPP Participation
Clinical characterisitics
Disease duration (years) [Md, (IQR)] 2.2 (1.4e4.9)
subscale 22% (n ¼ 19) (Table 2).
BloomeRichardsoneElston grading (n ¼ 83)
Grade 1 (low) 10 (12.0%) Factors associated with current level of functioning and wellbeing
Grade 2 (intermediate) 28 (33.7%)
Grade 3 (High) 45 (54.2%)
Oestrogen-receptor positive (n ¼ 82) 70 (85.4%) A series of univariate analyses were conducted to identify
Lymph node affected 56 (65.9%) predictive factors associated with current levels of functioning,
Menopause 72 (84.7%) participation, and wellbeing.
Surgery 85 (100%)
2 surgery episodes 36 (42.4%)
Type of surgery
Mastectomy 14 (16.5%) Table 2
Mastectomy with axillary clearance 26 (30.6%) Descriptive Statistics for subscales of the Depression Anxiety Stress Scale (DASS-21),
Lumpectomy 12 (14.1%) Functional Independent Measure (FIM) and the Perceived Impact of Problem Profile
Lumpectomy with axillary clearance 31 (36.5%) (PIPP) (n ¼ 85).
Mastectomy/Lumpectomy with axillary clearance 2 (2.4%)
Scales Statistics
Chemotherapy 63 (74.1%)
Multiple episode 54 (96.4%) DASS (Md, IQR)
Side effects 60 (70.6%) Depression (0e42) Md ¼ 2, IQR ¼ 0e12
Severe side effects (n ¼ 60) 23 (38.3%) Anxiety (0e42) Md ¼ 4, IQR ¼ 2e8
Radiotherapy 63 (74.1%) Stress (0e42) Md ¼ 8, IQR ¼ 4e14
Multiple episode 48 (76.2%) DASS group: (n, %)
Side effects 47 (55.3%) Depression
Severe side effects (n ¼ 47) 8 (17.0%) Normal/mild 66 (77.6%)
Reconstructive surgery or alternatives 25 (29.4%) Moderate/severe/extreme severe 19 (22.4%)
Family history Anxiety
Breast cancer 30 (35.3%) Normal/mild 69 (81.2%)
Ovarian cancer 10 (11.8%) Moderate/severe/extreme severe 16 (18.8%)
Currently on treatment 55 (64.7%) Stress
Co-morbidities Normal/mild 75 (88.2%)
Hypertension 27 (31.8%) Moderate/severe/extreme severe 10 (11.8%)
Diabetes 5 (5.9%) FIM (Md, IQR)
Depression 28 (32.9%) Total (13e91) Md ¼ 78, IQR ¼ 78e78
Other 17 (20.0%) Self-care (6e42) Md ¼ 36, IQR ¼ 36e36
Shoulder limitation in range of movement 28 (32.9%) Sphincter control (2e14) Md ¼ 12, IQR ¼ 12e12
Shoulder limitation due to pain 26 (30.6%) Mobility (3e21) Md ¼ 18, IQR ¼ 18e18
Lymphoedema 25 (29.4%) Locomotion (2e14) Md ¼ 12, IQR ¼ 12e12
Pain 63 (74.1%) PIPP (n, % recording score of 3e6 indicating moderate to extreme impact, Md,
Pain score (0 no pain; 10 ¼ extreme pain) IQR)
Mean (SD), Range 3.8 (2.1), 1e8 Psychological 27 (32%)
Phantom breast pain 5 (5.9%) Md ¼ 2.2, IQR ¼ 1.4e3.4)
Phantom breast sensation (n ¼ 77) 13 (15.3%) Self-care 1 (1%)
Upper limb weakness (MRC motor scale) Md ¼ 1.0, IQR ¼ 1e1
(0 ¼ no contraction; 5 ¼ normal power) Mobility 6 (7%)
0 (No contraction) 1 (1.2%) Md ¼ 1.2, IQR ¼ 1.0e1.6
1 (Flicker or trace of contraction) 0 Participation 19 (22%)
2 (Active movement, with gravity eliminated) 1 (1.2%) Md ¼ 1.4, IQR ¼ 1.0e2.7
3 (Active movement against gravity 5 (5.9%) Relationship 7 (8%)
but no resistance) Md ¼ 1.0, IQR ¼ 1.0e1.6

DASS ¼ Depression Anxiety Stress Scale, FIM ¼ Functional Independent Measure;

PIPP ¼ Perceived Impact of Problem Profile, n ¼ total number; SD ¼ standard
deviation, Md ¼ median, IQR ¼ interquartile range.
318 F. Khan et al. / The Breast 21 (2012) 314e320
Demographic and disease factors
Scale scores were compared for two age groups (57 yrs, 57þ
yrs) using ManneWhitney U tests, and the younger group showed
significant differences in two of the PIPP subscales (Psychological,
p ¼ .02; Relationship, p ¼ .007). Women in BRE Grade 3 reported
higher impact on their PIPP Psychological subscale (p ¼ .04).
Time since diagnosis was divided into three approximately
equal groups (<¼1.8 yrs, 1.9e4.1 yrs, 4.2þ yrs). Kruskal Wallis tests
showed significantly different scores across these groups on the
DASS Depression (p ¼ .01), PIPP Participation (p ¼ .01) and PIPP
Relationship (p ¼ .02) scales, with higher depression levels and
greater impact for the more recently diagnosed.
Treatment related factors
There were no significant differences in scale scores across
different surgery types, or for women who received reconstructive
surgery, had lymph node involvement, or were estrogen-receptor
positive. Chemotherapy was associated with greater impact scores
on the PIPP subscales (Psychological, p ¼ .005; Mobility, p < .001;
Participation, p ¼ .002; Relationships, p ¼ .02). Women who
received radiotherapy recorded slightly higher FIM motor total
scores (p ¼ .02).
Current symptoms
Lymphodema was associated with higher impact scores on the
PIPP subscales (Psychological, p ¼ .003; Self-care, p ¼ .001;
Mobility, p ¼ .03; Participation, p ¼ .007), and on DASS Anxiety
scale (p ¼ .02).
Participants with shoulder limitations due to pain recorded
higher scores on all PIPP subscales (p < .005), and the DASS Stress
(p ¼ .03) and Anxiety (p ¼ .007) subscales. Limited range of
shoulder movement was also associated with higher scores on the
PIPP subscales (Psychological, p ¼ .03; Mobility, p ¼ .02; Relation-
ship, p ¼ .03; Self-Care, p ¼ .001).
Participants with upper limb weakness (MRC scores of 0e4 on
affected side) had worse scores on the FIM Locomotion scale
(p ¼ .04); higher impact on PIPP Self-Care (p ¼ .01), Mobility
(p < .001), Participation (p < .001), and Relationship (p ¼ .04)
subscales; and higher DASS Anxiety scores (p ¼ .007).
Discussion
This is the first report of factors associated with long-term
functional and psychological outcomes for women after BC
treatment, residing in the Australian community. The BC patients
in this study are similar to those in other studies in terms of age,
gender, disease severity and treatment.21e23 Most patients are
expected to make a good recovery following definitive treatment
for BC, as the medium to long-term effects of treatment are
considered minimal in the majority of cases. However, long-term
physical and psychological morbidity associated with BC treat-
ment can be under estimated.24 A recent study showed that 1 year
after BC surgery, patients did not recover their pre-operative
physical activity levels, especially in older patients, smokers and
those without a spouse.21 Although participants in our study
made good functional recovery (a median motor FIM score of 78),
they reported residual neurological deficits (motor and sensory)
with weakness of the upper limb on the affected side, limited
shoulder movements (adhesive capsulits), pain limiting shoulder
range; and lymphoedema, similar to other reports.24e26 The
incidence of lymphoedema (29%) in this cohort is within the
reported range of 6e30%.16 A number of reviews support exercise
in BC patients (with or without lymphoedema), in reducing side
effects of treatment, fatigue and deconditioning.24,27 Healthy life
style, health promotion and exercise therefore, should be
encouraged in this population24,26,28,29 including conservative
therapies for lymphoedema.30
Breast pain is a common symptom in women following BC
generally, and its prevalence is reported to be as high as 67%.31
Three-quarters of our sample reported some degree of breast-
specific pain (mixed patterns), similar to other reports7; although
these have not been well studied in BC. Interestingly, participants
also reported phantom breast pain (6%) and phantom breast
sensation (15%). These however were beyond the scope of this
preliminary study and needs further exploration.
Improved survival in BC has produced a growing acceptance
of BC as a long-term illness impacting psychological functioning
and QoL. Psychological morbidity (anxiety, depression, stress,
altered emotional reactions, sleep disturbance, social isolation)
are common responses to BC.32e34 These responses may be
related to pain,35 treatment side effects, especially chemo-
therapy36; and early onset menopause and fertility concerns.37,38
Fann et al. suggest the rate for major depression of 10e25% in
women with BC.39 Within one year of diagnosis up to 30% of
women with BC may develop a psychological morbidity either
anxiety or depressive disorder.40 Participants in our study, with
a median time since diagnosis of 2.2 years, reported elevated
levels of anxiety and depression (22%) (higher than normative
Australian data), in contrast to a previous study of psychological
distress that showed a decrease over a 5-year study period.41
Another study however showed that anxiety or depression or
both reported by women with BC did not change over 5 years of
follow-up.42 This range of variation in psychological disorders
may be attributed to methodological differences across studies.43
This has important clinical implications for long-term moni-
toring, education, support and counselling of the BC patients
(and their families).
Restricted activity alone explains only a minor part in the vari-
ance of health-related QoL,44 as many factors may influence QoL. In
our study 32% of women after BC reported high impact on PIPP
Psychological wellbeing, and substantial impact (22%) on the
Participation subscales. These are consistent with reports of
participatory limitation (work, social and recreational activity,
family life, caregiver stress, activities of daily life) in other BC
cohorts.32,34 This study identified factors associated with poorer
current level of functioning and wellbeing (i.e., high impact on PIPP
and DASS anxiety subscales): younger patients; recent diagnoses,
aggressive tumour, those receiving chemotherapy, shoulder limi-
tation due to pain, and lymphoedema; consistent with other
reports.45e48 No significant differences in scale scores were found
across different surgical procedures (including reconstructive
surgery), estrogen-receptor status or lymph node involvement on
outcomes used.
The ICF11 provides a framework for describing the impact of
disease at the level of impairment, limitation in activity and
participation. This is the first study to assess functional limitation in
women after BC using the ICF domains. Recently, patient reported
problems due to BC were linked with categories of ICF49 to high-
light the patient perspective; so that selected disabilities can be
addressed in multidisciplinary care settings. These in the future
may enable more comprehensive measurement of participatory
issues in this population.
Some caution needs to be exercised in the interpretation of the
group comparisons conducted in this study due to the substantial
number of univariate statistical analyses undertaken, with no
adjustment to the alpha value used to indicate statistical signifi-
cance. This study was intended as a preliminary descriptive study,
 F. Khan et al. / The Breast 21 (2012) 314e320
with the aim to identify possible factors that may impact on long-
term outcomes. Further research using larger studies and sophis-
ticated multivariate analyse need to be undertaken to extend these
finding. This study utilized a relatively small sample in a tertiary
regional metropolitan region which may limit the generalizability
and validity of these findings. The BC survivors in this study
however are similar to BC patients in other cohorts in terms of their
gender, disease severity and course. This study provides longitu-
dinal information, including information from the BC participants
in the community. The participants had strict inclusion criteria and
were listed on a database of people with BC held at the RMH and
who agreed to participate in research projects. In an attempt to
reduce recall bias, all questions were limited in the main to the
current situation. Medical records were used to confirm participant
self-report. This method of information gathering has potential
information bias. Problems not included within the domains of the
outcome measures used were not able to be identified; the
measures used however were broad and expansive. We acknowl-
edge that other factors may have impacted depression and anxiety
in BC participants and were not studied. More research into
ongoing pain, shoulder limitation and lymphoedema outcomes in
these persons is needed.
Conclusions
Many challenges can exist for BC survivors’ years after definitive
treatment, requiring integrated long-term management. The
factors associated with long-term functional and psychological
sequelae in BC participants in this study have important implica-
tions for treating clinicians and need to be explored in larger and
different BC cohorts. The ICF may provide clinicians a common
framework for targeted multidisciplinary care in specific domains,
and focus on participatory issues in these persons.
Ethical approval
The study was approved by the Royal Melbourne Hospital
Ethical Committee and informed consent was obtained from all the
subjects.
Conflict of interest statement
The authors declare that they have no conflict of interest.
Financial disclosure
None.
Licence statement
The Corresponding Author has the right to grant on behalf of all
authors and does grant on behalf of all authors, an exclusive licence
to The Breast.
Acknowledgement
We thank all the participants with breast cancer who partici-
pated in this study. We particularly wish to thank Ms L Oscari for
arranging interviews and Drs N Zhang, M Demetrious and L Ng for
participant assessments. We also acknowledge support of Prof B
Mann and Dr A Skandarajah of Cancer Services at the Royal
Melbourne Hospital.
319
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