Risk factors for long-term arm morbidities following breast cancer treatments: A systematic review

Abstract

Purpose: To examine the risk factors for arm morbidity following breast cancer treatments, taking a broad view of all types of physical morbidity, including prolonged pain, lymphedema, decreased range of motion, and functional limitations.

Methods: A systematic literature review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. Studies exploring the risk factors for prolonged arm morbidity following breast cancer surgery and treatments were included. The studies were assessed independently according to pre-eligibility criteria, following data extraction and methodological quality assessment.

Results: 1,242 articles were identified. After removing duplicates, the full texts of 1,153 articles were examined. Sixty-nine of these articles met the criteria and were included in the review. These 69 articles identified 29 risk factors for arm morbidity following treatments for breast cancer. The risk of bias was evaluated using NIH study quality assessment tools. The studies reviewed were published between 2001 and 2021 and included a total of 22,886 patients who were followed up for between three months and 10 years.

Conclusions: The main risk factors for long-term morbidity are removal of lymph nodes from the axilla, body mass index >30, having undergone a mastectomy, the stage of the disease, radiation therapy, chemotherapy, infection and trauma to the affected arm after surgery. An understanding of the risk factors for prolonged arm morbidity after surgery can help doctors and therapists in making personalized decisions about the need and timing of rehabilitation treatments.

Keywords: arm morbidity; breast cancer; physical rehabilitation; risk factors.

Figure 1. Flow chart of the study selection.

Search process and selection of articles according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) Guidelines [102].

Figure 2. A summary and risk-of-bias assessment according to the National Institutes of Health quality assessment tool for randomized control studies (https://www.nih.gov/).

This figure describes the risk of bias in each of the 65 observational studies, cohort studies, and cross-sectional studies included in the review. The National Institute of Health (NIH) risk-assessment tool includes 14 questions evaluating bias risk. This diagram represents the answer options; green indicates a positive answer; red indicates a negative answer; yellow indicates questions that are cannot be determined or not.

Figure 3. A summary and risk-of-bias using the quality assessment tool for observational cohort and cross-sectional studies (https://www.nih.gov/).

This figure describes the risk of bias in each of the 65 observational studies, cohort studies, and cross-sectional studies included in the review. The National Institute of Health (NIH) risk-assessment tool includes 14 questions evaluating bias risk. This diagram represents the answer options; green indicates a positive answer; red indicates a negative answer; yellow indicates questions that are cannot be determined or not applicable.

Figure 4. Forest plot diagram of odds ratio (95% CI) for surgery related factors as risk factors for prolonged arm morbidity.

This figure describes studies that reported the odds ratio and 95% confidence interval for mastectomy and axillary surgery as risk factors for combined morbidity of the arm including: pain, lymphedema, decreased function and decreased range of motion. (A) Describes the risk of morbidity after mastectomy surgery. (B) Describes the risk of morbidity after axillary lymph node dissection. Abbreviation: CI: confidence interval.

Figure 5. Forest plot diagram of odds ratio (95% CI) for risk factors for arm morbidity related to oncological treatment.

This figure describes studies that reported the odds ratio and 95% confidence interval for radiotherapy and chemotherapy as risk factors for combined morbidity of the arm including: pain, lymphedema, decreased function and decreased range of motion. (A) Describes the risk of radiation therapy morbidity. (B) Describes the risk of morbidity after chemotherapy (adjuvant and neoadjuvant). Abbreviation: CI: confidence interval.