Long-term follow-up on shoulder and arm morbidity in patients treated for early breast cancer

Figures & data

Figure 1. Flow diagram of the study population – from the original study to long-term follow-up.

Table 1. Patient, tumor, and treatment characteristics.

		Long-term follow-up	Original study	p Value
Number of participants		70	395	–
Age at operation – median (range)		54.4 (40.9–68.0)	59.1 (29.0–75.6)	–
Age at long-term follow-up – median (range)		64.8 (51.5–78.5)	NA	–
Years since operation – median (range)		11.7 (11.0–12.5)	NA	–
BMI at long-term follow-up – mean (SD)		24.6 (3.7)	NA	–
Smoking status	Smoking at inclusion	14 (20.0%)	128 (34.1%)	.038*
Laterality – N (%)	Right	58 (82.9%)	359 (90.9%)	.647
	Left	1 (1.4%)	10 (2.5%)
	Missing	11 (15.7%)	26 (6.6%)
Operation side – N (%)	Right	31 (44.3%)	189 (47.6%)	.582
	Left	39 (55.7%)	206 (52.2%)
Operation groups – N (%)	1: BCS + SLNB^a	22 (31.4%)	137 (34.7%)	.185
	2: BCS + ALND^a	27 (38.6%)	102 (25.8%)
	3: Mastectomy + SLNB^b	3 (4.3%)	27 (6.8%)
	4: Mastectomy + ALND^b	18 (25.7%)	129 (32.7%)
Lymph nodes removed – median (range)	All	14.5 (1–39)	12.0 (1–39)
	SLNB	2.0 (1–6)	2.0 (1–9)
	ALND	17.0 (4–39)	17.0 (5–39)
Tumor size mm – median (range)		17.2 (3–51)	15.0 (1–60)
T-stage – N (%)	1–20 mm (T1)	48 (68.6%)	276 (69.9%)	.633
	21–50 mm (T2)	19 (27.1%)	105 (26.7%)
	>50 mm (T3)	1 (1.4%)	3 (0.8%)
	Unknown (Tx)	2 (2.9%)	11 (2.7%)
N-stage – N (%)	0 (N0)	34 (48.6%)	215 (54.5%)	.517
	1–3 (N1)	26 (37.1%)	136 (34.3%)
	4–9 (N2)	7 (10.0%)	24 (6.1%)
	10+ (N3)	1 (1.4%)	11 (2.9%)
	Unknown (Nx)	2 (2.9%)	9 (2.2%)
RT – N (%)	Yes^a,b	61 (87.1%)	310 (78.5%)	.096
Chemotherapy – N (%)	Yes	32 (45.7%)	137 (34.7%)	.077
Anti-estrogen – N (%)	Yes	41 (58.6%)	223 (56.4%)	.742
No adjuvant medical therapy – N (%)		16 (22.9%)	105 (26.6%)	.513

N: number; BCS: breast conserving surgery; SLNB: sentinel lymph node biopsy; ALND: axillary lymph node dissection; RT: radiation therapy; *: marks when the difference is significant.

^aEvery participant who had BCS received RT.

^bNone of the participants in ‘operation group 3’ had RT. Two-thirds of the participants in ‘operation group 4’) received RT (those with lymph node metastasis).

Table 2. Questionnaire evaluation.

		Operation group
Symptoms		All N = 70	BCS + SLNB N = 22	BCS + ALND N = 27	Mast + SLNB N = 3	Mast + ALND N = 18
Functional impairment	One or more of the following: - Hand and arm function	34 (48.6%) 17 (24.3%)
			4 (18.2%)	10 (37.0%)	1 (33.3%)	2 (11.1%)
	- Dressing habits	7 (10.0%)	0	3 (11.1%)	1 (33.3%)	3 (16.7%)
	- Habits of household chores	12 (17.1%)	2 (9.1%)	6 (22.2%)	1 (33.3%)	3 (16.7%)
	- Washing and styling hair	7 (10.0%)	1 (4.5%)	3 (11.1%)	2 (66.7%)	3 (16.7%)
	- Reaching above the head	15 (21.4%)	4 (18.2%)	3 (11.1%)	1 (33.3%)	7 (38.9%)
	- Carrying heavy bags	29 (41.4%)	6 (27.3%)	13 (48.1%)	0	10 (55.5%)
	- Hobbies and sports activities	14 (20.0%)	2 (9.1%)	9 (33.3%)	1 (33.3%)	2 (11.1%)
Arm volume	Arm swelling or heaviness	18 (25.7%)	2 (9.1%)	8 (29.6%)	1 (33.3%)	7 (38.9%)
	Bother score
	1	3	0	0	0	3
	2	11	2	6	0	3
	3	4	0	2	1	1
	4	0	0	0	0	0
	Use of compression sleeve	5 (27.8%)	1	2	0	2
Mobility	Decreased shoulder mobility	18 (25.7%)	6 (27.3%)	6 (22.2%)	1 (33.3%)	5 (27.8%)
	Bother score
	1	5	2	2	0	1
	2	10	4	3	0	3
	3	1	0	1	0	0
	4	2	0	0	1	1
	Doing weekly exercise	40 (57.1%)	10 (45.5%)	17 (63.0%)	2 (66.7%)	11 (61.1%)
Pain	Shoulder pain	21 (30.0%)	7 (31.8%)	8 (29.6%)	1 (33.3%)	5 (27.8%)
	Bother score
	1	3	2	0	0	1
	2	12	4	7	0	1
	3	4	1	1	0	2
	4	2	0	0	1	1
	VAS	4 (2-9)	3 (2-7)	3.5 (2-5)	7 (7)	5 (2-9)
	Arm pain	15 (21.4%)	2 (9.1%)	8 (29.6%)	1 (33.3%)	4 (22.2%)
	Bother score
	1	2	0	0	0	2
	2	9	2	7	0	0
	3	3	0	1	0	2
	4	1	0	0	1	0
	VAS	3 (1-7)	4 (3-5)	3 (1-6)	5 (5)	3.5 (1-7)
	Breast region pain	37 (52.9%)	11 (50%)	16 (59.3%)	1 (33.3%)	9 (50%)
	Bother score
	1	20	7	9	0	4
	2	12	3	6	0	3
	3	5	1	1	1	2
	4	0	0	0	0	0
	VAS	2 (1-6)	3 (1-6)	2 (1-5)	5 (5)	2 (1-6)
Sensibility of upper arm	Paresthesia of the arm	16 (22.9%)	4 (18.2%)	6 (22.2%)	0	6 (33.3%)
	Bother score
	1	7	0	2	0	5
	2	8	4	3	0	1
	3	1	0	1	0	0
	4	0	0	0	0	0

Functional impairment and loco regional symptoms on ipsilateral side of breast cancer operation. Prevalence (number = N) and prevalence proportion (%) of participants confirming having symptom. Visual analog scale (VAS) is stated as the median score with min. and max. values. Bother score: 1 = no problem, 2 = minor problem, 3 = moderate problem, 4 = major problem. BCS: breast conserving surgery; SLNB: sentinel lymph node biopsy; ALND: axillary lymph node dissection; Mast = mastectomy.

Table 3. Changes in shoulder and arm morbidity in 10 years.

			1.5 years FU	11.5 years LT-FU	Timely Development	p Value
Subjective symptoms					⇓	.008*
Reduced hand and arm functioning	Yes		26 (39.4%)	16 (24.2%)
N = 66	No		40 (60.6%)	50 (75.8%)
Arm swelling/heaviness	Yes		23 (35.4%)	17 (26.2%)	⇓	.000*
N = 65	No		42 (64.6%)	48 (73.8%)
Decreased mobility	Yes		15 (22.7%)	17 (25.8%)	⇑	.015*
N = 66	No		51 (77.3%)	49 (74.2%)
Pain shoulder	Yes		17 (25.4%)	20 (29.9%)	–	.073
N = 67	No		50 (74.6%)	47 (70.1%)
Pain operated area	Yes		27 (40.3%)	35 (52.2%)	⇑	.000*
N = 67	No		40 (59.7%)	32 (47.8%)
Objective findings
Sensibility changes N = 67	Yes		40 (59.7%)	28 (41.8%)	⇓	.000*
	No		27 (40.3%)	39 (58.2%)
Flexion N = 67	Severe	<120	1 (1.5%)	2 (3.0%)	⇑	.001*
	Moderate	121–150	5 (7.5%)	6 (9.0%)
	None	>150	61 (91.0%)	59 (88.1%)
Extension N = 67	Severe	<45	6 (9.0%)	13 (19.4%)	–	.323
	Moderate	45-60	21 (31.3%)	16 (23.9%)
	None	>60	40 (59.7%)	38 (56.7%)
Abduction N = 67 Difference (%) from non-operated	Severe	Min – −5%	18 (26.9%)	17 (25.4%)	–	.321
	Moderate	−5–0%	39 (58.2%)	29 (43.3%)
	None	0–max%	10 (14.9%)	21 (31.3%)
Inward rotation N = 67	Severe	<50	2 (3.0%)	15 (22.4%)	–	.261
	Moderate	50–70	30 (44.8%)	38 (56.7%)
	None	>70	35 (52.2%)	14 (20.9%)
Outward rotation N = 67	Severe	<60	4 (6.0%)	12 (17.9%)	⇑	.005*
	Moderate	60–80	22 (32.8%)	20 (56.6%)
	None	>80	41 (61.2%)	35 (52.2%)
Adjusted arm	Severe	>10%	2 (3.9%)	4 (7.8%)	–	.323
Volume difference N = 51	Moderate	>5–10%	2 (3.9%)	10 (19.6%)
	None	≤5%	47 (92.2%)	37 (72.5%)

Comparison of prevalence of shoulder and arm morbidity in 10 years (1.5 and 11.5 years postoperatively). For each parameter the given number of participants is shown as N. Prevalence and prevalence proportion (number (%)) of participants with shoulder and arm symptoms and objective findings. Based on the questionnaire, objective measurements of shoulder movements in degrees of passive range of movement (ROM), arm volumes in ml by SWDI, and alterations in sensibility on the upper arm on the ipsilateral side of the operation.

⇑ marks a worsening in symptoms/findings, ⇓ marks an improvement, and ⇒ marks status quo.

FU: follow up; LT-FU: long-term follow-up; SWDI: simplified water displacement instrument; *: marks if the difference is significant.