• breast cancer;
  • surveillance model;
  • rehabilitation;
  • survivorship care


  1. Top of page
  2. Abstract


The current model of care for individuals with breast cancer focuses on treatment of the disease, followed by ongoing surveillance to detect recurrence. This approach lacks attention to patients' physical and functional well-being. Breast cancer treatment sequelae can lead to physical impairments and functional limitations. Common impairments include pain, fatigue, upper-extremity dysfunction, lymphedema, weakness, joint arthralgia, neuropathy, weight gain, cardiovascular effects, and osteoporosis. Evidence supports prospective surveillance for early identification and treatment as a means to prevent or mitigate many of these concerns. This article proposes a prospective surveillance model for physical rehabilitation and exercise that can be integrated with disease treatment to create a more comprehensive approach to survivorship health care. The goals of the model are to promote surveillance for common physical impairments and functional limitations associated with breast cancer treatment; to provide education to facilitate early identification of impairments; to introduce rehabilitation and exercise intervention when physical impairments are identified; and to promote and support physical activity and exercise behaviors through the trajectory of disease treatment and survivorship.


The model is the result of a multidisciplinary meeting of research and clinical experts in breast cancer survivorship and representatives of relevant professional and advocacy organizations.


The proposed model identifies time points during breast cancer care for assessment of and education about physical impairments. Ultimately, implementation of the model may influence incidence and severity of breast cancer treatment-related physical impairments. As such, the model seeks to optimize function during and after treatment and positively influence a growing survivorship community. Cancer 2012;118(8 suppl):. © 2012 American Cancer Society.


  1. Top of page
  2. Abstract

Treatments for breast cancer typically include surgery, chemotherapy, radiation therapy, and endocrine therapies, which introduce a variety of physiologic effects known to adversely impact body structure and function.1-8 Treatment effects may lead to physical impairments including pain, fatigue, lymphedema, weakness, restricted range of motion, joint arthralgia, neuropathy, and osteoporosis.9-27 Treatment also is known to adversely affect physical function, body weight, and cardiovascular health.28-33 These impairments may adversely affect patients' participation in activities of daily living and employment and negatively affect healthy lifestyle behaviors such as regular exercise.34-41 Although there may be a clinical impression that these issues are uncommon, emerging evidence indicates that a majority of women experience 1 or more of these physical impairments and suffer from the aggregate burden of impairments, comorbidities, and disease treatment.42-44 When breast cancer–related physical impairments occur, they often go unrecognized and untreated, eventually reaching levels that negatively impact function.45, 46 Because breast cancer is the most common cancer diagnosed in women with relatively high overall survival rates, a comprehensive model of survivorship care that focuses on improving the physical function of women living with breast cancer is needed.

A seminal 2005 report by the Institute of Medicine highlighted the lack of comprehensive care for cancer survivors and issued recommendations to target improved survivorship care.47 To this end, new initiatives have emerged in survivorship-care planning to define and address needs in follow-up care after breast cancer treatments.48 These efforts focus on monitoring for disease recurrence and late effects of treatment. However, physical and functional recovery after breast cancer treatment has been relatively neglected. Considering the growing body of literature supporting oncology rehabilitation and its potential to mitigate or prevent physical impairment and functional decline in cancer patients,9, 49-60 there is an urgent need to consider ways to meet the rehabilitative needs for women treated for breast cancer.

The purposes of this article are to introduce a prospective surveillance model (PSM) of care for breast cancer physical rehabilitation derived from discussions at a 1.5-day meeting supported by the American Cancer Society, to describe the details and goals of the model, and to present a meeting discussion summary. The evidence base supporting the need for this model and a deeper discussion of cost and implementation issues are provided in accompanying articles in this supplement.44, 61-72

Methods and Meeting Deliberations

The meeting assembled a multidisciplinary core panel of researchers and expert clinicians who deliberated and discussed evidence for a PSM of care, targeting identification and treatment of early physical impairments and functional limitations in breast cancer survivors. The meeting included presentations, open deliberations by the core panel, and ample discussion time with stakeholder participants. The core panel represented a broad array of breast cancer researchers and clinicians with experience in issues pertaining to breast cancer survivorship, exercise, and rehabilitation. The introductory article to this supplement provides a list of core panel participants. In addition, stakeholders from major professional organizations; breast cancer patient advocacy, lymphedema, and educational organizations; and government agencies participated in the meeting. The purpose of stakeholder involvement was to: 1) enhance development of the model based on a broad array of experience with patient needs and the current context of care delivery; 2) prepare their organizations for potential roles in dissemination and implementation of a PSM.

Physical impairments to be addressed were identified before the meeting based on relative prevalence and potential for impact on function, and included pain, fatigue, upper-extremity dysfunction, lymphedema, weakness, joint arthralgia, neuropathy, adverse effects on the cardiovascular system, and osteoporosis. The issue of weight gain/weight management was added to the impairment list based on feedback from meeting participants. The meeting was structured around 4 key evidence-based presentations: 1) descriptive epidemiology of physical impairments and functional limitations specific to breast cancer and its treatment; 2) clinical identification and diagnosis of common physical impairments; 3) efficacy of prevention and treatment interventions; 4) key elements for a prospective surveillance model of care.

Participants generally agreed that there is evidence to support the prevalence of physical impairments and functional limitations among breast cancer survivors and a potential for early rehabilitation intervention to prevent or mitigate many of these treatment effects.40, 50, 55, 73-76 At the conclusion of the meeting, a draft of the PSM was presented and discussed in a general session with all meeting participants.

Prospective Model of Surveillance

In oncology rehabilitation, prospective surveillance has been defined as a proactive approach to periodically examining patients and providing ongoing assessment during and after disease treatment, often in the absence of impairment, in an effort to enable early detection of and intervention for physical impairments known to be associated with cancer treatment.77

The goals of the PSM are:

  • To promote surveillance for common physical impairments and functional limitations associated with breast cancer treatment.

  • To provide education to reduce risk or prevent adverse events and facilitate early identification of physical impairments and functional limitations.

  • To introduce rehabilitation and exercise interventions when physical impairments are identified.

  • To promote and support physical activity, exercise, and weight-management behaviors through the trajectory of disease treatment and survivorship.

A PSM of care providing evidence-based clinical assessment using valid tests and measures has clinical utility.14, 49, 75, 78-80 The model seeks to ensure that physical impairments, function, and exercise are assessed and managed proactively and periodically throughout the course of breast cancer treatment and survivorship to expedite implementation of exercise and rehabilitation strategies known to alleviate these impairments.81, 82 Specific rehabilitation interventions are not addressed by the model.

Figure 1 depicts the PSM of care. The PSM is not a stand-alone plan for survivorship care but is designed to be incorporated into existing and emerging multidisciplinary survivorship care. Comprehensive rehabilitation assessment is not accomplished in a single visit, and ideally patients will be seen for multiple visits during and after cancer treatment.

thumbnail image

Figure 1. A prospective surveillance model for physical rehabilitation for women with breast cancer.

Download figure to PowerPoint

The two primary components within the PSM, generally extrapolated from the Chronic Care Model,83 are: 1) impairment identification and management, including comanagement of treatment effects with other members of the oncology care team; 2) health-promoting skills and behaviors. A summary of the key features of these components are outlined below.

Impairment identification and management

This component highlights common physical impairments that may be seen at various intervals of disease management. Assessment uses tests and measures known to identify physical impairments and coincides with standard follow-up appointments for disease management and recurrence surveillance. This comanagement approach serves as a mechanism to integrate medical management of treatment effects with an individualized exercise and rehabilitation prescription and enables referral to other providers for further evaluation or treatment as appropriate.

Facilitation of health-promoting skills and behaviors

This component highlights assessment of the patient's level of exercise, physical activity habits, and functional status in a relatively normal state of health. The model provides advice and education for initiating exercise, promoting weight management, and introducing ongoing, community-based exercise that the patient can perform independently or with provider monitoring. Education prepares patients to recognize and act on symptoms consistent with adverse effects over the course of recovery, enabling self-monitoring and self-management through patient activation.

Rehabilitation assessment phases in the PSM are preoperative, early postoperative, and ongoing surveillance. Entry into the PSM model occurs around the preoperative and postoperative period because surgery is the first intervention for the majority of breast cancer patients. The PSM, therefore, will be most relevant for newly diagnosed women with stage 0-III breast cancer before and after breast-conserving surgery or mastectomy, with or without reconstruction. Women with stage IV breast cancer have significant aggregate effects of treatment that may also benefit from rehabilitation intervention.84 Although the PSM does not address these women specifically, it is anticipated that the ongoing surveillance phase of the model will enhance access to rehabilitation care and exercise for women with metastatic breast cancer.

Preoperative rehabilitation: evaluation and education

Premorbid level of function, current exercise habits, prior physical impairments, and other comorbidities are assessed to establish a baseline from which to follow the patient and detect change over time. Specifically, upper-extremity range of motion, volume, and strength, as well as body weight, function, fatigue, and level of physical activity and exercise should be assessed at the preoperative visit. In addition, this visit allows for education regarding the postoperative plan of care, including postoperative rehabilitative exercises, advice for weight control, and advice for returning to activities during and after treatment, as well as discussion regarding known risk factors for adverse effects of the treatment plan.

Arguments have been made that informing patients about potential adverse effects of treatment can engender unnecessary fears. Although health care providers should be sensitive to patients' reactions to information about treatment adverse effects, patients consistently express the need for information before treatment and especially before developing physical impairments,62, 85-88 as reflected in the patient perspective article in this supplement.

Early postoperative rehabilitation: reassessment and exercise program

Evidence suggests that upper-extremity range-of-motion exercise should be initiated 1-2 weeks after surgery, and an early postoperative reassessment visit should take place within the first month after surgery.89-92 This visit repeats baseline tests and measures and further reinforces education regarding weight control, exercise, and return to activity. Some level of surgical sequelae will be present at this visit and, if functional limitations are noted, rehabilitation intervention may be initiated.

This reassessment visit also provides an opportunity for patient education on prevention and early detection of common treatment-related impairments as well as education about exercise and health-promoting behaviors. An individualized exercise program is prescribed for independent exercise throughout the course of cancer treatment, aimed at improving function and preventing impairments related to treatment.93 It should be emphasized that evaluation by a rehabilitation specialist is not needed for women to begin following the American College of Sports Medicine (ACSM) and UK recommendations of aerobic activity for at least 150 minutes weekly during and after cancer treatment.94, 95

Ongoing surveillance

Baseline tests and measures are repeated at each follow-up visit in an effort to identify changes and to detect early signs of physical impairment. If impairments are detected, rehabilitation may be initiated. This proactive approach promotes early intervention to optimize recovery and return to premorbid levels of function.54, 75, 89

Additional assessments should take place at these visits specific to the treatments outlined in the cancer plan of care. For example, patients who will receive a neurotoxic chemotherapy agent should have sensory and balance screening before initiation of the chemotherapy to enable ongoing monitoring for physical impairments. Assessment findings may warrant referral back to the medical oncology team or to other care providers.

Ongoing education is vital to heighten the patient's awareness of potential late effects from treatment and to promote a proactive approach to their diagnosis and treatment. In addition, reinforcement of health-promoting behaviors such as exercise, weight control, and physical activity continues.96 Finally, the model supports education for exercise promotion regardless of presence or absence of impairments.97-99

Panel Perspectives and Discussion Points on the Prospective Surveillance Model

The panel of experts endorsed the concept of a PSM for early identification of breast cancer-related impairments. Overall, the panel noted that significant disparities exist in referral patterns for physical rehabilitation and that a concerted, streamlined method is needed to remedy this. Major areas of discussion on elements of the model included: facilitation of early identification of impairments and reduced time to rehabilitation intervention; inclusion of all breast cancer patients versus those at high risk for impairment; patient burden; facilitation of exercise; provision of evidence-based patient education; provider barriers and potential cost impact.

Differing viewpoints were raised about several issues related to the model, including the ability of health care settings to implement such a model; the demands placed on providers both in knowledge and in capacity to implement the model; who should be responsible for ongoing assessment and coordination of the model; the potential for the model to be a barrier to independent exercise; whether there is truly a need for a model like this in addition to the rehabilitation care already being rendered to patients; and whether this model is applicable to every patient undergoing treatment.

Early identification of impairments and reduced time to rehabilitation intervention

The panel supported the premise that prospective surveillance offers the potential to put a patient and her care team ahead of pending functional limitations by making rehabilitation an integral part of breast cancer care. The importance of such a model is that early intervention is enabled more rapidly than in a traditional, impairment-based model.

Inclusion of all breast cancer patients versus risk-based triage approach to rehabilitation referral

A recurring question raised by the panel was the extent to which every breast cancer patient needs to be included in the model. Disparate viewpoints were raised about the need for all patients to receive care through prospective surveillance. Some patients may experience little or no adverse effects during or after treatment, prompting the question: Is this model of surveillance necessary for every patient? Counterpoints were made as to the compelling data that at each point along the continuum of care and with each intervention offered, there are potential physical impairments that might be prevented or mitigated using the PSM.

When panel members were asked to identify the group of patients for whom the model does not apply, discussion centered on the issue of risk for impairments. The point was made that being low risk during treatment does not necessarily translate into being low risk in the future, considering what is known about late effects of treatment.

There was further discussion about a possible triage approach that would include a screening tool for symptom identification and risk assessment to trigger referral to rehabilitation for early treatment of physical impairments. A counterpoint to this suggestion was made by rehabilitation professionals on the panel that this is the current approach used and has proven to be ineffective in promoting early detection and intervention. Although the symptom-based triage approach would prompt questions about physical impairment and function, it relies on functionally disabling problems to be reported by the patient. Evidence exists that even among metastatic breast cancer survivors in a health care system with outstanding rehabilitation services on site, few patients are referred for help with physical impairments or function, even among those with difficulty ambulating.45 In addition, the current structure of waiting for patients to self-identify a need for rehabilitation is insufficient to enable early identification. The PSM could incorporate a triage system that would utilize an impairment- and risk-screening tool in every patient, with a validated set of questions in which certain responses would trigger automatic referral to rehabilitation needs to be evaluated.

Patient burden

Panel discussions supported the premise that prospective surveillance may aid in reducing patient burden through ongoing assessment by professionals with expertise in function and exercise. A rehabilitation or exercise professional who is knowledgeable in oncology rehabilitation can be a resource to advise the patient about known adverse effects of disease treatment, thus providing an opportunity to mitigate patient burden. Dissenting viewpoints included concern that adding visits to yet another health care provider during the course of treatment presents an additional burden for patients. Proximity of the rehabilitation provider to others on the patient's health care team was of concern; patients may be required to travel farther to see the provider and, depending on their payer, may require additional paperwork and incur extra costs. Counterpoints were made that the model is structured to align with ongoing medical appointments and, if assessments are introduced from diagnosis as an integrated part of patient care, acceptance among patients may be improved. The literature supports the premise that women's needs for education and intervention for the adverse effects of breast cancer treatment appear to outweigh these perceived barriers to rehabilitation.40, 100

In an article on patient perspectives in this supplement, Binkley et al. report that patients are often surprised and conflicted when faced with impairments and functional limitations during and after cancer treatment. They often hesitate to address these issues with their medical care team so as not to appear to complain about relatively minor issues. Fear is also a significant burden experienced by the patient:101 Will she do harm by exercising? Should she push herself through fatigue or through pain or will it make things worse? The panel agreed that, in general, the education points offered by the PSM could help to alleviate this burden for the patient.

Facilitation of exercise

Panel members agreed that the model should expressly encourage patients, at all phases of disease treatment, to engage in exercise. Efforts to implement this model should emphasize means to facilitate exercise and avoid perceptions of increasing barriers to exercise. Concerns were raised that a model such as this could become a barrier to facilitating exercise programs that are community based or of the individual's own volition. Whether the proposed system would increase or decrease exercise among survivors is a testable hypothesis.

Various stakeholders highlighted unique, community-based exercise programs through groups such as the YMCA (in conjunction with Livestrong), which provide oncology-specific exercise guidance and are popular throughout the US, as well as Reach to Recovery, which provides individualized recovery instruction, and other programs.102 The panel emphasized the important role that community organizations and patient advocacy groups could play in promoting exercise, weight management, and healthy lifestyle behaviors so that patients access such programs in a timely manner, before experiencing functional decline.

Provision of evidence-based education and advice

Currently, information about physical function and exercise is provided in a fragmented manner; some panel members and patients noted that information could be conflicting among various providers on the health care team. Panelists recognized that the PSM, integrated within multidisciplinary breast cancer care, could contribute to consistent guidance and promote return to full function and activity levels. Patients noted the need to have streamlined care from diagnosis through treatment and beyond, by a provider who focuses on mobility, function, and physical activity.62 The potential to integrate the PSM within burgeoning systems for providing survivorship health care is discussed in an accompanying article by Gerber et al.61

Provider barriers

Although the panel recognized that there is increasing awareness of the sequelae associated with cancer treatments, many of which affect function, many oncology and primary care providers may lack knowledge of and experience with reliable and valid screening tools and effective rehabilitative interventions to alleviate these sequelae. Health care providers who lack substantial exercise and rehabilitation expertise are often uncertain in making exercise prescriptions beyond broad, general recommendations. This creates a conundrum for patients who want to participate in daily life, activities, and exercise, knowing it is beneficial for them but not knowing how much they can participate without doing harm or causing further pain. Patients trust their providers and tend to follow their advice regarding initiation of exercise.103

The panel identified the model's potential to reduce burden on oncologic practitioners by providing a defined course of action for reducing impairments and restoring function. There was much discussion about who should provide baseline examinations and ongoing assessments to patients. The rehabilitation community is composed of physiatrists, physical therapists, occupational therapists, and exercise professionals who are experts in function and are likely knowledgeable in this area. Core panel members as well as stakeholders representing various rehabilitation professional associations noted that there are not nearly enough professionals practicing in oncology specialty areas to accommodate the needs of all breast cancer patients. The panel agreed that although rehabilitation and exercise professionals are the preferred providers in these domains, there is an ongoing need to educate physicians, nurses, physician assistants, nurse practitioners, and other health care providers about prospective surveillance for early detection of impairments and prompt referral for patients to receive intervention.

Cost impact

The panel agreed that there are minimal data on the cost burden of treating physical impairments related to cancer treatment and that it would be premature to make any claim that such a program would positively impact the cost of health care or unreasonably increase costs. This issue is discussed in greater detail by Cheville et al. in an accompanying article in this supplement.72

Rationale for Prospective Surveillance

Cancer treatments carry with them a number of adverse physiologic effects that can escalate during active disease treatment (ie, surgery, chemotherapy, radiation, and endocrine therapy) but may resolve spontaneously upon treatment withdrawal.104-106 Whereas some adverse effects contribute to early physical impairments, others occur months or years after treatment is withdrawn.3, 8, 12, 107-110 As a result of these impairments, breast cancer patients often attenuate their activities and develop decreased tolerance to activity.38, 40, 85, 111 Patients have described the need for education about treatment-related impairments as well as information to help them return to exercise and activity.40, 85

Although cancer treatment can lead to significant morbidity, many impairments respond to rehabilitation interventions.9-33, 58 Screening for physical impairments through a surveillance program that spans the treatment trajectory may help to expedite their identification and treatment. Studies demonstrate that rehabilitation care reduces the incidence of breast cancer–related physical impairments.75, 79, 112, 113 Prospective surveillance goes a step further by enabling early detection and treatment of these impairments, which may reduce short- and long-term morbidity.14, 49, 50, 75, 78, 80, 89, 108, 112 Further, there is evidence to demonstrate improved impairment treatment outcomes—specifically regarding lymphedema, fatigue, and shoulder morbidity—with early intervention through a PSM.78, 79, 113, 114 These examples support a growing consensus that there is merit to including assessment for physical impairments in breast cancer follow-up.115


Evidence supports the need for ongoing monitoring to detect and treat functional decline and to promote healthy lifestyles throughout treatment and survivorship, thus supporting the contention that ongoing surveillance should be part of the patient's plan of care from diagnosis.11, 116-118 The current system for breast cancer care provides a structured avenue to disseminate the proposed approach to prospective surveillance. This would require an organized plan for implementation and would rely on a collaborative effort among stakeholders including health care providers, patients, health care professional organizations, government agencies, and patient advocacy groups. The final article in this supplement provides a synopsis of stakeholder perspectives on the model and feasibility of its implementation.119

Never before have breast cancer patients had a dedicated plan to guide functional rehabilitation, identify exercise prescription, and promote health behaviors during and after cancer treatment. The PSM for early detection of physical impairment provides such a framework and focuses on values that have been articulated by the survivors, namely return to needed and desired life activities. Because up to 80% of patients will attain full life expectancy, they should do so with full functional capabilities and without disability from cancer treatments that can be readily identified and remedied within this prospective surveillance model of care.


  1. Top of page
  2. Abstract

Support for this meeting and supplement was provided by the American Cancer Society, through The Longaberger Company®, a direct selling company offering home products including handcrafted baskets made in Ohio, and the Longaberger Horizon of Hope® Campaign, which provided a grant to the American Cancer Society for breast cancer research and education.


The authors made no disclosures.


  1. Top of page
  2. Abstract
  • 1
    Avraham T, Yan A, Zampell JC, et al. Radiation therapy causes loss of dermal lymphatic vessels and interferes with lymphatic function by TGF-beta1-mediated tissue fibrosis. Am J Physiol Cell Physiol. 2010; 299: C589-605.
  • 2
    Malicka I, Stefanska M, Pawlowska K, Wozniewski M. Function of muscles of flexors and extensors of the elbow joint in women after treatment of breast cancer. Ortop Traumatol Rehabil. 2009; 11: 111-119.
  • 3
    Westrup JL, Lash TL, Thwin SS, Silliman RA. Risk of decline in upper-body function and symptoms among older breast cancer patients. J Gen Intern Med. 2006; 21: 327-333.
  • 4
    Taira N, Shimozuma K, Shiroiwa T, et al. Associations among baseline variables, treatment-related factors and health-related quality of life 2 years after breast cancer surgery. Breast Cancer Res Treat. 2011; 128: 735-747.
  • 5
    Deutsch M, Flickinger JC. Shoulder and arm problems after radiotherapy for primary breast cancer. Am J Clin Oncol. 2001; 24: 172-176.
  • 6
    Hack TF, Kwan WB, Thomas-Maclean RL, et al. Predictors of arm morbidity following breast cancer surgery. Psychooncology. 2010; 19: 1205-1212.
  • 7
    Shamley DR, Srinanaganathan R, Weatherall R, et al. Changes in shoulder muscle size and activity following treatment for breast cancer. Breast Cancer Res Treat. 2007; 106; 19-27.
  • 8
    Albert US, Koller M, Kopp I, Lorenz W, Schulz KD, Wagner U. Early self-reported impairments in arm functioning of primary breast cancer patients predict late side effects of axillary lymph node dissection: results from a population-based cohort study. Breast Cancer Res Treat. 2006; 100: 285-292.
  • 9
    Ewertz M, Jensen AB. Late effects of breast cancer treatment and potentials for rehabilitation. Acta Oncol. 2011; 50: 187-193.
  • 10
    Cheville AL. Cancer rehabilitation. Semin Oncol. 2005; 32: 219-224.
  • 11
    Devoogdt N, Van Kampen M, Christiaens MR, et al. Short- and long-term recovery of upper limb function after axillary lymph node dissection. Eur J Cancer Care (Engl). 2011; 20: 77-86.
  • 12
    Hayes SC, Rye S, Battistutta D, DiSipio T, Newman B. Upper-body morbidity following breast cancer treatment is common, may persist longer-term and adversely influences quality of life. Health Qual Life Outcomes. 2010; 8: 92.
  • 13
    Hayes SC, Janda M, Cornish B, Battistutta D, Newman B. Lymphedema after breast cancer: incidence, risk factors, and effect on upper body function. J Clin Oncol. 2008; 26: 3536-3542.
  • 14
    Gerber LH, Stout N, McGarvey C, et al. Factors predicting clinically significant fatigue in women following treatment for primary breast cancer. Support Care Cancer. 2011; 19: 1581-1591.
  • 15
    Smoot B, Wong J, Cooper B, et al. Upper extremity impairments in women with or without lymphedema following breast cancer treatment. J Cancer Surviv. 2010; 4: 167-178.
  • 16
    Nesvold IL, Dahl AA, Lokkevik E, Marit Mengshoel A, Fossa SD. Arm and shoulder morbidity in breast cancer patients after breast-conserving therapy versus mastectomy. Acta Oncol. 2008; 47: 835-842.
  • 17
    Helms G, Kuhn T, Moser L, Remmel E, Kreienberg R. Shoulder-arm morbidity in patients with sentinel node biopsy and complete axillary dissection—data from a prospective randomised trial. Eur J Surg Oncol. 2009; 35: 696-701.
  • 18
    Augusto C, Pietro M, Cinzia M, et al. Peripheral neuropathy due to paclitaxel: study of the temporal relationships between the therapeutic schedule and the clinical quantitative score (QST) and comparison with neurophysiological findings. J Neurooncol. 2007; 86: 89-99.
  • 19
    Paim CR, de Paula Lima ED, Fu MR, de Paula Lima A, Cassali GD. Postlymphadenectomy complications and quality of life among breast cancer patients in Brazil. Cancer Nurs. 2008; 31: 302-309; quiz 10-11.
  • 20
    Perez EA, Weilbaecher K. Aromatase inhibitors and bone loss. Oncology (Williston Park). 2006; 20: 1029-1039; discussion 39-40, 42, 48.
  • 21
    Michaud LB, Goodin S. Cancer-treatment-induced bone loss, part 2. Am J Health Syst Pharm. 2006; 63: 534-546.
  • 22
    Rietman J, Dijkstra P, Debreczeni R, Geertzen J, Robinson D, De Vries J. Impairments, disabilities and health related quality of life after treatment for breast cancer: a follow-up study 2.7 years after surgery. Disabil Rehabil. 2004; 26: 78-84.
  • 23
    Bennett B, Goldstein D, Lloyd A, Davenport T, Hickie I. Fatigue and psychological distress—exploring the relationship in women treated for breast cancer. Eur J Cancer. 2004; 40: 1689-1695.
  • 24
    Leidenius M, Leppanen E, Krogerus L, von Smitten K. Motion restriction and axillary web syndrome after sentinel node biopsy and axillary clearance in breast cancer. Am J Surg. 2003; 185: 127-130.
  • 25
    Fleissig A, Fallowfield LJ, Langridge CI, et al. Post-operative arm morbidity and quality of life. Results of the ALMANAC randomised trial comparing sentinel node biopsy with standard axillary treatment in the management of patients with early breast cancer. Breast Cancer Res Treat. 2005: 1-15.
  • 26
    Hirbe A, Morgan EA, Uluckan O, Weilbaecher K. Skeletal complications of breast cancer therapies. Clin Cancer Res. 2006; 12( Pt 2): 6309s-6314s.
  • 27
    Downie FP, Mar Fan HG, Houede-Tchen N, Yi Q, Tannock IF. Cognitive function, fatigue, and menopausal symptoms in breast cancer patients receiving adjuvant chemotherapy: evaluation with patient interview after formal assessment. Psychooncology. 2006; 15: 921-930.
  • 28
    Gartner R, Jensen MB, Kronborg L, Ewertz M, Kehlet H, Kroman N. Self-reported arm-lymphedema and functional impairment after breast cancer treatment—a nationwide study of prevalence and associated factors. Breast. 2010; 19: 506-515.
  • 29
    Visovsky C. Muscle strength, body composition, and physical activity in women receiving chemotherapy for breast cancer. Integr Cancer Ther. 2006; 5: 183-191.
  • 30
    Braithwaite D, Satariano WA, Sternfeld B, et al. Long-term prognostic role of functional limitations among women with breast cancer. J Natl Cancer Inst. 2010; 102: 1468-1477.
  • 31
    Treish I, Schwartz R, Lindley C. Pharmacology and therapeutic use of trastuzumab in breast cancer. Am J Health Syst Pharm. 2000; 57: 2063-2076; quiz 77-79.
  • 32
    Boehmke MM, Dickerson SS. Symptom, symptom experiences, and symptom distress encountered by women with breast cancer undergoing current treatment modalities. Cancer Nurs. 2005; 28: 382-389.
  • 33
    Forsyth PA, Balmaceda C, Peterson K, Seidman AD, Brasher P, DeAngelis LM. Prospective study of paclitaxel-induced peripheral neuropathy with quantitative sensory testing. J Neurooncol. 1997; 35: 47-53.
  • 34
    Chachaj A, Malyszczak K, Pyszel K, et al. Physical and psychological impairments of women with upper limb lymphedema following breast cancer treatment. Psychooncology. 2010; 19: 299-305.
  • 35
    Nesvold IL, Fossa SD, Holm I, Naume B, Dahl AA. Arm/shoulder problems in breast cancer survivors are associated with reduced health and poorer physical quality of life. Acta Oncol. 2010; 49: 347-353.
  • 36
    Bosompra K, Ashikaga T, O'Brien PJ, Nelson L, Skelly J. Swelling, numbness, pain, and their relationship to arm function among breast cancer survivors: a disablement process model perspective. Breast J. 2002; 8: 338-348.
  • 37
    Tahan G, Johnson R, Mager L, Soran A. The role of occupational upper extremity use in breast cancer related upper extremity lymphedema. J Cancer Surviv. 2010; 4: 15-19.
  • 38
    Karki A, Simonen R, Malkia E, Selfe J. Impairments, activity limitations and participation restrictions 6 and 12 months after breast cancer operation. J Rehabil Med. 2005; 37: 180-188.
  • 39
    Hayes SC, Battistutta D, Parker AW, Hirst C, Newman B. Assessing task “burden” of daily activities requiring upper body function among women following breast cancer treatment. Support Care Cancer. 2005; 13: 255-265.
  • 40
    Levangie PK, Santasier AM, Stout NL, Pfalzer L. A qualitative assessment of upper quarter dysfunction reported by physical therapists treated for breast cancer or treating breast cancer sequelae. Support Care Cancer. 2011; 19: 1367-1378.
  • 41
    Engel J, Kerr J, Schlesinger-Raab A, Sauer H, Holzel D. Axilla surgery severely affects quality of life: results of a 5-year prospective study in breast cancer patients. Breast Cancer Res Treat. 2003; 79: 47-57.
  • 42
    Deshpande AD, Sefko JA, Jeffe DB, Schootman M. The association between chronic disease burden and quality of life among breast cancer survivors in Missouri. Breast Cancer Res Treat. 2011; 129: 877-886.
  • 43
    Kjaer TK, Johansen C, Ibfelt E, et al. Impact of symptom burden on health related quality of life of cancer survivors in a Danish cancer rehabilitation program: a longitudinal study. Acta Oncol. 2011; 50: 223-232.
  • 44
    Schmitz KH, Speck RM, Rye SA, DiSipio T, Hayes SC. Prevalence of breast cancer treatment sequelae over 6 years of follow up: The Pulling Through Study. Cancer. 2012; 118( suppl 8): 2217-2225.
  • 45
    Cheville AL, Beck LA, Petersen TL, Marks RS, Gamble GL. The detection and treatment of cancer-related functional problems in an outpatient setting. Support Care Cancer. 2009; 17: 61-67.
  • 46
    Bland KL, Perczyk R, Du W, et al. Can a practicing surgeon detect early lymphedema reliably? Am J Surg. 2003; 186: 509-513.
  • 47
    Hewitt M, Greenfield S, Stovall E. Cancer patient to cancer survivor: lost in transition. Washington, DC: The National Academies Press; 2005.
  • 48
    Ganz PA, Hahn EE. Implementing a survivorship care plan for patients with breast cancer. J Clin Oncol. 2008; 26: 759-767.
  • 49
    Box RC, Reul-Hirche HM, Bullock-Saxton JE, Furnival CM. Physiotherapy after breast cancer surgery: results of a randomised controlled study to minimise lymphoedema. Breast Cancer Res Treat. 2002; 75: 51-64.
  • 50
    Cinar N, Seckin U, Keskin D, Bodur H, Bozkurt B, Cengiz O. The effectiveness of early rehabilitation in patients with modified radical mastectomy. Cancer Nurs. 2008; 31: 160-165.
  • 51
    de Rezende LF, Franco RL, de Rezende MF, Beletti PO, Morais SS, Gurgel MS. Two exercise schemes in postoperative breast cancer: comparison of effects on shoulder movement and lymphatic disturbance. Tumori. 2006; 92: 55-61.
  • 52
    Fialka-Moser V, Crevenna R, Korpan M, Quittan M. Cancer rehabilitation: particularly with aspects on physical impairments. J Rehabil Med. 2003; 35: 153-162.
  • 53
    McAnaw MB, Harris KW. The role of physical therapy in the rehabilitation of patients with mastectomy and breast reconstruction. Breast Dis. 2002; 16: 163-174.
  • 54
    McNeely ML, Campbell K, Ospina M, et al. Exercise interventions for upper-limb dysfunction due to breast cancer treatment. Cochrane Database Syst Rev. 2010; 6: CD005211.
  • 55
    McNeely ML, Campbell KL, Rowe BH, Klassen TP, Mackey JR, Courneya KS. Effects of exercise on breast cancer patients and survivors: a systematic review and meta-analysis. CMAJ. 2006; 175: 34-41.
  • 56
    Lee SA, Kang JY, Kim YD, et al. Effects of a scapula-oriented shoulder exercise programme on upper limb dysfunction in breast cancer survivors: a randomized controlled pilot trial. Clin Rehabil. 2010; 24: 600-613.
  • 57
    Wonders KY, Reigle BS. Trastuzumab and doxorubicin-related cardiotoxicity and the cardioprotective role of exercise. Integr Cancer Ther. 2009; 8: 17-21.
  • 58
    Schwartz AL, Winters-Stone K, Gallucci B. Exercise effects on bone mineral density in women with breast cancer receiving adjuvant chemotherapy. Oncol Nurs Forum. 2007; 34: 627-633.
  • 59
    Turner J, Hayes S, Reul-Hirche H. Improving the physical status and quality of life of women treated for breast cancer: a pilot study of a structured exercise intervention. J Surg Oncol. 2004; 86: 141-146.
  • 60
    Gomide LB, Matheus JP, Candido Dos Reis FJ. Morbidity after breast cancer treatment and physiotherapeutic performance. Int J Clin Pract. 2007; 61: 972-982.
  • 61
    Gerber LH, Stout NL, Schmitz KH, Stricker CT. Integrating a prospective model of surveillance for physical impairments into breast cancer survivorship care. Cancer. 2012; 118( suppl 8): 2201-2206.
  • 62
    Binkley JM, Harris SR, Levangie PK, et al. Patient perspectives on breast cancer treatment side effects and the prospective surveillance model for physical rehabilitation for women with breast cancer. Cancer. 2012; 118( suppl 8): 2207-2216.
  • 63
    McNeely ML, Binkley JM, Pusic AL, Campbell KL, Gabram S, Soballe PW. A prospective model of care for breast cancer rehabilitation: postoperative and postreconstructive issues. Cancer. 2012; 118( suppl 8): 2226-2236.
  • 64
    Hayes SC, Johansson K, Stout NL, et al. Upper-body morbidity following breast cancer: incidence and evidence for evaluation, prevention and management within a prospective surveillance model of rehabilitation. Cancer. 2012; 118( suppl 8): 2217-2225.
  • 65
    Stubblefield MD, McNeely ML, Alfano CM, Mayer DK. A prospective surveillance model for physical rehabilitation of women with breast cancer: chemotherapy induced neuropathy. Cancer. 2012; 118( suppl 8): 2250-2260.
  • 66
    Berger AM, Gerber LH, Mayer DK. Cancer-related fatigue: implications for breast cancer survivors. Cancer. 2012; 118( suppl 8): 2261-2269.
  • 67
    Schmitz KH, Prosnitz RG, Schwartz AL, Carver JR. Prospective surveillance and management of cardiovascular health in breast cancer survivors. Cancer. 2012; 118( suppl 8): 2270-2276.
  • 68
    Demark-Wahnefried W, Campbell KL, Hayes SC. Weight management and its role in breast cancer rehabilitation. Cancer. 2012;118 lpar;suppl 8): 2277-2287.
  • 69
    Winters-Stone KM, Schwartz AL, Hayes SC, Fabian CJ, Campbell KL. A prospective model of care for breast cancer rehabilitation: bone health and arthralgia. Cancer. 2012; 118( suppl 8): 2288-2299.
  • 70
    Campbell KL, Pusic AL, Zucker DS, et al. A prospective model of care for breast cancer rehabilitation: function. Cancer. 2012; 118( suppl 8): 2300-2311.
  • 71
    Harris SR, Schmitz KH, Campbell KL, McNeely ML. Clinical practice guidelines for breast cancer rehabilitation: syntheses of guideline recommendations and qualitative appraisals. Cancer. 2012; 118( suppl 8): 2312-2324.
  • 72
    Cheville AL, Nyman JA, Pruthi S, Basford JR. Cost considerations regarding the prospective surveillance model for breast cancer survivors. Cancer. 2012; 118( suppl 8): 2325-2330.
  • 73
    Stout Gergich NL, Pfalzer LA, McGarvey C, Springer B, Gerber LH, Soballe P. Preoperative assessment enables the early diagnosis and successful treatment of lymphedema. Cancer. 2008; 112: 2809-2819.
  • 74
    Armer JM, Stewart BR. Post-breast cancer lymphedema: incidence increases from 12 to 30 to 60 months. Lymphology. 2010; 43: 118-127.
  • 75
    Springer BA, Levy E, McGarvey C, et al. Pre-operative assessment enables early diagnosis and recovery of shoulder function in patients with breast cancer. Breast Cancer Res Treat. 2010; 120: 135-147.
  • 76
    Yang EJ, Park WB, Seo KS, Kim SW, Heo CY, Lim JY. Longitudinal change of treatment-related upper limb dysfunction and its impact on late dysfunction in breast cancer survivors: a prospective cohort study. J Surg Oncol. 2010; 101: 84-91.
  • 77
    Stout NL. Cancer prevention in physical therapist practice. Phys Ther. 2009; 89( 11): 1119-1122.
  • 78
    Stout Gergich NL, Pfalzer LA, McGarvey C, Springer B, Gerber LH, Soballe P. Preoperative assessment enables the early diagnosis and successful treatment of lymphedema. Cancer. 2008; 112: 2809-2819.
  • 79
    Torres Lacomba M, Yuste Sanchez MJ, Zapico Goni A, et al. Effectiveness of early physiotherapy to prevent lymphoedema after surgery for breast cancer: randomised, single blinded, clinical trial. BMJ. 2010; 340: b5396.
  • 80
    Box RC, Reul-Hirche HM, Bullock-Saxton JE, Furnival CM. Shoulder movement after breast cancer surgery: results of a randomised controlled study of postoperative physiotherapy. Breast Cancer Res Treat. 2002; 75: 35-50.
  • 81
    Midtgaard J, Tveteras A, Rorth M, Stelter R, Adamsen L. The impact of supervised exercise intervention on short-term postprogram leisure time physical activity level in cancer patients undergoing chemotherapy: 1- and 3-month follow-up on the body & cancer project. Palliat Support Care. 2006; 4: 25-35.
  • 82
    Milne HM, Wallman KE, Gordon S, Courneya KS. Effects of a combined aerobic and resistance exercise program in breast cancer survivors: a randomized controlled trial. Breast Cancer Res Treat. 2008; 108: 279-288.
  • 83
    Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q. 1996; 74: 511-544.
  • 84
    Cheville AL, Troxel AB, Basford JR, Kornblith AB. Prevalence and treatment patterns of physical impairments in patients with metastatic breast cancer. J Clin Oncol. 2008; 26: 2621-2629.
  • 85
    Lee TS, Kilbreath SL, Sullivan G, Refshauge KM, Beith JM. Patient perceptions of arm care and exercise advice after breast cancer surgery. Oncol Nurs Forum. 2010; 37: 85-91.
  • 86
    Fu MR, Chen CM, Haber J, Guth AA, Axelrod D. The effect of providing information about lymphedema on the cognitive and symptom outcomes of breast cancer survivors. Ann Surg Oncol. 2010; 17: 1847-1853.
  • 87
    Windsor PM, Potter J, McAdam K, McCowan C. Evaluation of a fatigue initiative: information on exercise for patients receiving cancer treatment. Clin Oncol (R Coll Radiol). 2009; 21: 473-482.
  • 88
    Beaver K, Twomey M, Witham G, Foy S, Luker KA. Meeting the information needs of women with breast cancer: piloting a nurse-led intervention. Eur J Oncol Nurs. 2006; 10: 378-390.
  • 89
    Chan DN, Lui LY, So WK. Effectiveness of exercise programmes on shoulder mobility and lymphoedema after axillary lymph node dissection for breast cancer: systematic review. J Adv Nurs. 2010; 66: 1902-1914.
  • 90
    Favarao KU, Mantese JC, Barros AC. Shoulder mobility after axillary sentinel node biopsy for early infiltrating breast cancer treatment. Eur J Gynaecol Oncol. 2010; 31: 23-26.
  • 91
    Todd J, Scally A, Dodwell D, Horgan K, Topping A. A randomised controlled trial of two programmes of shoulder exercise following axillary node dissection for invasive breast cancer. Physiotherapy. 2008; 94: 265-273.
  • 92
    Box R. Restriction of the range of arm elevation exercises for one week after surgery for breast cancer can reduce the incidence of lymphoedema. Aust J Physiother. 2009; 55: 64.
  • 93
    Blanchard CM, Courneya KS, Rodgers WM, Murnaghan DM. Determinants of exercise intention and behavior in survivors of breast and prostate cancer: an application of the theory of planned behavior. Cancer Nurs. 2002; 25: 88-95.
  • 94
    Schmitz KH, Courneya KS, Matthews C, et al. American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Med Sci Sports Exerc. 2010; 42: 1409-1426.
  • 95
    MacMillan Cancer Support. The importance of physical activity for people living with and beyond cancer: a concise evidence review. London: MacMillan Cancer Support; 2011: 1-15.
  • 96
    Luctkar-Flude M, Groll D, Woodend K, Tranmer J. Fatigue and physical activity in older patients with cancer: a six-month follow-up study. Oncol Nurs Forum. 2009; 36: 194-202.
  • 97
    Ng A, Constine LS, Advani R, et al. ACR Appropriateness Criteria: follow-up of Hodgkin's lymphoma. Curr Probl Cancer. 2010; 34: 211-227.
  • 98
    Partsch H. Intermittent pneumatic compression in immobile patients. Int Wound J. 2008; 5: 389-397.
  • 99
    McBride D. ACSM releases new guidelines for physical activity for patients with cancer. ONS Connect. 2010; 25: 16.
  • 100
    Lattanzi JB, Giuliano S, Meehan C, Sander B, Wootten R, Zimmerman A. Recommendations for physical and occupational therapy practice from the perspective of clients undergoing therapy for breast cancer-related impairments. J Allied Health. 2010; 39: 257-264.
  • 101
    Larsson IL, Jonsson C, Olsson AC, Gard G, Johansson K. Women's experience of physical activity following breast cancer treatment. Scand J Caring Sci. 2008; 22: 422-429.
  • 102
    Hennessy EM, Stevinson C, Fox KR. Preliminary study of the lived experience of exercise for cancer survivors. Eur J Oncol Nurs. 2005; 9: 155-166.
  • 103
    Jones LW, Courneya KS, Fairey AS, Mackey JR. Effects of an oncologist's recommendation to exercise on self-reported exercise behavior in newly diagnosed breast cancer survivors: a single-blind, randomized controlled trial. Ann Behav Med. 2004; 28: 105-113.
  • 104
    Armer JM, Heckathorn PW. Post-breast cancer lymphedema in aging women: self-management and implications for nursing. J Gerontol Nurs. 2005; 31: 29-39.
  • 105
    Bartsch HH, Weis J, Moser MT. Cancer-related fatigue in patients attending oncological rehabilitation programs: prevalence, patterns and predictors. Onkologie. 2003; 26: 51-57.
  • 106
    Lee TS, Kilbreath SL, Refshauge KM, Herbert RD, Beith JM. Prognosis of the upper limb following surgery and radiation for breast cancer. Breast Cancer Res Treat. 2008; 110: 19-37.
  • 107
    Bajrovic A, Rades D, Fehlauer F, et al. Is there a life-long risk of brachial plexopathy after radiotherapy of supraclavicular lymph nodes in breast cancer patients? Radiother Oncol. 2004; 71: 297-301.
  • 108
    Johansson K, Branje E. Arm lymphoedema in a cohort of breast cancer survivors 10 years after diagnosis. Acta Oncol. 2010; 49: 166-173.
  • 109
    Bar Ad V, Cheville A, Solin LJ, Dutta P, Both S, Harris EE. Time course of mild arm lymphedema after breast conservation treatment for early-stage breast cancer. Int J Radiat Oncol Biol Phys. 2010; 76: 85-90.
  • 110
    Ogce F, Ozkan S. Changes in functional status and physical and psychological symptoms in women receiving chemotherapy for breast cancer. Asian Pac J Cancer Prev. 2008; 9: 449-452.
  • 111
    Blanchard CM, Courneya KS, Stein K. Cancer survivors' adherence to lifestyle behavior recommendations and associations with health-related quality of life: results from the American Cancer Society's SCS-II. J Clin Oncol. 2008; 26: 2198-2204.
  • 112
    Schmitz KH, Ahmed RL, Troxel AB, et al. Weight lifting for women at risk for breast cancer-related lymphedema: a randomized trial. JAMA. 2010; 304: 2699-2705.
  • 113
    Boccardo FM, Ansaldi F, Bellini C, et al. Prospective evaluation of a prevention protocol for lymphedema following surgery for breast cancer. Lymphology. 2009; 42: 1-9.
  • 114
    Springer BA, Levy E, McGarvey C, et al. Pre-operative assessment enables early diagnosis and recovery of shoulder function in patients with breast cancer. Breast Cancer Res Treat. 2010; 120: 135-147.
  • 115
    Oeffinger KC, McCabe MS. Models for delivering survivorship care. J Clin Oncol. 2006; 24: 5117-5124.
  • 116
    Gosselink R, Rouffaer L, Vanhelden P, Piot W, Troosters T, Christiaens MR. Recovery of upper limb function after axillary dissection. J Surg Oncol. 2003; 83: 204-211.
  • 117
    Kitamura Y, Ohno Y, Kasahara S, et al. Statistical estimation of the number of breast cancer patients with disabilities resulting from surgery. Breast Cancer. 2005; 12: 130-134.
  • 118
    Ganz PA, Casillas J, Hahn EE. Ensuring quality care for cancer survivors: implementing the survivorship care plan. Semin Oncol Nurs. 2008; 24: 208-217.
  • 119
    Stout NL, Andrews K, Binkley JM, Schmitz KH, Smith RA. Stakeholder perspectives on dissemination and implementation of a prospective surveillance model of rehabilitation for breast cancer treatment. Cancer. 2012; 118( suppl 8): 2331-2334.