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Value of Physical Function in Breast Cancer Survivors: A Systematic Review Nishikawa, Kei; Lo, Kenneth; Lam, Jackson; Sy, Vincent; Chu, Johnathan Aug 31, 2012

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Physical Function in Breast Cancer Survivors: A systematic review of published values  Nishikawa, K., Chu, J. Y., Lam, J. B., Lo, K. K., Sy, V. S. & Campbell, K. L. University of British Columbia Masters of Physical Therapy Objectives The primary objective of this review is to examine the published values of physical function in breast cancer survivors in current research literature - Limited data on normative or expected values of physical function in breast cancer survivors – difficult to interpret research and clinical findings - Aim: Provide a summary of published values of physical function in breast cancer survivors and identify gaps to provide direction for future research  Introduction Background Information In 2012, 22,700 women will be diagnosed with breast cancer in Canada1 - 5-year survival rate - 88% in Canada1 - Growing population of cancer survivors left with long term effects of the disease and its treatments2 - Declining physical function common in women who have undergone treatments3 Domains of physical function included lower extremity strength, upper extremity strength, aerobic fitness, balance, and mobility Study Design Population - Females > 18 y.o. diagnosed with breast cancer Intervention - Any type of treatment (no treatment, chemotherapy, radiation, medications, etc.) or combination Outcomes - Primary outcome measures chosen are most commonly used among the healthy or clinical populations determined by the authors of this review a priori  Physical Function  Data sources and searches • Five independent search strategies for five aspects of physical function • Same terms for breast cancer survivors for all searches combined with specific terms for each component of physical function Databases used: • Medline (1990 to present + In-process & Other Non-Indexed Citations) • Embase (1990 to present, daily update) • CINAHL (1990 to present)  • Limited to English and human studies • Duplicates taken out with Refworks • “Surgery” not explicitly searched  Study selection Exclusion criteria: • Did not report data of females, who were 18 years of age or older and were breast cancer survivors • Did not provide the outcome measure of interest • Did not report the baseline data • If the studies were not observational, cohort, case control and random clinical trials • Not published between 1990 and February 28th, 2012 Relevant values are included if they are retrieved from a search within another aspect of physical function  Data extraction • Data extracted include: age, publication information, values of outcome measures of interest • Only baseline values of original studies were extracted • Values were calculated if original studies reported only postintervention values and percentage of change  Quality Assessment Quality of the papers were not assessed, as primary objective of the study is to report values of physical function at baseline  RESEARCH POSTER PRESENTATION DESIGN © 2012  Lower Extremity Strength – Total Studies 1-RM (measured) – Leg Press 1-RM (predicted) – Leg Press 1-RM (NA)* – Leg Press Endurance – Leg Press Sit to Stand – Time for 5 repetitions Sit to Stand – Repetitions in 30 seconds Dynamometer – Leg Extension  # of Studies 18 4 4 2 3 3 3 2  Upper Extremity Strength – Total Studies Dynamometer – Handgrip Dynamometer – Others 1-RM (measured) – Bench Press 1-RM (measured) – Shoulder Press 1-RM (measured) – Seated Row 1-RM (predicted) – Shoulder Press 1-RM (predicted) – Seated Row 1-RM (predicted) – Bench Press Endurance – Bench Press  33 23 7 3 1 1 1 1 3 4  Aerobic Fitness – Total Studies VO2 max - Measured VO2 Max (maximal test) - Measured VO2 Max (submaximal test) - Predicted VO2 Max (maximal test) - Predicted VO2 Max (submaximal test) Resting Heart Rate 6-Minute Walk Test 12-Minute Walk Test Power Output  42  Balance – Total Studies Timed Backward Tandem Walk Sensory Organization Test - Somatosensory - Visual - Vestibular - Preference - SOT5: - SOT6: One Legged Stance – Eyes open or Eyes closed Fullerton Advanced Balance Scale  5 2 2  Mobility – Total Studies Functional Independence Measure Timed Stair Climb (Ascend) Timed Stair Climb (Descend) Time Required to get up from floor Time Required to get down to floor Short Physical Performance Battery Normal Gait Speed Fast Gait Speed Timed Up and Go Test  6 1 2 2 1 1 1 1 1 2  Range of values  Normative Values  73.02 - 99.3 kg 24.4 - 134.8 kg 60.40 - 84.4 kg 10.1 - 16.9 reps 7.53 - 12.6 s 10 - 13.6 reps 27.3 - 27.7 peak torque/BW; 69.1 - 72.1 kg  11.4 s (60-69 y.o.) 15 reps (60-64 y.o.) -  13 - 34 kg 15.4 - 19.5 kg 12.2 kg 32.7 kg 3.6 kg 4.5 kg 29.8 - 56 kg 0 - 10.7 reps  1 3 4 10 6 4 10 2  1 1  28.6 kg (40-49) -  16.5 mL/kg/min 17.1-26.1 mL/kg/min 24.3 - 25.5 mL/kg/min 14.5 - 32.9 mL/kg/min 73 - 86 bpm 403 - 611 m 753 - 1128 m 1.38 - 1.43 W/kg  • 29.4mL/kg/min (4049 y.o.)** • 26.6 mL/kg/min (5059 y.o.)** 70 - 73 bpm (46-55 y.o.) 400 - 700m -  12.6 - 14.6s  40.4s / 7.4s (40-49 y.o.) -  94.6 - 95.6 77.6 - 84.1 41.4 - 57.3 96.6 - 98.6 44.90 49.00 60.6 s / 15.7 s 33.90  97.9 - 124.4 0.25 - 0.27 m/s, 19 s 0.28 - 0.31 m/, 27.2 s 7.3 s 6.0 s 10 out of 12 0.33 - 0.33 m/s 0.43 - 0.48 m/s 5.7 – 6.7 s  1.10 m/s (50-59 y.o.) 1.47 m/s (50-59 y.o.) 8.1 s (60-99 y.o.)  *1-RM (NA): Methods not defined as measured or predicted **VO2 Max normative values at 25th percentile  Acknowledgments: The authors would like to thank Sarah Neil, Charlotte Beck, Dr. Teresa Liu-Ambrose, and Dr. Lynne Feehan for their assistance in this systematic review  Discussions  Results  Methods  Data Analysis • Relevant characteristics of the studies • Values of physical function reported • Outcome measures identified for each domain of physical function • Normative data in healthy and clinical populations identified in the literature if available • No statistical techniques were utilised  References 1) Canadian Cancer Society. Breast cancer statistic in 6) Peters MJ, et al. Revised normative values for grip postural instability in women with breast cancer treated with glance. Available from strength with the Jamar dynamometer. Journal of the taxane chemotherapy. Archives of Physical Medicine & Nervous System. 2011: 16; 47-50. Rehabilitation. 2007; 88(8): 1002-1008. 20statistics/Stats%20at%20a%20glance/Breast%20cancer.as7) Sanders AP. A safe and effective upper extremity resistive 12) Damush TM, et al. The implementation of an oncologist px?sc_lang=en exercise program for women post breast cancer treatment. referred, exercise self-management program for older breast 2) Campbell KL. Review of exercise studies in breast cancer Rehabilitation Oncology. 2008: 26(3); 3-10. cancer survivors. Psycho-Oncology. 2006; 15(10): 884-890. survivors: attention to principles of exercise training. Br J 8) Enright PL, Sherrill DL. Reference equations for the six13) Winters-Stone K, et al. Identifying factors associated with Sports Med. 2011. minute walk in healthy adults. Am J Respir Crit Care Med. falls in postmenopausal breast cancer survivors: A multi3) Speck RM, et al. An update of controlled physical activity 1998; 158: 1384-1387. disciplinary approach. Archives of Physical Medicine & trials in cancer survivors: a systematic review and metaRehabilitation. 2011; 92(4): 646-652. 9) Springer BA et al. Normative values for the unipedal analysis. J Cancer Surviv. 2011; 5 (1):112. stance test with eyes open and closed. Journal of Geriatric 14) De Paleville, et al. Effects of aerobic training prior to and 4) American College of Sports Medicine. ACSM’s guidelines Physical Therapy.2007; 8(15): 8-15. during chemotherapy in a breast cancer patient: A case study. for exercise testing and prescription (8th ed.). Philadelphia: Journal of Strength & Conditioning Research. 2007; 21(2): 10) Winters-stone KM, et al. Identifying factors associated Lippincott Williams & Wilkins; 2010. with falls in postmenopausal breast cancer survivors: A multi- 635-637. 5) Hokken JWE, et al. Impact of anthracycline dose on quality disciplinary approach. Archives of Physical Medicine & of life and rehabilitation in breast cancer treatment. The Rehabilitation. 2009: 92; 646 – 652. Netherlands Journal of Medicine. 2009; 67(6): 220-225. 11) Wampler MA, et al. Quantitative and clinical description of  Lower Extremity Strength - Most common outcome measure 1-RM leg press - Normative values are 1.18, 1.05, and 0.99 (units=kg/kg of body weight) for aged 40-49, 50-59, and 60+4 - Cannot compare normative values to literature as they are measured in different units4 - One study measured 1-RM in kg/kg of bodyweight, but values were extraordinarily high5 - Sit to stands are also commonly used (two types) - Repetitions in 30s: Lower than healthy population Upper Extremity Strength - Most common outcome measure handgrip strength - Weaker handgrip strengths compared to age-matched healthy women6 - Other measures of upper extremity strength are also decreased7 - Proximal UE movements are more common in recent studies to predict UE strength Aerobic Fitness - VO2 max measurements mostly scored below 25th percentile4 - Resting heart rate elevated - 6MWT falls within range of healthy population8 Balance - Single legged stance was longer than the normative values9,10 - Fullerton Advanced Balance Scale score lower than healthy control (36.48.) but still above cut off for the risk of falls, which is equal or below 2511 Mobility - Timed-up-and-go (TUG) test faster than norms, but age of the population is younger11,12 - Decreased gait speed (normal and fast) despite walking for shorter distance13 - Mixed results for ascending/descending stairs13,14  Limitations - Search strategy and methods may not have captured all relevant papers - Specific outcome measures for physical function were identified a priori - some appropriate outcome measures may have not been included - Studies had varying methods for the same outcome measures - Lack of normative values for some of the selected outcome measures and normative values vary by age  Conclusion - Upper extremity strength and aerobic fitness values reported in breast cancer survivors are significantly lower than normative values - Lower extremity strength, mobility, and balance measures are less conclusive - More consistent outcome measures needed in the future to assess mobility and balance  


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