Early Recovery and Chronic Sequelae after Treatment for Breast Cancer
Author: Rune Gärtner, MD, PhD
Supervisors: Henrik Kehlet, Professor, MD, DMSc, Torben Callesen, MD, DMSc and Niels Kroman, MD, DMSc
Date, Institution and University: 2010, Department of Breast Surgery, Section for Surgical Pathophysiology and Department of Anaesthesiology, Abdominal Centre, Rigshospitalet
Breast cancer is the most common cancer among women in the Western world. Today more than 45,000 women are living in Denmark after treatment for breast cancer and more than 4,000 new breast cancer cases are diagnosed every year.
According to the literature, postoperative pain, nausea and vomiting cause substantial problems in postoperative care, thus compromising early recovery. The population of women treated for breast cancer is growing due to increased incidence and higher survival rates. Accordantly physical problems such as persistent pain, sensory disturbances, lymphedema and functional impairment are affecting an increasing number of women with longer general life expectations.
The studies on which this thesis is based were aimed at 1) optimising the early recovery after surgery for breast cancer and 2) describing the prevalence of, and factors associated with, physical problems in the late recovery phase.
1. Early recovery after surgery for breast cancer
In an attempt to improve early recovery, an evidence-based multimodal opioid-sparing regimen for preventing pain and postoperative nausea and vomiting (PONV) was introduced. Effects on pain and PONV, as well as major side effects, were recorded for 36 hours postoperatively. Additionally, the pathway of the patients through the postoperative anaesthetic care unit was monitored in order to examine why the patients were at the unit and which factors prolonged their stay.
The postoperative pathway of the patients was changed in accordance with the findings, discharging 70% of the patients directly to the ward and reducing mean hospitalisation from 3.6 days to 1.2 days.
2. Chronic sequelae after breast cancer surgery and adjuvant treatment
In order to determine the prevalence of, and factors associated with, chronic physical problems, a nationwide questionnaire study was undertaken. Patients following modern standardised treatment, according to the Danish Breast Cancer Cooperative Group protocols for 2004, were included.
According to these treatment protocols, the patients could be divided into 12 distinct treatment groups. The prevalence of persistent pain, sensory disturbances, lymphedema and functional impairment was recorded for each group, and odds ratio estimates were calculated for the factors associated with these problems. Depending on their treatment group, 25-60% of the patients reported pain, 40-85% reported sensory disturbances, 13-65% lymphedema and 11-44% functional impairment.
Research into the recovery of patients after treatment for breast cancer has become increasingly complicated, as the process of tailoring the treatment to the individual breast cancer status has increased the number of treatment modalities affecting the course of recovery and long-term physical problems. The pace at which the treatment of breast cancer is changing highlights the importance of adjusting the postoperative care continuously, as well as monitoring the long term consequences in order to identify patients at high risk of developing physical problems and find ways to reduce this risk and improve the treatment of the treatment related problems.