{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,2]],"date-time":"2026-09-02T19:56:52Z","timestamp":1788379012562,"version":"build-2803163510"},"reference-count":43,"publisher":"MDPI AG","issue":"20","license":[{"start":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T00:00:00Z","timestamp":1760140800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Israel Cancer Society and the Office of the Chief Scientist, Ministry of Health, Israel"},{"name":"Israel Cancer Society"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Cancers"],"abstract":"<jats:p>Background: Upper-extremity morbidity after breast cancer surgery\u2014including pain, lymphedema, and restricted shoulder range of motion\u2014often develops gradually, emerging months after treatment and limiting daily activities. We aimed to characterize morbidity trajectories, physical therapy utilization, and predictors of physical therapy use. Methods: A retrospective multicenter cohort included 1602 women treated with breast surgery 0\u201336 months earlier. Patient-reported outcomes included Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), pain, range of motion limitation, axillary web syndrome, and lymphedema. Clinical variables included surgery type and nodal procedure. Outcomes were summarized across four postoperative windows (0\u20136, 7\u201312, 13\u201324, 25\u201336 months). Logistic and multinomial regression identified predictors of physical therapy uptake and timing (early, \u22643 months vs. late, &gt;3 months; No physical therapy). Results: Anxiety declined across postoperative windows (p &lt; 0.001), and axillary web syndrome decreased from early to later periods (p &lt; 0.001). In contrast, range of motion restriction and decreased function remained common without significant differences between windows (p = 0.145 and p = 0.273). Pain was generally low-to-moderate by median [interquartile range], with a modest rise at 7\u201312 months (p &lt; 0.001). In adjusted multinomial models (reference: Early physical therapy \u2264 3 months), higher pain was associated with No physical therapy and Late physical therapy (both p &lt; 0.05); lymphedema with No PT and Late physical therapy (both p &lt; 0.05); and axillary web syndrome with Late physical therapy (p = 0.001). Other symptoms (range of motion, function level, anxiety and physical activity) were not independently associated with physical therapy timing. Conclusions: Long-term postoperative morbidity is common. Early assessment and structured follow-up can mitigate its impact and should be embedded as core elements of survivorship health-promotion policy.<\/jats:p>","DOI":"10.3390\/cancers17203296","type":"journal-article","created":{"date-parts":[[2025,10,14]],"date-time":"2025-10-14T07:51:28Z","timestamp":1760428288000},"page":"3296","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Physical Therapy Utilization and Morbidity Outcomes After Breast Cancer Surgery: A Longitudinal Analysis of Three Combined Cohorts"],"prefix":"10.3390","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0650-4798","authenticated-orcid":false,"given":"Ifat","family":"Klein","sequence":"first","affiliation":[{"name":"Physical Therapy Department, Assuta Medical Centers, Tel Aviv 6971028, Israel"},{"name":"Department of Epidemiology, Biostatistics and Community Health, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1000-1819","authenticated-orcid":false,"given":"Danit R.","family":"Shahar","sequence":"additional","affiliation":[{"name":"Department of Epidemiology, Biostatistics and Community Health, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael","family":"Friger","sequence":"additional","affiliation":[{"name":"Department of Epidemiology, Biostatistics and Community Health, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-2602-6502","authenticated-orcid":false,"given":"Irena","family":"Rosenberg","sequence":"additional","affiliation":[{"name":"Physical Therapy Department, Assuta Medical Centers, Tel Aviv 6971028, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7736-6364","authenticated-orcid":false,"given":"Daphna","family":"Barsuk","sequence":"additional","affiliation":[{"name":"Breast Surgery Department, Assuta Medical Centers, Tel Aviv 6971028, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4928-3529","authenticated-orcid":false,"given":"Merav A.","family":"Ben-David","sequence":"additional","affiliation":[{"name":"Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer sheva 8410501, Israel"},{"name":"Oncology Department, Assuta Medical Centers, Tel Aviv 6971028, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3069-8334","authenticated-orcid":false,"given":"Sergio","family":"Susmallian","sequence":"additional","affiliation":[{"name":"Surgery Department, Assuta Medical Centers, Tel Aviv 6971028, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,10,11]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"851","DOI":"10.1080\/0284186X.2020.1745269","article-title":"Long-term follow-up on shoulder and arm morbidity in patients treated for early breast cancer","volume":"59","author":"Hauerslev","year":"2020","journal-title":"Acta Oncol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1416","DOI":"10.1007\/s11764-022-01165-4","article-title":"Long-term trajectory of postoperative health-related quality of life in young breast cancer patients: A 15-year follow-up study","volume":"17","author":"Tran","year":"2023","journal-title":"J. Cancer Surviv."},{"key":"ref_3","first-page":"641","article-title":"Is it really over when it is over? physical, mental and emotional health status of long-term breast cancer survivors compared to healthy matched controls","volume":"32","year":"2024","journal-title":"Support. Care Cancer"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"108591","DOI":"10.1016\/j.ejso.2024.108591","article-title":"\u2018I presumed the pain would eventually get better by itself\u2019; challenges with access to rehabilitation for upper limb dysfunction after breast cancer treatment\u2014Descriptive and qualitative findings from a cross-sectional survey","volume":"50","author":"Johnson","year":"2024","journal-title":"Eur. J. Surg. Oncol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"572","DOI":"10.1097\/SLA.0000000000005671","article-title":"Impact of Axillary Lymph Node Dissection and Sentinel Lymph Node Biopsy on Upper Limb Morbidity in Breast Cancer Patients: A Systematic Review and Meta-Analysis","volume":"277","author":"Kwasnicki","year":"2023","journal-title":"Ann. Surg."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"271","DOI":"10.1007\/s12282-022-01420-7","article-title":"Predictors of persistent post-surgical pain intensity and interference at 1 year after breast cancer surgery: Assessing central sensitization, central sensitivity symptoms, and psychological factors","volume":"30","author":"Manfuku","year":"2023","journal-title":"Breast Cancer"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"143","DOI":"10.1097\/01.REO.0000000000000224","article-title":"Shoulder Dysfunction in Breast Cancer Survivors: Can Treatment Type or Musculoskeletal Factors Identify Those at Higher Risk?","volume":"39","author":"Lang","year":"2021","journal-title":"Rehabil. Oncol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"8068","DOI":"10.3390\/curroncol30090585","article-title":"Upper-Limb Disability and the Severity of Lymphedema Reduce the Quality of Life of Patients with Breast Cancer-Related Lymphedema","volume":"30","author":"Pinto","year":"2023","journal-title":"Curr. Oncol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1007\/s12609-023-00471-9","article-title":"Breast Cancer\u2013Related Lymphedema: The Prospective Surveillance Model, Early Intervention Strategies, and Role of Complete Decongestive Therapy","volume":"15","author":"Brunelle","year":"2023","journal-title":"Curr. Breast Cancer Rep."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"403","DOI":"10.1016\/j.apmr.2022.09.014","article-title":"Shoulder Kinematics of Axillary Web Syndrome in Women Treated for Breast Cancer","volume":"104","author":"Braudy","year":"2023","journal-title":"Arch. Phys. Med. Rehabil."},{"key":"ref_11","first-page":"257","article-title":"Effectiveness of physical therapy in axillary web syndrome after breast cancer: A systematic review and meta-analysis","volume":"31","year":"2023","journal-title":"Support. Care Cancer"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1876","DOI":"10.1177\/0269215519873026","article-title":"Effectiveness of early rehabilitation on range of motion, muscle strength and arm function after breast cancer surgery: A systematic review of randomized controlled trials","volume":"33","author":"Ribeiro","year":"2019","journal-title":"Clin. Rehabil."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Mu\u00f1oz-Fern\u00e1ndez, M.J., Medrano-S\u00e1nchez, E.M., Ostos-D\u00edaz, B., Mart\u00edn-Valero, R., Su\u00e1rez-Serrano, C., and Casuso-Holgado, M.J. (2021). Preliminary Study on the Effect of an Early Physical Therapy Intervention after Sentinel Lymph Node Biopsy: A Multicenter Non-Randomized Controlled Trial. Int. J. Environ. Res. Public Health, 18.","DOI":"10.3390\/ijerph18031275"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"347","DOI":"10.2147\/JMDH.S117362","article-title":"Optimizing post-acute care in breast cancer survivors: A rehabilitation perspective","volume":"10","author":"Amatya","year":"2017","journal-title":"J. Multidiscip. Healthc."},{"key":"ref_15","first-page":"pzab314","article-title":"Manual Lymph Drainage with Progressive Arm Exercises for Axillary Web Syndrome After Breast Cancer Surgery: A Randomized Controlled Trial","volume":"102","author":"Ferrandez","year":"2022","journal-title":"PTJ Phys. Ther. Rehabil. J."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1798","DOI":"10.1016\/j.apmr.2022.03.007","article-title":"Five-Year Cumulative Incidence of Axillary Web Syndrome and Comparison in Upper Extremity Movement, Function, Pain, and Lymphedema in Survivors of Breast Cancer with and Without Axillary Web Syndrome","volume":"103","author":"Koehler","year":"2022","journal-title":"Arch. Phys. Med. Rehabil."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"oyaf060","DOI":"10.1093\/oncolo\/oyaf060","article-title":"Ben David Advancing Breast Cancer Rehabilitation: A Novel Tool for Assessing Physical Morbidity Risk","volume":"30","author":"Klein","year":"2025","journal-title":"Oncologist"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"360","DOI":"10.1016\/j.jht.2014.08.011","article-title":"Minimal Clinical Important Difference of the Quick Disabilities of the Arm Shoulder and Hand (Quickdash) for Post-surgical Distal Radius Fractures","volume":"29","author":"Howell","year":"2016","journal-title":"J. Hand Ther."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"132","DOI":"10.1097\/AJP.0000000000000999","article-title":"A systematic review and synthesis of psychometric properties of the numeric pain rating scale and the visual analog scale for use in people with neck pain","volume":"38","author":"Modarresi","year":"2022","journal-title":"Clin. J. Pain"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"30","DOI":"10.2519\/jospt.2014.4893","article-title":"Minimal Clinically Important Difference of the Disabilities of the Arm, Shoulder and Hand Outcome Measure (DASH) and Its Shortened Version (QuickDASH)","volume":"44","author":"Franchignoni","year":"2014","journal-title":"J. Orthop. Sports Phys. Ther."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Salas, M., Mordin, M., Castro, C., Islam, Z., Tu, N., and Hackshaw, M.D. (2022). Health-related quality of life in women with breast cancer: A review of measures. BMC Cancer, 22.","DOI":"10.1186\/s12885-021-09157-w"},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Amireault, S., Godin, G., Lacombe, J., and Sabiston, C.M. (2015). The use of the Godin-Shephard Leisure-Time Physical Activity Questionnaire in oncology research: A systematic review. BMC Med. Res. Methodol., 15.","DOI":"10.1186\/s12874-015-0045-7"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"90","DOI":"10.1016\/j.jphys.2024.02.020","article-title":"Physiotherapy management of breast cancer treatment-related sequelae","volume":"70","author":"Devoogdt","year":"2024","journal-title":"J. Physiother."},{"key":"ref_24","first-page":"593","article-title":"Effects of resistance training on quality of life, fatigue, physical function, and muscular strength during chemotherapy treatment: A systematic review and meta-analysis","volume":"32","author":"Metcalfe","year":"2024","journal-title":"Support. Care Cancer"},{"key":"ref_25","first-page":"pzab287","article-title":"Physical Therapists in Oncology Settings: Experiences in Delivering Cancer Rehabilitation Services, Barriers to Care, and Service Development Needs","volume":"102","author":"Brennan","year":"2022","journal-title":"PTJ Phys. Ther. Rehabil. J."},{"key":"ref_26","first-page":"46","article-title":"Physical therapy after breast cancer surgery improves range of motion and pain over time","volume":"29","author":"Rett","year":"2022","journal-title":"Fisioter. Pesqui."},{"key":"ref_27","unstructured":"Nareeba, D., Ainembabazi, B., Asiimwe, D., Atuhaire, G., Ochom, K.P., Whitehouse, Z., Arubaku, W., Nuwahereza, A., Kazibwe, H., and Niyonsenga, J.D. (2025, October 08). Barriers and Facilitators to the Referral of Patients with Cancer for Physiotherapy Rehabilitation at Uganda Cancer Institute (UCI). Research Square. Available online: https:\/\/www.researchsquare.com\/article\/rs-2413367\/v1."},{"key":"ref_28","first-page":"3593","article-title":"Physical activity level, exercise behavior, barriers, and preferences of patients with breast cancer\u2013related lymphedema","volume":"29","author":"Gursen","year":"2021","journal-title":"Support. Care Cancer"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"e972","DOI":"10.1200\/OP.20.00625","article-title":"Exercise Barriers and Adherence to Recommendations in Patients with Cancer","volume":"17","author":"Ng","year":"2021","journal-title":"JCO Oncol. Pract."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1176","DOI":"10.1080\/09638288.2020.1800835","article-title":"The association between upper limb function and variables at the different domains of the international classification of functioning, disability and health in women after breast cancer surgery: A systematic review","volume":"44","author":"Dams","year":"2022","journal-title":"Disabil. Rehabil."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"121","DOI":"10.1016\/j.suc.2022.08.007","article-title":"Postoperative Complications from Breast and Axillary Surgery","volume":"103","author":"Thalji","year":"2023","journal-title":"Surg. Clin. N. Am."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"107918","DOI":"10.1016\/j.maturitas.2024.107918","article-title":"Effect of comorbidity and multimorbidity on adherence to follow-up recommendations among long-term breast cancer survivors","volume":"182","author":"Domingo","year":"2024","journal-title":"Maturitas"},{"key":"ref_33","first-page":"11","article-title":"Sociodemographic and clinical characteristics associated with rehabilitation services utilization in older women with early-stage breast cancer from SEER-Medicare 2009\u20132018","volume":"18","author":"Gorzelitz","year":"2024","journal-title":"J. Cancer Surviv."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1007\/s10549-023-06947-7","article-title":"Advances in the prevention and treatment of breast cancer-related lymphedema","volume":"200","author":"Donahue","year":"2023","journal-title":"Breast Cancer Res. Treat."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"154","DOI":"10.1097\/PHM.0000000000001017","article-title":"Integrated Rehabilitation for Breast Cancer Survivors","volume":"98","author":"Cheville","year":"2019","journal-title":"Am. J. Phys. Med. Rehabil."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"406","DOI":"10.1080\/03630242.2018.1478362","article-title":"A call to action: The need for improved service coordination during early survivorship for women with breast cancer and partners","volume":"59","author":"Keesing","year":"2019","journal-title":"Women Health"},{"key":"ref_37","doi-asserted-by":"crossref","unstructured":"Lin, Y., and Pan, P. (2012). The use of rehabilitation among patients with breast cancer: A retrospective longitudinal cohort study. BMC Health Serv. Res., 12.","DOI":"10.1186\/1472-6963-12-282"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"2217","DOI":"10.1002\/cncr.27474","article-title":"Prevalence of breast cancer treatment sequelae over 6 years of follow-up","volume":"118","author":"Schmitz","year":"2012","journal-title":"Cancer"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"2201","DOI":"10.1002\/cncr.27472","article-title":"Integrating a prospective surveillance model for rehabilitation into breast cancer survivorship care","volume":"118","author":"Gerber","year":"2012","journal-title":"Cancer"},{"key":"ref_40","first-page":"1081","article-title":"Implementing a prospective surveillance and early intervention model of care for breast cancer\u2013related lymphedema into clinical practice: Application of the RE-AIM framework","volume":"29","author":"Koelmeyer","year":"2021","journal-title":"Support. Care Cancer"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"509","DOI":"10.1007\/s11764-022-01304-x","article-title":"Implementing and sustaining a breast cancer prospective surveillance rehabilitation program: An institutional perspective","volume":"17","author":"Stout","year":"2023","journal-title":"J. Cancer Surviv."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1007\/s12609-020-00397-6","article-title":"Model-Based Patterns of Lymphedema Symptomatology: Phenotypic and Biomarker Characterization","volume":"13","author":"Fu","year":"2021","journal-title":"Curr. Breast Cancer Rep."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1237","DOI":"10.1002\/pmrj.12543","article-title":"The Feasibility of Prehabilitation as Part of the Breast Cancer Treatment Pathway","volume":"13","author":"Wu","year":"2021","journal-title":"PM&R"}],"container-title":["Cancers"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6694\/17\/20\/3296\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,14]],"date-time":"2025-10-14T08:02:19Z","timestamp":1760428939000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6694\/17\/20\/3296"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,10,11]]},"references-count":43,"journal-issue":{"issue":"20","published-online":{"date-parts":[[2025,10]]}},"alternative-id":["cancers17203296"],"URL":"https:\/\/doi.org\/10.3390\/cancers17203296","relation":{},"ISSN":["2072-6694"],"issn-type":[{"value":"2072-6694","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,10,11]]}}}