Restricted accessResearch articleFirst published online 2026-4
The Effects of a Nurse-Led Case Management Model on Upper Limb Function and Limb Complications Among Postoperative Breast Cancer Survivors: A Quasi-Experimental Study
Case management models (CMM) have proven effective in improving cancer patients’ transition from hospitals back into the community. However, whether a CMM has long-term effects in improving cancer patients’ health requires further investigation. Therefore, this study aimed to evaluate the short-term and long-term effects of a nurse-led CMM on upper limb function and the incidence of affected limb complications among postoperative breast cancer patients.
Methods and Results:
A non-concurrent, quasi-experimental design was used to compare upper limb function and the incidence of affected limb complications between two groups: a care as usual group (CAU; control group) and a CMM group (intervention group). This study was conducted in the largest department for breast cancer in south China, where women newly diagnosed with breast cancer (N = 157) were assigned to either the CMM group (n = 77, recruited from June to July 2017) or the CAU group (n = 80, recruited from June to July 2016). Data on limb function—including objective shoulder range of motion (ROM), muscle strength, and the subjective Functional Evaluation Scale of the Ipsilateral Shoulder and Arm Function (FESISA)—were collected at baseline (upon admission), and at 3, 6, and 12 months after surgery. Additionally, the incidence of limb pain, paresthesia, and lymphedema was measured at 3, 6, and 12 months postoperatively. The results showed that affected limb function decreased for more than one year, and the incidence of upper limb complications in both groups declined over time, except for lymphedema in the CAU group. Furthermore, patients in the CMM group demonstrated significantly better limb function and a lower incidence of limb complications compared to those in the CAU group.
Conclusion:
The nurse-led CMM is a feasible and effective approach to improve the short-term and long-term quality of care and patient outcomes among patients with breast cancer.
FanL, Strasser-WeipplK, LiJ-J, et al.Breast cancer in China. Lancet Oncol, 2014; 15(7):e279–e289; doi: 10.1016/S1470-2045(13)70567-9
2.
ChenW, SunK, ZhengR, et al.Cancer incidence and mortality in China, 2014. Chin J Cancer Res, 2018; 30(1):1–12; doi: 10.21147/j.issn.1000-9604.2018.01.01
3.
BrayF, FerlayJ, SoerjomataramI, et al.Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin, 2018; 68(6):394–424; doi: 10.3322/caac.21492
GalantinoML, StoutNL. Exercise interventions for upper limb dysfunction due to breast cancer treatment. Phys Ther, 2013; 93(10):1291–1297; doi: 10.2522/ptj.20120049
6.
MerchantCR, ChapmanT, KilbreathSL, et al.Decreased muscle strength following management of breast cancer. Disabil Rehabil, 2008; 30(15):1098–1105; doi:10.1080/09638280701478512
7.
DasIJ, ChevilleAL, ScheuermannJ, et al.Use of lymphoscintigraphy in radiation treatment of primary breast cancer in the context of lymphedema risk reduction. Radiother Oncol, 2011; 100(2):293–298; doi: 10.1016/j.radonc.2010.09.016
8.
KibarS, DalyanAM, UnsalDS. The risk factors and prevalence of upper extremity impairments and an analysis of effects of lymphoedema and other impairments on the quality of life of breast cancer patients. Eur J Cancer Care (Engl), 2017; 26(4); doi: 10.1111/ecc.12433
9.
KuehnT, KlaussW, DarsowM, et al.Long-term morbidity following axillary dissection in breast cancer patients--clinical assessment, significance for life quality and the impact of demographic, oncologic and therapeutic factors. Breast Cancer Res Treat, 2000; 64(3):275–286; doi: 10.1023/a:1026564723698
10.
NesvoldIL, DahlAA, LøkkevikE, et al.Arm and shoulder morbidity in breast cancer patients after breast-conserving therapy versus mastectomy. Acta Oncol, 2008; 47(5):835–842; doi: 10.1080/02841860801961257
11.
BosompraK, AshikagaT, O’BrienPJ, et al.Swelling, numbness, pain, and their relationship to arm function among breast cancer survivors: A disablement process model perspective. Breast J, 2002; 8(6):338–348; doi: 10.1046/j.1524-4741.2002.08603.x
12.
IsakssonG, FeukB. Morbidity from axillary treatment in breast cancer--a follow-up study in a district hospital. Acta Oncol, 2000; 39(3):335–336; doi: 10.1080/028418600750013104
13.
DylkeES, KilbreathS. Current rehabilitation processes do not prevent long-term impairments after treatment for breast cancer in Australia. Aust Fam Physician, 2015; 44(6):405–409.
14.
LeeCH, ChungSY, KimWY, et al.Effect of breast cancer surgery on chest tightness and upper limb dysfunction. Medicine (Baltimore), 2019; 98(19):e15524; doi: 10.1097/MD.0000000000015524
15.
Neil-SztramkoSE, KirkhamAA, HungSH, et al.Aerobic capacity and upper limb strength are reduced in women diagnosed with breast cancer: A systematic review. J Physiother, 2014; 60(4):189–200; doi: 10.1016/j.jphys.2014.09.005
16.
BrookhamRL, CudlipAC, DickersonCR. Examining upper limb kinematics and dysfunction of breast cancer survivors in functional dynamic tasks. Clin Biomech (Bristol), 2018; 55:86–93; doi: 10.1016/j.clinbiomech.2018.04.010
17.
LevenhagenK, DaviesC, PerdomoM, et al.Diagnosis of upper-quadrant lymphedema secondary to cancer: Clinical practice guideline from the oncology section of APTA. Rehabil Oncol, 2017; 35(3):E1–E18; doi: 10.1097/01.REO.0000000000000073
18.
SagenA, KaaresenR, SandvikL, et al.Upper limb physical function and adverse effects after breast cancer surgery: A prospective 2.5-year follow-up study and preoperative measures. Arch Phys Med Rehabil, 2014; 95(5):875–881; doi: 10.1016/j.apmr.2013.12.015
19.
DiSipioT, RyeS, NewmanB, et al.Incidence of unilateral arm lymphoedema after breast cancer: A systematic review and meta-analysis. Lancet Oncol, 2013; 14(6):500–515; doi: 10.1016/S1470-2045(13)70076-7
20.
ShahC, ViciniFA. Breast cancer-related arm lymphedema: Incidence rates, diagnostic techniques, optimal management and risk reduction strategies. Int J Radiat Oncol Biol Phys, 2011; 81(4):907–914; doi: 10.1016/j.ijrobp.2011.05.043
21.
BelmonteR, Messaggi-SartorM, FerrerM, et al.Prospective study of shoulder strength, shoulder range of motion, and lymphedema in breast cancer patients from pre-surgery to 5 years after ALND or SLNB. Support Care Cancer, 2018; 26(9):3277–3287; doi: 10.1007/s00520-018-4186-1
22.
DistelhorstSR, ClearyJF, GanzPA, et al.; Breast Health Global Initiative Global Summit on Supportive Care and Quality of Life Consensus Panel Members. Optimisation of the continuum of supportive and palliative care for patients with breast cancer in low-income and middle-income countries: Executive summary of the Breast Health Global Initiative, 2014. Lancet Oncol, 2015; 16(3):e137–e147; doi: 10.1016/S1470-2045(14)70457-7
23.
CardosoF, KyriakidesS, OhnoS, et al.; ESMO Guidelines Committee. Early breast cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol, 2019; 30(10):1674; doi: 10.1093/annonc/mdz189
Case Management Society of America. CMSA. 2019. Available from: https://www.cmsa.org/ [Last accessed: December18, 2019].
26.
ChowSK, WongFK. Health-related quality of life in patients undergoing peritoneal dialysis: Effects of a nurse-led case management programme. J Adv Nurs, 2010; 66(8):1780–1792; doi: 10.1111/j.1365-2648.2010.05324.x
27.
MullenBA, KelleyPA. Diabetes nurse case management: An effective tool. J Am Acad Nurse Pract, 2006; 18(1):22–30; doi: 10.1111/j.1745-7599.2006.00095.x
28.
RappCA, GoschaRJ. The Strengths Model: Case Management with People with Psychiatric Disabilities. 2nd ed. Oxford University Press: New York; 2006.
29.
MacNeil VroomenJ, BosmansJE, van de VenPM, et al.Community-dwelling patients with dementia and their informal caregivers with and without case management: 2-year outcomes of a pragmatic trial. J Am Med Dir Assoc, 2015; 16(9):800.e1–800.e8; doi: 10.1016/j.jamda.2015.06.011
30.
KwokT, LamL, ChungJ. Case management to improve quality of life of older people with early dementia and to reduce caregiver burden. Hong Kong Med J., 2012; 18(Suppl 6):4–6.
31.
DicksonNR, BilbreyLE, LesikarPE, et al.Use of a case management system to reduce the response time for symptom management calls in a high-volume practice. J Oncol Pract, 2016; 12(10):851–854; doi: 10.1200/JOP.2016.013698
32.
ChenYC, ChangYJ, TsouYC, et al.Effectiveness of nurse case management compared with usual care in cancer patients at a single medical center in Taiwan: A quasi-experimental study. BMC Health Serv Res, 2013; 13:202; doi: 10.1186/1472-6963-13-202
33.
HarrisRC, PopejoyLL. Case management: An evolving role. West J Nurs Res, 2019; 41(1):3–5; doi: 10.1177/0193945918797601
34.
BleichC, BüscherC, MelchiorH, et al.Effectiveness of case management as a cross-sectoral healthcare provision for women with breast cancer. Psychooncology, 2017; 26(3):354–360; doi: 10.1002/pon.4139
35.
ClarkCR, BarilN, HallA, et al.Case management intervention in cervical cancer prevention: The Boston REACH coalition women’s health demonstration project. Prog Community Health Partnersh, 2011; 5(3):235–247; doi: 10.1353/cpr.2011.0034
36.
LillquistPP. Implementing case management in New York State’s partnerships for publicly funded breast cancer screening. Prev Chronic Dis, 2008; 5(2):A45.
37.
ScherzN, Bachmann-MettlerI, ChmielC, et al.Case management to increase quality of life after cancer treatment: A randomized controlled trial. BMC Cancer, 2017; 17(1):223; doi: 10.1186/s12885-017-3213-9
38.
ChiangT, WangC, LinY, et al.Colorectal cancer in Taiwan: A case-control retrospective analysis of the impact of a case management programme on refusal and discontinuation of treatment. J Adv Nurs, 2018; 74(2):395–406; doi: 10.1111/jan.13443
39.
MiddendorffG, ElseyR, LounsberyB, et al.Impact of a specialty pharmacy case management service on adherence in patients receiving oral antineoplastic agents. J Oncol Pharm Pract, 2018; 24(5):371–378; doi: 10.1177/1078155217708022
40.
Jennings-SandersA, KuoYF, AndersonET, et al.How do nurse case managers care for older women with breast cancer? Oncol Nurs Forum, 2005; 32(3):625–632; doi: 10.1188/05.ONF.625-632
41.
GoodwinJS, SatishS, AndersonET, et al.Effect of nurse case management on the treatment of older women with breast cancer. J Am Geriatr Soc, 2003; 51(9):1252–1259; doi: 10.1046/j.1532-5415.2003.51409.x
42.
XingWJ, HuangJL, LuZQ, et al.Effects of nurse-led case management on limb function and disease uncertainty in breast cancer patients. Chin J Pract Nurs, 2012; 31(28):83–86.
MartinEG, LovettRW. A method of testing muscular strength in infantile paralysis. JAMA, 1915; 65:1512–1513; doi:10.1001/jama.1915.02580180016006
45.
NaYM, LeeJS, ParkJS, et al.Early rehabilitation program in postmastectomy patients: A prospective clinical trial. Yonsei Med J, 1999; 40(1):1–8; doi: 10.3349/ymj.1999.40.1.1
46.
WingateL. Efficacy of physical therapy for patients who have undergone mastectomies. A prospective study. Phys Ther, 1985; 65(6):896–900; doi: 10.1093/ptj/65.6.896
47.
ZhangXJ. The Effect of Progressive Rehabilitation Nursing on the Improvement of Upper Limb Function and Quality of Life after Modified Radical Mastectomy for Breast Cancer [dissertation].Fudan University: Shanghai; 2007.
48.
International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: 2016 consensus document of the international society of lymphology. Lymphology, 2016; 49(4):170–184.
49.
AssisMR, MarxAG, MagnaLA, et al.Late morbidity in upper limb function and quality of life in women after breast cancer surgery. Braz J Phys Ther, 2013; 17(3):236–243; doi: 10.1590/s1413-35552012005000088
50.
ChenMC, ChenWY, TsuiWY, et al.Effects of an interdisciplinary care program on improving the return-to-treatment rate among cancer patients. Hu Li Za Zhi, 2018; 65(2):75–84; doi: 10.6224/JN.201804_65(2).10
