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 Table of Contents  
Year : 2019  |  Volume : 2  |  Issue : 1  |  Page : 22-29

Postbreast cancer surgery outpatient rehabilitation program: Analysis of clinical profile, impact, and direct medical costs

1 Health Administrator, Instituto do Câncer do Estado de São Paulo – HCFMUSP; Professional Master's Program, Instituto Sírio-Libanês de Ensino e Pesquisa, São Paulo, Brazil
2 Physiotherapist, São Paulo, Brazil
3 Center for Translational Research in Oncology, Instituto do Câncer do Estado de São Paulo - HCHMUSP, São Paulo, Brazil
4 Rehabilitation Service, Instituto do Câncer do Estado de São Paulo – HCFMUSP, São Paulo, Brazil; Instituto Sírio-Libanês de Ensino e Pesquisa, São Paulo, Brazil

Date of Web Publication22-May-2019

Correspondence Address:
Prof. Marina Boralli de Sousa
Health Administration – Planning and Management Center, Instituto do Câncer do Estado de São Paulo - HCHMUSP, São Paulo
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jisprm.jisprm_17_18

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Context: Approximately 600,000 new cases of cancer are estimated to occur in Brazil over the 2-year period of 2018–2019, and the world economic impact of cancer was $895 billion dollars in 2008. Aims: To perform an analysis contemplating the clinical profile, impact, and direct medical costs of an outpatient rehabilitation program for patients who have undergone breast cancer surgery. Settings and Design: A partial economic analysis was performed from the perspective of a Brazilian public hospital. Subjects and Methods: An observational study was conducted using data from a retrospective cohort of patients who had undergone breast cancer surgery. These patients had their first rehabilitation appointment between August 2015 and July 2016. Statistical Analysis Used: Pearson's Chi-square test or Fisher's exact test, Student's t-test, Fisher's F-test analysis of variance, or the nonparametric Kruskal–Wallis test. Post hoc tests were conducted to check for differences between the pairs of categories. The nonparametric Kolmogorov–Smirnov test evaluated the data normality. All hypothesis testing used a significance level of 5%. Results: A total of 132 patients underwent the referred rehabilitation program. The goal of total rehabilitation was achieved in approximately 70% of cases. There was improvement in patients' quality of life in most Short-Form Health Survey-36 dimensions. The program's direct cost had an overall median per patient of R$ 7235.32. Conclusions: The study found good results in the indicators of clinical outcome and quality of life. The costs were reported from a partial evaluation point of view and may contribute to future full evaluations.

Keywords: Breast neoplasms, hospital costs, rehabilitation result

How to cite this article:
de Sousa MB, Bueno Cd, Mendoza Lopez RV, de Almeida EP, Cecatto RB, de Brito CM. Postbreast cancer surgery outpatient rehabilitation program: Analysis of clinical profile, impact, and direct medical costs. J Int Soc Phys Rehabil Med 2019;2:22-9

How to cite this URL:
de Sousa MB, Bueno Cd, Mendoza Lopez RV, de Almeida EP, Cecatto RB, de Brito CM. Postbreast cancer surgery outpatient rehabilitation program: Analysis of clinical profile, impact, and direct medical costs. J Int Soc Phys Rehabil Med [serial online] 2019 [cited 2022 Aug 12];2:22-9. Available from: https://www.jisprm.org/text.asp?2019/2/1/22/254005

  Introduction Top

Numerous Factors Influence Health Systems and Services, Including an Aging Population, an Increased Burden Due to Chronic Diseases, and Greater Reliance on Technologies, Which Require More Financial Resources and Undermine Health Budgets.[1] from the Management Perspective, Oncology Is an Area That Incurs Considerable Health-Care Expenses Because Cancer Control Depends on a Set of Actions in Various Areas, Requiring the Use of High-Cost Procedures, Medicines, and Equipment.[2]

Approximately 600,000 new cases of cancer are estimated to occur in Brazil over the 2-year period of 2018–2019.[3] If nonmelanoma skin cancer is excluded, approximately 420,000 new cancer cases will occur, and for women, breast cancer (60,000) will be the most frequent.

According to the American Cancer Society Journal,[4] in 2008, the worldwide economic impact of cancer, considering premature deaths and disabilities, was $895 billion dollars. The three main types of cancer that caused this global economic impact were lung cancer ($188 billion), colon and rectum cancer ($99 billion), and breast cancer ($88 billion). This report also declared cancer as the cause of the greatest economic loss among the 15 leading causes of death in the world. Cancer is 20% higher than the second most common cause, which is heart disease.

Breast cancer treatment is performed through surgical procedures and therapies, including radiation therapy, chemotherapy, and hormone therapy. Regardless of radical or conservative techniques, axillary dissection has been a procedure used for breast cancer. When performed in isolation or in conjunction with radiotherapy, this procedure may cause severe morbidity in the upper limb homolateral to the surgery.[5]

After undergoing breast cancer surgery, women should have access to a rehabilitation program because studies show the high prevalence of complications. For example, up to 67% of patients will have shoulder joint restriction following treatment. Of these, 68% will have pain both in the shoulder and upper limb, and up to 34% of women will develop lymphedema.[6] Postmastectomy pain syndrome is a prevalent disorder that negatively impacts breast cancer survivors' functioning and quality of life. There are many potential treatments for this syndrome, including rehabilitation, medications, injections, and other nonpharmacologic treatments.[7] Exercise promotes significant improvements in clinical, functional, and, in some populations, survival outcomes, and can be recommended regardless of the cancer type.[8]

While the reported rates of cancer-related disability and physical disability are currently high and should increase, the rates of treatment, even for readily remediable physical deficiencies, remain as low as 1%–2%. There remains a limited clinical workforce possessing cancer rehabilitation training, and the existing access barriers must be addressed.[9],[10]

The present study aimed to perform a partial economic analysis contemplating the clinical profile, impact, and direct medical costs of an outpatient rehabilitation program for patients who had undergone breast cancer surgery at a high-complexity, university-based oncology center at a public hospital located in the state of São Paulo, Brazil.

  Subjects and Methods Top

A partial economic analysis was conducted from the perspective of a hospital health-care provider to the National Health System (Sistema Único de Saúde), particularly from the perspective of a high-complexity oncology care center. This type of center is equipped to provide comprehensive care to the oncological patient, including prompt care for oncological complications, outpatient services, day-hospital, chemotherapy, and radiotherapy, as well as hospitalization units, intensive care unit, surgical center, and oncological rehabilitation center. The rehabilitation program addressed in this study is prescribed through medical referral from the institution's specialties – mainly clinical oncology, mastology, plastic surgery, and physiatry – due to complications detected in the follow-up medical appointments that require rehabilitation. In general, patients who remain limited during the follow-up, despite the initial interventions and guidelines, are referred.

An observational study was conducted using data from a retrospective cohort of patients who had undergone breast cancer surgery at a high-complexity oncology care center. These patients had their first rehabilitation appointment between August 2015 and July 2016, just before admission to the outpatient rehabilitation program. This study followed the essential guidelines for observational studies in epidemiology (STROBE-https://www.strobe-statement.org).[11] The proponent and copartner ethical committees approved the study.

Among the partial economic analysis, the cost-consequence studies are the most significant. These studies make an inventory of all costs incurred with an intervention, and all the results, whether positive or negative, are presented separately.[12] The examined intervention was the outpatient rehabilitation program offered to patients who had undergone oncology breast surgery at the oncology center.

In this outpatient rehabilitation intervention, the following components stand out: educational group activities and outpatient rehabilitation therapies, according to the patients' needs, including physiotherapy, occupational therapy, psychotherapy, and physical conditioning, either supervised by a physical educator or a physical therapist.

The rehabilitation program starts with a medical evaluation by the physiatrist who clinically evaluates and identifies rehabilitation needs and sets goals to be met in the rehabilitation program. The patient is then directed to an educational group who gives information about the rehabilitation treatment. At the first rehabilitation session, the patient completes a quality-of-life questionnaire[13] distributed by the therapist in charge. The medical outcomes Short-Form Health Survey (SF-36) is a generic quality-of-life instrument developed in the English language, and it is easy to understand and administer. The survey contains 36 items that are scored as the following eight multi-item scales: physical functioning, role-physical, pain, general health perception, vitality, social functioning, role-emotional, and mental health. A Portuguese version was developed and cross-culturally adapted, and its measurement properties of reliability and validity were evaluated in Brazilian patients.[14] This survey is registered on the electronic health record, and the score for each dimension (0–100) is automatically calculated. Furthermore, clinical outcomes were analyzed regarding rehabilitation goal attainment at the end of the rehabilitation program, and the results were in the following percentile ranges: total attainment (75%–100%), partial attainment (25%–74%), or nonattainment (0%–24%). A total of 21 possible established goals were mapped. The study sample was selected from the Tasy® electronic health record system.

Regarding the description of program costs in this study, direct medical costs were measured by sampling patients. The technique for collecting cost data was that of micro costing with the use of resources per individual (medical appointments, group guidance, and multiprofessional interventions), according to the information on the electronic health record; thus, they were primary data [Figure 1].
Figure 1: Composition of the unit cost of multiprofessional outpatient rehabilitation sessions

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The costs were established in Brazilian reais. The costs were collected from August 2015 to July 2016 from the tables containing the institution's hospital costs. The studied oncology center uses the method of absorption costing to calculate costs. The absorption costing system entails not only full costs (direct, indirect, overhead, and variable), but also final products/services. The direct costs are directly related to the procedures performed, whereas indirect costs are prorated according to the institution's needs.

The unit costs were multiplied by the number of sessions per patient, and the cost of materials for lymphedema was allocated to patients who had undergone the specific protocol [Table 1] and [Table 2].
Table 1: Human resources component cost by type of therapy

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Table 2: Cost per patient with lymphedema treatment materials - 8-week protocol

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The oncology center's infrastructure component covers the direct costs associated to the operation of the area (hygiene and cleaning, laundry, and central sterile supply department), indirect costs (all the logistics, storage, building structure such as elevators, air conditioning, maintenance services, and building engineering), and administrative costs (finance, costs, equity, human resources, health information management, training center, receptions, dining areas, and hospital systems). This is all done through the apportionment allocated to outpatient rehabilitation, a 190 m2 area located on the ground floor of the vertical hospital. Therefore, in view of cost under the optics of hospital service, it is important to prevent the generalization or extrapolation of these results for other scenarios and locations.

Statistical analysis

The statistical analyses were performed using the statistical software IBM SPSS® for Windows version 18 (SPSS Inc., Chicago, Illinois, USA). The association between two qualitative variables was performed by Pearson's Chi-square test or Fisher's exact test, according to the expected results. The Student's t-test was used for comparing the variable “followed the rehabilitation program.”

The comparison between groups of objectives achieved and the quantitative variables was tested by Fisher's F-test analysis of variance or by the nonparametric Kruskal–Wallis test, according to the assumption of data normality. Post hoc tests were conducted to check for differences between the pairs of categories for the variable “objectives achieved.” The nonparametric Kolmogorov–Smirnov test evaluated the data normality.

All hypothesis testing used a significance level of 5%.

  Results Top

The physiatry specialty received 1197 new outpatients in 1 year (between August 2015 and July 2016), with 461 (38.5%) female breast cancer patients. For this study, undertaking surgery for breast cancer at the institution prior to the physiatry appointment was a premise for inclusion [Figure 2].
Figure 2: Flow diagram

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The program's median duration for the group was 138 days, approximately 20 weeks, and previous clinical oncological treatments were found in 85% of the cases [Table 3]. Regarding the main complaints presented by patients at the first consultation with physiatry, the highest frequencies were for “limitation + lymphedema,” “pain + limitation + lymphedema,” “lymphedema,” and “lymphedema + pain.” The rehabilitation programs that have been prescribed are marked by the combination of therapies [Table 4] and [Table 5].
Table 3: Characteristics presented by the patients studied (n=132)

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Table 4: Results of the first medical care in physiatrics: Clinical findings and rehabilitation program prescribed (n=132 patients)

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Table 5: Description of the 21 goals that can be defined for the rehabilitation program and number of patients who had the indication

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The goal of total rehabilitation was achieved in approximately 70% of cases, with an average of six goals set per patient [Table 6], according to their clinical rehabilitation needs and the use of the international classification of the functioning biopsychosocial model. Regarding the presentation of resource use, there were averages ranging from 26.5 to 37.6 sessions per patient considering the established goals and their achievement. In the paired analyses by type of care, there was a statistically higher number of medical appointments, physiotherapy, and physical conditioning sessions, with a physiotherapist in the group that totally achieved the objectives.
Table 6: Results of the clinical indicator of the program according to the group of achievement of the indicated goals (n=131)*

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The patients reported improved quality of life in the different dimensions of the SF-36 questionnaire [Table 7], particularly regarding functional capacity; physical aspects; pain; general condition; and social, emotional, and mental health aspects in the postintervention follow-up.
Table 7: Results of the dimensions of the quality-of-life questionnaire - SF36 (n=52)

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From the perspective of hospital service, the program's direct costs had the overall median per patient of R$ 7235.32 [Table 8]. This cost considers the use of resources, including physiatric medical consultations and multiprofessional interventions carried out in the outpatient rehabilitation center.
Table 8: Average cost per patient according to the group of achievement of the indicated goals and overall

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The cost of lymphedema materials was assessed separately and considered in the mean cost of the group of patients who had undergone that management. There was a difference in medians of cost per patient in accordance with the objectives not being achieved (R$ 4616.36), partially achieved (R$ 6711.53), or totally achieved (R$ 8886.7); this is probably due to the program's duration and the volume of patients who followed it, as shown in [Table 6].

  Discussion Top

Patients who had undergone breast cancer surgery at the center and who had performed the outpatient rehabilitation program had their results fully achieved in 70% of the cases, and this was corroborated by the improvement in the quality-of-life dimensions for those who completed the SF-36 questionnaire before and after the intervention.

The therapy combinations highlighted the program's multidisciplinary characteristics as follows: 24% of patients who participated in the program underwent “physiotherapy, occupational therapy, physical conditioning, and psychology” and 22% of the cases received “physiotherapy, occupational therapy, and psychology.” Combined therapy requests were favored over isolated therapy requests. In the literature, the existence of a rehabilitation program based on psychological intervention, physical exercises, and a 10-week support group designed and directed by medical and interdisciplinary staff promoted quality-of-life improvement, as well as relief of physical symptoms, psychosocial adjustments, and improvement in painful conditions and in range of motion, particularly that of the shoulder in patients with previously diagnosed cancer.[6]

Regarding the program's duration, the median for the group was approximately 20 weeks. This points to the need for a future in-depth analysis to assess which conditions interfere with the patients' commitment and if these conditions may extend the rehabilitation program's duration.

Surgery is one of the pillars of primary breast cancer therapy. While surgical techniques reduce normal tissue injury, pain and functional impairment continue after treatment. A tenuous evidence base reinforced by considerable expert opinion suggests that early intervention with conventional rehabilitation modalities may reduce the pain and dysfunction associated with surgery. Barriers to timely sequelae of functionally morbid sequels arise from a wide range of academic, human, logistical, and financial resources. Despite obstacles, many institutions are rapidly and effectively delivering postsurgical rehabilitation to patients with breast cancer.[15],[16]

Few care delivery models integrate comprehensive oncology rehabilitation services into the oncology care continuum. The recommendations suggest more intense efforts to integrate cancer rehabilitation care models in oncology care from the point of diagnosis, incorporating evidence-based clinical assessment tools for rehabilitation, including rehabilitation professionals sharing the decision-making, to provide comprehensive cancer care and to maximize cancer survivors' functional capabilities.[17]

The analysis of the reasons of care highlights the presence of lymphedema in patients who followed the program. The presence of lymphedema after breast cancer surgery has also been reported in other studies as a public health issue that deserves attention. According to the Australian study that examined 287 patients diagnosed with breast cancer, between 6 and 18 months after surgery, 33% (n = 62) of the samples were classified with the presence of lymphedema.[18] Of these, 40% had late lymphedema. Factors such as advanced age, extensive surgery or axillary node dissection, and the presence of one or more complications or symptoms related to the treatment were associated with higher chances of developing lymphedema. Treatment of lymphedema associated with breast cancer can include combined modality approaches, compression therapy, therapeutic exercises, and pharmacotherapy.[19] Complete decongestive therapy, a multimodality approach, is the “gold standard” for lymphedema treatment. This therapy includes various techniques, such as manual lymphatic drainage, external compression garments and bandages, skin care, and exercises guided by specially trained therapists.

In comparing the verified costs in this study with those in the literature, a gap exists in the published studies concerning the costs of primary data from the perspective of health-care services. Regarding the cost of lymphedema rehabilitation, an American study compared the direct costs of two distinct approaches: the traditional model (with identification of lymphedema by a doctor and the subsequent referral to treatment) and the prospective model (with an early approach to the patient). In this study, the direct costs from the perspective of the health provider were compared through the Medicare cost table (American health system).[20] The costs per patient, in dollars, ranged from $636.19 in the prospective model to $3124.92 in the traditional model. This is the closest to the model adopted in the rehabilitation center analyzed in the current study. However, these are different perspectives because this study uses the payer health system as a reference.

Furthermore, this American study estimated material costs (bandages and dressings) used in physiotherapy management according to the median of three local suppliers.[20] In relation to material costs, the estimated costs in dollars were $344.00 for the prospective model and $1630.00 for the traditional model. Drawing a parallel with the results presented to the scenario of a high-complexity, university-based oncology center, the estimated material costs per patient in Brazilian reais was R$ 101.89. However, there is variability in the different realities according to the management protocol used on site and its number of bandages/dressings.

There is also concern regarding the cost of complications related to the lymphedema, particularly because of the elevated risk of infections and the impact on cost. In 2009, according to the American Society of Clinical Oncology Journal, a study compared women groups who developed lymphedema and those who did not in terms of costs.[21] The women in this study had been in breast cancer treatment for 2 years. The treatment of complications, in dollars, ranged from $14,877.00 to $23,167.00 in the period. Ambulatory care, particularly mental health-care services; diagnostic imaging; and visits with moderate or high complexity accounted for the greatest impact.

Partial economic assessments create an impact framework for an intervention. The cost–effect studies may also be a useful preparatory base for a future economic assessment because there is an initial technical difficulty for economic analyses in health care due to the limited availability of primary studies of good quality (evidence) regarding the effects of technologies, particularly in patient subgroups.[12],[22]

To complete cost analysis of rehabilitation after surgery for breast cancer, more studies are necessary to consider indirect costs, such as loss of productivity due to absence at work and direct nonmedical costs (food and transportation expenses). Knowing the costs related to lymphedema complications corroborates the importance of an early and proper rehabilitation program for this population. Cost studies with primary data in health-care services are important to demonstrate real-world scenarios (costs of procedures and interventions) for the allocation of resources and the proper updating of payment and budget tables.

  Conclusions Top

The study found good results for the indicators of clinical outcome and quality of life regarding patients who had performed the rehabilitation program at the integrated oncology center. Costs have been reported from the standpoint of a partial evaluation and may contribute to future full assessments.


For this study, the main clinical outcome could have had greater sensitivity with subdivision of the partially achieved segment into partially achieved (50%–74% attainment) and partially missed (25%–49% attainment). This refinement was adopted after this study. Since 2017, the rehabilitation center team begun to use quartile division to gain sensitivity in the evaluation of the clinical outcome regarding the attainment of patients' needs (totally achieved, partially achieved, partially missed, and not achieved). However, it is important to emphasize that the great majority of the patients analyzed in this study (70%) totally achieved their objectives.

The health professionals' low adherence regarding the recording of the SF-36 questionnaire in all electronic records made it more difficult to analyze the impact on quality of life (n = 52; 40%).

Another limiting factor to be considered is that, because it is a partial economic analysis from an observational retrospective study, the health-care results were not compared to another group, and such a comparison would allow for an additional assessment regarding effectiveness. However, the approach used is based on recommended and validated rehabilitation interventions.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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American Cancer Society. The Global Economic Cost of Cancer. Atlanta (GA): American Cancer Society; 2010.  Back to cited text no. 4
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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]


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