Pain Catastrophizing as a Predictor of Shoulder Dysfunction and Lymphedema in Geriatric Breast Cancer Survivors

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This study investigates their longitudinal associations in geriatric patients over 60 months. Methods: In this retrospective cohort study, 89 geriatric women (medianage = 72, SD = 4.5, range = 65–88) who underwent MRM were assessed at baseline (pre-surgery), 1, 3, post-radiotherapy 2nd month, and 12, 24, 36, 48, and 60 months post-surgery. Pain Catastrophizing Scale (PCS), Geriatric Depression Scale (GDS), Brief Pain Inventory (BPI) interference scores, shoulder range of motion (ROM) differences (flexion and abduction), and lymphedema severity (from 3 months on ward using the Frustum formulaand ISL staging) were measured. Patients were stratified into high (PCS ≥ 25) and low (PCS < 25) pain catastrophizing groups based on baseline PCS median. Spearman correlations, Wilcoxon signed-ranktests, Mann-Whitney U tests, and Fisher’s exact tests analyzed associations and group differences. Results: Strong correlations existed between PCS, GDS, and BPI acrossall time points (ρ = 0.911–1.000, p < 0.001), peaking at 12 months (PCS vs. BPI: ρ = 1.000, p < 0.001). Shoulder ROM differences correlated with PCS, GDS, and BPI from 1 month (ρ = 0.864–0.939, p < 0.001), peaking at 24 months. Lymphedema correlated moderately with PCS, GDS, BPI, and ROM differences at 3 months (ρ = 0.443–0.516, p < 0.001), strengthening by 24–36 months (ρ = 0.687–0.803, p < 0.001). High PCS patients had worse outcomes (p < 0.05). Conclusions: Persistent associations between pain catastrophizing, depression, shoulder dysfunction, and lymphedema under score its critical role as a predictor. Patients should be evaluated and managed based on pain catastrophizing levels to optimize outcomes in geriatric breast cancer survivors. Pain catastrophizing depression lymphedema shoulder dysfunction geriatric breast cancer Figures Figure 1 Figure 2 Background Breast cancer is a leading malignancy among geriatric women, with modified radical mastectomy (MRM) being a standard treatment for local control [ 1 ]. MRM is associated with significant complications, including pain catastrophizing, depression, pain interference, shoulder mobility impairments, and lymphedema [ 2 , 3 ]. Pain catastrophizing, measured by the Pain Catastrophizing Scale (PCS), reflects maladaptive cognitive responses to pain, amplifying psychological distress and physical limitations [ 4 ]. The Geriatric Depression Scale (GDS) assesses depressive symptoms in older adults, whilet he Brief Pain Inventory (BPI) evaluates pain interference with Daily activities [ 5 ]. Shoulder mobility deficits, measured as angle differences in flexion and abduction, and lymphedema, a chronic condition involving lymphatic fluid accumulation, impairquality of life [ 6 , 7 ]. Although prior studies explored associations between pain catastrophizing, depression, and pain interference, their longitudinal relationships with shoulder dysfunction and lymphedema in geriatric breast cancer patients remain underexplored [ 8 , 9 ]. This study evaluates these associations over 60 months post-MRM in 89 geriatric women stratified by baseline PCS (high: ≥ 25; low: < 25), to assess pain catastrophizing as a predictor of shoulder dysfunction and lymphedema. Methods Study Design andParticipants: This retrospective cohort study included 89 geriatric women (median age = 72, SD = 4.5, range = 65–88) who underwent MRM for breast cancer at Istanbul Bagcilar Training and Research Hospital. Inclusion criteri awereage ≥ 65 years at surgery, completion of 60 months of regular follow-up, andreceipt of post-surgical radiotherapy to the chest wall and axilla. Exclusion criteria included history of shoulder joint surgery, muscle disease, cognitive impairment, prior lymphedema, other cancer saffecting the upper limb, or irregular follow-up. Data were collected from medical records at baseline (pre-surgery), 1, 3, post-radiotherapy 2nd month, and 12, 24, 36, 48, and 60 months post-surgery. The study was approved by the Medipol University Non-Interventional Ethics Committee (Approval No: E-10840098-772.02-4021), and all participants provided written in formed consent. Measures: Pain Catastrophizing Scale (PCS) : Assessed catastrophic thinking related to pain (range: 0–50; higher scores indicate greater catastrophizing) [ 4 ]. Geriatric Depression Scale (GDS) : Measured depressive symptoms in older adults (range: 0–15; higher scores indicate greater depression) [ 10 ]. Brief Pain Inventory (BPI) Interferenc eScores : Evaluated pain interference with Daily activities (range: 0–10; higher scores indicate greater interference) [ 5 ]. Baseline BPI scores were approximated using 1-month data due to unavailability. Shoulder Range of Motion (ROM) Measured flexion and abduction angles (degrees) using a goniometer, with angle differences calculated as the difference between the affected and contralateral sides. Lymphedema Severity Assessed at 3, post-radiotherapy 2nd month, 12, 24, 36, 48, and 60 months post-surgery using the Frustum formula, which calculates limb volüme from circumferential measurements at the metacarpophalangeal joint, web space, and ulnar styloid, with a 3.3% correction for armdominance. Lymphedema was defined as a ≥ 5% volüme difference between the affected and unaffected limbs. Patients with < 5% volüme difference were classified as having “nolymphedema.” Severity was graded using the International Society of Lymphology (ISL) system [ 11 ] -Stage 0: Subclinical, no visible swelling but risk/symptoms present. Stage I: Pitting edema (+), softedema, reversible with elevation. StageIIa: Persistent edema, pitting (+), early fibrosis. StageIIb: Persistent edema, pitting (−), significant fibrosis. Stage III: Fibrosis, sclerosis, and skin changes (elephantiasis). Statistical Analysis Spearman correlation analyses examined associations among PCS, GDS, BPI, shoulder angle differences (flexion and abduction), and lymphedema severity at each time point (0, 1, 3, post-radiotherapy 2nd month, 12, 24, 36, 48, and 60 months). Patients were stratified into high (PCS ≥ 25) andlow (PCS < 25) pain catastrophizing groups based on the baseline PCS median, as this cutoff provided a balanced stratification and aligned with previous studies using median splits to identify patients at risk of worse psychological and physical outcomes [ 4 , 9 ]. Longitudinal changes in PCS, GDS, BPI, shoulder angle differences, and lymphedema were analyzed using descriptive statisticsand Wilcoxon signed-rank tests for pair wise comparisons with baseline. Differences between high and low PCS groups were assessed using Mann-Whitney U tests for continuous outcomes (GDS, BPI, shoulder angle differences) and Fisher’s exact tests for lymphedema incidence. Statistical significance was set at p < 0.05. Analyses were performed using SPSS v26.0 (IBM Corp.). Results Correlations Between PCS, GDS, and BPI Spearman correlations revealed strong associations between PCS, GDS, and BPI acrossall time points (Table 1 ). At baseline, PCS correlated strongly with GDS (ρ = 0.975, p < 0.001) and BPI (ρ = 0.969, p < 0.001), with GDS and BPI also correlated (ρ = 0.964, p < 0.001). The sepeaked at 12 months (PCS vs. GDS: ρ = 0.994, p < 0.001; PCS vs. BPI: ρ = 1.000, p < 0.001; GDS vs. BPI: ρ = 0.994, p < 0.001) and remained strong at 60 months (PCS vs. GDS: ρ = 0.994, p < 0.001; PCS vs. BPI: ρ = 0.988, p < 0.001; GDS vs. BPI: ρ = 0.985, p < 0.001). Table 1 Spearman Correlation Coefficients for PCS, GDS, and BPI Across Time Points Time Point PCS vs. GDS (ρ, p) PCS vs. BPI (ρ, p) GDS vs. BPI (ρ, p) 0 months 0.975, < 0.001 0.969, < 0.001 0.964, < 0.001 1 month 0.981, < 0.001 0.979, < 0.001 0.970, < 0.001 3 months 0.979, < 0.001 0.963, < 0.001 0.952, < 0.001 Post-RT2nd month 0.979, < 0.001 0.970, < 0.001 0.957, < 0.001 12 months 0.994, < 0.001 1.000, < 0.001 0.994, < 0.001 24 months 0.994, < 0.001 0.924, < 0.001 0.925, < 0.001 36 months 0.993, < 0.001 0.921, < 0.001 0.916, < 0.001 48 months 0.995, < 0.001 0.924, < 0.001 0.911, < 0.001 60 months 0.994, < 0.001 0.988, < 0.001 0.985, < 0.001 Note: ρ = Spearman correlation coefficient; p-values indicate statistical significance. Correlations with Shoulder Angle Differences Correlations between PCS, GDS, BPI, and shoulder angle differences were non-significant at baseline (flexion: ρ = 0.022–0.055, p > 0.610; abduction: ρ = 0.022–0.049, p > 0.610) but became significant from 1 month on ward (Table 2 ; Fig. 1 ). At 1 month, PCS correlated with flexion (ρ = 0.899, p < 0.001) and abduction (ρ = 0.888, p < 0.001) angle differences, with similar patterns for GDS (flexion: ρ = 0.874, p < 0.001; abduction: ρ = 0.867, p < 0.001) and BPI (flexion: ρ = 0.873, p < 0.001; abduction: ρ = 0.864, p < 0.001). The sepeaked at 24 months (e.g., PCS vs. abduction: ρ = 0.932, p < 0.001; GDS vs. abduction: ρ = 0.939, p < 0.001) and remained strong at 60 months (e.g., PCS vs. flexion: ρ = 0.917, p < 0.001; abduction: ρ = 0.929, p < 0.001). Flexion and abduction angle differences were highly correlated acrossall time points (ρ = 0.973–1.000, p < 0.001). Table 2 Spearman Correlation Coefficients for PCS, GDS, BPI, and Shoulder Angle Differences Time Point PCS vs. Flexion (ρ, p) PCS vs. Abduction (ρ, p) GDS vs. Flexion (ρ, p) GDS vs. Abduction (ρ, p) BPI vs. Flexion (ρ, p) BPI vs. Abduction (ρ, p) Flexion vs. Abduction (ρ, p) 0 months 0.022, 0.839 0.022, 0.839 0.055, 0.610 0.055, 0.610 0.049, 0.651 0.049, 0.651 1.000, < 0.001 1 month 0.899, < 0.001 0.888, < 0.001 0.874, < 0.001 0.867, < 0.001 0.873, < 0.001 0.864, < 0.001 0.973, < 0.001 3 months 0.903, < 0.001 0.914, < 0.001 0.865, < 0.001 0.881, < 0.001 0.868, < 0.001 0.883, < 0.001 0.982, < 0.001 Post-RT 2ndmonth 0.918, < 0.001 0.930, < 0.001 0.895, < 0.001 0.907, < 0.001 0.882, < 0.001 0.900, < 0.001 0.985, < 0.001 12 months 0.920, < 0.001 0.931, < 0.001 0.916, < 0.001 0.930, < 0.001 0.920, < 0.001 0.931, < 0.001 0.985, < 0.001 24 months 0.920, < 0.001 0.932, < 0.001 0.929, < 0.001 0.939, < 0.001 0.908, < 0.001 0.909, < 0.001 0.985, < 0.001 36 months 0.923, < 0.001 0.934, < 0.001 0.915, < 0.001 0.926, < 0.001 0.908, < 0.001 0.909, < 0.001 0.985, < 0.001 48 months 0.917, < 0.001 0.929, < 0.001 0.910, < 0.001 0.924, < 0.001 0.908, < 0.001 0.909, < 0.001 0.985, < 0.001 60 months 0.917, < 0.001 0.929, < 0.001 0.906, < 0.001 0.920, < 0.001 0.909, < 0.001 0.917, < 0.001 0.985, < 0.001 Note: Flexion = Shoulder angle difference (flexion); Abduction = Shoulder angle difference (abduction); ρ = Spearman correlation coefficient; p-values indicate statistical significance. Correlations with Lymphedema Lymphedema correlations were assessed at 3, post-radiotherapy 2nd month, 12, 24, 36, 48, and 60 months post-surgery (Table 3 ; Fig. 1 ). At 3 months, PCS (ρ = 0.502, p < 0.001), GDS (ρ = 0.477, p < 0.001), BPI (ρ = 0.443, p < 0.001), and shoulder angle differences (flexion: ρ = 0.516, p < 0.001; abduction: ρ = 0.508, p < 0.001) showed moderate correlations with lymphedema. These strengthened by 24–36 months (e.g., lymphedema vs. BPI at 24 months: ρ = 0.803, p < 0.001; vs. abduction at 36 months: ρ = 0.749, p < 0.001) and remained significant at 60 months (e.g., lymphedema vs. PCS: ρ = 0.718, p < 0.001; vs. abduction: ρ = 0.743, p < 0.001). Correlations Between Shoulder Angle Differences and Lymphedema Shoulder angle differences and lymphedema showed moderate correlations at 3 months (flexion: ρ = 0.516, p < 0.001; abduction: ρ = 0.508, p < 0.001), increasing at post-radiotherapy 2nd month (flexion: ρ = 0.595, p < 0.001; abduction: ρ = 0.592, p < 0.001) andpeaking at 24–36 months (flexion: ρ = 0.727–0.731, p < 0.001; abduction: ρ = 0.734–0.749, p < 0.001) (Table 4 ; Fig. 1 ). At 60 months, correlations remained strong (flexion: ρ = 0.720, p < 0.001; abduction: ρ = 0.743, p < 0.001). Table 3 Spearman Correlation Coefficientsfor PCS, GDS, BPI, Shoulder Angle Differences, andLymphedema Time Point PCS vs. Lymphedema (ρ, p) GDS vs. Lymphedema (ρ, p) BPI vs. Lymphedema (ρ, p) Flexion vs. Lymphedema (ρ, p) Abduction vs. Lymphedema (ρ, p) 3 months 0.502, < 0.001 0.477, < 0.001 0.443, < 0.001 0.516, < 0.001 0.508, < 0.001 Post-RT 2nd month 0.537, < 0.001 0.524, < 0.001 0.488, < 0.001 0.595, < 0.001 0.592, < 0.001 12 months 0.561, < 0.001 0.559, < 0.001 0.561, < 0.001 0.603, < 0.001 0.604, < 0.001 24 months 0.687, < 0.001 0.698, < 0.001 0.803, < 0.001 0.727, < 0.001 0.734, < 0.001 36 months 0.703, < 0.001 0.694, < 0.001 0.819, < 0.001 0.731, < 0.001 0.749, < 0.001 48 months 0.682, < 0.001 0.665, < 0.001 0.813, < 0.001 0.693, < 0.001 0.718, < 0.001 60 months 0.718, < 0.001 0.702, < 0.001 0.711, < 0.001 0.720, < 0.001 0.743, < 0.001 Note: Flexion = Shoulder angle difference (flexion); Abduction = Shoulder angle difference (abduction); ρ = Spearman correlation coefficient; p-values indicate statistical significance. Lymphedema data were not available at 0 and not measured in patients at 1 month. Table 4 Spearman Correlation Coefficients for Shoulder Angle Differences and Lymphedema Time Point Flexion vs. Abduction (ρ, p) Flexion vs. Lymphedema (ρ, p) Abduction vs. Lymphedema (ρ, p) 3 months 0.982, < 0.001 0.516, < 0.001 0.508, < 0.001 Post-RT 2nd month 0.985, < 0.001 0.595, < 0.001 0.592, < 0.001 12 months 0.985, < 0.001 0.603, < 0.001 0.604, < 0.001 24 months 0.985, < 0.001 0.727, < 0.001 0.734, < 0.001 36 months 0.985, < 0.001 0.731, < 0.001 0.749, < 0.001 48 months 0.985, < 0.001 0.693, < 0.001 0.718, < 0.001 60 months 0.985, < 0.001 0.720, < 0.001 0.743, < 0.001 Note: Flexion = Shoulder angle difference (flexion); Abduction = Shoulder angle difference (abduction); ρ = Spearman correlation coefficient; p-values indicate statistical significance. Lymphedema data were not available at 0 and not measured in patients at 1 month. Longitudinal Trends and Group Differences PCS, GDS, and BPI scores, reflecting pain catastrophizing, depression, and pain interference, peaked post-surgery at 3 and post-radiotherapy 2nd month, reflecting the mos tpronounced symptoms (p 0.05) (Fig. 2 ). Shoulder angle differences were mostpronounced at 1 month (p 0.05). Lymphedema severity peaked at 12 months and stabilized by 60 months. Patients with high PCS (≥ 25) had significantly higher GDS, BPI, shoulder angle differences, and lymphedema incidence compared tolow PCS patients (Mann-Whitney U and Fisher’s exact tests, p < 0.05). Discussion This retrospective study of 89 geriatric breast cancer patients post-MRM examines associations between pain catastrophizing (PCS), depressive symptoms (GDS), pain interference (BPI), ROM differences, and lymphedema over 60 months. Strong correlations between PCS, GDS, and BPI (ρ = 0.911–1.000, p < 0.001) high light the interplay between psychological distress and pain perception, consistent with prior research [ 4 , 8 ]. The near-perfect correlation at 12 months (PCS vs. BPI: ρ = 1.000, p 0.610) reflect minimal pre-surgical impairments. Strong correlations from 1 month on ward (ρ = 0.864–0.939, p < 0.001) suggest pain catastrophizing predicts shoulder dysfunction, aligning with studies on its role in physical limitations [ 9 ]. Lymphedema correlations with PCS, GDS, BPI, and ROM differences were moderate at 3 months (ρ = 0.443–0.516, p < 0.001) but strengthened by 24–36 months (ρ = 0.687–0.803, p < 0.001). The strong correlation between lymphedema and ROM differences at 60 months (ρ = 0.720–0.743, p < 0.001) suggests lymphedema contributes to shoulder dysfunction due to fibrosis and swelling [ 7 ]. Longitudinal trends (Fig. 2 ) show PCS, GDS, and BPI peaking at 3 and post-radiotherapy 2nd month, reflecting acute surgical and radiotherapy effects, with a decline toward baseline levels by 60 months, suggestin gadaptation. Persistent correlations with lymphedema and ROM differences indicate chronic challenges. Lymphedema’speak at 12 months and stabilization by 60 months align with its chronic nature [ 2 ]. High PCS patients (≥ 25) exhibited worse outcomes, underscoring pain catastrophizing as a predictor of adverse outcomes [ 9 ]. Clinical Implications The associations between pain catastrophizing, depression, shoulder dysfunction, and lymphedema highlight its predictive role in geriatric breast cancer survivors[ 12 , 13 ]. These findings support future research into integrated interventions, such as cognitive-behavioral therapy to address pain catastrophizing and depression, and physical rehabilitation to improve shoulder mobility and manage lymphedema [ 13 , 14 ]. Early assessment of PCS at 1–3 months could identify at-risk patients, guiding targeted strategies to enhance quality of life. Limitations The retrospective design limits causal inferences, as data werec ollected from medical records, potentially introducing selection or documentation biases. Prospective studies could validate these findings and establish temporal relationships more robustly. Conclusion This 60-month study demonstrates that paincatastrophizing predicts shoulder dysfunction and lymphedema in geriatric breast cancer patients post-MRM. Persistent correlations with depressive symptoms, pain interference, and physical impairments, alongside the decline of psychological measures toward baseline levels by 60 months, under score its critical role in patient outcomes. These findings emphasize the importance of evaluating and managing patients based on pain catastrophizing levels to addresslong-terms equelae effectively and improve quality of life in this population. Abbreviations BPI BriefPain Inventory GDS Geriatric Depression Scale ISL International Society of Lymphology MRM Modified Radica lMastectomy PCS Pain Catastrophizing Scale ROM Range of Motion Declarations Author Contributions: Merve Tokocin, Turan Pehlivan, and Atilla Celik contributed equallyt other conception and design of the study, data collection, data analysis, manuscript writing, and manuscript review. Ethics Approval and Consentto Participate: The study was approved by the Medipol University Non-Interventional Ethics Committee (Approval No: E-10840098-772.02-4021). All participants provided written in formed consent. Consent for publication: Not applicable. Competing Interests: The authors declare no competing interests. Funding: None declared. Authors' contributions: Merve Tokocin, Turan Pehlivan, and Atilla Celik contributed equally to the conception and design of the study, data collection, data analysis, manuscript writing, and manuscript review. 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A systematic review of the evidence for completede congestive therapy in the treatment of lymphedema from 2004 to 2011. PM R. 2012;4(8):580–601. 10.1016/j.pmrj.2012.05.003 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 29 Nov, 2025 Read the published version in BMC Geriatrics → Version 1 posted Editorial decision: Revision requested 23 Oct, 2025 Reviews received at journal 21 Oct, 2025 Reviewers agreed at journal 10 Oct, 2025 Reviews received at journal 03 Oct, 2025 Reviewers agreed at journal 02 Oct, 2025 Reviewers invited by journal 20 Sep, 2025 Editor assigned by journal 18 Sep, 2025 Submission checks completed at journal 18 Sep, 2025 First submitted to journal 07 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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10:05:10","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":79351,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7557503/v1/bbb0ac5b36a68ced18315c9c.html"},{"id":92584552,"identity":"aab5b157-7e59-4703-aaa8-9262dfa57754","added_by":"auto","created_at":"2025-10-01 10:13:10","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":217504,"visible":true,"origin":"","legend":"\u003cp\u003eSperman Correlation Matrices Across Time Points\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7557503/v1/bc1c00f75ab1c3fdab6e3983.jpeg"},{"id":92583087,"identity":"115ac2a3-bf32-4b0b-809a-60f72632e8ca","added_by":"auto","created_at":"2025-10-01 10:05:10","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":100085,"visible":true,"origin":"","legend":"\u003cp\u003eLongitudinal Trends of PCS, GDS, BPI, Shoulder Angle Difference, and Lymphedema Over 60 months\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7557503/v1/098fab6b84770d7dab5c3f64.jpeg"},{"id":97178451,"identity":"43090d26-755f-4faa-b5aa-e8eaeb09114e","added_by":"auto","created_at":"2025-12-01 16:10:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1205922,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7557503/v1/2e22f5ef-1939-463e-9597-b39243ac0505.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Pain Catastrophizing as a Predictor of Shoulder Dysfunction and Lymphedema in Geriatric Breast Cancer Survivors","fulltext":[{"header":"Background","content":"\u003cp\u003eBreast cancer is a leading malignancy among geriatric women, with modified radical mastectomy (MRM) being a standard treatment for local control [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. MRM is associated with significant complications, including pain catastrophizing, depression, pain interference, shoulder mobility impairments, and lymphedema [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Pain catastrophizing, measured by the Pain Catastrophizing Scale (PCS), reflects maladaptive cognitive responses to pain, amplifying psychological distress and physical limitations [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The Geriatric Depression Scale (GDS) assesses depressive symptoms in older adults, whilet he Brief Pain Inventory (BPI) evaluates pain interference with Daily activities [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Shoulder mobility deficits, measured as angle differences in flexion and abduction, and lymphedema, a chronic condition involving lymphatic fluid accumulation, impairquality of life [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Although prior studies explored associations between pain catastrophizing, depression, and pain interference, their longitudinal relationships with shoulder dysfunction and lymphedema in geriatric breast cancer patients remain underexplored [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This study evaluates these associations over 60 months post-MRM in 89 geriatric women stratified by baseline PCS (high: \u0026ge; 25; low: \u0026lt; 25), to assess pain catastrophizing as a predictor of shoulder dysfunction and lymphedema.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design andParticipants:\u003c/h2\u003e\u003cp\u003eThis retrospective cohort study included 89 geriatric women (median age\u0026thinsp;=\u0026thinsp;72, SD\u0026thinsp;=\u0026thinsp;4.5, range\u0026thinsp;=\u0026thinsp;65\u0026ndash;88) who underwent MRM for breast cancer at Istanbul Bagcilar Training and Research Hospital. Inclusion criteri awereage\u0026thinsp;\u0026ge;\u0026thinsp;65 years at surgery, completion of 60 months of regular follow-up, andreceipt of post-surgical radiotherapy to the chest wall and axilla. Exclusion criteria included history of shoulder joint surgery, muscle disease, cognitive impairment, prior lymphedema, other cancer saffecting the upper limb, or irregular follow-up. Data were collected from medical records at baseline (pre-surgery), 1, 3, post-radiotherapy 2nd month, and 12, 24, 36, 48, and 60 months post-surgery. The study was approved by the Medipol University Non-Interventional Ethics Committee (Approval No: E-10840098-772.02-4021), and all participants provided written in formed consent.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eMeasures:\u003c/h3\u003e\n\u003cp\u003e\u003cem\u003ePain Catastrophizing Scale (PCS)\u003c/em\u003e: Assessed catastrophic thinking related to pain (range: 0\u0026ndash;50; higher scores indicate greater catastrophizing) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cem\u003eGeriatric Depression Scale (GDS)\u003c/em\u003e: Measured depressive symptoms in older adults (range: 0\u0026ndash;15; higher scores indicate greater depression) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cem\u003eBrief Pain Inventory (BPI) Interferenc eScores\u003c/em\u003e: Evaluated pain interference with Daily activities (range: 0\u0026ndash;10; higher scores indicate greater interference) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Baseline BPI scores were approximated using 1-month data due to unavailability.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eShoulder Range of Motion (ROM)\u003c/strong\u003e\u003cp\u003eMeasured flexion and abduction angles (degrees) using a goniometer, with angle differences calculated as the difference between the affected and contralateral sides.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eLymphedema Severity\u003c/strong\u003e\u003cp\u003eAssessed at 3, post-radiotherapy 2nd month, 12, 24, 36, 48, and 60 months post-surgery using the Frustum formula, which calculates limb vol\u0026uuml;me from circumferential measurements at the metacarpophalangeal joint, web space, and ulnar styloid, with a 3.3% correction for armdominance. Lymphedema was defined as a\u0026thinsp;\u0026ge;\u0026thinsp;5% vol\u0026uuml;me difference between the affected and unaffected limbs. Patients with \u0026lt;\u0026thinsp;5% vol\u0026uuml;me difference were classified as having \u0026ldquo;nolymphedema.\u0026rdquo; Severity was graded using the International Society of Lymphology (ISL) system [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e\u003c/p\u003e\u003cp\u003e-Stage 0: Subclinical, no visible swelling but risk/symptoms present.\u003c/p\u003e\u003cp\u003eStage I: Pitting edema (+), softedema, reversible with elevation.\u003c/p\u003e\u003cp\u003eStageIIa: Persistent edema, pitting (+), early fibrosis.\u003c/p\u003e\u003cp\u003eStageIIb: Persistent edema, pitting (\u0026minus;), significant fibrosis.\u003c/p\u003e\u003cp\u003eStage III: Fibrosis, sclerosis, and skin changes (elephantiasis).\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eSpearman correlation analyses examined associations among PCS, GDS, BPI, shoulder angle differences (flexion and abduction), and lymphedema severity at each time point (0, 1, 3, post-radiotherapy 2nd month, 12, 24, 36, 48, and 60 months). Patients were stratified into high (PCS\u0026thinsp;\u0026ge;\u0026thinsp;25) andlow (PCS\u0026thinsp;\u0026lt;\u0026thinsp;25) pain catastrophizing groups based on the baseline PCS median, as this cutoff provided a balanced stratification and aligned with previous studies using median splits to identify patients at risk of worse psychological and physical outcomes [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Longitudinal changes in PCS, GDS, BPI, shoulder angle differences, and lymphedema were analyzed using descriptive statisticsand Wilcoxon signed-rank tests for pair wise comparisons with baseline. Differences between high and low PCS groups were assessed using Mann-Whitney U tests for continuous outcomes (GDS, BPI, shoulder angle differences) and Fisher\u0026rsquo;s exact tests for lymphedema incidence. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Analyses were performed using SPSS v26.0 (IBM Corp.).\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eCorrelations Between PCS, GDS, and BPI\u003c/h2\u003e\u003cp\u003eSpearman correlations revealed strong associations between PCS, GDS, and BPI acrossall time points (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). At baseline, PCS correlated strongly with GDS (ρ\u0026thinsp;=\u0026thinsp;0.975, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and BPI (ρ\u0026thinsp;=\u0026thinsp;0.969, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with GDS and BPI also correlated (ρ\u0026thinsp;=\u0026thinsp;0.964, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The sepeaked at 12 months (PCS vs. GDS: ρ\u0026thinsp;=\u0026thinsp;0.994, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; PCS vs. BPI: ρ\u0026thinsp;=\u0026thinsp;1.000, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; GDS vs. BPI: ρ\u0026thinsp;=\u0026thinsp;0.994, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and remained strong at 60 months (PCS vs. GDS: ρ\u0026thinsp;=\u0026thinsp;0.994, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; PCS vs. BPI: ρ\u0026thinsp;=\u0026thinsp;0.988, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; GDS vs. BPI: ρ\u0026thinsp;=\u0026thinsp;0.985, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSpearman Correlation Coefficients for PCS, GDS, and BPI Across Time Points\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTime Point\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePCS vs. GDS (ρ, p)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePCS vs. BPI (ρ, p)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eGDS vs. BPI (ρ, p)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd 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\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.979, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.963, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.952, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePost-RT2nd month\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.979, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.970, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.957, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.994, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.000, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.994, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e24 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.994, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.924, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.925, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e36 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.993, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.921, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.916, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e48 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.995, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.924, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.911, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e60 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.994, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.988, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.985, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eNote: ρ\u0026thinsp;=\u0026thinsp;Spearman correlation coefficient; p-values indicate statistical significance.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eCorrelations with Shoulder Angle Differences\u003c/h2\u003e\u003cp\u003eCorrelations between PCS, GDS, BPI, and shoulder angle differences were non-significant at baseline (flexion: ρ\u0026thinsp;=\u0026thinsp;0.022\u0026ndash;0.055, p\u0026thinsp;\u0026gt;\u0026thinsp;0.610; abduction: ρ\u0026thinsp;=\u0026thinsp;0.022\u0026ndash;0.049, p\u0026thinsp;\u0026gt;\u0026thinsp;0.610) but became significant from 1 month on ward (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e; Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). At 1 month, PCS correlated with flexion (ρ\u0026thinsp;=\u0026thinsp;0.899, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and abduction (ρ\u0026thinsp;=\u0026thinsp;0.888, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) angle differences, with similar patterns for GDS (flexion: ρ\u0026thinsp;=\u0026thinsp;0.874, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; abduction: ρ\u0026thinsp;=\u0026thinsp;0.867, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and BPI (flexion: ρ\u0026thinsp;=\u0026thinsp;0.873, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; abduction: ρ\u0026thinsp;=\u0026thinsp;0.864, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The sepeaked at 24 months (e.g., PCS vs. abduction: ρ\u0026thinsp;=\u0026thinsp;0.932, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; GDS vs. abduction: ρ\u0026thinsp;=\u0026thinsp;0.939, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and remained strong at 60 months (e.g., PCS vs. flexion: ρ\u0026thinsp;=\u0026thinsp;0.917, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; abduction: ρ\u0026thinsp;=\u0026thinsp;0.929, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Flexion and abduction angle differences were highly correlated acrossall time points (ρ\u0026thinsp;=\u0026thinsp;0.973\u0026ndash;1.000, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSpearman Correlation Coefficients for PCS, GDS, BPI, and Shoulder Angle Differences\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTime Point\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePCS vs. Flexion (ρ, p)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePCS vs. Abduction (ρ, p)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eGDS vs. Flexion (ρ, p)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eGDS vs. Abduction (ρ, p)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eBPI vs. Flexion (ρ, p)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eBPI vs. Abduction (ρ, p)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eFlexion vs. Abduction (ρ, p)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.022, 0.839\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.022, 0.839\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.055, 0.610\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.055, 0.610\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.049, 0.651\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.049, 0.651\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e1.000, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1 month\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.899, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.888, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.874, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.867, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.873, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.864, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.973, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.903, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.914, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.865, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.881, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.868, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.883, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.982, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePost-RT 2ndmonth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.918, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.930, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.895, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.907, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.882, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.900, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.985, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.920, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.931, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.916, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.930, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.920, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.931, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.985, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e24 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.920, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.932, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.929, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.939, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.908, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.909, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.985, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e36 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.923, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.934, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.915, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.926, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.908, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.909, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.985, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e48 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.917, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.929, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.910, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.924, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.908, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.909, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.985, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e60 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.917, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.929, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.906, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.920, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.909, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.917, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.985, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eNote: Flexion\u0026thinsp;=\u0026thinsp;Shoulder angle difference (flexion); Abduction\u0026thinsp;=\u0026thinsp;Shoulder angle difference (abduction); ρ\u0026thinsp;=\u0026thinsp;Spearman correlation coefficient; p-values indicate statistical significance.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eCorrelations with Lymphedema\u003c/h3\u003e\n\u003cp\u003eLymphedema correlations were assessed at 3, post-radiotherapy 2nd month, 12, 24, 36, 48, and 60 months post-surgery (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e; Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). At 3 months, PCS (ρ\u0026thinsp;=\u0026thinsp;0.502, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), GDS (ρ\u0026thinsp;=\u0026thinsp;0.477, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), BPI (ρ\u0026thinsp;=\u0026thinsp;0.443, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and shoulder angle differences (flexion: ρ\u0026thinsp;=\u0026thinsp;0.516, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; abduction: ρ\u0026thinsp;=\u0026thinsp;0.508, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) showed moderate correlations with lymphedema. These strengthened by 24\u0026ndash;36 months (e.g., lymphedema vs. BPI at 24 months: ρ\u0026thinsp;=\u0026thinsp;0.803, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; vs. abduction at 36 months: ρ\u0026thinsp;=\u0026thinsp;0.749, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and remained significant at 60 months (e.g., lymphedema vs. PCS: ρ\u0026thinsp;=\u0026thinsp;0.718, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; vs. abduction: ρ\u0026thinsp;=\u0026thinsp;0.743, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\n\u003ch3\u003eCorrelations Between Shoulder Angle Differences and Lymphedema\u003c/h3\u003e\n\u003cp\u003eShoulder angle differences and lymphedema showed moderate correlations at 3 months (flexion: ρ\u0026thinsp;=\u0026thinsp;0.516, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; abduction: ρ\u0026thinsp;=\u0026thinsp;0.508, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), increasing at post-radiotherapy 2nd month (flexion: ρ\u0026thinsp;=\u0026thinsp;0.595, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; abduction: ρ\u0026thinsp;=\u0026thinsp;0.592, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) andpeaking at 24\u0026ndash;36 months (flexion: ρ\u0026thinsp;=\u0026thinsp;0.727\u0026ndash;0.731, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; abduction: ρ\u0026thinsp;=\u0026thinsp;0.734\u0026ndash;0.749, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e; Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). At 60 months, correlations remained strong (flexion: ρ\u0026thinsp;=\u0026thinsp;0.720, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; abduction: ρ\u0026thinsp;=\u0026thinsp;0.743, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSpearman Correlation Coefficientsfor PCS, GDS, BPI, Shoulder Angle Differences, andLymphedema\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTime Point\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePCS vs. Lymphedema (ρ, p)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGDS vs. Lymphedema (ρ, p)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBPI vs. Lymphedema (ρ, p)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eFlexion vs. Lymphedema (ρ, p)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAbduction vs. Lymphedema (ρ, p)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.502, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.477, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.443, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.516, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.508, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePost-RT 2nd month\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.537, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.524, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.488, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.595, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.592, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.561, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.559, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.561, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.603, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.604, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e24 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.687, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.698, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.803, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.727, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.734, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e36 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.703, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.694, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.819, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.731, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.749, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e48 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.682, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.665, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.813, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.693, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.718, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e60 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.718, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.702, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.711, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.720, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0.743, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote: Flexion\u0026thinsp;=\u0026thinsp;Shoulder angle difference (flexion); Abduction\u0026thinsp;=\u0026thinsp;Shoulder angle difference (abduction); ρ\u0026thinsp;=\u0026thinsp;Spearman correlation coefficient; p-values indicate statistical significance. Lymphedema data were not available at 0 and not measured in patients at 1 month.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSpearman Correlation Coefficients for Shoulder Angle Differences and Lymphedema\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTime Point\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFlexion vs. Abduction (ρ, p)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFlexion vs. Lymphedema (ρ, p)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAbduction vs. Lymphedema (ρ, p)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.982, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.516, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.508, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePost-RT 2nd month\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.985, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.595, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.592, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.985, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.603, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.604, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e24 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.985, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.727, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.734, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e36 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.985, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.731, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.749, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e48 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.985, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.693, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.718, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e60 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.985, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.720, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.743, \u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eNote: Flexion\u0026thinsp;=\u0026thinsp;Shoulder angle difference (flexion); Abduction\u0026thinsp;=\u0026thinsp;Shoulder angle difference (abduction); ρ\u0026thinsp;=\u0026thinsp;Spearman correlation coefficient; p-values indicate statistical significance. Lymphedema data were not available at 0 and not measured in patients at 1 month.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eLongitudinal Trends and Group Differences\u003c/h2\u003e\u003cp\u003ePCS, GDS, and BPI scores, reflecting pain catastrophizing, depression, and pain interference, peaked post-surgery at 3 and post-radiotherapy 2nd month, reflecting the mos tpronounced symptoms (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Wilcoxon signed-rank test), and declined toward baseline levels by 60 months (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Shoulder angle differences were mostpronounced at 1 month (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) but improvedby 60 months (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Lymphedema severity peaked at 12 months and stabilized by 60 months. Patients with high PCS (\u0026ge;\u0026thinsp;25) had significantly higher GDS, BPI, shoulder angle differences, and lymphedema incidence compared tolow PCS patients (Mann-Whitney U and Fisher\u0026rsquo;s exact tests, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis retrospective study of 89 geriatric breast cancer patients post-MRM examines associations between pain catastrophizing (PCS), depressive symptoms (GDS), pain interference (BPI), ROM differences, and lymphedema over 60 months. Strong correlations between PCS, GDS, and BPI (ρ\u0026thinsp;=\u0026thinsp;0.911\u0026ndash;1.000, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) high light the interplay between psychological distress and pain perception, consistent with prior research [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The near-perfect correlation at 12 months (PCS vs. BPI: ρ\u0026thinsp;=\u0026thinsp;1.000, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) indicates a critical period of heightened pain interference, likely due to post-radio therapy effects [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eNon-significant correlations with ROM differences at baseline (ρ\u0026thinsp;=\u0026thinsp;0.022\u0026ndash;0.055, p\u0026thinsp;\u0026gt;\u0026thinsp;0.610) reflect minimal pre-surgical impairments. Strong correlations from 1 month on ward (ρ\u0026thinsp;=\u0026thinsp;0.864\u0026ndash;0.939, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) suggest pain catastrophizing predicts shoulder dysfunction, aligning with studies on its role in physical limitations [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eLymphedema correlations with PCS, GDS, BPI, and ROM differences were moderate at 3 months (ρ\u0026thinsp;=\u0026thinsp;0.443\u0026ndash;0.516, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) but strengthened by 24\u0026ndash;36 months (ρ\u0026thinsp;=\u0026thinsp;0.687\u0026ndash;0.803, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The strong correlation between lymphedema and ROM differences at 60 months (ρ\u0026thinsp;=\u0026thinsp;0.720\u0026ndash;0.743, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) suggests lymphedema contributes to shoulder dysfunction due to fibrosis and swelling [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eLongitudinal trends (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) show PCS, GDS, and BPI peaking at 3 and post-radiotherapy 2nd month, reflecting acute surgical and radiotherapy effects, with a decline toward baseline levels by 60 months, suggestin gadaptation. Persistent correlations with lymphedema and ROM differences indicate chronic challenges. Lymphedema\u0026rsquo;speak at 12 months and stabilization by 60 months align with its chronic nature [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. High PCS patients (\u0026ge;\u0026thinsp;25) exhibited worse outcomes, underscoring pain catastrophizing as a predictor of adverse outcomes [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eClinical Implications\u003c/h2\u003e\u003cp\u003eThe associations between pain catastrophizing, depression, shoulder dysfunction, and lymphedema highlight its predictive role in geriatric breast cancer survivors[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. These findings support future research into integrated interventions, such as cognitive-behavioral therapy to address pain catastrophizing and depression, and physical rehabilitation to improve shoulder mobility and manage lymphedema [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Early assessment of PCS at 1\u0026ndash;3 months could identify at-risk patients, guiding targeted strategies to enhance quality of life.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eThe retrospective design limits causal inferences, as data werec ollected from medical records, potentially introducing selection or documentation biases. Prospective studies could validate these findings and establish temporal relationships more robustly.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis 60-month study demonstrates that paincatastrophizing predicts shoulder dysfunction and lymphedema in geriatric breast cancer patients post-MRM. Persistent correlations with depressive symptoms, pain interference, and physical impairments, alongside the decline of psychological measures toward baseline levels by 60 months, under score its critical role in patient outcomes. These findings emphasize the importance of evaluating and managing patients based on pain catastrophizing levels to addresslong-terms equelae effectively and improve quality of life in this population.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBPI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBriefPain Inventory\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGDS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGeriatric Depression Scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eISL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInternational Society of Lymphology\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMRM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eModified Radica lMastectomy\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePCS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePain Catastrophizing Scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eROM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRange of Motion\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eAuthor Contributions:\u003c/em\u003e Merve Tokocin, Turan Pehlivan, and Atilla Celik contributed equallyt other conception and design of the study, data collection, data analysis, manuscript writing, and manuscript review.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics Approval and Consentto Participate:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eThe study was approved by the Medipol University Non-Interventional Ethics Committee (Approval No: E-10840098-772.02-4021). All participants provided written in formed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting Interests:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding:\u003c/em\u003e\u003c/strong\u003eNone declared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors' contributions:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eMerve Tokocin, Turan Pehlivan, and Atilla Celik contributed equally to the conception and design of the study, data collection, data analysis, manuscript writing, and manuscript review.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data andmaterials:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eData are available from the corresponding author upon reasonable request, subject to ethical and privacy restrictions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. 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PM R. 2012;4(8):580\u0026ndash;601. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.pmrj.2012.05.003\u003c/span\u003e\u003cspan address=\"10.1016/j.pmrj.2012.05.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pain catastrophizing, depression, lymphedema, shoulder dysfunction, geriatric, breast cancer","lastPublishedDoi":"10.21203/rs.3.rs-7557503/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7557503/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eBackground: \u003c/strong\u003e\u003c/em\u003eModified radical mastectomy (MRM) for breast cancer is associated with psychological and physicals equelae, including pain catastrophizing, depression, pain interference, shoulder mobility impairments, and lymphedema. This study investigates their longitudinal associations in geriatric patients over 60 months.\u003cbr\u003e\n \u003cem\u003e\u003cstrong\u003eMethods: \u003c/strong\u003e\u003c/em\u003eIn this retrospective cohort study, 89 geriatric women (medianage = 72, SD = 4.5, range = 65–88) who underwent MRM were assessed at baseline (pre-surgery), 1, 3, post-radiotherapy 2nd month, and 12, 24, 36, 48, and 60 months post-surgery. Pain Catastrophizing Scale (PCS), Geriatric Depression Scale (GDS), Brief Pain Inventory (BPI) interference scores, shoulder range of motion (ROM) differences (flexion and abduction), and lymphedema severity (from 3 months on ward using the Frustum formulaand ISL staging) were measured. Patients were stratified into high (PCS ≥ 25) and low (PCS \u0026lt; 25) pain catastrophizing groups based on baseline PCS median. Spearman correlations, Wilcoxon signed-ranktests, Mann-Whitney U tests, and Fisher’s exact tests analyzed associations and group differences.\u003cbr\u003e\n \u003cem\u003e\u003cstrong\u003eResults: \u003c/strong\u003e\u003c/em\u003eStrong correlations existed between PCS, GDS, and BPI acrossall time points (ρ = 0.911–1.000, p \u0026lt; 0.001), peaking at 12 months (PCS vs. BPI: ρ = 1.000, p \u0026lt; 0.001). Shoulder ROM differences correlated with PCS, GDS, and BPI from 1 month (ρ = 0.864–0.939, p \u0026lt; 0.001), peaking at 24 months. Lymphedema correlated moderately with PCS, GDS, BPI, and ROM differences at 3 months (ρ = 0.443–0.516, p \u0026lt; 0.001), strengthening by 24–36 months (ρ = 0.687–0.803, p \u0026lt; 0.001). High PCS patients had worse outcomes (p \u0026lt; 0.05).\u003cbr\u003e\n \u003cem\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003e\u003c/em\u003ePersistent associations between pain catastrophizing, depression, shoulder dysfunction, and lymphedema under score its critical role as a predictor. Patients should be evaluated and managed based on pain catastrophizing levels to optimize outcomes in geriatric breast cancer survivors.\u003c/p\u003e","manuscriptTitle":"Pain Catastrophizing as a Predictor of Shoulder Dysfunction and Lymphedema in Geriatric Breast Cancer Survivors","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-01 10:05:05","doi":"10.21203/rs.3.rs-7557503/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-23T04:54:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-21T14:39:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"159991507243898702315124708050206685971","date":"2025-10-10T10:09:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-03T14:39:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"310507847811417703530763810716570273831","date":"2025-10-02T23:49:27+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-20T11:53:30+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-18T10:42:52+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-18T10:42:19+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2025-09-07T15:57:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"88a7a37e-c79e-4308-a894-3c39bcd9dda9","owner":[],"postedDate":"October 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T16:02:27+00:00","versionOfRecord":{"articleIdentity":"rs-7557503","link":"https://doi.org/10.1186/s12877-025-06813-9","journal":{"identity":"bmc-geriatrics","isVorOnly":false,"title":"BMC Geriatrics"},"publishedOn":"2025-11-29 15:57:55","publishedOnDateReadable":"November 29th, 2025"},"versionCreatedAt":"2025-10-01 10:05:05","video":"","vorDoi":"10.1186/s12877-025-06813-9","vorDoiUrl":"https://doi.org/10.1186/s12877-025-06813-9","workflowStages":[]},"version":"v1","identity":"rs-7557503","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7557503","identity":"rs-7557503","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}