When Need Exceeds Care: The Rehabilitation Gap After Breast Cancer Surgery

Purpose To quantify the extent to which physiotherapy (PT) utilization aligns with objectively defined postoperative upper-limb morbidity among women after breast-cancer surgery. Methods This pooled analysis included 1,602 women enrolled across three prospective observational cohorts (2023–2024) at two tertiary centers in Israel. Morbidity was defined using standardized criteria across four domains: pain (> 1/10), shoulder range-of-motion limitation, functional impairment (QuickDASH ≥ 20), and clinician-diagnosed lymphedema. PT utilization was defined as ≥ 1 postoperative PT session. Multivariable logistic regression was used to identify predictors of morbidity and PT use. Results Among the 1,589 women with complete PT data, morbidity was common (978/1,589; 61.5%). Women with morbidity had higher clinical burden, including greater comorbidity prevalence, more advanced tumor stage, and increased exposure to adjuvant treatments. Despite this burden, PT utilization remained inconsistent. Only 68.5% of women with morbidity (670/978) received PT, while 31.5% remained symptomatic without treatment, indicating substantial unmet rehabilitation need. Preventive PT in women without morbidity was infrequent (16.2%). Utilization was driven primarily by pain (OR 2.32), whereas chemotherapy (OR 0.66), insomnia (OR 0.75), and anxiety (OR 0.94 per point) were associated with lower likelihood of PT attendance. Objective impairment (ROM limitation, functional disability) was not independently associated with PT use. Conclusion Postoperative upper-limb morbidity is highly prevalent yet remains undertreated under current symptom-driven survivorship pathways. The mismatch between clinical need and care delivery highlights a critical opportunity for proactive, risk-stratified screening and earlier rehabilitation referral to support equitable recovery and prevent long-term disability.