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Purpose Chronic upper extremity disability (UED) is common after breast cancer treatment but under-identified and under-treated. Although UED has been linked to quality of life (QoL), the role of UED as mediator between contemporary treatment practices and QoL has not been quantified. This investigation describes UED in a contemporary sample of breast cancer patients and examines its relationship with personal and treatment factors and QoL. Methods Eight hundred and thirty-three women diagnosed at eight medical institutions during 2013–2014 with microscopically confirmed ductal carcinoma in situ or invasive stage I–III breast cancer were surveyed an average of 22 months after diagnosis. UED was measured with a modified QuickDASH and QoL with the FACT-B. The questionnaire also collected treatments, sociodemographic information, comorbidity, body mass index, and a 3-item health literacy screener. Results Women who received post-mastectomy radiation and chemotherapy experienced significantly worse UED and QoL. Women who had lower income, lower health literacy and prior diabetes, arthritis or shoulder diagnoses had worse UED. Patients with worse UED reported significantly worse QoL. Income and health literacy were independently associated with QoL after adjustment for UED but treatment and prior conditions were not, indicating mediation by UED. UED mediated 52–79% of the effect of mastectomy-based treatments on QoL as compared with unilateral mastectomy without radiation. UED and QoL did not differ by type of axillary surgery or post-mastectomy reconstruction. Conclusions A large portion of treatment effect on QoL is mediated by UED. Rehabilitation practices that prevent and alleviate UED are likely to improve QoL for breast cancer survivors.

In a multicenter sample of breast cancer patients, lower income was strongly associated with less receipt of neoadjuvant chemotherapy. Since patients with lower socioeconomic status are more likely to present with later-stage disease, this pattern has the potential to contribute to breast cancer outcome disparities.

These findings suggest that contralateral uptake on lymphoscintigraphy, though rare (0.2 %), is clinically significant and such nodes should undergo excision. Because contralateral uptake is significantly associated with prior chest/axillary surgery, routine lymphoscintigraphy should be considered in this group, as it has potential to change disease stage and management.

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