Prospective surveillance of breast cancer-related lymphoedema in the first-year post-surgery: feasibility and comparison of screening measures

Multinational Association of Supportive Care in Cancer (MASCC) clinical practice guidance for the prevention of breast cancer-related arm lymphoedema (BCRAL): international Delphi consensus-based recommendations

Background

Developing strategies to prevent breast cancer-related arm lymphoedema (BCRAL) is a critical unmet need because there are no effective interventions to eradicate it once it reaches a chronic state. Certain strategies such as prospective surveillance programs and prophylactic lymphatic reconstruction have been reported to be effective in clinical trials. However, a large variation exists in practice based on clinician preference, organizational standards, and local resources.

Methods

A two-round international Delphi consensus process was performed from February 27, 2023 to May 25, 2023 to compile opinions of 55 experts involved in the care and research of breast cancer and lymphoedema on such interventions.

Findings

Axillary lymph node dissection, use of post-operative radiotherapy, relative within-arm volume increase one month after surgery, greater number of lymph nodes dissected, and high body mass index were recommended as the most important risk factors to guide selection of patients for interventions to prevent BCRAL. The panel recommended that prospective surveillance programs should be implemented to screen for and reduce risks of BCRAL where feasible and resources allow. Prophylactic compression sleeves, axillary reverse mapping and prophylactic lymphatic reconstruction should be offered for patients who are at risk for developing BCRAL as options where expertise is available and resources allow. Recommendations on axillary management in clinical T1-2, node negative breast cancer patients with 1-2 positive sentinel lymph nodes were also provided by the expert panel. Routine axillary lymph node dissection should not be offered in these patients who receive breast conservation therapy. Axillary radiation instead of axillary lymph node dissection should be considered in the same group of patients undergoing mastectomy.

Interpretation

An individualised approach based on patients' preferences, risk factors for BCRAL, availability of treatment options and expertise of the healthcare team is paramount to ensure patients at risk receive preventive interventions for BCRAL, regardless of where they are receiving care.

Funding

This study was not supported by any funding. RJC received investigator grant support from the Australian National Health and Medical Research Council (APP1194051).

Bioelectrical Impedance Analysis (BIA) for the Assessment of Body Composition in Oncology: A Scoping Review

Bioelectrical Impedance Analysis (BIA) is a reliable, non-invasive, objective, and cost-effective body composition assessment method, with high reproducibility. This scoping review aims to evaluate the current scientific and clinical evidence on BIA for body composition assessment in oncology patients, under active treatment. Literature search was conducted through MEDLINE, CINAHL, Scopus and Web of Science databases, following PRISMA-ScR Guidelines. Inclusion criteria comprised studies reporting the use of BIA for body composition evaluation in adults with cancer diagnosis. Studies including non-cancer pathology or only assessing nutritional status were excluded. This scoping review comprised a total of 36 studies: 25 were original studies including 18 prospective studies, six cross-sectional studies and one retrospective study and 11 were systematic reviews. Population size for the included original articles ranged from 18 to 1217 participants, comprising a total of 3015 patients with cancer with a mean baseline Body Mass Index (BMI) ranging from 20.3 to 30.0 kg/m2 and mean age ranging between 47 and 70 years. Review articles included a total of 273 studies, with a total of 78,350 participants. The current review considered studies reporting patients with head and neck cancer (HNC) (n = 8), breast cancer (BC) (n = 4), esophageal cancer (EC) (n = 2), liver cancer (n = 2), pancreatic cancer (PC) (n = 3), gastric cancer (GC) (n = 3), colorectal cancer (CRC) (n = 8), lung cancer (LC) (n = 1), skin cancer (SK) (n = 1) and multiple cancer types (n = 6). BIA is a suitable and valid method for the assessment of body composition in oncology. BIA-derived measures have shown good potential and relevant clinical value in preoperative risk evaluation, in the reduction of postoperative complications and hospital stay and as an important prognostic indicator in persons with cancer. Future research on the diagnostic value and clinical applications of BIA and BIA-derived phase angle (PhA) should be conducted in order to predict its impact on patient survival and other clinical outcomes.

Seasonal Variation in Upper Limb Size, Volume, Fluid Distribution, and Lymphedema Diagnosis, Following Breast Cancer Treatment

Background: Breast cancer-related lymphedema (BCRL) is a common complication of breast cancer treatment. Anecdotal and qualitative research suggests that heat and hot weather cause an exacerbation of BCRL; however, there is little quantitative evidence to support this. The aim of this article is to investigate the relationship between seasonal climate variation and limb size, volume, fluid distribution, and diagnosis in women following breast cancer treatment. Methods and Results: Women older than the age of 35 years who had undergone treatment for breast cancer were invited to participate. Twenty-five women aged between 38 and 82 years were recruited. Seventy-two percent received surgery, radiation therapy, and chemotherapy as part of their breast cancer treatment. Participants completed anthropometric, circumferential, and bioimpedance measures and a survey on three occasions: November (spring), February (summer), and June (winter). Diagnostic criteria of >2 cm and >200 mL difference between the affected and unaffected arm, and a positive bioimpedance ratio of >1.139 for a dominant arm and >1.066 for nondominant arm was applied across the three measurement occasions. No significant correlation between seasonal variation in climate and upper limb size, volume, or fluid distribution were found in women diagnosed with or at risk of developing BCRL. Lymphedema diagnosis depends on the season and diagnostic measurement tool utilized. Conclusion: There was no statistically significant variation in limb size, volume, or fluid distribution in this population across spring, summer, and winter, although there were linked trends in these values. The diagnosis of lymphedema, however, varied between individual participants throughout the year. This has important implications for the implementation/commencement of treatment and management. Further research with a larger population in different climates is required to explore the status of women with respect to BCRL. The use of common clinical diagnostic criteria did not result in consistent diagnostic classification of BCRL for the women involved in this study.

Age as a risk factor for breast cancer-related lymphedema: a systematic review

PURPOSE

Breast cancer-related lymphedema (BCRL) has been widely reported in the medical literature. Various patient characteristics, including age, have been investigated as possible risk factors for this disease entity, but the existence and direction of the cause-and-effect relationship are still unclear. In this review, we aimed to evaluate the effect of age on development of BRCL.

METHODS

PubMed, Scopus, and Ovid MEDLINE were searched for relevant articles, which were found to be published between 1974 and 2020.

RESULTS

Twenty-six studies involving 19,396 patients were selected. The average age of patients was 54.9. 26 studies were included in the final analysis, and 13 articles reported no association between age and BCRL development.

CONCLUSIONS

Though studies presented different findings, the majority did not identify age as a risk factor for development of lymphedema. However, the level of evidence of individual studies was low. In this article, we call attention to the need for uniform design of lymphedema studies and diagnosis.

IMPLICATIONS FOR CANCER SURVIVORS

All patients should be informed and screened regularly for lymphedema during and after the treatment independent of their age.

Evaluation of Sleep Quality, Depression, and Quality of Life in Patients with Breast Cancer Related Lymphedema

Background: Breast cancer-related lymphedema (BCRL) is a serious health condition negatively affecting psychological state, sleep quality, and quality of life (QOL) of patients. These complications of BCRL can be overlooked in routine clinical practice. The aim of this study is to evaluate sleep quality, depression, and QOL in patients with different stages of BCRL. Methods: This cross-sectional study included 111 consecutive women patients with BCRL attending to lymphedema unit of Physical Medicine and Rehabilitation Hospital in Ankara City Hospital. Demographical and clinical data of patients were noted. Sleep quality was assessed with Pittsburgh Sleep Quality Index, day-time sleepiness was assessed with Epworth Sleepiness Scale, depression was assessed with Beck Depression Questionnaire, and QOL was assessed with Lymphedema Quality of Life Questionnaire-arm. Results: Median age of patients was 57 (49-63) (25%-75% interquartile range). Nearly 58.8% of the patients had sleep disturbances, and 29.7% of the patients had depression. Presence of both sleep disturbance and depression was associated with increased age. Patients with sleep disturbance were found to be more depressive and vice versa, (p < 0.001, p < 0.001, respectively). Sleep disturbance, depression and day-time sleepiness, and higher body mass index were all associated with lower QOL scores. Conclusions: Presence of sleep disturbances and depression should be evaluated in every patient with BCRL with special attention to elderly. Rehabilitative management of BCRL should include psychiatric evaluation and interventions. Future studies should intend to assess the risk factors that affect psychological state, sleep quality, and QOL in patients with BCRL.

Prospective Surveillance for Breast Cancer-Related Arm Lymphedema: A Systematic Review and Meta-Analysis

PURPOSE

The call to integrate prospective surveillance for lymphedema into cancer care pathways is building momentum to enable early intervention and prevent the progression of the condition. We offer a critical evaluation of the literature on prospective surveillance and early management for cancer-related lymphedema and evaluate the effect of such programs in preventing chronic lymphedema (CRD42019137965).

METHODS

Five databases and two registries were searched for randomized controlled trials or observational studies that assessed the incidence or prevalence of lymphedema associated with participation in a prospective surveillance program, published until February 26, 2021. Numbers triggered for early lymphedema management, resolved, and chronic lymphedema were extracted. Pooled relative risk (trials) and pooled rate (cumulative incidence; observational studies) of chronic lymphedema was calculated. Subgroup analyses assessed the effect of study design, length of follow-up, and extent of axillary surgery.

RESULTS

Twenty-three studies were included, of which 21 studies evaluated breast cancer-related arm lymphedema (BCRaL). Participation in prospective surveillance with early management reduced the risk of chronic BCRaL versus usual care (relative risk 0.31; 95% CI, 0.10 to 0.95; two randomized controlled trials; N = 106). The pooled rate of chronic BCRaL was 4% (95% CI, 3 to 6; 15 observational studies; N = 3,545), and 6% (95% CI, 4 to 9) when restricted to participants with axillary lymph node dissection (12 studies; N = 1,527).

CONCLUSION

The findings suggest that participation in prospective surveillance with early management reduces the risk of chronic BCRaL. Only a minority of patients at high risk of lymphedema because of axillary surgery developed chronic lymphedema. More robust research is needed to determine whether prospective surveillance with early management can reduce the risk of chronic lymphedema, particularly among cancer survivors other than breast cancer.

The efficacy of different bandaging methods in patients with breast cancer-related lymphedema: A prospective, randomized study

Objectives

The aim of this study was to evaluate the comparative efficacy of 3MTM CobanTM 2 layer system and conventional multi-layer short-stretch bandaging in terms of volume reduction, ultrasonographic measurements, functional status, and quality of life (QoL) in the treatment of patients with breast cancer-related lymphedema (BCRL).

Patients and methods

This prospective, single-blind, randomized study included a total of 60 BCRL patients (60 females; mean age 54.9±9.6 years; range, 30 to 73 years). The patients were randomly allocated to Group 1 (n=30) and Group 2 (n=30). Both groups received complex decongestive therapy (CDT) including skin care, lymphedema exercises, and manual lymphatic drainage (MLD) combined with traditional multi-layer short-stretch bandaging five times per week for three weeks in Group 1 and with 3MTM CobanTM 2 layer system bandaging two times per week for three weeks in Group 2. Differences in volumes, excess volumes, ultrasonographic measurements, QoL, and functional assessment scores were evaluated at baseline, after three weeks of intensive treatment period, and at two months of follow-up. Functional status was evaluated by the Quick Disability of Arm Shoulder and Hand Questionnaire (Q-DASH), while the QoL was assessed using the Turkish version of Lymphedema Quality of Life Questionnaire-Arm (LYMQOL-Arm). The duration and easiness of applying bandages by physiotherapists and comfortableness of bandages according to patients and physiotherapists were also evaluated using a questionnaire.

Results

The demographic and clinical properties were similar between the groups. There were significant improvements in the volumes, excess volumes, ultrasonographic measures, functional scores, and QoL scores in both groups at the end of treatment. The improvements were sustained at two months of follow-up.

Conclusion

The 3MTM CobanTM 2 layer bandaging as a part of CDT twice a week for a period of three weeks can significantly reduce the volume and improve the disability and impaired QoL, similar to conventional short-stretch multi-layer bandages. In addition, treatment with this layer system enables a time-efficient, easy, and comfortable application of bandaging with increased mobility of the upper extremity.

Avoiding the Swell: Advances in Lymphedema Prevention, Detection, and Management

Lymphedema is a feared complication of cancer treatments that negatively affects survivors' quality of life. The true incidence of lymphedema is difficult to determine given its long latency period. As the number of survivors of cancer is increasing in the United States, lymphedema is poised to be a major health concern. The most noteworthy risk factor for lymphedema is comprehensive lymph node dissection. The last 2 decades have witnessed a dramatic shift in cancer treatment in an attempt to systematically de-escalate therapeutic interventions, specifically seeking to shift treatment away from routine lymph node dissection in favor of sentinel node biopsy or radiation strategies, thereby reducing the risk for lymphedema while maintaining survival outcomes. A growing body of robust evidence supports prospective screening and thereby a prospective surveillance model (PSM) for early diagnosis and intervention for the prevention and treatment of lymphedema. Finally, investigators are actively evaluating the effectiveness of contemporary surgical procedures in ameliorating the symptoms and disability of patients with lymphedema and reducing the risk of future episodes of cellulitis, with outcomes of surgery significantly better than with conservative therapy alone. In this article, we review the current data surrounding these initiatives.

The impact of monitoring techniques on progression to chronic breast cancer-related lymphedema: a meta-analysis comparing bioimpedance spectroscopy versus circumferential measurements

BACKGROUND

Chronic breast cancer-related lymphedema (BCRL) is a potentially serious complication following treatment. Monitoring for progression to BCRL may allow for earlier detection and intervention, reducing the rate of progression to chronic BCRL. Therefore, the purpose of this meta-analysis is to evaluate the impact of monitoring techniques on the incidence of chronic BCRL among patients monitored by bioimpedance spectroscopy (BIS) and circumference as compared to background rates.

METHODS

Eligible peer-reviewed studies from PubMed, CINHAL, or Google Scholar that were published in English from 2013 onward and conducted in North America, Europe, or Oceania. Incidence rates abstracted from studies were classified by BCRL monitoring method: background (no standardized BIS or circumference assessments), BIS or circumference. A random-effects model was used to calculate a pooled annualized estimate of BCRL incidence while accounting for clinical and methodological heterogeneity. Subgroup analyses examined differences in duration of follow-up as well as breast and axillary surgery.

RESULTS

50 studies were included, representing over 67,000 women. The annualized incidence of BCRL was 4.9% (95% CI: 4.3-5.5) for background studies (n = 35), 1.5% (95% CI: 0.6-2.4) for BIS-monitored studies (n = 7), and 7.7% (95% CI: 5.6-9.8) for circumference-monitored studies (n = 11). The cumulative BCRL incidence rate in BIS-monitored patients was 3.1% as compared to 12.9% with background monitoring (69% reduction) and 17.0% with circumference-monitored patients (81% reduction).

CONCLUSIONS

Evidence suggests that monitoring with BIS allowing for early intervention significantly reduces the relative risk of chronic BCRL with a 69% and 81% reduction compared to background and circumference, respectively. Circumference monitoring did not appear to provide a benefit with respect to chronic BCRL incidence. Based on these results, BIS should be considered for BCRL screening in order to detect subclinical BCRL and reduce rates of chronic BCRL, particularly in high-risk patients.

Increases in arm volume predict lymphoedema and quality of life deficits after axillary surgery: a prospective cohort study

Background

Lymphoedema develops after axillary clearance (ANC) in 25% of patients. This prospective, multi-centre study compared multi-frequency bioimpedance spectroscopy (BIS) with arm volume measurement to: (1) determine which test has better diagnostic accuracy, (2) identify factors predicting development of lymphoedema, and its effect on quality-of-life.

Methods

Participants (N = 1100) underwent measurements pre and post-ANC surgery for breast cancer. Relative arm volume increase (RAVI) of >10% diagnosed lymphoedema. Predictors of lymphoedema were determined using logistic regression. Optimal diagnostic method was assessed using diagnostic accuracy. Quality-of-life was assessed using the FACT B + 4 questionnaire.

Results

Lymphoedema was diagnosed in 22.8% women using RAVI > 10%, 45.6% using BIS criteria, while 24.5% underwent compression sleeve application by 24 months. BMI > 30 was an independent factor for both development (p = 0.005) and progression (p = 0.015) of lymphoedema. RAVI at 1 month, BMI > 30 and number of involved nodes contributed to a novel scoring model to predict lymphoedema by 36 months. Larger decreases in QoL scores post-surgery occurred in lymphoedema patients (p < 0.001). Progression to moderate lymphoedema occurred in 15% patients after sleeve application.

Conclusions

RAVI measurement was the best diagnostic tool for lymphoedema. BIS alone is not appropriate for lymphoedema screening or diagnosis. BMI > 30 predicted lymphoedema diagnosis and progression.

Feasibility of Bioimpedance Analysis to Assess the Outcome of Complex Decongestive Therapy in Cancer Treatment-Related Lymphedema

Background: Cancer treatment-related lymphedema (CTRL) affects patients physically, psychologically and emotionally, and remains a significant quality of life issue among patients with cancer. Reliable methods to measure changes in lymphedema are required for early detection, acute intensive treatment, and long-term management. Here, we evaluated the use of bioimpedance analysis (BIA) as a tool to measure lymphedema before and after treatment.

Patients and Methods: Patients with CTRL who were admitted to a secondary university hospital between October 2017 and July 2018 for complex decongestive therapy (CDT) were eligible for this prospective cohort study. Circumferential measure (CM) and BIA were used to evaluate lymphedema at admission (initial) and before discharge (follow-up, FU). Volume was calculated from the CM using the truncated cone formula. The inter-limb ratios (ILRs) of the circumference, volume, and impedance were also calculated as the unaffected limb to affected limb. Each parameter before and after treatment and correlations between parameters also were analyzed.

Results: A total of 29 patients (12 upper- and 17 lower-extremity CTRL) completed were included in this analysis. Absolute value and the ILRs of circumference, volume or impedance, and extracellular water/total body water (ECW/TBW) were significantly improved at FU (p < 0.01, p < 0.05). The initial and FU absolute values, ILRs, ECW/TBW correlated significantly with each other (p < 0.01, p < 0.05). The cutoff values of ECW/TBW for moderate and severe degree of CTRL were 0.3855 and 0.3955, respectively. The changes of ILRs between initial and FU assessments were significantly different among three groups according to lymphedema severity (p < 0.01, p < 0.05).

Conclusions: BIA data correlates significantly with clinical measurement, and therefore can be a practical tool in monitoring outcome measure after lymphedema treatment. In addition, BIA is more sensitive to subtle changes in lymphedema, and therefore can be useful for the long-term maintenance of lymphedema.

Lipedema and Dercum's Disease: A New Application of Bioimpedance

Background: Lipedema and Dercum's disease (DD) are incompletely characterized adipose tissue diseases, and objective measures of disease profiles are needed to aid in differential diagnosis. We hypothesized that fluid properties, quantified as tissue water bioimpedance in the upper and lower extremities, differ regionally between these conditions. Methods and Results: Women (cumulative n = 156) with lipedema (n = 110), DD (n = 25), or without an adipose disease matched for age and body mass index to early stage lipedema patients (i.e., controls n = 21) were enrolled. Bioimpedance spectroscopy (BIS) was applied to measure impedance values in the arms and legs, indicative of extracellular water levels. Impedance values were recorded for each limb, as well as the leg-to-arm impedance ratio. Regression models were applied to evaluate hypothesized relationships between impedance and clinical indicators of disease (significance criteria: two-sided p < 0.05). Higher extracellular water was indicated (i) in the legs of patients with higher compared with lower stages of lipedema (p = 0.03), (ii) in the leg-to-arm impedance ratio in patients with lipedema compared with patients with DD (p ≤ 0.001), and (iii) in the leg-to-arm impedance ratio in patients with stage 1 lipedema compared with controls (p ≤ 0.01). Conclusion: BIS is a noninvasive portable modality to assess tissue water, and this device is available in both specialized and nonspecialized centers. These findings support that regional bioimpedance measures may help to distinguish lipedema from DD, as well as to identify early stages of lipedema.

Long-Term Survivorship Care After Cancer Treatment: A New Emphasis on the Role of Rehabilitation Services

In May 2018, the National Cancer Policy Forum (NCPF) of the National Academies of Sciences, Engineering, and Medicine (formerly the Institute of Medicine) released a report, Long-Term Survivorship Care After Cancer Treatment: Proceedings of Workshop. NCPF-published reports have historically played a significant role in driving policy and payment model changes in oncology care, in addition to raising awareness about the needs of individuals with cancer. This 2018 report provides a specific set of recommendations for improving symptom management and rehabilitation that suggest the integration of rehabilitation services at the point of cancer diagnosis and throughout the continuum of cancer care to effectively screen for and manage the anticipated functional morbidity associated with cancer treatment. The specificity of these recommendations is of significant relevance to the physical therapy profession and should encourage bold steps to effectively increase the presence of physical therapists as members of interdisciplinary cancer care teams. The profession must act to implement models of prospective care, develop targeted education and training initiatives to assure the knowledge and skills of our workforce for this complex population, and augment the current evidence base with greater attention to health services research aiming to understand the effectiveness of rehabilitation services in improving costs, utilization, and meaningful functional outcomes.

A Bibliometric Analysis of the Landscape of Cancer Rehabilitation Research (1992-2016)

Cancer rehabilitation research has accelerated as great attention has focused on improving survivorship care. Recent expert consensus has attempted to prioritize research needs and suggests greater focus on studying physical functioning of survivors. However, no analysis of the publication landscape has substantiated these proposed needs. This manuscript provides an analysis of PubMed indexed articles related to cancer rehabilitation published between 1992 and 2017. A total of 22 171 publications were analyzed using machine learning and text analysis to assess publication metrics, topic areas of emphasis, and their interrelationships through topic similarity networks. Publications have increased at a rate of 136 articles per year. Approximately 10% of publications were funded by the National Institutes of Health institutes and centers, with the National Cancer Institute being the most prominent funder. The greatest volume and rate of publication increase were in the topics of Cognitive and Behavioral Therapies and Psychological Interventions, followed by Depression and Exercise Therapy. Four research topic similarity networks were identified and provide insight on areas of robust publication and notable deficits. Findings suggest that publication emphasis has strongly supported cognitive, behavioral, and psychological therapies; however, studies of functional morbidity and physical rehabilitation research are lacking. Three areas of publication deficits are noted: research on populations outside of breast, prostate, and lung cancers; methods for integrating physical rehabilitation services with cancer care, specifically regarding functional screening and assessment; and physical rehabilitation interventions. These deficits align with the needs identified by expert consensus and support the supposition that future research should emphasize a focus on physical rehabilitation.

Diagnosis and Treatment of Edema and Lymphedema in the Cancer Patient

BACKGROUND

Lymphedema occurs commonly in cancer survivors. It is crucial to properly assess cancer patients in order to distinguish lymphedema from general edema and to initiate evidence based treatment.

PURPOSE

To provide evidence based recommendations for screening, evaluating, and treating lymphedema and to establish the role of the nurse in the care of patients with lymphedema.

METHODOLOGY

Comprehensive overview with narrative literature review of evidence based lymphedema diagnosis and treatment.

FINDINGS

Cancer-related edema represents numerous complex conditions. A variety of interventions are needed to address prevention, early detection, patient education, and effective treatment.

CONCLUSION

Lymphedema treatment is complex and multimodal, and is provided by an interdisciplinary team of properly trained professionals. Nurses play a major role in evaluating, treating and educating patients on the signs and symptoms of cancer-related edema and patient self-management.

CLINICAL IMPLICATIONS

Evidence-based assessment and treatment should be initiated early to improve outcomes and quality of life in patients with cancer-related lymphedema.

Diagnosis of Upper Quadrant Lymphedema Secondary to Cancer: Clinical Practice Guideline From the Oncology Section of the American Physical Therapy Association

The Oncology Section of the American Physical Therapy Association (APTA) developed a clinical practice guideline to aid the clinician in diagnosing secondary upper quadrant cancer-related lymphedema. Following a systematic review of published studies and a structured appraisal process, recommendations were written to guide the physical therapist and other health care clinicians in the diagnostic process. Overall clinical practice recommendations were formulated based on the evidence for each diagnostic method and were assigned a grade based on the strength of the evidence for different patient presentations and clinical utility. In an effort to maximize clinical applicability, recommendations were based on the characteristics as to the location and stage of a patient's upper quadrant lymphedema.

Diagnosis of Upper-Quadrant Lymphedema Secondary to Cancer: Clinical Practice Guideline From the Oncology Section of APTA

INTRODUCTION

The Oncology Section of APTA developed a clinical practice guideline to aid the clinician in diagnosing secondary upper-quadrant cancer-related lymphedema.

METHODS

Following a systematic review of published studies and a structured appraisal process, recommendations were written to guide the physical therapist and other health care clinicians in their diagnostic process. Overall, clinical practice recommendations were formulated on the basis of the evidence for each diagnostic method and were assigned a grade based on the strength of the evidence for different patient presentations and clinical utility.

RECOMMENDATIONS

In an effort to make these clinically applicable, recommendations were based on the characteristics as to the location and stage of a patient's upper-quadrant lymphedema.

Measurement Properties of Instruments for Measuring of Lymphedema: Systematic Review

BACKGROUND

Lymphedema is a common complication of cancer treatment, resulting in swelling and subjective symptoms. Reliable and valid measurement of this side effect of medical treatment is important.

PURPOSE

The purpose of this study was to provide best evidence regarding which measurement instruments are most appropriate in measuring lymphedema in its different stages.

DATA SOURCES

The PubMed and Web of Science databases were used, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed.

STUDY SELECTION

Clinical studies on measurement instruments assessing lymphedema were reviewed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) scoring instrument for quality assessment.

DATA EXTRACTION

Data on reliability, concurrent validity, convergent validity, sensitivity, specificity, applicability, and costs were extracted.

DATA SYNTHESIS

Pooled data showed good intrarater intraclass correlation coefficients (ICCs) (.89) for bioimpedance spectroscopy (BIS) in the lower extremities and high intrarater and interrater ICCs for water volumetry, tape measurement, and perometry (.98-.99) in the upper extremities. In the upper extremities, the standard error of measurement was 3.6% (σ=0.7%) for water volumetry, 5.6% (σ=2.1%) for perometry, and 6.6% (σ=2.6%) for tape measurement. Sensitivity of tape measurement in the upper extremities, using different cutoff points, varied from 0.73 to 0.90, and specificity values varied from 0.72 to 0.78.

LIMITATIONS

No uniform definition of lymphedema was available, and a gold standard as a reference test was lacking. Items concerning risk of bias were study design, patient selection, description of lymphedema, blinding of test outcomes, and number of included participants.

CONCLUSIONS

Measurement instruments with evidence for good reliability and validity were BIS, water volumetry, tape measurement, and perometry, where BIS can detect alterations in extracellular fluid in stage 1 lymphedema and the other measurement instruments can detect alterations in volume starting from stage 2. In research, water volumetry is indicated as a reference test for measuring lymphedema in the upper extremities.

A comprehensive review of bioimpedance spectroscopy as a diagnostic tool for the detection and measurement of breast cancer-related lymphedema

As treatment for breast cancer improves and the threat of life-long chronic lymphedema becomes more prevalent, the need for effective screening tools emerges as crucial. This review was conducted using literature beginning in 1992 to analyze primary research testing the accuracy of bioimpedance spectroscopy as a diagnostic and early detection tool for breast cancer-related lymphedema. We concluded bioimpedance is an accurate diagnostic tool for pre-existent lymphedema, however, it has not been validated for early detection. J. Surg. Oncol. 2016;114:537-542. © 2016 Wiley Periodicals, Inc.

A Prospective Validation Study of Bioimpedance with Volume Displacement in Early-Stage Breast Cancer Patients at Risk for Lymphedema

BACKGROUND

Although volume displacement (VD) is considered the gold standard for diagnosing breast cancer-related lymphedema, it is inconvenient. We compared bioimpedance (L-Dex) and VD measurements in a prospective cohort of breast cancer patients at risk for lymphedema.

METHODS

Between 2010 and 2014, a total of 223 breast cancer patients were enrolled. Following exclusions (n = 37), 186 received baseline VD and L-Dex; follow-up measurements were performed at 3-6 months intervals for 3 years. At each visit, patients fitted into one of three categories: normal (normal VD and L-Dex); abnormal L-Dex (L-Dex > 10 or increase in 10 from baseline and normal VD); or lymphedema (relative arm volume difference of >10 % by VD ± abnormal L-Dex). Change in L-Dex was plotted against change in VD; correlation was assessed using the Pearson correlation.

RESULTS

At a median follow-up of 18.2 months, 152 patients were normal, 25 had an abnormal L-Dex, and 9 developed lymphedema without a prior L-Dex abnormality. Of the 25 abnormal L-Dex patients, 4 progressed to lymphedema, for a total of 13 patients with lymphedema. Evaluating all time points, 186 patients had 829 follow-up measurements. Sensitivity and specificity of L-Dex compared with VD were 75 and 93 %, respectively. There was no correlation between change in VD and change in L-Dex at 3 months (r = 0.31) or 6 months (r = 0.21).

CONCLUSIONS

VD and bioimpedance demonstrated poor correlation with inconsistent overlap of measurements considered abnormal. Of patients with an abnormal L-Dex, few progressed to lymphedema; most patients with lymphedema did not have a prior L-Dex abnormality. Further studies are needed to understand the clinical significance of bioimpedance.