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

Contemporaneous Symptom Networks of Breast Cancer-Related Upper Limb Lymphedema: A Network Analysis

BACKGROUND

Upper limb lymphedema (ULL) is a common and deliberating complication for breast cancer survivors (BCSs). Breast cancer survivors with ULL reported a wide range of symptoms. However, little is known about symptom patterns and interrelationships among them. This study was designed to explore symptom clusters and construct symptom networks of ULL-related symptoms among BCSs and to identify the core symptoms.

METHODS

This study is a secondary data analysis using datasets from three cross-sectional studies of BCSs in China. A total of 341 participants with maximum interlimb circumference ≥2 cm and complete responses in Part I of the Breast Cancer and Lymphedema Symptom Experience Index were included. Symptom clusters were identified through principal component analysis, and multiple linear regression analysis was employed to explore factors associated with severity of overall ULL-related symptoms. A contemporaneous network with 20 frequently reported symptoms were constructed after controlling for covariates.

RESULTS

Three symptom clusters, including lymph stasis symptom cluster, nerve symptom cluster, and movement limitation symptom cluster, were identified. Postsurgery time, axillary lymph node dissection, and radiotherapy were associated with the severity of ULL-related symptoms. Tightness (rs = 1.379; rscov = 1.097), tingling (rs = 1.264; rscov = 0.925), and firmness (rs = 1.170; rscov = 0.923) were the most central symptoms in both networks with and without covariates.

CONCLUSIONS

Breast cancer survivors with ULL experienced severe symptom burden. Tightness, tingling, and firmness were core symptoms of ULL among BCSs. Our findings demonstrated that the assessment and targeted intervention of specific core symptoms might help to relive effectively the burden of ULL-related symptom among BCSs.

Preoperative inter-arm differences and normative-based thresholds for lymphedema in Chinese breast cancer patients: Insights from a large cohort study

Objective

Early detection and diagnosis of lymphedema are crucial for effective treatment and prevention of its progression. Normative-based diagnostic thresholds can enhance diagnostic accuracy in the absence of preoperative measurements. This study aimed to investigate preoperative inter-arm differences and the associated factors, as well as to determine normative-based thresholds for lymphedema in Chinese breast cancer patients.

Methods

This study utilized baseline data from a large cohort of Chinese breast cancer patients. Bilateral arm circumferences were measured at the wrist and at 10 cm intervals proximally up to 40 cm. Arm volumes were calculated using the truncated cone formula. Paired t test, repeated measures analysis of variance, and regression analysis were performed.

Results

A total of 1707 breast cancer patients were included. Paired t tests showed that the dominant arm circumferences and volumes were significantly larger than those of the nondominant arm (P < 0.001). Regression analysis and repeated measures analysis of variance revealed that hand dominance was the influencing factor of inter-arm differences (P < 0.05). Normative-based thresholds determined by two standard deviations above the mean inter-arm volume ratio were 1.057 for the dominant arm and 1.079 for the nondominant arm.

Conclusions

The absolute and relative normative-based thresholds for Chinese breast cancer patients differed slightly from the commonly used diagnostic criteria and those reported in Western populations and among Chinese healthy women. The normal variability and asymmetry associated with arm dominance underscore the importance of preoperative baseline assessments. Implementing normative-based diagnostic thresholds can facilitate more accurate lymphedema diagnosis when preoperative measurements are unavailable.

Trial registration

Registration No. ChiCTR2200057083.

Current diagnostic and quantitative techniques in the field of lymphedema management: a critical review

Lymphedema evaluation entails multifaceted considerations for which options continue to evolve and emerge. This paper provides a critical review of the current status of diagnostic and quantitative measures for lymphedema, from traditional and novel bedside assessment tools for volumetric and fluid assessment, to advanced imaging modalities. Modalities are contrasted with regard to empirical support and feasibility of clinical implementation. The manuscript proposes a grid framework for comparing the ability of each modality to quantify specific lymphedema characteristics, including distribution, dysmorphism, tissue composition and fluid content, lymphatic anatomy and function, metaplasia, clinical symptoms, and quality of life and function. This review additionally applies a similar framework approach to consider how well assessment tools support important clinical needs, including: (1) screening, (2) diagnosis and differential diagnosis, (3) individualization of treatment, and (4) monitoring treatment response. The framework highlights which clinical needs are served by an abundance of assessment tools and identifies others that have problematically few. The framework clarifies which tools have greater or lesser empirical support. The framework is designed to assist stakeholders in selecting appropriate diagnostic and surveillance modalities, gauging levels of confidence when applying tools to specific clinical needs, elucidating overarching patterns of diagnostic and quantitative strengths and weaknesses, and informing future investigation.

Development of a core outcome set for breast cancer-related lymphedema: a Delphi study

PURPOSE

For breast cancer survivors (BCS) living with breast cancer-related lymphedema (BCRL), what outcome domains (OD) should be measured to assess the burden of the disease and efficacy of interventions? A Core Outcome Set (COS) that promotes standardized measurement of outcomes within the constraints of time influenced by work environments is essential for patients and the multidisciplinary professionals that manage and research BCRL.

METHODS

Using Delphi methodology, a multidisciplinary group of BCRL experts (physical and occupational therapists, physicians, researchers, physical therapist assistants, nurses, and massage therapist) completed two waves of online surveys. BCRL expert respondents that completed the first survey (n = 78) had an average of 26.5 years in practice, whereas, respondents who completed the second survey (n = 33) had an average of 24.9 years. ODs were included in the COS when consensus thresholds, ranging from 70% to 80%, were met.

RESULTS

A total of 12 ODs made up the COS. Reaching a minimum consensus of 70%; volume, tissue consistency, pain, patient-reported upper quadrant function, patient-reported health-related quality of life, and upper extremity activity and motor control were recommended at different phases of the BCRL continuum in a time-constrained environment. Joint function, flexibility, strength, sensation, mobility and balance, and fatigue met an 80% consensus to be added when time and resources were not constrained.

CONCLUSION

The COS developed in this study thoroughly captures the burden of BCRL. Using this COS may reduce selective reporting, inconsistency in clinical use, and variability of reporting across interdisciplinary healthcare fields, which manage or research BCRL.

Development of a core set of outcome measures to be applied toward breast cancer-related lymphedema core outcome domains

PURPOSE

For breast cancer survivors (BCS) living with breast cancer-related lymphedema (BCRL), what outcome measures (OMs) are recommended to be used to measure standardized outcome domains to fully assess the burden of the disease and efficacy of interventions? An integral component of a standardized core outcome set (COS) are the OMs used to measure the COS.

METHODS

A supplemental online survey was linked to a Delphi study investigating a COS for BCRL. OMs were limited to a maximum of 10 options for each outcome domain (OD). There were 14 ODs corresponding to the International Classification of Functioning, Disability, and Health (ICF) framework and respondents rated the OMs with a Likert level of recommendation. The feasibility of the listed OMs was also investigated for most outpatient, inpatient, and research settings.

RESULTS

This study identified 27 standardized OMs with a few ODs having 2-3 highly recommended OMs for proper measurement. A few of the recommended OMs have limitations with reliability due to being semi-quantitative measures requiring the interpretation of the rater.

CONCLUSION

Narrowing the choices of OMs to 27 highly recommended by BCRL experts may reduce selective reporting, inconsistency in clinical use, and variability of reporting across interdisciplinary healthcare fields which manage or research BCRL. There is a need for valid, reliable, and feasible OMs that measure tissue consistency. Measures of upper extremity activity and motor control need further research in the BCS with BCRL population.

Reducing rates of chronic breast cancer-related lymphedema with screening and early intervention: an update of recent data

PURPOSE

Breast cancer-related lymphedema (BCRL) represents a dreaded complication of breast cancer treatment that can lead to morbidity, diminished quality of life, and psychosocial harm and is associated with increased costs of care. Increasingly, data has supported the concept of prospective BCRL surveillance coupled with early intervention to mitigate these effects.

METHODS

We performed a systematic review of the literature searching for published randomized and prospective data evaluating prospective BCRL surveillance with early intervention.

RESULTS

We identified 12 studies (2907 patients) including 4 randomized trials (1203 patients) and 8 prospective studies (1704 patients). Randomized data consistently demonstrate that early intervention reduces rates of progression to chronic BCRL with multiple paradigms and diagnostic modalities utilized; the strongest data comes from the randomized PREVENT trial, which demonstrated early detection with bioimpedance spectroscopy (BIS), coupled with early intervention with a compression garment applied for 12 h a day over 4 weeks, significantly reduced the rate of chronic BCRL compared to tape measurement coupled with early intervention.

CONCLUSIONS

Current data support the role of prospective BCRL surveillance with early detection and intervention to reduce rates of chronic BCRL. Breast cancer patients at risk for BCRL should undergo prospective surveillance as part of survivorship. Because level 1 data demonstrate that BIS is superior to conventional tape measure, it should be included as the standard BCRL diagnostic modality unless an equally effective modality is employed.

IMPLICATIONS FOR CANCER SURVIVORS

Breast cancer survivor should undergo prospective BCRL screening with BIS.

Breast cancer survivors suffering from lymphedema: What really do affect to corporeality/body image? A qualitative study

Breast cancer-related lymphedema is currently one of the most serious complications that most affect the quality of life of women undergoing breast cancer. The aim of this study was to explore in-depth the experience of women who suffer from lymphoedema after breast cancer and how does this condition affect corporeality, with no judgements. For this purpose, a qualitative methodology was followed. In-depth interviews, interviewer's field notes and participants' letters were used for data collection. The participants were twenty Spanish women with lymphoedema after overcome a breast cancer in the past. Healthcare specialists with experience in the topic were also included. Results showed 2 main categories: "From cancer to lymphedema, another disease another disease" and "Potential for transition and transformation towards a new way of life". As a conclusion, the difficulty in accessing adequate treatment, the need for greater awareness of lymphedema and the importance of the emotional and psychological dimension of this chronic disease. Highlighting the attitudes that these women develop for self-care and the concept of new corporeality. After breast cancer, women with lymphedema experience a drastic change that affects all areas of their lives. The adaptation process, and the search for resources and aid, play a fundamental role in overcoming this process.

Upper Limb Morbidity in Newly Diagnosed Individuals After Unilateral Surgery for Breast Cancer: Baseline Results from the AMBER Cohort Study

PURPOSE

We aimed to examine potential associations between post-surgical upper limb morbidity and demographic, medical, surgical, and health-related fitness variables in newly diagnosed individuals with breast cancer.

METHODS

Participants were recruited between 2012 and 2019. Objective measures of health-related fitness, body composition, shoulder range of motion, axillary web syndrome, and lymphedema were performed within 3 months of breast cancer surgery, and prior to or at the start of adjuvant cancer treatment.

RESULTS

Upper limb morbidity was identified in 54% of participants and was associated with poorer upper limb function and higher pain. Multivariable logistic regression analysis identified mastectomy versus breast-conserving surgery (odds ratio [OR] 3.51, 95% confidence interval [CI] 2.65-4.65), axillary lymph node dissection versus sentinel lymph node dissection (OR 2.67, 95% CI 1.73-4.10), earlier versus later time from surgery (OR 1.58, 95% CI 1.15-2.18), and younger versus older age (OR 1.01, 95% CI 1.00-1.03) as significantly associated with a higher odds of upper limb morbidity, while mastectomy (OR 1.57, 95% CI 1.10-2.25), axillary lymph node dissection (OR 2.20, 95% CI 1.34-3.60), lower muscular endurance (OR 1.10, 95% CI 1.01-1.16) and higher percentage body fat (OR 1.04, 95% CI 1.00-1.07) were significantly associated with higher odds of moderate or greater morbidity severity.

CONCLUSIONS

Upper limb morbidity is common in individuals after breast cancer surgery prior to adjuvant cancer treatment. Health-related fitness variables were associated with severity of upper limb morbidity. Findings may facilitate prospective surveillance of individuals at higher risk of developing upper limb morbidity.

Barriers and facilitators to implementation of APTA's breast cancer-related lymphedema diagnosis and intervention clinical practice guidelines

PURPOSE

The purpose of this study was to identify barriers and facilitators influencing implementation of the diagnosis and intervention clinical practice guidelines (CPGs) related to the management of patients with breast cancer-related lymphedema (BCRL).

METHODS

A descriptive, cross-sectional web-based survey was conducted. Participants included physical therapists and assistants who were members of the APTA's Academy of Oncologic Physical Therapy and Lymphology Association of North America. Desriptive statisitcs were computed for all demographic and barriers and facilitators data. Individual exploratory factor analyses (EFA) were performed on survey items for both CPGs to identify themes of barriers and facilitators to implementation.

RESULTS

A total of 180 respondents completed the survey. 34.9% of respondents read the diagnosis CPG and 22.4% read the intervention CPG. A total of 77.8% reported that they did not have issues in changing their clinical routines and 69.5% did not have resistance working according to CPGs. The EFA resulted in 3 themes for each CPG, accounting for 46% of the variance for the diagnostic CPG and 54% of the variance for the intervention CPG. The 3 themes, clinician characteristics, patient demographics, therapist practice setting and beliefs/values, were weighted differently for each EFA.

CONCLUSION

Most respondents did not read either CPG, however, report a willingness to make changes to clinical practice and utilization of CPGs. For those who have attempted to implement the CPGs, this study was the first to identify the barriers and facilitators impacting the implementation of the CPGs related to the management of BCRL.

IMPLICATIONS FOR CANCER SURVIVORS

The results will inform the development of targeted implementation strategies to improve access to and adherence to recommendations from the CPGs ultimately improving the efficiency and efficacy of care delivery to patients.

Upper-Limb Disability and the Severity of Lymphedema Reduce the Quality of Life of Patients with Breast Cancer-Related Lymphedema

Breast cancer-related lymphedema (BCRL) is characterized by arm swelling, pain, and discomfort, reducing the quality of life (QoL) of affected individuals. BRCL is caused via the blockage or disruption of the lymphatic vessels following cancer treatments, leading to an accumulation of fluid in the affected arm. While current BCRL rehabilitation treatments seek to reduce arm swelling, our study aimed to examine the impact of both the magnitude of lymphedema (ΔVolume) and arm disability on three dimensions of QoL: social, physical, and psychological. Using the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) and the Upper Limb Lymphedema 27 questionnaire (ULL) in a group of 30 patients, we found that the magnitude of lymphedema (ΔVolume) was associated with the social dimension of QoL (r = 0.37, p = 0.041), but not with other dimensions. On the other hand, arm disability was associated with all evaluated dimensions of QoL (social, physical, and psychological: p < 0.001, p = 0.019, and p = 0.050 (borderline), respectively). These findings suggest that BCRL rehabilitation strategies should not only aim to reduce the magnitude of lymphedema but should also seek to improve or preserve arm functionality to enhance the QoL of BCRL patients.

Current Diagnostic Tools for Breast Cancer-Related Lymphedema

PURPOSE OF REVIEW

Breast cancer-related lymphedema (BCRL) can have a significant impact on breast cancer survivors quality of life. The purpose of this review is to evaluate diagnostic tools for the assessment of BCRL.

RECENT FINDINGS

Multiple BCRL diagnostic tools are available, though older diagnostic tools have low sensitivity, limiting the ability for sub-clinical BCRL diagnosis while BIS and perometry have increased sensitivity and the ability to diagnose BCRL sub-clinically. Prospective studies have demonstrated such an approach coupled to early intervention is associated with low rates of chronic BCRL while a recently published randomized trial demonstrated that prospective surveillance with BIS coupled with early intervention reduced rates of chronic BCRL as compared to circumference measurements with compression garments. Prospective and randomized data support the use of prospective surveillance for BCRL. The strongest data available comes from the PREVENT trial and supports prospective BCRL surveillance with bioimpedance spectroscopy coupled to early intervention with a compression sleeve.

The effect of adjuvant radiotherapy on skin biophysical properties in patients with breast cancer at risk for breast lymphedema: A prospective study

Breast cancer (BC) is the most common type of cancer among women. Radiotherapy (RT) is one of the main and primary treatment options for BC, especially in breast-conserving surgery (BCS). BC patients who underwent RT experience a wide range of symptoms, in which breast oedema and irritation of the skin take the lion's share. Breast oedema/lymphedema, which is also a prominent side effect after RT should be well determined in earlier settings due to the chronicity of lymphedema. Therefore, this study aimed to analyze the biophysical parameters of skin on the ipsilateral (IL) and contralateral (CL) sites via Tissue dielectric constant (TDC) and Transepidermal water loss (TEWL) methods in terms of oedema and skin barrier function (SBF). The following reference points before and after the RT were measured: (R1: Pectoralis muscle, R2: Upper breast, R3: Lower breast, R4: Lateral site of the thorax). A total of 24 BC patients (mean age and BMI: 52.78 ± 9.85 years and 28.42 ± 5.64 kg/m² ) were evaluated. In the IL site, the SBF was not found significant in R1-R3, whereas significantly lower SBF was observed in R4 after RT (t = -3.361, p = 0.003). A significant increase in TDC was observed in R2 at the 5.0 mm depth (t = -2.500, p = 0.02). We suggest that a longer period of follow-up should be carefully carried out to track changes in terms of SBF and oedema in the irradiated breast. The increased need for early detection of changes associated with breast lymphedema can be achievable via noninvasive, safe, cheap, and easily repeatable devices.

The Clinical Usefulness of Ultrasonographic Measurement Technique in Patients with Lower Extremity Lymphedema

Background: A previous study reported a new ultrasonography (US) measurement technique to evaluate the cross-sectional area (ΔCSA) of lymphedema in the upper extremity. This ΔCSA correlated well with parameters, such as the circumference, volumetry, and bioimpedance analysis (BIA) in healthy people and upper extremity lymphedema patients. This study examined whether a US measurement technique is clinically useful in patients with lymphedema in the lower extremity. Methods and Results: Forty patients diagnosed with unilateral lower extremity lymphedema were enrolled in this study. The subjects' leg circumference, BIA, isokinetic strength, and ΔCSA were examined on the same day. The leg circumference was measured at 15 cm above the knee (AK) and below the knee (BK) crease using a tape measure. BIA was performed by a trained physical therapist, and the data of impedance (Z) at 1 and 5 kHz of each side of the lower limbs and extracellular water (ECW) were used. A fully experienced physician measured soft tissue thickness, the distance between the skin and the fascia of the muscle, three times each at the anterior, medial, posterior, and lateral aspects of the bilateral legs by US at 15 cm AK and BK. The amount of soft tissue in the ΔCSA was calculated using the designed formula from the mean values of the thicknesses. Each parameter was calculated as the ratio of the sound side to the lesion side. The Pearson and Spearman correlation coefficients were used to assess the significance of these parameters. The ratio of ΔCSA measured at 15 cm AK and BK showed strong positive correlations with the circumference difference at the same level (rho = 0.790, p = 0.000, and rho = 0.882, p = 0.000, respectively). In addition, it showed moderate or strong correlations with the ratio of Z at 5 and 1 kHz in the BIA of the lower limbs (AK15, r = -0.511, p = 0.001 and r = -0.497, p = 0.001; BK15, r = -0.780, p = 0.000 and r = -0.756, p = 0.000, respectively). Although ECW and body mass index showed weak positive correlations with the ratio of ΔCSA measured at 15 cm BK, there was no significant correlation between the ratio of ΔCSA and the isokinetic muscle strength. Conclusion: The ΔCSA results showed moderate-to-strong correlations with other conveniently used methods except for the isokinetic muscle strength. As the US ΔCSA technique could measure lymphedema status with a structural consideration, it could also be recommended as a conventional measurement method in patients with upper and lower extremity lymphedema.

Rehabilitation interventions for the management of breast cancer-related lymphedema: developing a patient-centered, evidence-based plan of care throughout survivorship

PURPOSE

A work group from the American Physical Therapy Association Academy of Oncologic Physical Therapy developed and published a clinical practice guideline (CPG) to aid clinicians in identifying interventions for individuals with breast cancer-related lymphedema (BCRL). This guideline reviewed the evidence for risk mitigation and volume reduction beginning at cancer diagnosis and continuing through survivorship. Application of CPGs can be challenging due to the variability of clinical settings, heterogeneous patient populations, and range of rehabilitation clinician expertise. The purpose of this paper is to assist these clinicians in implementing the recommendations from the CPG to develop a patient-centered, evidence-based plan of care.

METHODS/RESULTS

This publication presents important considerations for the implementation of recommended rehabilitation interventions across the trajectory of BCRL.

CONCLUSION

Current evidence supports specific interventions to treat or mitigate the risk for the various stages of BCRL. As clinicians implement these recommendations into practice, they also need to address other impairments that may exist in every individual. Continued collaboration between clinicians and researchers is necessary to further develop optimal treatment modalities and parameters.

IMPLICATIONS FOR CANCER SURVIVORS

By implementing evidence-based interventions as outlined in the CPG, clinicians can improve the quality of care for survivors of breast cancer.

Practice patterns of physical therapists and physical therapist assistants treating patients with breast cancer related lymphedema

Clinical Practice Guidelines (CPGs) aim to improve patient outcomes through implementation of proven interventions and decrease variation in practices. The relevance of this article is to describe the current state practice of physical therapists who diagnose and treat patients with Breast Cancer Related Lymphedema (BCRL). It also provides a description of physical therapist-reported adherence to the BCRL CPG recommendations which establishes the need for implementation interventions to improve adherence.

PURPOSE

The purpose of this study is to describe practice patterns of physical therapists (PT) and physical therapist assistants (PTA) who treat patients with breast cancer-related lymphedema and determine if they are adherent to best evidence recommendations for lymphedema diagnosis and intervention.

METHODS

An electronic survey to collect practice pattern data of PTs and PTAs who treat patients with BCRL was distributed. A descriptive and quantitative statistical analysis was performed.

RESULTS

Twenty-six percent of respondents read the American Physical Therapy Association sponsored lymphedema diagnosis clinical practice guideline (CPG) and 20% read the lymphedema intervention CPG. Lymphoscintigraphy was the only diagnosis or intervention tool with a significant difference in use between therapists who read versus did not read the CPGs. Adherence to "should do" recommendations was variable: bioimpedance (18.2%), volume calculation (49.3%), ultrasound (0%), patient reported outcome tools (64.9%), compression garments (43.9%), exercise (87.2%), and compression bandaging (56.8%).

CONCLUSIONS

There is variability in adherence to recommendations for both the lymphedema diagnosis and intervention CPGs. Interventions to improve implementation and adherence to CPG recommendations are warranted.

Mitigating Breast-Cancer-Related Lymphedema-A Calgary Program for Immediate Lymphatic Reconstruction (ILR)

With increasing breast cancer survival rates, one of our contemporary challenges is to improve the quality of life of survivors. Lymphedema affects quality of life on physical, psychological, social and economic levels; however, prevention of lymphedema lags behind the progress seen in other areas of survivorship such as breast reconstruction and fertility preservation. Immediate lymphatic reconstruction (ILR) is a proactive approach to try to prevent lymphedema. We describe in this article essential aspects of the elaboration of an ILR program. The Calgary experience is reviewed with specific focus on team building, technique, operating room logistics and patient follow-up, all viewed through research and education lenses.

Guidelines Relevant to Diagnosis, Assessment, and Management of Lymphedema: A Systematic Review

Significance: Lymphedema is a common, distressing and debilitating condition with various etiologies. Effective diagnosis, assessment, and management rely on evidence-based clinical practice guidelines ("guidelines"). This study aims to describe and compare international guidelines on lymphedema diagnosis, assessment, and management. Recent Advances: The review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and registered on the International Prospective Register of Systematic Reviews (PROSPERO). Systematic searches of electronic literature databases and the web were completed in December 2020 for lymphedema guidelines published in English since 2000. Quality was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE)-II reporting checklist. Synthesis took a narrative approach to compare guideline recommendations and associated levels of evidence. Critical Issues: This systematic review of 1,564 articles and 159 web pages yielded 14 guidelines. All guidelines were from high-income countries. Ten focused exclusively on lymphedema, and four on cancer. Most (n = 13) guidelines recommended an integrated medical, psychological assessment, and physical examination, with a limb volume measurement of >10% in the affected limb compared, confirming a lymphedema diagnosis. Recommended management involved Complex Decongestive Therapy (CDT) followed by self-management using skincare, self-lymphatic drainage massage, exercise, and compression. Future Directions: The underlying etiology of lymphedema appeared to make little difference to guideline recommendations regarding care. High-quality guidelines are available to guide lymphedema care. However, their suitability for low-resource settings is unclear.

Bioimpedance spectroscopy for breast cancer-related lymphedema assessment: clinical practice guidelines

PURPOSE

Breast cancer-related lymphedema (BCRL) represents a significant concern for patients following breast cancer treatment, and assessment for BCRL represents a key component of survivorship efforts. Growing data has demonstrated the benefits of early detection and treatment of BCRL. Traditional diagnostic modalities are less able to detect reversible subclinical BCRL while newer techniques such as bioimpedance spectroscopy (BIS) have shown the ability to detect subclinical BCRL, allowing for early intervention and low rates of chronic BCRL with level I evidence. We present updated clinical practice guidelines for BIS utilization to assess for BCRL.

METHODS AND RESULTS

Review of the literature identified a randomized controlled trial and other published data which form the basis for the recommendations made. The final results of the PREVENT trial, with 3-year follow-up, demonstrated an absolute reduction of 11.3% and relative reduction of 59% in chronic BCRL (through utilization of compression garment therapy) with BIS as compared to tape measurement. This is in keeping with real-world data demonstrating the effectiveness of BIS in a prospective surveillance model. For optimal outcomes patients should receive an initial pre-treatment measurement and subsequently be followed at a minimum quarterly for first 3 years then biannually for years 4-5, then annually as appropriate, consistent with previous guidelines; the target for intervention has been changed from a change in L-Dex of 10 to 6.5. The lack of pre-operative measure does not preclude inclusion in the prospective surveillance model of care.

CONCLUSION

The updated clinical practice guidelines present a standardized approach for a prospective model of care using BIS for BCRL assessment and supported by evidence from a randomized controlled trial as well as real-world data.

Higher Rate of Lymphedema with Inguinal versus Axillary Complete Lymph Node Dissection for Melanoma: A Potential Target for Immediate Lymphatic Reconstruction?

Background: The present study was conducted to define the lymphedema rate at our institution in patients undergoing axillary (ALND) or inguinal (ILND) lymph node dissection (LND) for melanoma. It aimed to examine risk factors predisposing patients to a higher rate of lymphedema, highlighting which patients could be targeted for immediate lymphatic reconstruction (ILR). Methods: A retrospective chart review was conducted between October 2015 and July 2020 to identify patients who had undergone ALND or ILND for melanoma. The main outcome measures were rates of transient and permanent lymphedema. Univariate and multivariate analyses were performed to assess the relationship between lymphedema rate and factors related to patient characteristics, surgical procedure, pathology findings, and adjuvant treatment. Results: Between October 2015 and July 2020, 66 patients underwent LND for melanoma: 34 patients underwent ALND and 32 patients underwent ILND. At a median follow-up of 29 months, 85.3% (n = 29) of patients having had an ALND did not experience lymphedema, versus 50.0% (n = 16) of ILND (p = 0.0019). The rates of permanent lymphedema for patients having undergone ALND and ILND were 11.8% (n = 4) and 37.5% (n = 12) respectively (p = 0.016, NS). The rate of transient lymphedema was 2.9% (n = 1) for ALND and 12.5% (n = 4) for ILND (p = 0.13, NS). On univariate analysis, the location of LND and wound infection were found to be significant factors for lymphedema. On multivariate analysis, only the location of LND remained a significant predictor, with the inguinal location predisposing to lymphedema. Conclusion: This study highlights the high rate of lymphedema following ILND for melanoma and is a potential target for future patients to be considered for ILR.

Ultrasound for the Objective Measurement of Breast Lymphedema

OBJECTIVES

Breast lymphedema has supplanted upper extremity lymphedema as a common and debilitating sequela of breast cancer treatment, but has no objective measurement. We assessed the utility of ultrasound-measured difference in dermal thickness between affected and unaffected breasts as a measure of breast lymphedema. We associated this measure with patient characteristics, treatment parameters, and patient-reported impact on quality of life.

METHODS

We enrolled 30 invasive breast carcinoma patients treated with breast-conserving surgery, sentinel lymph node biopsy, and radiotherapy, and 10 control patients evaluated for benign breast conditions without prior breast surgery or radiotherapy. Patient and treatment variables were ascertained from medical records and radiotherapy instruments. Impacts on quality of life were measured with a modified Disability of the Arm, Shoulder, and Hand questionnaire. We characterized breast lymphedema by calculating the difference in ultrasound-measured dermal thickness between affected and unaffected breasts. Associations with patient characteristics, treatment, and quality of life were quantified with log-binomial regression models.

RESULTS

Breast lymphedema was defined as a dermal thickness difference of >0.3 mm. Nineteen patients in the invasive group (63%) had breast lymphedema by this definition. We observed positive associations between ultrasound-defined breast lymphedema and surgical factors (size of primary tumor, number of lymph nodes removed), radiotherapy factors (breast volume irradiated, receipt of radiation boost), and patient-reported outcomes (sleep quality and overall confidence).

CONCLUSIONS

Difference in dermal thickness is an easy and inexpensive measurement for quantifying breast lymphedema, and correlates with treatment parameters and patient-reported impacts on quality of life.

Use of Dual-Energy X-Ray Absorptiometry to Assess Soft Tissue Composition in Breast Cancer Survivors With and Without Lymphedema

Background: In patients with lymphedema (LE), in addition to hand dominance, between-group comparisons of interlimb soft tissue differences need to account for differences in whole-body adiposity, measured directly by dual energy X-ray absorptiometry (DXA) or indirectly by body mass index. No study has evaluated the effects of hand dominance and whole-body adiposity on limb composition in patients with LE. This study's purpose was to compare soft tissue composition of affected and unaffected limbs of women with breast cancer, who did and did not have LE, controlling for dominance and percent body fat. Methods and Results: Whole-body DXA scans were acquired and included measures of percent body fat, upper limb total mass, upper limb fat mass, and upper limb fat-free mass. Participants were classified into one of three groups: women without LE; women with only subjective LE; and women with objective signs of LE at the time of assessment. Differences among the LE groups were evaluated using analysis of variance (ANOVA) and Chi-square analyses. Analysis of covariance (ANCOVA) was used to control for percent body fat and for the affected limb dominance. Compared to women without LE, women with objective signs of LE have greater total limb mass, fat mass, and fat-free mass in their affected limbs, independent of affected side dominance and percent body fat. In addition, the interlimb differences in total mass, fat mass, and fat-free mass were greater for the women with objective signs of LE, compared to the other two groups. Conclusions: DXA is useful in identifying soft tissue changes in patients with LE. Given that limb circumferences measure only changes in limb volume and that bioimpedance provides estimates of extracellular fluid, DXA has the advantage of being able to estimate the volumes of specific tissues in the limb.

Effect of Supervised Resistance Training on Arm Volume, Quality of Life and Physical Perfomance Among Women at High Risk for Breast Cancer-Related Lymphedema: A Study Protocol for a Randomized Controlled Trial (STRONG-B)

Objectives

To determine the preventive effects of supervised resistance training on arms volume, quality of life, physical performance, and handgrip strength in Chilean women at high risk for breast cancer-related lymphedema (BCRL) undergoing chemotherapy.

Design

Randomized control trial.

Participants

One hundred and six women at high risk for breast cancer-related lymphedema aged 18 to 70 years.

Interventions

Participants will be randomized into two groups: [a] intervention, who will receive 12 weeks of supervised resistance training (STRONG-B) during adjuvant chemotherapy; and [b] control, who will receive education to promote lymphatic and venous return, maintain range of motion, and promote physical activity.

Main Outcome Measures

The primary outcome will be arms volume measured with an optoelectric device (perometer NT1000). Secondary outcomes will be quality of life, handgrip strength, and physical performance. Primary and secondary outcomes will be measured at baseline, just after the intervention, and 3 and 6 months after. Statistical analysis will be performed following intention-to-treat and per-protocol approaches. The treatment effect will be calculated using linear mixed models.

Discussion

The STRONG-B will be a tailored supervised resistance training that attempts to prevent or mitigate BCRL in a population that, due to both intrinsic and extrinsic factors, will commonly suffer from BCRL.

Clinical Trial Registration

[https://clinicaltrials.gov/ct2/show/NCT04821609], identifier NCT04821609.

Assessment of Arm Volume Using a Tape Measure Versus a 3D Optical Scanner in Survivors with Breast Cancer-Related Lymphedema

Background: Lymphedema (LE) is a significant clinical problem for breast cancer survivors. While the water displacement test and circumferential assessment using a tape measure (TM) are common methods to assess differences in arm volumes, faster and more reliable methods are needed. Study purposes, in breast cancer survivors (n = 294), were to compare the average total arm volumes and interlimb volume ratios for women with and without a history of LE, using a TM and three-dimensional (3D), whole-body surface scanner (3D scan); compare the level of agreement between arm volumes and interlimb volume ratios obtained using the two devices; and evaluate the percent agreement between the two measures in classifying cases of LE using three accepted thresholds. Methods and Results: Measurements were done using a spring-loaded TM and Fit3D ProScanner. Paired t-tests and Bland-Altman analyses were used to achieve the study aims. For circumference and volume comparisons, compared with the 3D scan, values obtained using the TM were consistently smaller. In terms of level of agreement, the Bland-Altman analyses demonstrated large biases and wide limits of agreement for the calculated arm volumes and volume ratios. In terms of the classification of caseness, using the 200-mL interlimb volume difference criterion resulted in 81.6% overall agreement; using the >10% volume difference between the affected and unaffected arms resulted in 78.5% overall agreement; and using the volume ratio ≥1.04 criterion resulted in 62.5% overall agreement. For all three accepted threshold criteria, the percentage of cases was significantly different between the TM and 3D scan techniques. Conclusions: The 3D technology evaluated in this study has the potential to be used for self-initiated surveillance for LE. With improvements in landmark identification and software modifications, it is possible that accurate and reliable total arm volumes can be calculated and used for early detection.

The Alberta moving beyond breast cancer (AMBER) cohort study: baseline description of the full cohort

Purpose

The Alberta Moving Beyond Breast Cancer (AMBER) Study is an ongoing prospective cohort study investigating how direct measures of physical activity (PA), sedentary behavior (SB), and health-related fitness (HRF) are associated with survival after breast cancer.

Methods

Women in Alberta with newly diagnosed stage I (≥ T1c) to IIIc breast cancer were recruited between 2012 and 2019. Baseline assessments were completed within 90 days of surgery. Measurements included accelerometers to measure PA and SB; a graded treadmill test with gas exchange analysis to measure cardiorespiratory fitness (VO_2peak); upper and lower body muscular strength and endurance; dual-X-ray absorptiometry to measure body composition; and questionnaires to measure self-reported PA and SB.

Results

At baseline, the 1528 participants’ mean age was 56 ± 11 years, 59% were post-menopausal, 62% had overweight/obesity, and 55% were diagnosed with stage II or III disease. Based on device measurements, study participants spent 8.9 ± 1.7 h/day sedentary, 4.4 ± 1.2 h/day in light-intensity activity, 0.9 ± 0.5 h/day in moderate-intensity activity, and 0.2 ± 0.2 h/day in vigorous-intensity activity. For those participants who reached VO_2peak, the average aerobic fitness level was 26.6 ± 6 ml/kg/min. Average body fat was 43 ± 7.1%.

Conclusion

We have established a unique cohort of breast cancer survivors with a wealth of data on PA, SB, and HRF obtained through both direct and self-reported measurements. Study participants are being followed for at least ten years to assess all outcomes after breast cancer. These data will inform clinical and public health guidelines on PA, SB, and HRF for improving breast cancer outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10552-021-01539-6.

A Comparison of Supine Versus Stand-on Bioimpedance Devices to Assess Breast Cancer-Related Lymphedema

Background: While supine bioimpedance devices are used to evaluate for lymphedema (LE), stand-on devices are gaining popularity. Because research on differences in bioimpedance values between the two devices is limited, this study's purposes were to: (1) determine the average upper limb impedance values and inter-limb ratios for women who self-reported having (n = 34) or not having (n = 61) a history of LE, using a single-frequency supine device and a multifrequency stand-on device; (2) compare the level of agreement in inter-limb impedance ratios between the two devices; evaluate the percent agreement between the two devices in classifying cases of LE using established supine thresholds; and evaluate the percent agreement in classifying cases of LE between the supine device using previously established supine thresholds and the stand-on device using two published standing thresholds. Methods and Results: Bioimpedance measures were done using the two devices. For the entire sample, absolute impedance values for both the affected and unaffected limbs were significantly higher for the stand-on device in women with and without LE. Impedance values for the two methods were highly correlated. Bland-Altman analysis determined that for the entire range of impedance ratios the values for the two devices could not be used interchangeably. Conclusions: Findings suggest that the stand-on device can be a useful and valid tool to assess for LE. However, because agreement is not perfect, values obtained from the two devices should not be used interchangeably to evaluate for changes in impedance ratios, particularly for ratios of >1.20.

Assessment of Potential Risk Factors and Skin Ultrasound Presentation Associated with Breast Cancer-Related Lymphedema in Long-Term Breast Cancer Survivors

Breast cancer has been reported to have the highest survival rate among various cancers. However, breast cancer survivors face several challenges following breast cancer treatment including breast cancer-related lymphedema (BCRL), sexual dysfunction, and psychological distress. This study aimed to investigate the potential risk factors of BCRL in long term breast cancer survivors. A total of 160 female breast cancer subjects were recruited on a voluntary basis and arm lymphedema was assessed through self-reporting of diagnosis, arm circumference measurement, and ultrasound examination. A total of 33/160 or 20.5% of the women developed BCRL with significantly higher scores for upper extremity disability (37.14 ± 18.90 vs. 20.08 ± 15.29, p < 0.001) and a lower score for quality of life (103.91 ± 21.80 vs. 115.49 ± 16.80, p = 0.009) as compared to non-lymphedema cases. Univariate analysis revealed that multiple surgeries (OR = 5.70, 95% CI: 1.21–26.8, p < 0.001), axillary lymph nodes excision (>10) (OR = 2.83, 95% CI: 0.94–8.11, p = 0.047), being overweight (≥25 kg/m²) (OR = 2.57, 95% CI: 1.04 – 6.38, p = 0.036), received fewer post-surgery rehabilitation treatment (OR = 2.37, 95% CI: 1.05–5.39, p = 0.036) and hypertension (OR = 2.38, 95% CI: 1.01–5.62, p = 0.043) were associated with an increased risk of BCRL. Meanwhile, multivariate analysis showed that multiple surgeries remained significant and elevated the likelihood of BCRL (OR = 5.83, 95% CI: 1.14–29.78, p = 0.034). Arm swelling was more prominent in the forearm area demonstrated by the highest difference of arm circumference measurement when compared to the upper arm (2.07 ± 2.48 vs. 1.34 ± 1.91 cm, p < 0.001). The total of skinfold thickness of the affected forearm was also significantly higher than the unaffected arms (p < 0.05) as evidenced by the ultrasound examination. The continuous search for risk factors in specific populations may facilitate the development of a standardized method to reduce the occurrence of BCRL and provide better management for breast cancer patients.

Treatment of Breast Cancer-Related Lymphedema Using Negative Pressure Massage: A Pilot Randomized Controlled Trial

OBJECTIVE

To evaluate the efficacy of negative pressure massage treatment (NPMT) compared with manual lymphatic drainage (MLD) in women with chronic breast cancer-related lymphedema (LE). We hypothesized that NPMT would result in greater improvements in LE and upper limb function.

DESIGN

Pilot single-blinded randomized controlled trial.

SETTING

Health sciences university.

PARTICIPANTS

Of 64 women screened, 28 met eligibility requirements (ie, >18y of age; completed active treatment for breast cancer; had unilateral arm LE for ≥1y; were not receiving LE care; had stable LE) and were randomized to the NPMT (n=15) and control groups (n=13).

INTERVENTIONS

The intervention group received NPMT and the control group received MLD; both received twelve 60-minute sessions over 4-6 weeks.

MAIN OUTCOME MEASURES

Bioimpedance (lymphedema index [L-Dex] units]), limb volume (mL) calculated from limb circumference, and Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) score.

RESULTS

Outcomes were analyzed for 28 women. Compared to the MLD group, the NPMT group demonstrated greater improvement with a large effect size in L-Dex scores (P=.001; standardized mean difference [SMD]=-1.15; 95% confidence interval, -1.96 to -0.35) and interlimb volume differences (P=.038; SMD=-0.83; 95% confidence interval, -1.60 to -0.05). Differences in DASH scores were not statistically significant (P=.067).

CONCLUSIONS

Compared to MLD, treatment with NPMT resulted in greater improvement in L-Dex scores and interlimb volume differences in women with a duration of unilateral upper limb LE of >1 year. Our findings need to be confirmed in a larger randomized controlled trial.

Patient-Reported Outcome Measures With Secondary Lower Limb Lymphedemas: A Systematic Review

Background

Patient-reported outcome measures are measures of patients' health-related quality of life. They should be added to other lymphedema measurements. With an improved disease-free survival of secondary lower limb lymphedema, attention must focus on such assessments.

Objective

The objectives of this study were to locate and critically appraise suitable patient-reported outcomes measures for lower limb lymphedemas and search for existing valid translations for native German speakers.

Methods

A systematic literature research was conducted. 20 semantical categories for qualitative analysis were evolved. Six questionnaires available in English and some in validated translations remained for analysis.

Results

Lower limb lymphedema patients experience poor quality of life, and one of the most critical denominators is skin quality. To establish skin care and prevent cellulitis, patients must learn about skin problems. Only two tools asked for past infections. This is considered crucial because of knowledge building and prophylactic behavior. Questions on movement restrictions were available in one questionnaire. As these have a close connection to one's ability to perform activities of daily life, they can affect quality of life. Afflicted patients have problems with the choice and availability of clothing. Only three questionnaires asked questions about clothing or shoes. Lymphedema patients are exposed to more psychological stress than healthy subjects, but only three questionnaires covered questions about this burden. There was a lack of reporting on psychometric data (Cronbach's alpha, intraclass correlation), which hinders the external validity. Analyzed questionnaires were available in English but only one in German.

Conclusions

The analyzed questionnaires were in English, and only one was adapted and tested for native German speakers. For clinical practice, Devoogdt's questionnaire is recommended despite some shortcomings. There is a need for validated lymphedema questionnaires in German.

Self-reported questionnaires for lymphoedema: a systematic review of measurement properties using COSMIN framework

INTRODUCTION

Lymphoedema may develop as a result of numerous genetic and traumatic causes; however, treatment for cancer is the most common cause of its development in more economically developed nations. This systematic review critically appraised, compared and summarised the measurement properties of lymphoedema-specific self-reported questionnaires (SRQs) measuring various patient-reported outcomes including quality of life (QOL), function, morbidity, and symptoms.

METHODS

Seven databases were searched to identify studies of the measurement properties of SRQs. Two review teams independently evaluated the quality of the individual studies using the risk of bias tool from the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN). Measurement properties of the SRQs presented in the studies were then rated. Study level ratings were summarised for an SRQ if they were reported in multiple studies, and their overall quality of the evidence were then graded.

RESULTS

Forty articles, reporting on 19 SRQs were identified from 8615 records. The focus of the 19 SRQs included eight on QOL, four on symptoms, two on function, and two on impairment. The other three SRQs were on illness perception, self-efficacy, and patient-relevant treatment benefit, respectively. Eight and three SRQs were upper limb and lower limb-specific, respectively, whereas seven questionnaires were for both upper and lower limb lymphoedema. One SRQ was developed for head and neck lymphoedema. According to the COSMIN framework, none of the SRQs reviewed had sufficient evidence to support all nine measurement properties. In lower limb questionnaires, the LYMQOL-leg has sufficient content, structural, and construct validity as well as internal consistency and reliability. For upper limb lymphoedema questionnaires, the Lymph-ICF-UL had sufficient content and construct validity as well as reliability.

CONCLUSION

LYMQOL-leg SRQ is recommended with confidence for evaluation of QOL of people with lower limb lymphoedema while the Lymph-ICF-UL is recommended for evaluation of the QOL of the breast cancer-related lymphoedema with some confidence. In view of the high level of the indeterminate ratings of the measurement properties of the existing SRQs, further research is desirable.

A systematic review of rehabilitation and exercise recommendations in oncology guidelines

Guidelines promote high quality cancer care. Rehabilitation recommendations in oncology guidelines have not been characterized and may provide insight to improve integration of rehabilitation into oncology care. This report was developed as a part of the World Health Organization (WHO) Rehabilitation 2030 initiative to identify rehabilitation-specific recommendations in guidelines for oncology care. A systematic review of guidelines was conducted. Only guidelines published in English, for adults with cancer, providing recommendations for rehabilitation referral and assessment or interventions between 2009 and 2019 were included. 13840 articles were identified. After duplicates and applied filters, 4897 articles were screened. 69 guidelines were identified with rehabilitation-specific recommendations. Thirty-seven of the 69 guidelines endorsed referral to rehabilitation services but provided no specific recommendations regarding assessment or interventions. Thirty-two of the 69 guidelines met the full inclusion criteria and were assessed using the AGREE II tool. Twenty-one of these guidelines achieved an AGREE II quality score of ≥ 45 and were fully extracted. Guidelines exclusive to pharmacologic interventions and complementary and alternative interventions were excluded. Findings identify guidelines that recommend rehabilitation services across many cancer types and for various consequences of cancer treatment signifying that rehabilitation is a recognized component of oncology care. However, these findings are at odds with clinical reports of low rehabilitation utilization rates suggesting that guideline recommendations may be overlooked. Considering that functional morbidity negatively affects a majority of cancer survivors, improving guideline concordant rehabilitative care could have substantial impact on function and quality of life among cancer survivors.

Implementing a prospective surveillance and early intervention model of care for breast cancer-related lymphedema into clinical practice: application of the RE-AIM framework

PURPOSE

Chronic lymphedema following breast cancer (BC) affects individuals physically, functionally, psychologically, and financially. Despite national guidelines and evidence-based research supporting a prospective surveillance and early intervention model of care (PSM), bridging the gap between research and clinical practice has been difficult.

METHOD

As part of an international randomized controlled trial (RCT), Australian women with BC from four hospitals were recruited, monitored for lymphedema at regular intervals over a 3-year period, and were provided a compression garment if intervention was triggered. The reach, effectiveness, adoption, implementation and maintenance (RE-AIM) evaluation framework was used retrospectively to assess a PSM at the individual and organizational level for those who had completed at least 2-year follow-up (N = 219) in the RCT.

RESULTS

The application of the RE-AIM framework retrospectively demonstrated an extensive reach to patients across public and private settings; the effectiveness of prospective surveillance and early intervention was achieved through low progression rates to clinical lymphedema (1.8%), and all hospital sites initially approached adopted the research study. Key implementation strategies necessary for effectiveness of this model of care included education to health professionals and patients, staff acceptability, and development of a referral and care pathway. Maintenance dimensions were evaluated both at the individual level with 92-100% adherence rates for all nonoptional study appointments over the 2-year period, and at the organizational-level, PSM was sustained after recruitment ceased for the research study.

CONCLUSION

The PSM for lymphedema in BC can be successfully implemented using the RE-AIM framework applied retrospectively. The implementation of the PSM used in the RCT has assisted in changing clinical practices and improving the quality and effectiveness of the health care system.

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.

Interventions for Breast Cancer-Related Lymphedema: Clinical Practice Guideline From the Academy of Oncologic Physical Therapy of APTA

A work group from the American Physical Therapy Association (APTA) Academy of Oncologic Physical Therapy developed a clinical practice guideline to aid clinicians in identifying interventions for people with breast cancer-related lymphedema, targeting volume reduction, beginning at breast cancer diagnosis and continuing through cancer treatments and survivorship. Following a systematic review of published studies and a structured appraisal process, recommendations were developed to guide physical therapists and other health care clinicians in their intervention selection. Overall, clinical practice recommendations were formulated based on the evidence for each intervention and were assigned a grade based on the strength of the evidence. The evidence for each specific intervention was synthesized and appraised by lymphedema stage, when the information was available. In an effort to make recommendations clinically applicable, they were presented by modality throughout the care trajectory. Methodology and research populations varied significantly across studies, and it will be important for future research to use standardized definitions for participant characteristics, diagnostic criteria, and interventions.

Assessing Arm Volume in People During and After Treatment for Breast Cancer: Reliability and Convergent Validity of the LymphaTech System

BACKGROUND

There are challenges related to the accurate and efficient measurement of lymphedema in people with breast cancer. The LymphaTech 3D Imaging System (LymphaTech, Atlanta, GA, USA) is a mobile, noninvasive platform that provides limb geometry measurements.

OBJECTIVE

The objective of this study was to estimate the reliability and validity of the LymphaTech for measuring arm volume in the context of women seeking care in a specialty breast cancer rehabilitation clinic.

DESIGN

This was a cross-sectional reliability and convergent validity study.

METHODS

People who had stage I to IV breast cancer with lymphedema or were at risk for it were included. Arm volume was measured in 66 participants using the LymphaTech and perometer methods. Test-retest reliability for a single measure, limb volume difference, and agreement between methods was analyzed for 30 participants. A method-comparison analysis was also used to assess convergent validity between methods.

RESULTS

Both LymphaTech and perometer methods displayed intraclass correlation coefficients (ICCs) of ≥0.99. The standard errors of measurement for the LymphaTech and length-matched perometer measurements were nearly identical. Similar intraclass correlation coefficients (0.97) and standard errors of measurement (38.0-40.7 mL) were obtained for the between-limb volume difference for both methods. The convergent validity analyses demonstrated no systematic difference between methods.

LIMITATIONS

The sample size was not based on a formal sample size calculation. LymphaTech measurements included interrater variance, and perometer measurements contained intrarater variance.

CONCLUSIONS

The LymphaTech had excellent test-retest reliability, and convergent validity was supported. This technology is efficient and portable and has a potential role in prospective surveillance and management of lymphedema in clinical, research, and home settings.

Lymphedema in survivors of breast cancer

The tremendous improvement of survival in patients with breast cancer can be attributed to several treatment strategies, but these strategies also lead to the occurrence of breast cancer-related lymphedema (BCRL). BRCL is regularly associated with factors such as axillary lymph node dissection and local lymph node radiotherapy and manifests as an increase of >10% in the volume of affected limbs. Being overweight or having obesity (body mass index ≥25 kg/m2), an excessive number of positive lymph nodes (>8) and capsular invasion by a tumor are additional risk factors for lymphedema. It is worth assessing the risk before surgery as this can prevent the occurrence of BCRL at the initial stage of breast cancer management. The clinical utility of many diagnostic tools and lymphedema surveillance allows early stage and even subclinical BCRL to be diagnosed, and allows real-time monitoring of the disease. The early diagnosis of BRCL allows treatment at an early stage, which is beneficial to the reduction of excess limb volume and the improvement of quality of life. At present, the major therapeutic methods of BCRL include complex decongestive therapy, pneumatic compression devices, participating in exercise, microsurgery and liposuction, each of which alleviates lymphedema effectively. No medications for treatment of BRCL have yet been developed. However, the recent findings on the success of molecular therapy in animal models may remedy this deficiency. Furthermore, the volume reduction of swollen limbs without swelling rebound by transplanting autologous stem cells has been successfully reported in some pilot studies, which may provide a new technique for treating BCRL. This review aimed to discuss the pathogenesis, clinical manifestation, risk factors, advantages and disadvantages of diagnostic tools, lymphedema surveillance and the characteristics of traditional and newly emerging BCRL treatments.

Examining Obesity in Lymphedema: A Retrospective Study of 178 New Patients with Suspected Lymphedema at a Canadian Hospital-Based Clinic

Purpose: Physiotherapists have an important role to play in the early detection and treatment of lymphedema, a chronic inflammatory condition characterized by excess interstitial protein-rich fluid, which is estimated to affect more than one million Canadians. Obesity has been identified both as an important cause of and as a risk factor for developing lymphedema of various aetiologies. Little is currently known about obesity in Canadians affected by lymphedema. The objective of this study was to report on the prevalence of overweight and obesity in a Canadian lymphedema clinic population and the relationships among BMI; demographic, medical, and lymphedema characteristics; and cellulitis history. Method: We conducted a retrospective electronic record review of the clinical data collected from new patients evaluated for suspected lymphedema at a specialized Canadian hospital-based clinic over a 2-year period. We used descriptive analyses to characterize the sample and one-way analysis of variance and χ2 tests for comparative analyses. Results: Of the 178 patients whose records were reviewed, 36.5% were classified as overweight and 39.3% as obese. Patients with non-cancer diagnoses had a higher mean BMI than those with cancer-related diagnoses (p < 0.001). A higher BMI was associated with a longer time since lymphedema onset (p < 0.001), bilateral lymphedema (p = 0.010), and history of cellulitis (p < 0.001). Conclusions: Obesity is prevalent in the Canadian population with lymphedema and is associated with delayed referral and increased cellulitis rates. Early detection and tailored management strategies are needed to address obesity in patients with lymphedema and the complexities associated with these two related conditions.

Effects of Different Bandaging Methods for Treating Patients With Breast Cancer-Related Lymphedema

Objective

To compare the treatment effects, satisfaction with the treatment, and performance improvement following bandage treatment using the spiral method and spica method for breast cancer-related lymphedema (BCRL).

Methods

A prospective study with 46 patients with BCRL was conducted. All patients were divided into either the spiral or spica group for non-elastic bandage therapy and received the same treatment for 2 weeks, apart from the group-specific bandaging method used. For both groups, the Quality of Life Instrument score before treatment, changes in the volume of lymphedema limb and the Disability of the Arm, Shoulder, and Hand (DASH) score before and after treatment, and treatment satisfaction after treatment were compared. The Student t-test was used to compare the parameters between the two different bandage methods.

Results

With respect to the treatment outcomes, total volume reduction and proximal part volume reduction after treatment were 98.0±158.3 mL and 56.0±65.4 mL in the spiral method group and 199.0±125.1 mL and 106.1±82.2 mL in the spica method group, respectively. Therefore, the spica method group showed a significantly better improvement (p<0.05). The DASH score changes after treatment showed that the spiral group score increased by 3.8±5.4 and the spica group score increased by 7.7±6.1; thus, a significantly better improvement was noted in the spica group (p<0.05).

Conclusion

The spica method indicated better volume reduction and DASH score improvement than the spiral method. Therefore, the spica method may be more effective for treating patients with BCRL.

Current practice trends of oedema management in the hands of people with tetraplegia in Australia

Study design

Survey research design.

Objectives

To describe current practice methods for oedema management in people with tetraplegia.

Setting

Australia.

Methods

Online survey with open and closed questions regarding clinical practice trends in the assessment and treatment of oedema in the hands in people with tetraplegia.

Results

Seventeen occupational therapists working in spinal cord injury (SCI) in Australia completed the survey. Oedema was identified by visual inspection (n = 17, 100%) and recorded using circumferential tape measurement (n = 13, 76%). Elevation was used by all participants in conjunction with compression gloves (n = 13, 76%), retrograde massage (n = 13, 76%), compression bandaging (n = 12, 71%) and the boxing glove splint (n = 9, 53%). Participants stated that oedema presented challenges to patients with difficulty exercising (n = 11, 65%), changes to body image (n = 5, 29%) and pain (n = 4, 24%).

Conclusion

Assessment and treatment practices were not consistent. Oedema in the hands in people with tetraplegia was perceived to have various impacts on a person's rehabilitation and hand function. The findings highlight the need for research evidence to guide practice.

The legacy of lymphedema: Impact on nursing practice and vascular access

Breast cancer is the most common cancer in women. Breast cancer related lymphedema (BCRL) is a chronic condition characterized by an abnormal accumulation of protein-rich fluid in tissues resulting in swelling of the upper limb or trunk after treatment. Lack of consensus on definition, classification and grading of BCRL has led to subjective and objective parameters estimating incidence and severity. Prospective studies estimate the risk of BCRL to be approximately 21.4% (14.9-29.8). In patients with axillary lymph node dissection (ALND), the estimated risk of 19% (13.5-28.2) was about four times higher than those patients who had sentinel lymph node biopsy (5.6%, 6.1-7.9). Seventy percent of these patients will experience BCRL within two years of surgery, 90% within three years, and a 1% rate per year thereafter. Many patients who have no high-risk variables such as mastectomy, ALND and radiation therapy develop BCRL. Patients fear this complication, which has no cure and no proven prevention strategies. Risk reduction strategies, primarily focused on reducing trauma to the surgical arm, are based on anecdotal information and effectively restrict the use of the at-risk limb for the patient's lifetime. Although broad risk reduction strategies have been recommended, the avoidance of needle sticks has become the most common strategy practised, enforced through institutional policies and procedures and reinforced through patient education initiatives and breast cancer support groups. Large cohort studies have found no significant association between blood draws and intravenous infusions in the surgical arm and the development of BCRL. Current literature supports that approximately 21% of patients will develop BCRL, leaving 79% free of the complication. Due to increased survival, breast cancer survivors go on to develop other healthcare issues that may require vascular access. Therefore, long-held beliefs with regards to risk factors and preventative measures need to be challenged. Education of healthcare providers, patients and support groups through the dissemination of evidence-based information on the diagnosis, prevention and treatment of BCRL is necessary to ensure that patients receive the best care possible with the least risk.

Identification and Management of Lymphedema in Patients With Breast Cancer

Breast cancer–related lymphedema (BCRL) is a potentially debilitating and often irreversible complication of breast cancer treatment. Risk of BCRL is proportional to the extent of axillary surgery and radiation. Other risk factors include obesity and infections. Given the 5-year survival rate of 90% and its potential impact on the quality of life of survivors of breast cancer, BCRL has become a significant financial burden on the health care system. Minimizing axillary surgery and radiation has been proven to reduce the risk of BCRL. Comprehensive multidisciplinary assessment at the time of initial diagnosis; early referral to physical therapy after surgery; and patient education regarding weight loss, skin, and nail care are cornerstones of the management of early-stage lymphedema. End-stage lymphedema may benefit from referral to a plastic surgeon specializing in lymphedema surgery. In this review, we attempt to review the incidence, risk factors, staging, prevention, and management of this complication of breast cancer treatment. We also describe our multidisciplinary approach for the prevention of this complication at the time of initial diagnosis.

Cancer-associated secondary lymphoedema

Lymphoedema is an oedematous condition with a specific and complex tissue biology. In the clinical context of cancer, the pathogenesis of lymphoedema ensues most typically from the modalities employed to stage and treat the cancer (in particular, surgery and radiotherapy). Despite advances in cancer treatment, lifelong lymphoedema (limb swelling and the accompanying chronic inflammatory processes) affects approximately one in seven individuals treated for cancer, although estimates of lymphoedema prevalence following cancer treatment vary widely depending upon the diagnostic criteria used and the duration of follow-up. The natural history of cancer-associated lymphoedema is defined by increasing limb girth, fibrosis, inflammation, abnormal fat deposition and eventual marked cutaneous pathology, which also increases the risk of recurrent skin infections. Lymphoedema can substantially affect the daily quality of life of patients, as, in addition to aesthetic concerns, it can cause discomfort and affect the ability to carry out daily tasks. Clinical diagnosis is dependent on comparison of the affected region with the equivalent region on the unaffected side and, if available, with pre-surgical measurements. Surveillance is indicated in this high-risk population to facilitate disease detection at the early stages, when therapeutic interventions are most effective. Treatment modalities include conservative physical strategies that feature complex decongestive therapy (including compression garments) and intermittent pneumatic compression, as well as an emerging spectrum of surgical interventions, including liposuction for late-stage disease. The future application of pharmacological and microsurgical therapeutics for cancer-associated lymphoedema holds great promise.

Perometry versus simulated circumferential tape measurement for the detection of breast cancer-related lymphedema

PURPOSE

Despite increasing emphasis on screening and early intervention for breast cancer-related lymphedema (BCRL), there is marked heterogeneity in diagnostic methodology, including for volumetric measures. This retrospective study compared two volumetric modalities, perometry and simulated circumferential tape measurement (anatomic- and interval-based), for BCRL detection.

METHODS

Between 2005 and 2017, 287 female patients with unilateral breast cancer were prospectively screened for BCRL by perometry and the relative volume change (RVC) formula. Circumferential measurement was performed by sampling at five anatomic landmark-based points or 4-cm intervals from pairs of perometer arm diameter measurements. Volumetric conversion was by a frustum model. The Bland-Altman method was used to compare segmental volume differences. Confusion matrix analysis was performed for each circumferential measurement technique against perometry.

RESULTS

Median follow-up was 34.7 months over 4 postoperative visits. There was no difference in total arm volume comparing any of the circumferential measurement techniques to perometry. Landmark-based methods significantly underestimated upper arm volume (mean difference - 207 mL [- 336, - 78 mL]) and overestimated forearm volume (mean difference + 170 mL [+ 105, + 237 mL]). Landmark-based methods had greater sensitivity and specificity compared to 4-cm interval methods for detection of both RVC ≥ 10 and 5-10%. Landmark-based methods were comparable to perometry for detection of RVC ≥ 10%, but sensitivity was only 63.2-66.7% for RVC 5-10%.

CONCLUSIONS

This hypothesis-generating study suggested the superiority of anatomic landmark-based circumferential tape measurement compared to interval-based methods, while generating questions about the underestimation of upper arm volume and overestimation of forearm volume of circumferential tape measurement compared to perometry.