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

Effectiveness of complete decongestive therapy for upper extremity breast cancer-related lymphedema: a review of systematic reviews

Breast cancer-related lymphedema (BCRL) remains a challenging condition impacting function and quality of life. Complete decongestive therapy (CDT) is the current standard of care, necessitating a comprehensive review of its impact. This paper presents a systematic review (SR) of SRs on CDT's efficacy in BCRL, and the components of manual lymph drainage (MLD) and exercise. A literature search yielded 13 SRs published between January 2018 and March 2023 meeting inclusion criteria, with varied quality ratings based on the AMSTAR II. A sub-analysis of CDT investigated the within group effect size estimations on volume in different stages of lymphedema. While a moderate quality SR indicated support for CDT in volume reduction, other SRs on the topic were of critically low quality. Larger effect sizes for CDT were found for later stage BCRL. The impact of MLD as a component of CDT demonstrated no additional volume benefit in a mix of moderate to low quality SRs. Similarly, exercise's role in volume reduction in CDT was limited, although it demonstrated some benefit in pain and quality of life. A rapid review of trials published January 2021-March 2023 reinforced these findings. Variability in CDT delivery and outcomes remained. These findings underscore the need to standardize staging criteria and outcome measures in research and practice. Future research should focus on refining interventions, determining clinically important differences in outcomes, and standardizing measures to improve evidence-based BCRL management. Current evidence supports CDT's efficacy in BCRL. MLD and exercise as components of CDT have limited support for volume reduction.

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.

Comparison of the effects of different functional exercise sequences on lymphedema in breast cancer: protocol for an exploratory randomised controlled cross-over trial

INTRODUCTION

Breast cancer-related lymphedema (BCRL) is a common postoperative complication of breast cancer. It develops in a chronic and vicious cycle. Once lymphedema occurs, it cannot be cured and bring serious physiological, psychological, social and economic burden to patients. Upper limb functional exercises are an effective and convenient intervention for managing lymphedema. However, the optimal exercise sequence remains unclear. Therefore, we aim to compare the effects of exercise sequences under the guidance of commonly used exercise sequences and lymphatic flow theory.

METHODS

An exploratory randomised controlled cross-over trial will be conducted. 32 patients with BCRL are randomly allocated into two groups (group A and group B). Group A patients will perform functional exercise from wrist joint to shoulder joint, and the exercise direction of group B is opposite to that of group A, that is, from shoulder joint to wrist joint end. Exercise time is once a day, each 20-30 min, for 2 weeks. After 2 weeks of washout period, A and B groups of exchange exercise sequences (exercise frequency and duration unchanged). The primary outcome is upper limb circumference, and secondary outcomes are upper limb function and lymphedema symptoms.

ETHICS AND DISSEMINATION

This study protocol is presented in accordance with the Standard Protocol Items: Recommendations for Interventional Trials guidelines. All participants will sign a written informed consent. The research ethics regional committee of Shanghai Seventh People's Hospital has approved the study. Regardless of the outcome of this study, the results will be published in open-access journals to ensure public access.

TRIAL REGISTRATION NUMBER

ChiCTR2200066463.

Evaluation of upper limb lymphoedema and diagnostic accuracy of bioimpedance spectroscopy. A comprehensive validation in a Brazilian population

Lymphoedema is a complication of breast cancer treatment. Its early diagnosis is related to a good prognosis for lymphoedema treatment. The bioimpedance spectroscopy (BIS) evaluates changes in extracellular fluid. The objective of our study was to evaluate the validity, agreement and accuracy of BIS in the diagnosis of breast cancer-related lymphoedema in a Brazilian population.

Methods

This is a prospective, cross-sectional study of a convenience sample of 462 women who underwent surgical treatment for breast cancer (mastectomy or breast-conserving treatment). The validity, agreement and accuracy were performed comparing BIS (lymphoedema index (L-DEX) ≥ 6.5 or 10) with volumetry by water displacement, which is the gold standard for evaluating lymphoedema. Receiver operating characteristic curve was performed. Additionally, other methods like perimetry and indirect volumetry of the upper limbs were compared with water displacement volumetry (direct volumetry), and the BIS were compared with subjective evaluation.

Results

Considering L-DEX ≥ 10 the sensitivity of the BIS was 44.1%, specificity 95.4%, positive predictive value (PPV) was 70.7%, negative predictive value (NPV) was 87% and kappa was 0.459. The BIS with L-DEX ≥ 6.5, the sensitivity, specificity, PPV, NPV and kappa were 57%, 88.5%, 55.8%, 89% and 0.452, respectively. Area under curve was 0.724 and a possible cut-off point of L-DEX ≥ 7.35 with sensitivity of 57%, specificity of 90.7% and kappa value = 0.489.

Conclusion

Although BIS was significantly associated with the subjective evaluation of lymphoedema, it showed low sensitivity and agreement and moderate correlation when used as a method for diagnosing the condition. Thus, it is not the most valid method for evaluating lymphoedema. In addition, it was not the most accurate method when compared with other objective evaluation tools. Public health resources are scarce and must be used consciously. The knowledge that BIS is not a more accurate method than other, lower-cost instruments allows for better targeting of these resources.

Quantification of breast lymphoedema following conservative breast cancer treatment: a systematic review

PURPOSE

Breast lymphoedema is a possible side effect of breast conserving surgery, but it is poorly understood. This is due, in part, to difficulty assessing the breast. This systematic review described outcome measures that quantify breast lymphoedema signs and symptoms and evaluated the measurement properties for these outcome measures.

METHOD

Seven databases were searched using terms in four categories: breast cancer, lymphoedema and oedema, clinician reported (ClinROM) and patient reported outcome measures (PROM) and psychometric and measurement properties. Two reviewers independently reviewed studies and completed quality assessments. The Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) methodology was used for studies including measurement property evidence.

RESULTS

Fifty-six papers were included with thirteen questionnaires, eight patient-reported rating scales, seven physical measures, seven clinician-rating scales and four imaging techniques used to quantify breast lymphoedema. Based on COSMIN methodology, one ClinROM had sufficient reliability, ultrasound measuring dermal thickness. Tissue dielectric constant (TDC) measuring local tissue water had promising reliability. Four questionnaires had sufficient content validity (BLYSS, BLSQ, BrEQ and LYMQOL-Breast).

CONCLUSIONS

Ultrasound is recommended to reliably assess breast lymphoedema signs. No PROM can be recommended with confidence, but BLYSS, BLSQ, BrEQ and LYMQOL-Breast are promising. Further research is recommended to improve evidence of measurement properties for outcome measures.

IMPLICATIONS FOR CANCER SURVIVORS

There are many approaches to assess breast lymphoedema, but currently, only ultrasound can be recommended for use, with others, such as TDC and questionnaires, showing promise. Further research is required for all approaches to improve evidence of measurement properties.

Measuring Biomechanical Properties Using a Noninvasive Myoton Device for Lymphedema Detection and Tracking: A Pilot Study

Background

Improved techniques for lymphedema detection and monitoring of disease progression are needed. This study aims to use the noninvasive MyotonPRO Device to detect differences in biomechanical skin characteristics in patients with breast cancer-related lymphedema (BCRL).

Methods

The handheld Myoton device was used to measure skin parameters including dynamic skin stiffness, oscillation frequency (tone), mechanical stress relaxation time, and creep in 11 women diagnosed with BCRL. Seven anatomical sites were measured bilaterally for each participant. The average values in the affected arms were compared with those in the contralateral unaffected arms.

Results

Among the 11 female participants with unilateral BCRL Stages 0 to II, the combined averages for dynamic skin stiffness and frequency measurements were decreased in the affected arms when compared with those for the contralateral control arms (ratio < 1). The median ratio of stiffness (affected to unaffected control arm) was 0.91 (interquartile range [IQR] 0.78-1.03) while frequency was 0.94 (IQR 0.89-1.0). Skin relaxation time and creep averages were increased in the affected arms. The relaxation time median ratio (affected to unaffected control arm) was 1.07 (IQR 1.02-1.14) and the median ratio of creep was 1.06 (IQR 1.03-1.16).

Conclusions

This study suggests the Myoton can detect differences in skin biomechanical parameters of the affected and unaffected arms in patients with BCRL. Larger studies are needed to draw strong conclusions.

Staging Breast Cancer-Related Lymphedema with Bioimpedance Spectroscopy

Background: A number of different classification schemes, with generally similar but not identical criteria, exist to describe the different stages of lymphedema. Criteria may include both subjective and objective assessments. The present study investigated whether bioelectrical impedance parameters had utility in staging breast cancer-related lymphedema. Methods and Results: Hierarchical agglomerative cluster analysis was used to assign women (n = 221) at risk of or with clinically ascribed lymphedema to clusters sharing similar impedance characteristics. Five clusters could be identified with each cluster containing proportions of participants that closely aligned with staging allocation, according to International Society of Lymphology criteria, at initial presentation. The use of cluster analysis for tracking of lymphedema progression or response to treatment is demonstrated. Conclusions: No single assessment provides definitive assignment of a patient to lymphedema stage. Staging is usually achieved by identifying and allocating a patient to a lymphedema stage shared by a group of patients with similar clinical signs. Cluster analysis of impedance data provides similar groupings of patients and could provide a useful adjunct objective assessment for staging lymphedema.

Combined Complete Decongestive Therapy Reduces Volume and Improves Quality of Life and Functional Status in Patients With Breast Cancer-Related Lymphedema

BACKGROUND

The aim of this study was to evaluate the effects of complete decongestive therapy (CDT) in patients with breast cancer-related lymphedema (BCRL), in regard to volume reduction, functional status and quality of life (QoL).

METHODS

Fifty patients with unilateral BCRL were included. The demographic variables focusing on lymphedema were recorded. All patients received combined phase 1 CDT including skin-care, manual lymphatic drainage, multilayer bandaging and supervised exercises, 5 times a week for 3 weeks, as a total of 15 sessions. Patients were assessed by limb volumes and excess volumes according to geometric approximation derived from serial circumference-measurements of the limb, prior and at the end of third week. The functional disability was evaluated by quick disability of arm, shoulder and hand questionnaire (Q-DASH). QoL was assessed by the European Organization for Research and Treatment of Cancer Core Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and its breast-cancer-module (EORTC QLQ-BR23).

RESULTS

Fifty females with mean age of 53.22 ± 11.2 years were included. The median duration of lymphedema was 12 months. There were 22 patients in stage1, 26 in stage2 and 2 patients in stage3. The mean baseline limb and excess volumes were significantly decreased at the end of therapies (3262 ± 753 cm³ vs. 2943 ± 646.6 cm³ and 31.36% ± 16.5% vs. 19.12% ± 10.4%, pP= 0.000 respectively). The Q-DASH and EORTC QLQ-C30 and BR23 scores were also decreased significantly (pP< 0.05). The improvements in volumes were related negatively with the duration of lymphedema, and the stage of lymphedema.

CONCLUSION

In conclusion phase 1 CDT in a combined manner performed daily for 3 weeks, greatly reduces the volumes as well as improves the disability and QoL, especially when performed earlier.

L-Dex, arm volume, and symptom trajectories 24 months after breast cancer surgery

Purpose

Study objectives were to examine: (a) biomarker trajectories (change from presurgical baseline values of Lymphedema index (L‐Dex) units and arm volume difference) and symptom cluster scores 24 months after breast cancer surgery and (b) associations of these objective biomarkers and symptom cluster scores. Patient/treatment characteristics influencing trajectories were also evaluated.

Methods

A secondary analysis of data from the published interim analysis of a randomized parent study was undertaken using trajectory analysis. Five hundred and eight participants included in the prior analysis with 24 months of postsurgical follow‐up were initially measured with bioelectric impedance spectroscopy (BIS) and tape measure (TM) and completed self‐report measures. Patients were reassessed postsurgery for continuing eligibility and then randomized to either BIS or TM groups and measured along with self‐report data at regular and optional* visits 3, 6,12,15*,18, 21*, and 24‐months.

Results

Three subclinical trajectories were identified for each biomarker (decreasing, stable, increasing) and symptom cluster scores (stable, slight increase/decrease, increasing). Subclinical lymphedema was identified throughout the 24‐month period by each biomarker. An L‐Dex increase at 15 months in the BIS group was noted. The self‐report sets demonstrated contingency coefficients of 0.20 (LSIDS‐A soft tissue, P = .031) and 0.19 (FACTB+4, P = .044) with the L‐Dex unit change trajectories.

Conclusions

These data support the need for long‐term (24 months) prospective surveillance with frequent assessments (every 3 months) at least 15 months after surgery. Statistically significant convergence of symptom cluster scores with L‐Dex unit change supports BIS as beneficial in the early identification of subclinical lymphedema.

A systematic review of guidelines for lymphedema and the need for contemporary intersocietal guidelines for the management of lymphedema

OBJECTIVE

Lymphedema (LED) affects an estimated 35 million patients in the United States and a staggering 140,200 million people worldwide, yet LED is the forgotten vascular disease. Whereas the diagnosis and treatment of arterial and venous diseases have been strengthened by the development of clinical practice guidelines (CPGs), few CPGs are available for LED. Moreover, for CPGs to have their greatest impact, they should be both of high quality and developed using the most rigorous evidence-based methods. We performed a systematic review of the available CPGs for LED, which were assessed for breadth of content and methodologic strength.

METHODS

A literature search was conducted from National Guideline Clearinghouse (www.

GUIDELINES

gov), BMJ Clinical Evidence (http://clinicalevidence.bmj.com), and National Institute for Health and Care Excellence (http://www.nice.org.uk) as well as from MEDLINE and Google, which selected 245 documents. After a horizon scan that identified 13 potential CPGs, 4 satisfied the criteria for LED. These were analyzed for inclusion of key elements of diagnosis and treatment.

RESULTS

A horizon scan (abstract review) of the 245 documents identified 10 potential CPGs. Of the 10 documents, 6 claimed to be CPGs, but 2 were limited in scope (rehabilitation or compression only), 2 were consensus statements, 1 was a position statement, and 1 was a systematic review. This process yielded four CPGs: Lymphedema Framework Best Practice for the Management of Lymphedema; Japanese Lymphedema Study Group-A Practice Guideline for the Management of Lymphedema; Clinical Resource Efficiency Support Team Guidelines for the Diagnosis, Assessment and Management of Lymphedema; and Guidelines of the American Venous Forum. Only one of four CPGs was based on a contemporary systematic review (2016 end date of references), whereas the remainder had older systematic reviews (end dates of 2005, 2007, and 2007). Several areas of contemporary diagnosis, treatment, and monitoring of LED were absent.

CONCLUSIONS

This systematic review of available LED CPGs demonstrates a limited number of guidelines. The four CPGs identified lack contemporary references while demonstrating low overall study quality. Therefore, it is imperative for our vascular societies to develop contemporary high-quality evidence-based CPGs for LED, as they have for other vascular diseases.

Reliability and validity of a Dutch Lymphoedema Questionnaire: Cross-cultural validation of the Norman Questionnaire

OBJECTIVE

To perform the cross-cultural validation process of the Dutch Norman Questionnaire (NQ), a questionnaire for the detection and characterisation of breast-cancer related lymphoedema (BCRL) using self-reported signs and symptoms.

METHODS

Test-retest reliability and construct (including convergent, divergent and known-groups validity), face and content validity were examined in breast cancer patients with (n = 30) and without (n = 30) lymphoedema. For concurrent validity, first, agreement between the diagnostic item of the NQ and a clinical diagnosis were analysed. Second, correlations between NQ scores and clinical arm volume assessment were tested.

RESULTS

Test-retest reliability was found to be strong to very strong (ICC 0.79-0.96) in the lymphoedema group and moderate to very strong ( ICC 0.64-0.99) in the non-lymphoedema group. Seventeen out of 20 hypotheses on convergent and divergent validity were accepted. There was good face, content and known-groups validity as well. For concurrent validity, agreement between evaluation methods was only 0.462. Moderate correlations were found between 6 out of 9 symptom scores (r = 0.422-0.630) of the NQ and clinical assessment.

CONCLUSION

The Dutch NQ is a reliable and valid questionnaire for the characterisation of BCRL using self-reported signs and symptoms. Only moderate agreement for the detection of BCRL was found.

Incidence and predictors of axillary web syndrome and its association with lymphedema in women following breast cancer treatment: a retrospective study

PURPOSE

Axillary web syndrome (AWS) presents as a common postsurgical complication in individuals with breast cancer. Breast cancer-related lymphedema (BCRL) contributes to the shoulder and arm morbidity common in breast cancer survivors and often associated to cancer treatment. A paucity of literature exists evaluating the risk factors for developing AWS and the association between AWS and BCRL. The purposes of this study were (1) to identify risk factors for AWS in individuals with breast cancer, (2) to examine the association between BCRL and AWS, and (3) to determine if AWS increases the risk for developing BCRL.

METHODS

A retrospective study of 354 women who underwent breast cancer treatment and received physical therapy was included.

RESULTS

Axillary web syndrome developed in a third of women and predominately occurred in the first 8 postoperative weeks. The odds of AWS development were 73% greater for participants over the age of 60 (OR = 1.73, CI 95% 1.05-2.84). Women with AWS had 44% greater risk to develop lymphedema during the first postoperative year (RR = 1.44, CI 95% 1.12-1.84, p = 0.002). If AWS developed within the first postoperative month, women were almost 3 times more likely to develop lymphedema within the first 3 postoperative months compared with other women with AWS (RR = 2.75, CI 95% 1.199-6.310, p = 0.007).

CONCLUSIONS

Our findings suggest that 30% of breast cancer survivors will have AWS during the first year of survivorship. As institutions prioritize screening efforts, early postoperative prospective surveillance is needed for women over 60 due to high risk for AWS development and any women with AWS for increased risk of lymphedema development based on our findings.

Self-Managed Surveillance for Breast Cancer-Related Upper Body Issues: A Feasibility and Reliability Study

BACKGROUND

Early identification of breast cancer-related upper body issues is important to enable timely physical therapist treatment.

OBJECTIVE

This study evaluated the feasibility and reliability of women performing self-managed prospective surveillance for upper body issues in the early postoperative phase as part of a hospital-based physical therapy program.

DESIGN

This was a prospective, single-site, single-group feasibility and reliability study.

METHODS

Presurgery arm circumference measurements were completed at home and at the hospital by participants and by a physical therapist. Instruction in self-measurement was provided using a video guide. After surgery, all circumference measurements were repeated along with self-assessment and therapist assessment for shoulder flexion and abduction active range of motion. Feasibility was determined by recruitment/retention rates and participant-reported ease of performing self-measurements (1 [very difficult] to 10 [very easy]). Reliability was determined as intrarater reliability, interrater reliability, and agreement.

RESULTS

Thirty-three women who were 53.4 (SD = 11.4) years old participated, with recruitment and retention rates of 79% and 94%, respectively. Participant-reported ease of measurement was 8.2 (SD = 2.2) before surgery and 8.0 (SD = 1.9) after surgery. The intrarater reliability and interrater reliability were excellent before surgery (intraclass correlation coefficient [ICC] ≥ 0.94; 95% confidence interval = 0.87-0.97) and after surgery (ICC ≥ 0.91; 95% confidence interval = 0.76-0.96). Agreement between self-assessed and therapist-assessed active shoulder flexion (κ = 0.79) and abduction (κ = 0.71) was good.

LIMITATIONS

Further testing is needed using a prospective design with a longer follow-up to determine whether self-managed prospective surveillance and timely treatment can hinder the development of chronic breast cancer-related upper body issues.

CONCLUSIONS

Self-measured arm circumference and shoulder range of motion are reliable, and their inclusion in a hospital-based program of prospective surveillance for upper body issues seems feasible. This approach may improve early detection and treatment.

The Role of Physiatry Practice in a Multidisciplinary Breast Tumor Board: A Descriptive Study

BACKGROUND

Cancer rehabilitation medicine is a growing field in physiatry, but more studies are needed to demonstrate how physiatry can contribute to patient care within the cancer care continuum.

OBJECTIVE

To quantify and describe physiatric participation during a multidisciplinary tumor board for breast cancer patients.

DESIGN

A prospective descriptive study.

SETTING

A multidisciplinary breast tumor board at a large academic medical center.

PARTICIPANTS

Five hundred thirty-seven breast cancer cases presented at a multidisciplinary breast tumor board.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The number of times physiatry actively participated in a multidisciplinary breast tumor board in the categories of referral to physiatry, referral to rehabilitation services, referral to other services, advice given on patients/symptom management, and discussion of available services.

RESULTS

Out of 537 breast cancer cases presented, 221 cases (41.2%) resulted in a physiatry recommendation for referral to either physiatry, rehabilitation services, other services, or advice on patient and symptom management.

CONCLUSION

Physiatry can actively participate in the care of cancer patients during a multidisciplinary breast cancer tumor board.

Assessment of Mechanical Properties of Tissue in Breast Cancer-Related Lymphedema Using Ultrasound Elastography

Breast cancer-related lymphedema is a consequence of a malfunctioning lymphatic drainage system resulting from surgery or some other form of treatment. In the initial stages, minor and reversible increases in the fluid volume of the arm are evident. As the stages progress over time, the underlying pathophysiology dramatically changes with an irreversible increase in arm volume most likely due to a chronic local inflammation leading to adipose tissue hypertrophy and fibrosis. Clinicians have subjective ways to stage the degree and severity such as the pitting test which entails manually comparing the elasticity of the affected and unaffected arms. Several imaging modalities can be used but ultrasound appears to be the most preferred because it is affordable, safe, and portable. Unfortunately, ultrasonography is not typically used for staging lymphedema, because the appearance of the affected and unaffected arms is similar in B-mode ultrasound images. However, novel ultrasound techniques have emerged, such as elastography, which may be able to identify changes in mechanical properties of the tissue related to detection and staging of lymphedema. This paper presents a novel technique to compare the mechanical properties of the affected and unaffected arms using quasi-static ultrasound elastography to provide an objective alternative to the current subjective assessment. Elastography is based on time delay estimation (TDE) from ultrasound images to infer displacement and mechanical properties of the tissue. We further introduce a novel method for TDE by incorporating higher order derivatives of the ultrasound data into a cost function and propose a novel optimization approach to efficiently minimize the cost function. This method works reliably with our challenging patient data. We collected radio frequency ultrasound data from both arms of seven patients with stage 2 lymphedema, at six different locations in each arm. The ratio of strain in skin, subcutaneous fat, and skeletal muscle divided by strain in the standoff gel pad was calculated in the unaffected and affected arms. The p -values using a Wilcoxon sign-rank test for the skin, subcutaneous fat, and skeletal muscle were 1.24×10^-5 , 1.77×10^-8 , and 8.11×10^-7 respectively, showing differences between the unaffected and affected arms with a very high level of significance.

Intra- and Interrater Reliability and Concurrent Validity of a New Tool for Assessment of Breast Cancer-Related Lymphedema of the Upper Extremity

OBJECTIVE

The goal of this study was to develop and assess intra- and interrater reliability and validity of a clinical evaluation tool for breast cancer-related lymphedema, for use in the context of outcome evaluation in clinical trials.

DESIGN

Blinded repeated measures observational study.

SETTING

Outpatient research laboratory.

PARTICIPANTS

Breast cancer survivors with and without lymphedema (N=71).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

The assessment of intraclass correlation coefficients (ICCs) for the Breast Cancer-Related Lymphedema of the Upper Extremity (CLUE) standardized clinical evaluation tool.

RESULTS

Intrarater reliability for the CLUE tool was ICC: 0.88 (95% confidence interval [95% CI], 0.71-0.96). Interrater reliability for the CLUE tool was ICC: 0.90 (95% CI, 0.79-0.95). Concurrent validity of the CLUE score (Pearson r) was 0.79 with perometric interlimb difference and 0.53 with the Norman lymphedema overall score.

CONCLUSIONS

The CLUE tool shows excellent inter- and intrarater reliability. The overall CLUE score for the upper extremity also shows moderately strong concurrent validity with objective and subjective measures. This newly developed clinical, physical assessment of upper extremity lymphedema provides standardization and a single score that accounts for multiple constructs. Next steps include evaluation of sensitivity to change, which would establish usefulness to evaluate intervention efficacy.