Abstract OT2-5-01: The PREDICT study (prospective, randomized early detection and intervention after breast cancer - Treatment, for women at risk of lymphedema)

Introduction: It is well-documented that lymphedema is one of the most feared long-term side effects of breast cancer (BC) treatment. However, to date, a standardized approach for the quantification and treatment of breast cancer-related lymphedema (BCRL) has yet to be established.

Aims: We propose a screening and intervention trial to assess the efficacy of early detection and intervention with various treatment strategies for BCRL. Intervention comprises the use of compression garments for mild lymphedema and compression garments +/- nighttime bandaging for moderate lymphedema. Other factors to be evaluated include: symptom clusters, treatment adherence, fear avoidance behavior, quality of life (QOL), upper extremity function, and risk factors for BCRL.

Eligibility Criteria: Women 18 years + with a confirmed BC diagnosis, no history of BC, no known metastatic or locally advanced disease, no history of primary lymphedema, sentinel lymph node biopsy or axillary lymph node dissection as part of definitive breast surgery.

Study Design: A two-stage study which includes a Screening and an Intervention trial. The screening trial will evaluate arm volume change during and after BC treatment with target accrual of 8000. Currently, 1286 participants have been enrolled among three sites including MGH, MD Anderson and Brigham and Women's Hospital. Patients will undergo perometer measurements and complete the MGH Lymphedema Evaluation Following Treatment for Breast Cancer (LEFT-BC) survey at each screening assessment to evaluate changes in functionality, upper extremity utilization, fear avoidance behaviors, and QOL. Screening visits will occur pre- and post-operatively, at the conclusion of chemotherapy and/or radiation therapy and every 3-8 months thereafter. Patients will become eligible for intervention trial enrollment if, during the course of screening, unilaterally affected patients develop a relative arm volume change (RVC) of ≥ 5% or bilaterally affected patients develop a weight adjusted change (WAC) of ≥ 5% which persists at a verification measurement within 4-8 weeks. Eligible subjects will be enrolled into one of two groups based on verification RVC/WAC: Group I – Mild Lymphedema (5-10% RVC/WAC) or Group II – Moderate Lymphedema (11-20% RVC/WAC). Subjects are then randomized within each group. Group I subjects are randomized to one of two arms: I-A – Observation, I-B – Compression, and Group II subjects are randomized to one of two arms: II-A – Compression, II-B – Compression + Night Compression Bandaging. Target accrual for the intervention trial is 336 subjects (Group I: 208, Group II: 128).

Clinical Relevance: The results of this study will yield Level I evidence on the effectiveness of early detection and intervention for BCRL. Findings may shape clinical practice in diagnosis and treatment, as well as provide insight regarding the risk factors, symptoms, upper extremity function, and QOL associated with BCRL.*Funding by award #s R01CA139118 &3P5OCA089393, AGT.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT2-5-01.

A novel, validated method to quantify breast cancer-related lymphedema (BCRL) following bilateral breast surgery

We sought to develop a formula to quantify breast cancer-related lymphedema (BCRL) after bilateral breast surgery, which functions independently of the contralateral arm and accounts for fluctuations in patient weight. Perometer arm measurements from 265 unilateral breast surgery patients were analyzed. We assessed the relationship between change in patient weight and contralateral arm volume and developed a weight-adjusted volume change formula (WAC). The WAC formula and previously-established RVC formula were compared for classification of BCRL (> or = 10% volume increase) in unilateral breast surgery patients. We then evaluated BCRL incidence using the WAC formula in 225 bilateral mastectomy patients. Change in patient weight and contralateral arm volume demonstrated an approximately linear relationship. Weight-adjusted arm volume change (WAC) was therefore calculated as WAC = (A2*W1)/(W2*A1) - 1 where A1 is pre-operative and A2 is post-operative arm volume, and W1, W2 are the patient's corresponding weights. In the unilateral analysis, there was no significant difference in number of patients classified as having BCRL using the RVC and WAC formulas (p = 0.65). In bilateral mastectomy patients 11.1% (25/225) developed BCRL, defined as > or = 10% WAC. Independent risk factors for lymphedema included axillary lymph node dissection (ALND) and higher pre-operative BMI (p<0.05). Use of this weight-adjusted arm volume change formula should be of value for quantification of BCRL after bilateral breast surgery.

Abstract P6-09-04: The Association of Low Level Arm Volume Increases with Lymphedema Symptoms Following Treatment for Breast Cancer

Purpose/Objective: The symptoms associated with breast cancer-related lymphedema are well-documented, and include sensations of heaviness, swelling, and tightness in the upper extremity and trunk. However, the clinical significance of low-level arm volume changes frequently experienced by breast cancer patients is not well understood. We sought to determine the association of low level arm volume changes with patient-reported lymphedema symptoms in women treated for breast cancer.

Methods: 267 patients who underwent surgical treatment for breast cancer from 2010–2012 were identified from a cohort of patients prospectively screened for lymphedema at our institution. Patients were assessed with perometer arm volume measurements and a survey of lymphedema symptoms pre and post operatively, and at 3–7 month intervals thereafter. Inclusion in this analysis was limited to unilaterally affected women with ≥ 3 assessments and ≥ 6 months of post-surgical follow-up. Arm volume changes were quantified as Relative Volume Change (RVC): RVC = (A2*U1)/(U2*A1) − 1, where A1 is pre-operative arm volume and A2 is post-operative arm volume on the affected side, and U1 and U2 are arm volumes on the unaffected side at these time points. Low level arm volume change was defined as a measurement with RVC ≥ 5% &lt;10% at an assessment ≥ 3 months post-operatively. Actuarial univariate and multivariate regression analysis was performed to determine the association of low level arm volume change with patient-reported lymphedema symptoms and clinicopathological characteristics.

Results: Low level arm volume changes occurred in 21.7% (58/267) of patients during the follow-up period at a median of 10.4 months post-operatively. Median post-operative follow-up was 12.4 months and 5 assessments per patient. By actuarial univariate analysis, symptoms of larger arm, shoulder, or neck (p &lt; 0.001), tighter sleeve, sleeve cuff, or ring (p &lt; 0.001), and having undergone axillary lymph node dissection (p = 0.02) or regional lymph node radiation (p = 0.01) were significantly associated with low-level arm volume change. By actuarial multivariate analysis, only symptoms of larger arm, shoulder, or neck (p &lt; 0.0001) were associated with low level arm volume change.

Conclusions: This data suggests that patients may be symptomatic for lymphedema even when experiencing low level arm volume changes. These patients should be followed closely for progression of measured arm volume or heightened lymphedema symptoms suggesting progression of the condition.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-09-04.

Abstract OT3-2-02: The PREDICT Study (Prospective, Randomized Early Detection and Intervention after Breast Cancer-Treatment, for women at risk of lymphedema)

Introduction: It is well-documented that lymphedema is one of the most feared long-term side effects of breast cancer (BC) treatment. However, to date, a standardized approach for the quantification and treatment of breast cancer-related lymphedema (BCRL) has yet to be established.

Aims: We propose a screening and intervention trial that will assess the efficacy of early detection and intervention for BCRL. Intervention comprises the use of compression garments for mild lymphedema and compression garments +/− nighttime bandaging for moderate lymphedema. Other factors to be evaluated include: symptom clusters, treatment adherence, fear avoidance behavior, quality of life (QOL), upper extremity function, and risk factors for BCRL.

Eligibility Criteria: Women 18 years + with a confirmed BC diagnosis, no history of BC, no known metastatic or locally advanced disease, no history of primary lymphedema, sentinel lymph node biopsy or axillary lymph node dissection as part of definitive breast surgery.

Study Design: A two-stage study which includes a Screening and an Intervention trial. The screening arm will evaluate arm volume change during and after BC treatment with target accrual of 8000. Patients will undergo measurements via perometry and complete the MGH Lymphedema Evaluation Following Treatment for Breast Cancer (LEFT-BC) Survey at each screening appointment to evaluate changes in functionality, upper extremity utilization (fear associated avoidance), and QOL. Screening visits will occur pre- and post - operatively, at the conclusion of chemotherapy and radiation therapy and every 3–7 months thereafter. Patients will become eligible for enrollment into the intervention trial if, during the course of screening, they develop a relative arm volume change (RVC) of ≥ 5% which persists at a verification measurement within 4–8 weeks. Eligible subjects are enrolled into one of two groups based on verification RVC: Group I – Mild Lymphedema (5–10% RVC) or Group II – Moderate Lymphedema (11–20% RVC). Subjects are then randomized within each group. Group I subjects are randomized to one of two arms: I-A – Observation, I-B – Compression, and Group II subjects are randomized to one of two arms: II-A – Compression, II-B – Compression + Night Compression Bandaging. Target accrual for the intervention trial is 336 subjects (Group I: 208, Group II: 128).

Clinical Relevance: The results of this study will yield level I evidence on the effectiveness of early detection and intervention for BCRL. Findings may shape clinical practice in diagnosis and treatment, as well as provide insight regarding the risk factors, symptoms, upper extremity function, and quality of life (QOL) associated with BCRL.

*Funding by awards R01CA139118 & 3P5OCA089393, AGT

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr OT3-2-02.