Integrated Treatment of Breast Cancer-related Lymphedema: A Descriptive Review of the State of the Art.

BACKGROUND/AIM: Upper limb breast cancer-related lymphedema (BCRL) is a chronic and severe condition affecting a significant percentage of breast cancer survivors. Even though its physiopathology is well-known, there is no worldwide consensus on BCRL evaluation and a gold-standard treatment. This narrative review aims at providing a brief descriptive overview with regard to BCRL treatment modalities. MATERIALS AND METHODS: We conducted a literature search within the PubMed database, and 33 articles out of 56 were selected, including reviews, systematic reviews, and meta-analyses aiming find the most updated evidence regarding BCRL treatment modalities. RESULTS: Physical exercise (aerobic exercise, resistance exercise, aquatic therapy), bandages, and intermittent pneumatic compression were shown to be most effective in BCRL patients, in terms of swelling reduction in the acute-intensive phase. Furthermore, physical exercise was beneficial also as a maintenance tool. Manual lymphatic drainage demonstrated efficacy in preventing secondary lymphedema if applied immediately after breast cancer surgery or in early phases of BCRL or as a maintenance tool. Complementary procedures such as acupuncture, reflexology, yoga and photo-biomodulation therapy did not show conclusive results in BCRL treatment. Surgery was shown effective in managing symptoms (liposuction), preventing (lymphaticovenular anastomosis) and treating BCRL (vascularized lymph node transfer). CONCLUSION: BCRL is still a challenging condition either for breast cancer survivors and clinicians, deeply impacting patient functioning and quality of life. Due to the lack of globally accepted criteria in evaluating BCRL, to date a gold standard treatment for this widespread issue is still needed.

The effects of post-mastectomy lymphedema on balance, Kinesiophobia and fear of falling.

The purpose of this study is to investigate the effects of post-mastectomy lymphedema on balance, kinesiophobia and fear of falling. A cross-sectional study with a control group. Seventy patients and 62 healthy volunteers were included. After determining the stage and limb volumes of the patients, all participants were evaluated with scales. There was a statistically significant difference in all scales compared to the control group (p < .001). There was a correlation between the stage of lymphedema and limb volume difference, balance, kinesiophobia, fear of falling (p < .001). In proportion with its stage and severity, lymphedema causes balance disorder, kinesiophobia and fear of falling.

Correlation of older age with severity of lymphedema in breast cancer survivors: A systematic review.

BACKGROUND: Breast cancer is the most frequent cause of secondary lymphedema. Besides being progressive and chronic, lymphedema is usually hard to treat. That is why the clinicians are more focused on the prevention of its development and progression. OBJECTIVE: The aim of this study is to evaluate the possible relationship between the age of patients and the severity of breast cancer-related lymphedema (BCRL). METHODS: PubMed, Scopus, and Ovid MEDLINE databases were searched for articles, which described the relationship between aging and BCRL development. Two authors searched for and selected articles independently. RESULTS: Out of 562 studies selected, 8 studies met the inclusion criteria. However, 2 papers had the same study population, so only 7 were included in the final analysis. The total number of patients in those 7 studies was 3,904. Five out of 7 studies included in our review depicted the association of more severe forms of BCRL with older age. CONCLUSION: The final analysis showed that aging is related to the severity of BCRL. However, due to heterogeneity in study outcome reporting, the cause and effect relationship could not be determined.

Tissue Dielectric Constant Measures in Women With and Without Clinical Trunk Lymphedema Following Breast Cancer Surgery: A 78-Week Longitudinal Study.

OBJECTIVE: Following breast cancer surgery with lymph node removal, women are at risk of developing lymphedema in the upper extremity or trunk. Currently, trunk lymphedema diagnosis relies on a clinical assessment because no quantifiable standard method exists. Tissue dielectric constant (TDC) values are quantifiable measures of localized skin tissue water and may be able to detect trunk lymphedema. The goal of this study was to (1) compare parameters derived from TDC measurements with those derived from clinically accepted criteria for trunk lymphedema in women following breast cancer surgery and (2) explore the potential utility of TDC to detect trunk lymphedema early in its progression. METHODS: This prospective longitudinal study, a secondary analysis from a larger study, observed women with and without clinically determined truncal lymphedema following breast cancer surgery. TDC was measured on the lateral trunk wall at post-surgery weeks 2, 4, 12, and 78 in women who had surgical breast cancer treatment with lymph node removal. Clinical assessment for trunk lymphedema was determined at 78 weeks by a lymphedema expert. Comparison of TDC measurements in women with and without clinical trunk lymphedema was analyzed. RESULTS: Clinical assessment identified trunk lymphedema in 15 out of 32 women at 78 weeks. These women had TDC ratios statistically higher than women without truncal lymphedema. CONCLUSION: The overall findings indicate that TDC has the ability to quantify trunk lymphedema and might be valuable in early detection. IMPACT: TDC may be a beneficial tool in the early detection of breast cancer-related trunk lymphedema, which could trigger intervention. LAY SUMMARY: A new device may help recognize trunk lymphedema in patients with breast cancer so they could receive appropriate treatment.

Bioimpedance Spectroscopy for Assessment of Breast Cancer-Related Lymphedema: A Systematic Review.

Bioimpedance spectroscopy is currently used to evaluate patients with breast cancer-related lymphedema (BCRL). We aimed to describe published studies on the use of bioimpedance spectroscopy for assessment for BCRL. We queried the PubMed, Ovid Medline, and Embase databases to identify studies that evaluated the use of bioimpedance spectroscopy as an assessment tool. We searched for the keywords "bioimpedance" AND ("lymphedema" OR "lymphoedema"). We included English-language studies that reported the use of bioimpedance spectroscopy for assessment of BCRL. Out of 152, 116, and 235 articles identified in each database, respectively, only a total of 11 articles were included. Bioimpedance spectroscopy was studied as a method to assess and predict response to BCRL treatment, assess volume changes, and calibrate L-Dex scores for conversion to units of volume. All studies reported that bioimpedance spectroscopy is a promising tool for predicting response to BCRL treatment and measuring volume changes. Bioimpedance spectroscopy can be used for assessment of BCRL. However, the accuracy of bioimpedance spectroscopy for BCRL assessment has not been determined, and consequently further studies are needed.

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.

Interrater Reliability of Dynamic Muscle Testing After Breast Cancer Surgery in Women at High Risk of Lymphedema: To Improve Quality in Clinical Practice.

Background: The purpose of this study is to determine the interrater reliability of dynamic muscle tests in the early rehabilitation phase in women after breast cancer surgery with axillary lymph node dissection (ALND) based on the "preventive intervention against lymphedema after breast cancer" (LYCA) randomised controlled trial. Methods: Fifteen women treated with breast cancer surgery including ALND were recruited from participants in the LYCA trial. In this interrater reliability study, women were tested in 4 dynamic muscle tests by 2 physiotherapists at a Capital Hospital in Denmark. Intraclass correlation coefficients (ICCs) with 95% confidence intervals (CIs) was used to assess the relative reliability between raters. A Bland-Altman plot and limits of agreement were calculated to describe the absolute reliability. Results: All 6 subtests displayed high interrater reliability. ICC values were: leg press 0.96 (95% CI = 0.87-0.99), elbow flexion (contralateral) 0.94 (0.83-0.98), elbow flexion (affected arm) 0.93 (0.80-0.98), elbow extension 0.80 (0.41-0.93), shoulder abduction (contralateral) 0.89 (0.68-0.96), and shoulder abduction (affected arm) 0.91 (0.74-0.97). Cumulated interrater reliability for the test battery was very high (ICC = 0.99, 95% CI = 0.990-1.0). The absolute reliability of this study was considered high, and the absence of large shifts between mean and the line of 0 difference suggest no systematic bias that could influence clinical interpretation. Conclusions: The dynamic muscle tests evaluated in this study had high interrater reliability and can be used reliably in women in the postoperative phase after breast cancer surgery with ALND.

Correlation between patency and clinical improvement after lymphaticovenous anastomosis (LVA) in breast cancer-related lymphedema: 12-month follow-up.

PURPOSE: Breast cancer-related lymphedema (BCRL) is caused by an interruption of the lymphatic system after breast cancer treatment. Lymphaticovenous anastomosis (LVA), by which one or more patent lymphatic collecting vessels are connected to subcutaneous veins, shows promising results. Postoperatively, the patency of these anastomosis can be evaluated; however, little is known concerning the long-term patency after LVA in patients with BCRL. The aim of this study was to analyse the long-term patency, quality of life (QoL) and arm circumference after LVA, and to explore differences between patent and non-patent anastomosis and its correlation with clinical improvement. METHODS: Twenty-five patients underwent indocyanine green (ICG) lymphography, lymph ICF-questionnaire, and arm circumference measurement preoperatively and 12 months after the LVA procedure. RESULTS: Seventy-six percent of the patients showed at least one patent anastomosis after 12 months. Quality of life according to the Lymph-ICF increased significantly (p < 0.000); however, arm circumference showed no significant decrease. Sixty-five percent discontinued wearing compression stockings. The patent anastomosis group, compared with the non-patent anastomosis group showed, without significance, more improvement in QoL, arm circumference, and discontinuation of compression stockings, as well as a lower rate of infections both pre- and postoperatively, a shorter duration of lymphedema preoperatively, and a higher rate of early lymphedema and ICG stage. CONCLUSIONS: LVA showed an acceptable patency and positive correlation between a patent anastomosis and clinical improvement after 12 months. Further research with a larger study population is required to determine whether outcomes or patient characteristics significantly correlate with a patent anastomosis after LVA operation.

The Effect of Serum 25(OH)D3 Level on Breast Cancer-Related Lymphedema.

Background: The aim of this study was to evaluate the effect of serum 25-hydroxyvitamin D3 [25(OH)D3] levels on the presence and severity of lymphedema, and on the levels of pain, disability, and function in patients with breast cancer-related lymphedema (BCRL). Methods and Results: This controlled study included 71 patients diagnosed with breast carcinoma. Participants were divided into two groups. The BCRL group included 37 breast cancer patients with lymphedema and the control group included 34 breast carcinoma patients without lymphedema. Demographic information, dominant extremity, affected breast, duration of malignancy, and serum 25(OH)D3 levels were recorded for all patients. The 25(OH)D3 levels were then compared between groups. The correlations between serum 25(OH)D3 levels and the visual analog scale (VAS) and Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire (Q-DASH) scales and the volumetric and diametric differences between the upper extremities were analyzed in the BCRL group. Serum 25(OH)D3 levels did not show statistically significant differences between groups (p > 0.05). There was no correlation in the BCRL group between 25(OH)D3 levels and the VAS and Q-DASH scores or the diametric and volumetric differences of extremities (r ≤ 0.3; p > 0.05). Conclusions: Serum 25(OH)D3 levels do not appear to affect the presence or severity of lymphedema, pain, disability, or physical function in BCRL patients. In routine clinical practice, evaluation of this vitamin level does not appear to be necessary for lymphedema in BCRL patients.

Economics of Lymphovenous Bypass.

BACKGROUND: The objective of this study was to compare the economic impact of complete decongestive therapy and lymphovenous bypass in the management of upper extremity lymphedema. METHODS: Economics were modeled for a patient with breast cancer-related lymphedema undergoing three different clinical pathways: (1) complete decongestive therapy alone; (2) lymphovenous bypass no longer requiring ongoing complete decongestive therapy; or (3) lymphovenous bypass requiring ongoing complete decongestive therapy. Activity-based cost analysis identified costs incurred with complete decongestive therapy and lymphovenous bypass. Costs were retrieved from supplier price lists, physician fee schedules, lymphedema therapists, and literature reviews. The net present value of all costs incurred for each clinical pathway were calculated. RESULTS: The estimated net present value of all costs for a patient with breast cancer-related lymphedema undergoing treatment were as follows: (1) complete decongestive therapy alone ($30,400); (2) lymphovenous bypass no longer requiring ongoing complete decongestive therapy ($15,000); or (3) lymphovenous bypass requiring ongoing complete decongestive therapy ($42,100). The expected net present value of all costs for lymphovenous bypass was $26,800, which was comparable to that of complete decongestive therapy alone. Sensitivity analysis demonstrated that the expected net present value of lymphovenous bypass was dependent on the patient's life expectancy, number of bypass anastomoses, and likelihood of discontinuing complete decongestive therapy. CONCLUSIONS: Lymphedema has substantial ongoing costs irrespective of the treatment modality. The cost of lymphovenous bypass appears comparable to that of complete decongestive therapy alone-the surgical costs of lymphovenous bypass are offset by the savings from discontinued ongoing therapy. Despite its limitations as a theoretical economic model, this study provides insight into the potential economic impact of lymphovenous bypass.

Effectiveness of Yoga Interventions in Breast Cancer-Related lymphedema: A systematic review.

OBJECTIVES: To synthesize recent empirical evidence on yoga-based interventions for patients with breast cancer-related lymphedema. METHODS: We searched the PubMed/MEDLINE, Cochrane Central Register of Controlled Trials and EMBASE databases for studies published between October 2007 and September 2018 in any language. Risk of bias and methodological quality were evaluated using the PRISMA statement and checklist and the Cochrane Collaboration tool. RESULTS: There was significant improvement in lymphedema status, range of shoulder motion and spinal mobility after an 8-week yoga intervention, whereas there was no consistency in quality of life following yoga intervention. Additionally, there was no difference in lymphedema status, extracellular fluid and tissue resistance outcomes in the affected arm following a long-term yoga practice. CONCLUSION: The current findings could not be clearly demonstrated that yoga programme intervention as an addition to usual care is superior to along usual care, and keep yoga exercise does not provide significant added benefits.

Comparison of effectiveness between warm acupuncture with local-distal points combination and local distribution points combination in breast cancer-related lymphedema patients: a study protocol for a multicenter, randomized, controlled clinical trial.

BACKGROUND: Lymphedema is the most common complication after breast cancer treatment, but management of lymphedema remains a clinical challenge. Several studies have reported the beneficial effect of acupuncture for treating breast cancer-related lymphedema (BCRL). Our objective is to verify the effectiveness of warm acupuncture on BCRL and compare the effectiveness of a local distribution acupoint combination with a local-distal acupoint combination for BCRL. METHODS: This is a study protocol for a multicenter, three-arm parallel, assessor blinded, randomized controlled trial. A total of 108 participants diagnosed as BCRL will be randomly allocated in equal proportions to a local distribution acupoint (LA) group, a local-distal acupoint (LDA) group, or a waiting-list (WL) group. The LA and LDA groups will receive 20 acupuncture treatment over 8 weeks with local distribution acupoint combination and local-distal acupoint combination, respectively. The WL group will receive acupuncture treatment after the study is concluded. The primary outcome is the mean change in inter-limb circumference difference from baseline to week 8. The secondary outcomes include volume measurement, skin hardness, common terminology criteria for adverse events 4.03 (edema limbs criteria), stages of lymphedema from the International Society of Lymphology, Disabilities of the Arm, Shoulder and Hand questionnaire, and the Medical Outcome Study 36-item Short-form Health Survey. DISCUSSION: This study aims to provide data on warm acupuncture as an effective treatment for BCRL and at the same time compare the effectiveness of different acupoint combinations. TRIAL REGISTRATION: ClinicalTrials.gov: Identifier NCT03373474 . Registered on 14th December 2017.

Perioperative variations in indices derived from noninvasive assessments to detect postmastectomy lymphedema.

OBJECTIVE: This study aimed to clarify the variations in indices derived from noninvasive assessments for the early detection of postmastectomy lymphedema (LE) from 1 month preoperatively until 2 years postoperatively. METHODS: In total, 120 patients who underwent surgery for breast cancer in our institution were prospectively followed up with a questionnaire for arm swelling as well as with tape measurements, bioimpedance analysis (BIA), and skin and subcutaneous tissue ultrasound at 1 month before and 3, 6, 12, 18, and 24 months after surgery. RESULTS: Ninety-seven patients completed the study. Among 93 patients who did not present with LE, 9% complained of arm swelling even before surgery, and the incidence peaked at 17% at 6 months after surgery. There were no differences in the circumferences of the upper arm, forearm, and hand between sides throughout the study period. However, the postoperative circumference values of the upper arm only on the operation side were slightly increased compared with the preoperative values. The mean excess fluid in the arm on the operation side compared with the contralateral side, as assessed by BIA, was nearly zero throughout the study period. There were no differences in subcutaneous echogenicity or skin and subcutaneous thicknesses between the sides throughout the study period. However, time-dependent increases in subcutaneous thicknesses were noticed on both sides. Four patients (4.1%) developed LE. In three of these patients, abnormality in the BIA was recorded 6 to 12 months before presentation. Immediately after presentation, the common findings included BIA abnormality and increased subcutaneous echogenicity and skin thickness in the medial forearm. CONCLUSIONS: In this study, a complaint of arm swelling was not sensitive enough for detection of the early onset of LE because a certain number of patients constantly complained of this symptom. Measurements of circumference might help in the diagnosis of LE onset, but this method is not specific enough because these measurements are also affected by various factors. However, BIA and skin and subcutaneous ultrasound were identified as potential tools for the early detection of LE.

The Concept of Chronic Edema-A Neglected Public Health Issue and an International Response: The LIMPRINT Study.

Lymphedema has always been a neglected global health care problem. A central requirement for the development of any chronic disease is the clear use of public health definitions that can be used internationally to define populations. The term "lymphedema" has historically been defined as either primary, resulting from failure of lymphatic development, or secondary, following damage to the lymphatics (e.g., cancer treatment, injury, or filariasis). Attempts to integrate causes of edema arising from damage to the venous system or the effects of gravity, immobility, and systemic disease have rarely been integrated. More recently, the prominent role of the lymphatics in tissue fluid homeostasis in all forms of chronic edema has been recognized. These advances led to the development of the term: "Chronic edema: a broad term used to describe edema, which has been present for more than three months." It can be considered an umbrella term that includes not only conventional "lymphedema" but also chronic swelling, which may have a more complex cause. This definition has been adapted in the international epidemiology study (LIMPRINT) that identified people throughout the health and social care systems in participating countries. Clearer definitions will allow for examination of this important public health problem that is likely to escalate given the projections of an aging population with multiple comorbidities. It will be possible to define both the hidden mortality and morbidity associated with complications, such as cellulitis and the impact on health-related quality of life. This evidence is urgently required to lobby for increased resource and effective health care in an increasingly competitive health care arena in which more established conditions have greater priority and funding.

The Development and Validation of the LIMPRINT Methodology.

The acronym Limprint stands for Lymphedema IMpact and PRevalence INTernational and was run under the auspices of the International Lymphedema Framework (ILF), a charity dedicated to improving provision of care globally. The primary aim was to identify the number of people with chronic edema (chronic edema present for >3 months and due to a range of underlying etiologies and associated risk factors) within diverse health services in nine participating countries and to determine its impact using validated methods. An international protocol and sampling framework, online data capture system, and standard operating procedures were adopted. An international consensus was used to create a core data tool that covered 13 domains. Specialist data on demographics and disability, details of swelling, wounds, cancer, and health-related quality of life were also available for sites. The study protocol was designed to allow flexibility in the types of studies undertaken within complex health care systems. All cases were confirmed using the modified pitting test. Sensitivity and specificity for this method were determined in Japanese and European populations. Following confirmation of a chronic edema case, Lymphologists defined whether it was a primary of a secondary form. The study was designed to provide robust evidence that chronic edema is an important and unrecognized public health problem in health services with significant morbidity. Without evidence of the size and complexity, it will remain considered a rare phenomenon and people affected will be denied access to appropriate treatment that would allow them to have fulfilled and productive lives.

Revision of the Lymphedema Functioning, Disability and Health Questionnaire for Upper Limb Lymphedema (Lymph-ICF-UL): Reliability and Validity.

Background: Lymphedema is associated with significant physical and psychosocial problems. The Lymphedema Functioning, Disability and Health questionnaire for upper limb lymphedema is a valid and reliable tool quantifying the amount of problems in functioning in patients with breast cancer-related lymphedema. Patients suggested a revision of the scoring system to facilitate completion of the questionnaire. Therefore, adjustment of the questionnaire was carried out by implementing a numeric rating scale instead of the existing visual analog scale. Purpose of this study was to investigate reliability and validity of the revised Lymph-ICF, called the Lymph-ICF-UL. Methods and Results: Reliability and validity of the Lymph-ICF-UL were examined in 56 participants with upper limb lymphedema. Intraclass correlation coefficients for test-retest reliability ranged from 0.79 to 0.95. Cronbach's alpha coefficients for internal consistency were higher than 0.80. Face and content validity were very good because the scoring system was clear for all participants (100%), questions were understandable for all participants (100%), and all complaints due to arm lymphedema were mentioned by 98% of the participants. Construct validity was good. Convergent validity was established since four out of five expected domains of the Lymph-ICF-UL showed a moderate correlation with expected domains of the 36-Item Short-Form Health Survey questionnaire. There was good divergent validity because seven out of nine hypotheses assessing divergent validity were accepted. Conclusion: The Lymph-ICF-UL is a reliable and valid questionnaire using a simplified and clearer scoring procedure to assess impairments in function, activity limitations, and participation restrictions of patients with breast cancer-related arm lymphedema.

Breast cancer treatment-related lymphedema (BCRL): An overview of the literature and updates in microsurgery reconstructions.

Breast cancer is the most common cancer in Dharmais hospital. The treatment can give rise to breast cancer treatment-related lymphedema (BCRL) that will cause significant morbidities. Based on author's (BB) patient series in Dharmais hospital, BCRL occurred in 27.7% after axillary lymph nodes dissection (ALND). The development of diagnostic modalities as well as lymphatic microsurgery have become promising instruments for lymphedema treatment. To date, modern approach of lymphedema care and surgical intervention have not been recognized and established in Indonesia. A literature review in this field is needed to overcome our limitation in BRCL or lymphedema management.

The Danish version of Lymphoedema Functioning, Disability and Health Questionnaire (Lymph-ICF) for breast cancer survivors: Translation and cultural adaptation followed by validity and reliability testing.

PURPOSE: To translate and culturally adapt the Lymphoedema Functioning, Disability and Health Questionnaire (Lymph-ICF) for breast cancer survivors with arm lymphedema into Danish and examine its content validity and reliability. METHODS: (1) Translation and cultural adaptation was performed in 10 steps following international guidelines (International Society for Pharmacoeconomics and Outcome Research); (2) cognitive interviewing (step 7) was conducted in 15 women with breast cancer related arm lymphedema to explore understandability, interpretation, and cultural relevance; (3) after adjustments, content validity (N = 52) was explored by interviews; and (4) reliability (N = 50) examined by intraclass correlation coefficients (ICC) statistics and Cronbach alpha analysis. RESULTS: Cognitive interviewing lead to an adapted and improved version of the translated questionnaire. Content validity was supported. Internal consistency (α) for all questions was .98 and ranged for the different domains between 0.92 and 0.97. Test-retest reliability for the total score was highly satisfactory, ICC = 0.95, standard error of measurement (SEM) = 4.5 and smallest detectable change = 12.5. ICC values for the domains ranged from 0.84 to 0.94. SEM values differed for the domains, 6.4 (physical function), 5.7 (mobility activities), 7.09 (life and social activities), 9.1 (mental functions), and 10.2 (household activities). CONCLUSION: The translated and adjusted Lymph-ICF DK (Denmark) is reliable and valid, allowing for assessing self-reported impairments in function, activity limitations, and participation restrictions in Danish patients with breast cancer-related arm lymphedema.

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.

Effect of Exercise on Breast Cancer-Related Lymphedema: What the Lymphatic Surgeon Needs to Know.

BACKGROUND: Breast cancer-related lymphedema (BCRL) affects many areas of daily living. Individuals with lymphedema may experience chronic and progressive swelling, recurrent skin infections, and decreased self-image and quality of life. For many years, it was considered best practice for this population to avoid exercise; however, in recent years, research has begun to challenge this belief. This systematic review and meta-analyses examined the recent literature on the effects of exercise for patients with, or at risk for, BCRL to inform best practice. METHODS: A total of 807 articles were retrieved from CINAHL, Academic Search Complete, Medline, and PubMed. Results were systematically filtered to 26 articles through inclusion criteria, exclusion criteria, and the Effective Public Health Practice Project quality assessment tool for quantitative studies. Data were pooled from studies containing relative and absolute volume measurements of limb volume, as well as upper extremity function measured by the Disabilities of Arm, Shoulder, and Hand (DASH) questionnaire; meta-analyses were conducted using SAS software. RESULTS: The literature was reviewed and statistically analyzed. Results have indicated aerobic exercise, resistance exercise, stretching, yoga, qigong, and pilates can be safe and effective in the management of symptoms for those with, or at risk for, BCRL. CONCLUSION: Several forms of exercise appear to be safe interventions for clinicians to use when treating this population and offer benefits such as improved quality of life, strength, body mass index, and mental health and decreased pain and lymphatic swelling. Additional research should be conducted to further examine the efficacy and safety of nontraditional forms of exercise in the treatment of BCRL.