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Data Synopsis: Early Diagnosis and Treatment Intervention for Lymphedema

By NL Stout Gergich, MPT and PW Soballe, MD, Breast Care Center, National Naval Medical Center, Bethesda, MD
LA Pfalzer, PT, PhD, University of Michigan-Flint, Flint, MI
CL McGarvey, DPT, MS, National Institutes of Health, Bethesda, MD, Physical Therapy Dept

Relevance

• 2.3 million women are survivors of breast cancer (BC)1.
• Incidence of lymphedema (LE)
  • 33% axillary lymph node dissection (ALND) and radiation therapy (RT)2
  • 14% after sentinel lymph node biopsy and RT3
  • LE impacts quality of life; range of motion (ROM), strength and function2
• LE is a chronic condition that is progressive if untreated

Diagnosing Lymphedema

• Traditionally, the diagnosis of LE occurs after the condition becomes clinically apparent resulting in delayed treatment and progression of the condition
• Current Valid/Reliable Measurement Techniques
• Circumferential limb girth4
• Water displacement2&5
• Infrared optoelectronic5
• Bioimpedence devices 6&8
• Early detection and treatment prevents the progression of LE to an advanced stage

Purpose

• To investigate the efficacy of a prospective PT screening method to accurately diagnose sub-clinical lymphedema and to evaluate the effectiveness of an early intervention in patients recently treated for breast cancer

Methods

Design:

• A subset analysis of a cohort of women from a large IRB approved study*
• Pre-operative and follow-up bilateral arm volume measurements taken at 80% of limb length measured from ulnar styloid to tip of acromion at 1, 3, 6, 9, 12 and 18 months by optoelectronic volumeter (Perometer®)6 from 1999-2006.

Diagnostic Criteria:

• 34 women 34-85 years old (mean=55.4) reported symptoms of LE including heaviness or increased limb volume
• Intervention was introduced if the volume change equated to approximately 100 ml or 3% volume change compared to the pre-op inter-limb measures

Intervention:

• Diagnosis of LE - a Jobst Ready-Made Compression Class I sleeve and gauntlet issued for daily wear and advised to follow up in 4-6 weeks
• Volume assessment was repeated on follow up
• Upon confirmation of volume decrease, continued garment wear was prescribed with
• Strenuous exercise
• Lifting
• The appearance of visible swelling
• Sensations of heaviness, fullness, aching
• Follow up in 3 months for repeated measures

Results

• Volume increase in the AA at intervention was significant (p=0.001). Baseline to intervention averaged 6.9 mos.
• A significant (p=0.0000) mean volume decrease of 111 ml (7.6%) in the AA using the sleeve. Time to post intervention avg= 4.4 weeks
• Limb volume was maintained through follow up. Avg = 5.8 months

Conclusions

• Pre-operative assessment, prospective surveillance and early intervention may have prevented the onset of irreversible LE in this small cohort
• The garment significantly reduced affected limb volume to nearly that of the unaffected limb and therefore provides effective treatment when sub-clinical LE can be detected.
• Further research is warranted to confirm the long term effectiveness and cost effectiveness of this preventive model compared to a traditional impairment based model.

References:

1. American Cancer Society (ACS). “Breast Cancer Facts and Figures 2006.” Retrieved from the World Wide Web on July 19, 2006 at http://www.cancer.org/downloads/STT/CAFF2005BrF.pdf
2. Petrek JA, Pressman PI, and Smith RA. Lymphedema: current issues in research and management. CA Cancer J Clin. 2000 Sep-Oct;50(5):pp:292-307.
3. Haid A, Koberle-Wuhrer R, Knauer M, Burtscher J, Fritzsche H, Peschina W et al. Morbidity of breast cancer patients following complete axillary dissection or sentinel node biopsy only: a comparative evaluation. Breast Cancer Res Treat 2002; 73(1):31-36.
4. Armer J, Radina M, and Culbertson S. “Predicting Breast Cancer-Related Lymphedema Using Self-Reported Symptoms.” Nursing Research. Volume 52, No.6 (2003):pp. 370-379.
5. Hayes S, Cornish B, and Newman B. “Comparison of methods to diagnose lymphedema among breast cancer survivors: 6 months follow-up.” Breast Cancer Research and Treatment. Volume 89 (2005):pp.221-226.
6. Stanton AW, Northfied JW, Holroyd B, Mortimer PS, and Levick, JR. Validation of an optoelectronic limb volumeter (Perometer). Lymphology. 1997 vol:30 (2): pp:77 -97.
7. Cheville AL, McGarvey CL, Petrek JA, Russo SA, Thiadens SR, Taylor ME. “The Grading of Lymphedema in Oncology Clinical Trials”. Semin Radiat Oncol. 2003 Jul; 13(3): pp: 214-25.
8. American Cancer Society (ACS). “Lymphedema: What Every Woman With Breast Cancer Should Know.” Retrieved from the World Wide Web on July 01, 2006 at http://www.cancer.org/docroot/MIT/content/MIT_7_2x_Lymphedema_and_Breast_Cancer.asp

*http://clinicaltrials.gov/ct/show/NCT00027118?order=5

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