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      Upper extremity impairments in women with or without lymphedema following breast cancer treatment

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          Abstract

          Introduction

          Breast-cancer-related lymphedema affects ∼25% of breast cancer (BC) survivors and may impact use of the upper limb during activity. The purpose of this study is to compare upper extremity (UE) impairment and activity between women with and without lymphedema after BC treatment.

          Methods

          144 women post BC treatment completed demographic, symptom, and Disability of Arm-Shoulder-Hand (DASH) questionnaires. Objective measures included Purdue pegboard, finger-tapper, Semmes-Weinstein monofilaments, vibration perception threshold, strength, range of motion (ROM), and volume.

          Results

          Women with lymphedema had more lymph nodes removed ( p < .001), more UE symptoms ( p < .001), higher BMI ( p = .041), and higher DASH scores (greater limitation) ( p < .001). For all participants there was less strength (elbow flexion, wrist flexion, grip), less shoulder ROM, and decreased sensation at the medial upper arm ( p < .05) in the affected UE. These differences were greater in women with lymphedema, particularly in shoulder abduction ROM ( p < .05). Women with lymphedema had bilaterally less elbow flexion strength and shoulder ROM ( p < .05). Past diagnosis of lymphedema, grip strength, shoulder abduction ROM, and number of comorbidities contributed to the variance in DASH scores ( R 2 of 0.463, p < .001).

          Implications for cancer survivors

          UE impairments are found in women following treatment for BC. Women with lymphedema have greater UE impairment and limitation in activities than women without. Many of these impairments are amenable to prevention measures or treatment, so early detection by health care providers is essential.

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          Most cited references32

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          Cancer statistics, 2006.

          Ahmedin Jemal, Rebecca Siegel, Elizabeth Ward … (2006)
          Each year, the American Cancer Society estimates the number of new cancer cases and deaths expected in the United States in the current year and compiles the most recent data on cancer incidence, mortality, and survival based on incidence data from the National Cancer Institute and mortality data from the National Center for Health Statistics. Incidence and death rates are age-standardized to the 2000 US standard million population. A total of 1,399,790 new cancer cases and 564,830 deaths from cancer are expected in the United States in 2006. When deaths are aggregated by age, cancer has surpassed heart disease as the leading cause of death for those younger than age 85 since 1999. Delay-adjusted cancer incidence rates stabilized in men from 1995 through 2002, but continued to increase by 0.3% per year from 1987 through 2002 in women. Between 2002 and 2003, the actual number of recorded cancer deaths decreased by 778 in men, but increased by 409 in women, resulting in a net decrease of 369, the first decrease in the total number of cancer deaths since national mortality record keeping was instituted in 1930. The death rate from all cancers combined has decreased by 1.5% per year since 1993 among men and by 0.8% per year since 1992 among women. The mortality rate has also continued to decrease for the three most common cancer sites in men (lung and bronchus, colon and rectum, and prostate) and for breast and colon and rectum cancers in women. Lung cancer mortality among women continues to increase slightly. In analyses by race and ethnicity, African American men and women have 40% and 18% higher death rates from all cancers combined than White men and women, respectively. Cancer incidence and death rates are lower in other racial and ethnic groups than in Whites and African Americans for all sites combined and for the four major cancer sites. However, these groups generally have higher rates for stomach, liver, and cervical cancers than Whites. Furthermore, minority populations are more likely to be diagnosed with advanced stage disease than are Whites. Progress in reducing the burden of suffering and death from cancer can be accelerated by applying existing cancer control knowledge across all segments of the population.
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            Measuring the whole or the parts? Validity, reliability, and responsiveness of the Disabilities of the Arm, Shoulder and Hand outcome measure in different regions of the upper extremity.

            D Beaton, J N Katz, A Fossel … (2001)
            The Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure was developed to evaluate disability and symptoms in single or multiple disorders of the upper limb at one point or at many points in time. The purpose of this study was to evaluate the reliability, validity, and responsiveness of the DASH in a group of diverse patients and to compare the results with those obtained with joint-specific measures. Two hundred patients with either wrist/hand or shoulder problems were evaluated by use of questionnaires before treatment, and 172 (86%) were re-evaluated 12 weeks after treatment. Eighty-six patients also completed a test-retest questionnaire three to five days after the initial (baseline) evaluation. The questionnaire package included the DASH, the Brigham (carpal tunnel) questionnaire, the SPADI (Shoulder Pain and Disability Index), and other markers of pain and function. Correlations or t-tests between the DASH and the other measures were used to assess construct validity. Test-retest reliability was assessed using the intraclass correlation coefficient and other summary statistics. Responsiveness was described using standardized response means, receiver operating characteristics curves, and correlations between change in DASH score and change in scores of other measures. Standard response means were used to compare DASH responsiveness with that of the Brigham questionnaire and the SPADI in each region. The DASH was found to correlate with other measures (r > 0.69) and to discriminate well, for example, between patients who were working and those who were not (p<0.0001). Test-retest reliability (ICC = 0.96) exceeded guidelines. The responsiveness of the DASH (to self-rated or expected change) was comparable with or better than that of the joint-specific measures in the whole group and in each region. Evidence was provided of the validity, test-retest reliability, and responsiveness of the DASH. This study also demonstrated that the DASH had validity and responsiveness in both proximal and distal disorders, confirming its usefulness across the whole extremity.
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              Prevalence of lymphedema in women with breast cancer 5 years after sentinel lymph node biopsy or axillary dissection: objective measurements.

              W Brockway, Elyn Riedel, G Giron … (2008)
              Sentinel lymph node biopsy was adopted for the staging of the axilla with the assumption that it would reduce the risk of lymphedema in women with breast cancer. The aim of this study was to determine the long-term prevalence of lymphedema after SLN biopsy (SLNB) alone and after SLNB followed by axillary lymph node dissection (SLNB/ALND). At median follow-up of 5 years, lymphedema was assessed in 936 women with clinically node-negative breast cancer who underwent SLNB alone or SLNB/ALND. Standardized ipsilateral and contralateral measurements at baseline and follow-up were used to determine change in ipsilateral upper extremity circumference and to control for baseline asymmetry and weight change. Associations between lymphedema and potential risk factors were examined. Of the 936 women, 600 women (64%) underwent SLNB alone and 336 women (36%) underwent SLNB/ALND. Patients having SLNB alone were older than those having SLNB/ALND (56 v 52 years; P < .0001). Baseline body mass index (BMI) was similar in both groups. Arm circumference measurements documented lymphedema in 5% of SLNB alone patients, compared with 16% of SLNB/ALND patients (P < .0001). Risk factors associated with measured lymphedema were greater body weight (P < .0001), higher BMI (P < .0001), and infection (P < .0001) or injury (P = .02) in the ipsilateral arm since surgery. When compared with SLNB/ALND, SLNB alone results in a significantly lower rate of lymphedema 5 years postoperatively. However, even after SLNB alone, there remains a clinically relevant risk of lymphedema. Higher body weight, infection, and injury are significant risk factors for developing lymphedema.
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                Author and article information

                Contributors
                : +1-707-4948262 , betty.smoot@ucsf.edu
                Journal
                Journal ID (nlm-ta): J Cancer Surviv
                Title: Journal of Cancer Survivorship
                Publisher: Springer US (Boston )
                ISSN (Print): 1932-2259
                ISSN (Electronic): 1932-2267
                Publication date (Electronic): 7 April 2010
                Publication date PMC-release: 7 April 2010
                Publication date (Print): June 2010
                Volume: 4
                Issue: 2
                Pages: 167-178
                Affiliations
                [1 ]Department of Physical Therapy and Rehabilitation Science, University of California San Francisco, San Francisco, CA USA
                [2 ]Department of Physiological Nursing, University of California San Francisco, San Francisco, CA USA
                [3 ]Graduate Program in Physical Therapy, San Francisco State University, San Francisco, CA USA
                [4 ]18787 Gillman Drive, Sonoma, CA 95476 USA
                Article
                Publisher ID: 118
                DOI: 10.1007/s11764-010-0118-x
                PMC ID: 2882040
                PubMed ID: 20373044
                SO-VID: f25927ce-e788-42dd-a5cd-a994fba91a08
                Copyright © © The Author(s) 2010
                History
                Date received : 23 August 2009
                Date accepted : 7 February 2010
                Categories
                Subject: Article
                Custom metadata
                issue-copyright-statement © Springer Science+Business Media, LLC 2010

                ScienceOpen disciplines: Oncology & Radiotherapy
                Keywords: breast cancer,upper extremity,movement,impairment,lymphedema
                Data availability:
                ScienceOpen disciplines: Oncology & Radiotherapy
                Keywords: breast cancer, upper extremity, movement, impairment, lymphedema

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