The need for preoperative baseline arm measurement to accurately quantify breast cancer-related lymphedema

Abstract

Breast cancer-related lymphedema (BCRL) is a feared outcome of breast cancer treatment, yet the push for early screening is hampered by a lack of standardized quantification. We sought to determine the necessity of preoperative baseline in accounting for temporal changes of upper extremity volume. 1028 women with unilateral breast cancer were prospectively screened for lymphedema by perometry. Thresholds were defined: relative volume change (RVC) ≥10 % for clinically significant lymphedema and ≥5 % including subclinical lymphedema. The first postoperative measurement (pseudo-baseline) simulated the case of no baseline. McNemar's test and binomial logistic regression models were used to analyze BCRL misdiagnoses. Preoperatively, 28.3 and 2.9 % of patients had arm asymmetry of ≥5 and 10 %, respectively. Without baseline, 41.6 % of patients were underdiagnosed and 40.1 % overdiagnosed at RVC ≥ 5 %, increasing to 50.0 and 54.8 % at RVC ≥ 10 %. Increased pseudo-baseline asymmetry, increased weight change between baselines, hormonal therapy, dominant use of contralateral arm, and not receiving axillary lymph node dissection (ALND) were associated with increased risk of underdiagnosis at RVC ≥ 5 %; not receiving regional lymph node radiation was significant at RVC ≥ 10 %. Increased pseudo-baseline asymmetry, not receiving ALND, and dominant use of ipsilateral arm were associated with overdiagnosis at RVC ≥ 5 %; increased pseudo-baseline asymmetry and not receiving ALND were significant at RVC ≥ 10 %. The use of a postoperative proxy even early after treatment results in poor sensitivity for identifying BCRL. Providers with access to patients before surgery should consider the consequent need for proper baseline, with specific strategy tailored by institution.

Preventing Early Postoperative Arm Swelling and Lymphedema Manifestation by Compression Sleeves After Axillary Lymph Node Interventions in Breast Cancer Patients: A Randomized Controlled Trial

“…Preoperative baseline arm measurements and monitoring after surgery, education, compression garments, exercise programs, and interdisciplinary collaboration are all interventions to consider in the development of LE surveillance. 11,12 Based on an expert consensus recommendation, 13 compression garment regime for prophylaxis could be efficient, but this needs to be verified by the principles of evidence-based medicine.…”

Diagnostic Methods, Risk Factors, Prevention, and Management of Breast Cancer-Related Lymphedema: Past, Present, and Future Directions

“…Of utmost importance, however, is establishing a screening program where newly diagnosed breast cancer patients are measured pre-operatively and post-operatively—at regularly scheduled follow-up visits—and are monitored clinically in order to screen for signs and symptoms of BCRL [7••]. Paired with an accurate analysis technique that controls for weight fluctuations, lymphedema development can be tracked accurately and effectively [53••, 54–57]. …”

“…1). From these findings, it is clear that pre-operative measurements for at-risk patients must be implemented for accurate BCRL diagnosis [53••, 54]. Furthermore, research presented on BCRL that does not include a pre-operative measurement must be reviewed closely for inaccuracies in the diagnosis of lymphedema.…”

“…This would allow for calculation of volume change as compared to baseline in order to successfully screen for, diagnose, and treat lymphedema as early as possible [7••, 53••]. …”

Reply to: Bergmann et al comment to “Patients who report cording after breast cancer surgery are at higher risk of lymphedema: Results from a large prospective screening cohort”

“…6 Lack of incorporation of a preoperative baseline measurement into BCRL diagnosis accounts for misdiagnosis rates up to 50%. 7 The third study cited by Bergmann et al was completed by their group and did not find a relationship between AWS and BCRL. 3 Their study differs from ours in terms of breast cancer treatment, BC risk in the cohort (eg, BCRL risk factors including axillary node dissection…”