Does the effect of weight lifting on lymphedema following breast cancer differ by diagnostic method: results from a randomized controlled trial

  • Sandra C. Hayes
  • Rebecca M. Speck
  • Elizabeth Reimet
  • Azadeh Stark
  • Kathryn H. SchmitzEmail author


The lymphedema diagnostic method used in descriptive or intervention studies may influence results found. The purposes of this work were to compare baseline lymphedema prevalence in the physical activity and lymphedema (PAL) trial cohort and to subsequently compare the effect of the weight-lifting intervention on lymphedema, according to four standard diagnostic methods. The PAL trial was a randomized controlled intervention study, involving 295 women who had previously been treated for breast cancer, and evaluated the effect of 12 months of weight lifting on lymphedema status. Four diagnostic methods were used to evaluate lymphedema outcomes: (i) interlimb volume difference through water displacement, (ii) interlimb size difference through sum of arm circumferences, (iii) interlimb impedance ratio using bioimpedance spectroscopy, and (iv) a validated self-report survey. Of the 295 women who participated in the PAL trial, between 22 and 52% were considered to have lymphedema at baseline according to the four diagnostic criteria used. No between-group differences were noted in the proportion of women who had a change in interlimb volume, interlimb size, interlimb ratio, or survey score of ≥5, ≥5, ≥10%, and 1 unit, respectively (cumulative incidence ratio at study end for each measure ranged between 0.6 and 0.8, with confidence intervals spanning 1.0). The variation in proportions of women within the PAL trial considered to have lymphoedema at baseline highlights the potential impact of the diagnostic criteria on population surveillance regarding prevalence of this common morbidity of treatment. Importantly though, progressive weight lifting was shown to be safe for women following breast cancer, even for those at risk or with lymphedema, irrespective of the diagnostic criteria used.


Lymphedema Breast cancer Strength training Diagnostic methods Randomized controlled trial 



This work was supported by grants from the National Cancer Institute (R01-CA106851, to Dr. Schmitz), the Geisinger Research Fund (ACR 500, to Azadeh Stark), and the National Center for Research Resources (UL1RR024134, to the University of Pennsylvania). BSN Medical provided custom-fitted compression garments to participants in the study, and the fitness centers where the weight-lifting sessions took place (YMCA of Philadelphia and Vicinity, Sisters in Shape, and the Family YMCA of Burlington County, NJ) provided discounted membership fees for study participants. We are greatly indebted to all the wonderful women who participated in this work.


  1. 1.
    National Cancer Institute, Breast Cancer (2008) Available from URL Accessed 11 May 2011
  2. 2.
    Soerjomataram I, Louwman MWJ, Ribot JG, Roukema JA, Coebergh JWW (2008) An overview of prognostic factors for long-term survivors of breast cancer. Breast Cancer Res Treat 107(3):309–330PubMedCrossRefGoogle Scholar
  3. 3.
    Peto R, Boreham J, Clarke M, Davies C, Beral V (2000) UK and USA breast cancer deaths down 25% in year 2000 at ages 20–69 years. Lancet 355(9217):1822–1823PubMedCrossRefGoogle Scholar
  4. 4.
    Ahmed RL, Prizment A, Lazovich D, Schmitz KH, Folsom AR (2008) Lymphedema and quality of life in breast cancer survivors: the Iowa women’s health study. J Clin Oncol 26:5689–5696PubMedCrossRefGoogle Scholar
  5. 5.
    Shih YC, Xu Y, Cormier JN, Giordano S, Ridner SH, Buchholz TA, Perkins GH, Elting LS (2009) Incidence, treatment costs, and complications of lymphedema after breast cancer among women of working age: a 2-year follow-up study. J Clin Oncol 27:2007–2014PubMedCrossRefGoogle Scholar
  6. 6.
    Fu MR, Ridner SH, Armer J (2009) Post-breast cancer lymphedema: part 1. Am J Nurs 109(7):48–54PubMedCrossRefGoogle Scholar
  7. 7.
    Cheville AL, McGarvey CL, Petrek JA, Russo SA, Thiadens SRJ, Taylor ME (2003) The grading of lymphedema in oncology clinical trials. Semin Radiat Oncol 13(3):214–225PubMedCrossRefGoogle Scholar
  8. 8.
    Casley-Smith JR (1995) Alterations of untreated lymphedema and it’s grade overtime. Lymphology 28(4):174–185PubMedGoogle Scholar
  9. 9.
    Damstra RJ, Voesten HG, Klinkert P, Brorson H (2009) Circumferential suction-assisted lipectomy for lymphedema after surgery for breast cancer. Br J Surg 96(8):859–864PubMedCrossRefGoogle Scholar
  10. 10.
    Hayes SC, Janda M, Cornish B, Battistutta D, Newman B (2008) Lymphoedema after breast cancer: incidence, risk factors and effect on upper body function. J Clin Oncol 26(21):3536–3542PubMedCrossRefGoogle Scholar
  11. 11.
    Clark B, Sitzia J, Harlow W (2005) Incidence and risk of arm oedema following treatment for breast cancer: a three-year follow-up study. QJM 98(5):343–348PubMedCrossRefGoogle Scholar
  12. 12.
    Norman SA, Localio AR, Potashnik SL, Simoes Torpey HA, Kallan MJ, Weber AL, Miller LT, DeMichele A, Solin LJ (2009) Lymphedema in breast cancer survivors: incidence, degree, time course, treatment, and symptoms. J Clin Oncol 27(3):390–397PubMedCrossRefGoogle Scholar
  13. 13.
    Armer JM, Stewart BR (2005) A comparison of four diagnostic criteria for lymphedema in a post-breast cancer population. Lymphat Res Biol 3(4):208–217PubMedCrossRefGoogle Scholar
  14. 14.
    Hayes SC, Janda M, Cornish B, Battistutta D, Newman B (2008) Lymphoedema secondary to breast cancer: how choice of measure influences diagnosis, prevalence and identifiable risk factors. Lymphology 41(1):18–28PubMedGoogle Scholar
  15. 15.
    Czerniec SA, Ward LC, Refshauge KM, Beith J, Lee MJ, York S, Kilbreath SL (2010) Assessment of breast-cancer-related arm lymphedema-comparison of physical measurement methods and self-report. Cancer Invest 28(1):54–62PubMedCrossRefGoogle Scholar
  16. 16.
    Cornish BH, Thomas BJ, Ward LC, Hirst C, Bunce IH (2002) A new technique for the quantification of peripheral edema with application in both unilateral and bilateral cases. Angiology 53(1):41–47PubMedCrossRefGoogle Scholar
  17. 17.
    Hayes SC, Rye S, Battistuta D, Newman B (2010) Prevalence of upper-body symptoms following breast cancer and its relationship with upper-body function and lymphoedema. Lymphology 43(4):178–187PubMedGoogle Scholar
  18. 18.
    Schmitz KH, Ahmed RL, Troxel A, Cheville A, Smith R, Lewis-Grant L, Bryan CJ, Williams-Smith CT, Greene QP (2009) Weight lifting in women with breast-cancer-related lymphedema. N Engl J Med 361(7):664–673PubMedCrossRefGoogle Scholar
  19. 19.
    Schmitz KH, Ahmed RL, Troxel AB, Cheville A, Lewis-Grant L, Smith R, Bryan CJ, Williams-Smith CT, Chittams J (2010) Weight-lifting for women at risk for breast cancer-related lymphedema: a randomized trial. JAMA 304(24):2699–2705PubMedCrossRefGoogle Scholar
  20. 20.
    Schmitz KH, Troxel AB, Cheville A, Grant LL, Bryan CJ, Gross CR, Lytle LA, Ahmed RL (2009) Physical activity and lymphedema (the PAL trial): assessing the safety of progressive strength training in breast cancer survivors. Contemp Clin Trials 30(3):233–245PubMedCrossRefGoogle Scholar
  21. 21.
    Ward LC, Bunce IH, Cornish BH, Mirolo BR, Thomas BH, Jones LC (1992) Multi-frequency bioelectrical impedance augments the diagnosis and management of lymphedema in post-mastectomy patients. Eur J Clin Invest 22(11):751–754PubMedCrossRefGoogle Scholar
  22. 22.
    Norman SA, Miller LT, Erikson HB, Norman MF, McCorkle R (2001) Development and validation of a telephone questionnaire to characterize lymphedema in women treated for breast cancer. Phys Ther 81(6):1192–1205PubMedGoogle Scholar
  23. 23.
    Cornish BH, Chapman M, Thomas BJ, Ward LC, Bunce IH, Hirst C (2000) Early diagnosis of lymphedema in postsurgery breast cancer patients. Ann N Y Acad Sci 904:571–575PubMedCrossRefGoogle Scholar
  24. 24.
    Torres Lacomba M, Yuste Sanchez MJ, Zapico Goni A, Prieto Merino D, Mayoral del Moral O, Cerezo Tellez E, Minayo Mogollon E (2010) Effectiveness of early physiotherapy to prevent lymphoedema after surgery for breast cancer: randomized, single blinded, clinical trial. BMJ 340:b5396PubMedCrossRefGoogle Scholar
  25. 25.
    Box RC, Reul-Hirche HM, Bullock-Saxton JE, Furnival CM (2002) Physiotherapy after breast cancer surgery: results of a randomised controlled study to minimise lymphoedema. Breast Cancer Res Treat 75(1):51–64PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC. 2011

Authors and Affiliations

  • Sandra C. Hayes
    • 1
  • Rebecca M. Speck
    • 2
    • 3
  • Elizabeth Reimet
    • 4
  • Azadeh Stark
    • 2
    • 5
    • 6
  • Kathryn H. Schmitz
    • 2
    • 7
    Email author
  1. 1.Queensland University of TechnologySchool of Public Health, Institute of Biomedical InnovationBrisbaneAustralia
  2. 2.Department of Biostatistics and EpidemiologyUniversity of PennsylvaniaPhiladelphiaUSA
  3. 3.Department of Anesthesiology and Critical CareUniversity of PennsylvaniaPhiladelphiaUSA
  4. 4.Department of Physical Medicine and Rehabilitation, School of MedicineUniversity of PennsylvaniaPhiladelphiaUSA
  5. 5.Center for Health ResearchGeisinger Health SystemDanvilleUSA
  6. 6.Department of PathologyHenry Ford Health SystemDetroitUSA
  7. 7.Department of Family Medicine and Community HealthUniversity of PennsylvaniaPhiladelphiaUSA

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