Comparison of relative versus absolute arm size change as criteria for quantifying breast cancer-related lymphedema: the flaws in current studies and need for universal methodology
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The purpose of this article is to evaluate arm measurements of breast cancer patients to critically assess absolute change in arm size compared to relative arm volume change as criteria for quantifying breast cancer-related lymphedema (BCRL). We used pre-operative measurements of 677 patients screened for BCRL before and following treatment of unilateral breast cancer at Massachusetts General Hospital between 2005 and 2008 to model the effect of an absolute change in arm size of 200 mL or 2 cm compared to relative arm volume change. We also used sequential measurements to analyze temporal variation in unaffected arm volume. Pre-operative arm volumes ranged from 1,270 to 6,873 mL and correlated strongly (Kendall’s τ = 0.55) with body mass index (BMI). An absolute arm volume change of 200 mL corresponded to relative arm volume changes ranging from 2.9 to 15.7 %. In a subset of 45 patients, modeling of a 2-cm change in arm circumference predicted relative arm volume changes ranging from 6.0 to 9.8 %. Sequential measurements of 124 patients with >6 measurements demonstrated remarkable temporal variation in unaffected arm volume (median within-patient change 10.5 %). The magnitude of such fluctuations correlated (τ = 0.36, P < 0.0001) with pre-operative arm volume, patient weight, and BMI when quantified as absolute volume change, but was independent of these variables when quantified as relative arm volume change (P > .05). Absolute changes in arm size used as criteria for BCRL are correlated with pre-operative and temporal changes in body size. Therefore, utilization of absolute volume or circumference change in clinical trials is flawed because specificity depends strongly on patient body size. Relative arm volume change is independent of body size and should thus be used as the standard criterion for diagnosis of BCRL.
KeywordsBreast cancer-related lymphedema Quantification of lymphedema Arm swelling Quality of life
The project described was supported by Award no. R01CA139118 (AGT) and Award no. P50CA089393 (AGT) from the National Cancer Institute. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute or the National Institutes of Health.
Conflicts of interest
The authors have no conflicts of interest to disclose.
- 6.Ward L (2009) Is BIS ready for prime time as the gold standard measure? J Lymphoedema 4(2):52–56Google Scholar
- 8.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: Month J Assoc Phys 98(5):343–348Google Scholar
- 10.International Society of Lymphology (2009) The diagnosis and treatment of peripheral lymphedema. 2009 Consensus document of the international society of lymphology. Lymphology 42:51–60Google Scholar
- 19.Wilke LG, McCall LM, Posther KE, Whitworth PW, Reintgen DS, Leitch AM, Gabram SG, Lucci A, Cox CE, Hunt KK, Herndon JE, Giuliano AE (2006) Surgical complications associated with sentinel lymph node biopsy: results from a prospective international cooperative group trial. Ann Surg Oncol 13(4):491–500PubMedCrossRefGoogle Scholar
- 24.Ancukiewicz M, Russell TA, Otoole J, Specht M, Singer M, Kelada A, Murphy CD, Pogachar J, Gioioso V, Patel M, Skolny M, Smith BL, Taghian AG (2011) Standardized method for quantification of developing lymphedema in patients treated for breast cancer. Int J Radiat Oncol Biol Phys 79(5):1436–1443PubMedCrossRefGoogle Scholar
- 27.Rockson SG (2007) Bioimpedance analysis in the assessment of lymphoedema diagnosis and management. J Lymphoedema 2(1):44–48Google Scholar
- 36.McLaughlin SA, Wright MJ, Morris KT, Giron GL, Sampson MR, Brockway JP, Hurley KE, Riedel ER, Van Zee KJ (2008) Prevalence of lymphedema in women with breast cancer 5 years after sentinel lymph node biopsy or axillary dissection: objective measurements. J Clin Oncol: Off J Am Soc Clin Oncol 26(32):5213–5219CrossRefGoogle Scholar
- 37.Lucci A, McCall LM, Beitsch PD, Whitworth PW, Reintgen DS, Blumencranz PW, Leitch AM, Saha S, Hunt KK, Giuliano AE (2007) Surgical complications associated with sentinel lymph node dissection (SLND) plus axillary lymph node dissection compared with SLND alone in the American College of Surgeons Oncology Group Trial Z0011. J Clin Oncol 25(24):3657–3663PubMedCrossRefGoogle Scholar
- 38.Devoogdt N, Christiaens MR, Geraerts I, Truijen S, Smeets A, Leunen K, Neven P, Van Kampen M (2011) Effect of manual lymph drainage in addition to guidelines and exercise therapy on arm lymphoedema related to breast cancer: randomised controlled trial. BMJ 343:d5326–d5326. doi: 10.1136/bmj.d5326 PubMedCrossRefGoogle Scholar
- 44.Soran A, Wu WC, Dirican A, Johnson R, Andacoglu O, Wilson J (2010) Estimating the probability of lymphedema after breast cancer surgery. Am J Clin Oncol 34(5):506–510Google Scholar
- 45.Ashikaga T, Krag DN, Land SR, Julian TB, Anderson SJ, Brown AM, Skelly JM, Harlow SP, Weaver DL, Mamounas EP, Costantino JP, Wolmark N (2010) Morbidity results from the NSABP B-32 trial comparing sentinel lymph node dissection versus axillary dissection. J Surg Oncol 102(2):111–118PubMedCrossRefGoogle Scholar
- 48.Smith MJ, Gill PG, Wetzig N, Sourjina T, Gebski V, Ung O, Campbell I, Kollias J, Coskinas X, Macphee A, Young L, Simes RJ, Stockler MR (2009) Comparing patients’ and clinicians’ assessment of outcomes in a randomised trial of sentinel node biopsy for breast cancer (the RACS SNAC trial). Breast Cancer Res Treat 117(1):99–109PubMedCrossRefGoogle Scholar
- 53.Hollander M, Wolfe DA (1999) Nonparametric statistical methods. Wiley, New YorkGoogle Scholar
- 61.Stout NL, Pfalzer LA, Levy E, McGarvey C, Springer B, Gerber LH, Soballe P (2011) Segmental limb volume change as a predictor of the onset of lymphedema in women with early breast cancer. PM & R: J Inj, Funct, Rehabil 3(12):1098–1105Google Scholar
- 62.Caudle AS, Hunt KK, Kuerer HM, Meric-Bernstam F, Lucci A, Bedrosian I, Babiera GV, Hwang RF, Ross MI, Feig BW, Hoffman K, Litton JK, Sahin AA, Yang W, Hortobagyi GN, Buchholz TA, Mittendorf EA (2011) Multidisciplinary considerations in the implementation of the findings from the American College of Surgeons Oncology Group (ACOSOG) Z0011 study: a practice-changing trial. Ann Surg Oncol 18(9):2407–2412PubMedCrossRefGoogle Scholar