Jasmine Yee

Normative volume difference between the dominant and nondominant upper limbs in healthy older women

BACKGROUND Upper limb lymphedema is a possible consequence of the treatment for breast cancer. Accurate detection of swelling is important in implementing appropriate treatment. Currently used diagnostic cut-offs for excess volume have been chosen for ease of use and are not based on normative differences. The aim of this study, therefore, was to determine the normal inter-limb variance for healthy older women and identify statistically-based diagnostic cut-offs for both circumference and volume. METHODS AND RESULTS Two hundred and four healthy women, over the age of 40 years, with no history of treatment for breast cancer or lymphedema, underwent measurement of their upper limbs with a perometer. Using the associated software, the circumference of the limb was determined at a number of set points along the limb and the volume of the intervening segments recorded. Segment volumes were also calculated from the circumferential measurements using the formulae for a truncated cone and cylinder. The mean inter-limb difference found was small but a large range was seen for all of the circumference and volume measurements. Dominance was found to have a significant effect on the limb size. Regression analysis showed that an individuals age was negatively related to their inter-limb difference. Diagnostic cut-offs, set at three standard deviations above the mean, were determined. CONCLUSIONS New circumference and volume criteria based on normative data, taking arm dominance into consideration, will allow for more accurate diagnosis of changes in limb volume, allowing treatment to be started and monitored appropriately.

Factors Affecting the Preoperative and Postoperative Extracellular Fluid in the Arm on the Side of Breast Cancer: A Cohort Study

BACKGROUND To explore what factors affect volume of extracellular fluid (ECF) in the arm on the side of surgery pre- and postoperatively and to determine the value of knowing preoperative ECF volume for diagnosis of lymphedema postoperatively. METHODS AND RESULTS Women (N=516) with early breast cancer were assessed preoperatively and within 4 weeks postoperatively. Baseline measures included inter-arm ECF ratio, side of cancer, number of nodes involved, and other individual characteristics. Postoperative assessment included inter-limb ECF ratio and details from surgery. The postoperative ECF ratio was categorized as to whether it exceeded previously established thresholds, and the change in ECF was categorized as to whether it exceeded 0.1. Linear regression identified which factors explained the variance for preoperative ECF ratio and the change in ratio. Chi square analysis compared whether women categorized using thresholds were the same as those whose ratio increased >0.1 postoperatively. Postoperative ECF ratio was significantly higher than the preoperative ratio (p<0.001). Women whose ECF ratio exceeded previously established thresholds were not the same as those whose ratio increased >0.1 postoperatively (p<0.001). Only the side of surgery explained the preoperative ECF measure; extent of surgery and actual weight explained the change in ECF ratio. CONCLUSION The ECF ratio preoperatively is not affected by nodal involvement. The change in ECF ratio is affected by the extent of surgery and body mass. Change from preoperative ECF ratio did identify more women at risk for lymphedema than reliance postoperatively on thresholds, supporting preoperative measures.

Living Well? Strategies Used by Women Living With Metastatic Breast Cancer

Metastatic breast cancer is a disease of changing status—once an imminent death sentence, now a chronic (albeit incurable) disease. Medical intervention advances mean women with metastatic breast cancer now have symptoms alleviated and, potentially, life extended. Living with this disease, however, requires more than a medical approach to symptoms. We were interested to know whether women manage, and if so, how, to “live well” with metastatic cancer. We conducted interviews with 18 women. Women differed in the approaches they used. Most common was the attempt to reestablish a sense of normality in their lives. However, a second group reevaluated and reprioritized their lives; and a third group was restricted in their capacity to live well because of symptoms. The findings provide the foundation for future research exploring normalization of experiences of metastatic cancer, and other chronic illnesses, where people are living with knowledge that they have contracted time.

A qualitative study of women's experiences of healthcare, treatment and support for metastatic breast cancer

OBJECTIVE The purpose of this qualitative research was to identify the healthcare, information and support needs of women living with metastatic breast cancer. MATERIALS AND METHODS Semi-structured qualitative interviews were conducted with 18 women. Women were asked about their experiences of living with metastatic breast cancer and their information and support needs. RESULTS Women valued relationships with their healthcare professionals, particularly their oncologists. They wanted more attention paid to side-effects of ongoing treatments, which had a negative impact on their health. While oncologists were a primary source of information, women also drew on other sources. There were mixed findings about the value of support groups, with women preferring to seek alternative sources of social support. CONCLUSION A diagnosis of metastatic breast cancer brings heightened reliance on healthcare professionals to respond to womens needs in a way that is different to that required with a diagnosis of early breast cancer.

Abstract P1-09-08: Risk factors for lymphedema are dependent on level of axillary surgery

Background: Differentiation of lymphoedema (LE) risk factors for those who have undergone a sentinel node biopsy (SNB) from those who have undergone axillary node dissection (AND) is not considered, even though the incidence rates for the two are vastly different. In addition, events women are typically cautioned against have not been well investigated. Methods: A prospective study was conducted in which women were recruited and assessed prior to surgery, and then seen within 4 weeks following surgery, and at 6, 12 and 18 months following surgery. Women were categorised as having LE if their bioimpedance interlimb ratio exceeded previously established thresholds. Following post-surgery assessment, women were asked to complete weekly diaries regarding events that occurred in the previous week. Risk factors were broadly grouped into demographic, lifestyle, breast cancer treatment-related, arm swelling-related, and post-surgical activities (eg, airplane travel). Crude association between each potential predictor and presence of arm swelling was then identified using unadjusted logistic regression. Those variables with P 2.0, taking into account biological plausibility. The final multivariable models were developed without and with consideration of the presence of swelling in the first year. Results: 450 women (SNB group: 241; AND group: 209) were recruited and attended the final assessment; a subgroup of 243 women, of whom 112 had AND completed >70% of the weekly diaries. The incidence of LE for the SNB group was 3.3% (n=8) and 18.2% (n=38) for the AND group. The unadjusted risk factors for LE at 18 months for SNB included high BMI and absolute body weight, living alone and presenting at diagnosis with three or more other medical conditions. The final model for the SNB group included a high BMI and not living with a partner, explaining 21.3% of the variance. Inclusion of post-operative swelling in the model explained 48.4% of the variance. The unadjusted risk factors for LE at 18 months for AND included being older, low education, Stage 3, high number of nodes removed and involved, and radiotherapy to the axilla, and receiving taxane chemotherapy. The final risk factors model for the AND group included clinical stage 3, being older, low education, and receiving taxane-based chemotherapy, explaining 20.4% of the variance. The addition of any swelling within the first 6 months following surgery explained 36.8% of the variance. Notably none of the factors related to air travel, arm trauma, medical procedures (eg, blood pressure, injections, blood drawn on the affected side), or exercise which women are typically cautioned against differentiated women who had and did not get LE at 18 months. Conclusion: Advice to women undergoing SNB should differ to that provided to those undergoing AND, and for both, we should not be burdening them with range of behaviors to avoid. Importantly, for women at high risk, periodic assessment in the first year should occur to identify and manage any arm swelling. Acknowledgement: Cancer Australia and NBCF. Citation Format: Sharon L Kilbreath, Kathryn M Refshauge, Jane M Beith, Leigh C Ward, Owen A Ung, James R French, Louise Koelmeyer, Katrina Kastania, Jasmine Yee. Risk factors for lymphedema are dependent on level of axillary surgery [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-09-08.

Physical activity and fitness in women with metastatic breast cancer.

136 Background: Women with metastatic breast cancer may survive for many years after disease onset, and there is little published evidence on their habitual levels of physical activity. The aim of this study was to investigate differences in physical activity levels and physical fitness between women with and without metastatic breast cancer. METHODS Seventy-one women with metastatic breast cancer (METS) aged 57.7 ± 9.5 y and 2.9 ± 3.1 y after disease onset, and 71 healthy controls (CONTROLS) aged 55.0 ± 9.4 y participated. Of those with metastatic disease, 27% had metastases in bone only, 35% in viscera only and 38% in both bone and viscera. Strength was measured using hand and leg dynamometry, aerobic fitness using the Modified Canadian Aerobic Fitness Test, and fatigue with the FACT-Fatigue questionnaire. Participants wore a SenseWear physical activity armband over 6 days, and the average steps taken per day over 5 of these days, where there was a minimum wear time of 8 hours per day, was derived. RESULTS METS possessed lower aerobic fitness than CONTROLS (25.3 ± 5.4 versus 31.9 ± 6.1 ml·kg·min-1 respectively; p<0.01). METS were significantly weaker than CONTROLS. Lower limb strength for the METS and CONTROLS was 53.8 ± 23.7 versus 76.0 ± 27.4 kg and handgrip strength was 26.6 ± 6.0 versus 30.2 ± 6.4 kg. METS were also significantly less active, attaining only 57% of the daily step counts of CONTROLS. Fatigue was significantly higher in women with metastatic cancer compared to their healthy counterparts (38.0 ± 9.8 versus 46.3 ± 4.6; p<0.01). Correlation between fatigue with average steps per day (r=0.46), handgrip strength (r=0.29) and leg strength (r=0.26) was low in the METS group. CONCLUSIONS Women living in the community with metastatic breast cancer are weaker, have lower aerobic fitness, and are relatively inactive compared to their healthy counterparts. Increased fatigue in these women is poorly associated with their decreased physical activity levels, hand and lower limb strength. Women with metastatic breast cancer may benefit from a program directed at improving their strength and fitness. Acknowledgements: Funded by National Breast Cancer Foundation, Australia.

Elevated extracellular fluid in the "at risk" arm from taxane-based chemotherapies in women treated for early breast cancer.

126 Background: Taxane-based regimes has improved survival in early breast cancer and now is used routinely. A common side effect is oedema which potentially increases the risk of lymphoedema in the arm after surgery. This has not been assessed prospectively. The aim of this study was to determine the effect of taxane-based regimens on extracellular fluid (ECF) in the arm on the side of surgery. METHODS Women (n=441) aged 56.8 (SD 11.2) years enrolled prior to surgery for early breast cancer and were reassessed within 1 month and 6, 12, and 18 months following surgery. Assessment included bioimpedance spectroscopy which quantifies ECF in each arm and used to derive the ECF ratio. Based on the ECF ratio, women were categorised as having, or not, swelling preferentially in their at risk arm at each time point and having no taxane-based chemotherapy (n=269), paclitaxel (n=73) or docetaxel chemotherapy (n=88). RESULTS Pre-surgery, the ECF ratio was not significantly different in women who later did or did not receive taxane-based chemotherapy. Following surgery but prior to commencing chemotherapy, 45 (11%) women had increased ECF in their at-risk arm. Both taxane-based chemotherapies and elevated postoperative arm swelling were associated with swelling at each follow-up timepoint (Table). CONCLUSIONS In addition to pre-existing swelling, both taxel chemotherapies were associated with swelling preferentially in the at-risk arm between 6 and 18 months following surgery. Strategies to prevent or minimise this swelling need to be developed. [Table: see text].