Lucinda Pfalzer

Preoperative assessment enables the early diagnosis and successful treatment of lymphedema

The incidence of breast cancer (BC)‐related lymphedema (LE) ranges from 7% to 47%. Successful management of LE relies on early diagnosis using sensitive measurement techniques. In the current study, the authors demonstrated the effectiveness of a surveillance program that included preoperative limb volume measurement and interval postoperative follow‐up to detect and treat subclinical LE.

Breast Cancer–Related Lymphedema: Comparing Direct Costs of a Prospective Surveillance Model and a Traditional Model of Care

Secondary prevention involves monitoring and screening to prevent negative sequelae from chronic diseases such as cancer. Breast cancer treatment sequelae, such as lymphedema, may occur early or late and often negatively affect function. Secondary prevention through prospective physical therapy surveillance aids in early identification and treatment of breast cancer–related lymphedema (BCRL). Early intervention may reduce the need for intensive rehabilitation and may be cost saving. This perspective article compares a prospective surveillance model with a traditional model of impairment-based care and examines direct treatment costs associated with each program. Intervention and supply costs were estimated based on the Medicare 2009 physician fee schedule for 2 groups: (1) a prospective surveillance model group (PSM group) and (2) a traditional model group (TM group). The PSM group comprised all women with breast cancer who were receiving interval prospective surveillance, assuming that one third would develop early-stage BCRL. The prospective surveillance model includes the cost of screening all women plus the cost of intervention for early-stage BCRL. The TM group comprised women referred for BCRL treatment using a traditional model of referral based on late-stage lymphedema. The traditional model cost includes the direct cost of treating patients with advanced-stage lymphedema. The cost to manage early-stage BCRL per patient per year using a prospective surveillance model is

Segmental Limb Volume Change as a Predictor of the Onset of Lymphedema in Women With Early Breast Cancer

636.19. The cost to manage late-stage BCRL per patient per year using a traditional model is

A qualitative assessment of upper quarter dysfunction reported by physical therapists treated for breast cancer or treating breast cancer sequelae

3,124.92. The prospective surveillance model is emerging as the standard of care in breast cancer treatment and is a potential cost-saving mechanism for BCRL treatment. Further analysis of indirect costs and utility is necessary to assess cost-effectiveness. A shift in the paradigm of physical therapy toward a prospective surveillance model is warranted.

Racial disparities in physical and functional domains in women with breast cancer

To demonstrate that segmental changes along the upper extremity occur before the onset of breast cancer–related lymphedema (BCRL). These changes may be subclinical in nature and may be predictive of the onset of chronic lymphedema.

Breast Cancer EDGE Task Force Outcomes Clinical Measures of Strength and Muscular Endurance: A Systematic Review

PurposeAs survival rates for breast cancer improve, long-term effects of treatment are receiving increasing attention, including upper quarter impairments and functional limitations. The purpose of this study was to assess, through qualitative means, the long-term effects of breast cancer treatment on upper quarter function as reported by those with expertise in upper quarter dysfunction. Participants were physical therapists who were either breast cancer survivors (“survivors”) or those who specialized in treatment of individuals post-breast cancer (“treaters”).Subjects and methodsThree focus groups (two groups of survivors [n = 16] and one group of treaters [n = 10]) were convened to discuss their experiences with upper quarter dysfunction post-breast cancer. Qualitative research methods were used to collect and analyze the data, to extract themes, and to assure reliability and validity of the original and extracted data.ResultsTwo themes emerged from the data and are supported by participant quotes. The first theme described the presence of upper quarter dysfunction that impacted body structure and function and resulted in activity/participation limitations. The second theme described the contextual factors that impacted the reported dysfunction, including access to comprehensive care, inadequate attention by health care providers, and a resulting need for self-advocacy.ConclusionsThe study supports the problem of late effects from breast cancer treatment on upper quarter function and points out the need for better education for health care providers, increased long-term surveillance of survivors, and a more proactive model of health care delivery for this population.

Pre operative assessment enables the early detection and treatment of shoulder impairments related to breast cancer treatment.

IntroductionAfrican-American women are more likely than white women to have functional impairments after breast cancer (BC) surgery; however, no differences were found in self-reported health status surveys at 12+ months postsurgery.PurposeThis analysis compared white and African-American BC survivors’ (BCS) health status, health-related quality of life, and the occurrence of physical impairments after BC treatment.MethodsOne hundred sixty-six women (130 white, 28 African-American, 8 other) were assessed for impairments preoperatively and at 1, 3, 6, 9, and 12+ months postsurgery. Health status was assessed at 12+ months using the Short Form Health Survey (SF36v2™). Analysis of variance estimated differences between groups for health status and impairment occurrence.ResultsNo differences were found between groups for BC type, stage, grade, or tumor size; surgery type; or number of lymph nodes sampled. African-American BCS had more estrogen/progesterone receptor-negative tumors (p < 0.001; p = 0.036) and received radiation more frequently (p = 0.03). More African-American BCS were employed (p = 0.022) and reported higher rates of social activities (p = 0.011) but less recreational activities (p = 0.020) than white BCS. African-American BCS had higher rates of cording (p = 0.013) and lymphedema (p = 0.011) postoperatively. No differences were found in self-reported health status.ConclusionIn a military healthcare system, where access to care is ubiquitous, there were no significant differences in many BC characteristics commonly attributed to race. African-American women had more ER/PR-negative tumors; however, no other BC characteristics differed between racial groups. African-American women exhibited more physical impairments, although their BC treatment only differed regarding radiation therapy. This suggests that African-American BCS may be at higher risk for physical impairments and should be monitored prospectively for early identification and treatment.

Prevalence of self-reported falls, balance or walking problems in older cancer survivors from Surveillance, Epidemiology and End Results—Medicare Health Outcomes Survey

Background: Muscular strength deficits are a common morbidity following treatment for breast cancer. Accurate assessment of strength and muscular endurance following breast cancer treatments is essential in identifying deficits and planning rehabilitation strategies. Purpose: The purpose of this systematic review was to identify strength and muscular endurance outcome measures for use with women treated for breast cancer that possess strong psychometric properties and are clinically useful. Methods: Multiple electronic databases were searched between February and June 2013. Included studies of tools used to assess strength and muscular endurance met the following criteria: reported psychometric properties, clinically feasible methods, adults (preferably female), and published in the English language. Each outcome measure was reviewed independently and rated by two reviewers separately. A single Cancer EDGE Task Force Outcome Measure Rating Form was completed for each category of strength or endurance assessment, and a recommendation was made using the 4‐point Breast Cancer EDGE Task Force Rating Scale. Results: Of the original 874 articles found, 22 were included in this review. Hand Grip Strength and Hand Held Dynamometry were rated 3, recommended for clinical use. Manual muscle test and one repetition maximum were rated 2B, unable to recommend at this time. Muscular endurance testing was rated 2A, unable to recommend at this time. Conclusions: Utilizing objective dynamometry for hand grip and muscle strength testing provides precise measurement to assess baseline status and monitor change among women treated for breast cancer.

Oncology Section EDGE Task Force on Prostate Cancer Outcomes: A Systematic Review of Clinical Measures of Strength and Muscular Endurance

CTRC-AACR San Antonio Breast Cancer Symposium: 2008 Abstracts Abstract #4091 Background: Early detection and management of impairments and limb dysfunction after breast cancer treatment contribute to more successful functional outcomes. Health care providers should be encouraged to provide a pre-operative screening visit to ascertain the patients baseline physical function measures. Patients should then be followed prospectively at regular intervals during and after treatment for early identification of impairments and to provide intervention while the functional limitations are minimal, thereby preventing long term loss of function. Materials and Methods: A prospective, observational study (n=196) with interval follow up over one year assessed the effects of an early identification and intervention model of physical therapy care on women after breast cancer treatment. Measurement of upper extremity (UE) function included; active range of motion (ROM), strength, and limb volume as measured by the optoelectronic volumeter (Perometer®), and self-reported physical activity disability. Individuals were seen for an initial visit prior to surgical treatment and followed-up at approximately one month post-operatively and at three month intervals thereafter, up to 18 months. Patients received a general home exercise program pre-operatively and instructed to initiate at 2 weeks post op. If impairments were identified at any of the follow up visits, physical therapy intervention was prescribed. Results: A significant decrease in active shoulder ROM was noted at one month post-op as compared to baseline measurement in 102 patients. This significance resolved at the 12+ month follow up visit. Loss of shoulder ROM correlated with other UE treatment related morbidities including; axillary web syndrome, seroma and pain. Discussion: Incidence of upper extremity morbidity after breast cancer treatment is documented as high as 70%. This study clearly demonstrates the potential for substantial reduction in UE dysfunction related to breast cancer treatment when using an early identification and intervention model. Many morbidities such as pain, reduced range of motion, decreased strength and sub-clinical lymphedema can be detected early and managed with minimal, cost-effective intervention. Additional research is needed to assess ways of maintaining this cost effective model of care in the long-term. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4091.

Oncology Section Task Force on Breast Cancer Outcomes: Clinical Measures of Balance A Systematic Review

OBJECTIVE To determine the prevalence of falls and balance/walking problems in the past 12months among older cancer survivors before and after cancer diagnosis. MATERIALS AND METHODS We analyzed cross-sectional data from individuals aged ≥65years with first primary cancer from the Surveillance, Epidemiology, and End Results and Medicare Health Outcomes Survey (SEER-MHOS) linkage (n=12,659). The first MHOS completed by each survivor from 0 to 2years before cancer diagnosis to 1-4years after cancer diagnosis were included. We estimated unadjusted and demographic-adjusted prevalence of falls and balance/walking problems for each type of cancer during five one-year time periods before and after cancer diagnosis. RESULTS Adjusted prevalence of falls was significantly higher post-diagnosis than pre-diagnosis in prostate (12% during years 1-2 pre-diagnosis vs. 17%-20% during years 1-4 post-diagnosis)(p=0.01) and lung cancer (17% during years 1-2 pre-diagnosis vs. 28% during years 1-2 post-diagnosis)(p=0.019). Adjusted prevalence of balance/walking problems were significantly higher post-diagnosis than pre-diagnosis in non-Hodgkins lymphoma (26% during years 1-2 pre-diagnosis vs. 45% during years 1-2 post-diagnosis)(p=0.012), breast (32% during years 1-2 pre-diagnosis vs. 41% during years 3-4 post-diagnosis)(p=0.001), prostate (22% during years 1-2 pre-diagnosis vs. 28%-29% during years 1-4 post-diagnosis)(p=0.012), and lung cancer (33% during years 1-2 pre-diagnosis vs. 40% during year 0-1 pre-diagnosis and 46% during years 1-2 post-diagnosis)(p=0.018). Prevalence did not differ across time periods in other cancers. CONCLUSIONS Falls and balance/walking problems may become more frequent after the diagnosis of some cancers. Screening, surveillance, and interventions need to consider functional deficits and cancer diagnosis.