Sandra C. Hayes

Lymphedema After Breast Cancer: Incidence, Risk Factors, and Effect on Upper Body Function

PURPOSE Secondary lymphedema is associated with adverse physical and psychosocial consequences among women with breast cancer (BC). This article describes the prevalence and incidence of lymphedema between 6 and 18 months after BC treatment; personal, treatment, and behavioral correlates of lymphedema status; and the presence of other upper-body symptoms (UBS) and function (UBF). PATIENTS AND METHODS A population-based sample of Australian women (n = 287) with recently diagnosed, invasive BC were evaluated on five occasions using bioimpedance spectroscopy. Lymphedema was diagnosed when the ratio of impedance values, comparing treated and untreated sides, was three standard deviations more than normative data. UBF was assessed using the validated Disability of the Arm, Shoulder, and Hand questionnaire. RESULTS From 6 to 18 months after surgery, 33% (n = 62) of the sample were classified as having lymphedema; of these, 40% had long-term lymphedema. Although older age, more extensive surgery or axillary node dissection, and experiencing one or more treatment-related complication(s) or symptom(s) at baseline were associated with increased odds, lower socioeconomic status, having a partner, greater child care responsibilities, being treated on the dominant side, participation in regular activity, and having good UBF were associated with decreased odds of lymphedema. Not surprisingly, lymphedema leads to reduced UBF; however, BC survivors report high prevalences of other UBS (34% to 62%), irrespective of their lymphedema status. CONCLUSION Lymphedema is a public health issue deserving greater attention. More systematic surveillance for earlier detection and the potential benefits of physical activity to prevent lymphedema and mitigate symptoms warrant further clinical integration and research.

Australian Association for Exercise and Sport Science Position Stand: Optimising Cancer Outcomes Through Exercise.

Cancer represents a major public health concern in Australia. Causes of cancer are multifactorial with lack of physical activity being considered one of the known risk factors, particularly for breast and colorectal cancers. Participating in exercise has also been associated with benefits during and following treatment for cancer, including improvements in psychosocial and physical outcomes, as well as better compliance with treatment regimens, reduced impact of disease symptoms and treatment-related side-effects, and survival benefits for particular cancers. The general exercise prescription for people undertaking or having completed cancer treatment is of low to moderate intensity, regular frequency (3-5 times/week) for at least 20 min per session, involving aerobic, resistance or mixed exercise types. Future work needs to push the boundaries of this exercise prescription, so that we can better understand what constitutes optimal, desirable and necessary frequency, duration, intensity and type, and how specific characteristics of the individual (e.g., age, cancer type, treatment, presence of specific symptoms) influence this prescription. What follows is a summary of the cancer and exercise literature, in particular the purpose of exercise following diagnosis of cancer, the potential benefits derived by cancer patients and survivors from participating in exercise programs, and exercise prescription guidelines and contraindications or considerations for exercise prescription with this special population. This report represents the position stand of the Australian Association of Exercise and Sport Science on exercise and cancer recovery and has the purpose of guiding exercise practitioners in their work with cancer patients.

Upper-Body Morbidity After Breast Cancer* Incidence and Evidence for Evaluation, Prevention, and Management Within a Prospective Surveillance Model of Care

The purpose of this paper is to review the incidence of upper‐body morbidity (arm and breast symptoms, impairments, and lymphedema), methods for diagnosis, and prevention and treatment strategies. It was also the purpose to highlight the evidence base for integration of prospective surveillance for upper‐body morbidity within standard clinical care of women with breast cancer. Between 10% and 64% of women report upper‐body symptoms between 6 months and 3 years after breast cancer, and approximately 20% develop lymphedema. Symptoms remain common into longer‐term survivorship, and although lymphedema may be transient for some, those who present with mild lymphedema are at increased risk of developing moderate to severe lymphedema. The etiology of morbidity seems to be multifactorial, with the most consistent risk factors being those associated with extent of treatment. However, known risk factors cannot reliably distinguish between those who will and will not develop upper‐body morbidity. Upper‐body morbidity may be treatable with physical therapy. There is also evidence in support of integrating regular surveillance for upper‐body morbidity into the routine care provided to women with breast cancer, with early diagnosis potentially contributing to more effective management and prevention of progression of these conditions. Cancer 2012;118(8 suppl).

Comparison of methods to diagnose lymphoedema among breast cancer survivors: 6-month follow-up

SummaryOne of the more problematic and dreaded complications of breast cancer is lymphoedema. Our objective was to determine the prevalence of lymphoedema 6-months following breast cancer treatment and to examine potential risk factors among a population-based sample of women residing in South-East Queensland (n=176). Women were defined as having lymphoedema if the difference between the sum of arm circumferences (SOAC) of the treated and untreated sides was >5 cm (prevalence=11.9%) or >10% (prevalence=0.6%), their multi- frequency bioelectrical impedance (MFBIA) score was ≥3 standard deviations above the reference impedance score (prevalence=11.4%), or they reported ‘yes’ when asked if arm swelling had been present in the previous 6 months (prevalence=27.8%). Of those with lymphoedema defined by MFBIA, only 35% were detected using the SOAC method (difference > 5 cm), while 65% were identified via the self-report method (i.e., respective sensitivities). Specificities for SOAC (difference > 5 cm) and self-report were 88.5% and 76.9%, respectively. When examining associations between presence of lymphoedema and a range of characteristics, findings also varied depending on the method used to assess lymphoedema. Nevertheless, one of the more novel and significant findings was that being treated on the non-dominant, compared to dominant, side was associated with an 80% increased risk of having lymphoedema (MFBIA). Our work raises questions about the use of circumferences as the choice of measurement for lymphoedema in both research and clinical settings, and assesses MFBIA as a potential alternative.

Weight Management and its Role in Breast Cancer Rehabilitation

Overweight and obesity are risk factors for postmenopausal breast cancer, and many women diagnosed with breast cancer, irrespective of menopausal status, gain weight after diagnosis. Weight management plays an important role in rehabilitation and recovery because obesity and/or weight gain may lead to poorer breast cancer prognosis, as well as prevalent comorbid conditions (eg, cardiovascular disease and diabetes), poorer surgical outcomes (eg, increased operating and recovery times, higher infection rates, and poorer healing), lymphedema, fatigue, functional decline, and poorer health and overall quality of life. Health care professionals should encourage weight management at all phases of the cancer care continuum as a means to potentially avoid adverse sequelae and late effects, as well as to improve overall health and possibly survival. Comprehensive approaches that involve dietary and behavior modification, and increased aerobic and strength training exercise have shown promise in either preventing weight gain or promoting weight loss, reducing biomarkers associated with inflammation and comorbidity, and improving lifestyle behaviors, functional status, and quality of life in this high‐risk patient population. Cancer 2012;.

Prevalence of Breast Cancer Treatment Sequelae Over 6 Years of Follow-Up The Pulling Through Study*

There is a need to better describe and understand the prevalence of breast cancer treatment‐related adverse effects amenable to physical therapy and rehabilitative exercise. Prior studies have been limited to single issues and lacked long‐term follow‐up. The Pulling Through Study provides data on prevalence of adverse effects in breast cancer survivors followed over 6 years.

Upper-body morbidity following breast cancer treatment is common, may persist longer-term and adversely influences quality of life

BackgroundImpairments in upper-body function (UBF) are common following breast cancer. However, the relationship between arm morbidity and quality of life (QoL) remains unclear. This investigation uses longitudinal data to describe UBF in a population-based sample of women with breast cancer and examines its relationship with QoL.MethodsAustralian women (n = 287) with unilateral breast cancer were assessed at three-monthly intervals, from six- to 18-months post-surgery (PS). Strength, endurance and flexibility were used to assess objective UBF, while the Disability of the Arm, Shoulder and Hand questionnaire and the Functional Assessment of Cancer Therapy-Breast questionnaire were used to assess self-reported UBF and QoL, respectively.ResultsAlthough mean UBF improved over time, up to 41% of women revealed declines in UBF between six- and 18-months PS. Older age, lower socioeconomic position, treatment on the dominant side, mastectomy, more extensive lymph node removal and having lymphoedema each increased odds of declines in UBF by at least two-fold (p < 0.05). Lower baseline and declines in perceived UBF between six- and 18-months PS were each associated with poorer QoL at 18-months PS (p < 0.05).ConclusionsSignificant upper-body morbidity is experienced by many following breast cancer treatment, persisting longer term, and adversely influencing the QoL of breast cancer survivors.

Quality of life changes following peripheral blood stem cell transplantation and participation in a mixed-type, moderate-intensity, exercise program.

Summary:The purpose of this investigation was to evaluate the impact of undertaking peripheral blood stem cell transplantation (PBST) on quality of life (QoL), and to determine the effect of participating in a mixed-type, moderate-intensity exercise program on QoL. It was also an objective to determine the relationship between peak aerobic capacity and QoL in PBST patients. QoL was assessed via the CARES questionnaire and peak aerobic capacity by a maximal graded treadmill test, pretransplant (PI), post transplant (PII) and following a 12-week intervention period (PIII). At PII, 12 patients were divided equally into a control or exercise intervention group. Undergoing a PBST was associated with a statistically but not clinically significant decline in QoL (P<0.05). Following the intervention, exercising patients demonstrated an improved QoL when compared with pretransplant ratings (P<0.01) and nonexercising transplant patients (P<0.05). Moreover, peak aerobic capacity and QoL were correlated (P<0.05). The findings demonstrated that exercise participation following oncology treatment is associated with a reduction in the number and severity of endorsed problems, which in turn leads to improvements in global, physical and psychosocial QoL. Furthermore, a relationship between fitness and QoL exists, with those experiencing higher levels of fitness also demonstrating higher QoL.

Total energy expenditure and body composition changes following peripheral blood stem cell transplantation and participation in an exercise programme

Summary:The purpose of this investigation was to assess changes in total energy expenditure (TEE), body weight (BW) and body composition following a peripheral blood stem cell transplant and following participation in a 3-month duration, moderate-intensity, mixed-type exercise programme. The doubly labelled and singly labelled water methods were used to measure TEE and total body water (TBW). Body weight and TBW were then used to calculate percentage body fat (%BF), and fat and fat-free mass (FFM). TEE and body composition measures were assessed pretransplant (PI), immediately post-transplant (PII) and 3 months post-PII (PIII). Following PII, 12 patients were divided equally into a control group (CG) or exercise intervention group (EG). While there was no change in TEE between pre- and post-transplant, BW (P<0.01) and FFM (P<0.05) significantly decreased during the same period. Participation in the exercise programme led to increases in TEE to levels that were both higher than pre- and post-transplant measures (P<0.01). By PIII, the exercising patients also showed gains in FFM (P<0.01) in association with a reduction in %BF (P<0.05). Exercise has a functionally important role in preserving and increasing skeletal mass in the rehabilitation phase of cancer patients.

Role of a mixed type, moderate intensity exercise programme after peripheral blood stem cell transplantation

Objectives: To evaluate the effect of peripheral blood stem cell transplantation on functional capacity, and to determine the role of a mixed type, moderate intensity exercise programme in the recovery of patients after intensive cancer treatment. Methods: Peak aerobic capacity and muscular strength (upper body, lower body, and handgrip strength) measures were assessed before (PI) and after (PII) transplant and after a 12 week intervention period (PIII). After PII, 12 patients aged 16–64 years were allotted in equal numbers to a control group or exercise intervention group. Results: Mean peak aerobic capacity and muscular strength were reduced after the transplant, with significant (p<0.05) decreases for upper body strength. No change was found in aerobic capacity and muscular strength between PII and PIII for the control group. In contrast, participation in the exercise programme led to significant improvements in peak aerobic capacity (p<0.05) and upper and lower body strength (p<0.01). In addition, values recorded after the three month intervention period were significantly higher than before treatment for peak aerobic capacity (litres/min (p<0.05) and ml/kg/min (p<0.01)) and lower body strength (p<0.01). Conclusion: Intensive treatment for cancer can adversely affect aerobic capacity and muscular strength. A mixed type, moderate intensity exercise programme can help patients to regain fitness and strength within three months. No exercise can exacerbate physical losses resulting from treatment.