Wow! This is incredible work! Thank you for all you do for this population!
Diana
Diana Tjaden PT, DPT
Clinical Director
Full Circle Physical Therapy an Ivy Rehab Partner
310 Old Country Rd. Ste 104
Garden City, NY 11530
516-741-7000
FullCircleBreastCancerPT.Com
On Nov 13, 2021, at 3:42 PM, Brunelle, Cheryl L. <CBRUNELLE@xxxxxxxxxxxxxxx>
wrote:
Hi Kelly, I applaud your efforts at trying to ensure there is a baseline
measurement as I am very aware this is not easy!
Our lymphedema research team at Mass General published risk data in JCO on
1,815 patients with invasive breast cancer who were enrolled in our
lymphedema screening trial. Patients were divided into the following 4 groups
according to axillary surgery approach: sentinel lymph node biopsy (SLNB)
alone, SLNB+RLNR, axillary lymph node dissection (ALND) alone, and ALND+RLNR.
A perometer was used to objectively assess limb volume. All patients received
baseline preoperative and follow-up measurements after treatment. Lymphedema
was defined as a ≥ 10% relative increase in arm volume arising > 3 months
postoperatively. The primary end point was the BCRL rate across the groups.
Secondary end points were 5-year locoregional control and
disease-free-survival. The overall median follow-up time after diagnosis was
52.7 months for the entire cohort. The 5-year cumulative incidence rates of
BCRL were 30.1%, 24.9%, 10.7%, and 8.0% for ALND+RLNR, ALND alone, SLNB+RLNR,
and SLNB alone, respectively. Note that we did not find a significant
difference in risk between the ALND and ALND + RLNR groups or between the
SLNB and SLNB+RLNR groups, indicating that axillary surgery is the driving
force in BCRL risk.
We define low risk as patients with SLNB only (although they are not without
risk!), moderate SLNB + RLNR and high ALND OR ALND + RLNR.
Here is the reference and link:
Quantifying the Impact of Axillary Surgery and Nodal Irradiation on Breast
Cancer–Related Lymphedema and Local Tumor Control: Long-Term Results From a
Prospective Screening Trial
George E. Naoum, Sacha Roberts, Cheryl L. Brunelle, Amy M. Shui, Laura
Salama, Kayla Daniell, Tessa Gillespie, Loryn Bucci, Barbara L. Smith, Alice
Y. Ho, and Alphonse G. Taghian
Journal of Clinical Oncology 202038:29, 3430-3438
https://ascopubs.org/doi/abs/10.1200/JCO.20.00459
As for BMI, it elevates risk in all categories although we have not
quantified the risk elevation. We published this paper finding BMI >/= 30 to
be an independent BCRL risk factor.
Here is the citation and link:
Jammallo LS, Miller CL, Singer M, Horick NK, Skolny MN, Specht MC, O'Toole J,
Taghian AG. Impact of body mass index and weight fluctuation on lymphedema
risk in patients treated for breast cancer. Breast Cancer Res Treat. 2013
Nov;142(1):59-67. doi: 10.1007/s10549-013-2715-7. PMID: 24122390; PMCID:
PMC3873728.
https://pubmed.ncbi.nlm.nih.gov/24122390/
Finally, we consider timing of BCRL post breast cancer treatment as we
counsel patients during screening. We analyzed data from 2171 women in our
screening program and found that the lymphedema risk peaked between 6 and 12
months in the ALND-without-RLNR group, between 18 and 24 months in the
ALND-with-RLNR group, and between 36 and 48 months in the group receiving
sentinel lymph node biopsy with RLNR.
So, we should screen patients for at least 4-5 years and we know that those
who have SLNB are at highest risk of BCRL 3-4 years out from surgery, but
certainly at risk before (and after) that too.
Here is that link and citation:
https://pubmed.ncbi.nlm.nih.gov/30165125/
McDuff SGR, Mina AI, Brunelle CL, Salama L, Warren LEG, Abouegylah M, Swaroop
M, Skolny MN, Asdourian M, Gillespie T, Daniell K, Sayegh HE, Naoum GE, Zheng
H, Taghian AG. Timing of Lymphedema After Treatment for Breast Cancer: When
Are Patients Most At Risk? Int J Radiat Oncol Biol Phys. 2019 Jan
1;103(1):62-70. doi: 10.1016/j.ijrobp.2018.08.036. Epub 2018 Aug 28. PMID:
30165125; PMCID: PMC6524147.
Best of luck, I am happy to discuss our findings and how we apply them in our
screening program with you at any time.
Cheryl Brunelle, PT, CCS, CLT
Associate Director
MGH Lymphedema Research Program
The information in this e-mail is intended only for the person to whom it isOn Nov 13, 2021, at 2:33 PM, Kelly Reed <kjreed88@xxxxxxxxx> wrote:
External Email - Use Caution
Hi Everyone!
We are in the middle of building out a new cancer institute with a lot of
growth in regional hospitals. Two of our more rural locations do not have
the capacity or staffing to be able to get limb-volume measurements
pre-surgery or immediately post-surgery for breast cancer for every single
patient. We are hoping to at least get those at moderate or high risk
measured and screened. In the short term, for those at lower risk, we'll
utilize a telehealth option for education until we can eventually get a
system in place to reach every patient.
We are looking at creating a risk stratification screen to decide who is at
low, moderate, and high risk based on lymph nodes removed, obesity, and the
other major risk factors.
Has anyone else had to do this and have a simple way to categorize patients?
Or is anyone familiar with any literature that has stratified this? I
figured I would ask before trying to reinvent the wheel.
Thank you all!
--
Kelly Reed Sturm, PT, DPT, CLT-LANA
Board-Certified Oncology Clinical Specialist
Cancer Rehabilitation and Lymphedema Program Therapy Coordinator
Courage Kenny Rehabilitation Institue- Allina Health
Minneapolis, MN
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