Evidence Update: TurningPoint – Avon Breast Center at Grady Study Published
Hot off the press! This month’s evidence update features a study published this week by TurningPoint and our research partners at The Avon Breast Center at Grady Hospital and Emory University. The study examined the benefit of early identification and treatment of the physical side effects of breast cancer treatment, such as pain, limitation in motion and function and lymphedema (chronic arm swelling). Participants were 120 patients being treated for breast cancer at the Avon Breast Center at Grady Hospital. Grady is a safety net hospital in downtown Atlanta. Study participants were primarily underserved and minority women who would not typically be able to access this type of care. Pain, range of motion, arm volume and function were evaluated by a physical therapist at designated intervals. These assessment intervals were: pre-op, early post-op (2-4 weeks), 6 weeks and 3, 6, 9 and 12 months after surgery. All patients received range of motion exercise and education. Patients with identified impairments such as significantly limited range of motion, axillary cording or lymphedema received more intense individualized rehabilitation. One third (36) of the patients required this more intense intervention. Sixteen patients developed lymphedema during the first post-operative year. In 12 patients, lymphedema was identified and treated early and managed at low levels (<10% greater than baseline measure). In just four patients, lymphedema progressed to more severe levels, defined in the study as 11% greater than baseline. Of interest is that participants who needed more intense rehab intervention had significantly lower arm function and more pain in the early post-operative phase as well as more nodes removed and higher stage of breast cancer. This finding may help us to identify early which patients will require more intense rehabilitation and plan their care accordingly. Our research team concluded that health care providers should have heightened awareness for rehabilitation intervention and that early identification and management of lymphedema, range of motion and functional issues appear to benefit breast cancer patients. The work exemplifies TurningPoint’s commitment to evidence-based practice and reducing barriers to breast cancer rehabilitation and exercise. Read the published study here. Lai L, Binkley J, Jones V, Kirkpatrick S, Furbish C, Stratford P, Thompson W, Sidhu A, Farley C, Okoli J, Beech D and Gabram S. Implementing the Prospective Surveillance Model (PSM) of Rehabilitation for Breast Cancer Patients with 1-Year Postoperative Follow-up, a Prospective Observational Study. Ann Surg Oncol. 2016 Jun 22. [Epub ahead of print]
Evidence Update: Lymphedema At Risk Activities: Fact or Fiction?
Many of the precautionary guidelines related to lymphedema provided to breast cancer patients are anecdotal and not based on research. Unfortunately, many of these guidelines place a large burden on patients and clinicians who go to great lengths to abide by them. The avoidance behaviors can often be more impactful on quality of life than actually having lymphedema! A recent study, published in March 2016, was the first large scale, prospective study to investigate whether there is an association between certain activities and increases in arm volume in patients treated for breast cancer and screened for lymphedema. These activities include blood draws, injections, blood pressure readings, trauma, cellulitis (infection) in the affected arm and air travel. Subjects were 632 patients (760 at-risk arms) with newly diagnosed breast cancer. Bilateral arm volume measurements were performed preoperatively and postoperatively at 3 to 7 month intervals using a perometer. At each measurement, patients reported the number of blood draws, injections, blood pressure measurements, trauma to the at-risk arm(s), and number of air travel flights taken since their last measurement. Arm volume was quantified using the relative volume change and weight-adjusted change formulas. In the total of 3,041 measurements carried out on the 632 subjects, there was no significant association between change in arm volume and undergoing one or more blood draws, injections, number of flights, or duration of flights. As has been previously found in other studies, factors significantly associated with increases in arm volume included weight gain (body mass index), axillary lymph node dissection and regional lymph node radiation and infection/cellulitis. This study suggests that although cellulitis increases risk of lymphedema, blood draws, injections and blood pressure readings on the affected side, as well as air travel, may not be associated with arm volume increases. The results of this study will provide clinicians and patients with much better evidence regarding risk factors and triggers of lymphedema. The clear risk factors for lymphedema are the number of lymph nodes removed, radiation to regional lymph nodes and higher BMI. Infection, or cellulitis, of the arm may be a trigger for lymphedema. Simple infection precautions make sense, such as using gloves when gardening and topical antibiotics for small cuts on the affected arm, https://suriaplasticsurgery.com/valtrex-valacyclovir/. Patients may prefer to continue to have blood draws and blood pressure taken on the unaffected arm, but should understand that these do not appear to trigger lymphedema based on this study. The issue of I.V.s was not addressed in this study and patients may want to continue to avoid these in the affected arm since, unlike a blood draw, fluid is being added to the limb. Flying does not appear to be a trigger to lymphedema; however, for women at moderate to high risk, TurningPoint physical therapists advise patients to travel with compression garments, in case swelling or lymphedema should become apparent while out of town. Ferguson CM et al. Impact of Ipsilateral Blood Draws, Injections, Blood Pressure Measurements, and Air Travel on the Risk of Lymphedema for Patients Treated for Breast Cancer. J Clin Oncol. 34;7: 691-698.
Evidence Update: TurningPoint-Avon Breast Center at Grady Partnership Continues at the American Society of Breast Surgeons
The results of a 2-year research joint project between TurningPoint, the Avon Breast Center at Grady Hospital, Emory University and Morehouse School of Medicine were presented by Dr. Lisa Lai at a recent meeting of the American Society of Breast Surgeons, held in Dallas, Texas. Dr. Lai is a surgeon doing Fellowship Training with Dr. Sheryl Gabram at the Avon Breast Center. Dr. Gabram is a TurningPoint Medical Advisory Board member. The goal of the research project was to examine the feasibility and impact of a prospective surveillance approach to breast cancer rehabilitation. Subjects were 110 patients with Stage 0 – III breast cancer. Most were inner-city and minority women. Shoulder range of motion, arm volume and function was measured before surgery, early post-operatively (2-4 weeks), 6 weeks and then at 3 month intervals for up to a year post-op. We found that approximately 1/3 of patients had early stage lymphedema and other upper extremity limitations that warranted rehabilitation intervention. Patients with higher breast cancer stage, greater numbers of lymph nodes removed and who received chemotherapy were found to have more treatment side effects that required more rehabilitation intervention. Patients with lower levels of function and higher pain levels at their early post-operative visit were more likely to need rehabilitation intervention. Our research team concluded that early identification and management of breast cancer treatment side effects (such as decreased function, limited range of motion and lymphedema) may decrease the impact of these issues and potentially improve quality of life. ASBS Poster April 2016 Photo above: Dr. Lisa Lai (left), Breast Cancer Surgical Fellow at Avon Breast Center at Grady and Emory University with members of TurningPoint’s physical therapy staff, l to r: Grayson Webb, Carrie Kozel and Lauren Bober. Dr. Lai visited TurningPoint recently to further increase her understanding of the role of rehabilitation for breast cancer patients.
Evidence Update: Water Exercise and Lymphedema
A recent study examined the effect of water versus land exercise in improving lymphedema. Eighty-eight eligible patients with secondary lymphedema after breast or gynecological cancer participated in this controlled clinical intervention study. Patients participated in either a water-based or land-based exercise program. Researchers measured subject’s arm volume, as well as BMI, function, well-being and body image. In patients who participated in water exercises, more women had reduced arm limb volume and there were also significant improvements for these women in lower BMI and decreased self-reported frequency of swelling. Women with arm lymphedema in the land exercise group showed more improvement in upper extremity function and range of motion. Researchers conclude that water exercise may be offered to patients when the goal is to reduced lymphedema while to improve daily shoulder function, land exercises are preferred. Your TurningPoint physical therapist can help you develop an exercise plan that is designed specifically to help meet your unique goals. Lindquist H et al. Water exercise compared to land exercise or standard care in female cancer survivors with secondary lymphedema. Lymphology. 2015 Jun;48(2):64-79.
