Lymphedema in ovarian cancer survivors: Assessing diagnostic methods and the effects of physical activity

Iyer NS1, Cartmel B2,3, Friedman L4, Li F2, Zhou Y2,3, Ercolano E3,5, Harrigan M2, Gottlieb L2, McCorkle R3,5, Schwartz PE3, Irwin ML2. Cancer. 2018 May 1;124(9):1929-1937

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Lymphedema in ovarian cancer survivors: Assessing diagnostic methods and the effects of physical activity

Iyer NS1, Cartmel B2,3, Friedman L4, Li F2, Zhou Y2,3, Ercolano E3,5, Harrigan M2, Gottlieb L2, McCorkle R3,5, Schwartz PE3, Irwin ML2.  Cancer. 2018 May 1;124(9):1929-1937

BACKGROUND:

Lymphedema is a poorly understood side effect of gynecologic cancer treatment. This study was designed to determine the prevalence of lower limb lymphedema (LLL) in a sample of ovarian cancer survivors via 3 different diagnostic methods and to assess the effect of a randomized exercise intervention.

METHODS:

Physically inactive ovarian cancer survivors (n = 95) were enrolled in a 6-month randomized trial of exercise (primarily brisk walking) versus attention control. LLL was measured at baseline and 6-month visits via a self-report questionnaire, optoelectronic perometry, and an evaluation by a certified lymphedema specialist.

RESULTS:

LLL prevalence ranged from 21% to 38% according to the diagnostic method, and there was substantial agreement between the self-report questionnaire and the lymphedema specialist evaluation (κ = 0.61). There was no agreement between the evaluation with optoelectronic perometry and the specialist evaluation. With LLL defined by any method, the baseline prevalence was 38% in both groups. At 6 months, both groups experienced a decreased LLL prevalence: 28% in the exercise group and 35% in the control group. There was no difference in the change in lymphedema prevalence between the 2 groups (P = .64). Body mass index was a significant predictor of LLL.

CONCLUSIONS:

With a potential prevalence of LLL as high as 40%, further evaluation of diagnostic methods is required to better characterize this side effect of ovarian cancer treatment. No adverse effect of exercise on LLL was found. Further research is strongly needed to evaluate predictors of LLL and the effects of exercise on LLL in order to develop effective physical activity recommendations for women with ovarian cancer. Cancer 2018;124:1929-37.

Main findings

  • Small sample size.
  • The purpose of this study was to determine the prevalence of LLL via perometry, a self-report questionnaire, and an evaluation by certified lymphedema specialists in a sample of ovarian cancer survivors. They also sought to assess the validity of the self report questionnaire and optoelectronic perometer against the gold-standard lymphedema specialist evaluation, evaluate potential predictors of LLL, and measure the effects of a 6-month randomized trial of exercise versus attention control on lymphedema prevalence within the Women’s Activity and Lifestyle Study in Connecticut (WALC).
  • It looked at the effect of a moderate-intensity aerobic exercise intervention versus attention control on the quality of life of physically inactive ovarian cancer survivors.
  • The eligibility criteria included being under the age of 75 years, having completed adjuvant treatment at least 1 month before randomization, having been diagnosed within the past 4 years, and having participated in less than 90 minutes of moderate-intensity aerobic exercise per week.
  • The exercise intervention consisted of a 6-month homebased moderate-intensity aerobic exercise program facilitated by weekly telephone calls from an American College of Sports Medicine–certified cancer exercise trainer. Women in the exercise arm were asked to participate in moderate-intensity aerobic exercise, mainly brisk walking, for 150 min/wk. They were asked to record their activity in a daily activity log and to include the type, duration, and intensity (from study-provided heart rate monitors) of their physical activity. The trainer provided weekly counseling and support via telephone to motivate participants using a 26-chapter book developed for the study (1 chapter per week of intervention). The attention control arm received weekly phone calls from a WALC staff member along with a 26 chapter book containing only information related to ovarian cancer survivorship. One chapter was discussed during each weekly call.
  • Both study groups showed a decrease in the prevalence of LLL assessed by any diagnostic method at 6 months versus the baseline prevalence. At 6 months, among the 80 women who completed both baseline and 6-month assessments, the prevalence of LLL with any definition of LLL was 28% in the exercise intervention group versus 33% at the baseline (a 15% reduction), and it was 35% in the attention control group versus 38% at the baseline (an 8% reduction). There was no significant difference in the change in LLL prevalence between the 2 study groups over the 6-month study.
  • BMI was found to be significantly lower in the women who did not have LLL at the baseline.
  • Prevalence of LLL in ovarian cancer survivors ranged from 21% to 38%, and it was dependent on the diagnostic method used. Individually, the 3 diagnostic methods evaluated—the self-report questionnaire, the optoelectronic perometer, and the lymphedema specialist evaluation—each indicated a prevalence of LLL of 21% to 27%, but when they were used collectively, the prevalence was 38%. The self-report questionnaire had strong agreement with the gold-standard evaluation by a trained lymphedema specialist, whereas there was no agreement between the optoelectronic perometer and the trained specialist evaluation.
  • This study did not find any adverse effect of exercise on LLL in this patient population.
  • Future studies need to evaluate the effects of exercise on LLL further in a larger sample of gynecologic cancer survivors to develop physical activity guidelines for these survivors.