Abstract

Screening for breast cancer–related lymphoedema: self-assessment of symptoms and signs

J. Svensson1,2 & E. S. Dylke1 & L. C. Ward1,3 & D. A. Black1 & Sharon L. Kilbreath1. Supportive Care in Cancer. 2019

Abstract

Introduction In the absence of monitoring programs, those at risk of developing breast cancer–related lymphoedema (BCRL) must detect its development. However, the efficacy of self-assessment for BCRL has not been widely investigated. This study will determine if symptoms and signs of BCRL are associated with lymphoedema detected by bioimpedance spectroscopy (BIS) and whether those with and without BCRL can accurately assess the signs of its presence.

Methods and results

Participants with a history of breast cancer (n=100)reported the presence/absence of symptoms associated with upper limb BCRL and underwent assessment for pitting oedema and differences in tissue texture between their arms(pinch). BIS detected BCRL in 48 women. Women were more likely to have BIS-detected BCRL if they reported swelling (odds ratio (OR),58.8;95%CI,4.9to709.4;p=0.001)or had inter-limb tissue texture differences in their forearm(OR,73.5;95%CI,7.3to 736.9;p=<0.001)or upper arm (OR, 23.9; 95% CI, 2.8 to201.7;p=0.003). Agreement between therapist and self-assessment of signs of BCRL was almost perfect (kappa, 0.819 to 0.940). A combination of self-reported swelling and/or self-assessed forearm tissue texture difference identified all cases of BIS-detected BCRL.

Conclusion

Participants accurately identified the presence or absence of physical signs of BCRL in their arm. Perceived swelling and differences in tissue texture in the affected arm were associated with, and sensitive to, BIS-detected BCRL. These findings support the use of self-assessment to determine if BCRL is developing, indicating the need for professional assessment

Main findings

• Agreement between participant and therapist in the detection of physical signs of BCRL
  • Inter-rater agreement between the therapist and the participant for the detection of physical signs of BCRL was ‘almost perfect’ for all physical assessments: pitting oedema (kappa,0.94(95%CI,0.87to1.00)),pinch test in the forearm (kappa, 0.94 (95% CI, 0.87 to 1.00)) and upper arm (kappa 0.82 (95% CI, 0.71 to 0.93)).
• Participant-reported symptoms and therapist-detected physical signs
  • Participant-reported symptoms and therapist-detected physical signs of BCRL were present in both the BIS DETECTED and NOT-DETECTED groups. For example, 96% of women in the BIS-DETECTED group and 33% of women in the NOT-DETECTED group perceived their arm as being swollen. There were, however, significantly more women in the BIS -DETECTED group than in the NOT DETECTED group who reported symptoms and had physical signs indicative of BCRL (Mann-Whitney P<0.01 for each variable).
• Association of symptoms and physical signs with BIS-detected BCRL.
  • Participants who perceived their upper limb to be swollen were 59 times more likely to have BCRL detected by BIS (95% CI, 4.88 to 709.43; P=0.001) than those who did not perceive their limb to be swollen.
  • Participants with a positive pinch test in the forearm were 74 times (95% CI, 7.32 to 736.91; P=<0.001) more likely to have BCRL detected by BIS than those who did not have a positive test, and those with a positive pinch test in the upper arm were 24 times (95% CI, 2.84to201.69;P=0.003)more likely to have BCRL detected by BIS compared with those without the physical sign.
• Sensitivity and specificity of symptoms ,physical signs and BIS-detected BCRL.
  • The majority of the symptoms and physical signs had greater sensitivity than specificity for BIS detected BCRL. For example, the presence of perceived swelling correctly classified 96% of those with BIS detected BCRL, whereas an absence of this sensation correctly classified only 67% of women who did not have BIS-detected BCRL.
  • One hundred percent of women who had BIS-detected BCRL perceived their arm to be swollen and/or had a positive forearm pinch test ((sensitivity, 1.00; 95% CI, 92.6 to 100%), (specificity, 0.62; 95% CI, 0.47 to 0.75)). There were no false negatives identified with this screening approach, i.e. no women withBIS-detected BCRL were identified as being disease-free by the screen. The false positive rate was 20%, i.e. only 20% of women who perceived their arm to be swollen and/or had a positive forearm pinch test did not have BCRL detected by BIS thresholds.
• A negative screening result, however, does not completely rule out the possibility of subclinical BCRL.
• Women at risk of BCRL are able to undertake their own screening to determine their likelihood of lymphoedema development. The screening process is based on the presence of perceived swelling in the at-risk arm and assessment of interlimb tissue texture differences between the forearms.
• This combination of perceived symptoms and physical signs of BCRL accurately identifies women without BCRL as well as women who require further investigation.
• Self-screening by women at risk of BCRL provides an alternative screening approach to one that is therapist driven. In addition to providing reassurance regarding BCRL-free status or signalling need for further clinical assessment, self-assessment may have other positive self-efficacy and self-care agency benefits for breast cancer survivors.