Prospective, early longitudinal assessment of lymphedema-related quality of life among patients with locally advanced breast cancer: The foundation for building a patient-centered screening program.

BACKGROUND: We examined how breast cancer-related lymphedema (BCRL) affects health-related quality of life (HRQOL), productivity, and compliance with therapeutic interventions to guide structuring BCRL screening programs. METHODS: We prospectively followed consecutive breast cancer patients who underwent axillary lymph node dissection (ALND) with arm volume screening and measures assessing patient-reported health-related quality of life (HRQOL) and perceptions of BCRL care. Comparisons by BCRL status were made with Mann-Whitney U, Chi-square, Fisher's exact, or t tests. Trends over time from ALND were assessed with linear mixed-effects models. RESULTS: With a median follow-up of 8 months in 247 patients, 46% self-reported ever having BCRL, a proportion that increased over time. About 73% reported fear of BCRL, which was stable over time. Further in time from ALND, patients were more likely to report that BCRL screening reduced fear. Patient-reported BCRL was associated with higher soft tissue sensation intensity, biobehavioral, and resource concerns, absenteeism, and work/activity impairment. Objectively measured BCRL had fewer associations with outcomes. Most patients reported performing prevention exercises, but compliance decreased over time; patient-reported BCRL was not associated with exercise frequency. Fear of BCRL was positively associated with performing prevention exercises and using compressive garments. CONCLUSIONS: Both incidence and fear of BCRL were high after ALND for breast cancer. Fear was associated with improved therapeutic compliance, but compliance decreased over time. Patient-reported BCRL was more strongly associated with worse HRQOL and productivity than was objective BCRL. Screening programs must support patients' psychological needs and aim to sustain long-term compliance with recommended interventions.

THE EFFECTS OF POSTERIOR TIBIAL MOBILIZATION ON MENISCAL MOVEMENT: AN IN-SITU INVESTIGATION.

BACKGROUND: Anterior knee pain during knee extension may be related to a meniscal movement restriction and increased meniscal load during function. One method of treatment involves the use of manual posterior mobilization of the tibia to specifically target the meniscotibial interface of the knee joint. PURPOSE: The purpose of this study was to measure motion at a cadaveric medial meniscus anterior horn during a posterior tibial mobilization. STUDY DESIGN: Prospective, multifactorial, repeated-measures laboratory study. METHODS: Eight unembalmed cadaveric knee specimens were mounted in a custom apparatus and markers were placed in the medial meniscus, tibia and femur. The tibia was posteriorly mobilized in two randomized knee positions (0 degrees and 25 degrees) using three randomly assigned loads (44.48N, 88.96N, and 177.93N). Markers were photographed and digitally measured and analyzed. RESULTS: All load x position conditions produced anterior displacement of the meniscus on the tibia, where the displacement was significant [t (7) = -3.299; p = 0.013] at 0 degrees loaded with 177.93N (mean 0.41 ± 0.35 mm). The results of 2(position) x 3(load) repeated measures ANOVA for meniscotibial displacement produced no significant main effects for load [F (2,14) = 2.542; p = 0.114) or position [F (1,7) = 0.324, p = 0.587]. All load x position conditions produced significant posterior tibial and meniscal displacement on the femur. The 2(position) x 3(load) repeated measures ANOVA revealed a significant main effect for load for both femoral marker displacement relative to the tibial axis [F (2,14) = 77.994; p < 0.001] and meniscal marker displacement relative to the femoral marker [F (2,14) = 83.620; p < 0.001]. CONCLUSION: Use of a mobilization technique to target the meniscotibial interface appears to move the meniscus anteriorly on the tibia. It appears that this technique may be most effective at the end range position. LEVEL OF EVIDENCE: 2 (laboratory study).

Optimizing Patient Positioning to Reduce Variation in the Measurement of Breast Cancer-Related Lymphedema.

Background: Prospective lymphedema screening is recommended for breast cancer patients. We observed interoperator variation in perometer-acquired arm volume measurements (P-AVMs) due to patient instability during measurements. We hypothesized that improved positioning during perometry would reduce P-AVM variability. Methods and Results: Each arm was measured three times by each operator using a perometer. With the original configuration, P-AVM was performed by 2 operators in 30 patients and four cohorts of 5 to 6 operators in 5 volunteers. Repeatability, reproducibility, and gage precision/tolerance (P/T) ratio were calculated. A customized handlebar was installed to optimize patient positioning. P-AVMs were performed in 20 patients with both configurations. Student's t-test was used to compare variation. With the new configuration, P-AVMs were performed by three operators in five volunteers and five operators in three volunteers. Repeatability, reproducibility, and gage P/T ratio were calculated. For the original configuration, gage P/T ratio was 19.9% for two operators and 35.9% for four cohorts of five to six operators. One operator using the new handlebar decreased P-AVM variability by 28% (p = 0.02). For the new configuration, gage P/T ratio was 6.5% for three operators and 18.7% for five operators. Conclusions: Optimizing patient setup improved P-AVM accuracy. P-AVM accuracy is critical as lack of accuracy results in either overdiagnosis or underdiagnosis of lymphedema, which in turn results in either over- or undertreatment of this dreaded condition. A higher number of operators were associated with greater P-AVM variability.