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Lymphland International Lymphedema Online
One dance step at a time for Colbert
By Diane Chiddister
Since being diagnosed with an aggressive breast cancer nine months ago, Shelley Colbert has
endured chemotherapy, major surgery and radiation treatment. Along with the resulting pain,
fatigue and anxiety of those treatments, Colbert has grappled with another challenge as well —
accepting help from the community where she grew up, raised her children, and cared for the
children of others.
“It’s very hard to ask for help,” Colbert said in an interview last week. “I’m tremendously
grateful to all who have stepped forward with help or good wishes.”
While asking for help is a struggle for Colbert, who prides herself on her independence, she’s
reluctantly allowing her friends to ask for her. Specifically, friends have organized a benefit
concert this Saturday, Jan. 16, from 5 p.m. to midnight at the Emporium with a variety of local
musicians. The music is organized by Steve McColaugh.
Carl Schumacher and Friends will play from about 5 p.m. to 7, Dawn Cooksey and Route 68
South at 8 p.m. and McColaugh’s band, the Undercovered, will play from 9:30 p.m. on.
Colbert vetoed charging admission for the event, according to her longtime friend and event
organizer Peggy Koebernick, so there is no charge, but donations are welcome. The purpose of
the event is to help cover Colbert’s living expenses since she has been unable to work since last
March and will remain unable for the foreseeable future. While most of Colbert’s medical
treatment is currently covered by a special short-term form of Medicaid, and a benefit fun
run/walk last May raised enough money to pay Colbert’s living expenses until now, those funds
are running out.
“I was thinking about what it would be like to be in her shoes,” Koebernick said, regarding her
decision to organize the event. “I wanted to tap into the energy of the community.”
The community’s energy so far has been extraordinary, according to Colbert, who describes
herself as astonished at people’s generosity, both in donating to a special fund at US Bank, and
offering goods and services. Those who can’t attend the fundraiser but would like to make a
donation may do so at the Shelley Colbert Fund at US Bank.
Colbert, one of a family of five children raised by her parents Chuck and Rita, grew up in Yellow
Springs. She left town to go to college, and returned after earning a degree in early childhood
education. When her sons, Ben and Spencer Beggs, were small, Colbert started her childcare
business at her Miami Drive home, where for 23 years she cared for village children until she
received her diagnosis of Stage III breast cancer. At that time, doctors told her she would no
longer be able to lift children after her treatment, Colbert said, adding with a smile that they also
advised her to give up chopping wood and hauling water from the well.
After chemotherapy ended in August, Colbert, who is 60, had a mastectomy in September. And
cancer doesn’t deal out any favors. The night before her surgery, her father, who had suffered a
stroke several weeks earlier, died at Friends Care Community. It was rough, she said, with the
saving grace that at least all her family had already come home for her surgery and were here
when her father died.
The chemotherapy Colbert initially received worked remarkably well, eradicating all traces of
tumors on her scans. Her doctors were amazed, as a complete response is relatively rare.
However, because her cancer had been so aggressive, they urged her to “play her hand all in”
and to accept equally aggressive treatments in surgery and radiation.
The decision to go ahead with seven weeks of radiation — which ends this week — has been the
hardest of all for Colbert. Her instincts told her that so much radiation can’t be good for her body.
Radiation often causes significant damage to the heart, lungs and thyroid, and her doctors couldn’
t guarantee those side effects wouldn’t happen to her.
And Colbert knows something about side effects. The tumors themselves caused lymphedema,
leading to pain and swelling in her right arm and shoulder area. The condition is chronic, and
Colbert is working on finding ways to manage it. She thinks swimming could be a good antidote,
as soon as she’s allowed back into her beloved swimming pools.
As with each step of the nine-month ordeal so far, Colbert has struggled with making decisions
that often seem overwhelming. Mountains of information are available on the Internet, but the
amount seems impossible to sort through, although a good friend, Mary Miller, has volunteered
her skills to analyze research results. But the process often makes her feel crazy, ever focused
on cancer, cancer, cancer.
The radiation left her in pain, with skin burns, and Colbert still worries whether she made the
right choice, or whether, even if the radiation does buy her time, it will be in a life that feels not
worth living. But in the end, she pursued the aggressive treatment that her doctors urged.
“I want people to know I’m doing everything I have to do to stay alive,” she said.
There are people who say that cancer has taught them how to live, or helped them to live better.
So far, Shelley Colbert is not one of those people, but she hasn’t ruled out the possibility.
“I’m hoping maybe the silver lining will reveal itself to me soon,” she said. And the silver lining
so far has been that cancer helped her know who her friends are, and that she has far more
friends than she ever imagined.
“I don’t know how to thank people for all they’ve done for me,” she said. “You don’t know how
many people care about you, but they do. It’s been heartening and humbling. This is a fantastic
community.”
And there’s a bright spot on the horizon. That puppy that Colbert has been longing for is the first
thing on her list after follow-up treatment begins and the weather warms up.
“I can’t wait to get my puppy,” she said.
While Colbert loves to dance and would like nothing better than to dance until midnight on Jan.
16, she’s expecting that fatigue from the radiation treatments may prevent her from doing so. But
she’ll do her best to show up, with her new sleek and short hair. And if she has to go home early,
well, she’ll spend a cold winter evening warmed by the thought of her many friends, new and old,
dancing the night away.
Contact: dchiddister@ysnews.com
http://www.ysnews.com/stories/2010/01/011410_colbert.html
My Bra? Color Me Furious
The bra-color meme that's sweeping Facebook and allegedly raising awareness of breast cancer
got a nice one-two punch from my colleague Frances Tobin.
Get the new
PD toolbar!
Allow me to pile on.
Not for myself, but for friends I've watched face this beast. Many of them aren't wearing bras of
any color because their breasts are long gone. Instead they might be wearing a lymphedema
sleeve on their arms, in some cases for the rest of their lives.
As a member of the all-too-exclusive club of long-term ovarian cancer survivors, let me first say I
used to resent the enormous amount of attention breast cancer got over other cancers. Breast
Cancer Awareness Month (also known as "pink nausea" by certain folks) seemed to begin in
late July and end in late November, totally eclipsing the far more lethal (per capita) cancers of
ovarian and pancreatic.
Where's all the teal in September? I realize fountains are not so good for awareness, since
they're always teal. But where are the endless rows of candy bars and other products sporting
teal?
Where's all the purple in November? If you're a playwright and you want your main character to
die, you choose ovarian if it's a woman and pancreatic if it's a guy. So where's the love for
pancreatic cancer patients?
Cancer envy – wishing you could trade in your bad-stat cancer for a more benign variety – is
known only to those with personal experience with this dreadful disease.
Like it was yesterday, I remember lunch with my friend Sherri. One year after my diagnosis with
ovarian cancer, she'd been diagnosed with breast cancer. She gazed out the window and said,
"This is going to kill me."
"How can you say that," I replied. "I'd give anything to trade my statistics for yours."
"Don't ask me how I know," she said. "I just know."
Sherri was earlier stage than me. She was younger than me. I thought about that when, six years
later, I attended her funeral.
For a while I went to a support group for cancer survivors of all types. That was my light-bulb
moment. The breast cancer patients in that group began detailing the experiences – waking up
from surgery, the day after surgery, going home with drainage tubes attached to their armpits.
"Tubes?" I shuddered. "I guess every kind of cancer is its own version of hell."
Bingo.
In spring of 2008, another friend was diagnosed with breast cancer. If only I had a dollar for
every time I said: My tumor was 11 centimeters. When was the last time you heard of an 11-
centimeter breast tumor?
"No, Donna, it's not early stage," my friend said. "The tumor is nine centimeters." My friend
had lobular breast cancer, which can grow into the chest instead of outward.
A few months later she got a bonus -- a second primary of lung cancer, the kind nonsmokers get.
She's had more surgery in 18 months than I've had in my whole life.
My friend is ten years younger than me. Her husband is a doctor. She's always been trim and fit,
and she has not a mean bone in her body.
Color me educated.
But don't color me pink. Or teal. I want a new color. I want a rainbow. We use the word "cancer"
for what is probably a thousand different diseases. The segregation and disparity in funding
between types of cancer is absurd. Name any cell in your body, and you've just named a chance
for mutation and cancer – at any time, for any person.
Even so, I suspect women are especially vulnerable. Their bodies are designed to grow things.
Like babies. And, it turns out, cancer, even if they don't smoke, and they eat healthy, and breast-
feed their children. While men can get male-specific cancers, women's cancers seem to be more
adept at hiding til it's too late.
Which brings us back to bra colors. Yes, awareness is good – unless people think awareness is as
good as action. Think before you pink, says Breast Cancer Action.
Last night on the Facebook wall of Matthew Zachary, founder of I'm Too Young for This (aka
Stupid Cancer), the bra-color meme was topic one for the evening. "Awareness," Matthew wrote,
"is the same as rhetoric. Like propaganda without the marketing. It's air. I welcome any cultural
anthropologist to demonstrate successful awareness without action."
Years ago I attended a lunch gathering of cancer survivors and medical professionals. The event
was supposed to end with some kind of hilarious musical spoof on the subject of "boobs," written
by a surgeon. At the last moment, the song got spiked. Through the grapevine I heard that a
patient facing mastectomy found the subject not one bit funny.
After walking a mile in the shoes of my friends, I have to say I agree. I would find no comfort in
Facebook games about colored lingerie that my new body no longer needed, or tight tee-shirts
with cute slogans about saving "second base" or the "ta-tas."
Or any other campaign that emphasized the womanliness, the beauty, the importance of breasts.
Never mind the breasts. Save the women.
http://www.politicsdaily.com/2010/01/11/my-bra-color-me-furious/
What Is Turner Syndrome? What Causes Turner Syndrome?
Turner syndrome, also known as Turners syndrome, Ullrich-Turner syndrome or Gonadal
dysgenesis, is a chromosomal disorder that affects only females. It is characterized by the
absence of part or all of a second sex chromosome in some or all cells. Approximately 1 in every
2,500 to 3,000 girls is born with the condition.
People without Turner syndrome have 46 chromosomes, of which 2 are sex chromosomes.
Females have two X chromosomes. In people with Turner syndrome, one of those sex
chromosomes is either missing or has other abnormalities - the chromosome may be missing in
some cells but not in others (mosaicism or Turner mosaicism). In other words, there are two types
of Turner syndromes:
Classical Turner syndrome - an X chromosome is completely missing.
Mosaic Turner syndrome (mosaicism or Turner mosaicism) - the abnormalities only occur in the
X chromosome of some of the cells in the body.
Chromosomes are strands of DNA (deoxyribonucleic acid) that exist in all the cells of the human
body. Chromosomes contain instructions that make a human's behavioral and physical
characteristics.
The syndrome is named after Dr. Henry Turner (USA 1892-1970), an Oklahoma endocrinologist,
who described it in 1938.
Turner syndrome can cause:
Physical disabilities
Emotional disabilities
Educational disabilities
According to Medilexicon's medical dictionary:
Turner syndrome is "a syndrome with chromosome count 45 and only one X chromosome; buccal
and other cells are usually sex chromatin-negative; anomalies include dwarfism, webbed neck,
valgus of elbows, pigeon chest, infantile sexual development, and amenorrhea; the ovary has no
primordial follicles and may be represented only by a fibrous streak; some affected people are
chromosomal mosaic, with two or more cell lines of different chromosome constitution; seen in
many animal species, in the meadow vole it is the normal female state."
What are the signs and symptoms of Turner syndrome?
A symptom is something the patient feels and reports, while a sign is something other people,
such as the doctor detect. For example, pain may be a symptom while a rash may be a sign.
The signs and symptoms of Turner syndrome vary considerably and may even appear before
birth.
Signs and symptoms before birth
Unborn females with Turner syndrome (TS) may develop lymphedema - fluid is not properly
transported around the organs of the body, excess fluid leaks into the surrounding tissue,
resulting in swelling. It is not uncommon for babies born with TS to have swollen hands and feet.
The unborn baby may also have:
•Thick neck tissue
•Cystic hygroma - swelling of the neck
•Lower than normal weight
The following signs and symptoms may be present at birth or during infancy
•Broad chest
•Cubitus valgus (arms turn outwards at the elbows)
•Eyelids that droop
•Fingernails that turn upward
•High, narrow palate (roof of mouth)
•Low hairline at the back of the head
•Low set ears
•Receding lower jaw
•Short hands
•Slower/delayed growth
•Small lower jaw
•Smaller height at birth
•Smaller weight at birth
•Swelling of the hands and feet
•Web-like neck
•Wide neck
•Widely spaced nipples
In some cases Turner syndrome may not become apparent until later on. The following signs and
symptoms that appear later may indicate Turner syndrome:
•Growth spurts do not occur at expected childhood times. During the first three years of life the
baby/toddler may be of normal height. However, by the age of three their growth rate will be
lower than average.
The person is much shorter than expected; about 8 inches (20 cms) shorter than expected for an
adult female member of that family (without treatment).
•Learning difficulties - the majority of girls with TS have normal intelligence, as well as good
verbal and reading skills. There may be some problems with math, spatial concepts, memory
skills and fine finger movements.
•Social problems - the patient may find it hard to properly interpret other people's reactions or
emotions.
•Non-functioning ovaries - during puberty a female's ovaries generally start producing estrogen
and progesterone (sex hormones). The majority of girls with TS will not produce these sex
hormones, resulting in:
•No onset of menstrual periods
•Poorly developed breasts
•Possible infertility
Although the TS female has non-functioning ovaries and is infertile, her vagina and uterus
(womb) will generally be normal and she will usually be able to have a normal sex life.
Approximately 30% of females with TS will undergo some physical changes during puberty.
About 0.5% of girls with TS can become pregnant without fertility treatment.
Other possible signs and symptoms - as well as those listed above, the following may also be
present:
•Eyes that slant downwards
•Prominent earlobes
•Mouth abnormalities which can cause dental problems
•Narrowing of the aorta which may result in heart murmur
•Hypothyroidism - an underactive thyroid gland. This can be treated with thyroxine tablets.
•Hypertension - females with TS are more likely to suffer from high blood pressure
•Brittle bones (osteoporosis) - caused by insufficient estrogen
•Otitis media (middle ear infection, glue ear) - very common among young girls with TS
•Hearing loss in adulthood - usually caused by otitis media during childhood
•Diabetes - older and overweight females with TS have a higher risk of developing diabetes
compared to other women of the same age or weight
•Moles - females with TS may have a large number of moles
•Small spoon-shaped nails
•A shorter than normal fourth finger or toe
What are the causes of Turner syndrome?
Experts say that the loss or abnormality of the X chromosome occurs spontaneously. If
somebody has a child with TS, this does not mean there is a higher risk of any subsequent
children having the condition.
TS occurs when the baby is conceived, when the sperm enters the egg (ovum) and the egg is
fertilized.
Only females are affected.
TS occurs when the second X chromosome is either incomplete or missing completely.
According to the National Health Service (NHS), UK, about 1 in every 2,500 baby girls is born
with the condition. If a baby is conceived with a missing X chromosome the pregnancy usually
miscarries (aborts naturally).
Approximately 10% of all miscarriages during the first trimester of pregnancy are caused by TS.
Most of us are born with two sex chromosomes. Males inherit the X chromosome for their
mothers and the Y chromosome from their fathers. Females inherit one X chromosome from each
parent. When a female has Turner syndrome one X chromosome copy is either absent or
significantly altered. The following genetic alterations of Turner syndrome are possible:
•Monosomy - one X chromosome is completely missing. Experts believe this is caused by an
error either in the father's sperm or the mother's ovum (egg). Every cell in the offspring's body
has one X chromosome missing.
•Mosaic Turner syndrome (mosaicism or Turner mosaicism) - during the early stages of fetal
development an error may have occurred in cell division, resulting in some cells having two X
chromosome copies, while others only have one. In some cases there may be some cells with both
X chromosome copies, and others with one altered copy.
•Y chromosome material - a small number of patients with TS have some cells with just one X
chromosome copy and other cells with just one X chromosome copy as well as some Y
chromosome material. The individual develops as a female, but has a higher risk of developing
gonadoblastoma (a type of cancer).
The missing or altered X chromosome causes errors during fetal development, as well as
subsequent development after birth.
What are the risk factors for Turner syndrome?
A risk factor is something which increases the likelihood of developing a condition or disease. For
example, obesity significantly raises the risk of developing diabetes type 2. Therefore, obesity is
a risk factor for diabetes type 2.
Experts say that the risk of having TS is the same for females in all regions of the world, races,
nationalities and socioeconomic groups. The condition occurs randomly and is not associated with
the age of the mother or father.
There are no known toxins or environmental factors that appear to alter the risk of developing
TS.
How is Turner syndrome diagnosed?
Diagnosis during pregnancy and birth - during an ultrasound test, for example, TS may be
suspected. Amniocentesis or Chorionic villus sampling, both antenatal tests that detect
chromosomal abnormalities, are possible ways to confirm a diagnosis. Diagnosis may also
eventually be made if heart or kidney problems, or swelling of the hands and feet are present at
birth.
Diagnosis during childhood - if the child has a wide or webbed neck, a broad chest and widely
spaced nipples TS may be suspected.
If the girl eventually has a short stature and undeveloped ovaries, TS may be suspected.
Sometimes diagnosis is not made until later, for example, when puberty does not occur.
Karotype - this blood test can be used to detect extra or missing chromosomes, chromosomal
rearrangements, or chromosomal breaks. This may be done either by taking a sample of the
amniotic fluid while the baby is still in the uterus, or taking a blood sample from a child/baby. If
one of the X chromosomes is missing or incomplete, TS is confirmed.
What are the treatment options for Turner syndrome?
Turner syndrome is a genetic condition for which there is no current cure. However, several
treatments may help with short stature, sexual development and learning difficulties.
Early preventative care - it is important that the child is checked regularly so that the risk of
complications can be minimized. Blood pressure and the thyroid gland need to be monitored
frequently, and any necessary treatment given immediately.
Treatment with medical specialists - as girls with TS are more likely to develop otitis media
(inner ear infections, glue ear) they need to be treated promptly to minimize the risk of hearing
difficulties later in life. Treatment should be carried out by an ENT (ear, nose and throat)
specialist.
Hormone therapy, which may include estrogen, progesterone and growth hormones, may be
required. These treatments will be done with an endocrinologist, or pediatric endocrinologist.
Growth hormone therapy - as soon as it is established that the girl with TS is not growing
properly growth hormone should be administered. Effective therapy may prevent short stature
later in life. Treatment may start as early as the age of one or two years. A daily injection is
given. Growth hormone therapy may add an extra 10cm (4 inches) to the girl's eventual stature.
Estrogen and progesterone replacement therapy - the girl needs these two hormones to develop
sexually. Estrogen will also stop her bones from becoming brittle (osteoporosis). The ovaries of a
girl with TS do not produce sufficient quantities of these hormones. How much the patient is
producing herself can be determined with blood tests.
Estrogen replacement therapy will start at the onset of puberty (11 years of age). The patient will
initially receive low doses, which are slowly increased. Progesterone therapy is generally given
later to trigger menstrual periods. TS patients require sexual hormone treatment for the rest of
their lives. Treatment may be given as tablets, injections or patches.
IVF (in vitro fertilization) - the majority of patients with TS are unable to become pregnant
without help. If a woman with TS wants to become pregnant she will probably require assistance,
for example, IVF. If the patient manages to become pregnant she will need to be monitored
closely, because of the extra strain on her heart and blood vessels.
Counseling and psychological therapy - some patients may develop psychological problems and
will benefit from psychological therapy.
Learning assistance - although girls with TS generally have normal levels of IQ, there may be
problems with numeracy, spatial concepts, memory skills and fine finger movements. Educational
support will help the child.
What are the possible complications related to Turner syndrome?
Heart problems - some girls with TS are born with either heart defects or very slight heart
abnormalities which may raise their risk of complications later in life. Defects in the aorta, the
main blood vessel leading out of the heart raises the risk of aortic dissection (a tear in the inner
layer of the aorta). If there is a defect in the valve between the aorta and the heart there is an
increased risk of an aortic valve stenosis (narrowing of the valve).
High blood pressure - people with TS are much more prone to suffer from high blood pressure
(hypertension) compared to others.
Diabetes - overweight or older women with TS have a higher risk of developing diabetes
compared to other women of the same age and weight.
Hearing - gradual loss of nerve function can cause hearing loss. Girls with TS are much more
likely to develop glue ear (otitis media, inner ear infection), which can lead to hearing loss.
Kidney problems - approximately 30% of TS patients have some kind of kidney malformation,
raising the risk of hypertension and urinary tract infections.
Hypothyroidism - having an underactive thyroid gland is more likely among patients with TS.
Tooth loss - patients with TS have a higher risk of having poor or abnormal tooth development,
resulting in more tooth loss. Also, because of the shape of the mouth and palate, the patient is
more likely to suffer from crowded and poorly aligned teeth.
Vision - strabismus is more common among girls with Turner syndrome (eyes to not work in
parallel and appear to be looking in different directions). Hyperopia (farsightedness, long-
sightedness) is more common among girls with TS.
Bones - women with TS have a significantly higher risk of developing osteoporosis. Sometimes
there may be problems with the curvature of the spine, leading to scoliosis. There is also a risk of
kyphosis (forward rounding of the upper back).
Pregnancy - a woman with TS who becomes pregnant has a significantly higher risk of developing
complications, including gestational diabetes, high blood pressure and aortic dissection.
Psychology - there is a greater risk of problems with self-esteem, anxiety, depression, ADHD
(attention deficit hyperactivity disorder). There may also be difficulties in social situations.
Written by Christian Nordqvist
Copyright: Medical News Today
Not to be reproduced without permission of Medical News Today
http://www.medicalnewstoday.com/articles/176083.php
Lives Lived
Sharon Enkin
Wife, mother, grandmother, aunt to many, teacher, community charitable leader, supporter of
Israel. Born March 18, 1927, in Winnipeg. Died Sept. 8, 2009, in Milton, Ont., of septicemia,
aged 82.
Sharon Enkin was one of three daughters of Buirt and Fanny Segal. The Segals settled in St.
Walburg in northern Saskatchewan during the Depression. They were the only Jewish family in
town. In addition to owning the general store, Buirt was one of the town founders and served as
mayor for some years.
The family retained their connection to Judaism and Israel, annually making the arduous day-
long journey on mud roads into North Battleford to attend the synagogue for major holidays.
Sharon displayed her talents early, winning many public-speaking awards. When her family
moved back to Winnipeg, she continued her education and interest in the arts at the University of
Manitoba. In 1949, she went on a trip that changed her life and sparked an abiding interest in
Israel. This was the first Canadian trip permitted for students to the new state of Israel. Instead
of returning to Canada, Sharon stayed on for two years, studying at the Hebrew University,
teaching English, becoming fluent in Hebrew and establishing lifelong friendships.
On her return to Canada after her father's stroke, Sharon headed to Toronto seeking a career in
radio theatre productions. There she met Larry Enkin. They married in 1954 and moved to
Hamilton, where Larry's father owned a men's clothing manufacturing company. Sharon and
Larry had three children, Peri, James and Marc. Throughout their marriage of more than 55
years, Sharon's personality and talents thrived.
In Hamilton, Sharon started a summer program for inner-city children called Painting in the Park.
She led this for 10 years, bringing art classes and theatre to countless children. She followed this
by teaching drama to children and acting in local productions.
In her 50s, Sharon furthered her education in teaching and drama at the University of Toronto.
These studies led to another bachelor's degree and the launch of Golden Horseshoe Players, a
non-profit professional theatre company presenting values-related performances in Ontario
schools. Thousands of students saw these plays, and many young actors got their professional
start with the company. Sharon's most recent effort was to launch a fundraising initiative to
provide birthday parties for children in Israel who would otherwise not have one.
Sharon suffered swelling in her legs from lymphedema, which together with osteoarthritis made
walking extremely difficult, and underwent several surgeries. Yet she continued to walk until the
end, rejecting any support except her cane, an example of her indomitable will not to give in.
Larry Enkin is Sharon's husband, Robyn Rypp is Sharon's niece and Howard Rypp is Sharon's
nephew.
http://www.theglobeandmail.com/life/facts-and-arguments/sharon-enkin/article1420043/
TINA THE LINK FOR THIS NEXT ONE SAID THERE WAS AN ERROR but the study itself
I had a link that went thru ok, so that is what I am sending below
error link: Physiotherapy cuts complications after breast surgery
study published on bmj.com today showed that women who had received phsyiotherapy had a
significanty reduced risk of secondary lymphedema after breast ...
STUDY LINK: http://www.bmj.com/
Problem of immortal time bias in cohort studies
Well designed observational studies have made important contributions to our understanding of
the risks and benefits of drug treatment. Such studies are often the first to identify or confirm
important adverse health events associated with drugs and can assess aspects of drug safety.
Cohort studies are often preferred to case-control studies because they are less susceptible to
certain biases, but the inappropriate accounting of follow-up time and treatment status in the
design and analysis of such studies can introduce immortal time bias, say the authors of this
research methods and reporting article, using the example of statins for preventing progression
of diabetes.
THEN THE LINK FOR THE TITLE Problem of immortal time bias... is: http://www.bmj.
com/cgi/content/citation/340/mar12_1/b5087
but there I needed to be a member for any further info and I dont join things:
Therapy May Relieve Breast Cancer Surgery Complication
A common complication of breast cancer surgery can be prevented or reduced if patients receive
physical therapy, including massage and shoulder exercises, soon after their operation, a new
study suggests.
Secondary lymphedema -- caused by damage to the lymphatic system during treatment -- results
in fluid retention and arm swelling. It affects 71 percent of patients within 12 months of breast
cancer surgery and can cause disfigurement, anxiety, depression and emotional distress.
Maria Torres Lacomba, a professor of physiotherapy at Alcala de Henares University in Madrid,
Spain, and colleagues selected 120 women who had breast cancer surgery involving removal of
lymph nodes and divided them into two groups -- an intervention group that received early
physiotherapy and education, and a control group that received education only. Both programs
lasted three weeks and the patients were followed up four weeks after surgery and again three,
six and 12 months after surgery.
The therapy included lymph drainage, scar tissue massage and shoulder exercises supervised by
a physiotherapist. The education program included materials about the lymphatic system and
advice on how to avoid injury and prevent infection.
After one year, 7 percent of women in the intervention group and 25 percent of those in the
control group developed secondary lymphedema. The researchers also found that secondary
lymphedema was diagnosed four times earlier in the control group than in the intervention group,
according to the report published online Jan. 12 in the BMJ.
Further research is needed to determine whether early physical therapy after breast cancer
surgery offers longer-term protection against secondary lymphedema, the researchers said.
More information
The American Cancer Society has more about breast cancer patients and lymphedema.
Copyright © 2010 ScoutNews, LLC. All rights reserved.
http://www.palmbeachpost.com/health/therapy-may-relieve-breast-cancer-surgery-complication-
176500.html
Physical Therapy Can Cut Risk of Post-Surgical Lymphedema
Condition is one of the most common complications of breast cancer surgery
WEDNESDAY, Jan. 13 (HealthDay News) -- The risk of secondary lymphedema in breast
cancer surgery patients can be significantly reduced by the early introduction of post-surgical
physical therapy, according to a study published online Jan. 12 in BMJ.
María Torres Lacomba, of Alcalá de Henares University in Madrid, Spain, and colleagues
conducted a study of 120 women who underwent breast cancer surgery involving the dissection of
axillary lymph nodes. All the participants were given education about the lymphatic system and
on strategies to avoid injury and reduce the risk of infection. The intervention group also
received a program of physical therapy, including manual lymph drainage, scar tissue massage
and shoulder exercises.
In all, 116 women completed follow-up at one year, and 18 (16 percent) developed secondary
lymphedema, including 14 (25 percent) in the control group and four (7 percent) in the
intervention group, the researchers found.
"This result emphasizes the role of physiotherapy in the awareness, prevention, early diagnosis,
and treatment of secondary lymphedema," the authors write. "Secondary lymphedema is a
chronic condition, which has negative effects on the quality of life of patients. The increase in risk
factors associated with secondary lymphedema, such as ageing populations and the growing
prevalence of obesity, along with the gradual improvement in rates of survival from cancer,
suggest that secondary lymphedema will remain a challenge."
http://www.modernmedicine.com/modernmedicine/Modern+Medicine+Now/Physical-Therapy-
Can-Cut-Risk-of-Post-Surgical-Lym/ArticleNewsFeed/Article/detail/651806?
contextCategoryId=40157
then the full text link: http://www.bmj.com/cgi/content/full/340/jan12_1/b5396
FULL TEXT INFO - has tables so not sure if they will be a problem for you and i didnt know if
you wanted all of this or not:
Research
Effectiveness of early physiotherapy to prevent lymphoedema after surgery for breast cancer:
randomised, single blinded, clinical trial
María Torres Lacomba, professor of physiotherapy1, María José Yuste Sánchez, professor of
physiotherapy1, Álvaro Zapico Goñi, professor of obstetrics and gynaecology1,2, David Prieto
Merino, lecturer3, Orlando Mayoral del Moral, professor of physiotherapy4, Ester Cerezo
Téllez, research fellow1, Elena Minayo Mogollón, research fellow1
1 Physiotherapy Department, School of Physiotherapy, Alcalá de Henares University, E-28871
Alcalá de Henares, Madrid, Spain, 2 Príncipe de Asturias University Hospital, Alcalá de
Henares, Madrid, 3 Medical Statistics Unit, Department of Epidemiology and Population Health,
London School of Hygiene and Tropical Medicine, London, 4 Physiotherapy Department,
Provincial Hospital, Toledo, Spain
Correspondence to: M Torres Lacomba maria.torres@uah.es
Abstract
Abstract
Introduction
Methods
Results
Discussion
References
Objective To determine the effectiveness of early physiotherapy in reducing the risk of
secondary lymphoedema after surgery for breast cancer.
Design Randomised, single blinded, clinical trial.
Setting University hospital in Alcalá de Henares, Madrid, Spain.
Participants 120 women who had breast surgery involving dissection of axillary lymph nodes
between May 2005 and June 2007.
Intervention The early physiotherapy group was treated by a physiotherapist with a
physiotherapy programme including manual lymph drainage, massage of scar tissue, and
progressive active and action assisted shoulder exercises. This group also received an
educational strategy. The control group received the educational strategy only.
Main outcome measure Incidence of clinically significant secondary lymphoedema (>2 cm
increase in arm circumference measured at two adjacent points compared with the non-affected
arm).
Results 116 women completed the one year follow-up. Of these, 18 developed secondary
lymphoedema (16%): 14 in the control group (25%) and four in the intervention group (7%). The
difference was significant (P=0.01); risk ratio 0.28 (95% confidence interval 0.10 to 0.79). A
survival analysis showed a significant difference, with secondary lymphoedema being diagnosed
four times earlier in the control group than in the intervention group (intervention/control, hazard
ratio 0.26, 95% confidence interval 0.09 to 0.79).
Conclusion Early physiotherapy could be an effective intervention in the prevention of secondary
lymphoedema in women for at least one year after surgery for breast cancer involving dissection
of axillary lymph nodes.
Trial registration Current controlled trials ISRCTN95870846 [controlled-trials.com] .
Introduction
Abstract
Introduction
Methods
Results
Discussion
References
Acquired interruption or damage to the axillary lymphatic system after surgery or radiotherapy
for breast cancer can lead to regional or generalised accumulation of lymph fluid in the interstitial
space, known as secondary lymphoedema.1 This condition is the most important chronic
complication after dissection of the axillary lymph nodes2 3 4 5 and has a tendency to progress.
Secondary lymphoedema can cause disfigurement, physical discomfort, and functional
impairment. Anxiety, depression, and emotional distress are more common in patients with than
without secondary lymphoedema. This can affect social relationships, undermining body image
and self esteem.6 7 8 The condition may also precipitate cellulitis, erysipelas, lymphangitis, and
occasionally lymphangiosarcoma.9 10 11
Reported incidence rates for secondary lymphoedema vary depending on the method used for
measurement.12 Inconsistent definitions and the lack of a standard classification system have
resulted in diverse incidence rates for secondary lymphoedema, ranging from 5% to 56% within
two years after surgery.7 13 14 15 16 After axillary lymph node dissection the incidence of
secondary lymphoedema is about 23-38% if the criterion used to identify it is a greater than 2 cm
increase in upper arm circumference measured at two adjacent points compared with the
circumferences in the other arm.17 Most women (71%) develop secondary lymphoedema within
12 months after surgery for breast cancer.18 19
The factors that might influence the development of secondary lymphoedema after surgery are
the number of lymph nodes removed, radiotherapy to the axilla, postoperative wound infection,
postsurgical drainage time, lack of mobility, and obesity.18 20 21 22 23 24
Currently, women with breast cancer have a 77% probability of surviving at least 10 years.25 26
Consequently the effective prevention and management of complications that can impair function
and affect quality of life after treatment are important.15
Efforts have been made to reduce the risk of secondary lymphoedema by preoperative and
postoperative counselling and education27 28 and by early detection.27 29 A randomised clinical
trial on the prevention of secondary lymphoedema through exercises and an educational strategy,
however, lacked sufficient evidence.30 We determined the effectiveness of an early
physiotherapy programme in reducing the risk of secondary lymphoedema in women after
surgery for breast cancer involving dissection of axillary lymph nodes.
Methods
Abstract
Introduction
Methods
Results
Discussion
References
We carried out a randomised, single blinded, clinical trial of women after unilateral breast cancer
surgery with axillary lymph node dissection at the Príncipe de Asturias Hospital in Madrid
between May 2005 and June 2007. We excluded women without axillary lymph node dissection or
with bilateral breast cancer, systemic disease, locoregional recurrence, or any contraindication to
physiotherapy.
Eligible women gave written informed consent to participate in the study after breast cancer had
been confirmed by biopsy. Each participant was assessed preoperatively and between days 3 and
5 after hospital discharge. Equal numbers of women were then randomly allocated by computer
using EPIDAT version 3.1 (Xunta de Galicia, Spain)31 to either early physiotherapy and an
educational strategy (early physiotherapy group) or the educational strategy only (control group).
Both programmes lasted three weeks, with three visits each week. The main outcome was the
incidence of secondary lymphoedema.
Follow-up
Initially we scheduled four follow-up visits: four weeks after surgery (shortly after the completion
of the intervention) and three, six, and 12 months after surgery. These dates were, however,
flexible, depending on the participant’s availability. At all visits lymphoedema was assessed using
the same protocol.
If patients experienced pain, discomfort, or any other symptoms, they could contact the
physiotherapist and a visit would be arranged. If secondary lymphoedema was diagnosed then
complex decongestive physiotherapy was carried out,32 33 34 which would effectively interrupt
follow-up.
Interventions
Each group had one physiotherapist, who carried out all interventions. Before the study it was
agreed that both groups would receive the same educational intervention. The physiotherapists
had more than five years’ experience in the treatment of vascular diseases using lymphatic
drainage. They were the only study members aware of group allocation.
Early physiotherapy group—The intervention included the manual lymph drainage technique
used for the treatment of postoperative oedema (thorax, breast, axilla, and upper arm of affected
side), using a modification of the strokes described by Leduc (only resorption strokes were used)
32 34; progressive massage of the scar (progressing from Jacquet and Leroy pincer to
Wetterwald pincer)32 35; stretching exercises for levator scapulae, upper trapezius, pectoralis
major, and medial and lateral rotators muscles of the shoulder36; and progressive active and
action assisted shoulder exercises, started in conjunction with functional activities and
proprioceptive neuromuscular facilitation exercises without resistance (rhythmic initiation
progressing from passive to active-assistive to active movement in two diagonal symmetrical
bilateral patterns and asymmetrical reciprocal patterns: D1 into flexion from hitch hike to swat
fly, and into extension from swat fly to hitch hike, and D2 into flexion from hand in opposite
pocket to carry tray, and into extension from carry tray to hand in opposite pocket).37 If axillary
web syndrome was diagnosed the physiotherapy protocol extended the manual lymph drainage
technique to axilla and to proximal ipsilateral arm and included specific thumb manual lymph
drainage on the characteristics taut cords, to make them gradually more flexible. The early
physiotherapy group also did shoulder exercises and stretching at home once daily during the
three week intervention period.
Educational strategy (both groups)—The educational strategy consisted of instruction with
printed materials about the lymphatic system, concepts of normal load versus overload, the
source of secondary lymphoedema, the identification of possible precipitating factors, and the
four categories of interventions to prevent secondary lymphoedema (avoidance of trauma or
injury, prevention of infection, avoidance of arm constriction, and use and exercise of the arm),27
28 38 39 together with individual strategies for implementing these measures.
Assessments
A different physiotherapist did the two initial and four follow-up assessments of all participants
and remained blinded to group allocation. Participants were instructed not to reveal their
allocation.
Lymphoedema—Direct measurement of the presence and severity of lymphoedema is difficult
and different diagnostic criteria have been described, including comparison between preoperative
and postoperative measurements within the affected arm and comparison of measurements
between the affected and unaffected arms.16 29 40 41 42 43 For our main analysis we used the
criteria stated in the trial protocol—that is, a 2 cm or greater increase in the circumference of
any two adjacent points compared with measurements in the other arm.19 41 44 45 46 We also
carried out the analysis using other criteria (data not shown).
Arm measurements—Whatever the criteria used for diagnosing lymphoedema they are all based
on changes in size or volume of the arms. Arm circumferences were measured at each visit and
always following the same procedure, using a standard 1 cm wide, retractable, fibreglass tailor’s
tape measure (Babel, Spain). With the patient in an upright sitting position with both arms on a
table, shoulders in neutral rotation and flexion of 45°, and forearms at maximum supination, we
measured the circumference at 5 cm intervals along both arms, using the elbow fold as the
reference starting point. This has been reported as a valid and reliable method for accurately
quantifying and diagnosing secondary lymphoedema.47 48 49
Other variables—During the preoperative assessment we collected personal data on the
participants, including age, ethnicity, marital status, body mass index, job, educational level,
socioeconomic status, information on breast cancer, and medical history. In postoperative
assessments, data were collected on the type of surgery done, the number of lymph nodes
removed, the use of adjuvant treatment, and the development of seroma and infection.
Participants were also asked an open question about whether they had any pain. If they did, a
physical examination was carried out to find the source, including axillary web syndrome. The
diagnostic criteria for axillary web syndrome were pain and restriction of range of motion in the
shoulders, with associated visible or palpable taut cords of tissue in the axilla in maximal
shoulder abduction.50 51 52 53 54 Other secondary outcomes were measured according to the
protocol but are not reported here.
Statistical analysis
The clinical criterion we chose to determine lymphoedema (binary variable) was based on
changes in circumference along the arm (continuous variable). The raw data are therefore
measures of circumference. To obtain the binary outcome several intermediate variables need to
be computed from these measurements (see web extra on bmj.com). The important variable here
would be the maximum difference in arm circumference between any two adjacent points. A
patient would have a diagnosis of secondary lymphoedema if the maximum difference between
any two adjacent points was 2 cm or greater. Lymphoedema can also be determined from the
increase in volume ratio of both arms (volume of affected arm divided by volume of unaffected
arm). 29 30 42 44 55 56 The volume ratio is computed in the variable "change in volume ratio"
(presented as percentages). Although we chose not to use this as part of our criteria for clinical
diagnosis we include a continuous analysis on this variable. This variable can be easily
interpreted as an increase or decrease of the proportional difference of the volumes of both arms
(affected minus unaffected; see web extra on bmj.com). Total arm volume was calculated by
adding up all the partial volumes between every two adjacent measurements. Each of these
partial volumes was calculated by an approximation to a truncated cone with the formula:
V=D(C12+C22+C1C2)/12
where C1 and C2 are the circumferences and the two adjacent locations and D is the distance
between C1 and C2. We have not included hand volume as this is difficult to model with a
truncated cone. Truncated cone calculations of limb segment volumes using the circumference of
segments have been reported to be reliable.16
Power calculations and sample size
Although the sample size was limited by patients’ availability we did some power calculations.
With this sample size and after 3% of dropouts, we would have a power of 70% to detect a
difference of 20% in the incidence of secondary lymphoedema between the groups. This assumes
an incidence of 30% in the control group (according to findings in earlier studies16 17 19 44) and
setting a type I error of 0.05.
Statistical analyses were done using Stata version 10.0.57 For the primary analysis we compared
the groups in three ways. Firstly, we used a binary outcome analysis to compare the incidence of
lymphoedema, determined according to the chosen criteria. Secondly, we used a continuous
outcome analysis to compare the variables "maximum difference in arm circumference between
two adjacent locations" and "change in volume ratio." Thirdly, as we had recorded the timing of
diagnosis of lymphoedema we carried out a survival analysis for the binary outcome. We
compared the incidence of lymphoedema using Fisher’s exact test. Logistic regression was used
when we needed to adjust for other variables. For the continuous outcomes sufficient data
ensured the asymptotic properties of Student’s t tests to compare means. A Cox proportional
hazard model was used to compare the survival rate between the groups.
Results
Abstract
Introduction
Methods
Results
Discussion
References
Of 120 women recruited, 60 were assigned to early physiotherapy and an educational strategy
and 60 to the educational strategy only (fig 1). All variables were similarly distributed between
the groups at randomisation (preoperative visit; table 1). The volume ratios were around 1 in both
groups. This was expected as no lymphoedema was present at the preoperative assessment.
Overall, 116 women completed the follow-up assessments; 59 in the intervention group and 57 in
the control group.
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Fig 1 Progress of participants through study
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Table 1 Comparison between randomised groups at baseline. Values are numbers
(percentages) unless stated otherwise
Table 2 shows the numbers of women in both groups with a diagnosis of secondary lymphoedema.
The incidence of secondary lymphoedema in the control group (14 cases, 25%) was significantly
higher than in the intervention group (four cases, 7%; P=0.010). Risk factors for secondary
lymphoedema18 22 23 24 were similar between the groups, therefore adjustment for these was
not necessary (table 1). Body mass index was higher in the intervention group, therefore the odds
ratio for treatment was adjusted by body mass index (table 2). The crude effect showed no
difference.
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Table 2 Comparison of secondary lymphoedema in groups
Table 3 compares the continuous variables for the outcome (parametric tests) between the
groups. By the 12 month follow-up visit the volume ratio between arms had increased in both
groups: in the control group the volume of the affected arm was on average 5.1% greater than
that of the unaffected arm, whereas in the intervention group the affected arm was on average
only 1.6% greater than the unaffected arm. The difference between groups was significant (P=0.
0065). The maximum difference between two adjacent points was on average also larger in the
control group than in the intervention group (1.15 cm v 0.68 cm, P=0.0207). Figures 2 and 3 show
the distributions of these variables in the groups. The distributions in the control group are more
skewed to the right.
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Fig 2 Increase in volume ratios between arms. Vertical lines correspond to cut-off values for
diagnoses of lymphoedema in other studies (>5% and >10% increase)
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Fig 3 Maximum increase in arm circumference (affected arm–unaffected arm) that could be
observed at least at two adjacent points. Vertical line corresponds to binary criteria used here to
diagnose lymphoedema—that is, a 2 cm or greater increase in arm circumference observed at
least at two adjacent points in affected arm compared with unaffected arm
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Table 3 Continuous analysis of circumferential and volume measurements. Values are means
(standard deviations) unless stated otherwise
The rate of survival was better in the intervention group than in the control group. Secondary
lymphoedema developed four times more rapidly in the control group (intervention group/control
group, hazard ratio 0.26, 95% confidence interval 0.09 to 0.79; P=0.010). The shape of the failure
curves (1 minus survival) suggests that the protective effect of early physiotherapy remained for
a long time, whereas the proportion of patients with a diagnosis of secondary lymphoedema in the
control group increased progressively (fig 4).
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Fig 4 Failure time for development of secondary lymphoedema by group
Discussion
Abstract
Introduction
Methods
Results
Discussion
References
Early physiotherapy with an educational strategy after surgery for breast cancer that involved
dissection of axillary lymph nodes was associated with a lower risk of secondary lymphoedema
than the educational strategy only (control group) after 12 months of follow-up: 25% in the
control group compared with 7% in the intervention group. Secondary lymphoedema developed
from six to 12 months postoperatively, which agrees with previous studies.29 30 This could be
due to the sum of various risk factors associated with secondary lymphoedema: axillary lymph
node dissection, the number of lymph nodes removed (between 10 and 20 nodes were removed in
17 of the 18 women with secondary lymphoedema), overweight (12 of the 18 women had a body
mass index >25), and postoperative complications (all 18 women had postoperative
complications) along with the effect of radiotherapy (completed in the fourth postoperative
month) as well as the gradual weight gain (11 of 12 women with secondary lymphoedema who
were overweight at baseline progressively increased in weight from six months after surgery).18
20 21 23 24 Further investigation of these risk factors is needed.
Secondary lymphoedema is thought to be caused by damage to the axillary lymphatic system,
impairing lymph drainage from the arm, although there is strong evidence that total blood flow in
the arm and vascular bed size are increased in secondary lymphoedema.1 Recently, a study to
develop an animal model of postsurgical lymphoedema reported that after nodal excisions the
limbs became progressively more oedematous up to three days after node dissection and that the
swelling decreased but had not resolved 16 weeks after surgery.58 Taking this into account and
since the basic rule is that all oedemas result from an imbalance between filtration and resorption
(tissue drainage), the implementation of a measure to restore this balance during the period of
higher filtration should prevent or delay the onset of secondary lymphoedema. Our study
included manual lymph drainage, which is a special method involving gentle massage to improve
the lymph circulation, especially subcutaneous circulation, to stimulate the initial lymphatics, and
to stretch the lymph vessels, consequently improving the removal of interstitial fluid. Manual
lymph drainage encourages and improves resorption without increasing filtration.34 59 It has
been shown to be effective in the treatment of lymphoedema because it improves the removal of
fluid from interstitial space.32 34 59 60 We therefore think that the implementation of manual
lymph drainage after surgery for breast cancer in the early physiotherapy group could have
contributed to the better results in that group. This, together with early physiotherapy for other
effects of breast cancer surgery, and related to the onset of secondary lymphoedema,18 20 21 23
24 could explain the effectiveness of early physiotherapy in the prevention of secondary
lymphoedema in women who have had surgery for breast cancer with axillary lymph node
dissection—at least during the first year after surgery.
We also found that 12 of the 18 women who developed secondary lymphoedema had axillary web
syndrome during the second and third week after surgery. The axillary web syndrome is a known
but poorly studied complication of surgery.54 61 62 No study has shown any link between the
axillary web syndrome and the onset of secondary lymphoedema. We and others32 50 suggest
that the axillary web syndrome may be a sign of injury to the lymphatic system and it could
produce a lymphatic overload as a result of failure of the lymphatic system. This overload,
together with other factors, could be responsible for the onset of secondary lymphoedema. When
axillary web syndrome was diagnosed in the postoperative period in the intervention group,
specific manual lymph drainage strokes were applied, together with progressive active and action
assisted shoulder and arm exercises. Manual lymph drainage acted on the pain and inflexibility
inherent to the vascular inflammation of the lymphatic vessel; also, if the axillary web syndrome
did produce a lymphatic overload, and therefore a possible subclinical oedema, the action of the
manual lymph drainage could help with reabsorption.32 34 59 60 63 Further research on a
possible relation between the axillary web syndrome and the development of secondary
lymphoedema in women after breast cancer surgery is needed.
Comparison with other studies
Secondary lymphoedema is a common complication of breast cancer surgery.2 3 4 5 As far as we
are aware, only one study has examined the effect of exercise and specific recommendations
about self care to minimise the onset of secondary lymphoedema.29 30 In addition, several
studies on the effectiveness of early rehabilitation after breast surgery reported data on
lymphoedema as secondary end points.64 65 66 67 68 Box and colleagues evaluated an
intervention to minimise postoperative lymphoedema in 65 women and stated that a
physiotherapy management care plan, including exercise strategies that were not described in the
paper, and progressive educational strategies may reduce the occurrence of secondary
lymphoedema two years after surgery.30 Our results for onset of secondary lymphoedema one
year after surgery are better than their results. Exercise is used in the management of secondary
lymphoedema of the arm to promote the recruitment of collateral lymphatics pathways.69 This
might explain the difference in results between the studies. The intervention programme in the
study by Box and colleagues did not include the diagnosis and treatment of postoperative
vascular complications (such as seroma and axillary web syndrome), which could be related to the
onset of lymphoedema and could benefit from a proper manual physiotherapy.50 51 52 53
Many studies have assessed the effectiveness of rehabilitation in patients after breast cancer
surgery.64 65 66 67 68 All of them present limitations in the sample size and assert that
physiotherapy is beneficial for shoulder mobility and functional capacity without causing adverse
effects in the postoperative period, but not in preventing secondary lymphoedema. All the studies
focused on the recovery or maintenance of the mobility of the shoulder so that the intervention
was based on mobility and stretching exercises of the shoulder.64 65 66 67 68 Only one study
included massage (not manual lymph drainage) in one of the intervention groups. This group
showed better results, but the onset of lymphoedema was not prevented.65 The development of
restricted shoulder mobility is one of the most important factors impairing functional activities of
patients after breast surgery.70 A delayed onset physiotherapy programme as required has been
suggested to improve shoulder mobility and daily activities of living.71 None of these studies
could correlate the exercise programme with the incidence of lymphoedema.64 65 66 67 68 Our
results in relation to the study by Box and colleagues30 could result from the early diagnosis and
treatment of postoperative vascular complications.
Strengths and limitations of the study
We believe that our study shows evidence of the positive effect of early physiotherapy in the
prevention of secondary lymphoedema, but the study is limited by the duration of follow-up (one
year after surgery) and recruitment in just one hospital. Although we have no reason to suspect
systematic differences in care provided by this hospital and other regional hospitals or hospitals
in other developed countries, this may limit the external validity of the results. Furthermore, that
the physiotherapy was provided by trained physiotherapists may limit the generalisability of this
intervention to other settings.
Another limitation is that we chose a particular criterion for diagnosing lymphoedema. We
followed the criterion specified in our protocol but other criteria could have been used. For
example, if the criterion of a greater than 10% increase in the volume ratio between arms
(affected v unaffected) had been chosen, the patients with a diagnosis of secondary lymphoedema
would be those appearing to the right of the vertical line furthest to the right in figure 2. Using
this criterion the early physiotherapy group would have three cases (5%) and the control group
13 (23%), with a risk ratio of 0.22 (95% confidence interval 0.06 to 0.74); results similar to those
in table 2.
A further limitation is the possibility of measurement errors. We have no reason to believe,
however, that this will have a differential effect on both intervention and control groups. The
physiotherapist who took the measurements was blinded to the patient’s treatment allocation.
Both groups were reasonably balanced for baseline characteristics. The use of ratios between
arms also reduces errors that could be correlated with some patient characteristics, such as body
mass index. In general, we believe that measurement error might have the effect of slightly
increasing the variance in the measurement, but not in a biased way. At the most, this would
reduce statistical power of the comparisons to identify differences but would not invalidate the
ones observed.
Conclusion
Early physiotherapy could help to prevent and reduce secondary lymphoedema in patients after
breast cancer surgery involving dissection of axillary lymph nodes, at least for one year after
surgery. This result emphasises the role of physiotherapy in the awareness, prevention, early
diagnosis, and treatment of secondary lymphoedema.
Secondary lymphoedema is a chronic condition, which has negative effects on the quality of life of
patients. The increase in risk factors associated with secondary lymphoedema, such as ageing
populations and the growing prevalence of obesity,18 23 24 along with the gradual improvement
in rates of survival from cancer,26 suggest that secondary lymphoedema will remain a challenge.
Further studies are needed to clarify whether early physiotherapy after breast cancer surgery
can remain effective in preventing secondary lymphoedema in the longer term.
What is already known on this topic
Secondary lymphoedema is the most important chronic complication after breast cancer surgery
with dissection of axillary lymph nodes
Early postsurgical rehabilitation improves shoulder mobility and functional capacity without
causing adverse effects but does not prevent secondary lymphoedema
What this study adds
Early physiotherapy with an educational strategy compared with the educational strategy alone
was associated with a lower risk of secondary lymphoedema 12 months after surgery for breast
cancer with axillary node dissection
The axillary web syndrome was an important complication in the immediate postoperative period
Cite this as: BMJ 2010;340:b5396
--------------------------------------------------------------------------------
We thank the staff and patients of the Gynecology Service of Príncipe de Asturias University
Hospital (Madrid), the Physical Therapy Research Unit at Alcala University (Madrid), and Jean
Claude Ferrandez for their valuable suggestions. The Physical Therapy Department of Alcalá
University and Principe de Asturias Hospital provided the facilities for the study.
Contributors: MTL conceived and designed the study. AZG recruited the patients. MTL (blinded
assessor), ECT, EMM (physiotherapy and educational strategies in the early physiotherapy
group), and MJYS (educational strategies in control group) devised the interventions. DPM
(blinded analyst), MTL, and OMdM analysed and interpreted the data. OMdM collected and
assembled the data. MTL, OMdM, and DPM wrote the manuscript. All authors approved the
final manuscript.
Funding: This study was funded by the Health Institute Carlos III (Protocol PI071124) of the
Spanish Health Ministry.
Competing interests: All authors have completed the unified competing interest form at www.
icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare (1)
no financial support for the submitted work from anyone other than their employer; (2) no
financial relationships with commercial entities that might have an interest in the submitted work;
(3) no spouses, partners, or children with relationships with commercial entities that might have
an interest in the submitted work; and (4) no non-financial interests that may be relevant to the
submitted work.
Ethical approval: This study was approved by the human research ethics committee of the
Príncipe de Asturias Hospital.
References
Abstract
Introduction
Methods
Results
Discussion
References
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(Accepted 9 October 2009)
© Torres Lacomba et al 2010
This is an open-access article distributed under the terms of the Creative Commons Attribution
Non-commercial License, which permits use, distribution, and reproduction in any medium,
provided the original work is properly cited, the use is non commercial and is otherwise in
compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http:
//creativecommons.org/licenses/by-nc/2.0/legalcode.
By Diane Chiddister
Since being diagnosed with an aggressive breast cancer nine months ago, Shelley Colbert has
endured chemotherapy, major surgery and radiation treatment. Along with the resulting pain,
fatigue and anxiety of those treatments, Colbert has grappled with another challenge as well —
accepting help from the community where she grew up, raised her children, and cared for the
children of others.
“It’s very hard to ask for help,” Colbert said in an interview last week. “I’m tremendously
grateful to all who have stepped forward with help or good wishes.”
While asking for help is a struggle for Colbert, who prides herself on her independence, she’s
reluctantly allowing her friends to ask for her. Specifically, friends have organized a benefit
concert this Saturday, Jan. 16, from 5 p.m. to midnight at the Emporium with a variety of local
musicians. The music is organized by Steve McColaugh.
Carl Schumacher and Friends will play from about 5 p.m. to 7, Dawn Cooksey and Route 68
South at 8 p.m. and McColaugh’s band, the Undercovered, will play from 9:30 p.m. on.
Colbert vetoed charging admission for the event, according to her longtime friend and event
organizer Peggy Koebernick, so there is no charge, but donations are welcome. The purpose of
the event is to help cover Colbert’s living expenses since she has been unable to work since last
March and will remain unable for the foreseeable future. While most of Colbert’s medical
treatment is currently covered by a special short-term form of Medicaid, and a benefit fun
run/walk last May raised enough money to pay Colbert’s living expenses until now, those funds
are running out.
“I was thinking about what it would be like to be in her shoes,” Koebernick said, regarding her
decision to organize the event. “I wanted to tap into the energy of the community.”
The community’s energy so far has been extraordinary, according to Colbert, who describes
herself as astonished at people’s generosity, both in donating to a special fund at US Bank, and
offering goods and services. Those who can’t attend the fundraiser but would like to make a
donation may do so at the Shelley Colbert Fund at US Bank.
Colbert, one of a family of five children raised by her parents Chuck and Rita, grew up in Yellow
Springs. She left town to go to college, and returned after earning a degree in early childhood
education. When her sons, Ben and Spencer Beggs, were small, Colbert started her childcare
business at her Miami Drive home, where for 23 years she cared for village children until she
received her diagnosis of Stage III breast cancer. At that time, doctors told her she would no
longer be able to lift children after her treatment, Colbert said, adding with a smile that they also
advised her to give up chopping wood and hauling water from the well.
After chemotherapy ended in August, Colbert, who is 60, had a mastectomy in September. And
cancer doesn’t deal out any favors. The night before her surgery, her father, who had suffered a
stroke several weeks earlier, died at Friends Care Community. It was rough, she said, with the
saving grace that at least all her family had already come home for her surgery and were here
when her father died.
The chemotherapy Colbert initially received worked remarkably well, eradicating all traces of
tumors on her scans. Her doctors were amazed, as a complete response is relatively rare.
However, because her cancer had been so aggressive, they urged her to “play her hand all in”
and to accept equally aggressive treatments in surgery and radiation.
The decision to go ahead with seven weeks of radiation — which ends this week — has been the
hardest of all for Colbert. Her instincts told her that so much radiation can’t be good for her body.
Radiation often causes significant damage to the heart, lungs and thyroid, and her doctors couldn’
t guarantee those side effects wouldn’t happen to her.
And Colbert knows something about side effects. The tumors themselves caused lymphedema,
leading to pain and swelling in her right arm and shoulder area. The condition is chronic, and
Colbert is working on finding ways to manage it. She thinks swimming could be a good antidote,
as soon as she’s allowed back into her beloved swimming pools.
As with each step of the nine-month ordeal so far, Colbert has struggled with making decisions
that often seem overwhelming. Mountains of information are available on the Internet, but the
amount seems impossible to sort through, although a good friend, Mary Miller, has volunteered
her skills to analyze research results. But the process often makes her feel crazy, ever focused
on cancer, cancer, cancer.
The radiation left her in pain, with skin burns, and Colbert still worries whether she made the
right choice, or whether, even if the radiation does buy her time, it will be in a life that feels not
worth living. But in the end, she pursued the aggressive treatment that her doctors urged.
“I want people to know I’m doing everything I have to do to stay alive,” she said.
There are people who say that cancer has taught them how to live, or helped them to live better.
So far, Shelley Colbert is not one of those people, but she hasn’t ruled out the possibility.
“I’m hoping maybe the silver lining will reveal itself to me soon,” she said. And the silver lining
so far has been that cancer helped her know who her friends are, and that she has far more
friends than she ever imagined.
“I don’t know how to thank people for all they’ve done for me,” she said. “You don’t know how
many people care about you, but they do. It’s been heartening and humbling. This is a fantastic
community.”
And there’s a bright spot on the horizon. That puppy that Colbert has been longing for is the first
thing on her list after follow-up treatment begins and the weather warms up.
“I can’t wait to get my puppy,” she said.
While Colbert loves to dance and would like nothing better than to dance until midnight on Jan.
16, she’s expecting that fatigue from the radiation treatments may prevent her from doing so. But
she’ll do her best to show up, with her new sleek and short hair. And if she has to go home early,
well, she’ll spend a cold winter evening warmed by the thought of her many friends, new and old,
dancing the night away.
Contact: dchiddister@ysnews.com
http://www.ysnews.com/stories/2010/01/011410_colbert.html
My Bra? Color Me Furious
The bra-color meme that's sweeping Facebook and allegedly raising awareness of breast cancer
got a nice one-two punch from my colleague Frances Tobin.
Get the new
PD toolbar!
Allow me to pile on.
Not for myself, but for friends I've watched face this beast. Many of them aren't wearing bras of
any color because their breasts are long gone. Instead they might be wearing a lymphedema
sleeve on their arms, in some cases for the rest of their lives.
As a member of the all-too-exclusive club of long-term ovarian cancer survivors, let me first say I
used to resent the enormous amount of attention breast cancer got over other cancers. Breast
Cancer Awareness Month (also known as "pink nausea" by certain folks) seemed to begin in
late July and end in late November, totally eclipsing the far more lethal (per capita) cancers of
ovarian and pancreatic.
Where's all the teal in September? I realize fountains are not so good for awareness, since
they're always teal. But where are the endless rows of candy bars and other products sporting
teal?
Where's all the purple in November? If you're a playwright and you want your main character to
die, you choose ovarian if it's a woman and pancreatic if it's a guy. So where's the love for
pancreatic cancer patients?
Cancer envy – wishing you could trade in your bad-stat cancer for a more benign variety – is
known only to those with personal experience with this dreadful disease.
Like it was yesterday, I remember lunch with my friend Sherri. One year after my diagnosis with
ovarian cancer, she'd been diagnosed with breast cancer. She gazed out the window and said,
"This is going to kill me."
"How can you say that," I replied. "I'd give anything to trade my statistics for yours."
"Don't ask me how I know," she said. "I just know."
Sherri was earlier stage than me. She was younger than me. I thought about that when, six years
later, I attended her funeral.
For a while I went to a support group for cancer survivors of all types. That was my light-bulb
moment. The breast cancer patients in that group began detailing the experiences – waking up
from surgery, the day after surgery, going home with drainage tubes attached to their armpits.
"Tubes?" I shuddered. "I guess every kind of cancer is its own version of hell."
Bingo.
In spring of 2008, another friend was diagnosed with breast cancer. If only I had a dollar for
every time I said: My tumor was 11 centimeters. When was the last time you heard of an 11-
centimeter breast tumor?
"No, Donna, it's not early stage," my friend said. "The tumor is nine centimeters." My friend
had lobular breast cancer, which can grow into the chest instead of outward.
A few months later she got a bonus -- a second primary of lung cancer, the kind nonsmokers get.
She's had more surgery in 18 months than I've had in my whole life.
My friend is ten years younger than me. Her husband is a doctor. She's always been trim and fit,
and she has not a mean bone in her body.
Color me educated.
But don't color me pink. Or teal. I want a new color. I want a rainbow. We use the word "cancer"
for what is probably a thousand different diseases. The segregation and disparity in funding
between types of cancer is absurd. Name any cell in your body, and you've just named a chance
for mutation and cancer – at any time, for any person.
Even so, I suspect women are especially vulnerable. Their bodies are designed to grow things.
Like babies. And, it turns out, cancer, even if they don't smoke, and they eat healthy, and breast-
feed their children. While men can get male-specific cancers, women's cancers seem to be more
adept at hiding til it's too late.
Which brings us back to bra colors. Yes, awareness is good – unless people think awareness is as
good as action. Think before you pink, says Breast Cancer Action.
Last night on the Facebook wall of Matthew Zachary, founder of I'm Too Young for This (aka
Stupid Cancer), the bra-color meme was topic one for the evening. "Awareness," Matthew wrote,
"is the same as rhetoric. Like propaganda without the marketing. It's air. I welcome any cultural
anthropologist to demonstrate successful awareness without action."
Years ago I attended a lunch gathering of cancer survivors and medical professionals. The event
was supposed to end with some kind of hilarious musical spoof on the subject of "boobs," written
by a surgeon. At the last moment, the song got spiked. Through the grapevine I heard that a
patient facing mastectomy found the subject not one bit funny.
After walking a mile in the shoes of my friends, I have to say I agree. I would find no comfort in
Facebook games about colored lingerie that my new body no longer needed, or tight tee-shirts
with cute slogans about saving "second base" or the "ta-tas."
Or any other campaign that emphasized the womanliness, the beauty, the importance of breasts.
Never mind the breasts. Save the women.
http://www.politicsdaily.com/2010/01/11/my-bra-color-me-furious/
What Is Turner Syndrome? What Causes Turner Syndrome?
Turner syndrome, also known as Turners syndrome, Ullrich-Turner syndrome or Gonadal
dysgenesis, is a chromosomal disorder that affects only females. It is characterized by the
absence of part or all of a second sex chromosome in some or all cells. Approximately 1 in every
2,500 to 3,000 girls is born with the condition.
People without Turner syndrome have 46 chromosomes, of which 2 are sex chromosomes.
Females have two X chromosomes. In people with Turner syndrome, one of those sex
chromosomes is either missing or has other abnormalities - the chromosome may be missing in
some cells but not in others (mosaicism or Turner mosaicism). In other words, there are two types
of Turner syndromes:
Classical Turner syndrome - an X chromosome is completely missing.
Mosaic Turner syndrome (mosaicism or Turner mosaicism) - the abnormalities only occur in the
X chromosome of some of the cells in the body.
Chromosomes are strands of DNA (deoxyribonucleic acid) that exist in all the cells of the human
body. Chromosomes contain instructions that make a human's behavioral and physical
characteristics.
The syndrome is named after Dr. Henry Turner (USA 1892-1970), an Oklahoma endocrinologist,
who described it in 1938.
Turner syndrome can cause:
Physical disabilities
Emotional disabilities
Educational disabilities
According to Medilexicon's medical dictionary:
Turner syndrome is "a syndrome with chromosome count 45 and only one X chromosome; buccal
and other cells are usually sex chromatin-negative; anomalies include dwarfism, webbed neck,
valgus of elbows, pigeon chest, infantile sexual development, and amenorrhea; the ovary has no
primordial follicles and may be represented only by a fibrous streak; some affected people are
chromosomal mosaic, with two or more cell lines of different chromosome constitution; seen in
many animal species, in the meadow vole it is the normal female state."
What are the signs and symptoms of Turner syndrome?
A symptom is something the patient feels and reports, while a sign is something other people,
such as the doctor detect. For example, pain may be a symptom while a rash may be a sign.
The signs and symptoms of Turner syndrome vary considerably and may even appear before
birth.
Signs and symptoms before birth
Unborn females with Turner syndrome (TS) may develop lymphedema - fluid is not properly
transported around the organs of the body, excess fluid leaks into the surrounding tissue,
resulting in swelling. It is not uncommon for babies born with TS to have swollen hands and feet.
The unborn baby may also have:
•Thick neck tissue
•Cystic hygroma - swelling of the neck
•Lower than normal weight
The following signs and symptoms may be present at birth or during infancy
•Broad chest
•Cubitus valgus (arms turn outwards at the elbows)
•Eyelids that droop
•Fingernails that turn upward
•High, narrow palate (roof of mouth)
•Low hairline at the back of the head
•Low set ears
•Receding lower jaw
•Short hands
•Slower/delayed growth
•Small lower jaw
•Smaller height at birth
•Smaller weight at birth
•Swelling of the hands and feet
•Web-like neck
•Wide neck
•Widely spaced nipples
In some cases Turner syndrome may not become apparent until later on. The following signs and
symptoms that appear later may indicate Turner syndrome:
•Growth spurts do not occur at expected childhood times. During the first three years of life the
baby/toddler may be of normal height. However, by the age of three their growth rate will be
lower than average.
The person is much shorter than expected; about 8 inches (20 cms) shorter than expected for an
adult female member of that family (without treatment).
•Learning difficulties - the majority of girls with TS have normal intelligence, as well as good
verbal and reading skills. There may be some problems with math, spatial concepts, memory
skills and fine finger movements.
•Social problems - the patient may find it hard to properly interpret other people's reactions or
emotions.
•Non-functioning ovaries - during puberty a female's ovaries generally start producing estrogen
and progesterone (sex hormones). The majority of girls with TS will not produce these sex
hormones, resulting in:
•No onset of menstrual periods
•Poorly developed breasts
•Possible infertility
Although the TS female has non-functioning ovaries and is infertile, her vagina and uterus
(womb) will generally be normal and she will usually be able to have a normal sex life.
Approximately 30% of females with TS will undergo some physical changes during puberty.
About 0.5% of girls with TS can become pregnant without fertility treatment.
Other possible signs and symptoms - as well as those listed above, the following may also be
present:
•Eyes that slant downwards
•Prominent earlobes
•Mouth abnormalities which can cause dental problems
•Narrowing of the aorta which may result in heart murmur
•Hypothyroidism - an underactive thyroid gland. This can be treated with thyroxine tablets.
•Hypertension - females with TS are more likely to suffer from high blood pressure
•Brittle bones (osteoporosis) - caused by insufficient estrogen
•Otitis media (middle ear infection, glue ear) - very common among young girls with TS
•Hearing loss in adulthood - usually caused by otitis media during childhood
•Diabetes - older and overweight females with TS have a higher risk of developing diabetes
compared to other women of the same age or weight
•Moles - females with TS may have a large number of moles
•Small spoon-shaped nails
•A shorter than normal fourth finger or toe
What are the causes of Turner syndrome?
Experts say that the loss or abnormality of the X chromosome occurs spontaneously. If
somebody has a child with TS, this does not mean there is a higher risk of any subsequent
children having the condition.
TS occurs when the baby is conceived, when the sperm enters the egg (ovum) and the egg is
fertilized.
Only females are affected.
TS occurs when the second X chromosome is either incomplete or missing completely.
According to the National Health Service (NHS), UK, about 1 in every 2,500 baby girls is born
with the condition. If a baby is conceived with a missing X chromosome the pregnancy usually
miscarries (aborts naturally).
Approximately 10% of all miscarriages during the first trimester of pregnancy are caused by TS.
Most of us are born with two sex chromosomes. Males inherit the X chromosome for their
mothers and the Y chromosome from their fathers. Females inherit one X chromosome from each
parent. When a female has Turner syndrome one X chromosome copy is either absent or
significantly altered. The following genetic alterations of Turner syndrome are possible:
•Monosomy - one X chromosome is completely missing. Experts believe this is caused by an
error either in the father's sperm or the mother's ovum (egg). Every cell in the offspring's body
has one X chromosome missing.
•Mosaic Turner syndrome (mosaicism or Turner mosaicism) - during the early stages of fetal
development an error may have occurred in cell division, resulting in some cells having two X
chromosome copies, while others only have one. In some cases there may be some cells with both
X chromosome copies, and others with one altered copy.
•Y chromosome material - a small number of patients with TS have some cells with just one X
chromosome copy and other cells with just one X chromosome copy as well as some Y
chromosome material. The individual develops as a female, but has a higher risk of developing
gonadoblastoma (a type of cancer).
The missing or altered X chromosome causes errors during fetal development, as well as
subsequent development after birth.
What are the risk factors for Turner syndrome?
A risk factor is something which increases the likelihood of developing a condition or disease. For
example, obesity significantly raises the risk of developing diabetes type 2. Therefore, obesity is
a risk factor for diabetes type 2.
Experts say that the risk of having TS is the same for females in all regions of the world, races,
nationalities and socioeconomic groups. The condition occurs randomly and is not associated with
the age of the mother or father.
There are no known toxins or environmental factors that appear to alter the risk of developing
TS.
How is Turner syndrome diagnosed?
Diagnosis during pregnancy and birth - during an ultrasound test, for example, TS may be
suspected. Amniocentesis or Chorionic villus sampling, both antenatal tests that detect
chromosomal abnormalities, are possible ways to confirm a diagnosis. Diagnosis may also
eventually be made if heart or kidney problems, or swelling of the hands and feet are present at
birth.
Diagnosis during childhood - if the child has a wide or webbed neck, a broad chest and widely
spaced nipples TS may be suspected.
If the girl eventually has a short stature and undeveloped ovaries, TS may be suspected.
Sometimes diagnosis is not made until later, for example, when puberty does not occur.
Karotype - this blood test can be used to detect extra or missing chromosomes, chromosomal
rearrangements, or chromosomal breaks. This may be done either by taking a sample of the
amniotic fluid while the baby is still in the uterus, or taking a blood sample from a child/baby. If
one of the X chromosomes is missing or incomplete, TS is confirmed.
What are the treatment options for Turner syndrome?
Turner syndrome is a genetic condition for which there is no current cure. However, several
treatments may help with short stature, sexual development and learning difficulties.
Early preventative care - it is important that the child is checked regularly so that the risk of
complications can be minimized. Blood pressure and the thyroid gland need to be monitored
frequently, and any necessary treatment given immediately.
Treatment with medical specialists - as girls with TS are more likely to develop otitis media
(inner ear infections, glue ear) they need to be treated promptly to minimize the risk of hearing
difficulties later in life. Treatment should be carried out by an ENT (ear, nose and throat)
specialist.
Hormone therapy, which may include estrogen, progesterone and growth hormones, may be
required. These treatments will be done with an endocrinologist, or pediatric endocrinologist.
Growth hormone therapy - as soon as it is established that the girl with TS is not growing
properly growth hormone should be administered. Effective therapy may prevent short stature
later in life. Treatment may start as early as the age of one or two years. A daily injection is
given. Growth hormone therapy may add an extra 10cm (4 inches) to the girl's eventual stature.
Estrogen and progesterone replacement therapy - the girl needs these two hormones to develop
sexually. Estrogen will also stop her bones from becoming brittle (osteoporosis). The ovaries of a
girl with TS do not produce sufficient quantities of these hormones. How much the patient is
producing herself can be determined with blood tests.
Estrogen replacement therapy will start at the onset of puberty (11 years of age). The patient will
initially receive low doses, which are slowly increased. Progesterone therapy is generally given
later to trigger menstrual periods. TS patients require sexual hormone treatment for the rest of
their lives. Treatment may be given as tablets, injections or patches.
IVF (in vitro fertilization) - the majority of patients with TS are unable to become pregnant
without help. If a woman with TS wants to become pregnant she will probably require assistance,
for example, IVF. If the patient manages to become pregnant she will need to be monitored
closely, because of the extra strain on her heart and blood vessels.
Counseling and psychological therapy - some patients may develop psychological problems and
will benefit from psychological therapy.
Learning assistance - although girls with TS generally have normal levels of IQ, there may be
problems with numeracy, spatial concepts, memory skills and fine finger movements. Educational
support will help the child.
What are the possible complications related to Turner syndrome?
Heart problems - some girls with TS are born with either heart defects or very slight heart
abnormalities which may raise their risk of complications later in life. Defects in the aorta, the
main blood vessel leading out of the heart raises the risk of aortic dissection (a tear in the inner
layer of the aorta). If there is a defect in the valve between the aorta and the heart there is an
increased risk of an aortic valve stenosis (narrowing of the valve).
High blood pressure - people with TS are much more prone to suffer from high blood pressure
(hypertension) compared to others.
Diabetes - overweight or older women with TS have a higher risk of developing diabetes
compared to other women of the same age and weight.
Hearing - gradual loss of nerve function can cause hearing loss. Girls with TS are much more
likely to develop glue ear (otitis media, inner ear infection), which can lead to hearing loss.
Kidney problems - approximately 30% of TS patients have some kind of kidney malformation,
raising the risk of hypertension and urinary tract infections.
Hypothyroidism - having an underactive thyroid gland is more likely among patients with TS.
Tooth loss - patients with TS have a higher risk of having poor or abnormal tooth development,
resulting in more tooth loss. Also, because of the shape of the mouth and palate, the patient is
more likely to suffer from crowded and poorly aligned teeth.
Vision - strabismus is more common among girls with Turner syndrome (eyes to not work in
parallel and appear to be looking in different directions). Hyperopia (farsightedness, long-
sightedness) is more common among girls with TS.
Bones - women with TS have a significantly higher risk of developing osteoporosis. Sometimes
there may be problems with the curvature of the spine, leading to scoliosis. There is also a risk of
kyphosis (forward rounding of the upper back).
Pregnancy - a woman with TS who becomes pregnant has a significantly higher risk of developing
complications, including gestational diabetes, high blood pressure and aortic dissection.
Psychology - there is a greater risk of problems with self-esteem, anxiety, depression, ADHD
(attention deficit hyperactivity disorder). There may also be difficulties in social situations.
Written by Christian Nordqvist
Copyright: Medical News Today
Not to be reproduced without permission of Medical News Today
http://www.medicalnewstoday.com/articles/176083.php
Lives Lived
Sharon Enkin
Wife, mother, grandmother, aunt to many, teacher, community charitable leader, supporter of
Israel. Born March 18, 1927, in Winnipeg. Died Sept. 8, 2009, in Milton, Ont., of septicemia,
aged 82.
Sharon Enkin was one of three daughters of Buirt and Fanny Segal. The Segals settled in St.
Walburg in northern Saskatchewan during the Depression. They were the only Jewish family in
town. In addition to owning the general store, Buirt was one of the town founders and served as
mayor for some years.
The family retained their connection to Judaism and Israel, annually making the arduous day-
long journey on mud roads into North Battleford to attend the synagogue for major holidays.
Sharon displayed her talents early, winning many public-speaking awards. When her family
moved back to Winnipeg, she continued her education and interest in the arts at the University of
Manitoba. In 1949, she went on a trip that changed her life and sparked an abiding interest in
Israel. This was the first Canadian trip permitted for students to the new state of Israel. Instead
of returning to Canada, Sharon stayed on for two years, studying at the Hebrew University,
teaching English, becoming fluent in Hebrew and establishing lifelong friendships.
On her return to Canada after her father's stroke, Sharon headed to Toronto seeking a career in
radio theatre productions. There she met Larry Enkin. They married in 1954 and moved to
Hamilton, where Larry's father owned a men's clothing manufacturing company. Sharon and
Larry had three children, Peri, James and Marc. Throughout their marriage of more than 55
years, Sharon's personality and talents thrived.
In Hamilton, Sharon started a summer program for inner-city children called Painting in the Park.
She led this for 10 years, bringing art classes and theatre to countless children. She followed this
by teaching drama to children and acting in local productions.
In her 50s, Sharon furthered her education in teaching and drama at the University of Toronto.
These studies led to another bachelor's degree and the launch of Golden Horseshoe Players, a
non-profit professional theatre company presenting values-related performances in Ontario
schools. Thousands of students saw these plays, and many young actors got their professional
start with the company. Sharon's most recent effort was to launch a fundraising initiative to
provide birthday parties for children in Israel who would otherwise not have one.
Sharon suffered swelling in her legs from lymphedema, which together with osteoarthritis made
walking extremely difficult, and underwent several surgeries. Yet she continued to walk until the
end, rejecting any support except her cane, an example of her indomitable will not to give in.
Larry Enkin is Sharon's husband, Robyn Rypp is Sharon's niece and Howard Rypp is Sharon's
nephew.
http://www.theglobeandmail.com/life/facts-and-arguments/sharon-enkin/article1420043/
TINA THE LINK FOR THIS NEXT ONE SAID THERE WAS AN ERROR but the study itself
I had a link that went thru ok, so that is what I am sending below
error link: Physiotherapy cuts complications after breast surgery
study published on bmj.com today showed that women who had received phsyiotherapy had a
significanty reduced risk of secondary lymphedema after breast ...
STUDY LINK: http://www.bmj.com/
Problem of immortal time bias in cohort studies
Well designed observational studies have made important contributions to our understanding of
the risks and benefits of drug treatment. Such studies are often the first to identify or confirm
important adverse health events associated with drugs and can assess aspects of drug safety.
Cohort studies are often preferred to case-control studies because they are less susceptible to
certain biases, but the inappropriate accounting of follow-up time and treatment status in the
design and analysis of such studies can introduce immortal time bias, say the authors of this
research methods and reporting article, using the example of statins for preventing progression
of diabetes.
THEN THE LINK FOR THE TITLE Problem of immortal time bias... is: http://www.bmj.
com/cgi/content/citation/340/mar12_1/b5087
but there I needed to be a member for any further info and I dont join things:
Therapy May Relieve Breast Cancer Surgery Complication
A common complication of breast cancer surgery can be prevented or reduced if patients receive
physical therapy, including massage and shoulder exercises, soon after their operation, a new
study suggests.
Secondary lymphedema -- caused by damage to the lymphatic system during treatment -- results
in fluid retention and arm swelling. It affects 71 percent of patients within 12 months of breast
cancer surgery and can cause disfigurement, anxiety, depression and emotional distress.
Maria Torres Lacomba, a professor of physiotherapy at Alcala de Henares University in Madrid,
Spain, and colleagues selected 120 women who had breast cancer surgery involving removal of
lymph nodes and divided them into two groups -- an intervention group that received early
physiotherapy and education, and a control group that received education only. Both programs
lasted three weeks and the patients were followed up four weeks after surgery and again three,
six and 12 months after surgery.
The therapy included lymph drainage, scar tissue massage and shoulder exercises supervised by
a physiotherapist. The education program included materials about the lymphatic system and
advice on how to avoid injury and prevent infection.
After one year, 7 percent of women in the intervention group and 25 percent of those in the
control group developed secondary lymphedema. The researchers also found that secondary
lymphedema was diagnosed four times earlier in the control group than in the intervention group,
according to the report published online Jan. 12 in the BMJ.
Further research is needed to determine whether early physical therapy after breast cancer
surgery offers longer-term protection against secondary lymphedema, the researchers said.
More information
The American Cancer Society has more about breast cancer patients and lymphedema.
Copyright © 2010 ScoutNews, LLC. All rights reserved.
http://www.palmbeachpost.com/health/therapy-may-relieve-breast-cancer-surgery-complication-
176500.html
Physical Therapy Can Cut Risk of Post-Surgical Lymphedema
Condition is one of the most common complications of breast cancer surgery
WEDNESDAY, Jan. 13 (HealthDay News) -- The risk of secondary lymphedema in breast
cancer surgery patients can be significantly reduced by the early introduction of post-surgical
physical therapy, according to a study published online Jan. 12 in BMJ.
María Torres Lacomba, of Alcalá de Henares University in Madrid, Spain, and colleagues
conducted a study of 120 women who underwent breast cancer surgery involving the dissection of
axillary lymph nodes. All the participants were given education about the lymphatic system and
on strategies to avoid injury and reduce the risk of infection. The intervention group also
received a program of physical therapy, including manual lymph drainage, scar tissue massage
and shoulder exercises.
In all, 116 women completed follow-up at one year, and 18 (16 percent) developed secondary
lymphedema, including 14 (25 percent) in the control group and four (7 percent) in the
intervention group, the researchers found.
"This result emphasizes the role of physiotherapy in the awareness, prevention, early diagnosis,
and treatment of secondary lymphedema," the authors write. "Secondary lymphedema is a
chronic condition, which has negative effects on the quality of life of patients. The increase in risk
factors associated with secondary lymphedema, such as ageing populations and the growing
prevalence of obesity, along with the gradual improvement in rates of survival from cancer,
suggest that secondary lymphedema will remain a challenge."
http://www.modernmedicine.com/modernmedicine/Modern+Medicine+Now/Physical-Therapy-
Can-Cut-Risk-of-Post-Surgical-Lym/ArticleNewsFeed/Article/detail/651806?
contextCategoryId=40157
then the full text link: http://www.bmj.com/cgi/content/full/340/jan12_1/b5396
FULL TEXT INFO - has tables so not sure if they will be a problem for you and i didnt know if
you wanted all of this or not:
Research
Effectiveness of early physiotherapy to prevent lymphoedema after surgery for breast cancer:
randomised, single blinded, clinical trial
María Torres Lacomba, professor of physiotherapy1, María José Yuste Sánchez, professor of
physiotherapy1, Álvaro Zapico Goñi, professor of obstetrics and gynaecology1,2, David Prieto
Merino, lecturer3, Orlando Mayoral del Moral, professor of physiotherapy4, Ester Cerezo
Téllez, research fellow1, Elena Minayo Mogollón, research fellow1
1 Physiotherapy Department, School of Physiotherapy, Alcalá de Henares University, E-28871
Alcalá de Henares, Madrid, Spain, 2 Príncipe de Asturias University Hospital, Alcalá de
Henares, Madrid, 3 Medical Statistics Unit, Department of Epidemiology and Population Health,
London School of Hygiene and Tropical Medicine, London, 4 Physiotherapy Department,
Provincial Hospital, Toledo, Spain
Correspondence to: M Torres Lacomba maria.torres@uah.es
Abstract
Abstract
Introduction
Methods
Results
Discussion
References
Objective To determine the effectiveness of early physiotherapy in reducing the risk of
secondary lymphoedema after surgery for breast cancer.
Design Randomised, single blinded, clinical trial.
Setting University hospital in Alcalá de Henares, Madrid, Spain.
Participants 120 women who had breast surgery involving dissection of axillary lymph nodes
between May 2005 and June 2007.
Intervention The early physiotherapy group was treated by a physiotherapist with a
physiotherapy programme including manual lymph drainage, massage of scar tissue, and
progressive active and action assisted shoulder exercises. This group also received an
educational strategy. The control group received the educational strategy only.
Main outcome measure Incidence of clinically significant secondary lymphoedema (>2 cm
increase in arm circumference measured at two adjacent points compared with the non-affected
arm).
Results 116 women completed the one year follow-up. Of these, 18 developed secondary
lymphoedema (16%): 14 in the control group (25%) and four in the intervention group (7%). The
difference was significant (P=0.01); risk ratio 0.28 (95% confidence interval 0.10 to 0.79). A
survival analysis showed a significant difference, with secondary lymphoedema being diagnosed
four times earlier in the control group than in the intervention group (intervention/control, hazard
ratio 0.26, 95% confidence interval 0.09 to 0.79).
Conclusion Early physiotherapy could be an effective intervention in the prevention of secondary
lymphoedema in women for at least one year after surgery for breast cancer involving dissection
of axillary lymph nodes.
Trial registration Current controlled trials ISRCTN95870846 [controlled-trials.com] .
Introduction
Abstract
Introduction
Methods
Results
Discussion
References
Acquired interruption or damage to the axillary lymphatic system after surgery or radiotherapy
for breast cancer can lead to regional or generalised accumulation of lymph fluid in the interstitial
space, known as secondary lymphoedema.1 This condition is the most important chronic
complication after dissection of the axillary lymph nodes2 3 4 5 and has a tendency to progress.
Secondary lymphoedema can cause disfigurement, physical discomfort, and functional
impairment. Anxiety, depression, and emotional distress are more common in patients with than
without secondary lymphoedema. This can affect social relationships, undermining body image
and self esteem.6 7 8 The condition may also precipitate cellulitis, erysipelas, lymphangitis, and
occasionally lymphangiosarcoma.9 10 11
Reported incidence rates for secondary lymphoedema vary depending on the method used for
measurement.12 Inconsistent definitions and the lack of a standard classification system have
resulted in diverse incidence rates for secondary lymphoedema, ranging from 5% to 56% within
two years after surgery.7 13 14 15 16 After axillary lymph node dissection the incidence of
secondary lymphoedema is about 23-38% if the criterion used to identify it is a greater than 2 cm
increase in upper arm circumference measured at two adjacent points compared with the
circumferences in the other arm.17 Most women (71%) develop secondary lymphoedema within
12 months after surgery for breast cancer.18 19
The factors that might influence the development of secondary lymphoedema after surgery are
the number of lymph nodes removed, radiotherapy to the axilla, postoperative wound infection,
postsurgical drainage time, lack of mobility, and obesity.18 20 21 22 23 24
Currently, women with breast cancer have a 77% probability of surviving at least 10 years.25 26
Consequently the effective prevention and management of complications that can impair function
and affect quality of life after treatment are important.15
Efforts have been made to reduce the risk of secondary lymphoedema by preoperative and
postoperative counselling and education27 28 and by early detection.27 29 A randomised clinical
trial on the prevention of secondary lymphoedema through exercises and an educational strategy,
however, lacked sufficient evidence.30 We determined the effectiveness of an early
physiotherapy programme in reducing the risk of secondary lymphoedema in women after
surgery for breast cancer involving dissection of axillary lymph nodes.
Methods
Abstract
Introduction
Methods
Results
Discussion
References
We carried out a randomised, single blinded, clinical trial of women after unilateral breast cancer
surgery with axillary lymph node dissection at the Príncipe de Asturias Hospital in Madrid
between May 2005 and June 2007. We excluded women without axillary lymph node dissection or
with bilateral breast cancer, systemic disease, locoregional recurrence, or any contraindication to
physiotherapy.
Eligible women gave written informed consent to participate in the study after breast cancer had
been confirmed by biopsy. Each participant was assessed preoperatively and between days 3 and
5 after hospital discharge. Equal numbers of women were then randomly allocated by computer
using EPIDAT version 3.1 (Xunta de Galicia, Spain)31 to either early physiotherapy and an
educational strategy (early physiotherapy group) or the educational strategy only (control group).
Both programmes lasted three weeks, with three visits each week. The main outcome was the
incidence of secondary lymphoedema.
Follow-up
Initially we scheduled four follow-up visits: four weeks after surgery (shortly after the completion
of the intervention) and three, six, and 12 months after surgery. These dates were, however,
flexible, depending on the participant’s availability. At all visits lymphoedema was assessed using
the same protocol.
If patients experienced pain, discomfort, or any other symptoms, they could contact the
physiotherapist and a visit would be arranged. If secondary lymphoedema was diagnosed then
complex decongestive physiotherapy was carried out,32 33 34 which would effectively interrupt
follow-up.
Interventions
Each group had one physiotherapist, who carried out all interventions. Before the study it was
agreed that both groups would receive the same educational intervention. The physiotherapists
had more than five years’ experience in the treatment of vascular diseases using lymphatic
drainage. They were the only study members aware of group allocation.
Early physiotherapy group—The intervention included the manual lymph drainage technique
used for the treatment of postoperative oedema (thorax, breast, axilla, and upper arm of affected
side), using a modification of the strokes described by Leduc (only resorption strokes were used)
32 34; progressive massage of the scar (progressing from Jacquet and Leroy pincer to
Wetterwald pincer)32 35; stretching exercises for levator scapulae, upper trapezius, pectoralis
major, and medial and lateral rotators muscles of the shoulder36; and progressive active and
action assisted shoulder exercises, started in conjunction with functional activities and
proprioceptive neuromuscular facilitation exercises without resistance (rhythmic initiation
progressing from passive to active-assistive to active movement in two diagonal symmetrical
bilateral patterns and asymmetrical reciprocal patterns: D1 into flexion from hitch hike to swat
fly, and into extension from swat fly to hitch hike, and D2 into flexion from hand in opposite
pocket to carry tray, and into extension from carry tray to hand in opposite pocket).37 If axillary
web syndrome was diagnosed the physiotherapy protocol extended the manual lymph drainage
technique to axilla and to proximal ipsilateral arm and included specific thumb manual lymph
drainage on the characteristics taut cords, to make them gradually more flexible. The early
physiotherapy group also did shoulder exercises and stretching at home once daily during the
three week intervention period.
Educational strategy (both groups)—The educational strategy consisted of instruction with
printed materials about the lymphatic system, concepts of normal load versus overload, the
source of secondary lymphoedema, the identification of possible precipitating factors, and the
four categories of interventions to prevent secondary lymphoedema (avoidance of trauma or
injury, prevention of infection, avoidance of arm constriction, and use and exercise of the arm),27
28 38 39 together with individual strategies for implementing these measures.
Assessments
A different physiotherapist did the two initial and four follow-up assessments of all participants
and remained blinded to group allocation. Participants were instructed not to reveal their
allocation.
Lymphoedema—Direct measurement of the presence and severity of lymphoedema is difficult
and different diagnostic criteria have been described, including comparison between preoperative
and postoperative measurements within the affected arm and comparison of measurements
between the affected and unaffected arms.16 29 40 41 42 43 For our main analysis we used the
criteria stated in the trial protocol—that is, a 2 cm or greater increase in the circumference of
any two adjacent points compared with measurements in the other arm.19 41 44 45 46 We also
carried out the analysis using other criteria (data not shown).
Arm measurements—Whatever the criteria used for diagnosing lymphoedema they are all based
on changes in size or volume of the arms. Arm circumferences were measured at each visit and
always following the same procedure, using a standard 1 cm wide, retractable, fibreglass tailor’s
tape measure (Babel, Spain). With the patient in an upright sitting position with both arms on a
table, shoulders in neutral rotation and flexion of 45°, and forearms at maximum supination, we
measured the circumference at 5 cm intervals along both arms, using the elbow fold as the
reference starting point. This has been reported as a valid and reliable method for accurately
quantifying and diagnosing secondary lymphoedema.47 48 49
Other variables—During the preoperative assessment we collected personal data on the
participants, including age, ethnicity, marital status, body mass index, job, educational level,
socioeconomic status, information on breast cancer, and medical history. In postoperative
assessments, data were collected on the type of surgery done, the number of lymph nodes
removed, the use of adjuvant treatment, and the development of seroma and infection.
Participants were also asked an open question about whether they had any pain. If they did, a
physical examination was carried out to find the source, including axillary web syndrome. The
diagnostic criteria for axillary web syndrome were pain and restriction of range of motion in the
shoulders, with associated visible or palpable taut cords of tissue in the axilla in maximal
shoulder abduction.50 51 52 53 54 Other secondary outcomes were measured according to the
protocol but are not reported here.
Statistical analysis
The clinical criterion we chose to determine lymphoedema (binary variable) was based on
changes in circumference along the arm (continuous variable). The raw data are therefore
measures of circumference. To obtain the binary outcome several intermediate variables need to
be computed from these measurements (see web extra on bmj.com). The important variable here
would be the maximum difference in arm circumference between any two adjacent points. A
patient would have a diagnosis of secondary lymphoedema if the maximum difference between
any two adjacent points was 2 cm or greater. Lymphoedema can also be determined from the
increase in volume ratio of both arms (volume of affected arm divided by volume of unaffected
arm). 29 30 42 44 55 56 The volume ratio is computed in the variable "change in volume ratio"
(presented as percentages). Although we chose not to use this as part of our criteria for clinical
diagnosis we include a continuous analysis on this variable. This variable can be easily
interpreted as an increase or decrease of the proportional difference of the volumes of both arms
(affected minus unaffected; see web extra on bmj.com). Total arm volume was calculated by
adding up all the partial volumes between every two adjacent measurements. Each of these
partial volumes was calculated by an approximation to a truncated cone with the formula:
V=D(C12+C22+C1C2)/12
where C1 and C2 are the circumferences and the two adjacent locations and D is the distance
between C1 and C2. We have not included hand volume as this is difficult to model with a
truncated cone. Truncated cone calculations of limb segment volumes using the circumference of
segments have been reported to be reliable.16
Power calculations and sample size
Although the sample size was limited by patients’ availability we did some power calculations.
With this sample size and after 3% of dropouts, we would have a power of 70% to detect a
difference of 20% in the incidence of secondary lymphoedema between the groups. This assumes
an incidence of 30% in the control group (according to findings in earlier studies16 17 19 44) and
setting a type I error of 0.05.
Statistical analyses were done using Stata version 10.0.57 For the primary analysis we compared
the groups in three ways. Firstly, we used a binary outcome analysis to compare the incidence of
lymphoedema, determined according to the chosen criteria. Secondly, we used a continuous
outcome analysis to compare the variables "maximum difference in arm circumference between
two adjacent locations" and "change in volume ratio." Thirdly, as we had recorded the timing of
diagnosis of lymphoedema we carried out a survival analysis for the binary outcome. We
compared the incidence of lymphoedema using Fisher’s exact test. Logistic regression was used
when we needed to adjust for other variables. For the continuous outcomes sufficient data
ensured the asymptotic properties of Student’s t tests to compare means. A Cox proportional
hazard model was used to compare the survival rate between the groups.
Results
Abstract
Introduction
Methods
Results
Discussion
References
Of 120 women recruited, 60 were assigned to early physiotherapy and an educational strategy
and 60 to the educational strategy only (fig 1). All variables were similarly distributed between
the groups at randomisation (preoperative visit; table 1). The volume ratios were around 1 in both
groups. This was expected as no lymphoedema was present at the preoperative assessment.
Overall, 116 women completed the follow-up assessments; 59 in the intervention group and 57 in
the control group.
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Fig 1 Progress of participants through study
View this table:
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Table 1 Comparison between randomised groups at baseline. Values are numbers
(percentages) unless stated otherwise
Table 2 shows the numbers of women in both groups with a diagnosis of secondary lymphoedema.
The incidence of secondary lymphoedema in the control group (14 cases, 25%) was significantly
higher than in the intervention group (four cases, 7%; P=0.010). Risk factors for secondary
lymphoedema18 22 23 24 were similar between the groups, therefore adjustment for these was
not necessary (table 1). Body mass index was higher in the intervention group, therefore the odds
ratio for treatment was adjusted by body mass index (table 2). The crude effect showed no
difference.
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Table 2 Comparison of secondary lymphoedema in groups
Table 3 compares the continuous variables for the outcome (parametric tests) between the
groups. By the 12 month follow-up visit the volume ratio between arms had increased in both
groups: in the control group the volume of the affected arm was on average 5.1% greater than
that of the unaffected arm, whereas in the intervention group the affected arm was on average
only 1.6% greater than the unaffected arm. The difference between groups was significant (P=0.
0065). The maximum difference between two adjacent points was on average also larger in the
control group than in the intervention group (1.15 cm v 0.68 cm, P=0.0207). Figures 2 and 3 show
the distributions of these variables in the groups. The distributions in the control group are more
skewed to the right.
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[PowerPoint Slide for Teaching]
Fig 2 Increase in volume ratios between arms. Vertical lines correspond to cut-off values for
diagnoses of lymphoedema in other studies (>5% and >10% increase)
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[PowerPoint Slide for Teaching]
Fig 3 Maximum increase in arm circumference (affected arm–unaffected arm) that could be
observed at least at two adjacent points. Vertical line corresponds to binary criteria used here to
diagnose lymphoedema—that is, a 2 cm or greater increase in arm circumference observed at
least at two adjacent points in affected arm compared with unaffected arm
View this table:
[in this window]
[in a new window]
Table 3 Continuous analysis of circumferential and volume measurements. Values are means
(standard deviations) unless stated otherwise
The rate of survival was better in the intervention group than in the control group. Secondary
lymphoedema developed four times more rapidly in the control group (intervention group/control
group, hazard ratio 0.26, 95% confidence interval 0.09 to 0.79; P=0.010). The shape of the failure
curves (1 minus survival) suggests that the protective effect of early physiotherapy remained for
a long time, whereas the proportion of patients with a diagnosis of secondary lymphoedema in the
control group increased progressively (fig 4).
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Fig 4 Failure time for development of secondary lymphoedema by group
Discussion
Abstract
Introduction
Methods
Results
Discussion
References
Early physiotherapy with an educational strategy after surgery for breast cancer that involved
dissection of axillary lymph nodes was associated with a lower risk of secondary lymphoedema
than the educational strategy only (control group) after 12 months of follow-up: 25% in the
control group compared with 7% in the intervention group. Secondary lymphoedema developed
from six to 12 months postoperatively, which agrees with previous studies.29 30 This could be
due to the sum of various risk factors associated with secondary lymphoedema: axillary lymph
node dissection, the number of lymph nodes removed (between 10 and 20 nodes were removed in
17 of the 18 women with secondary lymphoedema), overweight (12 of the 18 women had a body
mass index >25), and postoperative complications (all 18 women had postoperative
complications) along with the effect of radiotherapy (completed in the fourth postoperative
month) as well as the gradual weight gain (11 of 12 women with secondary lymphoedema who
were overweight at baseline progressively increased in weight from six months after surgery).18
20 21 23 24 Further investigation of these risk factors is needed.
Secondary lymphoedema is thought to be caused by damage to the axillary lymphatic system,
impairing lymph drainage from the arm, although there is strong evidence that total blood flow in
the arm and vascular bed size are increased in secondary lymphoedema.1 Recently, a study to
develop an animal model of postsurgical lymphoedema reported that after nodal excisions the
limbs became progressively more oedematous up to three days after node dissection and that the
swelling decreased but had not resolved 16 weeks after surgery.58 Taking this into account and
since the basic rule is that all oedemas result from an imbalance between filtration and resorption
(tissue drainage), the implementation of a measure to restore this balance during the period of
higher filtration should prevent or delay the onset of secondary lymphoedema. Our study
included manual lymph drainage, which is a special method involving gentle massage to improve
the lymph circulation, especially subcutaneous circulation, to stimulate the initial lymphatics, and
to stretch the lymph vessels, consequently improving the removal of interstitial fluid. Manual
lymph drainage encourages and improves resorption without increasing filtration.34 59 It has
been shown to be effective in the treatment of lymphoedema because it improves the removal of
fluid from interstitial space.32 34 59 60 We therefore think that the implementation of manual
lymph drainage after surgery for breast cancer in the early physiotherapy group could have
contributed to the better results in that group. This, together with early physiotherapy for other
effects of breast cancer surgery, and related to the onset of secondary lymphoedema,18 20 21 23
24 could explain the effectiveness of early physiotherapy in the prevention of secondary
lymphoedema in women who have had surgery for breast cancer with axillary lymph node
dissection—at least during the first year after surgery.
We also found that 12 of the 18 women who developed secondary lymphoedema had axillary web
syndrome during the second and third week after surgery. The axillary web syndrome is a known
but poorly studied complication of surgery.54 61 62 No study has shown any link between the
axillary web syndrome and the onset of secondary lymphoedema. We and others32 50 suggest
that the axillary web syndrome may be a sign of injury to the lymphatic system and it could
produce a lymphatic overload as a result of failure of the lymphatic system. This overload,
together with other factors, could be responsible for the onset of secondary lymphoedema. When
axillary web syndrome was diagnosed in the postoperative period in the intervention group,
specific manual lymph drainage strokes were applied, together with progressive active and action
assisted shoulder and arm exercises. Manual lymph drainage acted on the pain and inflexibility
inherent to the vascular inflammation of the lymphatic vessel; also, if the axillary web syndrome
did produce a lymphatic overload, and therefore a possible subclinical oedema, the action of the
manual lymph drainage could help with reabsorption.32 34 59 60 63 Further research on a
possible relation between the axillary web syndrome and the development of secondary
lymphoedema in women after breast cancer surgery is needed.
Comparison with other studies
Secondary lymphoedema is a common complication of breast cancer surgery.2 3 4 5 As far as we
are aware, only one study has examined the effect of exercise and specific recommendations
about self care to minimise the onset of secondary lymphoedema.29 30 In addition, several
studies on the effectiveness of early rehabilitation after breast surgery reported data on
lymphoedema as secondary end points.64 65 66 67 68 Box and colleagues evaluated an
intervention to minimise postoperative lymphoedema in 65 women and stated that a
physiotherapy management care plan, including exercise strategies that were not described in the
paper, and progressive educational strategies may reduce the occurrence of secondary
lymphoedema two years after surgery.30 Our results for onset of secondary lymphoedema one
year after surgery are better than their results. Exercise is used in the management of secondary
lymphoedema of the arm to promote the recruitment of collateral lymphatics pathways.69 This
might explain the difference in results between the studies. The intervention programme in the
study by Box and colleagues did not include the diagnosis and treatment of postoperative
vascular complications (such as seroma and axillary web syndrome), which could be related to the
onset of lymphoedema and could benefit from a proper manual physiotherapy.50 51 52 53
Many studies have assessed the effectiveness of rehabilitation in patients after breast cancer
surgery.64 65 66 67 68 All of them present limitations in the sample size and assert that
physiotherapy is beneficial for shoulder mobility and functional capacity without causing adverse
effects in the postoperative period, but not in preventing secondary lymphoedema. All the studies
focused on the recovery or maintenance of the mobility of the shoulder so that the intervention
was based on mobility and stretching exercises of the shoulder.64 65 66 67 68 Only one study
included massage (not manual lymph drainage) in one of the intervention groups. This group
showed better results, but the onset of lymphoedema was not prevented.65 The development of
restricted shoulder mobility is one of the most important factors impairing functional activities of
patients after breast surgery.70 A delayed onset physiotherapy programme as required has been
suggested to improve shoulder mobility and daily activities of living.71 None of these studies
could correlate the exercise programme with the incidence of lymphoedema.64 65 66 67 68 Our
results in relation to the study by Box and colleagues30 could result from the early diagnosis and
treatment of postoperative vascular complications.
Strengths and limitations of the study
We believe that our study shows evidence of the positive effect of early physiotherapy in the
prevention of secondary lymphoedema, but the study is limited by the duration of follow-up (one
year after surgery) and recruitment in just one hospital. Although we have no reason to suspect
systematic differences in care provided by this hospital and other regional hospitals or hospitals
in other developed countries, this may limit the external validity of the results. Furthermore, that
the physiotherapy was provided by trained physiotherapists may limit the generalisability of this
intervention to other settings.
Another limitation is that we chose a particular criterion for diagnosing lymphoedema. We
followed the criterion specified in our protocol but other criteria could have been used. For
example, if the criterion of a greater than 10% increase in the volume ratio between arms
(affected v unaffected) had been chosen, the patients with a diagnosis of secondary lymphoedema
would be those appearing to the right of the vertical line furthest to the right in figure 2. Using
this criterion the early physiotherapy group would have three cases (5%) and the control group
13 (23%), with a risk ratio of 0.22 (95% confidence interval 0.06 to 0.74); results similar to those
in table 2.
A further limitation is the possibility of measurement errors. We have no reason to believe,
however, that this will have a differential effect on both intervention and control groups. The
physiotherapist who took the measurements was blinded to the patient’s treatment allocation.
Both groups were reasonably balanced for baseline characteristics. The use of ratios between
arms also reduces errors that could be correlated with some patient characteristics, such as body
mass index. In general, we believe that measurement error might have the effect of slightly
increasing the variance in the measurement, but not in a biased way. At the most, this would
reduce statistical power of the comparisons to identify differences but would not invalidate the
ones observed.
Conclusion
Early physiotherapy could help to prevent and reduce secondary lymphoedema in patients after
breast cancer surgery involving dissection of axillary lymph nodes, at least for one year after
surgery. This result emphasises the role of physiotherapy in the awareness, prevention, early
diagnosis, and treatment of secondary lymphoedema.
Secondary lymphoedema is a chronic condition, which has negative effects on the quality of life of
patients. The increase in risk factors associated with secondary lymphoedema, such as ageing
populations and the growing prevalence of obesity,18 23 24 along with the gradual improvement
in rates of survival from cancer,26 suggest that secondary lymphoedema will remain a challenge.
Further studies are needed to clarify whether early physiotherapy after breast cancer surgery
can remain effective in preventing secondary lymphoedema in the longer term.
What is already known on this topic
Secondary lymphoedema is the most important chronic complication after breast cancer surgery
with dissection of axillary lymph nodes
Early postsurgical rehabilitation improves shoulder mobility and functional capacity without
causing adverse effects but does not prevent secondary lymphoedema
What this study adds
Early physiotherapy with an educational strategy compared with the educational strategy alone
was associated with a lower risk of secondary lymphoedema 12 months after surgery for breast
cancer with axillary node dissection
The axillary web syndrome was an important complication in the immediate postoperative period
Cite this as: BMJ 2010;340:b5396
--------------------------------------------------------------------------------
We thank the staff and patients of the Gynecology Service of Príncipe de Asturias University
Hospital (Madrid), the Physical Therapy Research Unit at Alcala University (Madrid), and Jean
Claude Ferrandez for their valuable suggestions. The Physical Therapy Department of Alcalá
University and Principe de Asturias Hospital provided the facilities for the study.
Contributors: MTL conceived and designed the study. AZG recruited the patients. MTL (blinded
assessor), ECT, EMM (physiotherapy and educational strategies in the early physiotherapy
group), and MJYS (educational strategies in control group) devised the interventions. DPM
(blinded analyst), MTL, and OMdM analysed and interpreted the data. OMdM collected and
assembled the data. MTL, OMdM, and DPM wrote the manuscript. All authors approved the
final manuscript.
Funding: This study was funded by the Health Institute Carlos III (Protocol PI071124) of the
Spanish Health Ministry.
Competing interests: All authors have completed the unified competing interest form at www.
icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare (1)
no financial support for the submitted work from anyone other than their employer; (2) no
financial relationships with commercial entities that might have an interest in the submitted work;
(3) no spouses, partners, or children with relationships with commercial entities that might have
an interest in the submitted work; and (4) no non-financial interests that may be relevant to the
submitted work.
Ethical approval: This study was approved by the human research ethics committee of the
Príncipe de Asturias Hospital.
References
Abstract
Introduction
Methods
Results
Discussion
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(Accepted 9 October 2009)
© Torres Lacomba et al 2010
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