International validation of the European Organisation for Research and Treatment of Cancer QLQ-BRECON23 quality-of-life questionnaire for women undergoing breast reconstruction

Background

The aim was to carry out phase 4 international field-testing of the European Organisation for Research and Treatment of Cancer (EORTC) breast reconstruction (BRECON) module. The primary objective was finalization of its scale structure. Secondary objectives were evaluation of its reliability, validity, responsiveness, acceptability and interpretability in patients with breast cancer undergoing mastectomy and reconstruction.

Methods

The EORTC module development guidelines were followed. Patients were recruited from 28 centres in seven countries. A prospective cohort completed the QLQ-BRECON15 before mastectomy and the QLQ-BRECON24 at 4–8 months after reconstruction. The cross-sectional cohort completed the QLQ-BRECON24 at 1–5 years after reconstruction, and repeated this 2–8 weeks later (test–retest reliability). All participants completed debriefing questionnaires.

Results

A total of 438 patients were recruited, 234 in the prospective cohort and 204 in the cross-sectional cohort. A total of 414 reconstructions were immediate, with a comparable number of implants (176) and donor-site flaps (166). Control groups comprised patients who underwent two-stage implant procedures (72, 75 per cent) or delayed reconstruction (24, 25 per cent). Psychometric scale validity was supported by moderate to high item-own scale and item-total correlations (over 0·5). Questionnaire validity was confirmed by good scale-to-sample targeting, and computable scale scores exceeding 50 per cent, except nipple cosmesis (over 40 per cent). In known-group comparisons, QLQ-BRECON24 scales and items differentiated between patient groups defined by clinical criteria, such as type and timing of reconstruction, postmastectomy radiotherapy and surgical complications, with moderate effect sizes. Prospectively, sexuality and surgical side-effects scales showed significant responsiveness over time (P < 0·001). Scale reliability was supported by high Cronbach's α coefficients (over 0·7) and test–retest (intraclass correlation more than 0·8). One item (finding a well fitting bra) was excluded based on high floor/ceiling effects, poor test–retest and weak correlations in factor analysis (below 0·3), thus generating the QLQ-BRECON23 questionnaire.

Conclusion

The QLQ-BRECON23 is an internationally validated tool to be used alongside the EORTC QLQ-C30 (cancer) and QLQ-BR23 (breast cancer) questionnaires for evaluating quality of life and satisfaction after breast reconstruction.

Abstract PD4-02: A study to determine the optimal method of detection and threshold for lymphoedema intervention: A multi-centre prospective study

Introduction

Lymphoedema, a complication of nodal surgery in 30-40% of patients, reduces quality of life for sufferers. This prospective, multi-centre study compared multi-frequency bioimpedance spectroscopy (BIS, ImpediMed) with a validated perometer method to determine which test is more sensitive for detecting lymphoedema after axillary clearance and identify the factors predicting lymphoedema development.

Material and methods

Participants (n = 629) undergoing axillary clearance at 9 UK centres underwent pre-operative and arm volume measurements post-surgery (1, 3, 6, 9 & 12 months, then 6 monthly) by arm perometry, BIS measurements (L-Dex) and recorded self-reported symptoms via questionnaires. Follow-up was a minimum of two years from surgery. Change in arm volume was calculated using relative arm volume change (RAVC) with >10% increase defined as lymphoedema. The predictors of lymphoedema development and optimal method for its detection were assessed using Cox Regression, Log Rank and Kaplan-Meier survival analyses.

Results

In total, 629 women underwent axillary surgery, with a median age of 56 (range 22 to 90) years; 80% were ER positive and received endocrine therapy, 78% received radiotherapy and 65% received chemotherapy. Lymphoedema was detected by 24 months in 124 (20%) women by perometry. Using the LDex >10 cut-off score, bioimpedance sensitivity was 71% and specificity was 89% (PPV 47%) compared to RAVC changes. Women who had an RAVC >5%-<10% at six months developed lymphoedema in 44% of cases by two years, whereas those who had less than 3% RAVC developed lymphoedema in 9% of cases (p=>0.000001). Twenty-six per cent of ER negative patients developed lymphoedema compared to 19% ER positive cancer patients.

The type (taxane versus no taxane) and whether chemotherapy was neo-adjuvant or adjuvant did not predict lymphoedema development.

Univariate analysis revealed BMI (p=0.003), ER negativity (p=<0.010), absence of endocrine therapy (p=0.034), number of nodes involved (p=0.001) and an increase in RAVC >5%-<10% (p<0.005) all predicted lymphoedema development by two years. On multivariate analysis, RAVC >5%-<10% after six months (HR 5.51 95% CI 3.05 – 9.94) along with number of nodes involved (HR 1.06 95% CI 1.03 – 1.09) and BMI HR 1.04 (1.04 – 1.09) were included in the model for predicting lymphoedema development at two years.

Conclusions

This is the first report; ER negative cancer is associated with an increased risk of lymphoedema after axillary node clearance. Arm measurements should be taken from baseline in all patients undergoing axillary surgery and increases greater than 3% should lead to further surveillance to prevent lymphoedema development. Perometer measurement is the optimal technique for measuring and predicting the development of lymphoedema.

A threshold RAVC of >5%-<10% after six months predicts lymphoedema in 44% of patients by two years.

(Funded by NIHR Programme Grant).

Citation Format: Bundred NJ, Ashton S, Riches K, Ashcroft L, Evans A, Todd C, Bramley M, Hodgkiss T, Purushotham A, Keeley V. A study to determine the optimal method of detection and threshold for lymphoedema intervention: A multi-centre prospective study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr PD4-02.

Abstract P6-08-07: Optimal method of detection and threshold for early intervention to prevent lymphoedema: A multi-centre prospective study

Introduction

Women who undergo axillary surgery are at risk of developing lymphoedema. Early detection is recommended by measuring arm volume from a baseline before surgery to enable early intervention. The optimal measurement method to enable early detection and time to intervention are unclear. This prospective multi-centre study compares multi-frequency bioimpedance spectroscopy (BIS, ImpediMed) with the validated perometer method to determine which test is more sensitive for detecting the optimal threshold to prevent lymphoedema.

Methods

Participants (N = 960) undergoing axillary clearance at 9 UK centres have pre-operative and regular arm volume measurements post-surgery (1, 3, 6, 9 & 12 months, then 6 monthly), by the validated arm perometry compared with BIS (L-Dex) measurements as well as self-reported symptoms questionnaire. Change in arm volume was calculated using relative arm volume change (RAVC). The predictors of lymphoedema development and optimal method were assessed.

Results

Currently 612 patients, median age 55 (range 24 to 90) years, have 6 month follow-up data and 327 have 18 month follow-up data. Seventy six percent were ER positive and received endocrine therapy, 84% percent received radiotherapy and 67% received chemotherapy in addition to surgery. Lymphoedema by 18 months was detected in 19% (n=79) of women by perometry (≥10% RAVC) and a change in L-Dex of 10 was observed in 31% of women. A moderate correlation between perometer and BIS at 3 months (r=0.40) and 6 months (r=0.60), with a sensitivity of 73% and specificity of 84% was found.

Univariate analysis revealed a threshold for early intervention to prevent lymphoedema was RAVC ≥5%-<10% (p=0.03). Multivariate analysis indicated that Oestrogen Receptor (ER) negative breast cancer (p=0.01, hazard ratio (HR)=0.43, 95% confidence interval (CI)=0.24 to 0.84), number of positive nodes (p=0.01, HR=1.05, 95% CI=1.01 to 1.09) and a measurement of ≥5%-<10% (p=0.04, HR=1.67, 95% CI=1.03 to 3.54) at 6 months after surgery predicted development of lymphoedema. Further investigation of why ER negative patients are at increased risk of developing lymphoedema is planned.

Conclusions

The optimal threshold for early intervention to prevent progression to lymphoedema is ≥5%-<10% relative arm volume change by perometry. Further data on the sensitivity of BIS will be obtained in this study. Arm volume measurements remain necessary before and after ANC to allow early intervention.

(Funded by NIHR Programme Grant).

Citation Format: Nigel J Bundred, Charlotte Stockton, Katie Riches, Linda Ashcroft, Abigail Evans, Anthony Skene, Maria Bramley, Tracey Hodgkiss, Arnie Purushotham, Vaughan Keeley, BEA Investigators. Optimal method of detection and threshold for early intervention to prevent lymphoedema: A multi-centre prospective study [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P6-08-07.

Comparison of multi-frequency bioimpedance with perometry for the early detection and intervention of lymphoedema after axillary node clearance for breast cancer

The importance of early detection of lymphoedema by arm volume measurements before surgery and repeated measurements after surgery in women undergoing axillary node clearance (ANC) in order to enable early intervention is recognised. A prospective multi-centre study was performed which studied the difference between multi-frequency bioimpedance electrical analysis (BIS) and perometer arm measurement in predicting the development of lymphoedema. Women undergoing ANC underwent pre-operative and regular post-operative measurements of arm volume by both methods. The primary endpoint is the incidence of lymphoedema (≥10 % arm volume increase compared to contralateral arm by perometer) at 2 and 5 years after ANC. The threshold for intervention in lymphoedema was also assessed. Out of 964 patients recruited, 612 had minimum 6 months follow-up data. Using 1-month post-operative measurements as baseline, perometer detected 31 patients with lymphoedema by 6 months (BIS detected 53). By 6 months, 89 % of those with no lymphoedema reported at least one symptom. There was moderate correlation between perometer and BIS at 3 months (r = 0.40) and 6 months (r = 0.60), with a sensitivity of 73 % and specificity of 84 %. Univariate and multivariate analyses revealed a threshold for early intervention of ≥5 to <10 % (p = 0.03). Threshold for early intervention to prevent progression to lymphoedema is ≥5 to <10 % but symptoms alone do not predict lymphoedema. The modest correlation between methods at 6 months indicates arm volume measurements remain gold standard, although longer term follow-up is required.

Abstract P3-09-09: Comparison of multi-frequency bioimpedance with perometry for the early detection of lymphoedema after axillary node clearance

Introduction

Women who undergo axillary clearance are at risk of developing lymphoedema. Early detection is recommended by arm volume measurements from a baseline before surgery but the optimal test is unclear. This prospective multi-centre study compares multi-frequency bioimpedance spectroscopy (BIS, ImpediMed) with the validated perometer method to determine which test is more sensitive for detecting lymphoedema within 24 months of surgery. Results from 441 women with up to six months follow-up are reported here to determine whether the timing of arm measurement affects results.

Methods

Participants (N = 441) undergoing Axillary Clearance underwent pre-operative and subsequent regular measurements post-surgery (1, 3, 6, 9 & 12 months, then 6 monthly), of arm volume by perometry and BIS measurements as well as self-reported symptoms of swelling, numbness or heaviness. The primary endpoint of lymphoedema was defined as ≥10% increase in volume compared to the contralateral arm by perometry.

Results

We report the data from 441 patients with 6 month follow-up data, their median age is 55 years ranging from 27 to 90 years. Eighty percent of patients were ER positive and received endocrine therapy as well as surgery. Eighty percent also underwent radiotherapy to the breast or chest wall, while 70% received chemotherapy in addition to surgery. Mean percentage increase in arm volume by perometry at 6 months was 2.03% with a moderate correlation between perometry and BIS at 3 months (r = 0.38) and 6 months (r = 0.37). In 441 patients with 6 months follow-up, the gold standard perometry detected lymphoedema in 44 (10%) patients by 6 months compared to the contralateral arm, whereas BIS measured using the unit L-Dex was positive (showed an increase of an L-Dex of 10) in 103 (21%) patients. Of the 99 patients with 18 months follow-up, 24% have lymphoedema as detected by perometry. When compared with the baseline measurements for perometry and BIS, the month 1 measurements detected fewer cases of lymphoedema by 6 months, 11 (42%) fewer for perometry and 18 (30%) fewer for BIS. 25% of patients reported symptoms before surgery. While 100% of those with lymphoedema at 6 months post-surgery reported symptoms, 23% with no lymphoedema also reported at least one symptom at 6 months.

Conclusions

Pre-operative measurements should be used as baseline to enable accurate monitoring of lymphoedema development. Symptoms alone are not an accurate predictor of current or future lymphoedema and arm sleeves should not be prescribed for symptoms without measuring arm volume change compared to the contralateral arm. The modest correlation between perometry and BIS at 6 months suggests arm volume measurements remain necessary before and after ANC for monitoring, although longer term follow-up data is required to determine the most sensitive method of predicting lymphoedema.(Funded by NIHR Programme Grant).

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-09-09.

Multiple hepatic abscesses caused by Streptococcus milleri in association with an intrauterine device

We report a case of Streptococcus milleri bacteremia and multiple hepatic abscesses secondary to an intrauterine device and a tuboovarian abscess. Hepatic abscess as a complication of an intrauterine device has previously been reported only once, with Actinomyces israelii as the causative agent. Our patient's hepatic abscesses were cured with medical therapy.