Hand Edema in Patients at Risk of Breast Cancer–Related Lymphedema: Health Professionals Should Take Notice

Abstract

Background

There is little research on hand edema in the population at risk for breast cancer–related lymphedema (BCRL).

Objectives

Study aims included reporting potential importance of hand edema (HE) as a risk factor for progression of edema in patients treated for breast cancer at risk for BCRL, reporting risk factors for BCRL, and reporting treatment of HE.

Design/Methods

This was a retrospective analysis of 9 patients treated for breast cancer in Massachusetts General Hospital's lymphedema screening program who presented with isolated HE. Limb volumes via perometry, BCRL risk factors, and HE treatment are reported.

Results

Edema was mostly isolated to the hand. Three patients had arm edema >5% on perometry; and 2 of these had edema outside the hand on clinical examination. Patients were at high risk of BCRL with an average of 2.9/5 known risk factors. Arm edema progressed to >10% in 2 high-risk patients. Treatment resulted in an average hand volume reduction of 10.2% via perometry and improvement upon clinical examination.

Limitations

The small sample size and lack of validated measures of subjective data were limitations.

Conclusions

In this cohort, patients with HE carried significant risk factors for BCRL. Two out of 9 (22%), both carrying ≥4/5 risk factors, progressed to edema >10%. Isolated HE may be a prognostic factor for edema progression in patients treated for breast cancer at risk for BCRL. Further research is warranted.

As the long-term survival rate for breast cancer improves, there is an increasing focus on the sequelae of breast cancer treatment that may affect function and/or quality of life. There are currently more than 3.5 million people who have been treated for breast cancer in the United States, and it is estimated that more than 1 in 5 will develop breast cancer–related lymphedema (BCRL).^1,2 The risk of developing BCRL is lifelong, making it one of the most feared side effects among patients treated for breast cancer.³ With no cure or preventative treatment options available for patients, those who develop BCRL often face long-term management of their edematous limb with bandaging, compression garments, and self-care through treatment by a Certified Lymphedema Therapist (CLT). The importance of prospective surveillance for BCRL cannot be overestimated. In a prospective surveillance model, patients’ limb volumes are preoperatively assessed and followed at regular intervals throughout and beyond their treatment. The model was developed to allow for early diagnosis and intervention for BCRL,⁴ in a move away from an impairment-based model which only allows for intervention after patients present with symptoms and signs of lymphedema, often at a later stage than that detected via a prospective surveillance model. There has, in recent years, been a movement toward prospective surveillance in response to the proven feasibility, sustainability, reduced health care cost, and patient outcomes of such programs.^5–8 Prospective surveillance for BCRL is now a recommendation of the National Lymphedema Network,⁹ the International Society of Lymphedema,⁴ and the American Society of Breast Surgeons.¹⁰ Prospective surveillance for BCRL as part of a comprehensive surveillance program for patients treated for breast cancer is also a recommendation of a panel of experts in lymphedema convened through funding from the American Cancer Society.¹¹ Massachusetts General Hospital implemented a prospective surveillance model for BCRL in 2005.⁷ More than 4500 patients who have been treated for breast cancer have been screened through the program.⁷ Previous analyses of our patient population have established risk factors for BCRL, including axillary lymph node dissection (ALND), regional lymph node radiation (RLNR),¹² Body Mass Index (BMI) >30 kg/m² at the time of breast cancer diagnosis,¹³ and increased arm swelling of ≥3% within 3 months of surgery or ≥5% at any time postoperatively.^12,14 Patients in this screening program are regularly monitored for arm volume changes via Perometer measurements, which are obtained preoperatively and every 3–8 months postoperatively, corresponding with their oncology follow-up visits. They are educated on the signs and symptoms of BCRL and asked that should they experience any, they report them to the team immediately. Diagnosis of BCRL is made through subjective report, clinical examination, and objective measurement, which allows for early diagnosis at low levels of edema. Establishment of risk factors for BCRL has allowed clinicians and researchers to better understand which patients treated for breast cancer are at risk for BCRL, and to monitor closely for early signs or symptoms. Although some treatment-related risk factors are well established, research is evolving in areas such as anatomic and genetic predisposition for BCRL. Any research which helps identify those who may progress to BCRL is a helpful adjunct to the prospective surveillance model, in that this information may allow for earlier diagnosis and therefore early intervention.

This report highlights cases of 9 patients who have been treated for breast cancer who presented to the Cancer Center with a primary complaint of early HE. It should be noted that isolated HE (as opposed to HE noted in patients with established BCRL) is anecdotally quite rare in those treated for breast cancer, and incidence is not reported to date in those at risk of BCRL. Stanton is one of few authors addressing HE in the population with BCRL,¹⁵ and he highlights that there are 2 populations of women with BCRL: those with HE and those without. Using lymphoscintigraphy, Stanton et al¹⁵ investigated lymph drainage in the hands of eight women with BCRL and moderate to severe hand swelling. Through imaging, the ipsilateral, swollen forearm showed dermal backflow and retention of Tc-labeled hIgC when compared to the contralateral hand. Results from this study suggest that hand swelling perhaps results from failure of peripheral lymphatics in the forearm or at the wrist, rather than as a result of axillary intervention.¹⁵

There is very limited evidence concerning HE after breast cancer treatment for those at risk for lymphedema, which is what we sought to study in the present case series. The data were obtained and analyzed with Institutional Review Board approval. In this study, 171 patients were referred to the CLT over a 12-month period; 9 (5.26%) were identified as this cohort presenting with isolated HE. All 9 patients in this study were at risk for BCRL, had no previous diagnosis of BCRL, and were referred to the CLT for evaluation and treatment for edema. The aim of this paper is to highlight the potential importance of HE in patients treated for breast cancer who are at risk for BCRL as a risk factor for progression of edema in the extremity, to report on the risk factors for BCRL among this series presenting with HE, and finally, to share treatment results and challenges in this population.

Methods

Patient Population

Among patients screened in our program, we identified 9 patients treated for breast cancer who contacted the Cancer Center reporting a primary complaint of HE. Of these, 1 patient reported edema which started in the hand but had evolved up to the lower forearm by time of evaluation, and another also reported swelling in the breast, which appeared at the same time as the HE presented. All 9 patients were referred to the CLT for evaluation and treatment of upper extremity edema. Retrospective chart review was conducted to identify patient demographics, treatment-related factors, and risk factors for BCRL.

Quantification of Hand and Arm Edema

As previously discussed, for the purpose of this study, HE was quantified via Perometry. The volume of the hand segment was entered into the RVC or WAC equation for those 4 patients with a preoperative baseline measurement in addition to calculation of absolute volume. Absolute volume was used as the measure of edema to compare left versus right for the remaining 5 patients without a baseline measure (eg, R arm 2601 mL, L arm 2966 mL would result in an absolute volume difference of 14.03% L>R). For the purposes of this study, HE was quantified by creating a hand segment from the Perometry data. The distal value used is the default value for the Perometer, 53 mm from the end of the frame, which is the point where the Perometer cuts off at the fingertip area. The proximal value was identified as the circumference at the smallest part of the forearm approaching the hand, and that location was used consistently for all measurements taken for that patient.

In terms of clinical examination, integumentary integrity, circulation (pulses, capillary refill, color, temperature), and sensory integrity (light touch) of bilateral upper extremities were examined in terms of norms and affected to non-affected limb symmetry. Stemmer's sign,²³ quantification of pain, anatomical location of edema, and quantification of pitting edema²⁴ should also be examined. A comprehensive past medical history, subjective evaluation, and clinical examination should be aimed at ruling out potential causes for edema other than BCRL.²⁵

Role of the Funding Source

The project was supported by Award Number R01CA139118 (AGT) and Award Number P50CA08393 (AGT) from the National Cancer Institute. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute or the National Institutes of Health, which played no role in the conduct of this study. The Massachusetts General Hospital Lymphedema Research Program is supported by the Adele McKinnon Research Fund for Breast Cancer–Related Lymphedema.

Results

Demographic and Treatment-Related Factors

The patients were on average 51.4 years of age (range: 37–75), and presented to the CLT at an average of 26.67 months (range: 10–50) after surgery. Of interest, 8 of the 9 patients were meeting or exceeding American College of Sports Medicine (ACSM) exercise guidelines for those treated for breast cancer²⁶ at their pre-diagnosis baseline, but only 4 were doing so at the time of presentation with HE. Five patients were working outside the home. Demographic and treatment-related factors of the cohort are summarized in Table 1.

Table 1.

Demographic and Treatment-Related Factors.^a

Patient (no.)	Age (y)	Hand dominance	Affected arm–Edema	Surgery type	Axillary surgery (# positive nodes/number removed)	Chemotherapy	Regional lymph node radiation
1	75	Right	Right	Bilateral lumpectomy	Left ALND (0/10)	Yes	No (only chest wall)
2	58	Right	Left	Left mastectomy No reconstruction	Left ALND (9/9)	Yes	Yes (SC)
3	53	Left	Right	Right mastectomy No reconstruction	Right ALND (0/20)	Yes	Yes (SC)
4	39	Right	Right	Bilateral mastectomy Implant reconstruction	Right ALND (0/16)	Yes	Yes (SC)
5	61	Right	Right	Right mastectomy Implant reconstruction	Right ALND (1/13)	Yes	Yes (SC)
6	64	Right	Right	Bilateral mastectomy Implant reconstruction	Right ALND (8/25) Left SLNBb	Yes	Yes (SC, A, IM)
7	42	Right	Left	Bilateral mastectomy Implant reconstruction	Left SLNB	No	No Radiation
8	37	Right	Left	Bilateral mastectomy Expanders	Left ALND (1/13) Right SLNB	Yes	Yes (IM, SC)
9	39	Right	Left	Bilateral mastectomy Expanders	Left ALND (2/15)	Yes	Yes (A, IM)

^aA = axillary, ALND = axillary lymph node dissection, IM = internal mammary lymph nodes, SC = supraclavicular, SLNB = sentinel lymph node biopsy.

Risk Factors for Breast Cancer-Related Lymphedema

For the purpose of examining the risk of BCRL in this cohort, we considered previously established by our group and well substantiated in the literature.^12–14 These risk factors are highlighted in Table 2, and include ALND, RLNR, BMI ≥30 kg/m² at diagnosis, edema ≥3% within 3 months of surgery, and edema ≥5% at any point following surgery. Patients had a mean of 2.9/5 known risk factors. Of note, although Patient 7 did not carry any of the 5 established risk factors, she was not entirely without risk, as she underwent SLNB, which carries a 5% risk of lymphedema on the ipsilateral side.²⁷

Table 2.

Risk Factors for Breast Cancer-Related Lymphedema.^a

Patient	BMI ≥ 30 kg/m2 at diagnosis	ALND (no. positive / no. removed)	Regional lymph node radiation	Edema ≥ 3% within 3 months of surgery	Edema ≥ 5% at any time	Total risk factors
1	23.6	Yes (0/10)	No	No	Yes	2
2	25.7	Yes (9/9)	Yes	No	Yes	3
3	21.2	Yes (0/20)	Yes	Yes	Yes	4
4	22.3	Yes (0/16)	Yes	No	Yes	3
5	30	Yes (1/13)	Yes	Yes	Yes	5
6	39	Yes (8/25)	Yes	Yes	Yes	5
7	21	No	No	No	No	0b
8	20.7	Yes (1/13)	Yes	No	No	2
9	18.2	Yes (2/15)	Yes	No data	No data	2
TOTAL	2/9	8/9	7/9	3/8	6/8	Mean 2.9

^aBMI = body mass index, ALND = axillary lymph node dissection.

^bPatient 7 underwent SLNB, which carries a small risk of lymphedema.¹²

Quantification of Hand and Arm Edema

All patients presented with the primary complaint of and demonstrated evidence of HE on clinical exam. HE was often noted on the dorsal aspect of the first web space, extending into the fingers. At times, this involved all fingers, and for others, all fingers were not involved, but rather preferentially the index, middle, and ring fingers. Integumentary integrity, circulation, and sensation were intact for all patients. There were no reports of pain. Four patients measured less than 5% HE on initial exam via Perometry (absolute % edema). Two of these patients had baseline or preoperative perometry measurements, and when considering the relative percent of HE, 1 had HE greater than 5%. Patients did not report any functional impairment as a result of the edema.

Edema was mostly isolated to the hand in this cohort. Three patients had arm edema just over 5% on initial exam when considering relative and absolute volumes (Patients 1, 3, and 5 at 6%, 5.95%, and 7.27%, respectively). Patient 1 did not report edema outside of the hand, and did not have edema outside of the hand on clinical examination. Patient 3 reported edema which started in the hand, but evolved into the wrist and lower forearm, which was consistent with the clinical examination. Patient 5 reported hand and breast edema, which was confirmed on clinical exam, and edema up into the wrist and lower forearm during clinical examination was also documented. Five patients did not have a baseline perometry measurement, all having undergone surgery in 2012 or prior. Perometry values for the hand and arm are reported in Table 3.

Table 3.

Clinical and Perometric Examination of Hand and Arm Edema.^a

Patient	Hand edema on clinical exam	Number of months postoperative at time of CLT evaluation	Hand edema via perometry (absolute % edema)		Hand edema via perometry patients with baseline values (relative % edema)		Arm edema at time of CLT presentation (absolute % edema)	Arm edema at time of CLT presentation patients with baseline values (relative % edema)
			Initial	Change	Initial	Change
1	Yes	40	18%	–24%	–	–	6%	–
2	Yes	10	7%	–1%	–	–	3%	–
3	Yes	10	1%	+8%	–4.26%	+9.86%	1%	RVC 5.95%
4	Yes	19	8%	–8%	23.90%	–12.61%	4%	WAC –0.44%
5	Yes	23	1%	+16%	6.92%	+9.57%	0%	RVC 7.27%
6	Yes	33	12%	–18%	19.01%	–14.88%	2%	WAC –6.72%
7	Yes	27	3%	0%	–	–	2%	–
8	Yes	28	4%	No value	–	–	0%	–
9	Yes	50	No value	No value	–	–	No value	–

^aCLT = Certified Lymphedema Therapist.

Treatment of Hand Edema

Patients were seen for an average of 3.67 CLT sessions (range: 1–7 sessions) for evaluation and treatment of edema. Of note, Patient 5 was lost to follow-up as she opted for treatment closer to home.

Treatment for edema was individualized depending on each patient's functional requirements, treatment preferences, and comfort level. Treatment included a combination of the following: a Class I glove, a quilted night glove, a Class I sleeve, multiple-layer bandaging of the hand ± forearm, quilted pad for the dorsum of the hand, kinesiotaping,²⁸ and exercise. These treatments are summarized in Table 4.

Table 4.

Treatment of Edema.

Patient	# CLT sessions (mean 3.67)	Treatment
		Class I glove	Night glove	Class I sleeve	Multiple-layer bandaging	Dorsal pad	Kinesiotape	Exercise
1	2	x	x	x				x
2	4	x	x	x				x
3	7	x		x	x			x
4	4	x	x	x	x	x		x
5	1	x						x
6	3	x						x
7	2	x				x		x
8	5	x				x
9	5	x	x	x			x	x

Exercise programs were self-selected by the patient at the discretion of the therapist, and included 1 or more of the following: stretching of the upper quarter, swimming, arm and hand pumping, resistance exercises, and aerobic exercise (walking, running, Zumba, swimming, salsa, swing dancing, horseback riding, and kickboxing). When specific exercises were recommended by the CLT, individualized prescription was completed and supervision provided to the point of the patient's independence with the exercises. The exercise recommendations were consistently given with the goal of meeting the ACSM guidelines for exercise in those treated for breast cancer.²⁶ Compression was recommended for 24 hours per day, with the exception of bathing. The compression glove or sleeve was worn during the day, and a night glove or wrapping was used at night. The dorsal pad was used in conjunction with the day glove, and the kinesiotape was used in lieu of a day glove at times. A latex-free medical glove was recommended over compression for activities of daily living.

With treatment, 7 patients had a reduction in HE as demonstrated by either perometry and/or clinical examination. For patients with perometry measures (N = 5), treatment resulted in an average hand volume reduction of 10.2%. One patient did not demonstrate a change in perometry values from the start to the end of their lymphedema management period (Patient 7), but showed a significant improvement on clinical examination. Two patients did not have perometry measures taken at the start and/or end of treatment (Patients 8 and 9) due to scheduling issues and location of the Perometer; however, they had significant improvement in HE on clinical examination.

Two patients (Patients 3 and 5) went on to develop edema >10% (RVC). Patient 3 progressed to an RVC of 12.73% (absolute difference: 6% right>left), which came down to 2.26% (5% right>left) with treatment. Patient 5 progressed to an RVC of 13.23% (8% right>left), and was lost to follow-up as she required treatment nearer to home and was not able to be reached. Relative volume change at the last follow-up measurement for this patient was 11.03% (6% right>left).

Discussion

To our knowledge, there is minimal research on HE in those treated for breast cancer at risk for BCRL. There is some evidence that segmental differences in surviving lymphatic function result in uneven distribution of swelling along the arm in BCRL, and that the pathophysiology of BCRL is more complex than axillary lymphatic obstruction alone.²⁹ The hand is spared in some patients with BCRL because local lymph flow is increased and diverted along collateral dermal routes, whereas other patients with BCRL experience hand edema.²⁹ Stout et al³⁰ examined 196 patients, 46 of whom developed BCRL an average of 6.9 months postoperatively. They found that at arm segments 10–20 cm and 20–30 cm, significant increases in segmental volume were noted before the diagnosis of BCRL, and the volume of these segments was found to predict total limb volume. This work underscores the importance of looking for segmental changes prior to onset of BCRL as a possible precursor. Perhaps the hand is no exception. In clinical practice, many patients with established BCRL present with hand swelling. As previously discussed, Stanton et al highlighted that there are 2 populations of women with BCRL: those with HE and those without, which is consistent with clinical practice experience. There is, however, limited understanding of whether or not isolated HE may be a sign of BCRL in at-risk individuals.

There remains no universal acceptance regarding the mode of measurement for screening and diagnosis of BCRL, and HE is no exception. Several articles have looked at measurement techniques assessing hand swelling in lymphedema.^13–16 Lee et al¹⁷ measured hand volumes of 20 women with and 20 women without BCRL using perometry and water volumetry. The Perometer was found to have high intra- (ICC_2,1 = 0.989 (95% CI: 0.98–0.99)) and inter-rater reliability (ICC_2,1 = 0.993 (95% CI: 0.99–1.0)), and there was high concordance between hand volumes obtained with the Perometer and water volumetry (R_c = 0.88).¹⁷ Dylke et al¹⁸ used perometry and bioimpedance spectroscopy to measure HE of 10 participants with and 50 participants without hand lymphedema. They found that impedance and volume measurements were strongly related (dominant hand r = –0.794) and both measurements were reliable (ICC_2,1 = 0.900–0.967 and 0.988–0.996, respectively).¹⁸ Considering published studies, perometry is a reliable and valid measure of and was used to measure HE in this study.

In addition to lack of consensus on measurement techniques, there is also no universally accepted definition for the threshold at which lymphedema is diagnosed. A recent review paper comprehensively summarized diagnostic methods and measurement techniques for BCRL.¹⁹ There has been some consensus in the literature that an arm volume change of ≥10% is indicative of lymphedema. The Lymphedema Research Team at MGH has previously developed and validated the Relative Volume Change formula and the Weight Adjusted Change formula for patients who have undergone unilateral and bilateral surgery for breast cancer, respectively.^20,21 These formulas take into account a preoperative, or baseline, arm volume measurement to accurately establish volume changes relative to baseline values. Without a baseline measure, there is misdiagnosis of 40–50% of cases of BCRL.²² It should be noted that arm volume calculated from tape measurement, perometry, or water displacement may be entered into the RVC or WAC formulas. At our institution, the arm volume included in each of the aforementioned equations is measured by the Perometer.

In this study, 9 patients treated for breast cancer presented with complaints of HE, and had evidence of HE on clinical exam. Although there is a distinct population of women with BCRL who have HE, edema was mostly isolated to the hand in this population at risk. The 3 patients who had arm edema were presenting with low-level, early edema (6%, 5.95%, and 7.27%, respectively). If one were to use the criterion of >10% RVC or WAC for lymphedema diagnosis, none of these patients would have been diagnosed with BCRL. Only 2 patients had edema outside of the hand on clinical examination, both extending into the wrist and lower forearm, and 1 of these 2 also had edema in the breast. This highlights the importance of considering measurement of edema together with clinical examination and patient symptoms when diagnosing lymphedema, and of incorporating an individualized understanding of each patient's risk factors for BCRL.

It is interesting to note that all 9 patients in this study presented to their oncologists with a primary complaint of edema which started in the hand. In the absence of functional impairments, this suggests that HE was a cause for significant concern among this small group of patients treated for breast cancer. Patients reported that they were fearful of developing lymphedema and were wondering whether HE was a sign of lymphedema. Furthermore, some patients were significantly concerned about the visual appearance of HE and its constant reminder of their breast cancer diagnosis.

Patients in this study presented with HE an average of 26.67 months postoperatively. Given that the median time to development of BCRL was found to be 14.4 months (range: 3.5–57.1) in a cohort of 1173 women screened in our program for BCRL at baseline and for an average of 27 months postoperatively,¹⁴ this highlights the importance of a longitudinal screening program, which monitors patients through and beyond their breast cancer treatment. All patients in this study carried risk factors for BCRL. The 2 patients whose edema progressed to >10% carried 4/5 and 5/5 well-established risk factors, respectively. These patients presenting with HE were at risk for BCRL, some at significantly high risk, which highlights the need for ongoing screening beyond duration of treatment for breast cancer.

Four of 9 patients in this study had a preoperative baseline perometry measurement. On initial examination, only 1 patient had arm edema >5% when considering absolute values, and 3 had arm edema >5% via relative volumes. In addition, when looking at perometry values for the 2 patients who progressed to edema >10%, their relative volume changes placed them into a diagnosis of lymphedema (12.73% and 13.23%, respectively), while their absolute values would not have (8% and 6% right>left respectively). In those cases, proper diagnosis and potentially intervention would have been missed, placing the patients at risk for further progression. Together, these situations highlight the discrepancy between quantification of edema when using preoperative measures relative to baseline and when using only postoperative measures. Our team published a study definitively quantifying the necessity of using baseline measurements for the screening and diagnosis of lymphedema. Participants included 1028 patients screened with perometry at baseline and throughout follow-up. Significant arm asymmetry in patients was noted at baseline, with 28.3% and 2.9% of the cohort having asymmetry >5 and 10%, respectively. Without knowledge of this baseline asymmetry, significant misdiagnosis of lymphedema would occur. Using perometry measurements immediately or at 3 months postoperatively as “pseudobaselines” also resulted in significant misdiagnosis of 40–50% of subclinical (>5%) and clinical (>10%) lymphedema.²² Every effort to obtain baseline measurements should be made to accurately screen and diagnose BCRL.

Among the patients in this study, the edema was mostly isolated to the hand, with the exception of 3 patients with low-level arm edema between 5 and 7%. Only edema in the wrist and lower forearm could be visualized on clinical examination, which may explain why these patients did not report it on initial presentation. This is an important distinction, however, because a universal threshold for intervention for lymphedema has not been established. We know that patients with low-level volume changes between 5 and 10% are at an increased risk for progression to edema >10%.¹⁴ This would put these patients at an increased risk of progression of edema, and in fact, in such a small cohort, it is striking that 2 patients did progress to edema >10% (RVC). It is important to note that HE may be a risk factor for progression of edema. This may be either directly, where HE would be an independent risk factor, or indirectly, where HE may reflect early total limb edema. In either case, HE should be monitored closely as part of a prospective screening program, and patients should be encouraged to report any signs of edema throughout the limb, including in the hand, to ensure early diagnosis.

Of concern in this analysis is the discrepancy between HE on clinical exam and quantification of HE via perometry. Perometry has been found to be a reliable and valid method of quantification of hand volume.¹⁷ In such a small cohort, however, 4 patients presented with HE <5% via perometry on initial measurement, which included 2 patients with measurements <3%. It is concerning that HE would be so low on perometry given the obvious signs of HE on clinical examination. Further research is recommended on the measurement of HE in this population to ensure accuracy.

Treatment was successful in this population, and resulted in an average hand volume reduction of 10.2% for those with perometry, and improvements for all patients on clinical examination. Arm edema progressed to >10% in 2 patients (Patients 3 and 5), both of whom were at high risk for BCRL (with 4/5 and 5/5 known risk factors, respectively). One of these patients was lost to follow-up, and the other, with treatment, reached an arm volume of <3%. It should be noted that although this was a small number who progressed, there may potentially be many more patients who do not present to the CLT for treatment of HE prior to progression of edema. This highlights the importance of early treatment of HE in this population.

Limitations of this study include the small sample size. Subjective data was not quantified in a validated fashion, but this would be helpful to pursue in future studies of HE. It would be helpful to clarify the reasons which lead patients to seek medical advice for HE. For example, fear of lymphedema development, emotional distress due to the visible nature of HE as a reminder of breast cancer diagnosis, or other reasons may motivate the patient to seek examination and treatment. Although compliance to compression was not quantified in this study, it is admittedly and understandably a challenge, given varied functional demands necessitating the use of the hand and the likelihood of the compression garment becoming wet or soiled. Obtaining subjective data describing barriers to compliance with hand compression is recommended for future studies. Finally, it would be helpful to quantify fine and gross motor hand function in these patients, to see if varying levels of HE result in impairments that may impact activities of daily living or vocational needs. Since these functional requirements are so individualized, a standardized, objective assessment would better capture any potential impairments resulting from HE.

Hand edema may be a potential risk factor for progression of edema in patients treated for breast cancer who are at risk of BCRL. Further research is warranted to definitively establish whether or not hand edema is a risk factor for progression of edema, and to ensure accurate measurement and effective treatment of hand edema in the at-risk population.

Ethics Approval

The data were obtained and analyzed with approval from Massachusetts General Hospital Institutional Review Board.

Funding

The project was supported by Award Number R01CA139118 (AGT) and Award Number P50CA08393 (AGT) from the National Cancer Institute. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute or the National Institutes of Health, which had no input into the conduct of this research. The MGH Lymphedema Research Program is supported by the Adele McKinnon Research Fund for Breast Cancer–Related Lymphedema.

Disclosures and Presentations

The authors completed the ICJME Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.