Reviewer's report
Title:Prevalence of lymphedema in women under treatment for breast cancer in
a referral center in southeastern brazil
Version: 2Date:9 July 2012
Reviewer: Aase S, A Sagen
Reviewer's report:
Review of manuscript
Prevalence of lymphedema in women under treatment for breast cancer in a
referral center in southeastern Brazil
Breast cancer operated women (N=250) were investigated 6 months to ?years
after surgery to estimate the prevalence of lymphedema and associated factors
in women treated for breast cancer.
General comments
Studies on arm morbidities from breast cancer treatment are highly warranted.
However, the material and the methods included in this study are poorly
described.
Major
The heading refers to women under treatment, but the ongoing treatment is not
described.
The chapter of Methods is porely described. The description of the material, the
inclusion/exclusion criteria and particularly the description of the methods and
measurements being employed are unclear.
1. The inclusion criteria
What is “Absence of functional change” regarding the upper limb?
2. The grouping of the material in time since surgery
The period from 6 months to 5 years after surgery is very wide. Lymphedema
and problems related to breast cancer surgery can possibly be much more
profound at 6 month than at 5 years. Analyses based on these wide groups will
not reveal important differences regarding time aspects. A simple table
describing the material’s age etc (demographics and treatment) before
adjustments, including descriptive statistics would have been clarifying.
3. The measurements
Only the measurement and definition of lymphedema has been described. The
other outcome measurements in the tables and results has not been defined or
described; pain?, obesity?, surgery; conservative? radical? Low dissection, high
dissection? How was seroma obtained?
Semi structured questionnaire?, - containing what variables? Vascular disorders?
-what kind? Self reported morbidities? -what kind? Was any of the
measurements validated?
The definition of lymphedema used as difference of 2 cm or more between
affected and control arm is problematic. It is well documented that the dominant
arm normally is bigger than the non-dominant arm1, 2. Furthermore; 2 cm
difference in a small arm can possibly be defined as lymphedema in the favor to
non-dominant arm, but in a large arm 2 cm must be considered within normal
differences 3-5,1. Without adjusting for dominant/non-dominant arm, the method
used in this study unfortunately suffers from lack of validity (probably both
sensitivity and specificity).
4. The age-grouping of the material
The age-groups are divided into below 57 years and older women up to 99
years? Why is that? Is it likely that women at 99 years can be compared to
women at 57 years of age?
5. Issues that should have been discussed:
Estimating prevalence without prospective (preoperative) assessments. The use
of observer-rated measurements and aspects regarding patients self reported (5
years back memories) measurements.
Reference List
1. Gebruers N, Truijen S, Engelborghs S, De Deyn PP. Volumetric evaluation of
upper extremities in 250 healthy persons. Clin Physiol Funct Imaging
2007;27:17-22.
2. Sagen A, Karesen R, Risberg MA. The reliability of a simplified water
displacement instrument: a method for measuring arm volume. Arch Phys Med
Rehabil 2005;86:86-9.
3. Engler HS, Sweat RD. Volumetric arm measurements: technique and results.
The american surgeon 1962;465-8.
4. Godal R, Swedborg I. A correction for the natural asymmetry of the arms in the
determination of the volume of oedema. Scand J Rehabil Med 1982;14:193-5.
5. Kettle JH, Rundle FF, Oddie TH. Measurement of upper limb volumes: A
clinical method. The Australian and New Zealand journal of surgery
1958;27:263-70.
Level of interest: An article of limited interest
Quality of written English: Needs some language corrections before being
published
Statistical review: Yes, but I do not feel adequately qualified to assess the
statistics.
Declaration of competing interests:
'I declare that I have no competing interests'