LYMPHATIC RESEARCH AND BIOLOGY

Volume 00, Number 00, 2019

ª Mary Ann Liebert, Inc.
DOI: 10.1089/lrb.2018.0064

Compression Treatment of Breast Edema:

A Randomized Controlled Pilot Study

Karin Johansson, PhD, RPT,1 Charlotta Jönsson, MSc, RPT,1 and Thomas Björk-Eriksson, PhD, MD2

Abstract
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Background: Patients treated for breast cancer with breast conserving surgery and radiotherapy (RT) often
complain about swelling, heaviness, and pain in the treated breast. This pilot study was undertaken to examine
if compression therapy was effective as an early treatment to reduce breast edema and symptoms assessed by
Visual Analogue Scale (VAS).
Methods and Results: Fifty-six breast cancer-treated women with breast edema, diagnosed by the measurement
of tissue water content by tissue dielectric constant (TDC) technique 3 months post-RT, were randomized to
either an intervention group, wearing a sports bra of compression type, or a control group, wearing a standard
bra daily for 9 months when tissue water content in breast, upper arm, and lateral thorax of the operated side,
and symptoms assessed by VAS were evaluated. No differences were found between the groups at start or end
of study concerning tissue water content or VAS. However, within both groups, a significant reduction in tissue
water content and experience of heaviness was found.
Conclusion: Breast edema as well as experience of heaviness in the affected breast found at 3 months post-RT
decreased after 9 months independent of whether a sports bra of compression type or a standard bra was used.

Keywords: breast edema, RCT, tissue dielectric constant, compression treatment

Introduction constant (TDC) technique based on high-frequency electro-

magnetic waves measuring tissue water content. The tech-

P atients treated for breast cancer with partial mas-

tectomy and radiotherapy (RT) to the breast complain
about swelling, heaviness, redness, and pain in the treated
breast.1,2 The incidence of swelling shows a great variation
between 0% and 90%, probably because of a large variation
of measurement methods as well as of time after RT.2 Con-
stantine et al. found that 17% of patients experienced breast
edema within 90 days of RT, scored on a 10-point scale.3 One
year post-surgery and -RT to the breast, Rönkä et al. found
subcutaneous edema of the breast, measured with ultrasound,
in 70% of patients with axillary node dissection and in 28%
with sentinel node biopsy.4 After a median follow-up of 27
months, Goffman et al. found an incidence of breast edema
only in about 10% of patients in a similar material, using
clinical signs such as erythema and changes similar to peau
d’orange of the breast as indicators of edema.1
In a recent study, the incidence of breast edema was 63%
at 3 months after breast conserving surgery and RT.5
The measurements were performed with a tissue dielectric
nique has been introduced showing potential to measure
breast edema.5 Since the technique enables the measurement
of different quadrants of the breast, it may provide informa-
tion that may lead to improvement in conservative treatment
of breast edema.
Prior studies have suggested that breast cancer-related arm
lymphedema can be diagnosed early with MoisterMeterD.6,7
The device, assessing the TDC, has also been compared with
bioimpedance spectroscopy assessing extracellular fluid in
this group of patients. Both methods can identify early lym-
phedema, but the TDC technique shows a higher sensitivity.8
Treatment of arm lymphedema, following breast cancer
treatment, by compression garment is well documented.9 It is
our clinical experience that breast edema commonly is trea-
ted with a compression bra, often a sports bra of compression
type, which can be expected to have an effect on breast
edema. For arm lymphedema it has also been shown that
early treatment can keep the lymphedema volume at a very
low level in 80% of patients during many years.10 Therefore,

1
Department of Health Sciences, Lund University, Lund, Sweden.
2
Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden.

1
 2 JOHANSSON ET AL.
we hypothesized that breast edema can be treated by com-
pression at an early stage. We also wanted to investigate if an
association between breast edema and edema in the upper
arm or lateral thorax could be found.
Materials and Methods
Design
This was a randomized controlled pilot study evaluating
the effect of 9-month intervention with compression treat-
ment for breast edema following breast conserving surgery
and RT to the breast.
Patients
Within a longitudinal study of breast edema, 118 patients
treated for breast cancer with breast conserving surgery and
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sentinel lymph node biopsy (SLNB) or axillary lymph node
dissection (ALND), and RT to the breast, at the Department
of Oncology at Skåne University Hospital, Sweden, were ex-
amined for breast edema.5 Patients with preoperative chemo-
therapy, recurrent cancer, or concurrent diseases that may
interfere with measurement of edema and patients with diffi-
culties in participating in the study, for example, dementia,
were excluded.
Ninety-six patients were examined 3 months post-RT
within the longitudinal study, and 70 patients diagnosed with
breast edema (inter-breast TDC ratio ‡1.40) were included in
the present intervention study. Twelve declined to take part
mostly due to long travel distance. Fifty-eight patients were
randomized to either control (CG) or intervention group (IG).
Two patients dropped out without giving any reason, one in
FIG. 1. Flowchart of patients treated for breast cancer with breast conserving surgery and RT to the breast.
RT, radiotherapy.
each group (Fig. 1). Finally, 56 patients, 28 in each group,
completed the study. There were no statistically significant
differences in patient characteristics between the groups
(Table 1).
All subjects provided written documentation of informed
consent before participation in the study. The study was ap-
proved by the Research Ethics Committee, Lund University,
Sweden, Dnr 2011/7, and performed in accordance with the
Declaration of Helsinki.
Procedure
After evaluation at 3 months within the longitudinal study
by one of the two physiotherapists (V.F. or L.J.) and inclusion
in the present study, patients were randomized by K.J., in
random blocks of four, to either IG or CG. Duration of the
longitudinal study was 1 year after completion of RT, con-
sisting of a randomization at 3 months post-RT and inter-
vention time of 9 months. Thus, patients included at 3 months
post-RT took part in the present study for 9 months.
The intervention group. Patients were provided with
sports bras of compression type with firm pressure flattening
the breasts. The bras were of different designs, fitted for each
woman, making sure they were comfortable. The bras were
worn during daytime, but not during nights, based on the
common regime applied for arm lymphedema where a
compression garment most usually is worn during daytime.
The control group. Patients used ordinary bras during
daytime, but were allowed to use loose-fitted sports bras.
 BREAST EDEMA TREATMENT
Table 1. Characteristics of Breast Edema Patients (N = 56) Taking Part in the Intervention Study
Age (years, mean – 1 SD)
Affected site, left/right, n (%)
Sentinel node/axillary dissection, n (%)
Tumor size (mm)a
Scar in quadrantb, n (%)
None or one/two or more
Radiotherapy
Total dose 42.5/50 Gy, n (%)
Chemotherapy, yes/no, n (%)
BMI (kg/m2, mean – 1 SD)
Bra sizec, n (%)
A–C/‡D
a
With multifocal tumors in 15 patients, the size of each tumor was added up to a total sum.
b
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Surgeries considered to be performed in 0 quadrant were performed at the border of the quadrants.
c
Bra size was reported by the patient.
BMI, body mass index; CG, control group; IG, intervention group.
Patients in both groups were told to continue with daily
activities such as work, household activities, and sports
during the study as they had done before.
By end of intervention, pressure of the bra was measured
by K.J., who was not blinded to group status. Evaluation
started with measuring weight and length to calculate body
mass index (BMI), followed by assessment of experiences of
tightness, heaviness, and pain in the breast, and at last TDC
measurements of breast, arm, and lateral thorax. Assessments
were performed by V.F. and C.J., who were blinded to group
status. Each physiotherapist performed both pre- and post-
intervention measurements for the same patients.
Measurements
Primary outcomes of interest of this study were TDC
values, as indices of local tissue water of the breast, and
patients’ experiences of tightness, heaviness, and pain in the
irradiated breast. Secondary end points were tissue water
FIG. 2. Each quadrant of the breast was measured with the
probe placed along a line that bisected each quadrant with
the edge of the probe 10 mm from the edge of the areola.
3
CG, n = 28 IG, n = 28
61.3 – 9.6 61.9 – 7.6
13 (46.4)/15 (53.6) 14 (50.0)/14 (50.0)
22 (78.6)/6 (21.4) 21(75.0)/7(25.0)
16.7 – 6.5 14.9 – 8.9
13 (46.4)/15 (53.6) 17 (60.7)/11 (39.3)
23 (81.4)/5 (17.8) 24 (85.7)/4 (14.3)
4 (14.3)/24 (85.7) 3 (10.7)/25 (89.3)
29.4 – 4.7 27.9 – 3.4
25 (89.3)/3 (10.7) 22 (78.6)/6 (21.4)
content in upper arm and lateral thorax of the affected side.
Assessments were made before and immediately after inter-
vention.
Local tissue water was measured by the TDC technique
(MoistureMeterD; Delfin Technologies Ltd., Finland). The
device transmits a very high-frequency electromagnetic
(EM) wave of 300 MHz into an open-ended coaxial probe in
contact with the skin. A part of the EM energy is absorbed by
tissue water, while the rest is reflected back to the coaxial
line, and an electrical parameter, TDC, directly proportional
to tissue water content in skin and upper subcutis is calcu-
lated.11 With the TDC technique, local tissue water in both
breasts was measured to an effective depth of 2.5 mm. The
effective depth illustrates the depth where the EM field in
water-equivalent material has attenuated to 37% of the value
at the skin surface. The TDC scale ranges from 1.0 to 78.5
based on the percentage of fluid at the measurement site,
where a value of 1 indicates that the object has no water, and
78.5 indicates that the object has 100% of water. The mea-
surement has been validated against circumference mea-
surements of the forearm by hemodialysis treatment and
showed a high correlation (r = -0.97, p < 0.05) in edema re-
duction and fluid removal during hemodialysis treatment
(r = -0.99, p < 0.01).
Breast. Affected and contralateral breast TDC values
were measured with the patient in supine position. The four
quadrants of the breast were marked, and the numbering of
the quadrants was based on the order used in the surgical
procedure. Measurements were performed in the following
order, starting with the operated breast; upper medial; lower
medial; lower lateral; and upper lateral quadrant. Measure-
ments were made along a line that bisected each quadrant
with the edge of the probe 10 mm from the edge of the areola
(Fig. 2), and measurement results were registered for both
breasts. The mean TDC value of the total breast (four quad-
rants) was then calculated; however, quadrant(s) with scar
tissue were excluded, and for the corresponding quadrant(s)
in the healthy breast, a TDC ratio was determined using mean
values from both breasts.
 4 JOHANSSON ET AL.
Arm. With the patient in supine position and with the
arms in outward rotation, the tissue water content in medial
upper arms of both upper limbs, 5 cm proximal to the antic-
ubital fossa, was measured by TDC technique.
Lateral thorax. With the patient in prone position with
arms along the side and the head resting in a neutral position
with face down, the thoracic measurement site was defined at
a spot 5 cm caudally from a line drawn between the highest
point of the fold between arm and body and the lateral scapula
edge (Fig. 3).
To eliminate individual differences in tissue water con-
tent, the TDC ratio between the affected and healthy breasts
was calculated for each measurement site. The TDC
threshold ratio for breast edema was defined as a TDC ratio
‡1.40,10 ‡1.45 for the upper arm,12 and ‡1.35 for the lateral
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thorax.7
Experiences of tightness, heaviness, and pain in the af-
fected breast were each self-scored by patients on a 100-mm
horizontal Visual Analogue Scale (VAS). The end points
were ‘‘no discomfort’’ (0 mm) and ‘‘worst imaginable’’
(100 mm).
BMI was calculated at start of study based on measured
body weight and length.
At start of study, pressure of the bra was measured by
the primary investigator (K.J.) using a device (Kikuhime;
TT Meditrade, Denmark) and a sensor that was placed in
the position of the third quadrant (lower lateral) of the
breast.
Data concerning previous cancer treatment were collected
from patients’ medical records.
FIG. 3. Measurement site at lateral thorax was defined at a
spot 5 cm below (caudal) the line drawn between the highest
point of the fold between arm and body, and the lateral
scapula edge.
Statistics
Descriptive statistics of baseline variables include rates for
binary variables and median and interquartile ranges for
continuous variables. Nonparametric tests for continuous
variables were used because the groups were small, and
values did not exhibit Gaussian distribution. Data were
compared between the IG and CG using Mann–Whitney
U test, and within groups using Wilcoxon sign rank test. Chi-
square exact method was used to compare binary outcomes.
A two-sided significance level of 0.05 was applied.
Results
There were no serious adverse events related to the inter-
vention. Slight adverse effects were reported by some pa-
tients who considered compression from the bra to have
caused discomfort. Baseline data for the TDC values, TDC
ratios, and patients’ scoring of tightness, heaviness, and pain
in the breast were not statistically different between the
groups (Tables 2 and 3).
Local tissue water
TDC values. After intervention, no differences were
found between the groups concerning TDC values. In the two
groups, a significant reduction in TDC values was found in
breast and lateral thorax in the RT side (Table 2). In the non-
RT side, a slight reduction was found for breast TDC values
in the CG and for lateral thorax TDC values in the IG.
TDC ratio. The mean TDC ratio for all patients was
1.73 – 0.2, 1.04 – 0.16, and 1.04 – 0.08 at start of study, and
1.49 – 0.28, 1.03 – 0.12, and 1.04 – 0.07 at end of study, in the
breast, upper arm, and lateral thorax, respectively.
At start 10.7% and at end 7.1% of patients had a TDC ratio
>2.0, illustrating 100% edema compared with the anatomi-
cally equivalent contralateral side.
After intervention, no differences were found between the
groups at different sites concerning the TDC ratio. In both
groups, a significant reduction was found for TDC ratio re-
lated to breast (Table 2). At end of study, the TDC ratio was
<1.40 in 16 patients (55%) in each group.
One patient had lymphedema in the upper arm at the be-
ginning of study (TDC ratio 1.48) and a borderline value at
end of study (TDC ratio 1.40). No lymphedema was found at
the lateral thorax. Hence no analysis of association between
breast edema and edema in arm or lateral thorax was per-
formed.
Experiences of tightness, heaviness, and pain
Tightness, heaviness, and pain were experienced in 48.2%,
41.1%, and 53.6% of all patients at start of study, and in
25.0%, 23.2%, and 33.9%, respectively, at end of study.
At start, tightness, heaviness, and pain were scored >50 on
the VAS in 5.4%, 1.8%, and 7.1% and at end in 0%, 3.5%,
and 7.1% of patients.
After intervention, no differences were found between the
groups concerning VAS scoring of tightness, heaviness, and
pain. Scores for feeling of heaviness decreased significantly
(>0.05) within both groups. No change within group was
found for feeling of tightness or pain, but pain increased in
the IG, but not significant (Table 3).
 BREAST EDEMA TREATMENT 5

Table 2. Median (q1–q3) and Mean – Standard Table 3. Median (q1–q3) Scores of Tightness,
Deviation for Tissue Dielectric Constant Values Heaviness, and Pain in the Breast on a Visual
and Tissue Dielectric Constant Ratio, Analogue Scale, by Intervention (n = 28)
Pre- and Postintervention with Compression with Compression Treatment or Controls (n = 28)
Treatment (I, n = 28) or No Treatment (C, n = 28) with No Treatment for Breast Edema
for Breast Edema
na Preintervention Postintervention pb
Preintervention Postintervention pa
Tightness VAS
TDC value RT side Intervention 12 12 (5–42) 13 (4–29) n.s.
Breast I 46.5 (42.2–53.7) 40.3 (34.0–45.4) £0.001 Control 17 17 (7–65) 25 (7–70) n.s.
edema 47.9 – 7.8 40.2 – 7.6 Heaviness VAS
C 48.0 (45.1–52.5) 40.0 (35.5–45.6) £0.001 Intervention 18 19 (12–36) 4 (1–8) 0.008
48.1 – 6.0 40.4 – 7.9 Control 17 47 (5–79) 10 (1–34) 0.022
Arm I 22.5 (20.0–25.6) 21.7 (20.3–24.9) n.s. Pain VAS
23.9 – 5.7 22.8 – 3.7 Intervention 14 1 (0–5) 9 (4–19) n.s.
C 22.2 (20.8–25.6) 21.9 (20.9–25.1) n.s. Control 9 16 (1–33) 14 (3–57) n.s.
23.0 – 2.9 22.7 – 3.1
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a
Lateral I 31.7 (29.5–34.5) 30.1 (28.5–33.2) 0.004 No. of patients with symptoms.
b
thorax 32.3 – 4.5 30.5 – 3.5 Within groups, Wilcoxon sign rank test.
C 31.9 (30.2–33.6) 31.0 (28.1–33.3) 0.009 VAS, Visual Analogue Scale.
32.0 – 2.9 30.7 – 3.4
TDC values non-RT side Edema origin
Breast I 27.2 (24.5–30.5) 26.5 (24.1–29.2) n.s.
27.5 – 3.6 26.8 – 3.2 The present study was based on the hypothesis that breast
C 28.2 (25.4–30.9) 27.7 (24.3–29.9) 0.035 edema had a similar origin as breast cancer-related arm
28.2 – 3.2 27.4 – 3.4 lymphedema, which can be successfully treated with com-
Arm I 22.5 (20.0–25.6) 22.1(20.3–23.5) n.s. pression garments.9 Thus, a larger reduction of edema could
23.0 – 3.5 22.2 – 3.1 be expected in the IG. However, similar results with de-
C 22.4 (20.8–23.4) 21.6 (20.3–24.5) n.s. creasing edema in both groups rise the question if breast
22.2 – 1.9 22.2 – 2.6 edema consists of edema of different origins. Edema created
Lateral I 31.7 (28.6–33.9) 28.5 (27.1–32.2) 0.003 by lymph node dissection with damage to lymphatic vessels
thorax 31.2 – 4.2 29.2 – 3.3 may be impossible to distinguish from RT-induced edema
C 31.1 (29.3–31.1) 30.2 (27.3–32.1) n.s. (also called delayed acute reaction in radiation oncology)
30.5 – 2.5 29.5 – 3.2 typically 3 months post-RT. This theory is supported by the
TDC ratio fact that the TDC ratio was high both in 77% of SLNB pa-
Breast I 1.73 (1.57–1.88) 1.47 (1.26–1.72) £0.001 tients (mean TDC ratio 1.73) and in 23% of ALND patients
1.75 – 0.21 1.51 – 0.3 (mean TDC ratio 1.74), implying that axillary nodes dis-
C 1.69 (1.59–1.82) 1.45 (1.27–1.68) £0.001 sected did not increase the risk of edema in the breast, as
1.71 – 0.18 1.48 – 0.25 could be expected based on the results of risk evaluation for
Arm I 1.00 (0.97–1.07) 1.00 (0.97–1.07) n.s. arm lymphedema.13
1.03 – 0.1 1.03 – 0.1 Though the TDC ratio significantly reduced from mean
C 1.03 (0.97–1.08) 1.00 (0.96–1.08) n.s. 1.73–1.49 in the whole group, still more than half of the
1.04 – 0.11 1.03 – 0.12 patients, equally divided between both groups, had a TDC
Lateral I 1.02 (0.99–1.08) 1.05 (0.99–1.1) n.s. ratio >1.4 (set as threshold to determine breast edema) at end
thorax 1.04 – 0.06 1.04 – 0.08 of study. The reason for this kind of long-lasting edema is
C 1.04 (1.0–1.09) 1.03 (1.0–1.07) n.s. unknown at present. In contrast, at the same time, only about
1.05 – 0.09 1.05 – 0.07 25% of patients experienced tightness or heaviness in the
a
Within groups, Wilcoxon sign rank test. breast, and none scored >50 on the VAS for tightness, and
RT, radiotherapy; TDC, tissue dielectric constant. only 3.5% for heaviness, implying that the experienced
symptoms at 3 months post-RT were very much fading away.
Also, the significant reduction of heaviness in both groups
Pressure of the bra was 9–11 mmHg in the sports bra and supports these findings.
2–3 mmHg in the ordinary bra. For patients still experiencing problematic heaviness, a
more extensive examination could be performed, such as
evaluating, for example, fibrotic tissue followed by specialist
Discussion
treatment.
Breast compression treatment evaluated in this study It should also be noted that high scoring of pain (>50 on
showed no effect. When comparing outcomes at start and end VAS) did not change during the study, indicating that pain
of study, we found no differences between the IG and CG in may have a completely different origin than tightness and
tissue water content in the skin or the patient’s experience of heaviness, such as, for example, nerve injury due to surgery.
tightness, heaviness, and pain in the breast. However, both In the IG, even an increase of pain was found, but not sig-
groups showed significant reduction of feeling of heaviness nificant, suggesting that a high pressure from the bras may
in the breast at end of study. impair the feeling of pain.
 6 JOHANSSON ET AL.
Breast edema treatment
At the end of 1 year post-RT, the mean TDC ratio was still
high (1.49), indicating that edema was still superficially
present in the breast. If the compression pressure applied had
been even higher than was achieved by a sports bra of
compression type, there may have been a possibility to reduce
breast edema in the IG compared to the CG. In contrast, to
fully compress the breast is very hard to manage and requires
firm garments or bandaging, and in some cases, where the
breast is large, it may even be impossible. A higher com-
pression with firm material would most likely lead to dis-
comfort and may even increase pain. One should then also
take into account that the rather low rates of tightness and
heaviness in the breast at 1 year post-RT, in both groups,
imply that edema for most patients was not a big problem.
Thus, the assumed reduction of edema from a higher com-
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pression would probably not have been in proportion to the
negative impact on comfort.
Beside breasts and arms, also a lateral thoracic measure-
ment was made based on the clinical experience that the area
posterior to the axilla often has increased thickness in the skin
and subcutaneous tissue, compared to the contralateral side,
implying that an edema may be present. This has recently
been shown by Mayrovitz et al.7 by TDC measurements.
Though there was no lymphedema at the lateral thorax (i.e.,
TDC ratio <1.35), a significant reduction in TDC values was
found in both groups at end of study, implying a similar
decrease in tissue water as was detected in the breast. The
cause of a significant reduction is most likely the pressure
from any bra, not in particular a sports bra, on the skin.
Further, the firmness of ribs just beneath the tissue in this area
may support the effectiveness of compression. The firmness
of ribs is just the same beneath the breast, but the breast is
much softer and instable, compared to the skin. This may
explain why compression may not work, as discussed above
due to the difficulties in achieving effective compression.
No serious adverse effects were reported; however, slight
adverse effects were reported by some patients due to ex-
cessive compression from the bras causing discomfort, even
if the bras were fitted for each woman. Based on clinical
experience, some women with breast edema find sports bras
comfortable to wear, in particular during a period when the
heaviness of the breast is large.
Experienced problems
The literature has called attention to problems experienced
by patients such as tightness, heaviness, and pain1,2 in the
breast following breast cancer treatment with surgery and
RT. Though all patients in the present study had breast ede-
ma, diagnosed by a high TDC ratio, only about half of the
patients experienced symptoms at start of intervention 3
months after completion of RT, where few scored >50. This
may imply that large problems concerning edema are only
experienced by a few patients.
A variety of treatments for breast edema have been re-
commended to patients. However, the success of these
treatments is most likely a result of the normal course of
breast edema development with a natural and progressive
decrease in associated inflammation. Though some patients
may have large problems during the first months after RT,
these problems, in most patients, will substantially reduce or
disappear during the following months. Therefore, patients
should be informed that the experienced symptoms most
likely will diminish within months. When the symptoms are
significant, a firm bra may diminish the feeling of, in par-
ticular, heaviness. However, this should not be mixed up with
the feeling that the edema is ‘‘treated.’’
Strengths and limitations
A limitation of the study may be that no prior data were
available for power calculations; hence no such calculation
could be performed. Therefore, this study was considered a
pilot study with a limited number of included patients.
However, a strength is that the study design was an RCT.
Data from this study can serve as a source for future power
calculations in repeated studies. Moreover, results from both
groups are very similar, and it is not likely that a larger
number of patients would be able to show any significant
difference between the groups.
Conclusion
No effect of 9-month compression treatment with sports
bras compared to ordinary bras for breast edema at 3 months
post-RT could be found, assessed by tissue water content and
experienced symptoms. Most likely, breast edema was re-
solving similarly in both groups. Thus, patients should be
informed of the normal course of breast edema development,
particularly that symptomatic problems soon after the com-
pletion of RT will substantially reduce within a year.
Acknowledgment
This study was supported by research grants from the
Swedish Cancer Foundation and the Swedish Breast Cancer
Association, and it was made possible by the women who
generously gave up their time to participate. Thanks to
physiotherapist Viveka Fredlund for assisting with mea-
surements.
Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Karin Johansson, PhD, RPT
Lymphedema Unit
Department of Oncology
Skåne University Hospital
Lasarettsgatan 23
22185 Lund
Sweden
E-mail: karin.johansson@med.lu.se