Accuracy, sensitivity, and specificity of the ULL27 and LLIS in detecting breast cancer related lymphedema
Leslie N Kim MD1, Leslie McGrath NP1, Elizabeth Encarnacion BA1, Nicholas Brereton BS1, Shen Yin PhD2, Andrea V Barrio MD3, Babak Mehrara MD1, Joseph H Dayan MD1, Michelle Coriddi MD1
1Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 2Department of Epidemiology-Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, 3Breast Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
Background: Lymphedema is one of the most common sequelae of breast cancer treatment, especially axillary lymph node dissection (ALND). Lymphedema is typically diagnosed based on volumetric criteria-a ≥ 10% difference in limb volumes is a commonly accepted cutoff-but this does not capture patients who suffer subjective symptoms without physical changes. As a result, patient-reported outcome measures (PROMs) such as the Upper Limb Lymphedema-27 scale (ULL27) and the Lymphedema Life Impact Scale (LLIS) have become important adjuncts for quantifying disability in these patients. However, lymphedema symptoms can overlap significantly with ALND symptoms and it is unclear whether these PROMs can detect lymphedema-specific symptoms in patients who have undergone ALND. This study aims to determine the accuracy, sensitivity, and specificity of ULL27 and LLIs in detecting lymphedema in breast cancer patients undergoing ALND.
Methods: The Lymphedema Life Impact Scale (LLIS) and the Upper Limb Lymphedema-27 scale (ULL27) were administered to patients who had undergone ALND at least 2 years prior and either did or did not develop lymphedema. Survey responses and the degree of disability were compared to generate receiver operator characteristic (ROC) curves and the sensitivity and specificity of PROMs to diagnose lymphedema were analyzed.
Results: Both PROMs were highly accurate, sensitive, and specific for detecting lymphedema. The LLIS had an accuracy of 97%, sensitivity of 100%, and specificity of 84.8% at a cutoff of ≥ 5.88 overall percent impairment score (higher scores indicate worse disability). The ULL27 had an accuracy of 93%, sensitivity of 88.6%, and specificity of 90.9% at a cutoff of ≤ 83.3 global score (lower scores indicate worse disability).
Conclusions: ULL27 and LLIS are both highly accurate, sensitive, and specific for detecting lymphedema symptoms, irrespective of volume change. Both PROMs could potentially be useful for diagnosing and tracking changes in lymphedema before volume changes manifest, which would hasten initiation of treatment. Furthermore, patients could take these PROMs online or at home, reducing the need for frequent clinic visits and time-consuming measurements. Larger scale studies to validate the efficacy of PROMs as diagnostic tools are needed.
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