Dhishant Asarpota recently completed his second year as a student at the Wright State University Boonshoft School of Medicine. In that short time, Asarpota also has led a project researching the effectiveness of lymphedema screenings for breast cancer survivors.
Breast cancer will be the most commonly diagnosed cancer in 2020, after skin cancer. With great strides taking place in its detection and treatment, Asarpota wanted to shed light on how to improve the quality of life for survivors.
Lymphedema is a common complication of mastectomy, affecting 20 to 30% of women. It refers to swelling in arms or legs. In breast cancer, lymphedema can occur as a side effect of cancer removal surgery or radiation therapy.
The most important form of disease treatment is prevention through physical therapy and prospective surveillance. By catching it early, Asarpota believes the incidence and severity of secondary lymphedema in survivors can be mitigated.
He collaborated with Mary Fisher, Ph.D., associate professor and chair of the Department of Physical Therapy at the University of Dayton. Fisher is board certified in orthopaedic physical therapy and a certified lymphedema therapist.
“We wanted to explore the screening practices for lymphedema and functional arm problems including range of motion deficits among women surgically treated for breast cancer,” Asarpota said. “With that in mind, the study was designed to retrospectively review patient charts from 2013–2018 to highlight gaps in published incidence data versus community data.”
Asarpota reviewed historical medical records in a surgical practice. He reviewed patient encounter documentation, noting especially any complications that arose after surgery to remove the cancer. A focus was arm morbidity and if or how proactive screening measures were conducted during the patient’s interview or physical examination.
With the chart review, Asarpota was able to discover the route of care taken by the patient’s physician. More importantly, it revealed the surgeon’s priorities in treatment.
“After reviewing 626 post-operative clinical encounters, current screening practices revealed an under-diagnosis of lymphedema by 10–24%. Although nearly two-thirds of patients received some level of screening, best practice screening techniques were utilized in less than 2% of encounters,” Asarpota said. “Rather, visual inspection of the upper extremities with occasional directed patient questioning was the mainstay approach. We believe this under-diagnosis is because the tools to effectively detect arm morbidity, such as limb-volume measurements, are being significantly underutilized.”
With gaps in screening identified as the cause, Asarpota hopes to next figure out why best practices are not being used. It may be that there are barriers in the way.
Some hypothesized barriers to diagnosing lymphedema include the time-consuming nature of limb-volume measurements; lack of arm morbidity severity or screening awareness by surgeons; an assumption that patients will verbalize any issues; and that other care providers will manage it.
“Future research should focus on adapting and tailoring this insight to local context and circumstances. We know that best-practice screening techniques are not being utilized — now we need to understand why,” Asarpota said. “Specifically, which barriers are present in a particular practice and how do we circumvent these barriers in order to implement scalable and sustainable screening practices.”
Asarpota presented his research at the Center on Health Services Training and Research (CoHSTAR), a partnership between Brown University, Boston University and the University of Pittsburgh. View the poster.