Dear Editor-in-Chief,
Please find enclosed the revision of our paper entitled “Breast edema in breast cancer patients
following breast-conserving surgery and radiotherapy: a systematic review”.
We thank the reviewer and the editor-in-chief for the valuable comments that have
contributed to a significant improvement of our manuscript. Please, find enclosed a point-topoint response to the remarks given by the reviewer and editor at the end of this cover letter.
We also enclose a copy of the revised manuscript.
We hope that the revised version of the manuscript is now suitable for publication in Breast
Cancer Research and Treatment.
The corresponding author is Nick Gebruers. Please, address correspondence to: Nick
Gebruers, PT PhD, Department of Rehabilitation Science and Physiotherapy, Faculty of
Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610 Antwerp,
Belgium (e-mail: nick.gebruers@uantwerpen.be )
On behalf of all authors,
yours sincerely,
Hanne Verbelen, PT
University of Antwerp
Faculty of Medicine and Health Sciences
Department of Rehabilitation Sciences and Physiotherapy
Point-to-point response to the Reviewers' comments:
Remark: I might ask that they make a stronger case as at the beginning as to why this is an
important topic. They do make some statement about impact on cosmesis/quality of life, and
increasing in cup size, but this might be expanded. How did this problem affect the quality of
life? This could be elaborated.
Reply: Thank you for this comment. We have incorporated your suggestions in the
introduction.
Despite the benefits of BCS, breast edema can be uncomfortable and is associated with distress[12].
The breast asymmetries due to swelling of the breast may cause an unsatisfactory cosmetic result and
patients with breast edema mention changes in clothing habits[9,13]. Because of the significant
symbolism of the breast, breast edema can influence the body image which has a definite impact on
quality of life (QoL)[2,5]. Especially younger patients have reported changes in body image[13].
Because of the evolution in the treatment of breast cancer, the survival rate has increased significantly
over years. As a result, the long term health problems, including QoL, related to breast cancer and its
treatment are becoming more important.
Remark: The second issue that I would like the authors to do is to add a paragraph or two on
the treatment of breast edema. It is interesting to read about breast edema, know the incidence
rates etc.., but if it is there, what do we do about it. Since this is a review, the authors could
also include the different ways of treatment as described in the literature and whether they are
successful or not.
Reply: Thank you for your comment. The treatment of breast edema was not incorporated in
the systematic search strategy. We did search the literature on the treatment of breast edema,
but it is little described. However, we tried to expand on this matter in the discussion.
Although breast edema is common, its treatment is little described in the literature. Mostly its
treatment is based upon the knowledge of the treatment of lymphedema of the upper limb.
Lymphedema is commonly treated by complex physical therapy (CPT) comprising manual lymphatic
drainage, compression therapy, skin care and exercises[9,36]. Another treatment investigated by Jahr
et al. is deep oscillation combined with manual lymphatic drainage on breast edema. Deep oscillation
is a therapeutic approach that consists in applying an intermittent electrostatic field of low intensity
and extremely low frequency to the target area. The study showed that additional deep oscillation
supplementary to manual lymphatic drainage can significantly enhance pain relief and swelling of the
breast[36]. Further studies are urgently needed to investigate the treatment of lymphedema of the
breast.