Health-related quality of life outcomes for the LEAP study-CALGB 70305 (Alliance): A lymphedema prevention intervention trial for newly diagnosed breast cancer patients

Assessment of Integrative Therapeutic Methods for Improving the Quality of Life and Functioning in Cancer Patients-A Systematic Review

Background: Cancer rehabilitation represents a series of measures adopted for the recovery of psychological, emotional, social, and financial functioning in the case of cancer patients. The purpose of this study is to identify the main elements of therapeutic management in the field of medical rehabilitation, as well as integrative, complementary medicine and holistic approaches that can be performed on the oncological patient. Methods: This systematic literature review follows the methodology outlined in the "Preferred Reporting Items for Systematic Reviews and Meta-Analysis" ("PRISMA") statement, which is an internationally recognized and widely accepted standard. Results: Active rehabilitative therapies offer therapeutic options for improving the functioning and quality of life of oncological patients; these therapies comprehensively address both the physical and psychological aspects of the disease. This review also includes the latest novelties and nanotechnologies applied in oncological rehabilitation, for example, drugs (or supplements) inspired by nature. Conclusions: Physical and rehabilitation medicine, mostly using stimulating therapeutic methods, was recently added to the list of contraindications in the management of oncological patients, both as an approach to the pathological concept itself and as an approach to the main clinical consequences and functional aspects of oncological therapies. Integrative, complementary medicine presents an important therapeutic resource in the case of oncological patients. Advanced studies are needed in the future to further ascertain the role of these therapies.

Patient-Reported Outcomes of Omission of Breast Surgery Following Neoadjuvant Systemic Therapy: A Nonrandomized Clinical Trial

Importance

Patients should have an active role in decisions about pursuing or forgoing specific therapies in treatment de-escalation trials.

Objective

To evaluate longitudinal patient-reported outcomes (PROs) encompassing decisional comfort and health-related quality of life (HRQOL) among patients who elected to enroll in a clinical trial evaluating radiotherapy alone, without breast surgery, for invasive breast cancers with exceptional response to neoadjuvant systemic therapy (NST).

Design, Setting, and Participants

Prospective, single-group, phase 2 clinical trial at 7 US medical centers. Women aged 40 years or older with invasive cT1-2 N0-1 M0 triple-negative or human epidermal growth factor receptor 2 (ERBB2)-positive breast cancer with no pathologic evidence of residual disease following standard NST enrolled from March 6, 2017, to November 9, 2021. Validated PRO measures were administered at baseline and 6, 12, and 36 months post-radiotherapy. Data were analyzed from January to February 2023.

Interventions

PRO measures included the Decision Regret Scale (DRS), Functional Assessment of Cancer Therapy-Lymphedema (FACT-B+4), and Breast Cancer Treatment Outcomes Scale (BCTOS).

Main Outcomes and Measures

Changes in PRO measure scores and subscores over time.

Results

Among 31 patients, the median (IQR) age was 61 (56-66) years, 26 (84%) were White, and 26 (84%) were non-Hispanic. A total of 15 (48%) had triple-negative disease and 16 (52%) had ERBB2-positive disease. Decisional comfort was high at baseline (median [IQR] DRS score 10 [0-25] on a 0-100 scale, with higher scores indicating higher decisional regret) and significantly increased over time (median [IQR] DRS score at 36 months, 0 [0-20]; P < .001). HRQOL was relatively high at baseline (median [IQR] FACT-B composite score 121 [111-134] on a 0-148 scale, with higher scores indicating higher HRQOL) and significantly increased over time (median [IQR] FACT-B score at 36 months, 128 [116-137]; P = .04). Perceived differences between the affected breast and contralateral breast were minimal at baseline (median [IQR] BCTOS score 1.05 [1.00-1.23] on a 1-4 scale, with higher scores indicating greater differences) and increased significantly over time (median [IQR] BCTOS score at 36 months, 1.36 [1.18-1.64]; P < .001). At 36 months postradiotherapy, the cosmetic subscore was 0.45 points higher than baseline (95% CI, 0.16-0.74; P = .001), whereas function, pain, and edema subscores were not significantly different than baseline.

Conclusions and Relevance

In this nonrandomized phase 2 clinical trial, analysis of PROs demonstrated an overall positive experience for trial participants, with longitudinal improvements in decisional comfort and overall HRQOL over time and minimal lasting adverse effects of therapy.

Trial Registration

ClinicalTrials.gov Identifier: NCT02945579.

Effects of a lymphedema prevention program based on the theory of knowledge-attitude-practice on postoperative breast cancer patients: A randomized clinical trial

BACKGROUND

Breast cancer-related lymphedema (BCRL) is one of the common postoperative complications that severely affects the functions of the arm and quality of life. Since lymphedema is difficult to treat and prone to recurrence, early prevention of lymphedema is crucial.

METHODS

Patient diagnosed with breast cancer (N = 108) were randomized to the intervention (n = 52) or control group (n = 56). In the intervention group, patients were provided the lymphedema prevention program based on the theory of knowledge-attitude-practice during the perioperative period and the first three chemotherapy sessions (mainly includes health education, seminars, knowledge manuals, sports guidance, peer education, and WeChat group).The limb volume, handgrip strength, arm function, and quality of life were measured in all patients at the baseline, 9 weeks (T1), and 18 weeks (T2) after surgery.

RESULTS

The incidence of lymphedema in the Intervention group was numerically lower than in the control group after implementing the lymphedema prevention program, but the difference was not statistically significant (T1: 1.9% vs. 3.8%, p = 1.000; T2: 3.6% vs. 7.1%, p = 0.744). However, compared with the control group, the intervention group showed there was less deterioration in handgrip strength (T1 [t = -2.512, p < 0.05] and T2 [t = -2.538, p < 0.05]), improved postoperative upper limb dysfunction (T1 [t = 3.087, p < 0.05] and T2 [t = 5.399, p < 0.05]) and less deterioration in quality of life (T1 [p < 0.05] and T2 [p < 0.05]).

CONCLUSION

Although the investigated lymphedema prevention program improved arm function and quality of life, it did not reduce the incidence of lymphedema in postoperative breast cancer patients.

Patient education for breast cancer-related lymphedema: a systematic review

PURPOSE

The aim was to identify the impact of the (a) components of breast cancer-related lymphedema (BCRL) educational content, (b) modes of education, and (c) timing of education on arm volume, quality of life, function, complications associated with BCRL, adherence to interventions, and knowledge acquisition in individuals diagnosed with breast cancer (BC).

METHODS

This review followed the Preferred Reported Items for Systematic Review and Meta-analysis (PRISMA) guidelines (PROSPERO CRD42021253084). Databases searched included PubMed, CINAHL, Web of Science, Google Scholar, and Scopus from January 2010 to December 2021. Study quality and bias were assessed using the American Physical Therapy Association's Critical Appraisal Tool for Experimental Intervention Studies.

RESULTS

Forty-five studies were eligible, and 15 met the inclusion criteria (4 acceptable and 11 low quality). This review was unable to determine the optimal content, mode, and timing for BCRL education across survivorship. Content included a brief overview of BCRL, early signs and symptoms, risk reduction practices, and a point of contact. Delivery was multi-modal, and knowledge acquisition was rarely assessed. Education was provided pre/post operatively and after BCRL developed.

CONCLUSIONS

Individualized BCRL education via a multi-modal approach, repeated at multiple time points, and assessment of survivors' knowledge acquisition is recommended. Consideration of the survivors' phase of treatment, content volume, and time required to complete the program is advised when developing the educational intervention.

IMPLICATIONS FOR CANCER SURVIVORS

Survivors of BC may need to advocate for BCRL education based on their individual risk and needs, request a point of contact for questions/follow up, and express their preferred style of learning.

The Effect of Exercise for the Prevention and Treatment of Cancer-Related Lymphedema: A Systematic Review with Meta-analysis

INTRODUCTION

The purpose of this systematic review and meta-analysis was to evaluate the effects of exercise on (i) the prevention of cancer-related lymphedema (CRL) and (ii) the treatment of CRL, lymphedema-associated symptoms, and other health outcomes among individuals with CRL.

METHODS

An electronic search was undertaken for exercise studies measuring lymphedema and involving individuals at risk of developing or with CRL. The Effective Public Health Practice Project Quality scale was used to assess study quality, and overall quality of evidence was assessed using the Grading of Recommendation, Assessment, Development and Evaluation approach. Meta-analyses were performed to evaluate effects of exercise on CRL incidence, existing CRL status, lymphedema-associated symptoms, and health outcomes.

RESULTS

Twelve studies ( n = 1955; 75% moderate-high quality) and 36 studies ( n = 1741; 58% moderate-high quality) were included in the prevention and treatment aim, respectively. Relative risk of developing CRL for those in the exercise group compared with the nonexercise group was 0.90 (95% confidence interval (CI), 0.72 to 1.13) overall and 0.49 (95% CI, 0.28 to 0.85) for those with five or more lymph nodes removed. For those with CRL in the exercise group, the standardized mean difference (SMD) before to after exercise of CRL was -0.11 (95% CI, -0.22 to 0.01), and compared with usual care postintervention, the SMD was -0.10 (95% CI, -0.24 to 0.04). Improvements after intervention were observed for pain, upper-body function and strength, lower-body strength, fatigue, and quality of life for those in the exercise group (SMD, 0.3-0.8; P < 0.05).

CONCLUSIONS

Findings support the application of exercise guidelines for the wider cancer population to those with or at risk of CRL. This includes promotion of aerobic and resistance exercise, and not just resistance exercise alone, as well as unsupervised exercise guided by symptom response.

Quality of Life Following Receipt of Adjuvant Chemotherapy With and Without Bevacizumab in Patients With Lymph Node-Positive and High-Risk Lymph Node-Negative Breast Cancer

IMPORTANCE

Breast cancer treatment can impact not only short-term health but may also affect longer-term quality of life (QOL).

OBJECTIVE

To describe and evaluate factors associated with diminished QOL following completion of active treatment.

DESIGN, SETTING, AND PARTICIPANTS

This was a secondary analysis of a randomized clinical trial included patients with lymph node-positive or high-risk lymph node-negative breast cancer who had undergone definitive surgery and were enrolled in ECOG-ACRIN E5103, a multisite phase 3 trial. A survey was administered 18 months after enrollment to patients enrolled between January and June 2010. Final analysis of the data took place from March to December 2021.

INTERVENTIONS

Patients received adjuvant doxorubicin, cyclophosphamide, and paclitaxel with either bevacizumab or placebo.

MAIN OUTCOMES AND MEASURES

QOL and health status assessed with the EuroQol 5-Dimension 3-Levels (EQ-5D-3L), EQ-visual analog scale (EQ-VAS), and the Functional Assessment of Cancer Therapy-Breast Cancer, with arm subscale (FACT-B+4). Groups were compared by Fisher exact test, Wilcoxon rank sum, or Kruskal-Wallis test. Multivariable linear regression was used to assess factors independently associated with FACT-B scores.

RESULTS

Data at 18 months were available from 455 of 519 patients (87.7%) enrolled in the trial. Median (range) age at enrollment was 52 (25-76) years. No differences in QOL (median [range] FACT-B scores: group A, 123 [67-146]; group B, 114 [54-148]; group C, 117 [42-148]; P = .23) or health status (median [range] EQ-5D-3L index scores: group A, 0.83 [0.28-1.00]; group B, 0.83 [0.20-1.00]; group C, 0.83 [0.17-1.00], P = .80; median EQ-VAS: group A, 85 [20-100]; group B, 85 [0-100]; group C, 85 [0-100]; P = .79) were observed across treatment groups; results for subsequent analyses were therefore reported irrespective of primary treatment. Overall, half of patients (258 of 444 [58%]) reported at least some pain or discomfort; 170 (38%) reported symptoms of anxiety or depression. In multivariable analyses, mastectomy with radiation (vs breast conserving surgery) and Asian, Black, or American Indian or Alaska Native race (vs White race) were associated with lower QOL (mastectomy with radiation: coefficient: -5.5; 95% CI, -10.1 to -0.9; Asian, Black, or American Indian or Alaska Native race: coefficient: -7.3; 95% CI, -13.2, -1.4).

CONCLUSIONS AND RELEVANCE

In this study, the addition of bevacizumab to chemotherapy was not negatively associated with QOL at 18 months. A substantial proportion of participants reported problems related to pain or discomfort and anxiety or depression, demonstrating persistent consequences for physical and psychosocial well-being in this heavily treated population. Many problems reported are amenable to intervention, underscoring the need for timely referral to supportive resources, especially for women of color and those who have more extensive local therapy.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00433511.