Breast cancer-related lymphedema and its treatment: how big is the financial impact?

Developing the Short-Form of Lymphedema Needs Questionnaire for Iranian Breast Cancer Patients

PURPOSE

The informational needs of patients with Breast Cancer-Related Lymphedema (BCRL) have not been sufficiently addressed in the scientific literature. Moreover, the only existing questionnaire in this field contains many items. Therefore, the purpose of this study is to develop a short-form version of this questionnaire.

METHODS

The questionnaire items were extracted from the Lymphoedema Needs Questionnaire-Breast Cancer (LNQ-BC). Demographic variables and clinical characteristics were considered separately. Out of 62 items, 24 were selected, and 2 additional questions were included based on feedback from 10 experts. 100 participants with BCRL completed the short-form questionnaire. Exploratory Factor Analysis (EFA) was performed using principal components extraction and varimax rotation, and Cronbach's alpha was calculated for each dimension.

RESULTS

After evaluating the content validity, the instrument's construct validity with 26 items was conducted using EFA. The KMO (Kaiser-Meyer-Olkin) value was equal to 0.879 and Bartlett's sphericity test was significant (p-value < 0.001), indicating the data's adequacy and appropriateness to perform EFA. Five extracted dimensions were named: "Lymphedema information needs" (5 items), "Informational support, peers" (5 items), "Access to a lymphedema care specialist" (5 items), "Physical and daily activities" (7 items) and "Financial issues and compression garments" (4 items). The level of needs in this study in all dimensions was high (more than 77%).

CONCLUSIONS

The high factor loadings and the total explained variance of 78.152% support the construct validity of the short questionnaire. Although some items exhibited cross-loadings, the majority loaded strongly on a single factor, indicating good discriminant validity. Providing services according to the needs of patients can be prioritized. Healthcare providers, insurers, and individuals should be better informed about lymphedema, its associated costs, and the importance of implementing appropriate management programs.

Randomized Trial Assessing Prospective Surveillance and Exercise for Preventing Breast Cancer-Related Lymphedema in High-Risk Patients

OBJECTIVE

To evaluate if combining a prospective surveillance model (PSM) with a supervised multimodal exercise program prevents breast cancer-related lymphedema (BCRL) and its effect on the functional capacity and quality of life (QoL) of high-risk breast cancer (BC) patients undergoing treatment.

DESIGN

Two-arm parallel superiority randomized controlled trial.

SETTING

Outpatient physical therapy service in a public hospital.

PARTICIPANTS

116 adult women (N=116; age ≥18y) diagnosed with stage I-III BC were enrolled. Inclusion criteria included recent surgery and indication for adjuvant chemotherapy. Exclusion criteria were significant arm volume difference, previous cancer, exercise contraindications, and extreme body mass index values.

INTERVENTIONS

Participants were randomized into experimental (n=61) or control groups (n=55) in a 1:1 ratio. The experimental group received PSM with a supervised multimodal exercise program for 12 weeks. The control group received PSM alone.

MAIN OUTCOME MEASURES

Arm volume, grip strength, 6-minute walk test, and QoL were blindly assessed at baseline, 3, 6, and 9 months.

RESULTS

The combination of PSM with a supervised multimodal exercise program significantly reduced arm volume and body weight and improved grip strength, functional capacity, and the QoL of patients.

CONCLUSIONS

Combining PSM and physical exercise reduces arm volume, prevents BCRL, and improves physical performance and QoL in high-risk patients. The combination of PSM and STRONG-B was superior to PSM alone, validating the study's superiority design.

Research trends on lymphedema after mastectomy for breast cancer patients from 2000 to 2023: a scientometric analysis

Background

Breast cancer-related lymphedema (BCRL) is a common and debilitating complication following breast cancer treatment. Despite its significant impact on patients' quality of life, bibliometric analyses focusing on BCRL are scarce. This study aims to explore global research trends on BCRL from 2000 to 2023, identify existing knowledge gaps, and highlight emerging focus areas through a bibliometric approach.

Methods

A comprehensive search was conducted using the Web of Science (WOS) database to retrieve literature published between January 2000 and November 2023. Bibliometric analyses and visualizations were performed using R Studio, CiteSpace, and VOSviewer. Key data extracted included publication trends, contributing countries and institutions, leading authors, journals, research categories, and keywords. Outcome measures for analysis included the number of publications, citation counts, author productivity, and keyword co-occurrence.

Results

A total of 919 eligible publications from 52 countries and regions, 1,163 institutions, and 3,550 authors were identified. These publications appeared in 255 journals, with "Lymphology" emerging as the journal with the highest citation count. The USA was the most prolific contributor to the field. The annual number of publications demonstrated a consistent upward trend. Keyword co-occurrence analysis revealed prominent research hotspots, including "lymphedema," "women," "breast cancer," "arm lymphedema," and "quality of life." Emerging keyword trends from 2021 to 2023 highlighted "prevention" and "validity" as pivotal research frontiers.

Conclusions

This bibliometric study highlights the growing interest in breast cancer-related lymphedema research and identifies key areas for future investigation, including prevention, diagnosis, and treatment strategies. The results underscore the need for further exploration of these emerging research areas to improve patient outcomes.

Prevalence of lymphedema symptoms across cancer diagnoses and association with depression, pain interference and health-related quality of life

BACKGROUND AND PURPOSE

Lymphedema is a debilitating late effect of cancer treatments, yet its prevalence beyond breast cancer remains understudied. This study examined the prevalence of lymphedema symptoms across cancer diagnoses and their association with depression, pain interference, and health-related quality of life (HRQoL).

PATIENTS/MATERIAL AND METHODS

This cross-sectional study was conducted at the Department of Oncology, Copenhagen University Hospital, from February to April 2021, as part of a broader investigation into cancer-related late effects. Here, we present data from patients in follow-up who received online lymphedema symptom assesments (swelling, heaviness, or tightness). Utilized questionnaires were the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, the Major Depression Inventory, and the Brief Pain Inventory. Associations between lymphedema symptoms and depression, pain interference, and HRQoL were examined via multiple linear regression.

RESULTS

Of 1,901 patients in follow-up who received the lymphedema symptom items, 1,296 responded. Most participants had breast cancer (48%), followed by testicular (17%), gynecological (16%), and head/neck cancer (11%). One-third (n = 397) reported lymphedema symptoms, with 38% (n = 152) reporting moderate/severe symptoms. The highest symptom prevalence was seen in gynecological cancer (59%), followed by head/neck (41%), breast (21%), and testicular cancer (19%). Participants with moderate/severe lymphedema symptoms were significantly more likely to report higher depression and pain interference scores and lower HRQoL scores compared to those with no/mild symptoms.

INTERPRETATION

Lymphedema symptoms are highly prevalent among patients who have completed treatment for diverse cancers and associated with higher scores for depression and pain interference, and lower HRQoL.

Efficacy, safety of and adherence to adjustable compression wraps in the control phase of breast cancer-related lymphedema: A randomized controlled trial

OBJECTIVE

To evaluate efficacy, safety, and adherence to using adjustable compression wraps (ACWs) for upper limb volume control in women with breast cancer-related lymphedema.

DESIGN AND SETTING

Randomized controlled trial at a reference hospital for breast cancer treatment in Brazil.

PARTICIPANTS

Women in control phase of the breast cancer-related lymphedema.

INTERVENTIONS

Compared use of ACWs versus compressive mesh.

MAIN MEASURES

Evaluated before treatment, at 30 days, and 6 months after initiating therapy. The primary outcome was the change in excess limb volume. Secondary outcomes included adherence, incidence of adverse events, functionality, quality of life, and hand grip. Statistical analysis involved calculating the effect size (ES) with a 95% confidence interval.

RESULTS

Were included 71 women with mean excess limb volume of 321.79 mL (±194.98). In the 30-day analysis (Time 1), a reduction of 37.6 mL in volume was observed only in the ACW group (p = .041, ES 0.20), with improved functionality (p = .013, ES 0.22). In the six months analysis (Time 2), the compressive mesh group increased by 2.48% in volume (p = .023, ES 0.26) and demonstrated improvement functionality (p = .036, ES 0.27). Mild adverse events and satisfactory adherence were observed. However, in the intergroup comparison, no statistically significant difference was observed for any evaluated outcome-excess volume, incidence of adverse events, adherence, hand grip, quality of life, and functionality between the groups (p > .05) at both times.

CONCLUSIONS

Both compression therapies achieved satisfactory adherence, were safe, effective and equivalent for controlling limb volume in breast cancer-related lymphedema.

Effects of dietary habits and catheterization type on breast cancer-related lymphedema: a retrospective cohort study

BACKGROUND

Understanding the factors that contribute to variability in breast cancer-related lymphedema (BCRL) is an important first step in developing targeted interventions to improve quality of life in breast cancer patients. Although previous research studies have has identified many risk factors for BCRL, dietary habits and catheterization type have rarely been studied until the present.

AIM

This study aims to explore the effects of nursing factors such as dietary habits and catheterization type on breast cancer-related lymphedema (BCRL).

METHODS

This retrospective cohort study included 1,476 breast cancer patients who underwent surgery between January 1, 2012, and September 1, 2020. Lymphedema was assessed with a validated self-report questionnaire. All research data were obtained from medical records and a follow-up database. Multivariate Cox regression was conducted to explore the effects of dietary habits and catheterization type on BCRL.

RESULTS

The results showed an increased risk for BCRL among breast cancer patients who followed a high-fat diet prehospitalization (HR = 2.47; 95% CI = 1.55-3.94; P < 0.001), indwelling totally implantable venous access ports (TIVAPs) compared with indwelling needles (HR = 0.56; 95% CI = 0.35-0.90;P = 0.017) or indwelling peripherally inserted central catheters (PICCs) (HR = 0.69; 95% CI = 0.45-1.05; P = 0.086).

CONCLUSION

High-fat diet pre-hospitalization was an independent risk factor for lymphedema. The TIVAPs did not exert a protective effect on lymphedema compared with the PICC and indwelling needle. This study finding offers new insights to develop targeted interventions to decrease the incidence of lymphedema.

Abemaciclib Therapy Using the MonarchE Criteria Results in Large Numbers of Excess Axillary Node Clearances-Time to Pause and Reflect?

The monarchE study added the CDK4/6 inhibitor abemaciclib to the care of women with oestrogen-positive (ER+) breast cancers. Eligibility required meeting monarchE criteria-either >3 positive axillary nodes, or 1-3 positive sentinel nodes (SNB+) with tumour size >50 mm or grade 3 cancers. Women were advised to proceed to completion axillary node clearance (cANC) if size/grade criteria were not fulfilled for >3 positive nodes to be identified. However, cANC is associated with significant morbidity, conflicting with the potential benefits of abemaciclib. We analysed data of 229 consecutive women (2016-2022) with ER+ breast cancer and SNB+ who proceeded to cANC, keeping with contemporary treatment guidelines. We used this cohort to assess numbers that, under national guidance in place currently, would be advised to undergo cANC solely to check eligibility for abemaciclib treatment. Using monarchE criteria, 90 women (39%) would have accessed abemaciclib based on SNB+ and size/grade, without cANC. In total, 139 women would have been advised to proceed to cANC to check eligibility, with only 15/139 (11%) having >3 positive nodes after sentinel node biopsy and cANC. The remaining 124 (89%) would have undergone cANC but remained ineligible for abemaciclib. Size, age, grade, and Ki67 did not predict >3 nodes at cANC. Following cANC, a large majority of women with ER+, <50 mm, and grade 1-2 tumours remain ineligible for abemaciclib yet are subject to significant morbidity including lifelong lymphoedema risk. The monarchE authors state that 15 women need abemaciclib therapy for 1 to clinically benefit. Thus, in our cohort, 139 women undergoing cANC would lead to one woman benefitting.

Bibliometric analysis of breast cancer-related lymphedema research trends over the last 2 decades

Objective

As breast cancer cases rise globally, post-mastectomy lymphedema garners increasing scholarly attention. This study aims to conduct a comprehensive bibliometric analysis of Breast Cancer-Related Lymphedema (BCRL) research from 2003 to 2022, identifying trends and providing global research insights for future studies.

Method

The literature for this analysis was extracted from the Web of Science (WoS) Core Collection, encompassing 1199 publications, including 702 articles and 101 reviews, totaling 803. Using advanced bibliometric tools such as VOSviewer and CiteSpace, quantitative and visual analyses were performed to map collaboration networks, research clusters, and emerging trends. The search strategy included specific terms related to lymphedema, breast cancer, and BCRL, ensuring a comprehensive representation of the research landscape.

Results

The bibliometric analysis revealed a steady increase in BCRL publications over the studied period, reaching a peak in 2018. The United States emerged as the leading contributor to BCRL literature, with China also demonstrating a significant presence. Collaboration networks were visualized, showcasing the interconnectedness of institutions and researchers globally. Key research hotspots identified include preventive strategies, complex decongestive therapy, and reconstructive interventions.

Conclusion

In conclusion, this pioneering bibliometric analysis provides a comprehensive overview of BCRL research trends and collaborations globally. The findings contribute valuable insights into the evolution of the field, highlighting areas of focus and emerging research themes. This study serves as a foundational resource for researchers, clinicians, and policymakers, fostering evidence-based practices and interventions for BCRL in the future.

Describing financial toxicity among cancer patients in different income countries: a systematic review and meta-analysis

Background

There is limited evidence of financial toxicity (FT) among cancer patients from countries of various income levels. Hence, this study aimed to determine the prevalence of objective and subjective FT and their measurements in relation to cancer treatment.

Methods

PubMed, Science Direct, Scopus, and CINAHL databases were searched to find studies that examined FT. There was no limit on the design or setting of the study. Random-effects meta-analysis was utilized to obtain the pooled prevalence of objective FT.

Results

Out of 244 identified studies during the initial screening, only 64 studies were included in this review. The catastrophic health expenditure (CHE) method was often used in the included studies to determine the objective FT. The pooled prevalence of CHE was 47% (95% CI: 24.0-70.0) in middle- and high-income countries, and the highest percentage was noted in low-income countries (74.4%). A total of 30 studies focused on subjective FT, of which 9 used the Comprehensive Score for FT (COST) tool and reported median scores ranging between 17.0 and 31.9.

Conclusion

This study shows that cancer patients from various income-group countries experienced a significant financial burden during their treatment. It is imperative to conduct further studies on interventions and policies that can lower FT caused by cancer treatment.

Breast Cancer-Related Lymphedema (BCRL) and Bioimpedance Spectroscopy: Long-Term Follow-Up, Surveillance Recommendations, and Multidisciplinary Risk Factors

BACKGROUND

Early detection and intervention for breast cancer-related lymphedema (BCRL) significantly decreases progression to persistent BCRL (pBCRL). We aimed to provide long-term follow-up on our early detection with bioimpedance spectroscopy (BIS) and early home intervention demonstrating reduced pBCRL to guide surveillance recommendations.

PATIENTS AND METHODS

In total, 148 female patients with breast cancer who had axillary lymph node dissection (ALND) from November 2014 to December 2017 were analyzed. Baseline BIS measurements and postoperative follow-up occurred every 3 months for 1 year, biannual for 1 year, and then annually. An elevated BIS triggered evaluation and initiation of at-home interventions with reassessment for resolution versus persistent BCRL (pBCRL). High-risk factors and timing were analyzed.

RESULTS

Mean follow-up was 55 months, and 65 (44%) patients had an abnormal BIS. Of these, 54 (82%) resolved with home intervention. The overall pBCRL rate was 8%. Average time to first abnormal BIS was 11.7 months. None of the stage 0 patients (0/34) and only 5/25 (20%) of stage 1 patients had pBCRL. All of stage 2 and stage 3 patients (7/7) had pBCRL. pBCRL correlated with number of positive nodes, percentage of positive nodes, stage of lymphedema at diagnosis, and recurring abnormal BIS measurements (p < 0.05).

CONCLUSIONS

We have shown that patients undergoing ALND with early BCRL identified by BIS who performed home interventions had an 8% pBCRL rate. Patients at high risk for pBCRL should have routine surveillance starting at 9 months postoperatively to identify an opportunity for early intervention.

Lymphedema self-care: economic cost savings and opportunities to improve adherence

BACKGROUND

Breast cancer-related lymphedema (BCRL) imposes a significant economic burden on patients, providers, and society. There is no curative therapy for BCRL, but management through self-care can reduce symptoms and lower the risk of adverse events.

MAIN BODY

The economic burden of BCRL stems from related adverse events, reductions in productivity and employment, and the burden placed on non-medical caregivers. Self-care regimens often include manual lymphatic drainage, compression garments, and meticulous skin care, and may incorporate pneumatic compression devices. These regimens can be effective in managing BCRL, but patients cite inconvenience and interference with daily activities as potential barriers to self-care adherence. As a result, adherence is generally poor and often worsens with time. Because self-care is on-going, poor adherence reduces the effectiveness of regimens and leads to costly treatment of BCRL complications.

CONCLUSION

Novel self-care solutions that are more convenient and that interfere less with daily activities could increase self-care adherence and ultimately reduce complication-related costs of BCRL.

Financial toxicity experienced by patients with breast cancer-related lymphedema: a systematic review

PURPOSE

To perform a systematic review on financial toxicity of breast cancer-related lymphedema.

METHODS

Seven databases were searched on September 11, 2022. Eligible studies were identified, analyzed, and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Empirical studies were appraised by the Joanna Briggs Institute (JBI) tools. The Mixed Methods Appraisal Tool version 2018 was used to assess the mixed method studies.

RESULTS

A total of 963 articles were identified, but only 7 articles reporting on 6 studies met the eligibility criteria. A 2-year treatment for lymphedema was approximately USD$14,877 to USD$23,167 in America. In Australia, the average out-of-pocket costs ranged from A$207 to A$1400 (USD$156.26 to USD$1056.83) per year. Outpatient visits, compressed clothing, and hospital admissions were the dominant costs. The financial toxicity was associated with the severity of lymphedema, and patients with heavy financial burden had to reduce other expenses or even forgo the treatment.

CONCLUSION

Breast cancer-related lymphedema aggravated the economic burden of patients. The included studies showed great variation in the methods used and therefore differences in cost results. The national government should further improve the healthcare system and increase the insurance coverage of lymphedema treatment to alleviate this burden. More research is needed to focus on financial toxicity experience of breast cancer patients with lymphedema.

IMPLICATIONS FOR CANCER SURVIVORS

The cost of the ongoing treatment of breast cancer-related lymphedema influences patients' economic situation and quality of life. Survivors need to be informed early about the potential financial burden associated with lymphedema treatment.

Surgical Treatment and Rehabilitation Strategies for Upper and Lower Extremity Lymphedema: A Comprehensive Review

Lymphedema is a chronic disabling condition affecting a growing number of patients worldwide. Although lymphedema is not life-threatening, several reports underlined detrimental consequences in terms of distress, pain, functional impairment, and infections with a relevant decrease in quality of life. Currently, there is no cure, and the therapeutic management of this condition aims at slowing down the disease progression and preventing secondary complications. Early diagnosis is paramount to enhance the effects of rehabilitation or surgical treatments. On the other hand, a multidisciplinary treatment should be truly integrated, the combination of microsurgical and reductive procedures should be considered a valid strategy to manage extremity lymphedema, and rehabilitation should be considered the cornerstone of the multidisciplinary treatment not only for patients not suitable for surgical interventions but also before and after surgical procedures. Therefore, a specialized management of Plastic Reconstructive Surgeons and Physical and Rehabilitative Medicine physicians should be mandatory to address patients’ needs and optimize the treatment of this disabling and detrimental condition. Therefore, the aim of this review was to characterize the comprehensive management of lymphedema, providing a broad overview of the potential therapy available in the current literature to optimize the comprehensive management of lymphedema and minimize complications.

Effect of Supervised Resistance Training on Arm Volume, Quality of Life and Physical Perfomance Among Women at High Risk for Breast Cancer-Related Lymphedema: A Study Protocol for a Randomized Controlled Trial (STRONG-B)

Objectives

To determine the preventive effects of supervised resistance training on arms volume, quality of life, physical performance, and handgrip strength in Chilean women at high risk for breast cancer-related lymphedema (BCRL) undergoing chemotherapy.

Design

Randomized control trial.

Participants

One hundred and six women at high risk for breast cancer-related lymphedema aged 18 to 70 years.

Interventions

Participants will be randomized into two groups: [a] intervention, who will receive 12 weeks of supervised resistance training (STRONG-B) during adjuvant chemotherapy; and [b] control, who will receive education to promote lymphatic and venous return, maintain range of motion, and promote physical activity.

Main Outcome Measures

The primary outcome will be arms volume measured with an optoelectric device (perometer NT1000). Secondary outcomes will be quality of life, handgrip strength, and physical performance. Primary and secondary outcomes will be measured at baseline, just after the intervention, and 3 and 6 months after. Statistical analysis will be performed following intention-to-treat and per-protocol approaches. The treatment effect will be calculated using linear mixed models.

Discussion

The STRONG-B will be a tailored supervised resistance training that attempts to prevent or mitigate BCRL in a population that, due to both intrinsic and extrinsic factors, will commonly suffer from BCRL.

Clinical Trial Registration

[https://clinicaltrials.gov/ct2/show/NCT04821609], identifier NCT04821609.

Lymphedema in Endometrial Cancer Survivor: A Nationwide Cohort Study

Background: Endometrial cancer is the most common gynecological cancer in developed countries. Treatment-related lymphedema negatively affects the quality of life and function of patients. This study investigated the cumulative incidence and risk factors of, and utilization of health care resources for, lymphedema in patients with endometrial cancer. Methods: We conducted a nationwide, retrospective cohort study of women with endometrial cancer who underwent cancer-direct treatment using the Korean National Health Insurance Service (NHIS) database. Patients were categorized by age, region, income, and treatment modality. Cox proportional hazards regression models were used to analyze the incidence and risk factors of lymphedema. We also analyzed utilization of health care resources for lymphedema using diagnostic and treatment claim codes. Results: A total of 19,027 patients with endometrial cancer were evaluated between January 2004 and December 2017. Among them, 2493 (13.1%) developed lymphedema. Age (<40 years, adjusted odds ratio [aOR] = 1 vs. 40–59 years, aOR = 1.413; 95% confidence interval (CI) 1.203–1.66 vs. 60+ years, aOR = 1.472; 95% CI 1.239–1.748) and multimodal treatment (surgery only, aOR = 1 vs. surgery + radiation + chemotherapy, aOR = 2.571; 95% CI 2.27–2.912) are considered to be possible risk factors for lymphedema in patients with endometrial cancer (p < 0.001). The utilization of health care resources for the treatment of lymphedema has increased over the years. Conclusions: Lymphedema is a common complication affecting women with endometrial cancer and leads to an increase in national healthcare costs. Post-treatment surveillance of lymphedema, especially in high-risk groups, is needed.