The incidence and risk factors of related lymphedema for breast cancer survivors post-operation: a 2-year follow-up prospective cohort study

Effectiveness of a lymphedema prevention program for patients with breast cancer: A randomized controlled trial based on the Protection Motivation Theory and Information-Motivation-Behavioral Skills Model

Objective

This study aims to evaluate the effectiveness of a lymphedema prevention program based on the Protection Motivation Theory and Information-Motivation-Behavioral Skills Model (PMT-IMB) in patients with breast cancer.

Methods

A randomized controlled trial was conducted at a tertiary hospital, enrolling 95 patients treated between December 2022 and June 2023. Participants were randomly assigned to either the control group (n ​= ​47), receiving standard nursing care, or the intervention group (n ​= ​48), receiving a PMT-IMB-based lymphedema prevention program. The intervention was delivered in hospital settings, with follow-up via WeChat and phone after discharge. Outcomes were assessed using the Lymphedema Risk-Reduction Behavior Checklist (LRRB), Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, upper limb circumference measurements, and self-lymphatic drainage records at baseline, 1 month, 3 months, and 6 months post-intervention.

Results

The intervention group demonstrated significantly higher lymphedema prevention behavior scores than the control group after the intervention. Upper limb dysfunction scores improved significantly in the intervention group compared to the control group at three and six months. In the control group, upper limb circumference gradually increased over time, with a significant difference observed at six months. Compliance with self-lymphatic drainage was also significantly better in the intervention group.

Conclusions

The PMT-IMB-based nursing intervention effectively enhances preventive behaviors, reduces lymphedema incidence, improves upper limb function, and increases patient adherence. These findings provide valuable insights for optimizing nursing strategies in lymphedema prevention.

Trial registration

http://www.chictr.org.cn, ChiCTR2300070705.

Scar Decompression in Managing Breast Cancer-Related Lymphedema: Is it Needed?

BACKGROUND

 Mastectomy, axillary lymph node dissection, and irradiation for breast cancer commonly result in perivascular and axillary scarring. This scarring is thought to cause functional venous stenosis that leads to downstream venous hypertension in the affected extremity. Standard surgical practice is to decompress perivascular scarring at the time of physiologic lymphedema surgery in patients with breast cancer-related lymphedema (BCRL). However, it is unknown whether this scar release influences surgical outcomes. The purpose of this study was to evaluate the prevalence of functional venous stenosis in patients with BCRL and determine whether scar decompression is a necessary step in physiologic lymphedema surgery.

METHODS

 The authors conducted a retrospective review of 64 patients with unilateral BCRL that presented to our lymphedema center between January 2020 and October 2022. Radiologist reports of venous duplex ultrasound for the bilateral upper extremities identified any disturbances in venous flow or indications of venous stenosis.

RESULTS

 Of the 64 patients with BCRL, 78% (n = 50) had prior axillary lymph node dissection. Forty-seven (73%) patients completed ultrasound imaging, of which, one patient (2%) had venous stenosis in the affected lymphedematous extremity identified on duplex ultrasound that may have suggested functional scarring. Vascularized lymph node transfer (VLNT) without scar decompression was performed in six patients (9%). Average preoperative Lymphedema Life Impact Scale and Lymphedema Index scores were 35 and 19 units, with a mean decrease of 23 (67%) and 6 (30%) units postoperatively.

CONCLUSION

 Most patients with BCRL did not have identifiable functional venous stenosis on duplex ultrasound, apart from one patient with suspected postthrombotic changes. All six patients that received VLNT without scar decompression had a successful outcome with decreased measures of lymphedema postoperatively. Scar decompression may therefore be unnecessary in physiologic lymphedema surgery, reducing operative times and avoiding risk of injury to neurovascular structures of the axilla.

Database study of risk factors for breast cancer-related lymphedema: a statistical analysis of 2359 cases over 10 years

PURPOSE

Identifying risk factors for breast cancer-related lymphedema (BCRL) is crucial for its prevention, necessitating large-scale epidemiological studies. Despite their suitability for large-scale surveys, to our knowledge, databases have not been the basis of any study done to investigate BCRL risk factors. This study aimed to test the hypothesis that a database-based study would be useful for identifying BCRL risk factors.

METHODS

Patients with breast cancer diagnosed between April 2009 and March 2020 were identified from the Hiroshima University Hospital's medical database. This retrospective observational study validated the risk factors for BCRL using logistic regression analysis (p < 0.05).

RESULTS

Among the total 4471 breast cancer patients identified, 2359 met the study criteria, with a BCRL incidence of 4.8%. Identified risk factors included obesity with a BMI of 25-30 (OR = 3.066, 95% CI 1.408-6.677), severe obesity with a BMI > 30 (OR = 5.791, 95% CI 2.239-14.97), surgical axillary lymph node dissection (OR = 3.212, 95% CI 1.918-5.378), chemotherapy with docetaxel (OR = 1.795, 95% CI 1.062-3.032), and conventional radiation to the breast or chest wall including lymph nodes in the irradiated area (OR = 3.299, 95% CI 1.842-5.910).

CONCLUSIONS

The BCRL risk factors identified by our database analysis were in line with those documented in previous studies, indicating the usefulness of database-based studies. Future studies should include more patients and study items.

Beyond cancer treatment: dermo-aesthetic and other wellness recommendations for breast cancer patients

Breast cancer, a prevalent malignancy among women, has various physical and psychological impacts. This comprehensive review offers an in-depth look at multidisciplinary dermo-aesthetic intervention approaches, emphasizing the balance between oncological therapies and the management of these effects. The information presented spans specialties such as aesthetic medicine, plastic surgery, dermatology, physiotherapy, nutrition, odontology, and gynecology. This review, which serves as a clinical guide, aims to establish a safe protocol for non-medical interventions involving oncologists, physicians, and specialists from various areas in patients with breast cancer focused on improving their quality of life. This work offers personalized and integrative care strategies for the eradication of cancer. However, it is still necessary for patients to consult with their oncologist before undergoing any dermo aesthetic treatment. However, it is still necessary for patients to consult with their oncologist before undergoing any dermo aesthetic treatment.

Bibliometric and visual analysis of breast cancer-related lymphedema: Knowledge structure, research status, and future trends

BACKGROUND

As the survival rate of breast cancer patients increases, breast cancer-related lymphedema (BCRL) has gradually received attention from researchers. This study aims to sort out and summarize the relevant studies on BCRL using bibliometric analysis and to explore future research trends.

METHODS

In this study, we searched the Web of Science Core Collection for publications related to BCRL, analyzed the publication trends by applying Microsoft Excel 2019, and analyzed authors, cited journals, journal mapping overlays, cited references, and keywords by applying CiteSpace (v.6.1.R3 Advanced). SCImago Graphica (v.1.0.39) was applied to analyze countries/regions, institutions, and published journals.

RESULTS

We finally included 1000 publications published between 2003 and July 4, 2024. Publications showed an upward trend, with the largest number of publications in 2023. USA is the most published country, Harvard University is the most published institution, Taghian AG is the most published author, and DiSipio T is the most cited author. Lymphatic Research and Biology is the most published journal, and Cancer-American Cancer Society is the most cited journal. "Breast cancer," "arm lymphedema," and "quality of life" were the most frequent keywords. Current research focuses on risk factors, treatment strategies, and patients' quality of life with BCRL. Future research will mainly focus on establishing BCRL evaluation protocols, improving treatment techniques, and early prevention and detection of BCRL.

CONCLUSION

Our study sorts out the current knowledge structure in the field and highlights the current state of research and future research directions. These findings inform researchers and clinicians.

Immediate Lymphatic Reconstruction May Decrease the Incidence of Lymphedema in Patients Undergoing Axillary Lymph Node Dissection

Background

Approximately one-third of patients undergoing axillary lymph node dissection (ALND) for breast cancer will develop breast cancer-related lymphedema (BCRL). To prevent BCRL, immediate lymphatic reconstruction (ILR) has been proposed, whereby lymphatics cut during the ALND are anastomosed to adjacent veins to restore lymphatic drainage. As evidence for ILR grows, the aim of this study was to investigate its efficacy at our institution.

Methods

This prospective single-center study included 17 women undergoing ALND with ILR. Our primary outcome was the incidence of BCRL, diagnosed using a greater than 10% relative difference in arm volume. Use of compression therapy was also followed. Our secondary outcome was patient-reported outcome measures, determined by the validated Lymphedema Quality of Life (LYMQOL-Arm) survey. Postoperatively, patients were followed up at regular intervals for a minimum of 18 months.

Results

The median age of included patients was 49 (interquartile range [IQR] 46-58). The average follow-up time was 34.4 months (range 18-42 mo). Two patients met the criteria for BCRL. Patients with BCRL had a significantly higher median arm volume difference of 27.5% (IQR 21.8%-33.2%) versus 4.2% (IQR 1.6%-7%; P = 0.02). Three patients used compression to control symptoms. Patients without lymphedema scored better in several domains of the LYMQOL-Arm survey, including function, appearance, and overall quality of life; however, these results did not meet statistical significance.

Conclusions

ILR in patients undergoing ALND is associated with a low incidence of BCRL. Our study is one of the first to use patient-reported outcome measures to study ILR.

The Usefulness of Portable Echo in the Preoperative Mapping of Lymphaticovenular Anastomosis

BACKGROUND AND OBJECTIVES

This study evaluated the effectiveness of a pocket-sized ultrasound device in preoperative planning for lymphaticovenular anastomosis (LVA) to enhance lymphedema treatment outcomes.

METHODS

A retrospective analysis was performed on 24 patients who underwent LVA for secondary upper extremity lymphedema between June 2020 and August 2022. Patients were categorized into two groups: the ultrasound group, which used a pocket-sized device (Vscan Air), for preoperative vein identification, and a control group that did not. Preoperative lymphatic mapping was performed using indocyanine green lymphography, and suitable veins for anastomosis were identified using ultrasound. Upper extremity lymphedema index and incision length were compared.

RESULTS

Participants in the ultrasound group had a shorter average incision length (2.85 ± 0.48 cm) than those in the control group (3.23 ± 0.78 cm, p = 0.038), indicating a more targeted and minimally invasive approach. Although volume reduction rates were not significantly different, the pocket ultrasound device facilitated more precise vein selection, enhancing surgical planning.

CONCLUSION

Pocket-sized ultrasound devices provide a cost-effective and practical solution for vein identification during LVA, particularly in resource-limited settings. While high-frequency ultrasound offers superior resolution, portable devices could become standard tools for lymphatic surgery with continued technological advancement.

Robotic-Assisted Lymphedema Surgery: Bridging the Gap in Training and Expanding Complex Surgical Options

The prevalence of lymphedema is likely to rise substantially in the coming decades, given projected increases in cancer. Lymphedema surgeries can improve patients' quality of life, but the shortage of surgeons capable of performing these surgeries may be a barrier to treatment. Robotic platforms may elevate novice and less-seasoned surgeons' skills, expediting their ability to perform lymphovenous anastomoses. At the same time, robotic systems may ameliorate work-related musculoskeletal stresses, which could extend the careers of microsurgeons. Moreover, as research progresses into novel applications, the integration of advanced robotic technology may become crucial. Continued exploration of these emerging fields will not only expand the possibilities for treatment but also necessitate further advancements in surgical techniques and training methodologies. The ongoing development and implementation of robotic systems like Symani could thus be instrumental in addressing the growing global burden of lymphedema and other complex surgical challenges.

Prediction of breast cancer Invasive Disease Events using transfer learning on clinical data as image-form

BACKGROUND AND OBJECTIVE

Detecting patients at high risk of occurrence of an Invasive Disease Event after a first diagnosis of breast cancer, such as recurrence, distant metastasis, contralateral tumor and second tumor, could support clinical decision-making processes in the treatment of this malignancy. Though several machine learning models analyzing both clinical and histopathological information have been developed in literature to address this task, these approaches turned out to be unsuitable for describing this problem.

METHODS

In this study, we designed a novel artificial intelligence-based approach which converts clinical information into an image-form to be analyzed through Convolutional Neural Networks. Specifically, we predicted the occurrence of an Invasive Disease Event at both 5-year and 10-year follow-ups of 696 female patients with a first invasive breast cancer diagnosis enrolled at IRCCS "Giovanni Paolo II" in Bari, Italy. After transforming each patient, represented by a vector of clinical information, to an image form, we extracted low-level quantitative imaging features by means of a pre-trained Convolutional Neural Network, namely, AlexNET. Then, we classified breast cancer patients in the two classes, namely, Invasive Disease Event and non-Invasive Disease Event, via a Support Vector Machine classifier trained on a subset of significative features previously identified.

RESULTS

Both 5-year and 10-year models resulted particularly accurate in predicting breast cancer recurrence event, achieving an AUC value of 92.07% and 92.84%, an accuracy of 88.71% and 88.82%, a sensitivity of 86.83% and 88.06%, a specificity of 89.55% and 89.3%, a precision of 71.93% and 84.82%, respectively.

CONCLUSIONS

This is the first study proposing an approach which converts clinical information into an image-form to develop a decision support system for identifying patients at high risk of occurrence of an Invasive Disease Event, and then defining personalized oncological therapeutic treatments for breast cancer patients.

Body Mass Index and Breast Cancer-Related Lymphedema: A Retrospective Cohort Study

OBJECTIVE

This study aims to evaluate the association between body mass index (BMI) and the incidence of breast cancer-related lymphedema (BCRL).

METHODS

This retrospective cohort study analyzed data from 1464 breast cancer patients treated at The Third Hospital of Nanchang between 2018 and 2021. Patients were categorized based on BMI (<25, 25 to < 30, ≥ 30 kg/m²). Variables such as axillary lymph node dissection, infections, radiotherapy, and comorbidities were taken into account.

RESULTS

The incidence of BCRL was 23.4%. Higher BMI was associated with increased risk of BCRL, with significant incidence rates observed at 1, 2, and 3 years in the higher BMI groups. Multivariate analysis confirmed BMI as an independent risk factor for BCRL.

CONCLUSION

Elevated BMI is associated with increased BCRL risk and decreased BCRL-free survival, underscoring the significance of weight management in breast cancer care.

The Predictive Role of Illness Perception on Lymphedema Risk-Management Behaviors in Women After Breast Cancer Surgery: A Longitudinal Study

BACKGROUND

Illness perception affects lymphedema risk-management behaviors. However, little is known about these behavioral changes within 6 months after surgery and how illness perception predicts behavioral trajectories.

OBJECTIVE

The aim of this study was to explore the trajectories of lymphedema risk-management behaviors in breast cancer survivors within 6 months after surgery and the predictive role of illness perception.

METHODS

Participants were recruited from a cancer hospital in China and completed a baseline survey (Revised Illness Perception Questionnaire) and follow-up assessments (Lymphedema Risk-Management Behavior Questionnaire and the physical exercise compliance dimension of the Functional Exercise Adherence Scale) at the first, third, and sixth months postoperatively.

RESULTS

A total of 251 women were analyzed. Regarding the Lymphedema Risk-Management Behavior Questionnaire, the total scores were stable. The scores of the "lifestyle" and "skin care" dimensions showed upward trends; the scores of the "avoiding compression and injury" and "other matters needing attention" dimensions showed downward trends. For "physical exercise compliance," scores remained stable. Furthermore, key illness perceptions (especially "personal control" and "causes") at baseline could predict the starting levels of and changes in behavioral trajectories.

CONCLUSION

Different lymphedema risk-management behaviors exhibited different trajectories and could be predicted by illness perception.

IMPLICATIONS FOR PRACTICE

Oncology nurses should focus on the early development of behaviors related to "lifestyle" and "skin care" and the later maintenance of "avoiding compression and injury" and "other matters needing attention" during follow-up, as well as help women strengthen their personal control beliefs and correctly understand the causes of lymphedema during hospitalization.

Analysis of Different Lymphedema Assessment Tools in Women with Breast Cancer After Mastectomy

Background: Lymphedema is a common complication after mastectomy in women with breast cancer. Several methods have been described to assess and diagnose lymphedema, one of the most studied being the perimeter and ultrasonography. However, the reliability of these methods and the correlation between them are still controversial. The aim of this study was to analyze the reliability of cytometry and ultrasound imaging in the assessment of lymphedema after mastectomy in women with breast cancer and to study the correlation between them. Methods and Results: A cross-sectional study was conducted in 29 women with mastectomy after breast cancer. Lymphedema in the arm was measured both with cytometry and ultrasonography. Reliability was calculated with intraclass correlation coefficient. The correlation between the two methods was carried out with the Pearson correlation coefficient. Both cytometry (M1: α = 0.999, ICC = 0.996; M2: = α = 0.998, ICC = 0.994) and ultrasonography (M1: α = 0.992, ICC = 0.976; M2: = α = 0.991, ICC = 0.973) are reliable methods to assess lymphedema in the arm. No significant correlation was found between them (p > 0.05). Conclusions: Cytometry and ultrasonography appear to be adequate for the measurement of edema in women with breast cancer after mastectomy. However, for an accurate measurement of lymphedema, these measurements should not be used interchangeably.

Supraclavicular Irradiation Induces Lymphedema in Breast Cancer Patients Treated with Axillary Lymph Node Dissection and Taxane-Containing Chemotherapy

Purpose

Breast cancer-related lymphedema (LE) significantly impairs the patients' quality of life. Axillary lymph node dissection (ALND) is a strong risk factor for LE in breast cancer surgery. In addition, postoperative administration of docetaxel (DTX) has been reported to be a risk factor for LE in patients who undergo ALND. Herein, we performed the risk of objective LE after ALND.

Methods

Patients who visited the medical follow-up clinic between 12 November 2018 and 11 January 2019 and at least one year postoperatively were eligible for this study. The risk factors for objective LE according to taxane-containing regimen, radiation therapy, and body mass index and the effects of a taxane-containing regimen followed by supraclavicular irradiation on LE were examined.

Results

A total of 214 patients were included in this analysis, and objective LE was observed in 52 patients (24%). Univariate and multivariate analyses showed that only supraclavicular field irradiation was a statistically significant risk factor for objective LE. In addition, the sequential use of taxane-containing regimens and supraclavicular RT was shown to be a more likely risk factor for LE than ALND alone. We also compared each taxane regimen with supraclavicular RT and found that DTX was more likely to be a risk factor for LE in cases of sequential use of supraclavicular RT than with ALND alone. However, when comparing DTX with supraclavicular RT and PTX with supraclavicular RT directly, there was no statistically significant difference in the risk of objective LE between the two groups.

Conclusion

The risk for LE was more likely to be higher with the sequential use of taxane-containing chemotherapy and supraclavicular field irradiation. Therefore, management of LE is important in these cases.

Association between quality of life and mortality risk in patients with breast cancer: a systematic review and meta-analysis

BACKGROUND

Patients with breast cancer present with various problems that have an adverse effect on the quality of life (QOL). However, the association between the QOL and mortality among patients with breast cancer remains controversial. Therefore, this systematic review and meta-analysis aimed to determine whether QOL impacts prognosis in patients with breast cancer.

METHODS

The databases of CINAHL, Scopus, and PubMed databases were searched to retrieve observational studies that assessed the QOL and mortality risk in patients with breast cancer published before December 2022.

RESULTS

Among the 119,061 articles retrieved, six observational studies were included in the meta-analysis. Physical QOL (hazard ratio [HR]: 1.04, 95% confidence interval [CI]: 1.01-1.07, p = 0.003), emotional QOL (HR: 1.01, 95% CI: 1.00-1.03, p = 0.05), and role QOL (HR: 1.01, 95% CI: 1.00-1.01, p = 0.007) showed significant associations with mortality risk. In contrast, global QOL, cognitive QOL, and social QOL showed no associations with mortality risk. Subgroup analysis performed according to treatment time points revealed that the post-treatment physical QOL was associated with mortality risk.

CONCLUSIONS

Physical QOL, emotional QOL, and role QOL are associated with mortality risk in patients with breast cancer. Furthermore, post-treatment physical QOL showed a more significant association with prolonged survival than pre-treatment physical QOL.

Breast Cancer-Related Lymphedema Assessed via Tissue Dielectric Constant Measurements

This review describes the use of tissue dielectric constant (TDC) measurements mainly in the assessment of breast cancer-related lymphedema (BCRL). PubMed, Web of Science, and EMBASE databases were initially searched using criteria that included the terms "dielectric" and "lymphedema." The initial search yielded a total of 131 titles. After removing studies not focused on upper extremity lymphedema, 56 articles remained. These articles, together with relevant articles from their bibliographies, formed the basis of the review. The findings show the potential utility and applications of TDC measurements to help detect and track BCRL, whether present in limbs, breasts, or trunks. It is reported as a non-invasive, simple-to-use method, with each measurement requiring less than 10 seconds, suggesting its practicality and useability as an in-office or in-clinic screening and tracking method. Although there are various ways to quantitatively evaluate lymphedema, most, if not all, are restricted to measurements on limbs. Thus, one significant advantage of the TDC approach is that almost any local region of interest can be effectively measured and tracked, which, for BCRL, could include specific regions of arms or hands, breasts, and truncal areas.

United States insurance coverage of immediate lymphatic reconstruction

INTRODUCTION

Immediate Lymphatic Reconstruction (ILR) is a prophylactic microsurgical lymphovenous bypass technique developed to prevent breast cancer related lymphedema (BCRL). We investigated current coverage policies for ILR among the top insurance providers in the United States and compared it to our institutional experience with obtaining coverage for ILR.

METHODS

The study analyzed the publicly available ILR coverage statements for American insurers with the largest market share and enrollment per state to assess coverage status. Institutional ILR coverage was retrospectively analyzed using deidentified claims data and categorizing denials based on payer reason codes.

RESULTS

Of the 63 insurance companies queried, 42.9% did not have any publicly available policies regarding ILR coverage. Of the companies with a public policy, 75.0% deny coverage for ILR. In our institutional experience, $170,071.80 was charged for ILR and $166 118.99 (97.7%) was denied by insurance.

CONCLUSIONS

Over half of America's major insurance providers currently deny coverage for ILR, which is consistent with our institutional experience. Randomized trials to evaluate the efficacy of ILR are underway and focus should be shifted towards sharing high level evidence to increase insurance coverage for BCRL prevention.

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.

Analysis of the effect of nursing care based on action research method on the prevention of postoperative lymphedema in breast cancer patients

RATIONALE

In recent times, the pervasive adoption of the action research method has garnered substantial attention both domestically and internationally. Its integration has traversed various domains of nursing research, nursing education, and nursing practice, yielding commendable outcomes. However, a notable gap persists, as this method remains untapped in the realm of nursing care concerning the prevention of postoperative lymphedema in breast cancer patients.

DIAGNOSIS

To employ the action research methodology in the context of patients undergoing axillary lymph node dissection surgery for breast cancer, aiming to investigate its impact on mitigating postoperative lymphedema and assessing its influence on the patient's quality of life, as well as levels of anxiety and depression postoperatively.

INTERVENTION

The study focused on breast cancer patients admitted to our hospital from January 2022 to December 2022. Among them, 44 patients from January to June constituted the control group, while 44 patients from July to December comprised the observation group. Conventional nursing measures were applied to the control group, whereas the observation group received nursing interventions rooted in the action research method. A comparative analysis was conducted between the 2 groups, assessing the incidence of postoperative lymphedema, daily life ability, as well as levels of anxiety and depression.

OUTCOMES

The prevalence of edema was notably reduced in the observation group (20.93%) compared to the control group (42.22%), with a statistically significant difference. Throughout the study, patients in both groups exhibited increased Barthel Index Scale scores from the study's initiation, and the scores for the observation group surpassed those of the control group, reaching statistical significance (P < .05). Furthermore, by the study's conclusion, anxiety and depression scores for patients in both groups were diminished compared to the study's commencement, and the observation group demonstrated significantly lower scores in anxiety and depression compared to the control group (P < .05).

LESSONS

The implementation of nursing care grounded in the action research methodology exhibits a capacity to diminish both the occurrence and intensity of postoperative lymphedema in breast cancer patients. Concurrently, it enhances the patients' daily life functionality and mitigates symptoms of anxiety and depression.

Medical Applications of Skin Tissue Dielectric Constant Measurements

Tissue dielectric constant (TDC) values assess certain skin properties that are dependent on multiple factors but mainly on the relative amount of water content within a locally measured tissue volume. Because of the non-invasive nature of these measurements and their ease of use, the method has been widely used in various medically related applications. The goal of this paper was to review and describe the uses and findings of such TDC measurements, considering and including the wide array of medical applications. The review is in part based on information derived from an analysis of published material obtained via literature searches of four major electronic databases and, in part, based on the author's experience with the TDC measurement methods and their various applications and his professional experiences. The databases searched were PubMed, Web of Science, EMBASE, and CINAHL Complete. Based on the initial search criteria, a total of 1257 titles were identified. After removing duplicates and filtering according to relevancy, 160 remained for detailed further review. In some cases, the bibliography of these retrieved articles provided additional sources. The findings demonstrate multiple research and medical uses and applications of TDC measurements, focusing on detecting and quantifying localized edema and lymphedema in multiple target sites. These include the upper and lower extremities, breasts, and trunk as regions involved in medical conditions causing lymphedema. In addition, the findings suggest that TDC evaluations are a convenient, non-invasive method to study and evaluate other conditions impacting skin, including diabetes mellitus and skin wounds or ulcers. Its ability to detect aspects of tissue changes simply and rapidly at almost any anatomical location makes it a useful tool for investigating multiple dermatological conditions and their treatment as future applications of this method.

Risk factors for long-term arm morbidities following breast cancer treatments: A systematic review

PURPOSE

To examine the risk factors for arm morbidity following breast cancer treatments, taking a broad view of all types of physical morbidity, including prolonged pain, lymphedema, decreased range of motion, and functional limitations.

METHODS

A systematic literature review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. Studies exploring the risk factors for prolonged arm morbidity following breast cancer surgery and treatments were included. The studies were assessed independently according to pre-eligibility criteria, following data extraction and methodological quality assessment.

RESULTS

1,242 articles were identified. After removing duplicates, the full texts of 1,153 articles were examined. Sixty-nine of these articles met the criteria and were included in the review. These 69 articles identified 29 risk factors for arm morbidity following treatments for breast cancer. The risk of bias was evaluated using NIH study quality assessment tools. The studies reviewed were published between 2001 and 2021 and included a total of 22,886 patients who were followed up for between three months and 10 years.

CONCLUSIONS

The main risk factors for long-term morbidity are removal of lymph nodes from the axilla, body mass index >30, having undergone a mastectomy, the stage of the disease, radiation therapy, chemotherapy, infection and trauma to the affected arm after surgery. An understanding of the risk factors for prolonged arm morbidity after surgery can help doctors and therapists in making personalized decisions about the need and timing of rehabilitation treatments.

A Low-Cost, Portable, and Mobile-Based Bioimpedance Lymphedema Diagnosis and Monitoring System (Mobilymph): A Validation Study

Background: Breast cancer-related lymphedema (BCRL) is a debilitating chronic illness. Early management and prevention of disease progression rely on lymphedema monitoring and assessment. At present, lymphedema monitoring systems are costly and do not promote remote monitoring. Thus, a low-cost, portable, mobile-based bioimpedance lymphedema monitoring system (Mobilymph) was developed to ensure continuous lymphedema surveillance. Method and Results: Forty-five healthy and 100 BCRL participants were recruited in this study. Mobilymph bioimpedance measurement was validated with a Quadscan 4000 on healthy participants' arms. The interarm bioimpedance ratio was determined to evaluate the discriminatory capability of Mobilymph to detect BCRL. Mobilymph's bioimpedance results show no significant difference compared to Quadscan 4000. The interarm bioimpedance ratios were significantly different (p < 0.001), between participants in healthy and Stage 1, Stage 0 and Stage 1, and Stage 1 and Stage 2. Healthy and Stage 0 participants had similar interarm impedance ratios (p = 0.63). Conclusion: The bioimpedance results show that Mobilymph bioimpedance measurement is comparable to Quadscan 4000 and can detect BCRL arms. Thus, Mobilymph lymphedema monitoring system offers a feasible solution for early lymphedema diagnosis and treatment monitoring. Clinical trial registration number: MREC ID No.: 2020316-8181.

Early Detection of Breast Cancer-Related Lymphedema: Accuracy of Indocyanine Green Lymphography Compared with Bioimpedance Spectroscopy and Subclinical Lymphedema Symptoms

Introduction: The reported incidences of breast cancer-related lymphedema (LE) affecting the arms vary greatly. Reason for this variability includes different diagnostic techniques used across studies. In the current study, we compared the accuracy of indocyanine green lymphography (ICG_L) and bioimpedance spectroscopy (BIS) in detecting LE before presentation of clinical signs. Methods and Results: Patients with no initial detectable signs of clinical LE of their arms after axillary lymph node dissection or removal of >5 lymph nodes on sentinel lymph node biopsy were included. Subclinical LE was defined as BIS values outside the normal range [(≥7 units (or >10 units)] or a 7-unit (or 10 unit) change between two measurements. We tracked ICG_L and BIS measurements for 133 potentially affected arms (n = 123). ICG_L detected signs of lymphatic flow disruption in 63 arms (47%). Based on the BIS value of 7 units, 60 arms (45%) had values outside the normal range. When using ICG_L-identified LE cases as true positives, BIS had a 54% accuracy (area under the curve [AUC] = 0.54) in detecting LE. Accuracy was 61% for subclinical LE symptoms when compared with ICG_L (AUC = 0.62). Both BIS and subclinical LE symptoms had <0.70 AUC-receiver characteristic operator curve, suggesting that BIS and development of subclinical LE symptoms are not adequate for identifying patients with subclinical LE. Conclusion: ICG_L is a reliable diagnostic tool for detecting early signs of lymphatic flow disruption in subclinical LE. Utilizing ICG_L to diagnose subclinical LE followed by a personalized treatment plan may provide patients the best chance of preventing disease progression.

Effectiveness of physical exercise programmes in reducing complications associated with secondary lymphoedema to breast cancer: a protocol for an overview of systematic reviews

INTRODUCTION

Breast cancer-related lymphoedema (BCRL) is one of the most underestimated and debilitating complications associated with the treatment that women with breast cancer receive. Several systematic reviews (SRs) of different physical exercise programmes have been published, presenting disperse and contradictory clinical results. Therefore, there is a need for access to the best available and summarised evidence to capture and evaluate all the physical exercise programmes that focus on reducing BCRL.

OBJECTIVE

To evaluate the effectiveness of different physical exercise programmes in reducing the volume of lymphoedema, pain intensity and improving quality of life.

METHOD AND ANALYSIS

The protocol of this overview is reported following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols, and its methodology is based on Cochrane Handbook for Systematic Reviews of Interventions. Only those SRs involving physical exercise by patients with BCRL will be included, whether on its own or combined with other exercises or other physical therapy interventions.The outcomes of interest to be considered will be lymphoedema volume, quality of life, pain intensity, grip strength, range of motion, upper limb function and any adverse event. The MEDLINE/PubMed, Lilacs, Cochrane Library, PEDro and Embase databases will be searched for reports published from database inception to April 2023.Two researchers will perform study selection, data extraction and risk of bias assessment independently. Any discrepancy will be resolved by consensus, or ultimately, by a third-party reviewer. We will use Grading of Recommendations Assessment, Development and Evaluation System to assess the overall quality of the body of evidence.

ETHICS AND DISSEMINATION

The results of this overview will be published in peer-reviewed scholarly journals and the scientific dissemination will take place in national or international conferences. This study does not require approval from an ethics committee, as it does not directly collect information from patients.

PROSPERO REGISTRATION NUMBER

CRD42022334433.

Machine learning survival models trained on clinical data to identify high risk patients with hormone responsive HER2 negative breast cancer

For endocrine-positive Her2 negative breast cancer patients at an early stage, the benefit of adding chemotherapy to adjuvant endocrine therapy is not still confirmed. Several genomic tests are available on the market but are very expensive. Therefore, there is the urgent need to explore novel reliable and less expensive prognostic tools in this setting. In this paper, we shown a machine learning survival model to estimate Invasive Disease-Free Events trained on clinical and histological data commonly collected in clinical practice. We collected clinical and cytohistological outcomes of 145 patients referred to Istituto Tumori "Giovanni Paolo II". Three machine learning survival models are compared with the Cox proportional hazards regression according to time-dependent performance metrics evaluated in cross-validation. The c-index at 10 years obtained by random survival forest, gradient boosting, and component-wise gradient boosting is stabled with or without feature selection at approximately 0.68 in average respect to 0.57 obtained to Cox model. Moreover, machine learning survival models have accurately discriminated low- and high-risk patients, and so a large group which can be spared additional chemotherapy to hormone therapy. The preliminary results obtained by including only clinical determinants are encouraging. The integrated use of data already collected in clinical practice for routine diagnostic investigations, if properly analyzed, can reduce time and costs of the genomic tests.

Treatment-related side effects among Hispanic and non-Hispanic white long-term breast cancer survivors by tamoxifen use and duration

PURPOSE

To determine the associations between ethnicity, age at diagnosis, obesity, multimorbidity, and odds of experiencing breast cancer (BC) treatment-related side effects among long-term Hispanic and non-Hispanic white (NHW) survivors from New Mexico and explore differences by tamoxifen use.

METHODS

Lifestyle and clinical information including self-reported tamoxifen use and presence of treatment- related side effects were collected at follow-up interviews (12-15 years) for 194 BC survivors. Multivariable logistic regression models were used to examine associations between predictors and odds of experiencing side effects overall and by tamoxifen use.

RESULTS

Women ranged in age at diagnosis (30-74, M = 49.3, SD = 9.37), most were NHW (65.4%) and had in-situ or localized BC (63.4%). Less than half reportedly used tamoxifen (44.3%), of which 59.3% reported using > 5 years. Overall, survivors who were overweight/obese at follow-up were 5.42 times more likely to experience treatment-related pain (95% CI 1.40-21.0) compared to normal weight survivors. Survivors with multimorbidity, compared to survivors without, were more likely to report treatment-related sexual health issues (aOR 6.90, 95% CI 1.43-33.2) and poorer mental health (aOR 4.51, 95% CI 1.06-19.1). The statistical interactions between ethnicity and overweight/obese with tamoxifen use were significant (p-interaction < 0.05) for treatment-related sexual health issues.

CONCLUSION

Our results demonstrate that survivors with overweightness/obesity or multimorbidity may be more likely to experience BC treatment-related side effects. Tamoxifen use modifies associations between ethnicity, being overweight/obese, and sexual health issues following treatment. The likelihood of experiencing treatment-related side effects were more favorable for those on tamoxifen or those who had used tamoxifen for longer durations. These findings highlight the importance of fostering side effect awareness and applying appropriate interventions to assist with disease management throughout BC survivorship care.

Risk factors for the development of severe breast cancer-related lymphedema: a retrospective cohort study

BACKGROUND

Severe lymphedema presents a challenge in terms of treatment due to the significant formation of scar tissue that accompanies it. The aim of this study was to identify intraoperative and preoperative risk factors of severe lymphedema and to develop a nomogram for estimating the risk of severe lymphedema within 3 years of surgery.

METHOD

Data was collected from a retrospective cohort of 326 patients with BCRL at the Zhejiang Cancer Hospital from November 2015 to November 2018. Univariate and multivariate logistic regression analysis was conducted to identify predictive indicators of severe lymphedema. A nomogram was developed to further improve the clinical applicability.

RESULTS

In the retrospective cohort, the ratio of severe/non-severe lymphedema within 3 years of surgery was 1:3. Independent risk factors for severe lymphedema were determined to be age, positive lymph nodes, interpectoral (Rotter's) lymph nodes (IPNs) dissection, and educational level. IPNs dissection was found to contribute greatly to the development of severe lymphedema with a higher odds ratio (7.76; 95% CI: 3.87-15.54) than other risk factors. A nomogram was developed by integrating age, positive lymph nodes, IPNs dissection, and educational level, which yielded a C-index of 0.810 and 0.681 in the training and validation cohort, respectively. This suggested a moderate performance of the nomogram in predicting the risk of severe lymphedema within 3 years of surgery. The cut-off values of the low-, medium- and high-risk probabilities were 0.0876 and 0.3498, and the severe lymphedema exhibited a significantly higher risk probability as compared with the non-severe lymphedema.

CONCLUSION

This study identified the risk factors of severe lymphedema and highlighted the substantial contribution of IPNs dissection to the severity of lymphedema.

Body mass index increases the risk of breast cancer-related lymphedema at 6-18 months after surgery: a retrospective study

PURPOSE

Breast cancer-related lymphedema (BCRL) is an incurable complication occurring after breast cancer treatment. The influence of obesity/overweight on the development of BCRL at different points after surgery was seldom verified. We aimed to determine the cut-off BMI/weight value associated with an increased risk of BCRL at different postoperative time in Chinese breast cancer survivors.

METHODS

Patients who underwent breast surgery plus axillary lymph node dissection (ALND) were retrospectively evaluated. Disease and treatment characteristics of participants were collected. BCRL was diagnosed by circumference measurements. Univariate and multivariable logistic regression was used to assess the relationship of lymphedema risk with BMI/weight and other disease- and treatment-related factors.

RESULTS

518 patients were included. Lymphedema occurred more frequently among breast cancer patients with preoperative BMI ≥ 25 kg/m² (37.88%) than among those with preoperative BMI < 25 kg/m²(23.32%), with significant differences at 6-12 and 12-18 months after surgery (χ² = 23.183, P = 0.000; χ² = 5.279, P = 0.022). By multivariable logistics analysis, preoperative BMI ≥ 30 kg/m² presented a significantly greater risk of lymphedema than a preoperative BMI < 25 kg/m² (OR [95% CI] = 2.928 [1.565, 5.480]). Other factors, including radiation (breast/chest wall + axilla vs. none: OR [95% CI] = 3.723[2.271-6.104]), was an independent risk factor for lymphedema.

CONCLUSIONS

Preoperative obesity was an independent risk factor for BCRL in Chinese breast cancer survivors, and a preoperative BMI ≥ 25 kg/m² indicated greater likelihood of lymphedema development within 6-18 months postoperatively.

Psychometric evaluation of the Chinese version of the Upper Limb Lymphedema Quality of Life Questionnaire in breast cancer-related lymphedema patients

PURPOSE

The purpose of this study was to translate and evaluate the psychometric properties of the Chinese version of the Upper Limb Lymphedema Quality of Life Questionnaire (C-ULLQoL).

METHODS

Eighty-five participants completed the C-ULLQoL and the Functional Assessment of Cancer Therapy-Breast (C-FACT-B). The Cronbach's alpha (α) was used to determine the internal consistency, and intraclass correlation coefficients (ICCs) - to evaluate the test-retest reliability. The content validity index (CVI) was assessed by a group of experts. Construct validity was examined by performing factor analysis and criterion validity by observing the correlations between C-ULLQoL with C-FACT-B.

RESULTS

Cronbach's α of the total scale was 0.930. ICC scores ranged from 0.874 to 0.938. The content validity of C-ULLQoL was acceptable. Two factors (65.488% of the variance) were extracted by exploratory factor analysis. A significant correlation was observed between C-ULLQoL and C-FACT-B (r = -0.611, p < 0.01).

CONCLUSION

The C-ULLQoL is a reliable and valid questionnaire that can be used in clinic and scientific practice for evaluating health-related quality of life in Chinese patients with breast cancer-related lymphedema.IMPLICATIONS FOR REHABILITATIONAn effective and comprehensive scale to measure the health-related quality of life (HRQoL) is essential because breast cancer-related lymphedema (BCRL) leads to various complications for patients, caregivers, and society.The Chinese version of the Upper Limb Lymphedema Quality of Life Scale (C-ULLQoL) is a valid, reliable, and practical instrument to comprehensively assess HRQoL in Chinese patients with BCRL.The C-ULLQoL can be used in both clinical and research settings to evaluate HRQoL of BCRL patients in China.

Lymphatic Microsurgical Preventive Healing Approach for the Primary Prevention of Lymphedema: A 4-Year Follow-Up

BACKGROUND

Axillary lymph node dissection (ALND) remains the leading cause of lymphedema nationally, and there is still no cure for the disease. The lymphatic microsurgical preventive healing approach (LYMPHA) is a promising option for lymphedema prophylaxis in patients undergoing ALND, but long-term outcomes of the LYMPHA are not well established.

METHODS

The authors conducted a retrospective review of patients undergoing ALND at their center from November of 2012 to November of 2016 and assembled two cohorts, those who received the LYMPHA and those who did not (non-LYMPHA). Patient data were collected to evaluate lymphedema risk and long-term lymphedema incidence of each group.

RESULTS

Forty-five women were included in both our LYMPHA and non-LYMPHA cohorts. Mean body mass index (27.7 kg/m2 versus 29.9 kg/m2; P = 0.15) and radiation therapy rates (60.0% versus 68.9%; P = 0.51) did not differ between groups. Non-LYMPHA patients underwent complete mastectomy more frequently than LYMPHA patients (97.8% versus 77.8%; P = 0.007), but had a similar number of nodes removed during ALND (14.4 versus 15.8; P = 0.32). Median follow-up time was greater than 4 years for both LYMPHA and non-LYMPHA groups (57.0 months versus 63.0 months; P = 0.07). Overall, lymphedema incidence was 31.1% in the LYMPHA group and 33.3% in the non-LYMPHA group (P > 0.99). No significant differences in lymphedema incidences were observed between the LYMPHA and non-LYMPHA groups for patients with obesity, patients who received radiation therapy, or patients with obesity who also received radiation therapy (P > 0.05 for all subgroups).

CONCLUSIONS

The LYMPHA may not prevent lymphedema long-term in patients who undergo ALND. More long-term studies are needed to determine the true potential of the procedure.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Current trends in postmastectomy breast reconstruction

PURPOSE OF REVIEW

Breast reconstruction is established as integral part of the treatment. New materials, indications and surgical techniques are subject to rapid modification to further improve safety, quality and longevity.

RECENT FINDINGS

Skin-sparing-mastectomy is accepted as an appropriate alternative in risk-reducing and many breast cancer patients, further reducing conventional mastectomy patterns.Radiation in combination with reconstruction is still challenging with no clear advances reducing skin-toxicity.Autologous reconstructions, not only in radiation settings, are turning to a first line approach. A trend driven by improved techniques to minimize morbidity and flap-variations.Breast implant surfaces associated with a high risk of Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) are now withdrawn. The residual risk for the remaining implant styles is not known, but can be expected considerably lower than estimations published presently.In order to reduce local complications, supplemental material often in combination with prepectoral implant placement is advertised. The present evidence on long-term outcome is limited.Super-microsurgery treating lymphedema is evolving rapidly. Refinements of various techniques and their differential indication are under evaluation to standardize the procedures.

SUMMARY

Breast reconstruction evolved to a complex, specialized field with a multitude of options. A multidisciplinary team is required to fully utilize todays potential and offer optimal individual treatments.

Risk factors for arm lymphedema following breast cancer surgery: a Japanese nationwide database study of 84,022 patients

BACKGROUND

Although arm lymphedema is a well-known complication following breast cancer surgery, previous studies involving a small population showed inconsistent results regarding the risk. Therefore, we examined the risk factors using a Japanese nationwide database.

METHODS

Female patients who underwent breast cancer surgery from April, 2016, to March, 2020, were identified from a Japanese nationwide database. Multivariable survival analyses for 19 baseline factors (12 patient characteristics, four tumor characteristics, and three surgical procedures) were conducted to investigate risk factors associated with treatments for postoperative lymphedema (such as lymphatic bypass, compositive drainage therapy, hospitalization, and Kampo use) with a multilevel model to adjust for within-hospital clustering. We also conducted multivariable analysis for five postoperative factors (two local complications and three postoperative therapies) with adjustment for 19 baseline factors.

RESULTS

The study included 84,022 patients; 1547 (1.8%) received treatments for lymphedema during a median follow-up of 119 weeks (interquartile range, 59-187 weeks). Young age, obesity, smoking, collagen diseases, advanced cancer stage, total mastectomy, axillary dissection, postoperative bleeding, chemotherapy, and radiotherapy were identified as risk factors. Postoperative chemotherapy (hazard ratio, 3.78 [95% confidence interval, 3.35-4.26]) and axillary dissection (2.46 [1.95-3.11]) showed the highest odds ratio among the risk factors. The cumulative probabilities in high-risk patients reached approximately 3% at 1 year and 6% at 4 years after surgery.

CONCLUSIONS

This study identified several risk factors for postoperative lymphedema in breast cancer surgery. The treatment initiation increased markedly within the first year and gradually after 1 year post-surgery.

Breast carcinoma presenting with upper limb lymphedema - A rare case

Lymphedema (LE) in a breast cancer patient usually results from axillary lymph node dissection, sentinel lymph node biopsy, and/or axillary radiotherapy. Although lymphatic obstruction and consequent LE can occur due to axillary lymph node involvement, such presentation in breast cancer patients has rarely been reported. This report describes the case of a 50-year-old lady with right breast carcinoma who presented with right upper limb lymphedema. Surprisingly, she did not have any bulky axillary lymphadenopathy that could have accounted for lymphedema of the upper limb, but a suspicious breast mass was present on clinical examination. Diagnosis of breast cancer on clinical examination can be challenging in such patients due to breast edema and careful imaging of the breast and axilla with appropriate imaging tools (mammogram, ultrasound, MRI, PET mammography) should be resorted to before excluding malignancy. Lymphoscintigraphy confirmed the findings of lymphedema in the right upper limb and revealed uptake in the epitrochlear lymph nodes of the contralateral limb suggesting that she might had pre-existing widespread "subclinical lymphedema" which presented as "clinical lymphedema" in right upper limb after axillary lymph node/lymphatic involvement by right breast carcinoma.

Risk factors of unilateral breast cancer-related lymphedema: an updated systematic review and meta-analysis of 84 cohort studies

PURPOSE

To review and update the incidence and risk factors for breast cancer-related lymphedema based on cohort studies.

METHODS

The study was guided by the Joanna Briggs Institute methodology and the Cochrane handbook for systematic reviews. PubMed, EMBASE, CINAHL, Scopus, Web of Science, The Cochrane Library, CNKI, SinoMed, and Wan Fang Database were searched from inception to November 15, 2021. Cohort studies reported adjusted risk factors were selected. PRISMA guideline was followed. Study quality were evaluated using the Newcastle-Ottawa scale. Random-effects models were adopted. The robustness of pooled estimates was validated by meta-regression and subgroup analysis. Lymphedema incidence and adjusted risk factors in the multivariable analyses with hazard / odds ratios and 95% CIs were recorded.

RESULTS

Eighty-four cohort studies involving 58,358 breast cancer patients were included. The pooled incidence of lymphedema was 21.9% (95% CI, 19.8-24.0%). Fourteen factors were identified including ethnicity (black vs. white), higher body mass index, higher weight increase, hypertension, higher cancer stage (III vs. I-II), larger tumor size, mastectomy (vs. breast conservation surgery), axillary lymph nodes dissection, more lymph nodes dissected, higher level of lymph nodes dissection, chemotherapy, radiotherapy, surgery complications, and higher relative volume increase postoperatively. Additionally, breast reconstruction surgery, and adequate finance were found to play a protective role. However, other variables such as age, number of positive lymph nodes, and exercise were not correlated with risk of lymphedema.

CONCLUSION

Treatment-related factors still leading the development of breast cancer-related lymphedema. Other factors such as postoperative weight increase and finance status also play a part. Our findings suggest the need to shift the focus from treatment-related factors to modifiable psycho-social-behavioral factors.

Effectiveness of three exercise programs and intensive follow-up in improving quality of life, pain, and lymphedema among breast cancer survivors: a randomized, controlled 6-month trial

PURPOSE

Postoperative complications of breast cancer (BC) seriously affect the quality of life (QOL) of survivors. Physical activity is related to prevention of complications and improvement of QOL. Follow-up can keep patients motivated to exercise. This study aimed to (1) compare the effect of three exercise programs on lymphedema, pain, and QOL in BC patients and (2) explore the effect of intensive follow-up on the outcomes of exercise programs.

METHODS

A single-blind randomized parallel controlled trial with a 6-month intervention was carried out in China in 2021. The study sample included 200 women with BC. The patients were randomly divided into 4 groups. G₀ (control group) was joint mobility exercise (JME) group; G₁ was joint mobility exercise + intensive follow-up (IF) group; G₂ was JME + aerobic exercise (AE) + IF group; and G₃ was JME + progressive resistance exercise (PRE) + IF group. Outcome measures were evaluated at baseline (T₁), 3 months post-intervention (T₂), and 6 months post-intervention (T₃). The following instruments and measurements were administered before and after the intervention: the Functional Assessment of Cancer Therapy-Breast (FACT-B) instrument, the numerical rating scale (NRS), and the relative volume change (RVC). Verificating aim 1 is by comparing the results of G₁, G₂, and G₃, and verificating aim 2 is achieved by comparing G₀ and G₁. Differences before and after the intervention were determined by analysis of variance of repeated measures and Kruskal-Wallis nonparametric analysis of variance.

RESULTS

Among the exercise programs, JME + PRE + IF resulted in the best improvement in QOL (T2: ΔG₃-G₀ = 13.032, P = 0.008; T2: ΔG₃-G₁ = 13.066, P < 0.001; ΔG₃-G₀ = 17.379, P < 0.001). For pain relief, JME + AE + IF had the best improvement (T3: ΔG₂-G₁ =  - 0.931, P = 0.010; ΔG₂-G₀ =  - 1.577, P < 0.001). For the prevention of lymphedema, JME + AE + IF (Z = 2.651, P = 0.048) and JME + PRE + IF (Z = 3.277, P = 0.006) had the similar effect, but JME + PRE + IF is better than JME + AE + IF.

CONCLUSION

JME + PRE have the best effect in improving the QOL and preventing lymphedema after surgery. In improving pain, the effect of JME + AE appears earlier, and the overall effect of JME + PRE is better. In addition, long-term and planned monitoring and follow-up are also important.

Long-Term Effects of Breast Cancer Therapy and Care: Calm after the Storm?

Breast cancer is still a lethal disease and the leading cause of death in women, undermining patients' survival and quality of life. Modern techniques of surgery and radiotherapy allow for the obtaining of good results in terms of survival, however they cause long-term side effects that persist over time, such as lymphedema and neuropathy. Similarly, the advent of new therapies such as endocrine therapy revolutionized breast cancer outcomes, but side effects are still present even in years of follow-up after cure. Besides the side effects of medical and surgical therapy, breast cancer is a real disruption in patients' lives considering quality of life-related aspects such as the distortion of body image, the psychological consequences of the diagnosis, and the impact on family dynamics. Therefore, the doctor-patient relationship is central to providing the best support both during treatment and afterwards. The aim of this review is to summarize the consequences of medical and surgical treatment on breast cancer patients and to emphasize the importance of early prevention of side effects to improve patients' quality of life.

The prevention and treatment of breast cancer- related lymphedema: A review

Background

Breast cancer- related lymphedema (BCRL) affects about 3 to 5 million patients worldwide, with about 20,000 per year in the United States. As breast cancer mortality is declining due to improved diagnostics and treatments, the long-term effects of treatment for BCRL need to be addressed.

Methods

The American Society of Breast Surgeons Lymphatic Surgery Working Group conducted a large review of the literature in order to develop guidelines on BCRL prevention and treatment. This was a comprehensive but not systematic review of the literature. This was inclusive of recent randomized controlled trials, meta-analyses, and reviews evaluating the prevention and treatment of BCRL. There were 25 randomized clinical trials, 13 systemic reviews and meta-analyses, and 87 observational studies included.

Results

The findings of our review are detailed in the paper, with each guideline being analyzed with the most recent data that the group found evidence of to suggest these recommendations.

Conclusions

Prevention and treatment of BCRL involve a multidisciplinary team. Early detection, before clinically apparent, is crucial to prevent irreversible lymphedema. Awareness of risk factors and appropriate practice adjustments to reduce the risk aids are crucial to decrease the progression of lymphedema. The treatment can be costly, time- consuming, and not always effective, and therefore, the overall goal should be prevention.

Early Referral for Breast-Cancer-Related Lymphedema: Do We Follow the Evidence? A Two-Year Prospective Multicenter Cohort Study

The early detection of breast-cancer-related lymphedema and referral for therapy has the potential to reduce lymphedema-related morbidity. Although research shows the benefits, a gap is observed between evidence and daily practice. We aimed to determine whether the early detection of lymphedema and referral for treatment is adequate following the current guidelines. Women with primary breast cancer treated with breast-conserving therapy or ablative treatment were included. Demographic-, general health-, tumor-, and treatment-related data were recorded. Bilateral arm volume measurements were performed preoperatively and 3, 6, 12, and 24 months post-surgery. A 5% or greater Relative Volume Change was considered the cutoff point for lymphedema and as an indication for therapy referral. After 24 months post-surgery, the main outcomes show that among the patients with early signs of lymphedema, based on a Relative Volume Change ≥5%, a nonreferral for therapy was noted in 83%. Additionally, we observed a significant improvement of the mean Relative Volume Change at 24 months within this group, which might implicate that nonreferral was an adequate choice and that watchful waiting is appropriate when lymphedema is detected within the first year post-surgery.

The Post-Operative Mammographic Appearance of Lymphovenous Bypass and Vascularized Lymph Node Transfer

The postoperative mammographic imaging appearance related to lymphovenous bypass and vascularized lymph node transfer has not been described. It is important for breast imagers to become familiar with the expected appearance of surgical changes that can be seen in the follow up imaging of breast cancer survivors in order to create accurate reports and adjust imaging protocols to improve imaging quality and lessen patient discomfort as needed.

Evaluation of Circulating MicroRNAs and Adipokines in Breast Cancer Survivors with Arm Lymphedema

Breast cancer-related lymphedema (BCRL) is a form of secondary lymphedema that is characterized by abnormal swelling of one or both arms due to the accumulation of lymph fluid in the interstitial tissue spaces, resulting from obstruction of the lymphatic vessels due to surgery insults, radiotherapy, or chemotherapy. Due to the multifactorial nature of this condition, the pathogenesis of secondary lymphedema remains unclear and the search for molecular factors associated with the condition is ongoing. This study aimed to identify serum microRNAs and adipokines associated with BCRL. Blood was collected from 113 breast cancer survivors and processed to obtain serum for small RNA-sequencing (BCRL vs. non-BCRL, n = 7 per group). MicroRNAs that were differentially expressed (fold change >1.5, p < 0.05) between lymphedema cases and those without lymphedema were further quantified in a validation cohort through quantitative reverse transcription PCR (BCRL n = 16, non-BCRL, n = 83). Leptin and adiponectin levels were measured in a combined cohort (BCRL n = 23, non-BCRL n = 90) using enzyme-linked immunosorbent assays. Two of the most significantly upregulated microRNAs, miR-199a-3p and miR-151a-3p, were strongly correlated with the onset of lymphedema and diabetes mellitus in the BCRL group. Leptin levels were higher in the BCRL cohort compared to the non-BCRL cohort (p < 0.05). A metabolic syndrome biomarker, the adiponectin/leptin ratio, was found to be lower in the BCRL group than in the non-BCRL group (median: 0.28 vs. 0.41, p < 0.05). Extensive studies on the mechanisms of the identified microRNAs and association of leptin with arm lymphedema may provide new insights on the potential biomarkers for lymphedema that should be followed up in a prospective cohort study.

A machine learning ensemble approach for 5- and 10-year breast cancer invasive disease event classification

Designing targeted treatments for breast cancer patients after primary tumor removal is necessary to prevent the occurrence of invasive disease events (IDEs), such as recurrence, metastasis, contralateral and second tumors, over time. However, due to the molecular heterogeneity of this disease, predicting the outcome and efficacy of the adjuvant therapy is challenging. A novel ensemble machine learning classification approach was developed to address the task of producing prognostic predictions of the occurrence of breast cancer IDEs at both 5- and 10-years. The method is based on the concept of voting among multiple models to give a final prediction for each individual patient. Promising results were achieved on a cohort of 529 patients, whose data, related to primary breast cancer, were provided by Istituto Tumori "Giovanni Paolo II" in Bari, Italy. Our proposal greatly improves the performances returned by the baseline original model, i.e., without voting, finally reaching a median AUC value of 77.1% and 76.3% for the IDE prediction at 5-and 10-years, respectively. Finally, the proposed approach allows to promote more intelligible decisions and then a greater acceptability in clinical practice since it returns an explanation of the IDE prediction for each individual patient through the voting procedure.

Early Blood Flow Abnormalities in Axillary and Brachial Arteries Precede the Onset of Persistent Lymphedema in Women Treated Surgically for Breast Cancer

Background: surgery to treat breast cancer (BC) is associated with upper limb (UL) lymphedema, which in some cases may become permanent. It is uncertain whether lymphedema results from injury to either lymphatic or blood vessels, or to both. Methods and Results: a cohort of 200 BC patients was examined 1, 3, 6, 12, and 24 months after surgery. Axillary and brachial blood vessels were evaluated using Doppler Ultrasound, and patients had their UL examined for lymphedema at each visit. Patients who developed lymphedema 24 months after surgery presented with higher mean flow velocity (MFV) and end diastolic velocity (EDV) in both axillary (MFV = 13.57 vs. 10.7 cm/s, p = 0.02; EDV = 5.62 vs. 3.47 cm/s; p = 0.004) and brachial (MFV = 11.44 vs. 8.74 cm/s; p = 0.03; EDV = 5.08 vs. 3.04; p = 0.04) arteries as early as 1 month after surgery. Similar associations were found 3, 6, and 12 months after surgery. Early abnormalities of the resistive and pulsatility indexes were also significantly associated with persistent lymphedema. EDV measured 1 month after surgery had the best performance to detect patients who will later develop long-term lymphedema, (sensitivity = 73.7%; specificity = 71.2%; negative predictive value = 57.6%). Conclusion: vascular abnormalities precede and are possible causal factors for UL lymphedema in BC patients.

Risk factors of non-sentinel lymph node metastasis in 443 breast cancer patients with sentinel lymph node-positive

Axillary lymph node dissection is the standard surgical procedure for breast cancer patients with sentinel lymph node (SLN) positive. In clinical practice, axillary lymph node dissection may be an unnecessary treatment for some breast cancer patients with non-sentinel lymph node (NSLN) negative. The aim of this study was to analyze the risk factors of NSLN metastasis in breast cancer patients with SLN positive. Four hundred fifty-six clinical early stage breast cancer patients with SLN positive were collected and analyzed in the oncological surgery department of Fujian Provincial Hospital during 2013 to 2018. All these patients underwent surgical treatment. The average age and tumor size of 443 patients with SLN positive breast cancer were (49.8 ± 10.8) years and (2.42 ± 0.94) cm. Univariate analysis showed that the size of primary tumor, the number of positive SLN, the number of negative SLN, the ratio of positive SLNs, and the type of metastases in SLN were the influencing factors of NSLN metastasis. Multivariate regression analysis showed that primary tumor size T > 2 cm (P < .001, OR = 2.609), the positive number of SLNs ≥3 (P = .002, OR = 5.435), the ratio of positive SLNs ≥ 50% (P = .017, OR = 1.770), and SLN macrometastases (P < 0.001, OR = 16.099) were independent risk factors for NSLN metastasis. Combined with the 4 independent risk factors, the area under the curve to predict NSLN metastasis was 0.747 > 0.7. For clinical early breast cancer with positive SLN, primary tumor size T > 2 cm,the positive number of SLNs ≥ 3, the ratio of positive SLNs ≥ 50%, and SLN macrometastases could predict NSLN metastasis well, and guide surgery to avoid overtreatment.

Risk factors for breast cancer-related lymphedema in patients undergoing 3 years of prospective surveillance with intervention

Background

To evaluate risk factors (treatment‐related, comorbidities, and lifestyle) for breast cancer–related lymphedema (BCRL) within the context of a Prospective Surveillance and Early Intervention (PSEI) model of care for subclinical BCRL.

Methods

The parent randomized clinical trial assigned patients newly diagnosed with breast cancer to PSEI with either bioimpedance spectroscopy (BIS) or tape measurement (TM). Surgical, systemic and radiation treatments, comorbidities, and lifestyle factors were recorded. Detection of subclinical BCRL (change from baseline of either BIS L‐Dex ≥6.5 or tape volume ≥ 5% and < 10%) triggered an intervention with compression therapy. Volume change from baseline ≥10% indicated progression to chronic lymphedema and need for complex decongestive physiotherapy. In this secondary analysis, multinomial logistic regressions including main and interaction effects of the study group and risk factors were used to test for factor associations with outcomes (no lymphedema, subclinical lymphedema, progression to chronic lymphedema after intervention, progression to chronic lymphedema without intervention). Post hoc tests of significant interaction effects were conducted using Bonferroni‐corrected alphas of .008; otherwise, an alpha of .05 was used for statistical significance.

Results

The sample (n = 918; TM = 457; BIS = 461) was female with a median age of 58.4 years. Factors associated with BCRL risk included axillary lymph node dissection (ALND) (p < .001), taxane‐based chemotherapy (p < .001), regional nodal irradiation (RNI) (p ≤ .001), body mass index >30 (p = .002), and rurality (p = .037). Mastectomy, age, hypertension, diabetes, seroma, smoking, and air travel were not associated with BCRL risk.

Conclusions

Within the context of 3 years of PSEI for subclinical lymphedema, variables of ALND, taxane‐based chemotherapy, RNI, body mass index >30, and rurality increased risk.

The Prospective Surveillance and Early Intervention Model promotes identification and treatment of subclinical lymphedema, facilitating prevention of chronic lymphedema and risk reduction. Axillary lymph node dissection, taxane‐based chemotherapy, regional nodal irradiation, body mass index >30, and rurality are critical risk factors within the context of the Prospective Surveillance and Early Intervention Model for some patients.

Risk Factors Associated With Postmastectomy Breast Cancer Lymphedema: A Multicenter Retrospective Analysis

BACKGROUND

Lymphedema is an edematous condition that afflicts the postmastectomy breast cancer population, with diminished quality of life with substantial financial costs. The factors predictive of postmastectomy lymphedema development in breast cancer patients are unknown. The objective was to evaluate the trends over time in lymphedema development and the risk factors predictive of lymphedema-related events within 2 years of mastectomy.

METHODS

Using the New York Statewide Planning and Research Cooperative System multicenter deidentified database from 2010 to 2016, a total of 65,543 breast cancer postmastectomy female patients (mean age, 59 ± 20 years) were identified across 177 facilities. The breast cancer patients were followed for any 2-year postmastectomy lymphedema-related events. A multivariable model identified predictors of 2-year lymphedema using eligible variables involving demographics, comorbidities, and complications. Elixhauser score was defined as a comorbidity index based on International Classification of Diseases codes used in hospital settings.

RESULTS

Overall, 5.2% (n = 3409) of the breast cancer postmastectomy patients experienced a lymphedema-related event within 2 years of initial surgery. Over time, 2-year postmastectomy lymphedema rates have more than doubled from 4.62% in 2010 to 9.75% in 2016 (P < 0.001). Two-year postmastectomy lymphedema rates varied significantly by mastectomy procedure type: 5.69% of the mastectomy-only procedures, 5.96% of the mastectomies with lymph node biopsies, and 7.83% of the mastectomies with lymph node dissections (P < 0.0001). Full mastectomies had a greater 2-year lymphedema rate of 7.31% when compared with partial mastectomies with 2.79% (P < 0.0001). The top predictive risk factors for a lymphedema-related event included higher Elixhauser score, prolonged hospitalization for mastectomy, more recent mastectomy procedure, obesity, younger age, non-Asian race, Medicaid insurance, and hypertension (all P's < 0.01).

CONCLUSIONS

Although more recent postmastectomy lymphedema rates may not be as high as historical estimates, the 2-year postmastectomy lymphedema rates have more than doubled from 2010 to 2016 requiring further elucidation as well as continued focus on treatment. Furthermore, risk factors were identified that predispose postmastectomy breast cancer patients to developing lymphedema. Given these findings, perioperative screening seems warranted to proactively identify, educate, and monitor postmastectomy patients at greatest risk of future lymphedema development.

Contrast-enhanced ultrasound: a new tool for imaging the superficial lymphatic vessels of the upper limb

Background

Despite the new lymphatic imaging methods, there is still a need for a straightforward method of detecting lymphatic abnormalities. Our goal was to investigate the feasibility of applying a contrast enhanced ultrasound (CEUS) procedure as a new approach for visualising the superficial lymphatic vessels of the upper limb.

Methods

Thirty healthy volunteers were examined with CEUS after bilateral intradermal injection of Sonazoid® contrast agent in distal antebrachium. We registered factors affecting intradermal injections, imaging of the superficial lymphatic vessels and the enhancement time of contrast agent reaching the levels of elbow and axilla.

Results

CEUS imaging of superficial lymphatic vessels was successful in 59 of 60 upper limbs (98.3%). Median [interquartile ranges] enhancement times of contrast agent to reach the elbow (right 18 s [11–25], left 15 s [12–25]) and axilla (right 77 s [33–118], left 66 s [42–115]) were equally fast. Successful intradermal injections were found to result in two types of contrast enhancement (strong or moderate), while the enhancement time depended on the type of the successful injection. No major differences in enhancement times were observed related to sex, body mass index, age, or side of the arm.

Conclusions

The superficial lymphatic pathways of the upper limb can be visualised with CEUS imaging. Since enhancement time is dependent on the success of intradermal injections, one must pay attention to the injection technique. Further studies are needed to evaluate the method in patients with lymphatic function disorders such as breast cancer therapy related lymphoedema.

Differences in the Glenohumeral Joint before and after Unilateral Breast Cancer Surgery: Motion Capture Analysis

After mastectomy, women might lose mobility and develop kinematic changes in the shoulder. The objective of this research was to compare the kinematics of the glenohumeral joint in women, before and after unilateral breast cancer surgery. This was a longitudinal study with a pre- and post-evaluation design; in total, 15 Mexican women who had a mastectomy for breast cancer and who received a physical therapy program after surgery were evaluated. Flexion–extension and abduction–adduction movements of the glenohumeral joint were evaluated (15 days before and 60 days after mastectomy). For the kinematic analysis of the glenohumeral joint, an optoelectronic motion capture system was used to monitor 41 reflective markers located in anatomical landmarks. There was no significant difference in the range of motion of the glenohumeral joint when comparing pre- and post-mastectomy, flexion–extension (p = 0.138), and abduction–adduction (p = 0.058). Furthermore, patients who received chemotherapy (53%) before mastectomy were more affected (lower range of motion) than those who did not receive it. There were no significant differences in the kinematics of the glenohumeral joint after mastectomy in this group of patients who received a physical therapy program after surgery. Moreover, patients who received chemotherapy treatment before breast cancer surgery tended to have a lower range of motion than those who did not receive it. Therefore, it is necessary for the physical rehabilitation team to attend to these patients even before the mastectomy.

The role of bioimpedance spectroscopy method in severity and stages of breast cancer-related lymphedema

Objective: The correlation between lymphedema severity and stages determined by standard diagnostic methods and Bioimpedance Spectroscopy (BIS) technique was examined in breast cancer-related lymphedema (BCRL) patients.

Material and Methods: The bioimpedance analyzer device was connected to the 1.0 cm disc electrodes which were connected to the affected and unaffected (healthy) arm of the patients. We evaluated the performance of the impedance (Z) at multiple frequencies (5-50-100-200 kHz) and phase angle (PA), resistance (R), and reactance (XC) at 50 kHz on the lymphedema severity and stages. Bioimpedance measurements were applied to all volunteers in cooperation with the Physical Therapy and Rehabilitation Department. In this study, the correlation between BCRL severity and stages and bioimpedance values was examined.

Results: A total of 31 female patients were recruited to compare the BIS technique with standard diagnostic techniques. The severity of lymphedema was found among the patients as follows; mild 14 (45.2%), moderate 10 (32.3%), and severe 7 (22.6%). The stage distribution of volunteers was; 15 (48.4%) patients in Stage 0, 10 (32.3%) patients in Stage 1, 5 (16.1%) patients in Stage 2, and 1 (3.2%) patient in Stage 3. The ratio of affected and unaffected arm bioimpedance mean values were calculated. Although, this ratio at 50-100-200 kHz Z and 50kHz R were significantly correlated with the lymphedema stages (p< 0.05), there was no correlation and significant difference between the ratio of the bioimpedance values and lymphedema severity (p> 0.05).

Conclusion: The BIS technique is timesaving and can determine lymphedema stages. We found a significant correlation between BCRL stages and BIS, and it appears that BIS is an appropriate, inexpensive, simple, and noninvasive technique for detecting the stages of BCRL.

Telerehabilitation for Managing Daily Participation among Breast Cancer Survivors during COVID-19: A Feasibility Study

We aimed to examine the feasibility and impact of a short-term occupation-based telerehabilitation intervention (Managing Participation with Breast Cancer (MaP-BC)) on daily participation, health-related quality-of-life, and breast-cancer-related symptoms and understand women's perspectives regarding strategies to manage daily participation and symptoms during COVID-19 pandemic. A mixed-methods study (single-arm pre-post with a qualitative component) included 14 women after their primary medical treatment for breast cancer. Women received six weeks of occupation-based intervention using a video-communication. Sessions focused on identifying functional goals and training strategies to manage daily participation. The primary outcome was perceived performance and satisfaction with meaningful activities by the Canadian Occupational Performance Measure (COPM). Secondary outcomes were participation in the Activity Card Sort (ACS), upper-extremity functioning of Disability Arm Shoulder Hand, self-reported symptom severity, executive-functioning, health-related quality of life, and a question regarding strategies used to manage daily participation. Women significantly improved their daily participation in meaningful activities in the COPM, most ACS activity domains, self-reported executive functioning, and health-related-quality-of-life. Qualitative findings revealed three main themes: (1) daily life under the threats of breast cancer and COVID-19, (2) women's own strategies to overcome challenges, and (3) contribution of the MaP-BC. Providing telerehabilitation during the COVID-19 pandemic is feasible and successful in improving women's daily participation after breast cancer.