Lymphedema following treatment for breast cancer: a new approach to an old problem

Commonly Prescribed Chronic Pharmacological Medications as Risk Factors for Breast Cancer-Related Lymphedema: An Observational Retrospective Cohort Study

Background/Objectives: Breast cancer-related lymphedema (BCRL) is a significant complication of breast cancer (BC) treatment, characterized by swelling and fluid accumulation. Many risk factors have already been proven to be related to BCRL; meanwhile, many others are still debated and poorly investigated in the literature. This study investigated the potential involvement of commonly prescribed chronic medications in BCRL development. Methods: This observational retrospective cohort study included 162 post-surgical breast cancer survivors attending an oncological rehabilitation outpatient service between January 2021 and April 2023. BCRL was diagnosed by physicians through clinical evaluation and objective measures (≥2 cm increase in circumferential girth measurements). Descriptive statistics summarized patient characteristics, and Cox regression models (univariable and multivariable) were employed to analyze risk factors for BCRL. Results: BCRL was observed in 53% of participants. The univariable model identified BMI (hazard ratio 1.07, 95% CI 1.02-1.11), overweight (BMI ≥ 25) (HR 1.46, 95% CI 0.95-2.25), and breast prosthesis implantation (HR 1.75, 95% CI 1.09-2.80) as potential risk factors for lymphedema. In the multivariable model, overweight (HR 2.90, 95% CI 1.18-7.14), hypertension (HR 5.09, 95% CI 1.88-13.79), radiotherapy (HR 3.67, 95% CI 1.43-9.38), and breast prosthesis implantation (HR 8.93, 95% CI 2.77-28.81) were identified as independent risk factors for BCRL. Conclusions: The findings emphasize the need for further research to understand the role of chronic medications in BCRL risk comprehensively.

Assessing Levels of Lymphedema Awareness Among Women With Breast Cancer in King Abdulaziz University Hospital, Jeddah

Introduction Breast cancer poses a global health challenge, requiring a comprehensive approach beyond diagnosis and treatment. Postoperative complications, especially upper limb lymphedema, present intricate challenges for survivors, impacting physical, emotional, and daily life aspects. Our research in Jeddah, Saudi Arabia, delves into cultural and healthcare dynamics, exploring demographic influences on lymphedema. Materials and methods A descriptive quantitative study with a cross-sectional design was conducted among female patients with breast cancer in Saudi Arabia. It included patients who underwent unilateral breast surgery with lymph node excision. Data was analyzed using the SPSS program (IBM Corp., Armonk, NY). Results Our study included 76 participants. Lymphedema was diagnosed in 38.2% of participants. More than half (52.8%) of participants had some knowledge of lymphedema. For instance, 52.6% recognized the impact of hygiene, and 81.6% understood the heightened risk of arm damage. Awareness percentages were also notable for factors like tight shirt pressure (71.1%), straining the arms (86.8%), and the association of being overweight with lymphedema (55.3%). Almost half of the participants recognized the physical therapy and rehabilitation department to be responsible for lymphedema treatment. The mean awareness score was 5.34 ± 1.56. Only 9.2% achieved a good awareness level, while 59.2% had fair awareness, and 31.6% had poor awareness. Conclusion The prevalence of lymphedema, coupled with proactive healthcare-seeking behavior, underscores the need for targeted educational interventions. While the majority recognized the importance of treatment, awareness gaps persisted, especially regarding risk-reduction activities.

Non-invasive technology to assess hydration status in advanced cancer to explore relationships between fluid status and symptoms: an observational study using bioelectrical impedance analysis

BACKGROUND

Oral fluid intake decreases in advanced cancer in the dying phase of illness. There is inadequate evidence to support the assessment, and management, of hydration in the dying. Bioelectrical impedance analysis (BIA) is a body composition assessment tool. BIA has the potential to inform clinal management in advanced cancer, by examining the relationships between hydration status and clinical variables.

AIM

BIA was used to determine the association between hydration status, symptoms, clinical signs, quality-of-life and survival in advanced cancer, including those who are dying (i.e. in the last week of life).

MATERIALS AND METHODS

We conducted a prospective observational study of people with advanced cancer in three centres. Advance consent methodology was used to conduct hydration assessments in the dying. Total body water was estimated using the BIA Impedance index (Height - H (m)2 /Resistance - R (Ohms)). Backward regression was used to identify factors (physical signs, symptoms, quality of life) that predicted H2/R. Participants in the last 7 days of life were further assessed with BIA to assess hydration changes, and its relationship with clinical outcomes.

RESULTS

One hundred and twenty-five people participated (males n = 74 (59.2%), females, n = 51 (40.8%)). We used backward regression analysis to describe a statistical model to predict hydration status in advanced cancer. The model demonstrated that 'less hydration' (lower H2/R) was associated with female sex (Beta = -0.39, p < 0.001), increased appetite (Beta = -0.12, p = 0.09), increased dehydration assessment scale score (dry mouth, dry axilla, sunken eyes - Beta = -0.19, p = 0.006), and increased breathlessness (Beta = -0.15, p = 0.03). 'More hydration' (higher H2/R) was associated with oedema (Beta = 0.49, p < 0.001). In dying participants (n = 18, 14.4%), hydration status (H2/R) was not significantly different compared to their baseline measurements (n = 18, M = 49.6, SD = 16.0 vs. M = 51.0, SD = 12.1; t(17) = 0.64, p = 0.53) and was not significantly associated with agitation (rs = -0.85, p = 0.74), pain (rs = 0.31, p = 0.23) or respiratory tract secretions (rs = -0.34, p = 0.19).

CONCLUSIONS

This is the first study to use bioimpedance to report a model (using clinical factors) to predict hydration status in advanced cancer. Our data demonstrates the feasibility of using an advance consent method to conduct research in dying people. This method can potentially improve the evidence base (and hence, quality of care) for the dying. Future BIA research can involve hydration assessment of cancers (according to type and stage) and associated variables (e.g., stage of illness, ethnicity and gender). Further work can use BIA to identify clinically relevant outcomes for hydration studies and establish a core outcome set to evaluate how hydration affects symptoms and quality-of-life in cancer.

Preoperative Risk Factors for Lymphedema in Inflammatory Breast Cancer

BACKGROUND

 Prophylactic lymphatic bypass or LYMPHA (LYmphatic Microsurgical Preventive Healing Approach) is increasingly offered to prevent lymphedema following breast cancer treatment, which develops in up to 47% of patients. Previous studies focused on intraoperative and postoperative lymphedema risk factors, which are often unknown preoperatively when the decision to perform LYMPHA is made. This study aims to identify preoperative lymphedema risk factors in the high-risk inflammatory breast cancer (IBC) population.

METHODS

 Retrospective review of our institution's IBC program database was conducted. The primary outcome was self-reported lymphedema development. Multivariable logistic regression analysis was performed to identify preoperative lymphedema risk factors, while controlling for number of lymph nodes removed during axillary lymph node dissection (ALND), number of positive lymph nodes, residual disease on pathology, and need for adjuvant chemotherapy.

RESULTS

 Of 356 patients with IBC, 134 (mean age: 51 years, range: 22-89 years) had complete data. All 134 patients underwent surgery and radiation. Forty-seven percent of all 356 patients (167/356) developed lymphedema. Obesity (body mass index > 30) (odds ratio [OR]: 2.7, confidence interval [CI]: 1.2-6.4, p = 0.02) and non-white race (OR: 4.5, CI: 1.2-23, p = 0.04) were preoperative lymphedema risk factors.

CONCLUSION

 Patients with IBC are high risk for developing lymphedema due to the need for ALND, radiation, and neoadjuvant chemotherapy. This study also identified non-white race and obesity as risk factors. Larger prospective studies should evaluate potential racial disparities in lymphedema development. Due to the high prevalence of lymphedema, LYMPHA should be considered for all patients with IBC.

Improving quality of life after breast cancer: a comparison of two microsurgical treatment options for breast cancer-related lymphedema (BCRL)

PURPOSE

Vascularized lymph node transfer (VLNT) entails the autologous relocation of lymph nodes to a lymphedematous region of the body, whereas lymphaticovenous anastomosis (LVA) creates a direct bypass between the lymphatic and venous system. Both techniques are meant to lastingly bolster the local lymphatic drainage capacity. This study compared safety and effectiveness of VLNT and LVA in patients with chronic breast cancer related lymphedema (BCRL).

METHODS

A retrospective cohort study was conducted using data from our encrypted database composed of patients with chronic BCRL who were treated with either VLNT or LVA and had a minimum follow-up of two years. Patient-specific variables analyzed included pre- and postoperative arm circumferences, lymphedema stages and postoperative complications.

RESULTS

A total of 105 patients met the inclusion criteria, of which 96 patients demonstrated a complete follow-up period of two years. The VLNT group displayed larger preoperative circumferential measurements, evident in both in the isolated examination of the affected arm, as well as when adjusted for the contralateral unaffected arm. Significant reduction in arm volume was achieved by both groups. However, VLNT demonstrated superior relative reduction rates than LVA, neutralizing any significant arm size disparities after 24 months. Surgery duration was slightly longer for VLNT than LVA. Postoperative complications, predominantly minor, were exclusively observed in the VLNT group.

CONCLUSIONS

Both VLNT and LVA offer significant improvement for patients suffering from chronic BCRL. VLNT shows an even greater potential for improvement in more severe cases of BCRL, but involves a higher risk for (mostly minor) complications.

Combining reconstructive and ablative surgical treatment of chronic breast cancer-related lymphedema (BCRL): safe and effective

PURPOSE

We investigated whether a one-stage combination of vascularized lymph node transfer (VLNT) with water jet-assisted liposuction (WAL) can be safely performed and results in improved patient outcomes such as a greater reduction in arm volume when treating chronic breast cancer-related lymphedema (BCRL).

METHODS

In this retrospective cohort study, we included all patients from our encrypted lymphedema database treated for chronic BCRL with VLNT or VLNT + WAL who had a minimum follow-up of two years. We analyzed patient-specific variables including arm circumferences as well as patient-reported outcomes before and after surgery as well as surgery time, surgery-related complications and patient satisfaction.

RESULTS

Only the mean preoperative differences of the circumferences between the lymphedematous and the unaffected arm in individual patients showed a statistically significant difference between treatment groups (p < 0.05). Indeed, patients treated with VLNT + WAL had consistently larger differences in individual sets of arms and therefore more pronounced chronic BCRL. The mean surgery time was significantly longer in the VLNT + WAL group (p < 0.05). Complications were seldom and similar in both groups. Using a numeric rating scale, the level of patient satisfaction following treatment did not differ significantly between groups (p = 0.323).

CONCLUSIONS

Our findings suggest that a one-stage combination of VLNT with WAL does not result in more complications even though it also entails a longer surgery time. This is acceptable as secondary interventions resulting in overall longer surgery times and higher costs can be avoided. A one-stage combination might be especially favourable for patients suffering from more severe chronic BCRL.

Lymphedema in Inflammatory Breast Cancer Patients Following Trimodal Treatment

BACKGROUND

Breast cancer-related lymphedema (BCRL) is a debilitating sequela of breast cancer treatment and is becoming a greater concern in light of improved long-term survival. Inflammatory breast cancer (IBC) is a rare and aggressive malignancy for which systemic therapy, surgery, and radiotherapy remain the standard of care, thereby making IBC patients highly susceptible to developing BCRL. This study evaluated BCRL in IBC following trimodal therapy.

METHODS

IBC patients treated from 2016 to 2019 were identified from an institutional database. Patients were excluded if they presented with recurrent disease, underwent bilateral axillary surgery, did not complete trimodal therapy, or were lost to follow-up. Demographic, clinicopathologic factors, oncologic outcomes, and perometer measurements were recorded. BCRL was defined by clinician diagnosis and/or objective perometer measurements when available. Time to development of BCRL and treatment received were captured.

RESULTS

Eighty-three patients were included. Median follow-up was 33 months. The incidence of BCRL was 50.6% (n = 42). Mean time to BCRL from surgery was 13 (range 2-24) months. Demographic and clinicopathologic features were similar between patients with and without BCRL with exception of higher proportion receiving delayed reconstruction in the BCRL group (38.1% vs. 14.6%, p = 0.03). Forty patients (95.2%) underwent BCRL treatment, which included physical therapy (n = 39), compression (n = 38), therapeutic lymphovenous bypass (n = 13), and/or vascularized lymph node transfer (n = 12).

CONCLUSIONS

IBC patients are at high-risk for BCRL after treatment, impacting 51% of patients in this cohort. Strategies to reduce or prevent BCRL and improve real-time diagnosis should be implemented to better direct early management in this patient population.

A Software Suite for Limb Volume Analysis Applicable in Clinical Settings: Upper Limb Quantification

In medicine, tridimensional scanning devices produce digital surfaces that replicate the bodies of patients, facilitating anthropometric measurement and limb volume quantification in pathological conditions. Free programs that address this task are not commonly found, with doctors mainly relying on proprietary software. This aspect brings reduced reproducibility of studies and evaluation of alternative measures. A software package made up of three programs has been developed and released together with supporting materials to enhance reproducibility and comparisons between medical centers. In this article, the functions of the programs and steps for volume assessment were introduced together with a pilot study for upper limb volume quantification. This initial experiment aimed to also verify the performance of digital volumes derived from the convex-hull gift-wrapping algorithm and the alternative analysis methods enclosed in the software. Few of these digital volumes are parameter-dependent, requiring a value selection. The experiment was conducted on a small mixed-gender group of young adults without correction for factors like arm dominance or specific physical training. In the sample under investigation, the analysis confirmed the substantial agreement between the clinical and current configurations of digital volumes produced by the package (R ² interval from 0.93 to 0.97, r ranged from 0.965 to 0.984); in addition, as a general consideration, gender appears as a variable that could influence upper limb volume quantification if a single model is built.

Impact of hand lymphedema on pain and grip strength of the hand in women with breast cancer

Background: It is not clear to what extent signs and symptoms other than arm swelling, including pain, grip strength  differ between women with hand lymphedema and without hand lymphedema in breast cancer–related lymphedema (BCRL)Aim of Study: To estimate the extent to which the impairments associated with hand  lymphedema on pain and grip strength in women with breast cancer related lymphedema (BCRL) and to see the association between severity of hand edema and each of independent variables ( pain and hand grip strength )Methods: sixty women experiencing lymphedema after breast surgery participated in this study. They were recruited from Kasr Al-ainy , between 40: 60 years old were assigned into two equal groups, group (A) women with hand edema (HE+, n = 30) and without hand edema (HE−, n = 30) after breast cancer treatment .Pain and grip strength were evaluated Results: inter group difference showed that there is a there was significant difference in pain difference between the group A and group B (p = 0.04)And there was a significant increase in median value of strength difference of the group A compared with that of group B (p = 0.001).

Quality of life improvement in breast cancer survivors affected by upper limb lymphedema through a novel multiperspective physical activity methodology: a monocentric pilot study

PURPOSE

Chronic lymphedema causes psychophysical sequelae jeopardizing quality of life (QoL) of breast cancer (BC) survivors, and lack of effective therapies represents a major challenge for healthcare professionals. Structured adapted physical activity (APA) may represent an effective strategy to attenuate cancer treatment-related impairments and improve QoL. Here, we describe the effects of a specific APA intervention based on a novel multiperspective methodology in counteracting lymphedema-related morphofunctional alterations and improving QoL of BC survivors.

METHODS

BC survivors with chronic moderate/severe lymphedema attending the Cancer Rehabilitation Center in Florence were assessed before and after 8-week APA. The protocol consisted of both APA specialist-supervised and self-leaded sessions using a tailor-designed proprioceptive board. Body mass index, bioimpedance parameters, indirect upper limb volume measurement, and ultrasonography were performed. Wrist flexion/extension and hand strength functional tests were also executed. QoL, depression/anxiety and pain intensity were evaluated by ULL27, HADS, distress thermometer and NRS questionnaires, respectively.

RESULTS

Although bioimpedance, ultrasound and volumetric measures remained mostly unchanged, wrist mobility, pain perception, depression, and QoL were all significantly ameliorated after APA.

CONCLUSIONS

Our findings suggest that a multidisciplinary treatment approach involving APA professionals should be employed in the management of BC-related lymphedema to improve patient psychophysical outcomes and QoL.

Diagnostic Criteria for Breast Cancer-Related Lymphedema of the Upper Extremity: The Need for Universal Agreement

With advances in breast cancer treatments and resultant increased survival rates, emphasis has been placed on post-treatment complications such as breast cancer-related lymphedema (BCRL), a chronic, negative sequela of breast cancer treatment. Accurate BCRL diagnosis necessitates longitudinal screening beginning at preoperative baseline. Prospective screening programs incorporating symptoms, objective measurements and clinical examination allow for early detection, early intervention, and improved BCRL prognosis. Currently, varied diagnostic criteria for BCRL exist, and this lack of consensus leads to variation in diagnostic and screening practices across institutions. This review outlines current diagnostic tools, including subjective and objective measurement methods and clinical examination. The merits of different criteria are evaluated and recommendations are made regarding measurement tools and diagnostic criteria for BCRL. Ultimately, the BCRL diagnostic process should be universalized and combine objective measurements, clinical evaluation, and symptoms assessment, and adhere to the best practices of the measurement tools used.

[Early and Late Toxicities and Socio-Medical Relevant Disorders after Oncological Treatment for Breast Cancer-Implications and Assessment of Rehabilitation Requirement]

INTRODUCTION

Reasonable to the improved prognosis of breast cancer (BC) long-term toxicities and side effects of oncological therapy gain more importance for work ability and social life of BC patients. Aim of this study was the analysis of occurence and differences of treatment-related side effects in relation to type of rehabilitation (so-called AHB vs. later rehabilitation) after therapy for BC.

METHODS

Clinical and patient related data as early and late toxicities after oncological treatment of 8.000 patients with BC (55.7±10.4y) were analyzed and compared with current literature.

RESULTS

In 23.9% a mastectomy was performed, in 87.3% radiotherapy. In most cases an additional systemic treatment (57,6% CTX, 15,1% anti-Her2, 71% antihormonal treatment) was carried out. In 8.1% women suffered from recurrent or metastatic BC. As most common side effects of multimodal treatment weakness/fatigue (73,6%), insomnia (51,9%), CIPN (33%), lymph edema (13,9%) and drug-induced arthralgia (24,8%) were detected. In addition, 60.4% of women reported high levels of psychological distress. Shortly after therapy typical side effects were drug-induced toxicities (Leucopenia, p<0.0001; anemia, p<0.001; weakness/fatigue p<0.001; CIPN, p<0.0001), whereas in a later course chronic lymphedema (p<0.0001), chronic or recurrent disease (p<0.0001), status after mastectomy (p<0.0001) and psychological distress (p<0.0001) were significantly more often seen. Moreover, in this collective patients were significantly younger (53,7±9,8 vs. 56,3±10,7y).

CONCLUSIONS

In BC patients, significantly different impairments and toxicities were documented between patients with early rehabilitation and patients with later onset of rehabilitation. These data may help to establish more individual and focused rehabilitation concepts in specialized centers.

Informational Needs in Patients With Breast Cancer With Lymphedema: Is It Important?

Introduction

Lymphedema is one of the complications of breast cancer treatment. It has no cure yet and can affect the quality of life. This study aimed to identify and investigate informational needs, preferred delivery methods, and time of receiving information about lymphedema for these patients.

Methods

One hundred participants were recruited through Lymphedema Clinic in Motamed Cancer Institute in Tehran, Iran, through convenience sampling and were asked to complete a self-administered survey. Data collection took place on all opening days between October 2018 and mid-March 2019.

Results

Most of the participants were above 40 years, have a diploma, homemaker, and the average income of most of the participants (57.2%) was low. The importance of having lymphedema information was very high for them. Most of them wanted detailed information at diagnosis of breast cancer. The preferred information of delivery methods were private sessions and social networks.

Conclusions

Patients with breast cancer who have lymphedema have high needs as regards concise lymphedema information. Private sessions with physicians and social networks can provide detailed information for them.

Kinesio taping versus compression garments for treating breast cancer-related lymphedema: a randomized, cross-over, controlled trial

OBJECTIVE

To determine the effectiveness of Kinesio taping compared to compression garments during maintenance phase of complex decongestive therapy for breast cancer-related lymphedema.

DESIGN

Randomized, cross-over, controlled trial.

SETTING

Outpatient tertiary-level hospital rehabilitation setting.

SUBJECTS

Randomized sample of 30 women with breast cancer-related lymphedema.

INTERVENTIONS

Participants received two interventions, Kinesio taping and compression garment, both lasting four weeks, whose order was randomized by blocks. A four-week washout period was established prior to the interventions and between them.

MEASUREMENTS

The main outcome was the lymphedema Relative Volume Change. Secondary outcomes were range of motion of arm joints, self-perception of comfort, and lymphedema-related symptoms (pain, tightness, heaviness, and hardness).

RESULTS

The decrease in the Relative Volume Change was greater in the Kinesio taping intervention (-5.7%, SD = 2.0) compared to that observed using compression garments (-3.4%, SD = 2.9) (P < 0.001). The range of motion of five upper-limb movements increased after applying taping (between 5.8° and 16.7°) (P < 0.05), but not after compression (P > 0.05). In addition, taping was perceived as more comfortable by patients (between 2.4 and 3 points better than compression in four questions with a 5-point scale (P < 0.001)) and further reduced lymphedema-related symptoms compared to compression (between 0.96 and 1.40 points better in four questions with a 6-point scale (P < 0.05)).

CONCLUSION

Kinesio taping was more effective than compression garments for reducing the lymphedema volume, with less severe lymphedema-related symptoms, better improvement of upper-limb mobility, and more comfort.

Intra- and Interrater Reliability and Concurrent Validity of a New Tool for Assessment of Breast Cancer-Related Lymphedema of the Upper Extremity

OBJECTIVE

The goal of this study was to develop and assess intra- and interrater reliability and validity of a clinical evaluation tool for breast cancer-related lymphedema, for use in the context of outcome evaluation in clinical trials.

DESIGN

Blinded repeated measures observational study.

SETTING

Outpatient research laboratory.

PARTICIPANTS

Breast cancer survivors with and without lymphedema (N=71).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

The assessment of intraclass correlation coefficients (ICCs) for the Breast Cancer-Related Lymphedema of the Upper Extremity (CLUE) standardized clinical evaluation tool.

RESULTS

Intrarater reliability for the CLUE tool was ICC: 0.88 (95% confidence interval [95% CI], 0.71-0.96). Interrater reliability for the CLUE tool was ICC: 0.90 (95% CI, 0.79-0.95). Concurrent validity of the CLUE score (Pearson r) was 0.79 with perometric interlimb difference and 0.53 with the Norman lymphedema overall score.

CONCLUSIONS

The CLUE tool shows excellent inter- and intrarater reliability. The overall CLUE score for the upper extremity also shows moderately strong concurrent validity with objective and subjective measures. This newly developed clinical, physical assessment of upper extremity lymphedema provides standardization and a single score that accounts for multiple constructs. Next steps include evaluation of sensitivity to change, which would establish usefulness to evaluate intervention efficacy.

Correlation of Bioimpedance Spectroscopy with Risk Factors for the Development of Breast Cancer-Related Lymphedema

Background: We reviewed serial bioimpedance measurements in order to quantify the relationship between changes in these scores and a patient's risk for developing breast cancer-related lymphedema (BCRL).

Methods and Results: From April 2010 through November 2016, 505 patients were prospectively evaluated using bioimpedance spectroscopy (BIS/L-Dex). Patients received preoperative and postoperative L-Dex measurements and were categorized based upon risk for BCRL with respect to axillary staging procedure, radiation use, taxane use, and body mass index (BMI). L-Dex change was associated with the type and number of BCRL risk factors. Both axillary lymph node dissection (ALND) and regional nodal irradiation (RNI) were associated with a greater change in L-Dex (p < 0.001), although elevated BMI was not associated. The median, maximal change in L-Dex for patients treated with ALND, RNI, and taxanes was 16.7 versus 5.2 for ALND alone and 3.7 for sentinel lymph node biopsy (SLNB) alone (p = 0.016). In a model using all four risk factors to predict the maximal change in L-Dex, ALND and RNI remained significantly associated with maximum change (p < 0.05). The time required to reach maximal change in L-Dex was shorter in patients treated with ALND or RNI (the time for 25% of patients achieving an L-Dex ≥7 was 4.3 months for ALND, RNI, and taxanes patients versus 30.8 months for SLNB-alone patients).

Conclusions: Risk factors for development of BCRL were associated with both the magnitude and timing of change in L-Dex scores. These findings demonstrate the utility of serial L-Dex measurements in providing an objective assessment of a patient's lymphedema status and the value of L-Dex serial measurements to assist in monitoring patients for the development of BCRL. This supports the clinical utilization of serial L-Dex scores to follow patients at risk for BCRL.

Community-based lymphedema risk reduction programs for cancer survivors: An Internet survey of public health nurses

AIM

Currently, there is no provision for continuous care to monitor lymphedema risk-reduction behavior for survivors of cancer. The aim was to explore the possibility of community-based lymphedema education programs by investigating the knowledge, training needs, and intention to organize such programs and barriers among government-employed public health nurses.

METHODS

A cross-sectional Internet survey was conducted among government-employed public health nurses in Japan. The participants were recruited from 2841 health center and community health centers.

RESULTS

The final sample included 641 government-employed public health nurses. The participants' knowledge about lymphedema risk-reduction strategies was relatively good, especially on the importance of observation, detection of early signs, and referral to lymphedema clinics. A small proportion of participants indicated an intention to organize community-based lymphedema education programs. Three determinants for this intention were identified: a general interest in lymphedema education, past experience of undertaking training in lymphedema risk-reduction strategies, and the perceived difficulty in organizing community-based lymphedema education programs. The participants' perceptions of difficulty included not knowing the needs for lymphedema education in their community with survivors of cancer.

CONCLUSIONS

The results suggest that working collaboratively with government-employed public health nurses to organize community-based lymphedema education programs is possible. Achieving this requires further investigation of the needs of survivors of cancer in the community, communicating these needs to governmental agencies, and organizing and delivering comprehensive training programs about lymphedema risk-reduction strategies for government-employed public health nurses.

Association Between Precautionary Behaviors and Breast Cancer-Related Lymphedema in Patients Undergoing Bilateral Surgery

Purpose This study examined the lifestyle and clinical risk factors for lymphedema in a cohort of patients who underwent bilateral breast cancer surgery. Patients and Methods Between 2013 and 2016, 327 patients who underwent bilateral breast cancer surgery were prospectively screened for arm lymphedema as quantified by the weight-adjusted volume change (WAC) formula. Arm perometry and subjective data were collected preoperatively and at regular intervals postoperatively. At the time of each measurement, patients completed a risk assessment survey that reported the number of blood draws, injections, blood pressure readings, trauma to the at-risk arm, and number of flights since the previous measurement. Generalized estimating equations were applied to ascertain the association among arm volume changes, clinical factors, and risk exposures. Results The cohort comprised 327 patients and 654 at-risk arms, with a median postoperative follow-up that ranged from 6.1 to 68.2 months. Of the 654 arms, 83 developed lymphedema, defined as a WAC ≥ 10% relative to baseline. On multivariable analysis, none of the lifestyle risk factors examined through the risk assessment survey were significantly associated with increased WAC. Multivariable analysis demonstrated that having a body mass index ≥ 25 kg/m2 at the time of breast cancer diagnosis ( P = .0404), having undergone axillary lymph node dissection ( P = .0464), and receipt of adjuvant chemotherapy ( P = .0161) were significantly associated with increased arm volume. Conclusion Blood pressure readings, blood draws, injections, and number or duration of flights were not significantly associated with increases in arm volume in this cohort. These findings may help to guide patient education about lymphedema risk reduction strategies for those who undergo bilateral breast cancer surgery.

Diagnosis of Upper Quadrant Lymphedema Secondary to Cancer: Clinical Practice Guideline From the Oncology Section of the American Physical Therapy Association

The Oncology Section of the American Physical Therapy Association (APTA) developed a clinical practice guideline to aid the clinician in diagnosing secondary upper quadrant cancer-related lymphedema. Following a systematic review of published studies and a structured appraisal process, recommendations were written to guide the physical therapist and other health care clinicians in the diagnostic process. Overall clinical practice recommendations were formulated based on the evidence for each diagnostic method and were assigned a grade based on the strength of the evidence for different patient presentations and clinical utility. In an effort to maximize clinical applicability, recommendations were based on the characteristics as to the location and stage of a patient's upper quadrant lymphedema.

Diagnosis of Upper-Quadrant Lymphedema Secondary to Cancer: Clinical Practice Guideline From the Oncology Section of APTA

INTRODUCTION

The Oncology Section of APTA developed a clinical practice guideline to aid the clinician in diagnosing secondary upper-quadrant cancer-related lymphedema.

METHODS

Following a systematic review of published studies and a structured appraisal process, recommendations were written to guide the physical therapist and other health care clinicians in their diagnostic process. Overall, clinical practice recommendations were formulated on the basis of the evidence for each diagnostic method and were assigned a grade based on the strength of the evidence for different patient presentations and clinical utility.

RECOMMENDATIONS

In an effort to make these clinically applicable, recommendations were based on the characteristics as to the location and stage of a patient's upper-quadrant lymphedema.

Diagnostic Methods, Risk Factors, Prevention, and Management of Breast Cancer-Related Lymphedema: Past, Present, and Future Directions

PURPOSE OF REVIEW

Breast cancer-related lymphedema (BCRL) is a chronic, adverse, and much feared complication of breast cancer treatment, which affects approximately 20% of patients following breast cancer treatment. BCRL has a tremendous impact on breast cancer survivors, including physical impairments and significant psychological consequences. The intent of this review is to discuss recent studies and analyses regarding the risk factors, diagnosis, prevention through early screening and intervention, and management of BCRL.

RECENT FINDINGS

Highly-evidenced risk factors for BCRL include axillary lymph node dissection, lack of reconstruction, radiation to the lymph nodes, high BMI at diagnosis, weight fluctuations during and after treatment, subclinical edema within and beyond 3 months after surgery, and cellulitis in the at-risk arm. Avoidance of potential risk factors can serve as a method of prevention. Through establishing a screening program by which breast cancer patients are measured pre-operatively and at follow-ups, are objectively assessed through a weight-adjusted analysis, and are clinically assessed for signs and symptoms, BCRL can be tracked accurately and treated effectively. Management of BCRL is done by a trained professional, with research mounting towards the use of compression bandaging as a first line intervention against BCRL. Finally, exercise is safe for breast cancer patients with and without BCRL and does not incite or exacerbate symptoms of BCRL.

SUMMARY

Recent research has shed light on BCRL risk factors, diagnosis, prevention, and management. We hope that education on these aspects of BCRL will promote an informed, consistent approach and encourage additional research in this field to improve patient outcomes and quality of life in breast cancer survivors.

Satisfaction with a therapeutic sleeve for arm lymphedema secondary to breast cancer treatment: Controlled crossover trial

Highlights

Secondary lymphedema is a late iatrogenic side effect of breast cancer treatment.Despite multimodal decongestive therapy in their daily life breast cancer survivors with lymphedema have few alternatives but to use a compressive sleeve.Concerned with the well-known low compliance to the daily use of traditional sleeves, we conducted a comparative study to evaluate the subjective assessment of an innovative class 1 compression sleeve.We concluded that the PRADEX^® sleeve, not being worse in its compressive efficacy, is much better with regard to patient comfort.

Abstract

Secondary arm lymphedema is a feared late iatrogenic side effect of breast cancer survivors with a negative impact on patient's self-image and quality of life. Its reported incidence is extremely variable, from 6% to 80%, as well as the effectiveness of the multimodal decongestive lymphedema therapy.In their daily life breast cancer survivors with lymphedema have few alternatives but to use a compressive sleeve. Concerned with the well-known low compliance to the daily use of traditional sleeves, we conducted a comparative study in a subgroup of our patients with lymphedema secondary to breast cancer treatment for the subjective assessment of PRADEX^®, an innovative class 1 compression sleeve. Secondarily, we aimed to assess the non-inferiority of PRADEX^® regarding subjective and objective measures of the severity of lymphedema.We studied 46 women with grade 1 secondary arm lymphedema, who used their usual sleeve and PRADEX^® daily for 2 weeks each, in a crossover design.The new therapeutic sleeve was classified as having a better design and a better usability and comfort (more comfortable, thinner, fresher, softer, more flexible, comfortable, resistant to dirt and easier to dress and to wear). Women's subjective opinion about the severity of lymphedema favored their usual sleeve in detriment of PRADEX^®, but this subjective feeling was contradicted by objective measurements of different perimeters of the arm at the beginning and at the end of the study.We concluded that the PRADEX^® sleeve, not being worse in its compressive therapeutic efficacy, is much better with regard to patient comfort.

The need for preoperative baseline arm measurement to accurately quantify breast cancer-related lymphedema

Breast cancer-related lymphedema (BCRL) is a feared outcome of breast cancer treatment, yet the push for early screening is hampered by a lack of standardized quantification. We sought to determine the necessity of preoperative baseline in accounting for temporal changes of upper extremity volume. 1028 women with unilateral breast cancer were prospectively screened for lymphedema by perometry. Thresholds were defined: relative volume change (RVC) ≥10 % for clinically significant lymphedema and ≥5 % including subclinical lymphedema. The first postoperative measurement (pseudo-baseline) simulated the case of no baseline. McNemar's test and binomial logistic regression models were used to analyze BCRL misdiagnoses. Preoperatively, 28.3 and 2.9 % of patients had arm asymmetry of ≥5 and 10 %, respectively. Without baseline, 41.6 % of patients were underdiagnosed and 40.1 % overdiagnosed at RVC ≥ 5 %, increasing to 50.0 and 54.8 % at RVC ≥ 10 %. Increased pseudo-baseline asymmetry, increased weight change between baselines, hormonal therapy, dominant use of contralateral arm, and not receiving axillary lymph node dissection (ALND) were associated with increased risk of underdiagnosis at RVC ≥ 5 %; not receiving regional lymph node radiation was significant at RVC ≥ 10 %. Increased pseudo-baseline asymmetry, not receiving ALND, and dominant use of ipsilateral arm were associated with overdiagnosis at RVC ≥ 5 %; increased pseudo-baseline asymmetry and not receiving ALND were significant at RVC ≥ 10 %. The use of a postoperative proxy even early after treatment results in poor sensitivity for identifying BCRL. Providers with access to patients before surgery should consider the consequent need for proper baseline, with specific strategy tailored by institution.

Symptoms: Lymphedema

Lymphedema is one of the main late effects from breast cancer treatment affecting 3-60% of breast cancer survivors. Primarily occurring in the hand, arm, and/or affected breast, symptoms of lymphedema include swelling, pain, redness, restriction of arm/hand movement, tightness and feelings of fullness. These symptoms not only may limit physical functioning but also negatively affect quality of life, body image, social functioning, and financial status of breast cancer survivors with lymphedema. Unfortunately, there are no standardized methods for prevention, diagnosis, and treatment of breast cancer-related lymphedema. Despite its prevalence and lack of clinical guidelines, lymphedema is one of the most poorly understood, relatively underestimated, and least researched complications of cancer treatment. This chapter reviews the current problem of breast cancer-related lymphedema by investigating prevention and risk reduction strategies, diagnosis, and treatment. In addition, this chapter identifies future research opportunities focusing on prevention and risk reduction strategies, quality of life and physical function, surveillance, patient education, cost, diagnosis, and treatment. Challenges and recommendations for future research in these areas, particularly among underserved populations, are discussed.

Establishing and sustaining a prospective screening program for breast cancer-related lymphedema at the massachusetts general hospital: lessons learned

There has been an increasing call to prospectively screen patients with breast cancer for the development of breast cancer-related lymphedema (BCRL) following their breast cancer treatment. While the components of a prospective screening program have been published, some centers struggle with how to initiate, establish, and sustain a screening program of their own. The intent of this manuscript is to share our experience and struggles in establishing a prospective surveillance program within the infrastructure of our institution. It is our hope that by sharing our history other centers can learn from our mistakes and successes to better design their own prospective screening program to best serve their patient population.

Impact of adjuvant taxane-based chemotherapy on development of breast cancer-related lymphedema: results from a large prospective cohort

Taxane-based chemotherapy for the treatment of breast cancer is associated with fluid retention in the extremities; however, its association with development of breast cancer-related lymphedema is unclear. We sought to determine if adjuvant taxane-based chemotherapy increased risk of lymphedema or mild swelling of the upper extremity. 1121 patients with unilateral breast cancer were prospectively screened for lymphedema with perometer measurements. Lymphedema was defined as a relative volume change (RVC) of ≥10 % from preoperative baseline. Mild swelling was defined as RVC 5- <10 %. Clinicopathologic characteristics were obtained via medical record review. Kaplan-Meier and Cox proportional hazard analyses were performed to determine lymphedema rates and risk factors. 29 % (324/1121) of patients were treated with adjuvant taxane-based chemotherapy. The 2-year cumulative incidence of lymphedema in the overall cohort was 5.27 %. By multivariate analysis, axillary lymph node dissection (ALND) (p < 0.0001), higher body mass index (p = 0.0007), and older age at surgery (p = 0.04) were significantly associated with increased risk of lymphedema; however, taxane chemotherapy was not significant when compared to no chemotherapy and non-taxane chemotherapy (HR 1.14, p = 0.62; HR 1.56, p = 0.40, respectively). Chemotherapy with docetaxel was significantly associated with mild swelling on multivariate analysis in comparison to both no chemotherapy and non-taxane chemotherapy groups (HR 1.63, p = 0.0098; HR 2.15, p = 0.02, respectively). Patients who receive taxane-based chemotherapy are not at an increased risk of lymphedema compared to patients receiving no chemotherapy or non-taxane adjuvant chemotherapy. Those treated with docetaxel may experience mild swelling, but this does not translate into subsequent lymphedema.

Recent progress in the treatment and prevention of cancer-related lymphedema

This article provides an overview of the recent developments in the diagnosis, treatment, and prevention of cancer-related lymphedema. Lymphedema incidence by tumor site is evaluated. Measurement techniques and trends in patient education and treatment are also summarized to include current trends in therapeutic and surgical treatment options as well as longer-term management. Finally, an overview of the policies related to insurance coverage and reimbursement will give the clinician an overview of important trends in the diagnosis, treatment, and management of cancer-related lymphedema.

Bioelectrical impedance for detecting and monitoring lymphedema in patients with breast cancer. Preliminary results of the florence nightingale breast study group

The aim of this study was to evaluate the efficacy of bioimpedance spectroscopy for the follow-up of patients with lymphedema in Turkey and its benefits in the diagnosis of stage 0, 1, and 2 lymphedema in patients who are under treatment for breast cancer. Thirty-seven female patients with breast cancer who underwent surgical procedures in our Breast Health Centre were followed up for lymphedema using bioimpedance, and clinical measurements were taken for a minimum period of 1 year at 3-month intervals. Patients who had been monitored regularly between November, 2011, and September, 2013, were enrolled to the study. In total, 8 patients developed lymphedema with an overall rate of 21.6%. Among the 8 patients who developed lymphedema, 4 had Stage 2, 1 had Stage 1, and 3 had Stage 0 lymphedema. Stage 0 lymphedema could not be detected with clinical measurements. During the patients' 1-year follow-up period using measurements of bioimpedance, a statistically significant relationship was observed between the occurrence of lymphedema and the disease characteristics. including the number of the extracted and remaining lymph nodes and the region of radiotherapy (p=0.042, p=0.024, p=0.040). Bioimpedance analysis seems to be a practical and reliable method for the early diagnosis of lymphedema. It is believed that regular monitoring of patients in the high-risk group using bioimpedance analyses increases the ability to treat lymphedema.

Prospective protocol for lymphedema education and surveillance in a breast health center

Participation in the ONS Foundation-supported Breast Cancer Survivorship Quality Measures Set pilot study indicated less than optimal assessment and educational practices for lymphedema surveillance at one author's institution. This finding led staff to expand on nursing practice associated with lymphatic dysfunction and to propose a surveillance tool that is easy to use in a busy clinical setting. Based on current trends in lymphatic surveillance, arm measurements were used to assess for relative percentage differences compared to baseline. The referral threshold for lymphedema diagnosis was set at a 10% relative difference in circumferential measurements, pre- and postoperatively, as well as during the survivorship period. Enhanced education efforts, inclusive of staff and patients, will be established throughout the continuum of care. As lymphedema research and standard of care consensus become established, this surveillance model will be adapted in accordance with evidence-based practice guidelines.

Long-term effects of complex decongestive therapy in breast cancer patients with arm lymphedema after axillary dissection

Objective

To investigate the long-term effects of complex decongestive therapy (CDT) on edema reduction in breast cancer-related lymphedema patients after axillary dissection, according to the initial volume of edema.

Methods

A retrospective review of 57 patients with unilateral arm after an axillary dissection for breast cancer was performed. The patients, treated with two weeks of CDT and self-administered home therapy, were followed for 24 months. Arm volume was serially measured by using an optoelectronic volumeter prior to and immediately after CDT; and there were follow-up visits at 3, 6, 12, and 24 months. Patients were divided into two groups according to the percent excess volume (PEV) prior to CDT: group 1, PEV<20% and group 2, PEV≥20%.

Results

In group 1, mean PEV before CDT was 11.4±5.0% and 14.1±10.6% at 24 months after CDT with no significant difference. At the end of CDT, PEV was 28.8±15.7% in group 2, which was significantly lower than the baseline (41.9±19.6%). The reduction of PEV was maintained for 24 months in group 2.

Conclusion

The long-term effects of CDT were well-maintained for 24 months, but there was a difference in progression of PEV between the two groups. The patients with more initial PEV showed significant volume-reducing effects of CDT. In patients with less initial PEV, the severity of lymphedema did not progress to higher grades.