Trends in risk reduction practices for the prevention of lymphedema in the first 12 months after breast cancer surgery

The effects of the-optimal-lymph-flow health IT system application on treatment-related high risk lymphedema in breast cancer patients: a randomized controlled trial

PURPOSE

To evaluate the application effects of The-Optimal-Lymph-Flow IT System in Chinese patients at high risk of developing breast cancer-related lymphedema.

METHODS

A total of 104 breast cancer patients were randomly assigned to either the control group or the intervention group. The intervention group was provided with the The-Optimal-Lymph-Flow program, while the control group received the usual care. Trial outcomes including symptom experience, quality of life, and limb volume were evaluated at baseline, and at end of the 1- and 3-month trials.

RESULTS

After controlling for covariates, the incidence of eight symptoms was significantly higher in the control group than in the intervention group. There were significant differences in the changes in the severity of symptoms and arm volume between the two groups from baseline to 3 months after the intervention.

CONCLUSIONS

The application of TOLF in patients at high risk of developing lymphedema following breast cancer treatment significantly improved the lymphedema-related symptoms experienced in the early stage after surgery. Trial registration ChiCTR1800016713.

Development and evaluation of a WeChat-based intervention program for prevention of breast cancer-related lymphedema

PURPOSE

Mobile health applications have been widely adopted among breast cancer survivors for disease management; however, their use specifically for the prevention of breast cancer-related lymphedema (BCRL) remains sparse. This study is aimed at developing a WeChat-based intervention program for the prevention of BCRL based on the common-sense model (CSM).

METHODS

This study was designed based on intervention mapping. First, a longitudinal investigation was conducted to determine the predictive effect of illness perception on BCRL prevention behaviors among breast cancer survivors. An intervention program was then constructed based on the CSM and longitudinal results. Finally, a WeChat mini-program was developed, and 15 patients were recruited to test its usability and user satisfaction through usability tests based on typical tasks and the Post-Study System Usability Questionnaire (PSSUQ), respectively.

RESULTS

The longitudinal study revealed that identity, personal control, illness coherence, and behavioral and physical factors in the causes dimension could positively predict prevention behaviors, whereas treatment control and uncontrollable factors exhibited negative predictive effects. This study then developed an individualized intervention program and a WeChat mini-program (named "Nantian e-Care") consisting of five modules: "resources," "questionnaires," "homepage," "consultation," and "personal center." Patients could read BCRL-related educational content, watch functional exercise videos, self-measure arm circumference, and consult questions. The five-task completion rates were 80.00 ~ 100.00%, the average completion time was 9.47 ~ 33.31 s, and the scores of PSSUQ were greater than 5 points (full score 7 points).

CONCLUSIONS

This study proposed a feasible intervention program for the prevention of BCRL and developed a customized WeChat mini-program with high usability and user satisfaction.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, URL: https://www.chictr.org.cn/ , ChiCTR2100048798.

The Effects of Daily-Living Risks on Breast Cancer-Related Lymphedema

BACKGROUND

Conventional advice to reduce the risk of breast cancer-related lymphedema (BCLE) suggests avoidance of daily-living risks, and limited research has investigated these risks.

OBJECTIVE

This study aimed to examine the occurrence, patterns, and effects of daily-living risks on BCLE.

METHODS

A cross-sectional design was used to collect data from 567 patients at a metropolitan cancer center in the United States. The Lymphedema Risk-Reduction Behavior Checklist was used to assess the occurrence of 11 daily-living risks. Descriptive, regression, and factor analyses were performed.

RESULTS

Significant odds of BCLE were associated with infection (odds ratio [OR] 2.58, 95% confidence interval [CI] 1.95-3.42), cuts/scratches (OR 2.65, 95% CI 1.97-3.56), sunburn (OR 1.89, 95% CI 1.39-3.56), oil splash or steam burns (OR 2.08, 95% CI 1.53-3.83), and insect bites (OR 1.59, 95% CI 1.18-2.13). The daily-living risks were clustered into factors related to skin trauma and carrying objects. Skin trauma risk was significantly associated with BCLE (B = 0.539, z = 3.926, OR 1.714, 95% CI 1.312-2.250; p < 0.001). Having three, four, or five skin trauma risks significantly increased the odds of BCLE to 4.31, 5.14, and 6.94 times, respectively. The risk of carrying objects had no significant or incremental effects on BCLE.

CONCLUSION

Complete avoidance of daily-living risks is challenging given 52.73% of patients incurred more than five daily-living risks. Our study findings underscore the importance of 'what to do' strategies to minimize infection and skin trauma.

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.

Etiology and treatment of cancer-related secondary lymphedema

Lymphedema and specifically cancer-related lymphedema is not the main focus for both patients and physicians dealing with cancer. Its etiology is an unfortunate complication of cancer treatment. Although lymphedema treatments have gained an appreciable consensus, many practitioners have developed and prefer their own specific protocols and this is especially true for conventional (manual) versus surgical treatments. This collection of presentations explores the incidence and genetics of cancer-related lymphedema, early detection and monitoring techniques, both conventional and operative treatment options, and the importance and role of exercise for patients with cancer-related lymphedema. These assembled presentations provide valuable insights into the challenges and opportunities presented by cancer-related lymphedema including the latest research, treatments, and exercises available to improve patient outcomes and quality of life.

Prospective, early longitudinal assessment of lymphedema-related quality of life among patients with locally advanced breast cancer: The foundation for building a patient-centered screening program

BACKGROUND

We examined how breast cancer-related lymphedema (BCRL) affects health-related quality of life (HRQOL), productivity, and compliance with therapeutic interventions to guide structuring BCRL screening programs.

METHODS

We prospectively followed consecutive breast cancer patients who underwent axillary lymph node dissection (ALND) with arm volume screening and measures assessing patient-reported health-related quality of life (HRQOL) and perceptions of BCRL care. Comparisons by BCRL status were made with Mann-Whitney U, Chi-square, Fisher's exact, or t tests. Trends over time from ALND were assessed with linear mixed-effects models.

RESULTS

With a median follow-up of 8 months in 247 patients, 46% self-reported ever having BCRL, a proportion that increased over time. About 73% reported fear of BCRL, which was stable over time. Further in time from ALND, patients were more likely to report that BCRL screening reduced fear. Patient-reported BCRL was associated with higher soft tissue sensation intensity, biobehavioral, and resource concerns, absenteeism, and work/activity impairment. Objectively measured BCRL had fewer associations with outcomes. Most patients reported performing prevention exercises, but compliance decreased over time; patient-reported BCRL was not associated with exercise frequency. Fear of BCRL was positively associated with performing prevention exercises and using compressive garments.

CONCLUSIONS

Both incidence and fear of BCRL were high after ALND for breast cancer. Fear was associated with improved therapeutic compliance, but compliance decreased over time. Patient-reported BCRL was more strongly associated with worse HRQOL and productivity than was objective BCRL. Screening programs must support patients' psychological needs and aim to sustain long-term compliance with recommended interventions.

Axillary reverse mapping in breast cancer: An overview

Standard operative management for breast carcinoma has significantly shifted from extensive procedures to minor interventions.Although axillary dissection was a fundamental component of operative management, sentinel biopsy is an actual process for axillary staging. Axillary dissection may be postponed for cases that have negative SLNs or 1 or 2 infiltrated lymph nodes undergoing breast or axillary radiation. Contrarily, axillary dissection is still the conventional management for patients with clinically positive nodes.Arm lymphedema is a frequent and overwhelming complication of axillary dissection, with a worse impact on the patient's life.Axillary reverse mapping was recently introduced to map and conserve the lymph drain of the upper limb throughout axillary dissection or sentinel biopsy. A technique based on the theory that the breast's lymphatic drainage differs from those that drain the arm, so preserving lymphatic drainage of the upper limb can prevent lymphedema, thereby not raising the risk of axillary recurrence.Therefore, this technique is the reverse of sentinel biopsy, which remove the lymph nodes that drain the breast.

Development and psychometric evaluation of a lymphoedema self-management behaviour questionnaire for breast cancer patients

OBJECTIVES

The study was aimed to develop and evaluate a lymphoedema self-management behaviour questionnaire (LSMBQ) for breast cancer patients.

METHODS

The initial version of the behaviour questionnaire was developed based on the framework of self-management and the evidence summary of lymphoedema self-management. Two rounds of expert consultation were conducted to validate the questionnaire's content validity. A cross-sectional survey was then conducted in breast wards of two hospitals in China to evaluate the reliability and validity of this scale. Exploratory structural equation model was used to test the construct validity. T-test was used to analyse the known group validity. Structural equation model was applied to verify the relationship between self-efficacy, social support, and lymphoedema self-management behaviour to test the convergent validity. Also, the internal consistency reliability and test-retest reliability were evaluated.

RESULTS

The questionnaire's content validity was satisfactory. There were 22 items included in the LSMBQ for validation and 260 completed the survey. A six-factor structure with good construct validity was identified. The result of t-test verified that patients who knew the risk of lymphoedema and those who received lymphoedema health education had higher scores of lymphoedema self-management behaviours (P < 0.05), indicating that the questionnaire has good known group validity. The fitting results of the structural equation model indicated that the 22-item questionnaire had good convergent validity. Cronbach's alpha coefficients and test-retest reliability for the total questionnaire were 0.910 and 0.875, respectively.

CONCLUSIONS

The 22-item LSMBQ appears to have adequate reliability and validity to assess the lymphoedema self-management behaviours for breast cancer patients.

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 Sleep Quality, Depression, and Quality of Life in Patients with Breast Cancer Related Lymphedema

Background: Breast cancer-related lymphedema (BCRL) is a serious health condition negatively affecting psychological state, sleep quality, and quality of life (QOL) of patients. These complications of BCRL can be overlooked in routine clinical practice. The aim of this study is to evaluate sleep quality, depression, and QOL in patients with different stages of BCRL. Methods: This cross-sectional study included 111 consecutive women patients with BCRL attending to lymphedema unit of Physical Medicine and Rehabilitation Hospital in Ankara City Hospital. Demographical and clinical data of patients were noted. Sleep quality was assessed with Pittsburgh Sleep Quality Index, day-time sleepiness was assessed with Epworth Sleepiness Scale, depression was assessed with Beck Depression Questionnaire, and QOL was assessed with Lymphedema Quality of Life Questionnaire-arm. Results: Median age of patients was 57 (49-63) (25%-75% interquartile range). Nearly 58.8% of the patients had sleep disturbances, and 29.7% of the patients had depression. Presence of both sleep disturbance and depression was associated with increased age. Patients with sleep disturbance were found to be more depressive and vice versa, (p < 0.001, p < 0.001, respectively). Sleep disturbance, depression and day-time sleepiness, and higher body mass index were all associated with lower QOL scores. Conclusions: Presence of sleep disturbances and depression should be evaluated in every patient with BCRL with special attention to elderly. Rehabilitative management of BCRL should include psychiatric evaluation and interventions. Future studies should intend to assess the risk factors that affect psychological state, sleep quality, and QOL in patients with BCRL.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Prognostic value and management of regional lymph nodes in locoregional breast cancer recurrence: a systematic review of the literature

PURPOSE

Management of regional lymph nodes in breast cancer recurrence has been heterogeneous. To facilitate clinical practice, this review aims to give an overview on the prognosis, staging and operative management of (inapparent) regional lymph nodes.

METHODS

Current national and international guidelines are reviewed and a structured search of the literature between Jan 1, 1999 and Feb 1, 2021 on the repeat sentinel node biopsy (re-SNB) procedure was performed.

RESULTS

Positive regional lymph nodes in recurrent breast cancer indicate a poorer outcome with axillary recurrences being the most favorable tumor site among all nodal regions. Most preferred staging method is ultrasound ± guided biopsy. PET-CT, scintimammography, SPECT-CT may improve visualization of affected lymph nodes outside the axilla. Concerning operative management 30 articles on re-SNB were identified with a mean harvesting rate of 66.4%, aberrant drainage and aberrant metastasis in 1/3 of the cases. Total rate of metastasis is 17.9%. After previous axillary dissection (ALND) the re-SNB has a significantly lower harvesting rate and higher aberrant drainage and aberrant metastasis rate. The prognostic outcome after re-SNB has been favorable.

CONCLUSION

Nodal status in recurrent disease has prognostic value. The choice of operative management of clinically inapparent regional lymph nodes during local recurrence should be based on the previous nodal staging method. Patients with previous ALND should be spared a second systematic ALND. Re-SNB or no axillary surgery at all are possible alternatives. Lymphoscintigraphy may be performed to identify extraaxillary drainage. However, for definite recommendations randomized controlled studies are heavily needed.

A Web- and Mobile-Based Intervention for Women Treated for Breast Cancer to Manage Chronic Pain and Symptoms Related to Lymphedema: Results of a Randomized Clinical Trial

BACKGROUND

The-Optimal-Lymph-Flow (TOLF) is a patient-centered, web- and mobile-based mHealth system that delivers safe, easy, and feasible digital therapy of lymphatic exercises and limb mobility exercises.

OBJECTIVE

The purpose of this randomized clinical trial (RCT) was to evaluate the effectiveness of the web- and mobile-based TOLF system for managing chronic pain and symptoms related to lymphedema. The primary outcome includes pain reduction, and the secondary outcomes focus on symptom relief, limb volume difference measured by infrared perometer, BMI, and quality of life (QOL) related to pain. We hypothesized that participants in the intervention group would have improved pain and symptom experiences, limb volume difference, BMI, and QOL.

METHODS

A parallel RCT with a control-experimental, pre- and posttest, and repeated-measures design were used. A total of 120 patients were recruited face-to-face at the point of care during clinical visits. Patients were randomized according to pain in a 1:1 ratio into either the arm precaution (AP) control group to improve limb mobility and arm protection or The-Optimal-Lymph flow (TOLF) intervention group to promote lymph flow and limb mobility. Trial outcomes were evaluated at baseline and at week 12 after the intervention. Descriptive statistics, Fisher exact tests, Wilcoxon rank-sum tests, t test, and generalized linear mixed effects models were performed for data analysis.

RESULTS

At the study endpoint of 12 weeks, significantly fewer patients in the TOLF intervention group compared with the AP control group reported chronic pain (45% [27/60] vs 70% [42/60]; odds ratio [OR] 0.39, 95% CI 0.17-0.90; P=.02). Patients who received the TOLF intervention were significantly more likely to achieve a complete reduction in pain (50% [23/46] vs 22% [11/51]; OR 3.56, 95% CI 1.39-9.76; P=.005) and soreness (43% [21/49] vs 22% [11/51]; OR 2.60, 95% CI 1.03-6.81; P=.03). Significantly lower median severity scores were found in the TOLF group for chronic pain (MedTOLF=0, IQR 0-1 vs MedAP=1, IQR 0-2; P=.02) and general bodily pain (MedTOLF=1, IQR=0-1.5 vs MedAP=1, IQR 1-3; P=.04). Compared with the AP control group, significantly fewer patients in the TOLF group reported arm/hand swelling (P=.04), heaviness (P=.03), redness (P=.03), and limited movement in shoulder (P=.02) and arm (P=.03). No significant differences between the TOLF and AP groups were found in complete reduction of aching (P=.12) and tenderness (P=.65), mean numbers of lymphedema symptom reported (P=.11), ≥5% limb volume differences (P=.48), and BMI (P=.12).

CONCLUSIONS

The TOLF intervention had significant benefits for breast cancer survivors to manage chronic pain, soreness, general bodily pain, arm/hand swelling, heaviness, and impaired limb mobility. The intervention resulted in a 13% reduction (from 40% [24/60] to 27% [16/60]) in proportions of patients who took pain medications compared with the AP control group, which had a 5% increase (from 40% [24/60] to 45% [27/60]). A 12% reduction (from 27% [16/60] to 15% [9/60]) in proportions of patients with ≥5% limb volume differences was found in the TOLF intervention, while a 5% increase in the AP control group (from 40% [24/60] to 45% [27/60]) was found. In conclusion, the TOLF intervention can be a better choice for breast cancer survivors to reduce chronic pain and limb volume.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02462226; https://clinicaltrials.gov/ct2/show/NCT02462226.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/resprot.5104.

Breast Cancer-Related Lymphedema Risk-Management Behaviors Among Chinese Breast Cancer Survivors and Relationships with Socio-Demographic and Clinical Characteristics: A Longitudinal Study

PURPOSE

We sought to determine changes in breast cancer-related lymphedema (BCRL) risk-management behaviors in the six-month period after surgery among Chinese breast cancer survivors and to explore the relationship between their socio-demographic and clinical characteristics and these behaviors.

PATIENTS AND METHODS

A longitudinal study design was adopted. Females aged ≥18 years with a first breast cancer diagnosis and who had undergone modified radical mastectomy were recruited from a cancer hospital in China. Respondents with a history of other malignant tumors, mental illness, or cognitive impairment were excluded from the study. Socio-demographic and clinical factors were assessed at baseline. BCRL risk-management behaviors were assessed with the Lymphedema Risk-Management Behavior Questionnaire (LRMBQ) and Functional Exercise Adherence Scale (FEAS) in the first, third, and sixth months after surgery. Repeated-measures analysis of variance was used to examine changes in BCRL risk-management behaviors over the three study time periods, and a generalized linear mixed model was used to determine socio-demographic and clinical factors associated with BCRL risk-management behaviors.

RESULTS

A total of 166 participants completed all three assessments. The scores of the total LRMBQ and its "Skin care" and "Lifestyle" subscales did not change significantly, but those of the "Avoidance of limb compression and injury" and "Other matters requiring attention" subscales changed over the three study time periods. Additionally, scores of the total FEAS and most of its subscales changed over the three study time periods. Furthermore, BCRL risk-management behaviors were significantly related to patients' geographic residence, education level, and tumor stage.

CONCLUSION

Some dimensions of BCRL risk-management behaviors changed over time, and several socio-demographic and clinical factors are related to BCRL risk-management behaviors. It is recommended that health care professionals consider the dynamic nature of BCRL risk-management behaviors and related factors when planning health education and promotion interventions.

Evidence Mapping of the Treatments for Breast Cancer-related Lymphedema

Women treated for breast cancer are facing a lifetime risk of developing lymphedema, which occurs in up to 40% of this population. There is a lack of evidence and limited knowledge regarding the treatment of breast cancer-related lymphedema (BCRL). The aim of this study was to identify, describe, and organize the currently available evidence in the treatment of BCRL.

METHODS

We conducted an evidence mapping review study according to the methodology proposed by Global Evidence Mapping. We performed a systematic search in Medline, Embase, Central (Cochrane), and Epistemonikos, from 2000-2020. We included studies about all treatment types for BCRL, including surgical and nonsurgical treatment. Results were summarized in narrative and tabular forms.

RESULTS

A total of 240 studies were included in this mapping review, distributed as follows: 147 experimental studies [102 randomized clinical trials (RCTs) and 45 quasi-experimental clinical trials], 48 observational studies (34 prospective and 14 retrospective studies), and 45 systematic reviews (17 of them with metanalysis). Most of the RCTs were on nonsurgical interventions. Only two RCTs addressed surgical intervention.

CONCLUSIONS

In the last 20 years, there were an average of 12 publications per year on the treatment of BCRL. Recently this lack of attention has been partially corrected, as the majority were published in the past 5 years. However, most of them were on nonsurgical interventions. Well-designed RCTs on surgery are needed to measure the effectiveness of the applied interventions.

Indocyanine Green for Leakage Control in Isolated Limb Perfusion

Sarcomas are characterized by a high metastatic potential and aggressive growth. Despite surgery, chemotherapy plays an important role in the treatment of these tumors. Optimal anti-cancer therapy with maximized local efficacy and minimized systemic side effects has been the object of many studies for a long time. To improve the local efficacy of anti-tumor therapy, isolated limb perfusion with high-dose cytostatic agents has been introduced in surgical oncology. In order to control the local distribution of substances, radiolabeled cytostatic drugs or perfusion solutions have been applied but often require the presence of specialized personnel and result in a certain exposure to radiation. In this study, we present a novel strategy using indocyanine green to track tumor perfusion with high-dose cytostatic therapy. In a rat cadaver model, the femoral vessels were cannulated and connected to a peristaltic pump to provide circulation within the selected limb. The perfusion solution contained indocyanine green and high-dose doxorubicin. An infrared camera enabled the visualization of indocyanine green during limb perfusion, and subsequent leakage control was successfully performed. Histologic analysis of sections derived proximally from the injection site excluded systemic drug dispersion. In this study, the application of indocyanine green was proven to be a safe and cost- and time-efficient method for precise leakage control in isolated limb perfusion with a high-dose cytostatic agent.

Evaluating the Quality of Life and Sleep Quality in Saudi Women with Breast Cancer-Related Lymphedema: A Cross-Sectional Correlational Study

Background

Among the different cancers found in women, breast cancer is the most common. Breast cancer-related lymphedema is a serious health complication affecting the quality of life and sleep quality. This study evaluates the quality of life and sleep quality among Saudi women with different stages of lymphedema following the treatment of breast cancer.

Methods

This cross-sectional correlational study included 163 Saudi women with breast cancer-related lymphedema (Stages I-III), aged 28 to 56 years. From the patients identified for this study, women who suffered from mental and psychological dysfunctions or other malignant disorders were excluded. Copies of structured questionnaires were given to each participant during their visits to outpatient physiotherapy clinics. Quality of life was assessed using a valid questionnaire (EORTC QLQ-C30), while sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). The differences between the different lymphedema stages have been assessed.

Results

Of the total number of participants 27 women had been diagnosed with stage I lymphedema, 84 women had been diagnosed with stage II lymphedema, and 52 women had been diagnosed with stage III lymphedema. All participants have shown low scores on both EORTC QLQ-C30 and PSQI. While analyzing the differences between the 3 stages of lymphedema with the Kruskal–Wallis test, noteworthy statistical differences between the 3 stages of lymphedema (P < .05) have been found. The Stage III lymphedema patients have been shown the lowest quality of life values in all scales when compared with the stage I and stage II lymphedema patients. For PSQI scores, the stage III lymphedema patients worse values than the stage I and stage II lymphedema patients (P < .05).

Conclusion and Recommendations

Both quality of life and quality of sleep have significantly decreased in Saudi women with different stages of breast cancer-related lymphedema. Quality of life and quality of sleep are the worst in stage III lymphedema patients. Future research should consider repeat and enlarge these results as well as assess the risk factors that affect the quality of life and quality of sleep among Saudi women suffering from breast cancer-related lymphedema.

American Society of Breast Surgeons' Practice Patterns for Patients at Risk and Affected by Breast Cancer-Related Lymphedema

BACKGROUND

In 2017, the American Society of Breast Surgeons (ASBrS) published expert panel recommendations for patients at risk for breast cancer-related lymphedema (BCRL) and those affected by BCRL. This study sought to determine BCRL practice patterns.

METHODS

A survey was sent to 2975 ASBrS members. Questions evaluated members' clinical practice type, practice duration, and familiarity with BCRL recommendations. Descriptive statistics, the chi-square test, and Fisher's exact test were used.

RESULTS

Of the ASBrS members surveyed, 390 (13.1%) responded. Most of the breast surgeons (58.5%, 228/390) indicated unfamiliarity with recommendations. Nearly all respondents (98.7%, 385/390) educate at-risk patients. Most (60.2%, 234/389) instruct patients to avoid venipuncture, injection or blood pressure measurements in the at-risk arm, and 35.6% (138/388) recommend prophylactic compression sleeve use during air travel. Nearly all (97.7%, 380/389) encourage those at-risk to exercise, including resistance exercise (86.2%, 331/384). Most do not perform axillary reverse mapping (ARM) (67.9%, 264/389) or a lymphatic preventive healing approach (LYMPHA) (84.9%, 331/390). Most (76.1%, 296/389) screen at-risk patients for BCRL. The most frequently used screening tools include self-reported symptoms (81%, 255/315), circumferential tape measure (54%, 170/315) and bioimpedance spectroscopy (27.3%, 86/315). After a BCRL diagnosis, most (90%, 351/390) refer management to a lymphedema-certified physical therapist. For affected patients, nearly all encourage exercise (98.7%, 384/389). Many (49%, 191/390) refer affected patients for consideration of lymphovenous bypass or lymph node transfer.

CONCLUSION

Most respondents were unfamiliar with the ASBrS expert panel recommendations for patients at risk for BCRL and those affected by BCRL. Opportunities exist to increase awareness of best practices and to acquire ARM and LYMPHA technical expertise.

Ipsilateral Intravenous Catheter Placement in Breast Cancer Surgery Patients

BACKGROUND

There is a continued perception that intravenous line (IV) placement is contraindicated in the arm ipsilateral to prior breast cancer surgery to avoid breast cancer-related lymphedema (BCRL). The aim of this retrospective study was to determine the risk for development of BCRL in ipsilateral arm IV placement compared to contralateral arm IV placement to prior breast cancer surgery.

METHODS

We performed a retrospective review, via our Integrated Clinical Systems and Epic Electronic Heath Record of IV placement for anesthesia and surgery in patients with a prior history of breast cancer surgery with or without axillary lymph node dissection. Complication rates were compared for IVs placed in the ipsilateral and contralateral arms. We identified 3724 patients undergoing 7896 IV placements between January 1, 2015, and May 5, 2018, with a prior history of breast cancer surgery via their index anesthesia and surgical procedures.

RESULTS

The median time from breast cancer surgery to IV placement was 1.5 years (range, 1 day to 17.8 years). Of 2743 IVs placed in the arm contralateral to prior breast cancer surgery, 2 had a complication, corresponding to an incidence of 7.3 per 10,000 (95% confidence interval [CI], 0.9-26.3 per 10,000). Of 5153 IVs placed in the arm ipsilateral to prior breast cancer surgery, 2 IVs had a complication, for an incidence of 3.9 per 10,000 (95% CI, 0.5-14.0 per 10,000). The frequency of complications was not found to differ significantly between the groups (P = .91), and the 95% CI for the risk difference (ipsilateral minus contralateral) was -23 to +8 complications per 10,000. The complication rate is similar when only the first IV placed following breast cancer surgery is considered (overall 5.4 per 10,000 [95% CI, 0.7-19.4] per 10,000; contralateral 7.0 [95% CI, 0.2-39.0] per 10,000, ipsilateral 4.4 [95% CI, 0.1-24.2] per 10,000; P = 1.00; 95% CI for risk difference [ipsilateral minus contralateral], -41 to +22 per 10,000).

CONCLUSIONS

We found very few complications in patients who had an IV placed for surgery following a previous breast cancer surgery and no complications in those patients with IV placement ipsilateral with axillary node dissection. Avoidance of IV placement in the arm ipsilateral to breast cancer surgery is not necessary.

Surgical complications occurring during minimally invasive sentinel lymph node detection in endometrial cancer patients. A systematic review of the literature and metanalysis

INTRODUCTION

Endometrial cancer (EC) is the most common gynecological cancer. Sentinel lymph node (SLN) technique has been adopted worldwide and showed lower morbidity and superimposable survival outcomes than the systematic lymphadenectomy (LND). Although these encouraging results, no meta-analyzes were performed on surgical complications during SLN research among patients undergoing laparoscopic (L) versus robotic surgery (R). The present review aims to report surgical complications during laparoscopic versus robotic SLN technique.

METHODS

The Preferred Reporting Items for Systematic reviews and Meta-Analyzes (PRISMA) and the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines have been followed for the present meta-analysis.

RESULTS

Six studies, including 769 participants, were included. L-LND resulted in a significantly higher risk of operative complications relative to L-SLN (RR 2.10 [95% CI 1.37 to 3.21]). The risk of complications was comparable between R-SLN and L-SLN (RR 2.32 [95% CI 0.04-121.02]) and between R-LND and L-LND (RR 2.17 [95% CI 0.04-126.69]). According to the SUCRA analysis, L-SLN and R-SLN had the highest chances of being ranked first among proposed surgical procedures (SUCRA 48.9% and 28.4% respectively).

CONCLUSIONS

Our study reported a lower surgical complications rate in patients undergoing L-SLN technique compared to L-LND. A lower rate of surgical complications was also reported for the R-SLN technique compared to the R-LND. Both laparoscopic and robotic SLN surgical techniques were found to be safe surgical procedures.

Prevention of Breast Cancer-Related Lymphedema

Tremendous progress has been made over the past several decades in the treatment of breast cancer. Mortality and recurrence rates continue to decline. Our ability to tailor patient- and tumor-specific treatments has rapidly advanced. The vast majority of our patients can safely have breast conservation. Unfortunately, for many patients, survivorship is burdened by ongoing quality-of-life issues. Most breast cancer patients are asymptomatic at presentation, and the onus is on us to preserve this. Surgery, radiation, and systemic therapy can result in long-term toxicities that can be amplified with multimodality approaches. We must strive to apply minimally effective therapies rather than a maximally tolerated approach. Breast cancer-related lymphedema (BCRL) is a particularly dreaded chronic complication. This review strives to give the reader a better understanding of BCRL and shed light on wisely choosing an integration of treatment modalities that minimizes BCRL risk. Key literature on emerging concepts is highlighted.

Managing Lymphedema, Increasing Range of Motion, and Quality of Life through Yoga Therapy among Breast Cancer Survivors: A Systematic Review

Lymphedema is a common complication of breast cancer treatment. Yoga is a nonconventional and noninvasive intervention that is reported to show beneficial effects in patients with breast cancer-related lymphedema (BCRL). This study attempted to systematically review the effect of yoga therapy on managing lymphedema, increasing the range of motion (ROM), and quality of life (QOL) among breast cancer survivors. The review search included studies from electronic bibliographic databases, namely Medline (PubMed), Embase, and Google Scholar till June 2019. Studies which assessed the outcome variables such as QOL and management of lymphedema or related physical symptoms as effect of yoga intervention were considered for review. Two authors individually reviewed, selected according to Cochrane guidelines, and extracted the articles using Covidence software. Screening process of this review resulted in a total of seven studies. The different styles of yoga employed in the studies were Iyengar yoga (n = 2), Satyananda yoga (n = 2), Hatha yoga (n = 2), and Ashtanga yoga (n = 1). The length of intervention and post intervention analysis ranged from 8 weeks to 12 months. Four studies included home practice sessions. QOL, ROM, and musculoskeletal symptoms showed improvement in all the studies. Yoga could be a safe and feasible exercise intervention for BCRL patients. Evidence generated from these studies was of moderate strength. Further long-term clinical trials with large sample size are essential for the development and standardization of yoga intervention guidelines for BCRL patients.

The Level of Lymphedema Awareness among Women with Breast Cancer in the Kingdom of Saudi Arabia

BACKGROUND

Lymphedema is a condition in which excessive fluid accumulates in soft tissues. It is a common complication of breast cancer treatments. It can lead to serious consequences and interfere with the activity of daily living. This study aimed to determine the level of awareness of breast-cancer-related lymphedema (BCRL) among women with breast cancer in the Kingdom of Saudi Arabia. This was a descriptive quantitative cross-sectional design that included a convenience sample of women diagnosed with breast cancer in the Kingdom of Saudi Arabia. Data were collected by distributing a self-administrated online questionnaire consisting of four parts, including demographic data (five items), the status of education about BCRL (three items), basic medical history of breast cancer (six items), and BCRL level of awareness of risk factors and management (nine items).

RESULTS

In total, 95 out of 135 of participants did not know about lymphedema, 119 of the participants (88.1%) did not receive any explanation about the possibility of lymphedema from their medical team before surgery, and 121 of them (89.6%) did not receive it after surgery. The most significant factor affecting participants' level of awareness regarding BCRL was the lack of information about the possibility of BCRL occurrence, which was not provided to them by the medical team.

RECOMMENDATION

Early and continuous education for future management is essential to prevent problems related to BCRL and improve quality of life.

Integrating Symptoms Into the Diagnostic Criteria for Breast Cancer-Related Lymphedema: Applying Results From a Prospective Surveillance Program

OBJECTIVE

The objectives of this study were to determine whether patients reporting symptoms are more likely to develop lymphedema and to describe the temporal relationship between symptom onset and lymphedema.

METHODS

This was a prospective longitudinal cohort study of 647 women treated for breast cancer and screened for lymphedema using arm volume measurements and subjective questionnaires (n = 647; 2284 questionnaires [median 3.5 per patient, range = 1-24]). Primary study outcome was lymphedema (relative volume change ≥10%). The Kaplan-Meier method was used to estimate cumulative lymphedema incidence. Cox proportional hazards models were used to assess the relationship between symptoms, other risk factors, and lymphedema.

RESULTS

A total of 64 patients (9.9%) developed lymphedema. On multivariable analysis, patients reporting increased arm size (hazard ratio = 3.09, 95% CI = 1.62-5.89) were more likely to progress to lymphedema than those who did not report this symptom. Of those who developed lymphedema, 37 (58%) reported an increased arm size a median of 6.1 months before lymphedema onset (range = 68.6 months before to 50.2 months after lymphedema onset).

CONCLUSION

Patients at risk of lymphedema who report increased arm size might do so prior to lymphedema onset and are at 3 times the risk of lymphedema as patients not reporting this symptom. Even without objective or observable edema, these patients should be followed vigilantly and considered for early intervention. Symptoms should be incorporated into screening and diagnostic criteria for lymphedema.

IMPACT

This study shows that patients at risk for breast cancer-related lymphedema who report increased arm size should be considered at high risk for progression to lymphedema-even without edema on measurement or clinical examination-and should be followed vigilantly, with consideration of early intervention.

LAY SUMMARY

If you are at risk of lymphedema and you feel as though your arm size has increased, you might develop lymphedema, and you are at 3 times the risk of lymphedema as patients not reporting this symptom. Even without measurable or observable edema, you should be followed vigilantly and consider early intervention.

The impact of monitoring techniques on progression to chronic breast cancer-related lymphedema: a meta-analysis comparing bioimpedance spectroscopy versus circumferential measurements

BACKGROUND

Chronic breast cancer-related lymphedema (BCRL) is a potentially serious complication following treatment. Monitoring for progression to BCRL may allow for earlier detection and intervention, reducing the rate of progression to chronic BCRL. Therefore, the purpose of this meta-analysis is to evaluate the impact of monitoring techniques on the incidence of chronic BCRL among patients monitored by bioimpedance spectroscopy (BIS) and circumference as compared to background rates.

METHODS

Eligible peer-reviewed studies from PubMed, CINHAL, or Google Scholar that were published in English from 2013 onward and conducted in North America, Europe, or Oceania. Incidence rates abstracted from studies were classified by BCRL monitoring method: background (no standardized BIS or circumference assessments), BIS or circumference. A random-effects model was used to calculate a pooled annualized estimate of BCRL incidence while accounting for clinical and methodological heterogeneity. Subgroup analyses examined differences in duration of follow-up as well as breast and axillary surgery.

RESULTS

50 studies were included, representing over 67,000 women. The annualized incidence of BCRL was 4.9% (95% CI: 4.3-5.5) for background studies (n = 35), 1.5% (95% CI: 0.6-2.4) for BIS-monitored studies (n = 7), and 7.7% (95% CI: 5.6-9.8) for circumference-monitored studies (n = 11). The cumulative BCRL incidence rate in BIS-monitored patients was 3.1% as compared to 12.9% with background monitoring (69% reduction) and 17.0% with circumference-monitored patients (81% reduction).

CONCLUSIONS

Evidence suggests that monitoring with BIS allowing for early intervention significantly reduces the relative risk of chronic BCRL with a 69% and 81% reduction compared to background and circumference, respectively. Circumference monitoring did not appear to provide a benefit with respect to chronic BCRL incidence. Based on these results, BIS should be considered for BCRL screening in order to detect subclinical BCRL and reduce rates of chronic BCRL, particularly in high-risk patients.

Features, Predictors, and Treatment of Breast Cancer-related Lymphedema

Purpose of review

Breast cancer-related lymphedema (BCRL) is a common sequelae among breast cancer survivors. This review provides updated information on recent studies to prevent, diagnose, and actively treat women with BCRL.

Recent findings

In total, 63 articles were identified from 2015 and 2020 that assessed incidence, risk factors, surveillance, measurement and definition, treatment, and awareness of BCRL. Depending on the approach and timing of assessment, BCRL incidence rates ranged from 9.1% to 39%. Modified radical mastectomy, number of positive lymph nodes, and postoperative complications were linked to BCRL risk, in addition to chemotherapy, radiation, axillary lymph node dissection, advanced cancer stage, and higher body mass index. Early detection showed favorable BCRL outcomes (e.g., severity, symptoms). Exercise, self-management, complete decongestive therapy, bandaging, and surgery had positive effects on BCRL outcomes.

Summary

Numerous gaps exist within BCRL literature, such as the value of self-reported surveillance options to identify BCRL early, measurement strategies, and definitions of BCRL. In terms of policies, efforts are needed to educate providers, patients, payers, and legislators about the need for consensus to reduce the burden of BCRL in women being treated for breast cancer.

Time to rethink vascular access in patients with breast cancer

Breast cancer management is a rapidly evolving field. Diagnosis and treatment options have changed dramatically over the years, as have options for vascular access devices used to administer therapies. We now need to critically rethink vascular access device options for our breast cancer patients.

Breast cancer (BC) is the most commonly diagnosed cancer among Canadian women. Although BC incidence continues to rise, the overall mortality rate in Canada is the lowest it has been for 70 years. The five-year net survival is 87%, and 83% of women are alive at 10 years. New oral therapies, shorter dose-dense treatments, and decreased use of anthracycline-base regimens are reducing the need for central venous access devices during acute treatment phases. However, these survivors go on to develop other health issues requiring routine venipuncture and insertion of vascular access devices.

Breast cancer-related lymphedema (BCRL) is a chronic complication that has no cure and no proven prevention strategies. Approximately 21% of breast cancer survivors are at risk of developing BCRL. Of those patients who do develop BCRL, 70% do so within two years of surgery, 90% within three years, and another one percent per year thereafter. The literature supports axillary lymph node dissection, mastectomy, administration of chemotherapy or radiotherapy, and obesity, as risk factors for the development of BCRL. However, 40% of patients who develop BCRL have no identifiable risk factors. Broader risk reduction strategies developed are not evidence based, the most commonly cited being avoidance of needle sticks. Large cohort studies have found no significant association between blood draws and intravenous infusion in the surgical arm with the development of BCRL. Recommendations that effectively eliminate vascular access on the surgical side for the patient's entire lifetime are neither necessary nor realistic.

Vascular access specialists can provide leadership by developing standardized, evidence-informed recommendations for safe vascular access and infusion practices for this patient population.

Incidence and predictors of axillary web syndrome and its association with lymphedema in women following breast cancer treatment: a retrospective study

PURPOSE

Axillary web syndrome (AWS) presents as a common postsurgical complication in individuals with breast cancer. Breast cancer-related lymphedema (BCRL) contributes to the shoulder and arm morbidity common in breast cancer survivors and often associated to cancer treatment. A paucity of literature exists evaluating the risk factors for developing AWS and the association between AWS and BCRL. The purposes of this study were (1) to identify risk factors for AWS in individuals with breast cancer, (2) to examine the association between BCRL and AWS, and (3) to determine if AWS increases the risk for developing BCRL.

METHODS

A retrospective study of 354 women who underwent breast cancer treatment and received physical therapy was included.

RESULTS

Axillary web syndrome developed in a third of women and predominately occurred in the first 8 postoperative weeks. The odds of AWS development were 73% greater for participants over the age of 60 (OR = 1.73, CI 95% 1.05-2.84). Women with AWS had 44% greater risk to develop lymphedema during the first postoperative year (RR = 1.44, CI 95% 1.12-1.84, p = 0.002). If AWS developed within the first postoperative month, women were almost 3 times more likely to develop lymphedema within the first 3 postoperative months compared with other women with AWS (RR = 2.75, CI 95% 1.199-6.310, p = 0.007).

CONCLUSIONS

Our findings suggest that 30% of breast cancer survivors will have AWS during the first year of survivorship. As institutions prioritize screening efforts, early postoperative prospective surveillance is needed for women over 60 due to high risk for AWS development and any women with AWS for increased risk of lymphedema development based on our findings.

The Effectiveness of the Sport "Dragon Boat Racing" in Reducing the Risk of Lymphedema Incidence: An Observational Study

BACKGROUND

Upper extremity lymphedema is a complication that often occurs in women with breast cancer as a result of surgery and/or radiotherapy. Some studies report that a boating activity known as the "dragon boat" sport can benefit these women.

AIM

The aim of this study was to assess whether this type of sport prevents or reduces lymphedema, its impact on quality of life (QoL), and the possible predictors of this condition.

METHODS

This was an observational study of 2 groups: group A (women who participated in dragon boat racing for at least 6 months) and group B (women who participated in other forms of physical exercise biweekly). Data were collected at the National Cancer Institute of Rome and the lake of Castel Gandolfo from June to October 2016. The instruments used were a questionnaire created for sociodemographic and clinical data, the European Organisation for Research and Treatment of Cancer Core Questionnaire for evaluating QoL, and a tape measure applied to estimate the local lymphedema.

RESULTS

One hundred women participated in the study. Lymphedema incidence in group A was 4.0% (2 of 50), whereas in group B it was 26.0% (13 of 50). Women who participated in dragon boat racing also reported a healthier lifestyle, lower body mass index, and a better QoL (set point: 61.8 group B vs 80.0 group A).

CONCLUSIONS

The dragon boat sport participants had more positive clinical and QoL outcomes than did the women who did not participate in that sporting activity.

IMPLICATIONS FOR CLINICAL PRACTICE

It would be important to make women with breast cancer aware of the practice of dragon boat racing.

A scoring system for predicting the risk of breast cancer-related lymphedema

Objective

We aimed to establish a scoring system to predict the risk of breast cancer-related lymphedema.

Methods

From April 2017 to December 2018, 533 patients who previously underwent surgery for breast cancer were enrolled in this cross-sectional study. Univariate analysis was performed to explore and define the risk factors. A scoring system was then established on the basis of odds ratio values in the regression analysis.

Results

The additive scoring system values ranged from 6 to 22. The receiver operating characteristic (ROC) curve of this scoring system showed a sensitivity and specificity of 83.3% and 57.3%, respectively, to predict the risk of lymphedema at a cut-off of 15.5 points; the area under the curve was 0.736 (95% confidence interval: 0.662–0.811), with χ² = 5.134 (P = 0.274) for the Hosmer–Lemeshow test.

Conclusions

The predictive efficiency and accuracy of the scoring system were acceptable, and the system could be used to predict and screen groups at high risk for breast cancer-related lymphedema.

Identification of Axillary Lymph Node Metastasis in Patients With Breast Cancer Using Dual-Phase FDG PET/CT

OBJECTIVE. The aim of this study was to assess the diagnostic performance of dual-phase ¹⁸F-FDG PET/CT in detecting axillary lymph node metastasis in patients with breast cancer. MATERIALS AND METHODS. A total of 826 patients with breast cancer were retrospectively evaluated. PET/CT scans were performed 1 hour and 2 hours after FDG administration before treatment. The maximum standardized uptake value (SUV_max) in the axillary lymph node at both time points (hereafter referred to as SUV_max1 and SUV_max2, respectively) and the retention index (RI) were calculated. RESULTS. Axillary lymph node metastasis was detected in 285 of 826 patients (34.5%). The median axillary SUV_max1, SUV_max2, and RI in patients with nodal metastasis were higher than those in patients without metastasis (1.5 vs 0.6, 1.6 vs 0.5, and 7.7 vs -3.7, respectively; all p < 0.001). The diagnostic accuracy of axillary SUV_max1 and SUV_max2 was equivalent, and the sensitivity and specificity of SUV_max1 were 74.7% and 83.4%, respectively. Although the performance of the axillary RI was inferior to that of SUV_max1 and SUV_max2, both the SUV_max and the RI were independent predictors of nodal metastasis, and a positive RI suggested axillary lymph node involvement when the SUV_max1 was significantly high. Of 533 patients with category T1-2 breast cancer without lymph node swelling, 101 (19.0%) had pathologic lymph node involvement; the negative predictive value of axillary SUV_max1 was 86.8%. CONCLUSION. Delayed phase imaging identified axillary lymph node metastasis as accurately as standard PET/CT. A high negative predictive value of PET/CT for the detection of nodal metastasis is helpful to avoid surgical axillary assessment in patients with category T1-2 breast cancer without lymph node swelling.

Differences in Perceived Risk at Which Clinician and Patient Stakeholders Initiate Activities to Prevent Late Effects Among Breast Cancer Survivors

Objective

To characterize the level of probability or perceived risk that will trigger patients, physicians, nurses, or therapists to initiate clinical activities to prevent late effects, including chronic physical impairments and adverse symptoms that often occur among breast cancer (BC) survivors.

Design

Cross-sectional survey querying participants regarding the level of probability or perceived risk of a patient developing a late effect, 0%-100% visual analog scale, that would cause them to initiate activities to prevent or preemptively address late effects such as lymphedema, upper quadrant pain, chemotherapy-induced peripheral neuropathy, shoulder contracture, and fatigue.

Setting

A quaternary medical center and community medical and radiation oncology clinics.

Participants

A purposive sample of 50 BC survivors, 10 breast clinic physicians, 10 breast surgeons, 10 radiation oncologists, 10 medical oncologists, 10 breast clinic nurses, and 10 cancer rehabilitation therapists (N=110).

Interventions

Not applicable.

Main Outcome Measures

Stakeholder ratings of the probability level at which they would initiate clinical activities to prevent BC-related late effects: education, screening, prevention, and therapist referral, scored on a visual analog scale 0%-100% with verbal anchors, to address lymphedema, chronic upper quadrant pain, function-limiting chemotherapy induced peripheral neuropathy, shoulder contracture, and chronic fatigue.

Results

For the 5 late effects, mean probability level ranges across the stakeholder groups were ordered as follows: education (2.8-27.1), prevention (8.1-44.1), screening (11.1-50.2), and therapist referral (16.4-59.2). BC survivors had the lowest thresholds for initiating education: lymphedema 2.0, pain 3.6, neuropathy 1.4, shoulder contracture 3.3, and fatigue 3.3. Therapists, in contrast, had the lowest thresholds for initiating all prevention activities except education. When averaged across late effects, mean probability levels for initiating activities were higher among physicians with breast surgeons having the highest mean levels for all activities except therapist referral. Nonetheless, mean probability levels differed significantly between survivors and clinicians (allied health and physicians combined) for only 2 of the 4 prevention activities and in these cases by ≤12%.

Conclusions

The probability level or perceived risk of a BC-related late effect at which stakeholders recommended initiating preventive activities differed across groups, with therapists generally having the lowest levels and breast surgeons the highest. However, the mean levels endorsed by survivors were congruent with or differed limitedly from clinicians and should be considered as a guide to initiating activities.

Frequency and risk factors for arm lymphedema after multimodal breast-conserving treatment of nodal positive breast Cancer - a long-term observation

Background

Arm-lymphedema is a major complication after breast cancer. Recent studies demonstrate the validity of predicting Breast Cancer Related Lymphedema (BCRL) by self-reports. We aimed to investigate the rate of BCRL and its risk factors in the long-term using self-reported symptoms.

Methods

Data was collected from 385 patients who underwent multimodal therapy for nodal positive breast cancer, including breast conserving surgery, axillary dissection, and local or locoregional radiotherapy. Two validated questionnaires were used for the survey of BCRL (i.e. LBCQ-D and SDBC-D). These were analysed collectively with retrospective data of our medical records.

Results

23.5% (n = 43) suffered a permanent BCRL (stage II-III) after a median follow-up time of 10.1 years (4.9–15.9 years); further 11.5% (n = 23) reported at least one episode of reversible BCRL (Stage 0-I) during the follow-up time. 87.1% of the patients with lymphedema developed this condition in the first two years. Adjuvant chemotherapy was a significant risk factor for the appearance of BCRL (p = 0.001; 95%-CI 7.7–10.2).

Conclusions

Breast cancer survivors face a high risk of BCRL, particularly if axillary dissection was carried out. Almost 90% of BCRL occurred during the first two years after radiotherapy. Self-report of symptoms seems to be a suitable instrument of early detection of BCRL.

Lymphoedema After Breast Cancer Treatment is Associated With Higher Body Mass Index: A Systematic Review and Meta-Analysis

Background:

Excess body weight has been identified as an important risk factor for lymphoedema following breast cancer treatment, however it remains unclear how much risk increases as weight increases. We conducted a meta-analysis to assess the relationship between body mass index (BMI) and risk of lymphoedema in breast cancer patients, and to estimate the level of risk by BMI category.

Methods:

We conducted a systematic search of all articles published through May 2018 in PubMed and the Cochrane library. Studies that included data on BMI and lymphoedema in breast cancer patients were included in the meta-analysis. We compared risk of lymphoedema in BMI groups as: BMI<25 versus BMI≥25, BMI<25 versus BMI≥30, BMI≥25 to <30 versus BMI≥30, BMI<30 versus BMI≥30, BMI<25 versus BMI≥25 to BMI<30.

Results:

After exclusion of ineligible studies, 57 studies were included in the meta-analysis. The mean difference in BMI between patients with lymphoedema compared to those without lymphoedema was 1.7 (95% CI, 1.3–2.2). Compared to patients with a BMI<25, risk of lymphoedema was higher in those with a BMI >25 to <30 (odds ratio [OR] 1.3; 95% CI, 1.2 to 1.5), a BMI≥25 (OR 1.7; 95% CI, 1.5 to 1.9), or a BMI≥30 (OR 1.9; 95% CI, 1.6 to 2.4). Compared to patients with a BMI of >25 to <30, risk of lymphoedema was higher in patients with a BMI>30 (OR 1.5; 95% CI,1.4 to 1.8).

Conclusion:

Excess body weight is a risk factor for lymphoedema following treatment of breast cancer, with the magnitude of risk increasing across higher categories of BMI.

Optimizing Patient Positioning to Reduce Variation in the Measurement of Breast Cancer-Related Lymphedema

Background: Prospective lymphedema screening is recommended for breast cancer patients. We observed interoperator variation in perometer-acquired arm volume measurements (P-AVMs) due to patient instability during measurements. We hypothesized that improved positioning during perometry would reduce P-AVM variability. Methods and Results: Each arm was measured three times by each operator using a perometer. With the original configuration, P-AVM was performed by 2 operators in 30 patients and four cohorts of 5 to 6 operators in 5 volunteers. Repeatability, reproducibility, and gage precision/tolerance (P/T) ratio were calculated. A customized handlebar was installed to optimize patient positioning. P-AVMs were performed in 20 patients with both configurations. Student's t-test was used to compare variation. With the new configuration, P-AVMs were performed by three operators in five volunteers and five operators in three volunteers. Repeatability, reproducibility, and gage P/T ratio were calculated. For the original configuration, gage P/T ratio was 19.9% for two operators and 35.9% for four cohorts of five to six operators. One operator using the new handlebar decreased P-AVM variability by 28% (p = 0.02). For the new configuration, gage P/T ratio was 6.5% for three operators and 18.7% for five operators. Conclusions: Optimizing patient setup improved P-AVM accuracy. P-AVM accuracy is critical as lack of accuracy results in either overdiagnosis or underdiagnosis of lymphedema, which in turn results in either over- or undertreatment of this dreaded condition. A higher number of operators were associated with greater P-AVM variability.

Heavy-Load Lifting: Acute Response in Breast Cancer Survivors at Risk for Lymphedema

Purpose

Despite a paucity of evidence, prevention guidelines typically advise avoidance of heavy lifting in an effort to protect against breast cancer–related lymphedema. This study compared acute responses in arm swelling and related symptoms after low- and heavy-load resistance exercise among women at risk for lymphedema while receiving adjuvant taxane-based chemotherapy.

Methods

This is a randomized, crossover equivalence trial. Women receiving adjuvant taxane-based chemotherapy for breast cancer who had undergone axillary lymph node dissection (n = 21) participated in low-load (60%–65% 1-repetition maximum, two sets of 15–20 repetitions) and heavy-load (85%–90% 1-repetition maximum, three sets of 5–8 repetitions) upper-extremity resistance exercise separated by a 1-wk wash-out period. Swelling was determined by bioimpedance spectroscopy and dual-energy x-ray absorptiometry, with breast cancer–related lymphedema symptoms (heaviness, swelling, pain, tightness) reported using a numeric rating scale (0–10). Order of low- versus heavy-load was randomized. All outcomes were assessed before, immediately after, and 24 and 72 h after exercise. Generalized estimating equations were used to evaluate changes over time between groups, with equivalence between resistance exercise loads determined using the principle of confidence interval inclusion.

Results

The acute response to resistance exercise was equivalent for all outcomes at all time points irrespective of loads lifted, with the exception of extracellular fluid at 72 h after exercise with less swelling after heavy loads (estimated mean difference, −1.00; 95% confidence interval, −3.17 to 1.17).

Conclusions

Low- and heavy-load resistance exercise elicited similar acute responses in arm swelling and breast cancer–related lymphedema symptoms in women at risk for lymphedema receiving adjuvant taxane-based chemotherapy. These represent important preliminary findings, which can be used to inform future prospective evaluation of the long-term effects of repeated exposure to heavy-load resistance exercise.

Information-seeking, information sources and ongoing support needs after discharge to prevent cancer-related lymphoedema

Objectives

To compare gynaecological and breast cancer patients in their information-seeking behaviours, usefulness of information sources and ongoing care needs after discharge to prevent the onset of lymphoedema.

Methods

We conducted a consecutive cross-sectional survey in an oncology hospital. Adult patients with stage I, II or III gynaecological or breast cancer who had undergone lymph node dissection and had not been diagnosed with lymphoedema were eligible for inclusion. The survey explored physical health status, knowledge of self-care, information-seeking behaviours, information sources and need for ongoing care from an oncology hospital and/or community health centre.

Results

Among 254 patients recruited, 202 responded (79.5% response rate). In total, 147 patients were eligible for statistical analysis. Irrespective of cancer type, the most commonly sought information was lymph drainage. Information on preventing weight gain was sought more often by breast cancer patients than gynaecological cancer patients. Regardless of cancer type, the most common information sources were nurses at an oncology hospital. Gynaecological cancer patients perceived nurses at the oncology hospital as useful for understanding risks, symptoms and prevention of lymphoedema. Irrespective of cancer type, ongoing need for help with lymphoedema prevention was reported both from the oncology hospital and the community centre. Limb symptoms, poor health status and poor knowledge affected the ongoing needs of gynaecological cancer patients at the oncology hospital, whereas poor health status affected ongoing needs in community health centres among both types of cancer patients.

Conclusions

Both gynaecological and breast cancer patients reported ongoing care needs, but that details of information-seeking behaviours differed.

Evaluation of the Brachial Plexus With Shear Wave Elastography After Radiotherapy for Breast Cancer

OBJECTIVES

The aim of this study was to analyze the elasticity characteristics of the brachial plexus by shear wave elastography (SWE) in patients receiving radiation therapy (RT) for breast cancer and to compare them with their contralateral brachial plexus to evaluate whether elasticity properties can be used as supporting findings for the early diagnosis of brachial plexus involvement in patients receiving RT.

METHODS

A prospective analysis with electromyography and SWE was performed on 23 brachial plexuses of patients receiving RT for breast cancer and their contralateral brachial plexuses. An electromyographic device was used for nerve conduction studies. Evaluations were done by the same investigator, and superficial electrodes were used in the recordings. A quantitative analysis of the brachial plexus with SWE was performed, with values in kilopascals on a color scale ranging from 0 (red, soft) to 150 (dark blue, hard) kPa.

RESULTS

Mean SWE values ± SD were 51.0 ± 14.0 kPa for the ipsilateral brachial plexuses of patients receiving RT and 18.0 ± 4.2 kPa for the contralateral brachial plexuses. Statistically significant differences were observed between the groups in the analysis of SWE values (P < .001). No significant correlation was found between the nerve conduction parameters and elastographic values (P > .05).

CONCLUSIONS

Shear wave elastography showed that the brachial plexuses of patients receiving RT were stiffer than the unaffected brachial plexuses. Brachial plexus stiffening may be associated with fibrotic processes.

Diagnosis and Treatment of Edema and Lymphedema in the Cancer Patient

BACKGROUND

Lymphedema occurs commonly in cancer survivors. It is crucial to properly assess cancer patients in order to distinguish lymphedema from general edema and to initiate evidence based treatment.

PURPOSE

To provide evidence based recommendations for screening, evaluating, and treating lymphedema and to establish the role of the nurse in the care of patients with lymphedema.

METHODOLOGY

Comprehensive overview with narrative literature review of evidence based lymphedema diagnosis and treatment.

FINDINGS

Cancer-related edema represents numerous complex conditions. A variety of interventions are needed to address prevention, early detection, patient education, and effective treatment.

CONCLUSION

Lymphedema treatment is complex and multimodal, and is provided by an interdisciplinary team of properly trained professionals. Nurses play a major role in evaluating, treating and educating patients on the signs and symptoms of cancer-related edema and patient self-management.

CLINICAL IMPLICATIONS

Evidence-based assessment and treatment should be initiated early to improve outcomes and quality of life in patients with cancer-related lymphedema.

Lymphovenous Anastomosis Bypass Surgery

The field of lymphedema surgery has witnessed tremendous advancements over the years and has been coupled to the rapid growth of supermicrosurgical techniques. A lymphovenous bypass or lymphaticovenular anastomosis is a new technique that requires identification of patent, residual lymphatic channels and performing an anastomosis to a recipient venule, thereby allowing outflow of lymphatic fluid and improvement in a patient's lymphedema. This article provides a summary of the maturation of the technique, as well as the technical aspects of the approach and the current outcomes in the treatment of postmastectomy lymphedema.

Arm morbidity of axillary dissection with sentinel node biopsy versus delayed axillary dissection

BACKGROUND

Staging of axillary lymph nodes in breast cancer is important for prognostication and planning of adjuvant therapy. The traditional practice of proceeding to axillary lymph node dissection (ALND) if sentinel lymph node biopsy (SLNB) is positive is being challenged and clinical trials are underway. For many centres, this will mean a move away from intra-operative SLNB assessment and utilization of a second procedure to perform ALND. It is sometimes perceived that a delayed ALND results in increased tissue damage and thus increased morbidity. We compared morbidity in those undergoing SLNB only, or ALND as a one- or two-stage procedure.

METHODS

A retrospective review of a prospectively collected institutional database was used to review rates of lymphoedema and shoulder function in women undergoing breast cancer surgery between 2008 and 2012.

RESULTS

The overall lymphoedema rate in 745 patients was 8.2% at 12 months. There was no difference in lymphoedema rates between those undergoing immediate or delayed ALND (17.8 and 8.6%, respectively, P = 0.092). Post-operative shoulder elevation, odds ratio (OR) = 0.390, 95% confidence interval (CI) = (0.218, 0.698) and abduction, OR = 0.437 (95% CI = (0.271, 0.705)) were reduced if an ALND was performed although there was no difference between immediate or delayed.

CONCLUSION

ALND remains a risk factor for post-operative morbidity. There is no increased risk of lymphoedema or shoulder function deficit with a positive SLNB and delayed ALND compared to immediate ALND.

Machine learning for detection of lymphedema among breast cancer survivors

BACKGROUND

In the digital era when mHealth has emerged as an important venue for health care, the application of computer science, such as machine learning, has proven to be a powerful tool for health care in detecting or predicting various medical conditions by providing improved accuracy over conventional statistical or expert-based systems. Symptoms are often indicators for abnormal changes in body functioning due to illness or side effects from medical treatment. Real-time symptom report refers to the report of symptoms that patients are experiencing at the time of reporting. The use of machine learning integrating real-time patient-centered symptom report and real-time clinical analytics to develop real-time precision prediction may improve early detection of lymphedema and long term clinical decision support for breast cancer survivors who face lifelong risk of lymphedema. Lymphedema, which is associated with more than 20 distressing symptoms, is one of the most distressing and dreaded late adverse effects from breast cancer treatment. Currently there is no cure for lymphedema, but early detection can help patients to receive timely intervention to effectively manage lymphedema. Because lymphedema can occur immediately after cancer surgery or as late as 20 years after surgery, real-time detection of lymphedema using machine learning is paramount to achieve timely detection that can reduce the risk of lymphedema progression to chronic or severe stages. This study appraised the accuracy, sensitivity, and specificity to detect lymphedema status using machine learning algorithms based on real-time symptom report.

METHODS

A web-based study was conducted to collect patients' real-time report of symptoms using a mHealth system. Data regarding demographic and clinical information, lymphedema status, and symptom features were collected. A total of 355 patients from 45 states in the US completed the study. Statistical and machine learning procedures were performed for data analysis. The performance of five renowned classification algorithms of machine learning were compared: Decision Tree of C4.5, Decision Tree of C5.0, gradient boosting model (GBM), artificial neural network (ANN), and support vector machine (SVM). Each classification algorithm has certain user-definable hyper parameters. Five-fold cross validation was used to optimize these hyper parameters and to choose the parameters that led to the highest average cross validation accuracy.

RESULTS

Using machine leaning procedures comparing different algorithms is feasible. The ANN achieved the best performance for detecting lymphedema with accuracy of 93.75%, sensitivity of 95.65%, and specificity of 91.03%.

CONCLUSIONS

A well-trained ANN classifier using real-time symptom report can provide highly accurate detection of lymphedema. Such detection accuracy is significantly higher than that achievable by current and often used clinical methods such as bio-impedance analysis. Use of a well-trained classification algorithm to detect lymphedema based on symptom features is a highly promising tool that may improve lymphedema outcomes.

Effectiveness of acupuncture for breast cancer related lymphedema: protocol for a single-blind, sham-controlled, randomized, multicenter trial

BACKGROUND

Although various treatments for breast cancer related lymphedema exist, there is still a need for a more effective and convenient approach. Pilot studies and our clinical observations suggested that acupuncture may be a potential option. This study aims to verify the effectiveness of acupuncture on BCRL and evaluate its safety using a rigorously designed trial.

METHODS/DESIGN

Women who are clinically diagnosed as unilateral BCRL, with a 10% to 40% increase in volume compared to the unaffected arm, will be recruited. Following baseline assessment, participants will be randomized to either the real acupuncture group or sham-acupuncture group at a ratio of 1:1, and given a standard real acupuncture or sham-acupuncture treatment accordingly on both arms followed by the same usual care of decongestive therapy. Volume measurements of both arms will be performed for every participant after each treatment. Data collected at baseline and the last session will be used to calculate the primary outcome and secondary outcomes. Other data will be exploited for interim analyses and trial monitoring. The primary outcome is the absolute reduced limb volume ratio. Secondary outcomes are incidence of adverse events and change in quality of life. A t test or non-parameter test will be used to compare the difference between two groups, and assess the overall effectiveness of acupuncture using the SPSS software (version 12).

DISCUSSION

This study will help expand our knowledge about the effectiveness of acupuncture on BCRL, and how acupuncture might be used in the management of this condition. Acupuncture may be a promising complement or alternative to conventional lymphedema treatment methods, if its effectiveness is confirmed.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02803736 (Registered on October 31, 2016).