Development of an All-Wales National Health Service Surgical Lymphedema Supermicrosurgery Service

Background

The management of lymphedema includes an array of conservative measures, but must also include surgical intervention as a management option where appropriate. Within the National Health Service in Great Britain, the surgical provision for lymphedema patients is very minimal. This article provides a historical overview of the inception of the lymphedema service within Wales, which is the only holistic lymphedema service within the National Health Service.

Methods

All patients discussed at the lymphedema multidisciplinary team (MDT) meeting were included. Data were collected during a 5-year period from June 2017 to May 2022. MDT meeting outcomes were also recorded (conservative or surgical management), and if surgical intervention was used, the type of surgical procedure was documented.

Results

A total of 175 patients were discussed by the lymphedema surgical MDT. Of these, 129 (74%) were recommended for surgery and 46 (26%) were managed using conservative measures alone. The most common surgical recommendation was for lymphovenous anastomosis (61, 47%), followed by liposuction (40, 31%). Vascularized lymph node transfer was recommended in 19 (15%) cases.

Conclusions

The authors highlight the efficiency of the service, whereby despite more than 7500 referrals a year, only a small minority that are eligible for surgery undergo a surgical assessment. The authors hope that this article provides an impetus for such services to be similarly replicated across other nations.

UK survey on experiences of men with non-cancer-related lymphoedema: part one

This initial article delves into the methodology, methods and theories, while the subsequent article will centre on the discoveries, discussion and conclusion. The study aimed to address the research question: how do men perceive their engagement in the self-management of non-cancer-related lymphoedema? An interpretivist qualitative methodology was employed, utilising an online survey based on the validated lymphoedema quality of life tool (LYMQoL). The data underwent inductive narrative inquiry. The study incorporated theories such as hegemonic masculinity and the health, illness, men and masculinities (HIMM) framework. The findings will be detailed in the second article in this series. This article has delineated the objective, methodologyand methods, employing a qualitative interpretivist approach through narrative inquiry. The study incorporated masculinity theories, including hegemonic masculinity and HIMM. The second article will present the findings and their significance within the broader literature.

Evaluation of incontinence and lymphedema in gynecological cancer patients along with their impact on the quality of life

PURPOSE

The aim of this study is to evaluate the patients who developed both urinary incontinence and lymphedema in gynecological cancer survivors and to investigate the impact of these conditions on the quality of life among these patients.

METHODS

Our study included 56 patients who have lymphedema and urinary incontinence which started within first 2 years after surgery for gynecological cancer. We evaluated the presence of urinary incontinence by Overactive Bladder Assessment Tool (OABT) and Urogenital Distress Inventory (UDI). Incontinence Impact Questionnaire (IIQ-7) was used to assess the quality of life.

RESULTS

OABT and UDI scores were found to be statistically significantly increased in patients with grade 3 lymphedema (respectively p: 0.006, p: 0.008). A statistically significant difference was found between lymphedema grade 1-2-3 patients in terms of IIQ-7 (p:0.002). The difference was statistically significant between the grade 1-3 (p:0.001) and grade 2-3 (p:0.013) groups. We did not find any correlation between age, type of cancer, radiotherapy, and urinary incontinence. There was a statistically significant positive correlation between BMI and OABT, UDI scores (respectively, r = 0.43, p = 0.001; r = 0.38, p = 0.003).

CONCLUSION

It was concluded that there was a relationship between urinary incontinence and grade 3 lymphedema in gynecological cancer survivors. Grade 3 lymphedema increases urinary incontinence and worsens daily living functions in these patients.

Ensuring patient centeredness in upper extremity lymphedema research: Identifying patient-prioritized agenda and preferences

PURPOSE

To elicit a patient-prioritized agenda and preferences for upper extremity lymphedema (LE) research.

METHODS

Focus group sessions (FGs) were conducted with English-speaking, adult women (18 years and older) with breast cancer-related LE (BCRL) seeking conservative or surgical care at two tertiary cancer centers in Ontario, Canada. An interview guide was used; women were asked to describe health-related quality of life (HRQL) outcomes that mattered the most to them, followed by their preferences for research study design and for providing patient-reported outcomes measure (PROM) data. Inductive content analysis was used to identify themes and subthemes.

RESULTS

A total of 16 women participated in 4 FG sessions (55 ± 9.5 years) and described the impact of LE on their appearance, physical, psychosocial, and sexual well-being. Women emphasized that psychosocial well-being was often not discussed in clinical care and that they were poorly informed of LE risk and care options. Most women said that they would not be willing to be randomized to surgical versus conservative management of LE. They also expressed a preference to complete PROM data electronically. All women emphasized the value of having an open text option alongside PROMs to expand on their concerns.

CONCLUSION

Patient centeredness is key to generating meaningful data and ensuring ongoing engagement in clinical research. In LE, comprehensive PROMs that measure a range of HRQL concerns, especially psychosocial well-being, should be considered. Women with BCRL are reluctant to be randomized to conservative care when a surgical option is available, resulting in implications for planning trial sample size and recruitment.

A qualitative systematic review and meta-aggregation of the experiences of men diagnosed with chronic lymphoedema

BACKGROUND

Lymphoedema is a chronic condition that is estimated to affect up to four people per 1000 of the UK population with this increasing with age. Men account for up to 20% of lymphoedema service caseloads with research focussing upon women affected.

AIMS

To retrieve primary qualitative research on the experiences of men with chronic lymphoedema.

METHODS

A qualitative review was undertaken using the Joanna Briggs Institute (JBI) meta-aggregation method. A search strategy was applied to 12 databases, from inception to February 2021, with 22 studies identified and appraised. The findings were extracted and synthesised via the JBI approach.

RESULTS

Four synthesised findings were identified: (1) The 'New Norm', how diagnosis led to men being faced with a 'new version' of themselves; (2) 'Journey into the Unknown' relates to the unforeseen diagnosis of the condition; (3) 'Access' - challenge in receiving a diagnosis, and support; and (4) 'Personhood' - the impact of the condition upon external constructs and relationships.

CONCLUSIONS

Men are faced with similar challenges as women coupled with societal expectations with respect to gender identity and expression. This leads to those wishing to engage with men to adopt 'gender-based tailoring' within healthcare services, information and support.

Upper Extremity Subcutaneous Lymphatic Drainage "Lymphocentesis" for Symptom Relief in End-Stage Breast Cancer

Lymphedema is a challenging condition that occurs as a complication to many life-limiting medical conditions. It has a number of associated symptoms including pain, functional impairments, and emotional distress. Majority of treatment interventions have been studied and applied outside of the palliative care context. Subcutaneous drainage is a technique that has been used in some case reports for the lower extremity and sacrum with good results. This report describes an adapted technique of subcutaneous drainage for treating upper extremity lymphedema in the palliative setting.

Yoga, breast cancer-related lymphoedema and well-being: A descriptive report of women's participation in a clinical trial

AIMS AND OBJECTIVES

To describe the experiences of women taking part in a yoga intervention trial for breast cancer-related lymphoedema.

BACKGROUND

Around 20% of women will experience lymphoedema as a consequence of treatment for breast cancer. Specialist lymphoedema clearing, along with self-management, remains the mainstay of therapy. Yoga, an increasingly popular complementary therapeutic practice, may provide another tool to augment self-management.

DESIGN

A qualitative, descriptive design.

METHODS

Interviews were conducted with 15 women with stage one breast cancer-related lymphoedema who had completed an 8-week yoga intervention trial. The intervention consisted of a weekly teacher-led 1.5-hr yoga class and a daily home practice using a 45-min DVD. Interviews were audio-taped and transcribed. These data were then analysed using an iterative-thematic approach.

RESULTS

Participants reported improved well-being, increased awareness of their physical body as well as improved physical, mental and social functioning. They gained from being part of the yoga group that also provided a forum for them to share their experiences. Nine women felt empowered to describe their yoga participation as a transformative journey through illness.

CONCLUSION

When safe to do so, the holistic practice of yoga may augment and provide additional benefit to current self-management and treatment practices for women with breast cancer-related lymphoedema.

RELEVANCE TO CLINICAL PRACTICE

Patients with breast cancer-related lymphoedema may seek advice and guidance from nurses and other healthcare professionals on a range of complementary therapies to help relieve symptoms and promote recovery. Patients who choose to augment their treatment of breast cancer-related lymphoedema by practicing yoga should be carefully assessed, be taught an appropriate technique by a qualified yoga teacher/therapist and its impact monitored by their yoga teacher/therapist, breast care nurse, lymphoedema therapist or treating clinician.

Effects of phase I complex decongestive physiotherapy on physical functions and depression levels in breast cancer related lymph edema

[Purpose] Breast cancer-related upper extremity lymph edema is known to cause physical, functional and psychological impairments in women after modified radical mastectomy. The aim of this study was to investigate the effects of phase I Complex Decongestive Physiotherapy (CDP) on physical functions and depression levels in women with breast cancer-related upper extremity lymph edema. [Subjects and Methods] Fifty-eight subjects with breast cancer-related upper extremity lymph edema were the subjects of this study. The arm circumference, shoulder range of motion (ROM), muscle strength and depression levels of the subjects were assessed before and after phase I CDP treatment. [Results] After phase I CDP, there was a statistically significant reduction in circumference measurements at all levels of the affected arm. There was not any statistically significant difference in muscle strength after CDP. The shoulder ROM improved after treatment. There was a significant reduction in the Beck Depression Inventory score. A significant positive correlation was found between depression levels and circumference measurement. [Conclusion] Based on the results we suggest that by reducing limb volume, beside improving physical functions, phase I CDP can affect psychological status, especially depression which is very common in women with breast cancer-related upper extremity lymph edema.

Functioning in lymphedema from the patients' perspective using the International Classification of Functioning, Disability and health (ICF) as a reference

PURPOSE

To identify and quantify meaningful concepts in lymphedema from the patients' perspectives using the International Classification of Functioning, Disability and Health (ICF).

METHODS

Six focus group interviews in five different centers were organized, audiotaped, transcribed verbatim and analyzed.

RESULTS

A total of 2681 relevant ICF linkings were performed with the focus group data, resulting in 130 different second-level categories. Of these 130 second-level categories, 41 (31.5%) categories were categorized as Body Functions, 20 (15.5%) as Body Structures, 41 (31.5%) as Activities and Participation, and 28 (21.5%) as Environmental Factors. Overall, the most important issues according to the patients were the use of hosiery and bandages, support and relationships, and the shape of structures related to movement.

CONCLUSION

Based on their experiences with lymphedema, patients reported activity limitations and participation restrictions combined with impaired body functioning. Anatomical changes (Body Structures) were also often mentioned as a problem in daily life. Environmental factors may act as a barrier or facilitator for patient functioning. The ICF provides a valuable reference to identify concepts in statements from lymphedema patients. The results of this research will be used in the development of ICF Core Sets for lymphedema.

Lymphoedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphoedema (Lymph-ICF-LL): reliability and validity

BACKGROUND

Patients may develop primary (congenital) or secondary (acquired) lymphedema, causing significant physical and psychosocial problems. To plan treatment for lymphedema and monitor a patient's progress, swelling, and problems in functioning associated with lymphedema development should be assessed at baseline and follow-up.

OBJECTIVE

The purpose of this study was to investigate the reliability (test-retest, internal consistency, and measurement variability) and validity (content and construct) of data obtained with the Lymphoedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphoedema (Lymph-ICF-LL).

DESIGN

This was a multicenter, cross-sectional study.

METHODS

The Lymph-ICF-LL is a descriptive, evaluative tool containing 28 questions about impairments in function, activity limitations, and participation restrictions in patients with lower limb lymphedema. The questionnaire has 5 domains: physical function, mental function, general tasks/household activities, mobility activities, and life domains/social life. The reliability and validity of the Lymph-ICF-LL were examined in 30 participants with objective lower limb lymphedema.

RESULTS

Intraclass correlation coefficients for test-retest reliability ranged from .69 to .94, and Cronbach alpha coefficients for internal consistency ranged from .82 to .97. Measurement variability was acceptable (standard error of measurement=5.9-12.6). Content validity was good because all questions were understandable for 93% of participants, the scoring system (visual analog scale) was clear, and the questionnaire was comprehensive for 90% of participants. Construct validity was good. All hypotheses for assessing convergent validity and divergent validity were accepted.

LIMITATIONS

The known-groups validity and responsiveness of the Dutch Lymph-ICF-LL and the cross-cultural validity of the English version of the Lymph-ICF-LL were not investigated.

CONCLUSIONS

The Lymph-ICF-LL is a Dutch questionnaire with evidence of reliability and validity for assessing impairments in function, activity limitations, and participation restrictions in people with primary or secondary lower limb lymphedema.

The effect of prospective monitoring and early physiotherapy intervention on arm morbidity following surgery for breast cancer: a pilot study

PURPOSE

Significant arm morbidity is reported following surgery for breast cancer, yet physiotherapy is not commonly part of usual care. This study compared the effect on arm morbidity after surgery for breast cancer of a clinical care pathway including preoperative education, prospective monitoring, and early physiotherapy (experimental group) to that of preoperative education alone (comparison group).

METHODS

A prospective quasi-experimental pretest-posttest, non-equivalent group design compared two clinical sites; Site A (n=41) received the experimental intervention, and Site B (n=31) received the comparison intervention. At baseline (preoperative) and 7 months postoperative, shoulder range of motion (ROM), upper-extremity (UE) strength, UE circumference, pain, UE function, and quality of life were assessed.

RESULTS

The experimental group maintained shoulder flexion ROM at 7 months, whereas the comparison group saw a decrease (mean 1° [SD 9°] vs. -6° [SD 15°], p=0.03). A lower incidence of arm morbidity and better quality of life were observed in the experimental group, but these findings were not statistically significant. Baseline characteristics and surgical approaches differed between the two sites, which may have had an impact on the findings.

CONCLUSION

Initial results are promising and support the feasibility of integrating a surveillance approach into follow-up care. This pilot study provides the foundation for a larger, more definitive trial.

Breast cancer survivors with lymphedema: glimpses of their daily lives

Breast cancer survivors with lymphedema experience physical, psychosocial, and quality-of-life difficulties. Cancer treatment-related lymphedema often is viewed as a disabling condition, and that assumption has fostered an environment in which oncology nurses are not actively involved in the care of patients with lymphedema. Little is known about how breast cancer survivors with lymphedema structure their daily lives. This article describes an effort to determine whether lymphedema truly is a disabling condition by collecting symptom data and self-generated narratives from breast cancer survivors with lymphedema regarding their eating habits, daily activities, substance use, and future plans. Although the sample experienced multiple symptoms, lymphedema duration and degree of extracellular arm fluid did not appear to influence those symptoms. In addition, participants led full, rich, busy lives. The findings do not support the notion that patients with lymphedema live as disabled people. A disability model may not be optimal to guide research design or patient care; rather, a symptom management model better explains the findings and implies that active involvement by nurses in lymphedema patient care and education is indicated.

The information needs and media preferences of Canadian cancer specialists regarding breast cancer treatment related arm morbidity

The information needs and media preferences of Canadian cancer specialists regarding breast cancer treatment related arm morbidity. Breast cancer treatment related arm morbidity is a common but pernicious condition that is under-recognised, under-diagnosed, and can result in long-term impairment and disability. Despite the prevalence of this condition, little is known about breast cancer specialists' information needs and media preferences around this issue. In-depth telephone interviews with 14 Canadian cancer specialists were conducted, and were coded and analysed using a grounded theory approach. Findings revealed that cancer specialists were open to receiving all types of information about treatment related arm morbidity, and have preferences for particular types of media formats. However, barriers that could problematise the uptake of research findings into clinical practice were also noted and included gaps in specialists' knowledge of the complex nature of treatment related lymphoedema. Hence providing specialists with summary information about arm morbidity will not suffice, and an educational campaign around this condition, including the importance of physician vigilance in regularly monitoring patients for early and latent indications of this morbidity may be necessary.

Psychosocial impact of living with cancer-related lymphedema

OBJECTIVES

To summarize the evidence of and identify factors influencing the psychosocial impact of lymphedema, as well as to discuss nursing strategies.

DATA SOURCES

Peer-reviewed publications from 2004 to 2011 in 11 major medical indices.

CONCLUSION

Poorer overall health-related quality of life was reported among cancer survivors with lymphedema. The consistent, detailed, and vivid descriptions from the qualitative studies suggest that cancer-related lymphedema exerts tremendous negative psychosocial impact, which quantitative studies failed to capture.

IMPLICATIONS FOR NURSING PRACTICE

Nursing strategies include helping patients to build a routine for daily care, setting goals, exercise, positive self-talk, providing helpful resources, and organizing support groups. Professional organizations should devote resources to public education through television advertisement, public meetings, and online education.

Lower limb lymphedema in gynecological cancer survivors--effect on daily life functioning

PURPOSE

Lower limb lymphedema (LLL) is a common condition after pelvic cancer treatment but few studies have evaluated its effect on the quality of life and its consequences on daily life activities among gynecological cancer survivors.

METHODS

We identified a cohort of 789 eligible women, treated with pelvic radiotherapy alone or as part of combined treatment of gynecological cancer, from 1991 to 2003 at two departments of gynecological oncology in Sweden. As a preparatory study, we conducted in-depth interviews with gynecological cancer survivors and constructed a study-specific questionnaire which we validated face-to-face. The questionnaire covered physical symptoms originating in the pelvis, demographic, psychological, and quality of life factors. In relation to the lymph system, 19 questions were asked.

RESULTS

Six hundred sixteen (78 %) gynecological cancer survivors answered the questionnaire and participated in the study. Thirty-six percent (218/606) of the cancer survivors reported LLL. Overall quality of life was significantly lower among cancer survivors with LLL. They were also less satisfied with their sleep, more worried about recurrence of cancer, and more likely to interpret symptoms from the body as recurrence. Cancer survivors reported that LLL kept them from physical activity (45 %) and house work (29 %) and affected their ability to partake in social activities (27 %) or to meet friends (20 %).

CONCLUSION

Lower limb lymphedema has a negative impact on quality of life among gynecological cancer survivors, affecting sleep and daily life activities, yet only a few seek professional help.

Efficacy of complete decongestive therapy (CDT) on edematous rat limb after lymphadenectomy demonstrated by real time lymphatic fluid tracing

Although complete decongestive therapy (CDT) is considered to reduce the volume of lymphedema, there is no concrete evidence to sustain its efficacy. The purpose of the present study was to find new evidence of CDT based on visualizing the changes of lymph fluid accumulating in an edematous limb using indocyanine green (ICG) fluorescent lymphography in real time.Twelve lymphedema rats were divided randomly into two groups. On the first day, ICG was injected into an edematous limb of rats, and no-intervention and CDT was applied to groups 1 and 2, respectively, for two weeks. ICG lymphography and circumferential measurements were done every two days in each two-week observation. The results indicates that a fluorescent flow to the ipsilateral axillary fossa was identified in all rats. In addition, network-like and dermal backflow patterns were observed in the lower legs and thighs. While manual lymph drainage was applied in the CDT group, the flow moved more rapidly through this pathway than that in the no-intervention group. An area of high-intensity fluorescent signals concentrated around the injection sites diminished in the CDT group more than that in the no-intervention-group after two weeks. Circumferential lengths of the edematous limbs were longer than the non-edematous limbs in both groups 1 and 2 on the day of ICG injection. The no-intervention group 1 showed no significance differences during 14 days, whereas the CDT group 2 exhibited very significant differences. These results suggest that CDT has beneficial effects in lymphedema treatment.

Psychosocial impact of lymphedema: a systematic review of literature from 2004 to 2011

OBJECTIVE

This systematic review aimed to evaluate the level of evidence of contemporary peer-reviewed literature published from 2004 to 2011 on the psychosocial impact of lymphedema.

METHODS

Eleven electronic databases were searched and 1311 articles retrieved; 23 met inclusion criteria. Twelve articles utilized qualitative methodology and 11 used quantitative methodology. An established quality assessment tool was used to assess the quality of the included studies.

RESULTS

The overall quality of the 23 included studies was adequate. A critical limitation of current literature is the lack of conceptual or operational definitions for the concept of psychosocial impact. Quantitative studies showed statistically significant poorer social well-being in persons with lymphedema, including perceptions related to body image, appearance, sexuality, and social barriers. No statistically significant differences were found between persons with and without lymphedema in the domains of emotional well-being (happy or sad) and psychological distress (depression and anxiety). All 12 of the qualitative studies consistently described negative psychological impact (negative self-identity, emotional disturbance, and psychological distress) and negative social impact (marginalization, financial burden, perceived diminished sexuality, social isolation, perceived social abandonment, public insensitivity, and non-supportive work environment). Factors associated with psychosocial impact were also identified.

CONCLUSIONS

Lymphedema has a negative psychosocial impact on affected individuals. The current review sheds light on the conceptualization and operationalization of the definitions of psychosocial impact with respect to lymphedema. Development of a lymphedema-specific instrument is needed to better characterize the impact of lymphedema and to examine the factors contributing to these outcomes in cancer and non-cancer-related populations.

The effect of yoga on women with secondary arm lymphoedema from breast cancer treatment

Background

Women who develop secondary arm lymphoedema subsequent to treatment associated with breast cancer require life-long management for a range of symptoms including arm swelling, heaviness, tightness in the arm and sometimes the chest, upper body impairment and changes to a range of parameters relating to quality of life. While exercise under controlled conditions has had positive outcomes, the impact of yoga has not been investigated. The aim of this study is to determine the effectiveness of yoga in the physical and psycho-social domains, in the hope that women can be offered another safe, holistic modality to help control many, if not all, of the effects of secondary arm lymphoedema.

Methods and design

A randomised controlled pilot trial will be conducted in Hobart and Launceston with a total of 40 women receiving either yoga intervention or current best practice care. Intervention will consist of eight weeks of a weekly teacher-led yoga class with a home-based daily yoga practice delivered by DVD. Primary outcome measures will be the effects of yoga on lymphoedema and its associated symptoms and quality of life. Secondary outcome measures will be range of motion of the arm and thoracic spine, shoulder strength, and weekly and daily physical activity. Primary and secondary outcomes will be measured at baseline, weeks four, eight and a four week follow up at week twelve. Range of motion of the spine, in a self-nominated group, will be measured at baseline, weeks eight and twelve. A further outcome will be the women’s perceptions of the yoga collected by interview at week eight.

Discussion

The results of this trial will provide information on the safety and effectiveness of yoga for women with secondary arm lymphoedema from breast cancer treatment. It will also inform methodology for future, larger trials.

Trial registration

ACTRN12611000202965

The challenges of managing complex lymphoedema/chronic oedema in the UK and Canada

This article explores the professional challenges of treating patients with complex/severe forms of chronic oedema/lymphoedema with compression therapy. Four focus groups were held, two in the UK and two in Canada, to examine the challenges faced by practitioners in their everyday practice. A number of challenges were identified by participants in both countries and include the changing profile of lymphoedema/chronic oedema and how increasing complexity is outpacing the development of services and research-based guidelines. Focus groups also highlighted a lack of public awareness, poor professional knowledge, delayed diagnosis and inappropriate treatment as having a significant impact on practice. Other practice-related issues include a poor understanding of treatment options among practitioners, a lack of evidence-based practice as well as difficulties associated with managing psychosocial problems and of ensuring concordance with treatment. In Canada, services tend to be more rural and remote than in the UK, autonomous specialist practice is less developed and practitioners were generally less confident and felt more vulnerable than their UK colleagues. There is a need for integrated, multi-disciplinary services in both countries, with improved education and training, as well as the development of cost-effective compression bandaging systems that can make a major contribution to meeting the challenges of contemporary lymphoedema practice.