Interpersonal Trauma and Substance Use Severity: The Serial Mediation of Emotional Intolerance and Emotional Dysregulation

Substance use is highly prevalent in those with trauma histories, especially in women, which may be in part explained by high rates of interpersonal trauma in this population. Research examining the potential mechanisms underlying the relationship between co-occurring interpersonal trauma histories and substance use disorders (SUDs) is in its infancy. The current study examined whether the relationship between interpersonal trauma and SUD severity could be understood via the sequential ordering of two transdiagnostic emotional vulnerability factors: 1) emotional intolerance (anxiety sensitivity, distress intolerance), and 2) emotional dysregulation (negative urgency, lack of clarity, nonacceptance, limited strategies, difficulties with goal-directed behavior). A sample of 130 adult community-based women self-identifying as experiencing substance use problems completed the online survey. Mediation analyses suggest that as women's lifetime interpersonal trauma increases, so does their SUD severity by way of emotional intolerance and subsequent difficulties regulating their emotions. The findings suggests that transdiagnostic interventions targeting tolerance of aversive emotions may facilitate the ability to learn and employ healthy emotion regulation strategies among women with interpersonal trauma histories and SUDs.

Heterogeneity In Women's Trauma Histories: Impact On Substance Use Disorder Severity

Trauma and substance use disorders (SUDs) frequently co-occur, especially in women. Previous studies have attempted to determine if individual differences in trauma histories could be meaningfully categorized but few studies have focused solely on women, especially those reporting substance use problems. A total of 130 women (M age = 30.7, SD = 7.9) self reporting past-year substance use problems completed comprehensive measures assessing lifetime exposure to a variety of traumatic events as well as substance use patterns and severity. Using latent class analysis, three classes emerged, a Low Lifetime Interpersonal Trauma class (40%, n = 52), a Moderate Lifetime Interpersonal Trauma class (23.8%, n = 31) and a High Lifetime Interpersonal Trauma class (36.2%, n = 47). Groups did not vary on daily/almost daily use of different types of substances and polysubstance use frequency but were significantly different on SUD severity, with the Moderate and the High Lifetime Interpersonal Trauma classes reporting severe SUD severity in comparison to moderate severity for the Low Interpersonal Trauma class. The findings of the current study indicate that women experiencing substance use problems should receive SUD treatment in a trauma-informed manner but that not all may require integrated trauma and substance use interventions.

Standardization of lower extremity quantitative lymphedema measurements and associated patient-reported outcomes in gynecologic cancers

Practice changing standardization of lower extremity lymphedema quantitative measurements with integrated patient reported outcomes will likely refine and redefine the optimal risk-reduction strategies to diminish the devastating limb-related dysfunction and morbidity associated with treatment of gynecologic cancers. The National Cancer Institute (NCI), Division of Cancer Prevention brought together a diverse group of cancer treatment, therapy and patient reported outcomes experts to discuss the current state-of-the-science in lymphedema evaluation with the potential goal of incorporating new strategies for optimal evaluation of lymphedema in future developing gynecologic clinical trials.

Abstract PD4-03: Chemotherapy-related risk factors associated with lymphedema in breast cancer patients: Should repeated ipsilateral arm infusions be avoided?

Background: Breast Cancer-Related Lymphedema (BCRL) is a chronic, iatrogenic condition that can occur after damage to the lymphatic system during surgery (sx) or radiation, precipitating edema of the arm, breast, or trunk. BCRL risk-reduction education is an essential component of clinical care, and practitioners often advise patients (pts) to avoid needle punctures on the treated arm when possible. There is, however, a lack of substantial scientific evidence to lessen patient distress. Considering the common use of chemotherapy (CT) agents in this population, we assessed whether repeated skin punctures on the ipsilateral arm for CT infusions increased the risk of BCRL compared to CT via central lines in a large, prospective cohort of breast cancer (BC) pts.

Methods: We prospectively screened 630 pts with unilateral (487) or bilateral (143) BC sx receiving neoadjuvant (NAC) and/or adjuvant CT (AdjCT) for arm lymphedema (defined as volume change ≥10%) at our hospital from 2005–16. Pts were measured with a perometer pre-operatively and at 3–7 month follow-up intervals. Clinicopathologic and treatment (tx)-related characteristics, including details on CT regimen and the method of intravenous (IV) CT administration [peripheral IV catheters (PIVCs), central venous access devices (CVADs), peripherally inserted central catheters (PICCs)] were obtained by chart review. Cox proportional hazard analyses were applied to ascertain the risk of BCRL associated with these factors.

Results: The median post-op follow-up was 44 months. Of the 630 pts, 40% underwent axillary lymph node dissection (ALND), 60% underwent sentinel lymph node biopsy (SLNB) or no nodal sx, 16% and 89% received NAC or AdjCT, respectively. CT was administered via PIVCs inserted in the hand/arm for 59%, via CVADs or PICCs for 26%, and via both PIVCs at least once and CVADs/PICCs for 15%. The 2-yr cumulative incidence of BCRL was 12% (95% CI 9.9-15.2%). Multivariable regression results indicated that pts with both peripheral IV infusions on the arm and implanted CVADs did not have a higher risk of BCRL (HR(95% CI)=1.4(0.6-3.6)) than pts who received CT via CVADs only (1.7(0.7-3.8)). The overall number of NAC (p=0.24;0.9(95% CI 0.8-1.1)) or AdjCT cycles (p=0.78;1.0(0.9-1.1)) was not associated with BCRL, nor was the number of peripheral IV infusions (p=0.17;1.0(1.0-1.1)). BMI >30 (p<0.0001;3.4(1.9-6.0)) and number of positive lymph nodes (p=0.02;3.2(1.3-8.1)) were significantly associated with BCRL. Among those with PIVCs, pts with bilateral SLNB/ALND were more likely to develop BCRL than pts with unilateral sx (p<0.01;5.0(1.9-13.4)). Only 38% of the 32 bilateral pts with BCRL received at least one peripheral IV infusion on their ipsilateral arm.

Conclusion: Results suggest that repeated skin punctures on the ipsilateral arm for CT infusions do not significantly increase the risk for BCRL compared to implanted CVADs, nor does the overall number of CT cycles. As survivors may be concerned about the risk of developing BCRL following sx and tx, healthcare practitioners should strive to mitigate pt worry during and well beyond the course of tx, educating pts about the lifestyle risk exposures for BCRL and precautionary guidelines not being definitive.

Citation Format: Asdourian MS, Rao SR, Skolny MN, Salama L, Brunelle C, Seward C, Taghian AG. Chemotherapy-related risk factors associated with lymphedema in breast cancer patients: Should repeated ipsilateral arm infusions be avoided? [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr PD4-03.

A comprehensive review of bioimpedance spectroscopy as a diagnostic tool for the detection and measurement of breast cancer-related lymphedema

As treatment for breast cancer improves and the threat of life-long chronic lymphedema becomes more prevalent, the need for effective screening tools emerges as crucial. This review was conducted using literature beginning in 1992 to analyze primary research testing the accuracy of bioimpedance spectroscopy as a diagnostic and early detection tool for breast cancer-related lymphedema. We concluded bioimpedance is an accurate diagnostic tool for pre-existent lymphedema, however, it has not been validated for early detection. J. Surg. Oncol. 2016;114:537-542. © 2016 Wiley Periodicals, Inc.

Impact of Ipsilateral Blood Draws, Injections, Blood Pressure Measurements, and Air Travel on the Risk of Lymphedema for Patients Treated for Breast Cancer

PURPOSE

The goal of this study was to investigate the association between blood draws, injections, blood pressure readings, trauma, cellulitis in the at-risk arm, and air travel and increases in arm volume in a cohort of patients treated for breast cancer and screened for lymphedema.

PATIENTS AND METHODS

Between 2005 and 2014, patients undergoing treatment of breast cancer at our institution were screened prospectively for lymphedema. Bilateral arm volume measurements were performed preoperatively and postoperatively using a Perometer. At each measurement, patients reported the number of blood draws, injections, blood pressure measurements, trauma to the at-risk arm(s), and number of flights taken since their last measurement. Arm volume was quantified using the relative volume change and weight-adjusted change formulas. Linear random effects models were used to assess the association between relative arm volume (as a continuous variable) and nontreatment risk factors, as well as clinical characteristics.

RESULTS

In 3,041 measurements, there was no significant association between relative volume change or weight-adjusted change increase and undergoing one or more blood draws (P = .62), injections (P = .77), number of flights (one or two [P = .77] and three or more [P = .91] v none), or duration of flights (1 to 12 hours [P = .43] and 12 hours or more [P = .54] v none). By multivariate analysis, factors significantly associated with increases in arm volume included body mass index ≥ 25 (P = .0236), axillary lymph node dissection (P < .001), regional lymph node irradiation (P = .0364), and cellulitis (P < .001).

CONCLUSION

This study suggests that although cellulitis increases risk of lymphedema, ipsilateral blood draws, injections, blood pressure readings, and air travel may not be associated with arm volume increases. The results may help to educate clinicians and patients on posttreatment risk, prevention, and management of lymphedema.