Reducing rates of chronic breast cancer-related lymphedema with screening and early intervention: an update of recent data

PURPOSE

Breast cancer-related lymphedema (BCRL) represents a dreaded complication of breast cancer treatment that can lead to morbidity, diminished quality of life, and psychosocial harm and is associated with increased costs of care. Increasingly, data has supported the concept of prospective BCRL surveillance coupled with early intervention to mitigate these effects.

METHODS

We performed a systematic review of the literature searching for published randomized and prospective data evaluating prospective BCRL surveillance with early intervention.

RESULTS

We identified 12 studies (2907 patients) including 4 randomized trials (1203 patients) and 8 prospective studies (1704 patients). Randomized data consistently demonstrate that early intervention reduces rates of progression to chronic BCRL with multiple paradigms and diagnostic modalities utilized; the strongest data comes from the randomized PREVENT trial, which demonstrated early detection with bioimpedance spectroscopy (BIS), coupled with early intervention with a compression garment applied for 12 h a day over 4 weeks, significantly reduced the rate of chronic BCRL compared to tape measurement coupled with early intervention.

CONCLUSIONS

Current data support the role of prospective BCRL surveillance with early detection and intervention to reduce rates of chronic BCRL. Breast cancer patients at risk for BCRL should undergo prospective surveillance as part of survivorship. Because level 1 data demonstrate that BIS is superior to conventional tape measure, it should be included as the standard BCRL diagnostic modality unless an equally effective modality is employed.

IMPLICATIONS FOR CANCER SURVIVORS

Breast cancer survivor should undergo prospective BCRL screening with BIS.

Abstract P5-08-15: Reducing Rates of Chronic Breast Cancer Related Lymphedema with Screening & Early Intervention: An Update of Recent Data

Background: Breast cancer related lymphedema (BCRL) represents a dreaded complication of breast cancer treatment that can lead to morbidity, diminished quality of life, and psychosocial harm and is associated with increased costs. Increasingly, data has supported the concept of prospective BCRL surveillance coupled with early intervention to mitigate these effects. Methods: We performed a systematic review of the literature searching for published randomized and prospective data evaluating prospective BCRL surveillance with early intervention. Results: We identified 12 studies (2,907 patients) including 4 randomized trials (1,203 patients) and 8 prospective studies (1,704 patients). Randomized data consistently demonstrate that early intervention reduces rates of progression to chronic BCRL with multiple paradigms and diagnostic modalities utilized; the strongest data in the review comes from the randomized PREVENT trial which demonstrated early detection with bioimpedance spectroscopy (BIS), coupled with a compression garment applied for 12 hours a day over 4 weeks, significantly reduced the rate of chronic BCRL compared to tape measurement. Conclusions: Current data support the role of prospective BCRL surveillance with early detection and intervention to reduce rates of chronic BCRL. Breast cancer patients at risk for BCRL should undergo prospective surveillance as part of survivorship. Given the level 1 data demonstrating that BIS is superior to conventional tape measure, it should be included as the standard BCRL diagnostic modality unless an equally effective modality is employed.

Citation Format: Pat Whitworth, Frank Vicini, Stephanie Valente, Kirstyn Brownson, Beth Dupree, Manpreet Kohli, Laura Lawson, Chirag Shah. Reducing Rates of Chronic Breast Cancer Related Lymphedema with Screening & Early Intervention: An Update of Recent Data [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-08-15.

Bioimpedance spectroscopy for breast cancer-related lymphedema assessment: clinical practice guidelines

PURPOSE

Breast cancer-related lymphedema (BCRL) represents a significant concern for patients following breast cancer treatment, and assessment for BCRL represents a key component of survivorship efforts. Growing data has demonstrated the benefits of early detection and treatment of BCRL. Traditional diagnostic modalities are less able to detect reversible subclinical BCRL while newer techniques such as bioimpedance spectroscopy (BIS) have shown the ability to detect subclinical BCRL, allowing for early intervention and low rates of chronic BCRL with level I evidence. We present updated clinical practice guidelines for BIS utilization to assess for BCRL.

METHODS AND RESULTS

Review of the literature identified a randomized controlled trial and other published data which form the basis for the recommendations made. The final results of the PREVENT trial, with 3-year follow-up, demonstrated an absolute reduction of 11.3% and relative reduction of 59% in chronic BCRL (through utilization of compression garment therapy) with BIS as compared to tape measurement. This is in keeping with real-world data demonstrating the effectiveness of BIS in a prospective surveillance model. For optimal outcomes patients should receive an initial pre-treatment measurement and subsequently be followed at a minimum quarterly for first 3 years then biannually for years 4-5, then annually as appropriate, consistent with previous guidelines; the target for intervention has been changed from a change in L-Dex of 10 to 6.5. The lack of pre-operative measure does not preclude inclusion in the prospective surveillance model of care.

CONCLUSION

The updated clinical practice guidelines present a standardized approach for a prospective model of care using BIS for BCRL assessment and supported by evidence from a randomized controlled trial as well as real-world data.

Risk factors for presence and severity of pulmonary embolism in patients with deep venous thrombosis

OBJECTIVE

The Caprini model estimates patients' risk for venous thromboembolism by 30 different factors. Hemodynamically significant pulmonary embolism (PE), defined as high-risk (massive) or intermediate-risk (submassive) PE, has high morbidity and mortality rates. This study tests whether the Caprini model and deep venous thrombosis (DVT) characteristics correlate with the prevalence of PE and hemodynamically significant PE in patients with DVT.

METHODS

A retrospective review of patients diagnosed with DVT between January 2013 and August 2014 in a tertiary care center was performed. Multivariable analysis was used to determine predictors of PE and hemodynamically significant PE.

RESULTS

Of 838 consecutive patients with DVT, 217 (25.9%) had concomitant PE at presentation, of whom 135 had hemodynamically significant PE (101 submassive PE, 34 massive PE). The mean age was 65 years, and 51.0% were women. There was no significant relation between age or gender and the occurrence of PE or hemodynamically significant PE. Patients with PE were less likely to have undergone recent surgery (18.4% vs 30.3%; P = .001), to have sepsis (4.6% vs 11.8%; P = .002), and to have higher Caprini scores (6.1 vs 6.5; P = .047). Patients with DVT were less likely to have hemodynamically significant PE after recent surgery (13.3% vs 27.2%; P = .011) but more likely to have hemodynamically significant PE with proximal DVT (80.7% vs 64.2%). There was no association between Caprini score and hemodynamically significant PE (6.3 vs 5.7; P = .171).

CONCLUSIONS

The Caprini model has a poor association with PE or hemodynamically significant PE in patients with DVT. Among all patients with DVT, a concomitant diagnosis of PE or hemodynamically significant PE is less common in those with sepsis or undergoing recent surgery but more common in those with proximal DVT.

Management of isolated calf vein thrombosis in cancer patients

The treatment of isolated calf vein thrombosis remains widely debated. This study highlights the characteristics of isolated calf vein thrombosis in cancer patients and compares to isolated calf vein thrombosis in patients without history of cancer. Between July 2013 and April 2014, a retrospective chart review of consecutive patients with isolated calf vein thrombosis was performed recording patient risk factors, ultrasound characteristics of the thrombus, treatment modalities, long-term recurrence of venous-thromboembolism, incidence of bleeding, and mortality. Of 131 patients with isolated calf vein thrombosis, 53 (40.1%) had history of cancer. Isolated calf vein thrombosis occurred at an older age in cancer patients (66.7 vs 58.5 years, p = 0.004). The anatomical characteristics of isolated calf vein thrombosis on ultrasound were comparable in both groups. Isolated calf vein thrombosis in cancer patients was less likely to be treated with anticoagulation (60.4% vs 80.8%, p = 0.018). However, a trend towards higher incidence of bleeding after initiation of anticoagulation for isolated calf vein thrombosis in cancer patients (11.3% vs 6.4%, p = 0.351) was noted. Mortality in cancer patients was higher (37.7% vs 9.00%, p < 0.001) but was unrelated to isolated calf vein thrombosis or its treatment. In conclusion, the risks of bleeding seem to exceed the benefits of anticoagulation in approximately 50% of cancer patients with isolated calf vein thrombosis. The management of isolated calf vein thrombosis does not seem to impact the survival of cancer patients.

Binge alcohol-induced bone damage is accompanied by differential expression of bone remodeling-related genes in rat vertebral bone

Binge alcohol-related bone damage is prevented by concurrent administration of bisphosphonates, suggesting an activation of bone resorption with patterned alcohol exposure. Although chronic alcohol abuse is known to cause osteopenia, little is known about the effects of binge drinking on bone metabolism. We examined the effects of binge alcohol exposure on the relationship between bone damage and modulation of bone remodeling-specific gene expression profiles. Our hypothesis was that bone damage observed in young adult rats after binge alcohol exposure is associated with differential expression of bone remodeling-related gene expression. We further hypothesized that this differential gene expression specific to bone remodeling (bone resorption or formation related) would be influenced by the duration of binge alcohol exposure. Binge alcohol (3 g/kg, i.p.) was administered on 3 consecutive days each week, for 1 or 4 weeks, to adult male rats. Matched control animals were injected with an equal volume of isotonic saline. Lumbar vertebrae, L4-5, were analyzed for the presence of bone damage by quantitative computed tomography and compressive strength analysis. Total RNA was isolated from an adjacent vertebrae (L3), and whole transcriptome gene expression data were obtained for each sample. The expression levels of a subset of bone formation and resorption-associated differentially expressed genes were validated by quantitative reverse transcriptase-polymerase chain reaction. Bone loss was not observed after 1 week of treatment but was observed after four binge alcohol cycles with a 23% decrease in cancellous bone mineral density and 17% decrease in vertebral compressive strength compared with control values (P < 0.05). We observed that the duration of binge alcohol treatment influenced the modulation of expression profiles for genes that regulate the bone formation process. The expression of key bone formation-related marker genes such as osteocalcin and alkaline phosphatase were significantly reduced (P < 0.05) after acute binge alcohol exposure, and expression of regulators of osteoblast activity such as bone morphogenetic proteins and parathyroid hormone receptor displayed significantly (P < 0.05) decreased differential expression. The expression of sclerostin, a key canonical Wnt inhibitory protein, was significantly increased after acute binge alcohol treatment. The expression of important regulators of osteoclast maturation and activity such as NF-kappabeta (nuclear factor kappabeta) ligand (RANKL) and interleukin-6 were significantly increased (P < 0.05) by binge alcohol, and osteoprotegerin levels were significantly decreased (P < 0.05) in vertebral bone. These results show that expression patterns of several key bone remodeling genes are significantly perturbed by binge alcohol treatment, suggesting that perturbation of gene expression associated with bone remodeling may be one mechanism contributing to the disruption of bone mass homeostasis and subsequent bone loss observed after binge alcohol exposure in rodents.

Talk to your staff about distance education

Most health care professionals and managers feel the need to finish their undergraduate or graduate degree to maintain their present position or to advance to a higher one. Distance education is a convenient alternative where students complete their studies from home using the postal service or computer.

Code of ethics

When an organization or department takes it upon itself to establish a code of conduct, levels of patient satisfaction project, or work-specific competencies it should mandate that these rules become standards of care. Administrators need to mandate that each individual be held accountable for his or her own actions and administrators must be held accountable for enforcing these standards.

Recruiting and retaining staff in the twenty-first century

There is a shortage of health care professionals across the country, as well as a shortage of registered nurses that is compromising patient care. This shortage will reach crisis proportions in the twenty-first century. Hospitals will have to upgrade their recruitment efforts and retain the employees that they have.

Hospital air is sick

Indoor air quality has deteriorated so much since the 1970s oil shortage and subsequent energy-efficient construction of buildings that people are becoming seriously ill by just breathing the indoor air. This is a problem with all industrial buildings and hospital staff are at particular risk. There are various things that hospital managers from different departments can do to make the air safe for staff and patients to breathe.

Distance education in the twenty-first century

Most health care professionals and managers feel the need to finish their undergraduate or graduate degree to maintain their present position or to advance to a higher position. Distance education is a convenient alternative where students complete their studies from home using the postal service or computer.

Distance education for health care professionals

Most health care managers and professionals are unable to think about going to college due to the disruption to their family and their profession. Distance education is an acceptable alternative. Adults can complete courses while remaining at home with very little disruption to their professional and home life.

Breathing hospital air can make you sick

Indoor air quality has deteriorated so much since the 1970s oil shortage and subsequent energy-efficient construction of buildings that people are becoming seriously ill by just breathing the indoor air. This is a problem with all industrial buildings and hospital staff are at particular risk. There are various things that hospital managers from different departments can do to make the air safe for staff and patients to breathe.

Literacy, cultural diversity, and client education

Client education offers many challenges to health care professionals. There is a mismatch between the reading level of most clients and the reading level of printed materials used in health education. Social and cultural factors also influence how our clients are able to learn about their health. These problems can lead to noncompliance with treatments, missed appointments, wrong dosages of medication, and undue fear among our clients. There are things that health care professionals can do to make written materials more user-friendly and culturally more acceptable.

Literacy: a problem that managers must handle

Patient and employee illiteracy is a problem that health care managers must deal with. More than half of all Americans may be unable to read and understand written materials used in hospitals, clinics, and other health care facilities. There is a mismatch between employees' and patients' reading level and the reading level of most written materials used by health care facilities. This can lead to noncompliance with treatment, missed appointments, wrong dosage of medications, uninformed consent, and undo fear among patients. Employees who are unable to read directions or policies and procedures are not able to do their jobs efficiently. There are things that managers can do to make written materials more user-friendly.

Education handouts. Are we wasting our time?

There is a mismatch between client reading level and the reading level of most health educational handouts. More than half of all Americans may be unable to read and understand health-related handouts given to them in a hospital or clinic. This can lead to noncompliance with treatment, missed appointments, taking the wrong dosage of medications, and unnecessary fear. Nurses can make handouts more user-friendly. The reading level can be changed so more patients can understand the materials, and the formatting of the handout can be modified to better serve all reading levels.

An equitable nursing assignment structure

An inconsistent nursing assignment structure increases unsafe nursing care situations and patient and staff litigation. Using a holistic perspective when scheduling places value on subjectivity, accountability and continuity of care. The conflicts involved with the nursing assignment structure and its implications for nursing managers are identified.

College at home for the home care professional

Most home care professionals are so busy that the idea of working full-time and going to college to obtain or complete a degree seems downright laughable. But through distance education, individuals can go to college without even leaving their homes. Distance education may provide the ideal complement to a home care professional's career.

Distance education for the health care supervisor

Health care supervisors are being driven by the rapid changes in health care today. One demand is to complete their undergraduate degree or even a graduate degree. Few of us are able to devote the many hours required to attend on-campus classes full time. Now there is an alternative. Busy health care supervisors can now complete their undergraduate or graduate degrees from the comfort of their home--maintaining a job and family life.

Floating: a nurse's nightmare?

Floating is the process of reassigning nurses from their regular assignments to short-staffed areas. Although viewed as cost-effective, there are a number of legal and ethical dilemmas to consider in this practice. Nurses tend to oppose floating, which may lead to rifts between management and staff. This article reviews some important considerations in floating, including some action strategies for management and staff. Not being proactive in the process can lead to compromised patient care.