Developing an Intranet-Based Lymphedema Dashboard for Breast Cancer Multidisciplinary Teams: Design Research Study

Janssen A, Donnelly C, Kay J, Thiem P, Saavedra A, Pathmanathan N, Elder E, Dinh P, Kabir M, Jackson K, Harnett P, Shaw T. J Med Internet Res. 2020 Apr 21;22(4)

BACKGROUND:

A large quantity of data is collected during the delivery of cancer care. However, once collected, these data are difficult for health professionals to access to support clinical decision making and performance review. There is a need for innovative tools that make clinical data more accessible to support health professionals in these activities. One approach for providing health professionals with access to clinical data is to create the infrastructure and interface for a clinical dashboard to make data accessible in a timely and relevant manner.

OBJECTIVE:

This study aimed to develop and evaluate 2 prototype dashboards for displaying data on the identification and management of lymphedema.

METHODS:

The study used a co-design framework to develop 2 prototype dashboards for use by health professionals delivering breast cancer care. The key feature of these dashboards was an approach for visualizing lymphedema patient cohort and individual patient data. This project began with 2 focus group sessions conducted with members of a breast cancer multidisciplinary team (n=33) and a breast cancer consumer (n=1) to establish clinically relevant and appropriate data for presentation and the visualization requirements for a dashboard. A series of fortnightly meetings over 6 months with an Advisory Committee (n=10) occurred to inform and refine the development of a static mock-up dashboard. This mock-up was then presented to representatives of the multidisciplinary team (n=3) to get preliminary feedback about the design and use of such dashboards. Feedback from these presentations was reviewed and used to inform the development of the interactive prototypes. A structured evaluation was conducted on the prototypes, using Think Aloud Protocol and semistructured interviews with representatives of the multidisciplinary team (n=5).

RESULTS:

Lymphedema was selected as a clinically relevant area for the prototype dashboards. A qualitative evaluation is reported for 5 health professionals. These participants were selected from 3 specialties: surgery (n=1), radiation oncology (n=2), and occupational therapy (n=2). Participants were able to complete the majority of tasks on the dashboard. Semistructured interview themes were categorized into engagement or enthusiasm for the dashboard, user experience, and data quality and completeness.

CONCLUSIONS:

Findings from this study constitute the first report of a co-design process for creating a lymphedema dashboard for breast cancer health professionals. Health professionals are interested in the use of data visualization tools to make routinely collected clinical data more accessible. To be used effectively, dashboards need to be reliable and sourced from accurate and comprehensive data sets. While the co-design process used to develop the visualization tool proved effective for designing an individual patient dashboard, the complexity and accessibility of the data required for a cohort dashboard remained a challenge.

Lymphoedema screening: setting the standard

Brunelle CL, Taghian AG . Br J Cancer. 2020 May 04

Existing literature which is changing practice should be scrutinised, in the interest of all women at risk for lymphoedema after breast cancer (BC). Bundred et al.’s prospective, multicentre trial of 1100 women made several solid findings, and novel screening recommendations presented may assist in incorporating lymphoedema screening into standard of care

Quality-of-Life Outcomes in Surgical vs Nonsurgical Treatment of Breast Cancer-Related Lymphedema: A Systematic Review

Fish ML, Grover R, Schwarz GS. JAMA Surg. 2020 Apr 29

IMPORTANCE:

Secondary lymphedema is a debilitating complication of breast cancer therapy and affects more than 1 in 5 breast cancer survivors. Patient-reported outcomes may be more important in predicting long-term health-related quality of life (HRQoL) than clinician-measured outcomes.

OBJECTIVE:

To summarize published evidence on HRQoL outcomes for vascularized lymph node transfer (VLNT) and complex decongestive therapy (CDT) used in the treatment of breast cancer-related lymphedema.

EVIDENCE REVIEW:

A literature search of PubMed/MEDLINE and Embase was conducted to identify articles on HRQoL in patients undergoing lymphedema treatment with CDT or VLNT published from January 1980 through April 2019. Studies using validated measurement instruments to assess HRQoL in patients with breast cancer-related lymphedema relative to baseline were included. This review is reported according to the PRISMA guidelines.

FINDINGS:

A total of 16 articles were included in this review. Evidence regarding VLNT was reviewed from 2 studies involving 65 patients, and HRQoL was evaluated using the Lymphoedema Quality of Life Study questionnaire. Data on VLNT indicated favorable HRQoL outcomes at 12-month postoperative follow-up. Evidence regarding CDT was reviewed from 14 studies involving 569 patients, and HRQoL was evaluated using the 36-Item Short Form Health Survey, Functional Assessment of Cancer Therapy-Breast, European Organization for Research and Treatment of Cancer, and Functional Living Index-Cancer measures. Data on CDT demonstrated variable association with HRQoL, and a majority of articles reported improvement in at least 1 subscale. The use of diverse patient-reported outcome measures and variability in CDT protocol limited interpretation of results in this population and between treatment modalities.

CONCLUSIONS AND RELEVANCE:

According to this review, in deciding among breast cancer-related lymphedema treatment modalities, HRQoL outcomes are an important consideration that cannot be compared based on currently available data. Health-related quality-of-life outcomes obtained through coordinated use of preference-based health utility measures may be required to compare outcomes among patients undergoing surgical and nonsurgical treatments of breast cancer-related lymphedema. Additional studies are needed to better understand the best lymphedema treatment options and direct evidence-based care.

A systematic review of the quality of clinical practice guidelines for lymphedema, as assessed by the AGREE II instrument

O’Donnell TF, Allison GM, Melikian R, Iafrati MD . J Vasc Surg Venous Lymphat Disord. 2020 Apr 23

THESIS:

CPGs provide recommendations for the management of medical conditions like lymphedema, but their evidentiary quality and methodology should determine their reliability. The AGREE II instrument was developed to externally and objectively evaluate the quality of CPGs and has been employed to assess other non-vascular CPGs. A systematic review identified four CPGs for lymphedema of varying content: The Lymphedema Framework’s Best Practice for the Management of Lymphedema (LED F); The Japanese Lymphedema Study Group – A Practice Guideline for the Management of Lymphedema (J LED); The Clinical Resource Efficiency Support Team (CREST) Guidelines for the Diagnosis, Assessment and Management of Lymphedema; and the Guidelines of the American Venous Forum (AVF). The quality of these CPGs appeared to vary.

METHODS:

The four CPGs were analyzed by the AGREE II instrument with three independent graders, who were blinded of each other’s scores. Six domains with 23 items were graded on a Likert scale as to satisfying the requirements of each item from 1-strongly disagree to 7-strongly agree. The score for each domain was calculated by summing up the scores of each item in that domain and then by scaling the total as a percentage of the maximum possible score for that domain (Obtained score – minimum score/maximum possible score – minimum possible score x 100 = the percent for that domain).

RESULTS:

CREST had the highest overall score (66.8%), as an average of all domains, while J LED had the lowest (37%). CREST also had five out of five domains rated above 50%, while J LED had only one and AVF two domains scored above 50%. Although the two domains, Rigor of Development and Applicability, were scored low with only one guideline rating greater than 50%, Editorial Independence scored the lowest of all six domains.

CONCLUSION:

Besides limitations in content and lack of contemporary references, these four guidelines were judged objectively to be of low quality by the AGREE II instrument. A contemporary CPG for lymphedema, guided by the AGREE II requirements. is needed.

Microsurgical Strategies for Prophylaxis of Cancer-Related Extremity Lymphedema: A Comprehensive Review of the Literature

Rodriguez JR, Fuse Y, Yamamoto T. J Reconstr Microsurg. 2020 Apr 29

BACKGROUND:

Cancer-related lymphedema represents the first cause of noninfectious secondary extremity lymphedema. This entity is a progressive and debilitating disease with no curative treatment available. With the advent of lymphedema microsurgery, focus has turned into risk reduction and prevention of the disease progression.

METHODS:

Literature review was conducted to clarify current microsurgical approach to prophylaxis of cancer treatment-related extremity lymphedema.

RESULTS:

Prophylactic approach could be classified into primary and secondary prevention; microsurgical procedures were performed simultaneously with cancer ablation in primary prevention, and secondary prevention was performed secondarily after cancer treatment for selected high-risk subclinical cases. Indocyanine green lymphography was the most useful method for lymphedema screening after cancer treatment and to diagnose subclinical lymphedema. Several lymphovenous shunt operations were performed as prophylactic procedures, and classified into microsurgical lymphovenous implantation and supermicrosurgical lymphovenous intima-to-intima coaptation. Both showed clinically significant prophylactic effects.

CONCLUSION:

This review provides a comprehensive overview of the literature regarding microsurgical interventions for the prevention of cancer-related extremity lymphedema. There are several methods for lymphedema prophylaxis and further studies are required to clarify indication of each method.