The influence of mastectomy and reconstruction on residual upper limb function in breast cancer survivors

Meghan E. Vidt1,2, John Potochny3,  Daleela Dodge4,5, Michael Green5,6, Kathleen Sturgeon7, Rena Kass4,6, Kathryn H. Schmitz2,7. Breast Cancer Research and Treatment (2020) 182:531–541

Purpose Breast cancer survivorship is common (90% of women survive 5 or more years), but many women are not able to return to full function and well-being after treatment due to functional limitations, persistent pain, and inability to perform daily activities. Since each surgical reconstructive option (e.g., autologous tissue flaps versus implants) can impact shoulder and arm function differently, it is important to understand how shoulder and upper limb strength, mobility, and function are influenced by the type of surgical intervention. Efforts can then focus on prehabiliation strategies to prevent the onset of limitations and on developing rehabilitation protocols that directly target shortcomings.

Methods The current paper presents a review summarising how shoulder and upper limb function may be affected by surgical mastectomy and breast reconstruction.

Results Mastectomy and breast reconstruction with implants or autologous tissues present different functional outcomes for patients. Each surgical procedure is associated with unique sequelae derived from the tissues and procedures associated with each surgery. Characterising the specific functional outcomes associated with each surgical approach will promote the development of targeted rehabilitation strategies that can be implemented into a multidisciplinary treatment planning athway for breast cancer patients.

Conclusions Surgical treatments for breast cancer, including mastectomy and breast reconstruction, can have negative effects. Focused efforts are needed to better understand treatment-specific effects so that targeted rehabilitation can be developed to improve patient function, QoL, and ability to return to work and life activities post-breast cancer.

Dysfunction of dermal initial lymphatics of the arm and upper body quadrant causes congenital arm lymphedema

Liu N, Gao M, Yu Z. J Vasc Surg Venous Lymphat Disord. 2020 Jun 26

Objectives: To explore the pathology underlying primary lymphedema.

Methods: Twenty-seven patients with unilateral congenital arm lymphedema who visited our clinic from 1 January 2014 to 30 May 2019 were enrolled. The patients’ clinical signs, indocyanine green (ICG) lymphography, skin tissue immunohistochemical (IHC) staining, and whole-exome sequencing (WES) of tissue and blood were evaluated.

Results: Among the 27 patients, 18 and 9 were diagnosed with stage II and III lymphedema, respectively. No lymphatic vessels were visualized in the affected arm in 25 of 27(93%) patients who underwent ICG lymphography; likewise, no lymphatics were found in the territories of axillary lymph node drainage in the trunk, irrespective of any anomalies of the axillary lymph nodes. In only two (7%) patients, an unclear lymphatic trunk gradually appeared in the dorsum of the affected hand. The number of initial lymphatics was increased in the skin specimens of all nine patients in whom lymphatics were not demonstrated by ICG. Among 14 tested patients, we found compound heterozygote variants in the PIEZO1 gene in only 1 (7%) patient. Two missense variants, c.4072C>T; p.Arg1358Cys and c.5033C>T; p. Ala1678Val, were identified and found to have been inherited from the father and mother, respectively. No other pathogenic or likely pathogenic variants of currently known lymphedema-related genes were identified in the remaining 13 patients. No genetic difference was found between the lymphedematous and non-edema healthy skin tissue of the same person.

Conclusion: Segmental/regional dysfunction of the dermal initial lymphatics causes congenital arm lymphedema and may have implications for clinical treatment.

Symptom patterns, physical function and quality of life among head and neck cancer patients prior to and after surgical treatment: A prospective study

Hu ZY, Feng XQ, Mei R. Fu, Yu R, Zhao HL. Eur J Oncol Nurs. 2020 May 16;46: 101770

PURPOSE: This study aimed to evaluate patterns of symptoms, physical function and quality of life (QoL) among patients with head and neck cancer (HNC) prior to, 3-9 days post-surgery, and one month post-surgery.

METHODS: A prospective, repeated-measures design with consecutively-identified sampling was used to recruit HNC patients undergoing surgical treatment. Data collected included demographic and clinical characteristics, symptoms by M.D. Anderson Symptom Inventory-Head and Neck Module-Chinese version (MDASI-H&N-C), physical function and QoL by Function Subscales of European Cancer Research Treatment Organization Quality of Life Core Scale (EORTC QLQ C30).

RESULTS: 105 HNC patients suffered multiple symptoms prior to and after surgery. Pain, difficulty with voice/speech, disturbed sleep and problems with mucus (30.48%~91.43%) were the most prevalent symptoms prior to and post-surgery. Numbers of symptoms as well as specific symptoms, such as fatigue, dry mouth, problems with mucus, pain and disturbed sleep, were significantly associated with poor physical function (p < 0.05). Tracheostomy, feeding tube and age were also linked with poor physical function and poor QoL (p < 0.05). CONCLUSIONS: Findings of our study underscore the importance of managing symptoms in HNC patients to ensure patients’ physical function and QoL prior to and after surgical treatment. Further research should focus on developing targeted interventions for symptoms that are linked to HNC patients’ poor physical function and QoL.

Effects of weight reduction on the breast cancer-related lymphedema: A systematic review and meta-analysis

Tsai CL, Chih-Yang Hsu, Chang WW, Yen-Nung Lin. Breast. 2020 May 28;52:116-121

BACKGROUND: Obesity has long been considered a risk factor for breast cancer-related lymphedema (BCRL), but the benefits of weight reduction in managing BCRL have not been clearly established. OBJECTIVE: To evaluate the beneficial effects of weight loss interventions (WLIs) on the reduction and prevention of BCRL.

METHODS: We conducted a systematic review and meta-analysis by searching the PubMed, Scopus, and Embase databases from their earliest record to October 1st, 2019. We included randomized and non-randomized controlled trials involving adult patients with a history of breast cancer, that compared WLI groups with no-WLI groups, and provided quantitative measurements of lymphedema.

RESULTS: Initial literature search yielded 461 nonduplicate records. After exclusion based on title, abstract, and full-text review, four randomized controlled trials involving 460 participants were included for quantitative analysis. Our meta-analysis revealed a significant between-group mean difference (MD) regarding the volume of affected arm (MD = 244.7 mL, 95% confidence interval [CI]: 145.3-344.0) and volume of unaffected arm (MD = 234.5 mL, 95% CI: 146.9-322.1). However, a nonsignificant between-group MD of -0.07% (95% CI: 1.22-1.08) was observed regarding the interlimb volume difference at the end of the WLIs.

CONCLUSIONS: In patients with BCRL, WLIs are associated with decreased volume of the affected and unaffected arms but not with decreased severity of BCRL measured by interlimb difference in arm volume.

Incidence and risk factors for lower limb lymphedema associated with endometrial cancer: Results from a prospective, longitudinal cohort study

Pigott A, Obermair A, Janda M, Vagenas D, Ward LC, Reul-Hirche H, Hayes SC. Gynecol Oncol. 2020 Jun 01.

BACKGROUND: Evidence on the incidence and risk factors for lower limb lymphedema (LLL) associated with endometrial cancer is limited. Our objective was to use data from a prospective, longitudinal gynecological cancer cohort study to determine LLL incidence up to 24 months post-diagnosis of endometrial cancer and to explore the relationship between personal and treatment-related factors and risk of developing LLL.

METHODS: Women recently diagnosed with endometrial cancer (n = 235) were evaluated at regular intervals post-diagnosis (up to 3-monthly) using bioimpedance spectroscopy (BIS) and self-reported leg swelling (SRLS).

RESULTS: Incidence of LLL at 24 months post-diagnosis was 33% and 45% according to BIS and SRLS, respectively. When analyses were restricted to obese women, incidence at 24 months post-diagnosis increased to 67% (BIS) and 54% (SRLS). Following adjusted analyses, higher body mass index was associated with higher odds of baseline lymphedema (BIS: OR 1.91, 95% CI 1.47-2.49, p < .01; SRLS: OR 1.06, 95% CI 1.00-1.12, p < .01) and LLL incidence by 24 months post-diagnosis (BIS: OR 1.29, 95% CI: 0.99-1.68, p = .055; SRLS: OR 1.06, 95% CI 1.02-1.11, p = .008). According to SRLS, presence of comorbidities was also associated with baseline lymphedema (OR: 1.43, 95% CI: 1.15-1.78, p = .001), and more extensive lymph node dissection (OR 1.06, 95% CI: 1.01-1.12, p = .026) and receipt of chemotherapy (OR: 2.65, 95% CI: 1.12-6.29, p = .027) were identified as risk factors for lymphedema incidence. CONCLUSIONS: These findings suggest that LLL following endometrial cancer is common, particularly in women with high body mass index, or comorbidities, and those requiring more extensive lymph node dissection or chemotherapy. Future studies should examine the potential of weight loss intervention as a strategy to reduce LLL incidence.

Patients who report cording after breast cancer surgery are at higher risk of lymphedema: Results from a large prospective screening cohort

Brunelle CL, Roberts SA, Shui AM, Gillespie TC, Daniell KM, Naoum GE, Taghian A.  J Surg Oncol. 2020;1–9

OBJECTIVES: To identify the association between cording and breast cancer-related lymphedema (BCRL); describe time course, location, symptoms and functional impairments.

METHODS: A total of 1181 patients were prospectively screened for BCRL after breast cancer (BC) surgery, including patient-reported outcome measures (4193) and perometric arm volume measurements (BCRL defined as relative or weight-adjusted volume change [RVC or WAC] ≥10% ≥3 months postoperatively).

RESULTS: A total of 374/1181 patients (31.7%) reported cording first a median of 4.5 months postoperatively, and were more likely to: have body mass index less than 30 kg/m2 ; be less than 55 years of age; have had mastectomy, axillary lymph node dissection, regional lymph node radiation, neoadjuvant chemotherapy (all P < .001), or RVC/WAC ≥10% (P = .002). Patients who reported cording had 2.4 times the odds of developing BCRL compared to those who did not (odds ratio = 2.40; 95% confidence interval = 1.40-4.11; P = .002), and most frequently reported these symptoms: tenderness (61.2%), aching (60.7%), and firmness/tightness (59.8%). On multivariable analysis, cording was significantly correlated with functional difficulty for 17 actions. CONCLUSIONS: Patients frequently present with cording, potentially months after BC surgery. Risk factors for and symptoms of cording are identified, and treatment is recommended. Patients reporting cording are at higher risk of BCRL, therefore, cording should be incorporated into BCRL risk stratification.

Prognostic factors for lymphedema in patients with locally advanced head and neck cancer after combined radio(chemo)therapy- results of a longitudinal study.

Tribius S, Pazdyka H, Tennstedt P, Busch CJ, Hanken H, Krüll A, Petersen C. Oral Oncol. 2020 Jul 02;109:104856

Aim: Treatment-associated lymphedema is a common side effect after multimodal therapy for locally advanced head and neck cancer (LAHNC). This study aims to evaluate potential prognostic factors for head and neck lymphedema (HNL) and its potential impact on clinical outcome.

Methods: This is a prospective data registry analysis on 280 patients treated for locally advanced head and neck cancer (LAHNC). All patients received surgery and risk-adapted platinum-based adjuvant intensity modulated radio(chemo)therapy (R(C)T, IMRT). Treatment- related toxicity was prospectively registered in a data base in regular intervals (baseline 3 months after R(C)T, every 3 months for 3 years, and every 6 months thereafter) and documented according to RTOG/EORTC toxicity criteria.

Results: Predictive for any grade HNL 3 months after R(C)T were age, BMI, number of removed nodes and RT modality. Multivariable logistic regression analysis showed that in the acute toxicity phase (3 months after R(C)T) higher body mass index (BMI), extracapsular spread (ECE), linac-based IMRT, bilateral treatment to the neck (surgery and RT), and the addition of chemotherapy increase the risk for grade 2 HNL. For chronic HNL, higher BMI, linac-based IMRT and ECE were predictive for grade 2 HNL. Higher BMI is associated with better local control rates. Advanced age and ECE had a negative impact on OS.

Conclusion: HNL is a common acute and late side effect after multimodal therapy for LAHNC. Knowing risk factors for HNL prior to therapy enables caregivers and patients to take measures prior to treatment to prevent or limit the effects of HNL.

L-Dex, arm volume, and symptom trajectories 24 months after breast cancer surgery.

Ridner SH, Shah C, John Boyages, Koelmeyer L, Ajkay N, DeSnyder SM, McLaughlin SA, Dietrich MS. Cancer Medicine. 2020;00:1–10.

Purpose: Study objectives were to examine: (a) biomarker trajectories (change from presurgical baseline values of Lymphedema index (L-Dex) units and arm volume difference) and symptom cluster scores 24 months after breast cancer surgery and (b) associations of these objective biomarkers and symptom cluster scores. Patient/treatment characteristics influencing trajectories were also evaluated.

Methods: A secondary analysis of data from the published interim analysis of a randomized parent study was undertaken using trajectory analysis. Five hundred and eight participants included in the prior analysis with 24 months of postsurgical follow-up were initially measured with bioelectric impedance spectroscopy (BIS) and tape measure (TM) and completed self-report measures. Patients were reassessed postsurgery for continuing eligibility and then randomized to either BIS or TM groups and measured along with self-report data at regular and optional* visits 3, 6,12,15*,18, 21*, and 24-months.

Results: Three subclinical trajectories were identified for each biomarker (decreasing, stable, increasing) and symptom cluster scores (stable, slight increase/decrease, increasing). Subclinical lymphedema was identified throughout the 24-month period by each biomarker. An L-Dex increase at 15 months in the BIS group was noted. The self-report sets demonstrated contingency coefficients of 0.20 (LSIDS-A soft tissue, P = .031) and 0.19 (FACTB+4, P = .044) with the L-Dex unit change trajectories.

Conclusions: These data support the need for long-term (24 months) prospective surveillance with frequent assessments (every 3  months) at least 15  months after surgery. Statistically significant convergence of symptom cluster scores with L-Dex unit change supports BIS as beneficial in the early identification of subclinical lymphedema.

Ultrasound Vibroelastography for Evaluation of Secondary Extremity Lymphedema: A Clinical Pilot Study.

Bustos SS, Zhou B, Huang TCT, Shao J, Ciudad P, Forte AJ, Zhang X, Manrique OJ

Ann Plast Surg. 2020 Jul;85(S1 Suppl 1):S92-S96

BACKGROUND: Lymphedema treatment is an ongoing challenge. It impacts quality of life due to pain, loss of range of motion of the extremity, and repeated episodes of cellulitis. Different modalities have been used to evaluate lymphedema; some are more error-prone and some are more invasive. However, these measurements are poorly standardized, and intrarater and interrater reliabilities are difficult to achieve. This pilot study aims to assess the feasibility of ultrasound vibroelastography for assessing patients with extremity lymphedema via measuring shear wave speeds of subcutaneous tissues.

METHODS: Patients with clinical and lymphoscintigraphic diagnosis of secondary lymphedema in the extremities without prior surgical treatment were included. A 0.1-s harmonic vibration was generated at three frequencies (100, 150, and 200 Hz) by the indenter of a handheld shaker on the skin. An ultrasound probe was used for noninvasively capturing of wave propagation in the subcutaneous tissue. Wave speeds were measured in the subcutaneous tissues of both the control and affected extremities.

RESULTS: A total of 11 female patients with secondary lymphedema in the extremities were enrolled in this study. The magnitudes of the wave speeds of the region of interest in the subcutaneous tissue at lymphedema sites in the upper extremity (3.9 ± 0.17 m/s, 5.96 ± 0.67 m/s, and 7.41 ± 1.09 m/s) were statistically higher than those of the control sites (2.1 ± 0.27 m/s, 2.93 ± 0.57 m/s, and 3.56 ± 0.76 m/s) at 100, 150, and 200 Hz (P < 0.05), and at 100 and 200 Hz (P < 0.05) between lymphedema (4.33 ± 0.35 m/s, 4.17 ± 1.00 m/s, and 4.56 ± 0.37 m/s) and controls sites (2.48 ± 0.43 m/s, 2.77 ± 0.55 m/s, and 3.06 ± 0.29 m/s) in the lower extremity. CONCLUSIONS: These preliminary data suggest that ultrasound vibroelastography may be useful in the evaluation of secondary lymphedema and can be a valuable tool to noninvasively track treatment progress.

Comparing the experience of individuals with primary and secondary lymphoedema: A qualitative study.

Río-González Á, Molina-Rueda F, Palacios-Ceña D, Alguacil-Diego IM. Braz J Phys Ther. 2020 Jun 01.

BACKGROUND: Lymphoedema is a chronic condition that has significant detrimental impact on patients’ quality of life. Secondary lymphoedema often results from anti-tumour treatment, in contrast to primary lymphoedema which is the result of genetic abnormalities that leads to an abnormal development of the lymphatic system.

OBJECTIVE: To describe and compare the experience of individuals with primary and secondary lymphoedema.

METHODS: A total of 19 patients (mean ± standard deviation age: 56.7 ± 16.2 years), 8 with primary and 11 with secondary lymphoedema, participated in this qualitative phenomenological study. Purposeful sampling method was applied. We recruited participants from specialised lymphoedema units of two physical therapy clinics and the Lymphoedema Patient Association in Spain. Data collection methods included unstructured and semi-structured interviews. An inductive thematic analysis was used.

RESULTS: The findings suggest differences between the experience of living with primary or secondary lymphoedema. Also, those with lower extremity lymphoedema have more pain, fatigue, and functional limitations. Three primary themes emerged: “Emotional challenge”, “Adapting your life to a new situation,” and “lymphoedema management”.

CONCLUSIONS: The experience of living with lymphoedema involves aspects of fear, suffering, coping, and management of the disease and differs between secondary and primary causes. However, it seems to be more dependent on its location than its cause.

Dermal thickness and echogenicity using DermaScan C high frequency ultrasound: Methodology and reliability testing in people with and without primary lymphoedema.

Phillips J, Reynolds KJ, Gordon SJ. Skin Res Technol. 2020 Jun 24

Background: DermaScan C high frequency ultrasound was investigated for image capture and analysis of dermal measures in people with and without primary lymphoedema.

Method: Three repeated images were taken at six sites in people without lymphoedema (NLO). Intra-rater reliability was assessed by taking three sets of measures on images from 10 people and inter-session reliability by capturing three images, lifting the probe from the skin in between. Methods were adjusted, and repeated images from four sites were taken in people with primary lymphoedema (PLO) and reliability re-assessed.

Results: Intra-rater reliability in NLO and PLO for echogenicity measures were excellent (NLO ICC(3,1) : .989; PLO .997) across all sites and specific to each site (calf: ICC(3,1) : .989; and foot: ICC(3,1) : .999, respectively). Inter-session reliability was moderate for NLO (ICC(3,1) : .727), improving after method modifications for PLO (ICC(3,1) : .916). When investigated by site, inter-session reliability was good in the foot (ICC(3,1) : .811) and moderate in the calf (ICC(3,1) : .616). Mean thickness analysed by site resulted in good inter-session reliability only in the foot (ICC(3,1) .838).

Conclusion: Intra-rater reliability was excellent using the DermaScan C for dermal measures in people with primary lymphoedema. Inter-session reliability required particular attention to method and gain settings

Effects of Local Forearm Skin Heating on Skin Properties

Harvey N. Mayrovitz. Clin Physiol Funct Imaging. 2020 Jul 06

This study investigated impacts of local skin‐heating on skin‐properties and tested if skin changes depended on heat‐induced hyperemia. It was reasoned that heat‐induced vasodilation impacts accompanying interstitial fluid changes. Forearm skin was locally heated from a baseline of 35°C to 40‐42°C in 30 young adults (15 females, 15 males, 24.9±2.1 years) and non‐heated in 10 others (5 females, 5 males, 25.2±1.3 years. Skin blood flow (SBF) was continuously measured using a laser‐Doppler method and skin tissue dielectric constant (TDC), stratum corneum capacitance (SCC) and transepidermal water loss (TEWL) were measured before and after maintained heat for 12 minutes. TDC values were determined to effective measurement depths of 1.5mm (TDC15) and 2.5mm (TDC25). Results showed a large heat‐induced hyperemia, with SBF increasing on average 8.8‐fold from its baseline of 35°C. Heating also caused significant increases in TDC, SCC and TEWL that, compared to pre‐heating, increased approximately 1.1‐fold, 3.1‐fold and 4.5‐fold. None of these skin changes correlated with the magnitude of the SBF hyperemic response. Absence of this correlation may indicate that in young healthy adults, increased capillary filtration due to heat‐induced arteriolar vasodilation is rapidly accommodated by post‐capillary reabsorption, enhanced lymphatic activity and TEWL processes. An alternate explanation is that heating caused increased red cell oscillations that were detected as part of the laser‐Doppler increase without representing increased capillary flux. The major determinant of the Increases in TDC, SCC and TEWL is likely a consequence of heat‐induced eccrine gland activation. Studies of older persons or those with depressed function are warranted.

Magnetic resonance imaging and bioimpedance evaluation of lymphatic abnormalities in patients with breast cancer treatment-related lymphedema.

Donahue PMC, Crescenzi R, Lee C, Garza M, Patel NJ, Petersen KJ, Donahue MJ. Breast Cancer Res Treat. 2020 Jun 29.

Purpose: Breast cancer treatment-related lymphedema (BCRL) evaluation is frequently performed using portable measures of limb volume and bioimpedance asymmetry. Here quantitative magnetic resonance imaging (MRI) is applied to evaluate deep and superficial tissue impairment, in both surgical and contralateral quadrants, to test the hypothesis that BCRL impairment is frequently bilateral and extends beyond regions commonly evaluated with portable external devices.

Methods: 3-T MRI was applied to investigate BCRL topographical impairment. Female BCRL (n = 33; age = 54.1 ± 11.2 years; stage = 1.5 ± 0.8) and healthy (n = 33; age = 49.4 ± 11.0 years) participants underwent quantitative upper limb MRI relaxometry (T2), bioimpedance asymmetry, arm volume asymmetry, and physical evaluation. Parametric tests were applied to evaluate study measurements (i) between BCRL and healthy participants, (ii) between surgical and contralateral limbs, and (iii) in relation to clinical indicators of disease severity. Two-sided p-value < 0.05 was required for significance. Results: Bioimpedance asymmetry was significantly correlated with MRI-measured water relaxation (T2) in superficial tissue. Deep muscle (T2 = 37.6 ± 3.5 ms) and superficial tissue (T2 = 49.8 ± 13.2 ms) relaxation times were symmetric in healthy participants. In the surgical limbs of BCRL participants, deep muscle (T2 = 40.5 ± 4.9 ms) and superficial tissue (T2 = 56.0 ± 14.8 ms) relaxation times were elevated compared to healthy participants, consistent with an edematous micro-environment. This elevation was also observed in contralateral limbs of BCRL participants (deep muscle T2 = 40.3 ± 5.7 ms; superficial T2 = 56.6 ± 13.8 ms).

Conclusions: Regional MRI measures substantiate a growing literature speculating that superficial and deep tissue, in surgical and contralateral quadrants, is affected in BCRL. The implications of these findings in the context of titrating treatment regimens and understanding malignancy recurrence are discussed.

Examination of a new mobile intermittent pneumatic compression device in healthy adults.

Chohan A, Abram S, Parkes A, Haworth L, Justine Whitaker. J Wound Care. 2020 Jun 02;29(6):370-374.

OBJECTIVE: Intermittent pneumatic compression (IPC) is an alternative method of compression treatment designed to compress the leg and mimic ambulatory pump action to actively promote venous return. This study explores the efficacy of a new portable IPC device on tissue oxygenation (StO2) in two sitting positions.

METHOD: In this quantitative, healthy single cohort study, participants were screened and recruited using Physical Activity Readiness Questionnaire (PAR-Q, Canada). Participants attended two separate one-hour sessions to evaluate StO2 in an upright chair-sitting position and in a long-sitting position. StO2 was recorded for 20 minutes before, during and after a 20-minute intervention of the IPC device (Venapro, DJO Global, US).

RESULTS: A total of 29 healthy volunteers took part in the study. A significant difference was seen between the two seating positions (p=0.003) with long-sitting showing a 12% higher StO2 level than chair-sitting post-intervention. A similar effect was seen in both sitting positions when analysing data over three timepoints (p=0.000). Post-hoc pairwise comparisons showed that significant improvements in StO2 (p≤0.000) were seen from baseline, throughout the intervention, continuing up to 15 minutes post-intervention, indicating a continued effect of the device after a short intervention.

CONCLUSION: Increasing StO2 through short intervention sessions with this portable device has potential for use within various health and sports-based practices, improving tissue health, potentially reducing postoperative deep vein thrombosis (DVT) risk or inflammation. Such devices lend themselves to wide self-management implementation.

Clinical management of patients with breast cancer-related lymphedema: a best practice implementation project.

Zhao H, Zhou C, Wu Y, Li W, Li X, Chen L. Int J Evid Based Healthc. 2020 Jun 08

BACKGROUND AND AIMS:

Breast cancer-related lymphedema (BCRL) is a burdensome complication of breast cancer that may significantly affect patients’ quality of life. Best evidence-based interventions should be applied to the clinical management of BCRL to provide the best care for patients. This project aimed to promote evidence-based practices in the management of patients with BCRL and to assess the impact of these changes on improving clinical outcomes in a large tertiary hospital.

METHODS:

The current evidence implementation project was conducted in the Breast Surgery Department of a tertiary hospital in China. Four audit criteria were developed for the baseline and follow-up audits. The project used the Joanna Briggs Institute’s Practical Application of Clinical Evidence System and the Getting Research into Practice audit and feedback tool to promote evidence-based healthcare into practice. Twenty patients with BCRL were assessed both in baseline and follow-up audits.

RESULTS:

The results of the baseline audit demonstrated that there was poor compliance with most of the audit criteria. Significant improvements were achieved in the four audit criteria in the follow-up audit compared with those in the baseline audit. The 55% of women with BCRL being offered complex decongestive therapy rose from 25 to 55%. Individualized exercise program implementation increased from 50% at baseline to 90% at follow-up. Compliance with resistance training being provided improved from 0 to 90%. Education of patients improved, with specific education about the benefits of exercise in the management of lymphedema increasing from 75 to 100%.

CONCLUSION:

The current evidence-based implementation project for the clinical management of patients with BCRL was successfully conducted. However, patient outcomes and the sustainability of the audit criteria were not evaluated, which are needed in further studies

Interventions for Breast Cancer-Related Lymphedema: Clinical Practice Guideline From the Academy of Oncologic Physical Therapy of APTA

Davies C, Levenhagen K, Ryans K, Perdomo M, Gilchrist L. Phys Ther. 2020 Jun 26

A work group from the American Physical Therapy Association (APTA) Academy of Oncologic Physical Therapy developed a clinical practice guideline to aid clinicians in identifying interventions for people with breast cancer-related lymphedema, targeting volume reduction, beginning at breast cancer diagnosis and continuing through cancer treatments and survivorship. Following a systematic review of published studies and a structured appraisal process, recommendations were developed to guide physical therapists and other health care clinicians in their intervention selection. Overall, clinical practice recommendations were formulated based on the evidence for each intervention and were assigned a grade based on the strength of the evidence. The evidence for each specific intervention was synthesized and appraised by lymphedema stage, when the information was available. In an effort to make recommendations clinically applicable, they were presented by modality throughout the care trajectory. Methodology and research populations varied significantly across studies, and it will be important for future research to use standardized definitions for participant characteristics, diagnostic criteria, and interventions.

Effectiveness of four types of bandages and kinesio-tape for treating breast-cancer-related lymphoedema: a randomized, single-blind, clinical trial.

Torres-Lacomba M, Navarro-Brazález B, Prieto-Gómez V, Ferrandez JC, Bouchet JY, Romay-Barrero H. Clin Rehabil. 2020 Jun 24

Objective: To compare the effects of four types of bandages and kinesio-tape and determine which one is the most effective in women with unilateral breast cancer-related lymphoedema.

Design: Randomized, single-blind, clinical trial.

Setting: Physiotherapy department in the Women’s Health Research Group at the University of Alcalá, Madrid, Spain.

Subjects: A total of 150 women presenting breast-cancer-related lymphoedema.

Interventions: Participants were randomized into five groups (n = 30). All women received an intensive phase of complex decongestive physiotherapy including manual lymphatic drainage, pneumatic compression therapy, therapeutic education, active therapeutic exercise and bandaging. The only difference between the groups was the bandage or tape applied (multilayer; simplified multilayer; cohesive; adhesive; kinesio-tape).

Main measurements: The main outcome was percentage excess volume change. Other outcomes measured were heaviness and tightness symptoms, and bandage or tape perceived comfort. Data were collected at baseline and finishing interventions.

Results: This study showed significant differences between the bandage groups in absolute value of excess volume (P < 0.001). The most effective were the simplified multilayer (59.5%, IQR = 28.7) and the cohesive bandages (46.3%, IQR = 39). The bandages/tape with the least difference were kinesio-tape (4.9%, IQR = 17.7) and adhesive bandage (21.7%, IQR = 17.9). The five groups exhibited a significant decrease in symptoms after interventions, with no differences between groups. In addition, kinesio-tape was perceived as the most comfortable by women and multilayer as the most uncomfortable (P < 0.001). Conclusion: Simplified multilayer seems more effective and more comfortable than multilayer bandage. Cohesive bandage seems as effective as simplified multilayer and multilayer bandage. Kinesio taping seems the least effective.

Implementing a prospective surveillance and early intervention model of care for breast cancer-related lymphedema into clinical practice: application of the RE-AIM framework.

Koelmeyer L, Gaitatzis K, Ridner SH, John Boyages, Nelms J, Hughes TM, Elder E, French J, Ngui N, Hsu J, Stolldorf D. Support Care Cancer. 2020 Jun 29

Purpose

Chronic lymphedema following breast cancer (BC) affects individuals physically, functionally, psychologically, and financially. Despite national guidelines and evidence-based research supporting a prospective surveillance and early intervention model of care (PSM), bridging the gap between research and clinical practice has been difficult.

Method

As part of an international randomized controlled trial (RCT), Australian women with BC from four hospitals were recruited, monitored for lymphedema at regular intervals over a 3-year period, and were provided a compression garment if intervention was triggered. The reach, effectiveness, adoption, implementation and maintenance (RE-AIM) evaluation framework was used retrospectively to assess a PSM at the individual and organizational level for those who had completed at least 2-year follow-up (N = 219) in the RCT.

Results

The application of the RE-AIM framework retrospectively demonstrated an extensive reach to patients across public and private settings; the effectiveness of prospective surveillance and early intervention was achieved through low progression rates to clinical lymphedema (1.8%), and all hospital sites initially approached adopted the research study. Key implementation strategies necessary for effectiveness of this model of care included education to health professionals and patients, staff acceptability, and development of a referral and care pathway. Maintenance dimensions were evaluated both at the individual level with 92–100% adherence rates for all nonoptional study appointments over the 2-year period, and at the organizational-level, PSM was sustained after recruitment ceased for the research study.

Conclusion

The PSM for lymphedema in BC can be successfully implemented using the RE-AIM framework applied retrospectively. The implementation of the PSM used in the RCT has assisted in changing clinical practices and improving the quality and effectiveness of the health care system.

Surgical versus Nonsurgical Management of Postmastectomy Lymphedema: A Prospective Quality of Life Investigation

Darrach H, Yesantharao PS, Persing S, Kokosis G, Carl HM, Bridgham K, Seu M, Stifler S, Sacks JM. J Reconstr Microsurg. 2020 Jul 05

Background Postmastectomy secondary lymphedema can cause substantial morbidity. However, few studies have investigated longitudinal quality of life (QoL) outcomes in patients with postmastectomy lymphedema, especially with regard to surgical versus nonoperative management. This study prospectively investigated QoL in surgically versus nonsurgically managed patients with postmastectomy upper extremity lymphedema.

Methods This was a longitudinal cohort study of breast cancer-related lymphedema patients at a single institution, between February 2017 and January 2020. Lymphedema Quality of Life Instrument (LyQLI) and RAND-36 QoL instrument were used. Mann–Whitney U and Fisher’s exact tests were used for descriptive statistics. Wilcoxon’s signed-rank testing and linear modeling were used to analyze longitudinal changes in QoL.

Results Thirty-two lymphedema patients were recruited to the study (20 surgical and 12 nonsurgical). Surgical and nonsurgical cohorts did not significantly differ in clinical/demographic characteristics or baseline QoL scores, but at the 12-month time point surgical patients had significantly greater LyQLI overall health scores than nonsurgical patients (79.3 vs. 58.3, p = 0.02), as well as higher composite RAND-36 physical (68.5 vs. 38.3, p = 0.04), and mental (77.0 vs. 52.7, p = 0.02) scores. Furthermore, LyQLI overall health scores significantly improved over time in surgical patients (60.0 at baseline vs. 79.3 at 12 months, p = 0.04). Besides surgical treatment, race, and age were also found to significantly impact QoL on multivariable analysis.

Conclusion Our results suggest that when compared with nonoperative management, surgery improved QoL for chronic, secondary upper extremity lymphedema patients within 12-month postoperatively. Our results also suggested that insurance status may have influenced decisions to undergo lymphedema surgery. Further study is needed to investigate the various sociodemographic factors that were also found to impact QoL outcomes in these lymphedema patients.

Managing Lymphedema in Fracture Care: Current Concepts and Treatment Principles

Thomas C, Le JT, Benson E. J Am Acad Orthop Surg. 2020 Jul 01

Lymphatic flow plays a notable role in the regulation of bone formation and remodeling. Chronic accumulation of the lymph fluid within tissues may lead to issues with proper bone healing after fractures, emphasizing the importance of proper management of lymphedema after trauma. Many associated risk factors place patients at risk for lymphedema, including previous surgery with nodal dissection, radiation therapy, infection, malignancy, family history of congenital lymphedema, and trauma. The benchmark imaging technique for the diagnosis of lymphedema is lymphoscintigraphy. Other modalities include duplex ultrasonography, CT, and MRI. First-line conservative treatment of lymphedema is compression. Complete decongestive therapy or complex physical therapy, also known as decongestive lymphatic therapy (DLT), has shown positive results in reducing lymphedema. Surgical interventions aim to either reconstruct and restore function of the lymphatic system or debulk and reduce tissues and fluids. Understanding the significance of lymphedema on bone healing and techniques available to recognize it are important factors in preventing delay in diagnosis and ensuring proper management of lymphedema after trauma.