Hot of the Press July 2021
We have collated some great articles and material published over the last month. Click on the links below to read the abstract or download the full paper.
Anatomy / Physiology /Pathophysiology
Advances in Lymphedema - click for abstract
Advances in Lymphedema
Prevalence and Risk Factors
Lower-Limb Lymphedema after Sentinel Lymph Node Biopsy in Cervical Cancer Patients
Weight management barriers and facilitators after breast cancer in Australian women: a national survey - click for abstract
Weight management barriers and facilitators after breast cancer in Australian women: a national survey
Carolyn Ee1* , Adele Elizabeth Cave1, Dhevaksha Naidoo1, Kellie Bilinski1 and John Boyages2. BMC Women’s Health (2020) 20:140.
Background: Breast cancer is the most common cancer in women worldwide. Weight gain after breast cancer is associated with poorer health outcomes. The aim of this study was to describe how Australian breast cancer survivors are currently managing their weight.
Methods: Online cross-sectional survey open to any woman living in Australia who self-identified as having breast cancer, between November 2017 and January 2018.
Results: We received 309 responses. Most respondents described their diet as good/excellent and reported moderate-high levels of weight self-efficacy. Despite this, the proportion of overweight/obesity increased from 47% at time of diagnosis to 67% at time of survey. More than three quarters of respondents did not receive any advice on weight gain prevention at the time of diagnosis. 39% of women reported being less active after cancer diagnosis, and and few weight loss interventions were perceived to be effective. Facilitators were structured exercise programs, prescribed diets, and accountability to someone else, while commonly cited barriers were lack of motivation/willpower, fatigue, and difficulty maintaining weight. Women who cited fatigue as a barrier were almost twice as likely to be doing low levels of physical activity (PA) or no PA than women who did not cite fatigue as a barrier.
Conclusions: We report high levels of concern about weight gain after BC and significant gaps in service provision around weight gain prevention and weight management. Women with BC should be provided with support for weight gain prevention in the early survivorship phase, which should include structured PA and dietary changes in combination with behavioural change and social support. Weight gain prevention or weight loss programs should address barriers such as fatigue. More research is required on the effectiveness of diet and exercise interventions in BC survivors, particularly with regard to weight gain prevention.
Loco-regional therapy and the risk of breast cancer-related lymphedema: a systematic review and meta-analysis - click for abstract
Loco-regional therapy and the risk of breast cancer-related lymphedema: a systematic review and meta-analysis
Background: This meta-analysis was designed to assess the association between two loco-regional therapies, regional nodal irradiation (RNI) and axillary lymph node dissection (ALND), and breast cancer-related lymphoedema (BCRL).
Methods: We searched PubMed, Science Direct, Embase, and BMJ databases for clinical studies published between January 1, 2010 and January 1, 2020, which assessed risk factors and incidence/prevalence of BCRL. Two investigators independently selected articles to extract relative data and calculate corresponding exact binomial 95% confidence intervals (CIs). In total, 93 articles were reviewed, from which 19 studies were selected. The extracted data were pooled using a random-effects mixed model.
Results: The incidence of lymphedema in the selected studies ranged from 3% to 36.7%, with a pooled incidence of 14.29% (95% CI 13.79-14.79). The summary odds ratio/risk ratio (OR/RR) of ALND vs. no-ALND was 3.67 (95% CI 2.25-5.98) with a heterogeneity (I2) of 81% (P < 0.00001). After excluding the studies with an abnormally high risk of lymphedema from self-reporting, the summary hazard ratio (HR) was 2.99 (95% CI 2.44-3.66) with no heterogeneity (I2 = 0%, P = 0.83). The summary OR/RR of patients with vs. without radiotherapy (RT) was 1.82 (95% CI 0.92-3.59), but the RR of RT to breast/chest vs. both axillary and supraclavicular areas was 2.66 (95% CI 0.73-9.70).
Conclusion: Regional nodal irradiation has a significantly higher risk for developing lymphedema than irradiation of the breast/chest wall. Axillary dissection and axillary RT have a similar risk for early-onset of breast cancer-related lymphoedema, although the risk trends higher for axillary dissection.
Lymphedema after Sentinel Lymph Node Biopsy: Who is at Risk? - click for abstract
Lymphedema after Sentinel Lymph Node Biopsy: Who is at Risk?
Assessment
The Interrater Reliability of the Scoring of the Lymphatic Architecture and Transport Through Near-InfraRed Fluorescence Lymphatic Imaging in Patients with Breast Cancer-Related Lymphedema - click for abstract
The Interrater Reliability of the Scoring of the Lymphatic Architecture and Transport Through Near-InfraRed Fluorescence Lymphatic Imaging in Patients with Breast Cancer-Related Lymphedema
Longitudinal, Long-Term Comparison of Single- versus Multipoint Upper Limb Circumference Periodical Measurements as a Tool to Predict Persistent Lymphedema in Women Treated Surgically for Breast Cancer: An Optimized Strategy to Early Diagnose Lymphedema and Avoid Permanent Sequelae in Breast Cancer Survivors - click for abstract
Longitudinal, Long-Term Comparison of Single- versus Multipoint Upper Limb Circumference Periodical Measurements as a Tool to Predict Persistent Lymphedema in Women Treated Surgically for Breast Cancer: An Optimized Strategy to Early Diagnose Lymphedema and Avoid Permanent Sequelae in Breast Cancer Survivors
Purpose: We aim to evaluate whether upper limb (UL) circumference (ULC) and UL swelling sensation (ULSS) performed shortly after surgery or later on during follow-up can predict long-term/persistent forms of lymphedema in women who underwent surgery for breast cancer.
Patients and methods: Eighty-five women completed at least 24 months of follow-up. At each follow-up visit (1, 3, 6, 12, and 24 months after surgery), patients were tested for lymphedema using ULC and ULSS. Two different approaches to ULC were compared: (1) a “positive” lymphedema diagnosis if a difference ≥ 2 cm between the affected and contralateral UL was detected in at least two contiguous measurement points (MPs) and (2) a “positive” result if just one MP ≥ 2 cm. Patients were also questioned about their perception of weight, swelling, and/or tension (ULSS). The gold standard for long-term lymphedema was a water displacement difference between the UL ≥ 200 mL 24 months after surgery (ULWD).
Results: Twenty-four months after surgery, 19 (22.4%) women were diagnosed with long-term lymphedema. Using 24-month data, comparison of log-likelihoods denoted a clear superiority of the ULC approach 1 compared with 2 for the diagnosis of long-term lymphedema (p < 0.001). Using approach 1, the best prediction of a woman developing long-term lymphedema if she had a positive ULC in the follow-up was obtained at 6 months after surgery (posterior probability of 60%). Conclusions: Our study reveals that performing ULC 6 months after surgery, regarding as “positive” only women with a difference ≥ 2 cm at two contiguous MPs, is the best strategy to identify women at increased risk of later developing permanent forms of lymphedema.
Subclinical Lymphedema After Treatment for Breast Cancer: Risk of Progression and Considerations for Early Intervention - click for abstract
Subclinical Lymphedema After Treatment for Breast Cancer: Risk of Progression and Considerations for Early Intervention
Evaluation and Management of Patients with Leg Swelling: Therapeutic Options for Venous Disease and Lymphedema - click for abstract
Evaluation and Management of Patients with Leg Swelling: Therapeutic Options for Venous Disease and Lymphedema
Relationship Between the Circumference Difference and Findings of Indocyanine Green Lymphography in Breast Cancer-Related Lymphedema - click for abstract
Relationship Between the Circumference Difference and Findings of Indocyanine Green Lymphography in Breast Cancer-Related Lymphedema
Background: Breast cancer-related lymphedema (BCRL) is a common complication. Indocyanine green (ICG) lymphography has been performed to assess lymphatic functionality. We found that some BCRL patients had a difference in circumference in partial regions only. The purpose of this study was to evaluate the patients with BCRL about the correlation between the difference in circumference and the findings of ICG lymphography.
Methods: One hundred fifty-five patients with unilateral BCRL were enrolled in this study. We evaluated the differences in circumference taken at 4 parts on the upper limb (at around the wrist, forearm, elbow, and brachium). The difference in circumference was evaluated between the affected part (Caf) and the unaffected part (Cun). We calculated the circumference difference rate (CDR) as follows: CDR = 100 (Caf – Cun)/Caf. First, we classified each part of all BCRL patients (620 parts) based on the findings of ICG lymphography (linear, collateral, dermal back flow [DBF], and no enhancement) and evaluated the correlation. Second, in the patients with partial volume change, we compared the mean CDR in each part.
Results: One hundred six parts were of a linear pattern, 31 parts were collateral, 350 parts were DBF, and 133 parts had no enhancement. The mean CDR of each finding was 3.3% in linear, 4.0% in collateral, 9.6% in DBF, and 9.4% in no enhancement. There was no significant difference between linear and collateral (P = 0.62), DBF, and no enhancement (P = 0.89) patterns. However, there was a significant difference between linear or collateral and DBF or no enhancement (all P < 0.001). In the 22 patients with distal DBF and proximal linear, the CDR was significantly higher in the forearm compared with the brachium (6.4% and 3.0%; P = 0.003). In the 26 patients with distal linear and proximal DBF, the CDR was significantly higher in the brachium compared with the forearm (4.3% and 7.7%; P = 0.005). Conclusions: There was a significant correlation between the difference in circumference and the severity of ICG findings.
Development and Psychometric Validation of a Patient-Reported Outcome Measure for Arm Lymphedema: The LYMPH-Q Upper Extremity Module - click for abstract
Development and Psychometric Validation of a Patient-Reported Outcome Measure for Arm Lymphedema: The LYMPH-Q Upper Extremity Module
Background: A multiphased mixed-methods study was performed to develop and validate a comprehensive patient-reported outcome measure (PROM) for arm lymphedema in women with breast cancer (i.e., the LYMPH-Q Upper Extremity Module).
Methods: Qualitative interviews (January 2017 and June 2018) were performed with 15 women to elicit concepts specific to arm lymphedema after breast cancer treatment. Data were audio-recorded, transcribed, and coded. Scales were refined through cognitive interviews (October and Decemeber 2018) with 16 patients and input from 12 clinical experts. The scales were field-tested (October 2019 and January 2020) with an international sample of 3222 women in the United States and Denmark. Rasch measurement theory (RMT) analysis was used to examine reliability and validity.
Results: The qualitative phase resulted in six independently functioning scales that measure arm symptoms, function, appearance, psychological function, and satisfaction with information and with arm sleeves. In the RMT analysis, all items in each scale had ordered thresholds and nonsignificant chi-square p values. For all the scales, the reliability statistics with and without extremes for the Person Separation Index were 0.80 or higher, Cronbach’s alpha was 0.89 or higher, and the Intraclass Correlation Coefficients were 0.92 or higher. Lower (worse) scores on the LYMPH-Q Upper Extremity scales were associated with reporting of more severe arm swelling, an arm problem caused by cancer and/or its treatment, and wearing of an arm sleeve in the past 12 months.
Conclusions: The LYMPH-Q Upper Extremity Module can be used to measure outcomes that matter to women with upper extremity lymphedema. This new PROM was designed using a modern psychometric approach and, as such, can be used in research and in clinical care.
The impact of lymphedema on health-related quality of life up to 10 years after breast cancer treatment
Analysis of Spinal Dysfunction in Breast Cancer Survivors with Lymphedema
Physical findings and tests useful for differentiating lymphedema
Determination of Bioelectrical Impedance Thresholds for Early Detection of Breast Cancer-related Lymphedema
Management Strategies
Lymphedema rehabilitation: Provision and practice patterns among service providers: National survey
The Effects of Kinect-Enhanced Lymphatic Exercise Intervention on Lymphatic Pain, Swelling, and Lymph Fluid Level
Velcro compression wraps as an alternative form of compression therapy for venous leg ulcers: a review - click for abstract
Velcro compression wraps as an alternative form of compression therapy for venous leg ulcers: a review
Breast cancer-related lymphedema patient and healthcare professional experiences in lymphedema self-management: a qualitative study - click for abstract
Breast cancer-related lymphedema patient and healthcare professional experiences in lymphedema self-management: a qualitative study
Purpose: Breast cancer-related lymphedema (BCRL) self-management plays an important role in the lymphedema therapy. However, clinical knowledge of BCRL self-management remains minimal. This study aims to explore the experience surrounding lymphedema self-management from the perspectives of BCRL patients and healthcare professionals.
Methods: Semi-structured interviews were implemented with BCRL patients and healthcare professionals. Audio-recordings of interviews were transcribed verbatim and thematic analysis was undertaken to analyze the interview data.
Results: Thirteen BCRL patients (aged 34-65 years) and nine healthcare professionals (2 physicians, 4 nurses, and 3 lymphedema therapists) were interviewed. Five themes emerged from interviews with participants: knowledge-attitude-practice surrounding lymphedema self-management, emotional reactions towards lymphedema self-management, factors influencing lymphedema self-management, support needs for lymphedema self-management, healthcare professional support of BCRL self-management.
Conclusions: This study showed knowledge-attitude-practice, feelings, influencing factors, roles, dilemmas, and support needs regarding BCRL self-management. Greater effort is required for healthcare professionals to strengthen the lymphedema self-management. Providing more educational program and holistic support, and strengthening the facilitators and controlling the barriers might benefit promoting lymphedema self-management. Likewise, healthcare professionals need adequate training to be able to meet patients’ self-management support needs.