Cost considerations regarding the prospective surveillance model for breast cancer survivors

Practice points for lymphoedema care in low- and middle- income countries developed by nominal group technique

BACKGROUND

Lymphoedema is a common, distressing, and debilitating condition affecting more than 200 million people globally. There is a small body of evidence to guide lymphoedema care which underpins several lymphoedema clinical practice guidelines developed for high-income countries (HIC). Some of these recommendations are unlikely to be feasible in low-resource settings.

AIM

To develop practice points for healthcare workers that optimise lymphoedema care in low- and middle-income countries (LMIC).

METHODS

A nominal group technique (NGT) was undertaken to gain consensus on which content from HIC guidelines was important and feasible to include in practice points for LMIC, and other important advice or recommendations. Participants included experts, clinicians, and volunteers involved in lymphoedema care in LMIC. The NGT followed five key stages: silent 'ideas' generation, round-robin rationale, clarification, refinement and verification. The first, fourth and fifth stages were completed via email, and the second and third during a video meeting in order to generate a series of consensus based prevention, assessment, diagnosis, and management of lymphoedema in LMIC practice points.

RESULTS

Of sixteen participants invited, ten members completed stage 1 of the NGT (ideas generation), of whom six contributed to stages 2 (round-robin) and 3 (clarification). All those who completed stage 1 also completed stages 4 (refinement) and 5 (verification). Practice points unanimously agreed on included Complex Decongestive Therapy (CDT) and good skin care, with management to be determined by lymphoedema stage. For podoconiosis-endemic areas, the use of socks and shoes was identified as very important in the prevention of non-filarial lymphoedema and other lymphoedema-causing conditions. Participants indicated that diagnosing lymphoedema using the lymphoscintigraphy and Indocyanine green (ICG) fluorescent lymphography was not possible due to unavailability and cost in LMIC. Surgical procedures for lymphoedema management were unanimously eliminated due to the unavailability of technology, limited workforce, and expensive cost in LMIC.

CONCLUSION

The consensus-based practice points generated by this project provide healthcare workers with guidance on caring for people with lymphoedema in LMIC. Further development of workforce capacity is needed.

Guidelines Relevant to Diagnosis, Assessment, and Management of Lymphedema: A Systematic Review

Significance: Lymphedema is a common, distressing and debilitating condition with various etiologies. Effective diagnosis, assessment, and management rely on evidence-based clinical practice guidelines ("guidelines"). This study aims to describe and compare international guidelines on lymphedema diagnosis, assessment, and management. Recent Advances: The review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and registered on the International Prospective Register of Systematic Reviews (PROSPERO). Systematic searches of electronic literature databases and the web were completed in December 2020 for lymphedema guidelines published in English since 2000. Quality was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE)-II reporting checklist. Synthesis took a narrative approach to compare guideline recommendations and associated levels of evidence. Critical Issues: This systematic review of 1,564 articles and 159 web pages yielded 14 guidelines. All guidelines were from high-income countries. Ten focused exclusively on lymphedema, and four on cancer. Most (n = 13) guidelines recommended an integrated medical, psychological assessment, and physical examination, with a limb volume measurement of >10% in the affected limb compared, confirming a lymphedema diagnosis. Recommended management involved Complex Decongestive Therapy (CDT) followed by self-management using skincare, self-lymphatic drainage massage, exercise, and compression. Future Directions: The underlying etiology of lymphedema appeared to make little difference to guideline recommendations regarding care. High-quality guidelines are available to guide lymphedema care. However, their suitability for low-resource settings is unclear.

Cost of a lymphedema treatment mandate - 16 years of experience in the Commonwealth of Virginia

BACKGROUND

Treatment of chronic illness accounts for over 90% of Medicare spending. Chronic lymphedema places 3-10 million Americans at risk for recurrent cellulitis. Without convincing predictions of the costs and benefits of lymphedema treatment, insurers are reluctant to fully cover treatment of this common condition. Earlier papers discussed the costs and benefits of the first 5, 7, and 10 years of a lymphedema treatment mandate in Virginia. This paper updates these costs and benefits to 16 years of experience, and includes the impacts of the Patient Protection and Affordable Care Act of 2010 and the transition to ICD-10-CM diagnostic codes in 2015. It provides added confidence that costs of a lymphedema treatment mandate are reasonable, and can result in health insurance contract savings for reduced medical visits and hospitalizations for lymphedema patients.

METHODS

Virginia requires annual reporting of the segregated costs of each of its 30 medical mandates. Data on Virginia's lymphedema treatment mandate for the years 2004 to 2019 have been collected from the series of annual reports. These data include actual lymphedema treatment claims data, utilization data, and claims-based estimates of the premium impact.

RESULTS

The average actual lymphedema claim cost was $2.03 per individual contract and $3.54 per group contract for the years reported, representing 0.05 and 0.08% of average total claims. The estimated premium impact was 0.16-0.32% of total average premium for all mandated coverage contracts. While lymphedema claim costs increased 3-6% per year over the study period, generally following the rise of health care costs, claim costs as a percent of average contract claims fell at a rate of 1.26-1.52% per year over that period. Medical office visits for lymphedema-related services fell from 0.10 to 0.02 visits per year per contract from the beginning to the end of the study period, and hospitalizations for lymphedema or lymphedema-related cellulitis fell to almost zero.

CONCLUSIONS

The Virginia data confirmed previous conclusions that the costs of treatment of lymphedema are a small part of a typical health insurance contract, and that treatment of lymphedema by managing swelling results in lower overall medical costs and fewer hospitalizations. This is a potent model for reduction in healthcare costs while improving the quality of care for cancer survivors and others suffering with this chronic progressive condition.

Translating 2019 ACSM Cancer Exercise Recommendations for a Physiatric Practice: Derived Recommendations from an International Expert Panel

In 2018, the American College of Sports Medicine (ACSM) reconvened an international, multi-disciplinary group of professionals to review pertinent published literature on exercise for people with cancer. The 2018 roundtable resulted in the publication of three articles in 2019. The three articles serve as an important update to the original ACSM Roundtable on Cancer, which convened in 2010. Although the focus of the three 2019 articles is on exercise, which is only one part of comprehensive cancer rehabilitation, the evidence presented in the 2019 ACSM articles has direct implications for physiatrists and other rehabilitation professionals who care for people with cancer. As such, the narrative review presented here has two primary objectives. First, we summarize the evidence within the three ACSM articles and interpret it within a familiar rehabilitation framework, namely the Dietz model of Cancer Rehabilitation, in order to facilitate implementation broadly within rehabilitation practice. Second, via expert consensus, we have tabulated relevant exercise recommendations for specific cancer populations at different points in the cancer care continuum and translated them into text, tables, and figures for ease of reference. Notably, the authors of this article are members of the Cancer Rehabilitation Physician Consortium (CRPC), a group of physicians who subspecialize in cancer rehabilitation medicine (CRM).

Identification and management of late dysfunction in survivors of head and neck cancer: Implementation and outcomes of an interdisciplinary quality of life (IQOL) clinic

BACKGROUND

Identifying and treating late dysfunction in survivors of head and neck cancer (HNC) is important; however, an effective way to do so is not established.

METHODS

A quality improvement initiative altering our HNC survivorship clinic to include surveillance by rehabilitation providers was undertaken. The nature of dysfunction identified, along with the number and type of referrals to ancillary/support services were collected and compared to baseline.

RESULTS

The baseline, single-provider, clinic evaluated 61 patients and referred 2 (3%) to ancillary/support services. Fifty-seven patients were evaluated in the interdisciplinary clinic, with 36 (63%) referred to at least one ancillary/support service for new/progressive dysfunction. Of 59 referrals made, 22 (37%) were for dysphagia, 17(29%) were for neck/shoulder dysfunction, and 28 (47%) were attended by the patient.

CONCLUSION

Many HNC survivors exhibit late dysfunction appropriate for referral to ancillary/support services. A survivorship clinic including surveillance by rehabilitation specialists may optimize identification of dysfunction.

From Cancer Rehabilitation to Recreation: A Coordinated Approach to Increasing Physical Activity

Participation in adequate physical activity improves the health status of cancer survivors, enhances their survival, and reduces their risk of cancer recurrence. However, cancer survivors engage in low levels of physical activity and have limited access to rehabilitation services that could increase their participation. No optimal framework has been developed that supports physical activity participation among cancer survivors. Given the growth in numbers of cancer survivors, development of a framework may provide a pathway to facilitate timely and appropriate care. This perspective paper describes the development of the Cancer Rehabilitation to Recreation (CaReR) Framework and its practical implications. The CaReR Framework uses a tailored, stepped approach to guide health services and clinicians on the design and implementation of interventions to promote physical activity among cancer survivors. Implementation of the CaReR Framework will improve continuity and quality of care for cancer survivors and promote physical activity with the ultimate aim of improving health outcomes.

Prevalence and incidence of cancer related lymphedema in low and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Little is known about the prevalence and incidence in low and middle-income countries (LMICs) of secondary lymphedema due to cancer. The purpose of the study is to estimate the prevalence and incidence in LMICs of secondary lymphedema related to cancer and/or its treatment(s) and identify risk factors.

METHOD

A systematic review and meta-analysis was conducted. Medline, EMBASE and CINAHL were searched in June 2019 for peer-reviewed articles that assessed prevalence and/or incidence of cancer-related lymphedema in LMICs. Risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Prevalence Studies. Estimates of pooled prevalence and incidence estimates were calculated with 95% confidence intervals (CI), with sub-group analyses grouping studies according to: country of origin, study design, risk of bias, setting, treatment, and lymphedema site and measurement. Heterogeneity was measured using X2 and I2, with interpretation guided by the Cochrane Handbook for Systematic Reviews.

RESULTS

Of 8766 articles, 36 were included. Most reported on arm lymphedema secondary to breast cancer treatment (n = 31), with the remainder reporting on leg lymphedema following gynecological cancer treatment (n = 5). Arm lymphedema was mostly measured by arm circumference (n = 16/31 studies), and leg lymphedema through self-report (n = 3/5 studies). Eight studies used more than one lymphedema measurement. Only two studies that measured prevalence of leg lymphedema could be included in a meta-analysis (pooled prevalence =10.0, 95% CI 7.0-13.0, I2 = 0%). The pooled prevalence of arm lymphedema was 27%, with considerable heterogeneity (95% CI 20.0-34.0, I2 = 94.69%, n = 13 studies). The pooled incidence for arm lymphedema was 21%, also with considerable heterogeneity (95% CI 15.0-26.0, I2 = 95.29%, n = 11 studies). There was evidence that higher body mass index (> 25) was associated with increased risk of arm lymphedema (OR: 1.98, 95% CI 1.45-2.70, I2 = 84.0%, P < 0.0001, n = 4 studies).

CONCLUSION

Better understanding the factors that contribute to variability in cancer-related arm lymphedema in LMICs is an important first step to developing targeted interventions to improve quality of life. Standardising measurement of lymphedema globally and better reporting would enable comparison within the context of information about cancer treatments and lymphedema care.

The Who, What, Why, When, Where, and How of Team-Based Interdisciplinary Cancer Rehabilitation

OBJECTIVE

To review the key components necessary for successful application of rehabilitation principles to oncology survivors.

DATA SOURCES

Validated databases, including PubMed, MEDLINE, and Scopus.

CONCLUSION

Rehabilitation is an essential component of cancer care that addresses functional needs for oncology survivors and is best accomplished via an interdisciplinary team. Interdisciplinary care, provided by nursing, physiatry, rehabilitation therapy, and exercise physiology, are critical components for comprehensive intervention. Challenges exist in implementing services, but opportunity also exists within the post-acute care sector.

IMPLICATIONS FOR NURSING PRACTICE

Nurses play an important role in the screening, assessment, and treatment of cancer-related functional impairments.

Prospective surveillance and targeted physiotherapy for arm morbidity after breast cancer surgery: a pilot randomized controlled trial

OBJECTIVE

To evaluate prospective surveillance and targeted physiotherapy (PSTP) compared to education (EDU) on the prevalence of arm morbidity and describe the associated program cost.

DESIGN

Pilot randomized single-blinded controlled trial.

SETTING

Urban with assessments and treatment delivered in hospitals.

PARTICIPANTS

Women scheduled for breast cancer surgery.

INTERVENTIONS

Participants were randomly assigned (1:1) to PSTP ( n = 21) or EDU ( n = 20) and assessed presurgery and 12 months postsurgery. All participants received usual care, namely, preoperative education and provision of an education booklet with postsurgical exercises. The PSTP group was monitored for arm morbidity every three months and referred for physiotherapy if arm morbidity was identified. The EDU group received three education sessions on nutrition, stress and fatigue management.

MAIN OUTCOME MEASURES

Arm morbidity was based on changes in the surgical arm(s) from presurgery in four domains: (1) shoulder range of motion, (2) strength, (3) volume, and (4) upper body function. Complex arm morbidity indicated ≥2 domains impaired. Second, the cost of the PSTP program was described.

RESULTS

At 12 months, 18 (49%) participants (10 PSTP and 8 EDU) had arm morbidity, with EDU participants presenting more complex arm morbidity compared to PSTP participants. PSTP participants attended 4.4 of 5 assessments with 90% retention. The PSTP program cost was $150 covered by the Health Care Provider and the Patient Out-of-Pocket Travel cost was CAN$40.

CONCLUSION

Our results suggest that PSTP is feasible among women with breast cancer for early identification of arm morbidity. A larger study is needed to determine the cost and effectiveness benefits.

Cancer Survivorship in Adults

With the favorable trend regarding survival of cancer in the Western world, there is an increasing focus among patients, clinicians, researchers, and politicians regarding cancer survivors' health and well-being. The number of survivors grows rapidly, and more than 3% of the adult populations in Western countries have survived cancer for 5 years or more. Cancer survivors are at increased risk for a variety of late effects after treatment, some life-threatening such as secondary cancer and cardiac diseases, while others mainly have negative impact on daily functioning and health-related quality of life (HRQOL). The latter factors include fatigue, anxiety disorders, sexual problems, insomnia, and reduced work ability, while depression does not seem to be more common among survivors than in the general population. Life style factors are highly relevant for cancer survivors concerning risk of relapse and somatic comorbidity. The field of cancer survivorship research has grown rapidly. How to best integrate the knowledge of the field into clinical practice with adequate follow-up of cancer survivors at risk for developing late effects, is still an unresolved question, although several models are under consideration.

Developing High-Quality Cancer Rehabilitation Programs: A Timely Need

The number of survivors of cancer in the United States, already 14.5 million, is growing with improved cancer treatment and aging of the population. Two-thirds of cancer survivors will be older than age 65 and are likely to enter cancer treatment already deconditioned and with multiple comorbidities. Survivors of cancer face numerous adverse consequences of cancer treatment that add to or exacerbate the effects of existing comorbidities and increase risk of functional decline. Many of these problems are amenable to rehabilitation interventions, but referral to cancer rehabilitation professionals is not a standard part of care. We present an expanded prospective model of surveillance, cancer rehabilitation assessment, and referral efforts using a multidisciplinary team approach. In this model, cancer rehabilitation begins at the time of cancer diagnosis and continues through and beyond cancer treatment. Physical impairments and psychosocial symptoms are assessed and treated, and lifestyle and exercise interventions are provided to optimize functioning, health, and quality of life. We present a stepped-care framework to guide decisions on when, how, and where to refer survivors to cancer rehabilitation specialists depending on safety requirements and needs. This model has the potential to result in early identification of symptoms and impairments, appropriate referral and timely treatment, and, in turn, will better address and minimize both acute and long-term cancer morbidity.

Use of a prospective surveillance model to prevent breast cancer treatment-related lymphedema: a single-center experience

Purpose

Breast cancer patients undergoing axillary lymph node dissection (ALND) are at risk of lymphedema (LE). Successful management of LE relies on early diagnosis using sensitive modalities. In the current study, we explored the effectiveness of a surveillance program for lymphedema management (SLYM) compared to standard care.

Methods

Breast cancer patients who underwent ALND in Seoul National University Bundang Hospital from January 2008 to December 2015 were included in this prospective study. The SLYM commenced in May 2011. The LE outcomes of patients treated prior to initiation of the SLYM were compared with those of patients after SLYM implementation.

Results

A total of 707 patients were included, 390 in the SLYM group and 317 in the historical control (HC) group. A total of 203 patients (28.7 %) had episodes of all-stage LE during follow-up. Of these, 126 (19.7 %) were in the surveillance group and 77 (24.3 %) in the HC group. The overall 5-year cumulative incidence of LE (greater than stage 3) was 25 (95 % CI 15.4–34.6) (6.4 %) in the SLYM group and 48 (95 % CI, 15.4–34.6) (15.1 %) in the HC group. In the SLYM group, poor compliance had a significant impact on LE incidence (OR = 2.98, P = 0.002). Low level of self-monitoring and insight scores were significantly related to LE incidence (OR = 1.31, P = 0.025) after adjusting for age, body mass index, the type of surgery chosen, radiation therapy, and chemotherapy. With a cut-off of 29.5 days from operation to the first visit to the LE clinic, the sensitivity was 60 % and the specificity 61 % in terms of predicting a LE event.

Conclusions

Surveillance improves LE prevention compared to clinical evaluation. The first visit to the LE clinic should be made within 1 month after surgery. In the first year, visits should be made at intervals of less than 3 months.

Electronic supplementary material

The online version of this article (doi:10.1007/s10549-016-3993-7) contains supplementary material, which is available to authorized users.

Intended follow up of women with breast cancer at low risk of recurrence and at least 5 years from diagnosis

BACKGROUND

Although there is evidence that minimal surveillance is compatible with an optimal outcome in women after early stage breast cancer, little is known of the surveillance that these women receive.

AIMS

To describe the intended clinical follow up and patterns of use of imaging modalities in low-risk breast cancer survivors who are at least 5 years from diagnosis.

METHODS

Participants in the Bupa Health Foundation Health and Wellbeing After Breast Cancer Study with stage 1 invasive breast cancer at diagnosis, who had survived free of recurrence or new primary breast cancer for at least 5 years, provided information for this analysis.

RESULTS

The most common choice of physician follow up was with one doctor only (54%). Within this group, the most frequent choice was a general practitioner (GP) (63%) followed by medical oncologist (23%). Thirty-five per cent of women said that they intended to consult two doctors and within this group, the most common combination was a GP and a medical oncologist (45%). This was despite two out of three women reporting being advised that there was no need to consult a medical oncologist. Over 90% of women reported having a mammogram with, or without, breast ultrasound in the previous 12 months. There was a low rate of use of other imaging tests in the absence of clear indications.

CONCLUSIONS

Minimising unnecessary medical consultations by women with breast cancer at low risk of recurrence 5 years from diagnosis will require education about the benefits of a minimal surveillance strategy.

Lymphedema following treatment for breast cancer: a new approach to an old problem

Lymphedema following treatment for breast cancer can be an irreversible condition with a profound negative impact on quality of life. The lack of consensus regarding standard definitions of clinically significant lymphedema and optimal methods of measurement and quantification are unresolved problems. Inconsistencies persist regarding the appropriate timing of intervention and what forms of treatment should be the standard of care. There are reports that early detection and intervention can prevent progression, however,the Level 1 evidence to support this hypothesis has yet to be generated. To assess these controversies, we propose the implementation of a screening program to detect early lymphedema in conjunction with a randomized, prospective trial designed to generate Level 1 evidence regarding the efficacy of early intervention and appropriate treatment strategies. Collaboration among institutions that manage breast cancer patients is essential to establish a standardized approach to lymphedema and to establish guidelines for best practice.

Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis

BACKGROUND

The body of evidence related to breast-cancer-related lymphoedema incidence and risk factors has substantially grown and improved in quality over the past decade. We assessed the incidence of unilateral arm lymphoedema after breast cancer and explored the evidence available for lymphoedema risk factors.

METHODS

We searched Academic Search Elite, Cumulative Index to Nursing and Allied Health, Cochrane Central Register of Controlled Trials (clinical trials), and Medline for research articles that assessed the incidence or prevalence of, or risk factors for, arm lymphoedema after breast cancer, published between Jan 1, 2000, and June 30, 2012. We extracted incidence data and calculated corresponding exact binomial 95% CIs. We used random effects models to calculate a pooled overall estimate of lymphoedema incidence, with subgroup analyses to assess the effect of different study designs, countries of study origin, diagnostic methods, time since diagnosis, and extent of axillary surgery. We assessed risk factors and collated them into four levels of evidence, depending on consistency of findings and quality and quantity of studies contributing to findings.

FINDINGS

72 studies met the inclusion criteria for the assessment of lymphoedema incidence, giving a pooled estimate of 16.6% (95% CI 13.6-20.2). Our estimate was 21.4% (14.9-29.8) when restricted to data from prospective cohort studies (30 studies). The incidence of arm lymphoedema seemed to increase up to 2 years after diagnosis or surgery of breast cancer (24 studies with time since diagnosis or surgery of 12 to <24 months; 18.9%, 14.2-24.7), was highest when assessed by more than one diagnostic method (nine studies; 28.2%, 11.8-53.5), and was about four times higher in women who had an axillary-lymph-node dissection (18 studies; 19.9%, 13.5-28.2) than it was in those who had sentinel-node biopsy (18 studies; 5.6%, 6.1-7.9). 29 studies met the inclusion criteria for the assessment of risk factors. Risk factors that had a strong level of evidence were extensive surgery (ie, axillary-lymph-node dissection, greater number of lymph nodes dissected, mastectomy) and being overweight or obese.

INTERPRETATION

Our findings suggest that more than one in five women who survive breast cancer will develop arm lymphoedema. A clear need exists for improved understanding of contributing risk factors, as well as of prevention and management strategies to reduce the individual and public health burden of this disabling and distressing disorder.

FUNDING

The National Breast Cancer Foundation, Australia.