Factors associated with psychological distress in women with breast cancer-related lymphoedema

Body image and cancer-related lymphoedema: A systematic review

OBJECTIVE

Cancer-related lymphoedema is a common side effect of cancer, affecting 24%-49% of people with cancer. Body image contributes to the well-being of individuals with this condition. This systematic review aimed to explore, for the first time, the state of the science concerning body image in cancer-related lymphoedema, including how body image is measured and variables associated with body image concerns.

METHODS

Six databases were systematically searched for peer-reviewed articles describing empirical quantitative studies where body image was measured with a reliable and valid measurement tool in adults with cancer-related lymphoedema.

RESULTS

Nine studies with 977 participants were included. The studies involved individuals who had experienced breast, head and neck, melanoma, and urogenital cancers and developed lymphoedema. There was considerable heterogeneity in body image measures used, precluding meta-analysis. The following variables were associated with increased body image concern: higher body integrity beliefs, experience of physical changes (e.g. pain) and differences in sensation and function, including changes in appearance related thoughts, feelings and emotions. Several studies described behavioural and psychological interventions which positively impacted body image outcomes in individuals with lymphoedema relating to specific cancers.

CONCLUSION

Regular screening for body image concerns could encourage more positive body image awareness in individuals with cancer-related lymphoedema and lessen some of its associated negative consequences. Future longitudinal and individual differences research in this area is important to inform intervention development. There is also need for a more standardised approach to the study and measurement of body image in people with cancer-related lymphoedema.

Longitudinal trajectories of illness perception regarding breast cancer-related lymphedema among women with breast cancer

OBJECTIVE

To identify longitudinal trajectories of illness perception (IP) regarding breast cancer-related lymphedema (BCRL) in the first six months after surgery among women with breast cancer and to explore the predictive effects of demographics and clinical factors on IP trajectories.

METHODS

From August 2019 to August 2021, a total of 352 patients participated in this study, 328 of whom were included in the data analysis. Demographic and clinical characteristics were collected at baseline (1-3 days after surgery). The BCRL-specific revised illness perception questionnaire was used to measure IP regarding BCRL at baseline and 1 month, 3 months and 6 months post-surgery. A multilevel model was conducted to analyze the data.

RESULTS

Over the first six months post-surgery, the "timeline acute/chronic" and "illness coherence" dimensions showed positive growth trajectories; the "personal control" and "treatment control" dimensions presented negative growth trajectories; and the trajectories of identity, consequences, cyclicality and emotional influence perceptions regarding BCRL showed no significant changes. Age, education level, marital status, employment status, family monthly income per person, cancer stage and status of removed lymph nodes were indicated to be predictive factors of IP trajectories.

CONCLUSIONS

The present study determined significant changes over the first six months post-surgery in four IP dimensions and predictive effects of some demographics and clinical details on IP trajectories. These findings may help healthcare providers know more about the dynamic characteristics of IPs regarding BCRL in patients with breast cancer and assist them in identifying patients with a tendency toward improper IP regarding BCRL.

Psychological distress in breast cancer patients during oncological inpatient rehabilitation: incidence, triggering factors and correlation with treatment-induced side effects

As a result of the cancer diagnosis and the mostly multimodal, stressful therapy, psychological distress is a common symptom in breast cancer patients. As part of this prospective study, 1400 patients who were admitted to the hospital for oncological rehabilitation were screened for distress and somatic, therapy-induced secondary disorders. Mean distress in the screened population was 5.6 ± 2.56 (range 0-10). In 942 cases (67.3%) a significant distress score (≥ 5) was detected and in 587 cases (41.9%) very high levels of distress (≥ 7) was observed. Psychological distress significantly correlated with younger age, presence of triple negative breast cancer (TNBC), tumor recurrence and metastasis, and inability to work. Treatment-induced side effects such as lymphedema, CIPN or extensive tumor resection (mastectomy) showed a (not significant) trend for higher distress. The high incidence of distress underscores the importance of psycho-oncological therapy offers and the great importance of occupational measures during oncological rehabilitation such as the importance of a successful return to work for a better quality of life in breast cancer patients.

Evaluation of Sleep Quality, Depression, and Quality of Life in Patients with Breast Cancer Related Lymphedema

Background: Breast cancer-related lymphedema (BCRL) is a serious health condition negatively affecting psychological state, sleep quality, and quality of life (QOL) of patients. These complications of BCRL can be overlooked in routine clinical practice. The aim of this study is to evaluate sleep quality, depression, and QOL in patients with different stages of BCRL. Methods: This cross-sectional study included 111 consecutive women patients with BCRL attending to lymphedema unit of Physical Medicine and Rehabilitation Hospital in Ankara City Hospital. Demographical and clinical data of patients were noted. Sleep quality was assessed with Pittsburgh Sleep Quality Index, day-time sleepiness was assessed with Epworth Sleepiness Scale, depression was assessed with Beck Depression Questionnaire, and QOL was assessed with Lymphedema Quality of Life Questionnaire-arm. Results: Median age of patients was 57 (49-63) (25%-75% interquartile range). Nearly 58.8% of the patients had sleep disturbances, and 29.7% of the patients had depression. Presence of both sleep disturbance and depression was associated with increased age. Patients with sleep disturbance were found to be more depressive and vice versa, (p < 0.001, p < 0.001, respectively). Sleep disturbance, depression and day-time sleepiness, and higher body mass index were all associated with lower QOL scores. Conclusions: Presence of sleep disturbances and depression should be evaluated in every patient with BCRL with special attention to elderly. Rehabilitative management of BCRL should include psychiatric evaluation and interventions. Future studies should intend to assess the risk factors that affect psychological state, sleep quality, and QOL in patients with BCRL.

Body image and sexuality concerns in women with breast cancer-related lymphedema: a cross-sectional study

PURPOSE

(1) To determine, in women with breast cancer-related lymphedema (BCRL), the frequency, intensity and distress of body image and sexuality concerns. (2) To examine relationships between body image and sexuality concerns, and lymphedema, personal and cancer treatment factors.

METHOD

Women with BCRL (n = 64) completed the Lymphedema Symptom Intensity and Distress Scale - Arm (LSIDS-A), which focuses on the intensity and distress of a range of lymphedema symptoms. They also underwent a lymphedema assessment. Responses to eight questions from the LSIDS-A regarding sexuality, body image and intimate relationships were considered. Frequency of responses was tabulated. Multiple linear regressions were used to determine if specific factors were related to higher intensity and distress scores associated with body image and sexuality issues.

RESULTS

Body image and sexuality concerns were common (48%, 23% respectively). Participants reported a range (0-10) of intensity and distress related to body image and sexuality symptoms. Univariate linear regression revealed greater intensity of sexuality concerns was associated with younger age, whilst distress related to sexuality concerns was associated with higher inter-arm bioimpedance ratio and shorter duration of lymphedema. Body image concerns were not related to any considered factors.

CONCLUSION

Body image and sexuality concerns are common, intense and distressing for patients with breast cancer lymphedema. Assessment of both the intensity and distressed caused by these symptoms is necessary to understand the impact of lymphedema.

Comparison of normal hindlimb lymphatic systems in rats with detours present after lymphatic flow blockage

In the present study, we aimed to identify the normal hindlimb lymphatic systems in rats and compare them with the detours after lymphatic flow blockage. The lymphatic systems of the hindlimbs of normal rats were investigated via lymphography using a near-infrared fluorescence imaging system. The lymphatic vessels were stained using Evans Blue. The lymphatic flow was blocked through lymphatic vessel ligation combined with inguinal and popliteal lymph node dissection. Detours that appeared after 30 days were visualized using lymphography and immunostaining with anti-podoplanin antibodies. Three main results were obtained in the present study. First, the deep medial system, the superficial medial system, a connection between the superficial and deep medial lymphatic systems, and the superficial lateral system, were elucidated. Second, three types of detours, namely the detour of the lateral abdomen, the detour to the lymphatic vessel near the midline of the abdomen, and the detour to the contralateral inguinal lymph node, were identified after lymphatic flow blockage. Lastly, detours were located in the fatty layer above the panniculus carnosus muscle and their lumina were wide. The histology suggested that the detour was a pre-collecting lymphatic vessel. Lymphatic routes in the rat hindlimbs after lymphatic flow blockage were different from those of the normal rat lymphatic system. It was suggested that the detour is a pre-collecting lymphatic vessel and that encouraging its development may be a new method of simple lymphatic drainage.

Influencia del optimismo y la percepción de apoyo social del personal sanitario sobre la calidad de vida de los enfermos de cáncer

Objetivo: El presente estudio se plantea analizar la relación del apoyo social proporcionado por el personal sanitario y el optimismo del paciente con la calidad de vida y el estrés percibido por los enfermos de cáncer. Método: Se recogen datos referidos a características sociodemográficas, de salud, optimismo, apoyo social, calidad de vida y estrés percibido de 200 pacientes de cáncer con una edad media de 50,5 años (DT = 13,05). El 73,5% son mujeres y el 26,5% son hombres. Resultados: La satisfacción con el apoyo recibido del personal sanitario (emocional, instrumental e informacional) y el optimismo se relacionan con una mayor calidad de vida y un menor estrés percibido. Los modelos predictivos indican que la satisfacción con el apoyo instrumental es el que más disminuye el estrés de los pacientes. Respecto a la calidad de vida los modelos predictivos indican que es el apoyo informacional el que más aumenta el estado global de salud, el apoyo emocional y el instrumental los que mejoran el funcionamiento y el apoyo instrumental es el que más reduce los síntomas de los pacientes. También se han encontrado diferencias de género, las mujeres perciben significativamente más estrés y peor calidad de vida que los hombres. Conclusión: El personal sanitario es una fuente de apoyo útil para las personas con cáncer y el optimismo mejora la calidad de vida de los pacientes oncológicos. De este estudio se resaltan importantes implicaciones prácticas.

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

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.

Lymphedema Surveillance and Patient-Reported Anxiety: Comparison Between Volumetric Assessment and Bioimpedance Analysis

Background: Lymphedema is a complication of breast cancer therapy associated with substantial anxiety. We designed a prospective, randomized study to assess the psychosocial impact of different surveillance methods for lymphedema. Methods and Results: In this open-label study of 38 women undergoing breast cancer surgery, we screened for lymphedema using traditional volumetric measurements (circumferential readings from the wrist to the axilla) versus bioimpedance spectroscopy (BIS) using electric current. The primary outcome measure was total anxiety measured by the Beck Anxiety Inventory, a 21-item questionnaire administered at preoperative, 6-week, 3-month, and 6-month postoperative visits (range 0-63 points). Outcome metrics were compared after adjustment for baseline anxiety. There were no differences in clinical characteristics or cancer therapies between groups, except for more reoperation for positive surgical margins in the BIS patients (5% vs. 32%, p = 0.036). Baseline anxiety, depression, and associated medical therapies were similar as well. Only one woman in each group developed lymphedema during the study. Anxiety was higher in the BIS group at baseline (mean Beck score 12.2 vs. 7.2, p < 0.001), but anxiety levels gradually declined by the end of the 6-month study in both groups, with no differences in adjusted anxiety scores between the two groups at any time point during follow-up (all p = NS). Conclusions: In this pilot study of women scheduled for breast cancer surgery, most subjects reported mild anxiety at baseline, and anxiety levels fell during continued lymphedema surveillance visits. There was no difference in patient-reported anxiety when surveillance was performed using standard volumetric versus BIS measurements.

Breast Cancer-Related Lymphedema in Hispanic Women: A Phenomenological Study

Introduction: Breast cancer-related lymphedema (BCRL), a long-term side effect of treatment, can occur at any point in time. With the extensive physical and psychological effects of BCRL, few studies have focused on the lived experience. The purpose of this study was to examine the lived experience of Hispanic women dealing with BCRL, particularly women of Mexican descent or origin. Method: Using interpretive phenomenology, 13 Hispanic women with BCRL, 42 to 80 years, were individually interviewed. Data analysis was conducted using interpretive reading of field notes, journal entries, and transcribed interviews. Results: Three central themes emerged from the findings, "sense of loss," "resignation to the new self," and "not knowing." Further subthemes highlight the physical, psychological, and spiritual aspects of living with BCRL. Discussion: Cultural awareness of the impact BCRL has on activities of daily living of Hispanic women should be part of a holistic plan of nursing care when caring for this population.

A Randomized Clinical Trial Comparing the Impact of a Web-Based Multimedia Intervention Versus an Educational Pamphlet on Patient Outcomes in Breast Cancer Survivors with Chronic Secondary Lymphedema

Objective: The purpose of this study was to evaluate the effects of a Web-based Multimedia Intervention (WBMI) for breast cancer-related lymphedema (BCRL) patients on symptom burden, function, psychological well-being, costs, and arm volume. Methods: Women with BCRL were randomized to intervention (n = 80) or control (n = 80) groups. The WBMI offered 12 modules, each of which took about 30 minutes to complete. The Pamphlet took about 2 hours to read. Data on symptom burden, psychological well-being, function, and costs were collected preintervention; and 1, 3, 6, and 12 months postintervention. A subgroup of 45 regional patients had arm extracellular fluid measured by bioimpedance at baseline and at 3, 6, and 12 months postintervention. Intervention perceived value was also captured. Results: A statistically significant difference (p = 0.011) was observed for rates of intervention completion, WBMI (58%), and Pamphlet (77%). With the exception of the number of biobehavioral symptoms (mood), no statistically significant differences between groups in symptom reduction were apparent between baseline and 1 or 12 months (effect sizes = 0.05-0.28, p > 0.05) based on the Lymphedema Symptom Intensity and Distress Scale-Arm (LSIDS-A). No statistically significant differences between the groups were observed for changes in other variables. The WBMI was perceived as providing better self-care information than the Pamphlet (p = 0.001). Conclusions: WBMI participants experienced improved biobehavioral symptoms and higher perceived quality of information. The lack of significant differences on other variables may be due to the high percentage of participants who did not complete the WBMI.

Illness perceptions and perceived stress in patients with advanced gastrointestinal cancer

OBJECTIVE

According to the Common-Sense Model of Self-Regulation, when faced with a health threat, we make cognitive and emotional assumptions about the illness. The aims of this study were to (a) examine the role of sociodemographic and disease-specific factors on illness perception and perceived stress and (b) test the association between perceived stress and illness perception in participants diagnosed with gastrointestinal cancer.

METHODS

Participants completed a battery of questionnaires including a Sociodemographic and Disease-Specific Questionnaire, the Illness Perception Questionnaire, Brief Version (Brief-IPQ), and the Perceived Stress Scale (PSS-14). Descriptive statistics, Pearson correlations, analysis of variance (ANOVA), and linear regression were performed to test the hypotheses.

RESULTS

Of the 627 participants, the mean age was 62 years (SD = 11); the majority were male (63.3%) and Caucasian (90.9%). Younger (F3,625 = 5.80, P < .01) and divorced or never married participants reported higher levels of perceived stress when compared with older and married participants (F4,618 = 3.52, P < .01). Younger participants (18-74 years old) reported more negative illness perceptions than older participants (75 years and older) (F3,511 = 4.08, P < .01). A weak, positive relationship between perceived stress and illness perceptions was observed (r = 0.22, P < .01), and illness perceptions predicted 36.1% of the variance of perceived stress.

CONCLUSIONS

Our findings suggest that participants who negatively perceived their illness experienced greater levels of perceived stress. Interventions that aim to adjust patients' illness perceptions in order to facilitate a reduction of stress and improvement in quality of life are needed.

The 10-Min Holistic Self-Care for Patients with Breast Cancer-Related Lymphedema: Pilot Randomized Controlled Study

About 20% of patients with breast cancer are likely to develop breast cancer-related lymphedema (BCRL) following an axillary clearance, and BCRL can be refractory or irreversible to treatment. The aim of this pilot randomized controlled study was to evaluate the effectiveness of a 10-min holistic self-care program for patients with BCRL in Japan. The intervention group (n = 22) practiced the BCRL self-care program including 1) modified Japanese Radio Taiso (Rajio Taiso, national calisthenics in Japan), 2) gentle arm exercises combined with deep breathing, 3) central lymphatic drainage, and 4) skin care using a traditional lymphatic drainage technique daily for 6 months, while the control group (n = 21) received usual care from their hospitals. There was significant group*time interaction in the relative edema volume and relative volume change of the hand, with the intervention group having the better outcome. The intervention group showed significant improvement in transepidermal water loss as well as the mental health component summary score of the SF-8, most of BCRL-related symptoms, self-care time and score, frequencies of exercise, self-lymphatic drainage and skin care, and perceived adherence and effectiveness to self-care, although we were unable to exclude the possibility of the Hawthorne effect. Notably, even in the control group, the self-care was similarly increased, but the significant improvements were detected only in transepidermal water loss on the forearm and upper arm, pain and coldness. In conclusion, the patients who practiced the holistic BCRL self-care for 6 months have shown greater improvement.

Early surveillance is associated with less incidence and severity of breast cancer-related lymphedema compared with a traditional referral model of care

Background

Bioimpedance spectroscopy (BIS) has enabled the early identification of breast cancer‐related lymphedema. In this study, differences in health service metrics and in the incidence of breast cancer‐related lymphedema are evaluated in an early surveillance model of care compared with a traditional referral model of care.

Methods

In a retrospective analysis of data from 753 women who underwent BIS measures between January 1, 2007 and December 31, 2016, 188 women were assigned to the “early surveillance” group if they began lymphedema monitoring presurgery (n = 121) or within 90 days postsurgery (n = 67), and 285 women were assigned to the “traditional referral” group if they began monitoring after 90 days postsurgery. Health service metrics were calculated as the time to the first BIS measure after 90 days postsurgery, the median follow‐up, and the number of health care visits. Lymphedema was diagnosed based on BIS measures.

Results

Women in the early surveillance group received lymphedema care significantly earlier than those in the traditional referral group. However, there was no difference in the number of visits per year to the clinic between groups. Significantly more women in the traditional referral group were diagnosed with clinical lymphedema (stage I‐III, 39 % vs 14%; P < .001) and with greater severity (stage II‐III, 24%) compared with those in the early surveillance group (4%).

Conclusions

The current findings support the adoption of an early prospective surveillance model of care using BIS for the early detection and management of breast cancer–related lymphedema.

The differences in health service metrics and in the incidence of breast cancer–related lymphedema are evaluated in an early surveillance model of care compared with a traditional referral model of care. The findings support the adoption of an early prospective surveillance model of care using bioimpedance spectroscopy for the early detection and management of breast cancer–related lymphedema.

Reducing Body Image-Related Distress in Women With Breast Cancer Using a Structured Online Writing Exercise: Results From the My Changed Body Randomized Controlled Trial

Purpose Breast cancer treatment adverse effects result in one in three survivors experiencing body image-related distress (BID) that negatively impacts on a woman's ability to recover after cancer and into survivorship. My Changed Body (MyCB) is a Web-based psychological intervention to alleviate BID and improve body appreciation in survivors of breast cancer (BCSs) through a single-session, self-compassion focused writing activity. This randomized controlled trial evaluated the impact of MyCB on BID and body appreciation in BCSs. The moderating effect of lymphedema status (affected or unaffected) and appearance investment (self-importance placed on personal appearance) and the mediating effect of self-compassion were evaluated. Patients and Methods Women (disease-free stage I to III BCSs who had experienced at least one negative event related to bodily changes after breast cancer) were randomly assigned to MyCB (n = 149) or an expressive writing control arm (n = 155). Primary outcomes were reduction in BID and improvement in body appreciation 1 week after intervention. Secondary outcomes included psychological distress (depression and anxiety) and self-compassion. Follow-up assessments occurred 1 week, 1 month, and 3 months after writing. Results Compliance with the MyCB intervention was 88%, and attrition was 9.2%. Intent-to-treat linear mixed models indicated that participants who received MyCB reported significantly less BID ( P = .035) and greater body appreciation ( P = .004) and self-compassion ( P < .001) than expressive writing participants. Intervention effects on BID were moderated by lymphedema status ( P = .007) and appearance investment ( P = .042). Self-compassion mediated effects on both primary outcomes. Therapeutic effects were maintained at 1 month (BID and body appreciation) and 3 months (body appreciation) after intervention. Significant reductions in psychological distress (1-month depression, P = .001; 1-week and 1-month anxiety, P = .007) were evident for MyCB participants with lymphedema. Conclusion This study supports the efficacy of MyCB for reducing BID and enhancing body appreciation among BCSs.

Effects of complex decongestive therapy on quality of life, depression, neuropathic pain, and fatigue in women with breast cancer-related lymphedema

Objectives

To investigate the effects of complex decongestive therapy (CDT) on the quality of life, depression, neuropathic pain, and fatigue in patients with breast cancer-related lymphedema (BCRL).

Patients and methods

Between March 2015 and June 2015, a total number of 60 patients (mean age 55.7±10.3 years; range 18 to 85 years) with BCRL were included in the study. Demographic data and previous medical records were recruited from medical files. The European Organization for Research and Treatment of Cancer Quality of Life- C30 (EORTC QLQ-C30) for the quality of life, the Brief Fatigue Inventory (BFI) for fatigue, Douleur Neuropathique 4 Questions (DN4) for neuropathic pain, and the Beck Depression Inventory (BDI) for the emotional status were used before and after the treatment. All patients received 20 sessions (one hour) of CDT for four weeks (five days per week).

Results

There was a statistically significant reduction in the volume of the involved limbs after the treatment (p<0.001). There was also a significant reduction in the general health and functional scores of the EORTC QLQ-C30 (p<0.001, p=0.004, respectively). The DN4, BFI, and BDI scores were significantly improved after the treatment (p<0.001, p=0.043, p=0.019, respectively).

Conclusion

Our study results suggest that CDT is an effective and safe method to achieve not only a significant volume reduction in the limbs involved by lymphedema, but also good outcomes in the management of other symptoms related to BCRL.

Racial Disparities in Emotional Distress Among Cancer Survivors: Insights from the Health Information National Trends Survey (HINTS)

The purpose of this study was to examine the impact of race, cancer history, and their interaction on emotional distress among a nationally representative sample of US adults. Data utilized for this analysis were obtained from the first, second, and fourth iterations of the fourth cycle of the Health Information National Trends Survey (HINTS). The study sample included 3959, 3630, and 3677 respondents for the years 2011, 2012, and 2014, respectively, for a total sample size of 11,266. A multivariable ordered logistic regression model was used to assess the relationship between emotional distress, race, and cancer history. The effect of cancer history on emotional distress was found to be moderated by race. Specifically, emotional distress was significantly higher among African American cancer survivors. Factors found to be protective against emotional distress included healthy lifestyle, older age, and higher income. Factors associated with high levels of emotional distress included poor general health status, low self-efficacy, and being female. The authors recommend the design, advancement, and implementation of evidence-based culturally sensitive interventions aimed at effectively screening and managing psychological distress symptoms, particularly among African American long-term cancer survivor patient populations.