Symptoms: Lymphedema

Bibliometric and visual analysis of breast cancer-related lymphedema: Knowledge structure, research status, and future trends

BACKGROUND

As the survival rate of breast cancer patients increases, breast cancer-related lymphedema (BCRL) has gradually received attention from researchers. This study aims to sort out and summarize the relevant studies on BCRL using bibliometric analysis and to explore future research trends.

METHODS

In this study, we searched the Web of Science Core Collection for publications related to BCRL, analyzed the publication trends by applying Microsoft Excel 2019, and analyzed authors, cited journals, journal mapping overlays, cited references, and keywords by applying CiteSpace (v.6.1.R3 Advanced). SCImago Graphica (v.1.0.39) was applied to analyze countries/regions, institutions, and published journals.

RESULTS

We finally included 1000 publications published between 2003 and July 4, 2024. Publications showed an upward trend, with the largest number of publications in 2023. USA is the most published country, Harvard University is the most published institution, Taghian AG is the most published author, and DiSipio T is the most cited author. Lymphatic Research and Biology is the most published journal, and Cancer-American Cancer Society is the most cited journal. "Breast cancer," "arm lymphedema," and "quality of life" were the most frequent keywords. Current research focuses on risk factors, treatment strategies, and patients' quality of life with BCRL. Future research will mainly focus on establishing BCRL evaluation protocols, improving treatment techniques, and early prevention and detection of BCRL.

CONCLUSION

Our study sorts out the current knowledge structure in the field and highlights the current state of research and future research directions. These findings inform researchers and clinicians.

Contemporaneous Symptom Networks of Breast Cancer-Related Upper Limb Lymphedema: A Network Analysis

BACKGROUND

Upper limb lymphedema (ULL) is a common and deliberating complication for breast cancer survivors (BCSs). Breast cancer survivors with ULL reported a wide range of symptoms. However, little is known about symptom patterns and interrelationships among them. This study was designed to explore symptom clusters and construct symptom networks of ULL-related symptoms among BCSs and to identify the core symptoms.

METHODS

This study is a secondary data analysis using datasets from three cross-sectional studies of BCSs in China. A total of 341 participants with maximum interlimb circumference ≥2 cm and complete responses in Part I of the Breast Cancer and Lymphedema Symptom Experience Index were included. Symptom clusters were identified through principal component analysis, and multiple linear regression analysis was employed to explore factors associated with severity of overall ULL-related symptoms. A contemporaneous network with 20 frequently reported symptoms were constructed after controlling for covariates.

RESULTS

Three symptom clusters, including lymph stasis symptom cluster, nerve symptom cluster, and movement limitation symptom cluster, were identified. Postsurgery time, axillary lymph node dissection, and radiotherapy were associated with the severity of ULL-related symptoms. Tightness (rs = 1.379; rscov = 1.097), tingling (rs = 1.264; rscov = 0.925), and firmness (rs = 1.170; rscov = 0.923) were the most central symptoms in both networks with and without covariates.

CONCLUSIONS

Breast cancer survivors with ULL experienced severe symptom burden. Tightness, tingling, and firmness were core symptoms of ULL among BCSs. Our findings demonstrated that the assessment and targeted intervention of specific core symptoms might help to relive effectively the burden of ULL-related symptom among BCSs.

In Vivo Dynamic and Static Analysis of Lymphatic Dysfunction in Lymphedema Using Near-Infrared Fluorescence Indocyanine Green Lymphangiography

BACKGROUND

Near-infrared fluorescence indocyanine green lymphangiography, a primary modality for detecting lymphedema, which is a disease due to lymphatic obstruction, enables real-time observations of lymphatics and reveals not only the spatial distribution of drainage (static analysis) but also information on the lymphatic contraction (dynamic analysis).

METHODS

We have produced total lymphatic obstruction in the upper limbs of 18 Sprague-Dawley rats through the dissection of proximal (brachial and axillary) lymph nodes and 20-Gy radiation (dissection limbs). After the model formation for 1 week, 9 animal models were observed for 6 weeks using near-infrared fluorescence indocyanine green lymphangiography by injecting 6-μL ICG-BSA (indocyanine green-bovine serum albumin) solution of 20-μg/mL concentration. The drainage pattern and leakage of lymph fluid were evaluated and time-domain signals of lymphatic contraction were observed in the distal lymphatic vessels. The obtained signals were converted to frequency-domain spectrums using signal processing.

RESULTS

The results of both static and dynamic analyses proved to be effective in accurately identifying the extent of lymphatic disruption in the dissection limbs. The static analysis showed abnormal drainage patterns and increased leakage of lymph fluid to the periphery of the vessels compared with the control (normal) limbs. Meanwhile, the waveforms were changed and the contractile signal frequency increased by 58% in the dynamic analysis. Specifically, our findings revealed that regular lymphatic contractions, observed at a frequency range of 0.08 to 0.13 Hz in the control limbs, were absent in the dissection limbs. The contractile regularity was not fully restored for the follow-up period, indicating a persistent lymphatic obstruction.

CONCLUSIONS

The dynamic analysis could detect the abnormalities of lymphatic circulation by observing the characteristics of signals, and it provided additional evaluation indicators that cannot be provided by the static analysis. Our findings may be useful for the early detection of the circulation problem as a functional evaluation indicator of the lymphatic system.

The effects of post-mastectomy lymphedema on balance, Kinesiophobia and fear of falling

The purpose of this study is to investigate the effects of post-mastectomy lymphedema on balance, kinesiophobia and fear of falling. A cross-sectional study with a control group. Seventy patients and 62 healthy volunteers were included. After determining the stage and limb volumes of the patients, all participants were evaluated with scales. There was a statistically significant difference in all scales compared to the control group (p < .001). There was a correlation between the stage of lymphedema and limb volume difference, balance, kinesiophobia, fear of falling (p < .001). In proportion with its stage and severity, lymphedema causes balance disorder, kinesiophobia and fear of falling.

Combined Complete Decongestive Therapy Reduces Volume and Improves Quality of Life and Functional Status in Patients With Breast Cancer-Related Lymphedema

BACKGROUND

The aim of this study was to evaluate the effects of complete decongestive therapy (CDT) in patients with breast cancer-related lymphedema (BCRL), in regard to volume reduction, functional status and quality of life (QoL).

METHODS

Fifty patients with unilateral BCRL were included. The demographic variables focusing on lymphedema were recorded. All patients received combined phase 1 CDT including skin-care, manual lymphatic drainage, multilayer bandaging and supervised exercises, 5 times a week for 3 weeks, as a total of 15 sessions. Patients were assessed by limb volumes and excess volumes according to geometric approximation derived from serial circumference-measurements of the limb, prior and at the end of third week. The functional disability was evaluated by quick disability of arm, shoulder and hand questionnaire (Q-DASH). QoL was assessed by the European Organization for Research and Treatment of Cancer Core Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and its breast-cancer-module (EORTC QLQ-BR23).

RESULTS

Fifty females with mean age of 53.22 ± 11.2 years were included. The median duration of lymphedema was 12 months. There were 22 patients in stage1, 26 in stage2 and 2 patients in stage3. The mean baseline limb and excess volumes were significantly decreased at the end of therapies (3262 ± 753 cm³ vs. 2943 ± 646.6 cm³ and 31.36% ± 16.5% vs. 19.12% ± 10.4%, pP= 0.000 respectively). The Q-DASH and EORTC QLQ-C30 and BR23 scores were also decreased significantly (pP< 0.05). The improvements in volumes were related negatively with the duration of lymphedema, and the stage of lymphedema.

CONCLUSION

In conclusion phase 1 CDT in a combined manner performed daily for 3 weeks, greatly reduces the volumes as well as improves the disability and QoL, especially when performed earlier.

Lymphedema: A Significant Risk Factor for Infection and Implant Failure After Total Knee Arthroplasty

BACKGROUND

Lymphedema is characterized by fluid buildup and swelling, leading to skin fibrosis and recurring soft-tissue infections. There is a paucity of data examining the impact of lymphedema in total knee arthroplasty (TKA). The purpose of this study was to review the outcomes of TKA in patients with lymphedema compared with a matched cohort with primary osteoarthritis.

METHODS

One hundred forty-four knees underwent primary TKA with a preceding diagnosis of ipsilateral lymphedema. The mean follow-up was 7 years. A blinded 1:2 match of knees with lymphedema to a group of knees without lymphedema undergoing primary TKA was performed. Matching criteria included sex, age, date of surgery, and body mass index. The mean follow-up for the comparison cohort was 8 years.

RESULTS

Lymphedema increased revision hazard ratio [HR] 7.60; P < 0.001), reoperation (HR, 2.87; P < 0.001), and infection (HR, 6.19; P < 0.001) in addition to periprosthetic fracture (P = 0.04) and tibial component loosening (P = 0.01). The mean time to infection trended toward later time points in knees with lymphedema (19 versus 2 months, P = 0.25).

DISCUSSION

Lymphedema increased the risk of revision, reoperation, and infection. These data highlight the need for appropriate patient counseling and the need for further investigation into the effects of preoperative and postoperative optimization of lymphedema management in the TKA setting.

LEVEL OF EVIDENCE

Therapeutic Level III.

Drivers of cost differences between US breast cancer survivors with or without lymphedema

PURPOSE

Breast cancer-related lymphedema is an adverse effect of breast cancer surgery affecting nearly 30% of US breast cancer survivors (BCS). Our previous analysis showed that, even 12 years after cancer treatment, out-of-pocket healthcare costs for BCS with lymphedema remained higher than for BCS without lymphedema; however, only half of the cost difference was lymphedema-related. This follow-up analysis examines what, above and beyond lymphedema, contributes to cost differences.

METHODS

This mixed methods study included 129 BCS who completed 12 monthly cost diaries in 2015. Using Cohen's d and multivariable analysis, we compared self-reported costs across 13 cost categories by lymphedema status. We elicited quotes about specific cost categories from in-person interviews with 40 survey participants.

RESULTS

Compared with BCS without lymphedema, BCS with lymphedema faced 122% higher mean overall monthly direct costs ($355 vs $160); had significantly higher co-pay, medication, and other out-of-pocket costs, lower lotion costs; and reported inadequate insurance coverage and higher costs that persisted over time. Lotion and medication expenditure differences were driven by BCS' socioeconomic differences in ability to pay.

CONCLUSIONS

Elevated patient costs for BCS with lymphedema are for more than lymphedema itself, suggesting that financial coverage for lymphedema treatment alone may not eliminate cost disparities.

IMPLICATIONS FOR CANCER SURVIVORS

The economic challenges examined in this paper have long been a concern of BCS and advocates, with only recent attention by policy makers, researchers, and providers. BCS identified potential policy and programmatic solutions, including expanding insurance coverage and financial assistance for BCS across socioeconomic levels.

"It still affects our economic situation": long-term economic burden of breast cancer and lymphedema

PURPOSE

Financial toxicity after breast cancer may be exacerbated by adverse treatment effects, like breast cancer-related lymphedema. As the first study of long-term out-of-pocket costs for breast cancer survivors in the USA with lymphedema, this mixed methods study compares out-of-pocket costs for breast cancer survivors with and without lymphedema.

METHODS

In 2015, 129 breast cancer survivors from Pennsylvania and New Jersey completed surveys on demographics, economically burdensome events since cancer diagnosis, cancer treatment factors, insurance, and comorbidities; and prospective monthly out-of-pocket cost diaries over 12 months. Forty participants completed in-person semi-structured interviews. GLM regression predicted annual dollar amount estimates.

RESULTS

46.5% of participants had lymphedema. Mean age was 63 years (SD = 8). Average time since cancer diagnosis was 12 years (SD = 5). Over 98% had insurance. Annual adjusted health-related out-of-pocket costs excluding productivity losses totaled $2306 compared to $1090 (p = 0.006) for those without lymphedema, or including productivity losses, $3325 compared to $2792 (p = 0.55). Interviews suggested that the cascading nature of economic burden on long-term savings and work opportunities, and insufficiency of insurance to cover lymphedema-related needs drove cost differences. Higher costs delayed retirement, reduced employment, and increased inability to access lymphedema care.

CONCLUSIONS

Long-term cancer survivors with lymphedema may face up to 112% higher out-of-pocket costs than those without lymphedema, which influences lymphedema management, and has lasting impact on savings and productivity. Findings reinforce the need for actions at policy, provider, and individual patient levels, to reduce lymphedema costs. Future work should explore patient-driven recommendations to reduce economic burden after cancer.

Patient recommendations for reducing long-lasting economic burden after breast cancer

Background

In the United States, patients who have breast cancer experience significant economic burden compared with those who have other types of cancers. Cancer‐related economic burden is exacerbated by adverse treatment effects. Strategies to resolve the economic burden caused by breast cancer and its adverse treatment effects have stemmed from the perspectives of health care providers, oncology navigators, and other subject‐matter experts. For the current study, patient‐driven recommendations were elicited to reduce economic burden after 1) breast cancer and 2) breast cancer‐related lymphedema, which is a common, persistent adverse effect of breast cancer.

Methods

Qualitative interviews were conducted with 40 long‐term breast cancer survivors who were residents of Pennsylvania or New Jersey in 2015 and were enrolled in a 6‐month observational study. Purposive sampling ensured equal representation by age, socioeconomic position, and lymphedema diagnosis. Semistructured interviews addressed economic challenges, supports used, and patient recommendations for reducing financial challenges. Interviews were coded, and representative quotes from the patient recommendations were analyzed and reported to illustrate key findings.

Results

Of 40 interviewees (mean age, 64 years; mean time since diagnosis, 12 years), 27 offered recommendations to reduce the economic burden caused by cancer and its adverse treatment effects. Nine recommendations emerged across 4 major themes: expanding affordable insurance and insurance‐covered items, especially for lymphedema treatment (among the 60% who reported lymphedema); supportive domestic help; financial assistance from diagnosis through treatment; and employment‐preserving policies.

Conclusions

The current study yielded 9 actionable, patient‐driven recommendations—changes to insurance, supportive services, financial assistance, and protective policies—to reduce breast cancer‐related economic burden. These recommendations should be tested through policy and programmatic interventions.

Nine actionable, patient‐driven recommendations are offered for reducing economic burden after breast cancer. Recommendations address changes to insurance, supportive services, financial assistance, and protective policies that can reduce economic burden after cancer.

Social factors matter in cancer risk and survivorship

Greater attention to social factors, such as race/ethnicity, socioeconomic position, and others, are needed across the cancer continuum, including breast cancer, given differences in tumor biology and genetic variants have not completely explained the persistent Black/White breast cancer mortality disparity. In this commentary, we use examples in breast cancer risk assessment and survivorship to demonstrate how the failure to appropriately incorporate social factors into the design, recruitment, and analysis of research studies has resulted in missed opportunities to reduce persistent cancer disparities. The conclusion offers recommendations for how to better document and use information on social factors in cancer research and care by (1) increasing education and awareness about the importance of inclusion of social factors in clinical research; (2) improving testing and documentation of social factors by incorporating them into journal guidelines and reporting stratified results; and (3) including social factors to refine extant tools that assess cancer risk and assign cancer care. Implementing the recommended changes would enable more effective design and implementation of interventions and work toward eliminating cancer disparities by accounting for the social and environmental contexts in which cancer patients live and are treated.

Cancer Pain Syndromes

Patients with cancer experience many acute and chronic pain syndromes, the identification of which may be helpful in the assessment and treatment of pain. Syndromes are defined by the relationship with the cancer, the pain pathophysiology, and the clinical characteristics of the pain. The most common pain syndromes are directly related to the tumor; bone pain syndromes are most common. Neuropathic pain syndromes may involve cancer-related injury at any level of the peripheral nervous system. Treatment-related pain syndromes may follow any type of antineoplastic therapy. This article reviews the phenomenology of common acute and chronic cancer pain syndromes.

Psychometric Evaluation of the Chinese Breast Cancer Prevention Trial Symptom Scale

BACKGROUND

Women with breast cancer experience a wide spectrum of symptoms after diagnosis and treatment. Symptoms experienced by this specific population might not be fully assessed using available traditional Chinese-language symptom measures.

OBJECTIVES

The aim of this study was to examine the latent constructs and psychometric properties of the Chinese Breast Cancer Prevention Trial (C-BCPT) Symptom Scale.

METHODS

Two hundred women with breast cancer were recruited in Taiwan. Psychometric properties, including construct validity, internal consistency, and test-retest reliability, of the C-BCPT Symptom Scale were tested after translating the original instrument.

RESULTS

A 21-item C-BCPT Symptom Scale, with 7 extracted factors accounting for 72.26% of the total variance, resulted from an exploratory factor analysis. Construct validity was confirmed by significant correlations between scores on the C-BCPT Symptom Scale and the Taiwan-version Short Form-36 Health Survey (r = -0.49 to -0.53)/Greene Climacteric Scale (r = 0.81). Reliability coefficients for the overall scale/6 extracted factors (Cronbach's α = 0.72-0.88) and test-retest reliability (intraclass correlation coefficients = 0.77-0.94) of the translated instrument were satisfactory, whereas 1 reliability coefficient for 1 extracted factor was inadequate (Cronbach's α = 0.57).

CONCLUSION

An interpretable structure with preliminary acceptable psychometric properties of the C-BCPT Symptom Scale was obtained; the C-BCPT can help traditional Chinese-speaking healthcare professionals perform adequate assessments of the symptoms experienced by women with breast cancer.

IMPLICATIONS FOR PRACTICE

The C-BCPT Symptom Scale can be used in clinical practice and research to assess symptoms experienced by this specific population or effects of related interventions.

Edema and pain reduction using transcutaneous electrical nerve stimulation treatment

[Purpose] The purpose of this study was to investigate the impact on the edema and pain when applying transcutaneous electrical nerve stimulation. [Subjects and Methods] Eleven patients who were diagnosed with lymphedema were selected as the subjects of the study. The experimental group received transcutaneous electrical nerve stimulation treatment on edema regions three times per week for four weeks. Surface tape measurement was used to measure changes in lower extremity edema. Pain intensity was measured using the visual analog scale. [Results] The edema decrements in the experimental group were significantly larger than those in the control group. The pain decrements in the experimental group were significantly larger than those in the control group. [Conclusion] In conclusion, application of transcutaneous electrical nerve stimulation was confirmed to be effective in reducing edema and pain.

Lymphatic mapping and preoperative imaging in the management of post-mastectomy lymphoedema

Early detection and diagnosis of upper extremity lymphoedema in patients after mastectomy and axillary lymph node clearance is important in order to treat disease before it is too advanced to achieve favourable outcomes. Patients with disease refractory to conservative management can be efficiently assessed for diagnosis and surgical intervention using advanced lymphatic imaging techniques. The current paper highlights the more readily available of these: lymphoscintigraphy, indocyanine green (ICG) lymphangiography and immunofluorescence, magnetic resonance lymphangiography (MRL) and computed tomographic lymphangiography in combination or individually. With such techniques, both diagnosis and treatment of lymphoedema has become more readily achieved, with lymphatico-venous and lymphatico-lymphatic anastomosis, and lymph node transfer now increasingly common undertakings.

Race or Resource? BMI, Race, and Other Social Factors as Risk Factors for Interlimb Differences among Overweight Breast Cancer Survivors with Lymphedema

Introduction. High BMI is a risk factor for upper body breast cancer-related lymphedema (BCRL) onset. Black cancer survivors are more likely to have high BMI than White cancer survivors. While observational analyses suggest up to 2.2 times increased risk of BCRL onset for Black breast cancer survivors, no studies have explored race or other social factors that may affect BCRL severity, operationalized by interlimb volume difference (ILD). Materials and Methods. ILD was measured by perometry for 296 overweight (25 > BMI < 50) Black (n = 102) or White (n = 194) breast cancer survivors (>6 months from treatment) in the WISER Survivor trial. Multivariable linear regression examined associations between social and physical factors and ILD. Results. Neither Black race (-0.26, p = 0.89) nor BMI (0.22, p = 0.10) was associated with ILD. Attending college (-4.89, p = 0.03) was the strongest factor associated with ILD, followed by having more lymph nodes removed (4.75, p = 0.01), >25% BCRL care adherence (4.10, p = 0.01), and years since treatment (0.55, p < 0.001). Discussion. Neither race nor BMI was associated with ILD among overweight cancer survivors. Education, a proxy for resource level, was the strongest factor associated with greater ILD. Tailoring physical activity and weight loss interventions designed to address BCRL severity by resource rather than race should be considered.