Retrospective trial of complete decongestive physical therapy for lower extremity secondary lymphedema in melanoma patients

Health-related Quality of Life Measurement Tools for Lymphedema: A Review of the Literature

Lymphedema can significantly affect patients' health-related quality of life (HRQoL). Various quality of life scales have been developed to assess the extent of the disease burden. The purpose of this study is to review various HRQoL instruments that have been used in lymphedema studies and compare their qualities against the COSMIN checklist.

Methods

A systematic literature review search was conducted for clinical lymphedema studies published between January 1, 1984, and February 1, 2020, using Pubmed database. All clinical lymphedema studies which used HRQoL instruments as outcome measures were identified.

Results

One thousand seventy-six studies were screened-of which, 288 studies were individually assessed. Thirty-nine HRQoL instruments were identified in these clinical lymphedema studies. Of these, there are eight lymphedema-specific questionnaires that cover all HRQoL domains, all of which have been validated for use in lymphedema. We contrasted the two most popular questionnaires [LYMQOL and Upper Limb Lymphedema (ULL)-27] and compared their features.

Conclusion

There is currently no ideal lymphedema HRQoL measurement tool available based on the COSMIN criteria. However, our review suggested that LYMQOL and ULL-27 are the most used and most validated instruments at present, but each has their own limitations. We recommend the use of LYMQOL and ULL-27 for future studies to allow direct HRQoL comparison to current literature. Further research is required to develop an optimal HRQoL questionnaire that can ultimately become the gold standard HRQoL instrument for lymphedema.

The efficacy of change in limb volume on functional mobility, health-related quality of life, social appearance anxiety, and depression in patients with lower extremity lymphedema

Objectives

This study aims to investigate the impact of change in limb volume on the levels of functional mobility, health-related quality of life, social appearance anxiety, and depression before and after complex decongestive physiotherapy in patients with lower extremity lymphedema.

Method

Twenty-seven patients with unilateral lower extremity lymphedema were included. The treatment period was 20 sessions. The outcome measures were the limb volume, the Timed Up and Go test, the Short Form-36, the Social Appearance Anxiety Scale, and the Beck Depression Inventory.

Results

A statistically significant decrease in the limb volume ( p < 0.001) and statistically significant improvements in the Timed Up and Go test performance ( p < 0.001), the Short Form-36 Physical Component Summary score ( p < 0.01), the Social Appearance Anxiety Scale score ( p < 0.001), and the Beck Depression Inventory score ( p < 0.001) were found. No statistically significant difference was found on the Short Form-36 Mental Component Summary score ( p > 0.05).

Conclusion

The decrease in the limb volume improves the functional mobility, physical health-related quality of life, social appearance anxiety, and depression in patients with lower extremity lymphedema, but not the mental health-related quality of life.

Associations of Physical Activity and Exercise with Health-related Outcomes in Patients with Melanoma During and After Treatment: A Systematic Review

Purpose:

Although exercise medicine is recommended to counter treatment-related side-effects and improve health-related outcomes of patients affected by different cancers, no specific recommendations exist for patients with melanoma. As a result, we systematically examined the current evidence regarding the effects of physical activity and exercise on objectively-measured and patient-reported outcomes among patients with melanoma.

Methods:

Searches were conducted in PubMed, CINAHL, EMBASE, SPORTDiscus, and Web of Science databases. This review included published data involving physical activity or exercise and objectively-measured or patient-reported outcomes of patients with cutaneous melanoma. The quality of included studies was assessed using the McMaster University Critical Appraisal Tool for Quantitative Studies.

Results:

Six studies including 882 patients with melanoma were included. Studies presented heterogeneity of design with 2 cross-sectional surveys, 2 retrospective analyses, and 2 non-randomized intervention trials. No statistically significant change in quality of life, fatigue, physical function, cardiorespiratory fitness, body composition, psychological distress, cognitive function, or treatment-related side-effects were attributable to physical activity or exercise. Importantly, physical activity or exercise during melanoma treatment or into survivorship did not adversely impact patients/survivors.

Conclusion:

In summary, physical activity or exercise did not adversely impact quality of life, objectively-measured or patient-reported outcomes in patients with melanoma. In addition, there is a paucity of quality studies examining the effects of physical activity or exercise on patients with melanoma throughout the cancer care continuum.

Patient-Reported Outcome Measures in Lymphedema: A Systematic Review and COSMIN Analysis

BACKGROUND

Lymphedema is a chronic and debilitating condition that affects many cancer survivors. Patient-reported outcome measures (PROMs) can give valuable insight into the impact of lymphedema on a patient's quality of life and can play an essential role in treatment decisions. This study aims to (1) identify PROMs used to assess health-related quality of life (HRQoL) in patients with lymphedema; and (2) assess the quality of the lymphedema-specific PROMs.

METHODS

We performed a systematic search to identify articles on lymphedema, quality of life, and PROMs. An overview was created of all PROMs used to assess HRQoL in patients with lymphedema. The methodological quality of the lymphedema-specific PROMs was assessed using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) criteria.

RESULTS

A total of 235 articles met the inclusion criteria, of which 200 described studies using one or more PROMs as an outcome measure in patients with lymphedema. The other 35 studies described the development and/or validation of a lymphedema-specific PROM. The COSMIN assessment demonstrated that none of these PROMs met all quality standards for development.

CONCLUSION

The use of PROMs in lymphedema is increasing; however, based on our findings, we cannot fully support the use of any of the existing instruments. A well-developed lymphedema-specific PROM, based on patient input, is needed to gain better insight into the impact of this condition, and can be used to measure the effect of possible medical and surgical treatments.

Is the Effect of Complex Decongestive Therapy the Same for Primary and Secondary Lower Lymphedema?

Background: The aim was to compare edema and quality of life (QOL) after complex decongestive therapy (CDT) in two types of lymphedema: primary lower limb lymphedema (PLL) and secondary lower limb lymphedema (SLL). Methods and Results: Participants with PLL (n = 20) and SLL (n = 20) were recruited in this prospective single-blinded study. Patients in both groups were treated with CDT for 4 weeks 5 days a week. The amount of edema in their lower extremities was assessed by circumference measurement. The QOL for the patients was evaluated by a Lymphedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphedema (Lymph-ICF-LL) before and immediately following the therapy. There was no significant difference in the volume reductions between the two groups (p > 0.05). Overall initial QOL was significantly lower in patients with PLL than in patients with SLL scores. Post-CDT differed significantly between PLL and SLL groups, QOL was significantly lower for patients with PLL than for patients with SLL scores (p < 0.05). When the changes in both groups were examined, it was found that their QOL increased after the treatment (p < 0.05). Conclusions: While there was no difference in the amount of edema in both groups, the results of patients with SLL were more positive than patients with PLL in terms of QOL. Lymphedema therapists should approach patients with different therapeutic considerations specific to each type of lymphedema before using CDT in clinical practice.

The Reliability and Validity of Lymphedema Quality of Life Questionnaire-Leg in Turkish Patients with Lower Limb Lymphedema

Background: Accurate information on quality of life (QoL) outcomes among patients with lower limb lymphedema (LLL) is substantially needed to capture lymphedema-specific impairments and make clinical decisions for the management of this suffering condition. No specific instrument for QoL in patients with LLL has been translated to Turkish and validated. This study aims to adapt the Lymphedema Quality of Life Questionnaire-leg (LYMQOL-Leg) to Turkish and to test its reliability and validity in patients with LLL. Methods and Results: The Turkish-LYMQOL-Leg was obtained using forward-backward translation and administered to 138 patients with LLL, along with Short Form 36 (SF-36), and Lower Extremity Functional Scale (LEFS), between May 2015 and October 2017. A test-retest interval of 7 days was used to assess the reliability. Descriptive analysis was applied for demographic variables and validation studies were conducted by means of construct validity using Spearman's rank correlation coefficient. Internal consistency and test-retest reliability were assessed using Cronbach's α and intraclass correlation coefficient (ICC), respectively. All patients with LLL completed the questionnaires. The mean age and lymphedema duration were 52.01 ± 14.73 years and 95.6 ± 108.6 months, respectively. Internal consistency and test-retest reliability of the Turkish-LYMQOL-Leg were good with Cronbach's α (0.85-0.90) and test-retest ICC (0.68-0.85). External construct validity was highly confirmed by expected correlations with comparator scales SF-36 and LEFS (p < 0.01). Conclusion: The Turkish version of the LYMQOL-Leg is a valid and reliable tool for evaluating QoL in patients with LLL that can readily be applied as an outcome measure both in clinical practice and research studies.

Quality of life measurement in skin cancer patients: literature review and position paper of the European Academy of Dermatology and Venereology Task Forces on Quality of Life and Patient Oriented Outcomes, Melanoma and Non-Melanoma Skin Cancer

The European Academy of Dermatology and Venereology (EADV) Task Forces (TFs) on Quality of Life (QoL) and Patient Oriented Outcomes, Melanoma and Non-Melanoma Skin Cancer (NMSC) present a review of the literature and position statement on health-related (HR) QoL assessment in skin cancer patients. A literature search was carried out to identify publications since 1980 that included information about the impact of SC on QoL. Generic, dermatology-specific, cancer-specific, SC-specific, facial SC-specific, NMSC-specific, basal cell carcinoma-specific and melanoma-specific QoL questionnaires have been used to assess HRQoL in SC patients. HRQoL was assessed in the context of creation and validation of the HRQoL instruments, clinical trials, comparison of QoL in SC and other cancers, other diseases or controls, HRQoL assessment after treatment, comorbidities, behaviour modification, predictors of QoL and survival, supportive care needs, coping strategies and fear of cancer recurrence. The most widely used instruments for HRQoL assessment in SC patients are the European Organisation for Research and Treatment of Cancer Core Questionnaire (EORTC QLQ-C30), the Functional Assessment of Cancer Therapy-Melanoma (FACT-M), Skin Cancer Index (SCI), Short Form 36 Item Health Survey (SF-36) and the Dermatology Life Quality Index (DLQI). The TFs recommend the use of the cancer-specific EORTC QLQ-C30, especially in late stages of disease, and the melanoma-specific FACT-M and SC-specific SCI questionnaires. These instruments have been well validated and used in several studies. Other HRQoL instruments, also with good basic validation, are not currently recommended because the experience of their use is too limited. Dermatology-specific HRQoL instruments can be used to assess the impact of skin-related problems in SC. The TFs encourage further studies to validate HRQoL instruments for use in different stages of SC, in order to allow more detailed practical recommendations on HRQoL assessment in SC.

Putting evidence into practice: cancer-related lymphedema

Cancer-related lymphedema is a progressive and chronic syndrome of abnormal swelling and multiple symptoms resulting from cancer treatment. Even with modern medical advances, lymphedema remains a major health problem affecting thousands of cancer survivors. To provide healthcare professionals with evidence-based clinical practice guidelines for lymphedema treatment and management, a systematic review was conducted to evaluate 75 selected articles from 2009-2014 by the Oncology Nursing Society Putting Evidence Into Practice lymphedema team. Findings of the systematic review support complete decongestive therapy, compression bandages, and compression garments with highest evidence for best clinical practice. Weight management, full-body exercise, information provision, prevention, and early intervention protocols are likely to be effective for clinical practice. Historic recommendations for activity restriction and avoidance of aerobic and resistive exercises that limit cancer survivors' daily lives have been challenged with more evidence. Cancer survivors may not need to restrict activities such as resistive or aerobic exercises and weightlifting with gradual exercise progression. Future research should focus on providing high-level evidence using randomized clinical trials with larger samples and studying lymphedema beyond breast cancer.

Systematic review of quality of life and patient reported outcomes in patients with oncologic related lower extremity lymphedema

BACKGROUND

Lower limb lymphedema (LLL) is a common complication of cancer treatment. The disease is chronic and progressive with no cure. Although a common and significant source of morbidity, the impact of this condition on health-related quality of life (HRQOL) has only recently been addressed. In effort to identify valid treatment strategies for LLL, we performed a systematic review, identifying studies describing HRQOL outcomes in patients with LLL secondary to cancer.

METHODS AND RESULTS

Seven medical databases were searched to identify reports using validated Patient Reported Outcome (PRO) instruments on patients with cancer-related LLL. Studies were classified by levels of evidence set by the Agency for Healthcare Research and Quality (AHRQ) and evaluated using the Efficace criteria. 25 studies were identified, 6 met inclusion criteria. Levels of evidence included: no level I studies, level II (n=3), level III (n=1), and level 4 (n=2). 50% of studies were compliant with the Efficace criteria. 5 PRO HRQOL instruments were used, but only 1 was specific to cancer-related lymphedema. Treatment strategies assessed included complete decongestive physiotherapy (CDP), exercise, and compression bandaging. CDP yielded significant enhancements in HRQOL.

CONCLUSIONS

There is a deficit in high quality studies for HRQOL in patients with LLL secondary to cancer. Furthermore, of the studies present, most did not conform to guidelines set for assessment of HRQOL, nor did they use lymphedema condition specific PRO instruments. New measures specific to assessing LLL are necessary to gain more accurate evaluation of how this debilitating disorder affects HRQOL.