Weight lifting in patients with lower-extremity lymphedema secondary to cancer: a pilot and feasibility study

Lymphedema self-assessment among endometrial cancer survivors

PURPOSE

Lower extremity lymphedema (LEL), which causes ankle, leg, and feet swelling, poses a significant challenge for endometrial cancer survivors, impacting physical functioning and psychological well-being. Inconsistent LEL diagnostic methods result in wide-ranging LEL incidence estimates.

METHODS

We calculated the cumulative incidence of LEL based on survivor-reported Gynecologic Cancer Lymphedema Questionnaire (GCLQ) responses in addition to survivor- and nurse-reported leg circumference measurements among a pilot sample of 50 endometrial cancer survivors (27 White, 23 Black) enrolled in the ongoing population-based Carolina Endometrial Cancer Study.

RESULTS

Self-leg circumference measurements were perceived to be difficult and were completed by only 17 survivors. Diagnostic accuracy testing measures (sensitivity, specificity, positive and negative predictive value) compared the standard nurse-measured ≥ 10% difference in leg circumference measurements to GCLQ responses. At a mean of ~11 months post-diagnosis, 54% of survivors met established criteria for LEL based on ≥ 4 GCLQ cutpoint while 24% had LEL based on nurse-measurement. Percent agreement, sensitivity, and specificity approximated 60% at a threshold of ≥ 5 GCLQ symptoms. However, Cohen's kappa, a measure of reliability that corrects for agreement by chance, was highest at ≥ 4 GCLQ symptoms (κ = 0.27).

CONCLUSION

Our findings emphasize the need for high quality measurements of LEL that are feasible for epidemiologic study designs among endometrial cancer survivors. Future studies should use patient-reported survey measures to assess lymphedema burden and quality of life outcomes among endometrial cancer survivors.

Effects of exercise on lower limb lymphedema in gynecologic cancer: A systematic review and meta-analysis

PURPOSE

A systematic review investigated the effectiveness of physical activity in alleviating lower limb lymphedema among patients with gynecological cancer after surgery.

METHODS

A systematic review of randomized controlled trials and quasi-experimental designs was conducted. Six databases, Cinahl, Cochrane, Embase, Medline, Scopus, and Web of Science, were searched for relevant publications from inception to October 2022 and updated in January 2024. RevMan software was used to perform meta-analysis using a random-effects model.

RESULTS

Seven studies (5 randomized controlled trials) containing 261 subjects were synthesized. The risk of bias was low in the included studies. The exercise interventions for lower limb lymphedema included active, aerobic, aquatic, and weight-lifting exercises. Meta-analyses showed that active exercise had no effect on lymphedema symptoms of limb volume, pain, and heaviness. However, the effectiveness of exercise on limb volume had subthreshold borderline significance in 2 studies (standardized mean difference = 0.43, 95% confidence interval - 0.01, 0.88; I2 = 0%, p = 0.06). Three studies found that lymphedema symptoms were significantly improved after exercise interventions. The adherence rate of the exercise was 77-100%, with the only complication being cellulitis.

CONCLUSIONS

Although the meta-analysis does not reveal a significant effect, the systematic review study demonstrated that exercise is feasible, safe, and has a clinical effect on alleviating lymphedema-related symptoms of women following gynecological cancer surgery.

Postural stability, spinal alignment, mobility, and postural competency in women with unilateral lower extremity lymphedema after radical hysterectomy following gynecologic cancer: A case-control study

PURPOSE

To compare postural stability, spinal alignment, mobility, and postural competency in women with unilateral lower extremity lymphedema after radical hysterectomy following gynecologic cancer with a matched control group.

METHODS

Twenty-seven women with unilateral lower extremity lymphedema (lymphedema group, age: 54.14 ± 5.80 years) and 30 healthy women (control group, age: 51.90 ± 6.54 years) were included. The lymphedema severity was evaluated with circumferential measurements. Postural stability with the Biodex Balance System SD and the spinal alignment, mobility, and postural competency with the Spinal Mouse device were assessed.

RESULTS

In the lymphedema group, it was found that 3.7% of the women had mild lymphedema, 7.4% had moderate lymphedema, and 88.9% had severe lymphedema. Static eyes open (EO) (overall, medio-lateral and antero-posterior) and eyes closed (EC) (antero-posterior) stability scores and dynamic EO and EC stability scores (overall and antero-posterior) were detected to be higher in the lymphedema group than in the controls (p < 0.05). Spinal mobility and postural competency scores were lower in the lymphedema group than in the control group (p < 0.05). In other parameters, there were no significant differences between the groups (p > 0.05).

CONCLUSION

Decreased postural stability, spinal mobility, and postural competency were detected in women with unilateral lower extremity lymphedema; however, no difference was seen in spinal alignment. These changes should be taken into account in the assessment and the treatment of unilateral lower extremity lymphedema.

Evaluation of incontinence and lymphedema in gynecological cancer patients along with their impact on the quality of life

PURPOSE

The aim of this study is to evaluate the patients who developed both urinary incontinence and lymphedema in gynecological cancer survivors and to investigate the impact of these conditions on the quality of life among these patients.

METHODS

Our study included 56 patients who have lymphedema and urinary incontinence which started within first 2 years after surgery for gynecological cancer. We evaluated the presence of urinary incontinence by Overactive Bladder Assessment Tool (OABT) and Urogenital Distress Inventory (UDI). Incontinence Impact Questionnaire (IIQ-7) was used to assess the quality of life.

RESULTS

OABT and UDI scores were found to be statistically significantly increased in patients with grade 3 lymphedema (respectively p: 0.006, p: 0.008). A statistically significant difference was found between lymphedema grade 1-2-3 patients in terms of IIQ-7 (p:0.002). The difference was statistically significant between the grade 1-3 (p:0.001) and grade 2-3 (p:0.013) groups. We did not find any correlation between age, type of cancer, radiotherapy, and urinary incontinence. There was a statistically significant positive correlation between BMI and OABT, UDI scores (respectively, r = 0.43, p = 0.001; r = 0.38, p = 0.003).

CONCLUSION

It was concluded that there was a relationship between urinary incontinence and grade 3 lymphedema in gynecological cancer survivors. Grade 3 lymphedema increases urinary incontinence and worsens daily living functions in these patients.

Usability evaluation of a novel compact pneumatic compression device for the treatment of lymphoedema: Pilot study

Objective

To perform a preliminary usability evaluation of a novel, compact pneumatic compression device in patients with lymphoedema.

Methods

This open-label, single-arm trial had two phases: the first focused on the fitting of the pneumatic compression device (Aria Free^TM, Aria Health, San Diego CA, USA) and the second focused on evaluating the comfort of the entire system during a 45-min usage period. Both phases were conducted in a monitored clinical environment. Patients aged ≥18 years with a diagnosis of lower limb lymphoedema who had used a pneumatic compression device for ≥3 months were eligible. Patients rated subjective fit, comfort and usability on an 11-point Likert scale (where higher scores indicate better fit/comfort/usability). The truncated cone method was used to infer limb volume before and after therapy in phase 2.

Results

Twenty-four patients were screened, and 15 were enrolled (80% female; mean age 62 years); all completed both study phases. Patients rated the garment as easy to set up and fit (median score 6.5), and all reported that the therapy was comfortable (median score 10; p < 0.001 vs. reference score of 6). There was a 1.85% reduction in limb volume after device use for 45 min (p = 0.018 vs. before therapy). No safety issues were identified.

Conclusions

The new pneumatic compression device fitted well, was easy to use and reduced leg oedema.

The Effect of Exercise for the Prevention and Treatment of Cancer-Related Lymphedema: A Systematic Review with Meta-analysis

INTRODUCTION

The purpose of this systematic review and meta-analysis was to evaluate the effects of exercise on (i) the prevention of cancer-related lymphedema (CRL) and (ii) the treatment of CRL, lymphedema-associated symptoms, and other health outcomes among individuals with CRL.

METHODS

An electronic search was undertaken for exercise studies measuring lymphedema and involving individuals at risk of developing or with CRL. The Effective Public Health Practice Project Quality scale was used to assess study quality, and overall quality of evidence was assessed using the Grading of Recommendation, Assessment, Development and Evaluation approach. Meta-analyses were performed to evaluate effects of exercise on CRL incidence, existing CRL status, lymphedema-associated symptoms, and health outcomes.

RESULTS

Twelve studies ( n = 1955; 75% moderate-high quality) and 36 studies ( n = 1741; 58% moderate-high quality) were included in the prevention and treatment aim, respectively. Relative risk of developing CRL for those in the exercise group compared with the nonexercise group was 0.90 (95% confidence interval (CI), 0.72 to 1.13) overall and 0.49 (95% CI, 0.28 to 0.85) for those with five or more lymph nodes removed. For those with CRL in the exercise group, the standardized mean difference (SMD) before to after exercise of CRL was -0.11 (95% CI, -0.22 to 0.01), and compared with usual care postintervention, the SMD was -0.10 (95% CI, -0.24 to 0.04). Improvements after intervention were observed for pain, upper-body function and strength, lower-body strength, fatigue, and quality of life for those in the exercise group (SMD, 0.3-0.8; P < 0.05).

CONCLUSIONS

Findings support the application of exercise guidelines for the wider cancer population to those with or at risk of CRL. This includes promotion of aerobic and resistance exercise, and not just resistance exercise alone, as well as unsupervised exercise guided by symptom response.

Breast cancer-related lymphoedema and resistance exercise: An evidence-based review of guidelines, consensus statements and systematic reviews

AIMS AND OBJECTIVES

Breast cancer-related lymphoedema (BCRL) is a side effect of cancer treatment and can be alleviated by resistance exercise. This systematic, evidence-based review examined the existing best evidence on resistance exercise for BCRL to accurately describe the current status of the field and offer recommendations for clinicians.

METHODS

This review adheres to the PRISMA guidelines. Clinical practice guidelines, consensus documents, systematic reviews and other related evidence-based resources about resistance exercise for BCRL were retrieved through the English databases and guideline websites. The publication data limit was set to December 2020. The following search terms were used: 'breast cancer/breast neoplasm/breast carcinoma/breast tumor/breast malignancy, lymphedema/swelling/edema/lymphoedema, resistance/weight/strength training, best practice/clinical practice/guideline/consensus documents'. The quality of the included studies was evaluated by two authors independently using AGREE II and AMSTAR II tools. Evidence-based recommendations on resistance exercise relevant for BCRL were synthesised and categorised.

RESULTS

Twenty two articles (seven guidelines, four consensus documents and eleven systematic reviews) were included. The overall quality of the eleven eligible guidelines and consensus documents was moderate to high according to the AGREE II criteria. The quality of the eleven systematic reviews was critically low to high according to the AMSTAR criteria. Six clinical topics involving 43 recommendations were identified. Recommendations were categorised by safety of resistance training, effectiveness of resistance training, evaluation prior to resistance exercise, resistance exercise prescription, resistance training outcome index and points for attention.

CONCLUSIONS

This study summarises 43 recommendations for resistance training for BCRL and provides guidance for clinicians. Based on randomised trials and systematic reviews published in recent years, there is an urgent need to update the guidelines and consensus documents in terms of topics, for example effectiveness of resistance training and resistance training outcome index.

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.

Association of Lower Extremity Lymphedema With Physical Functioning and Activities of Daily Living Among Older Survivors of Colorectal, Endometrial, and Ovarian Cancer

Importance

Lower extremity lymphedema (LEL) is associated with decreased physical functioning (PF) and activities of daily living (ADLs) limitations. However, the prevalence of LEL in older survivors of cancer is unknown.

Objectives

To examine LEL among older female survivors of colorectal, endometrial, or ovarian cancer and investigate the association of LEL with PF and ADLs.

Design, Setting, and Participants

This secondary analysis of the Women's Health Initiative (WHI) Life and Longevity After Cancer (LILAC) study was conducted using data from postmenopausal women enrolled at 40 US centers. Participants were women who had a prior diagnosis of endometrial, colorectal, or ovarian cancer and who had completed the WHI LILAC baseline and year 1 follow-up questionnaires as of September 2017.

Exposures

The 13-item Lower Extremity Lymphedema Screening Questionnaire in Women was used to determine LEL (ie, score ≥5).

Main Outcomes and Measures

Validated surveys were used to assess PF and ADLs.

Results

Among 900 older women diagnosed with endometrial, colorectal, or ovarian cancer, the mean (SD) age was 78.5 (5.9) years and the mean (range) time since cancer diagnosis was 8.75 (1.42-20.23) years. Overall, 292 women (32.4%) reported LEL, with the highest LEL prevalence among survivors of ovarian cancer (38 of 104 women [36.5%]), followed by survivors of endometrial cancer (122 of 375 women [32.5%]) and colorectal cancer (132 of 421 women [31.4%]). Compared with women without LEL, women with LEL had a PF score that was lower by a mean (SE) 16.8 (1.7) points (P < .001) and higher odds of needing help with ADLs (odds ratio [OR], 2.45; 95% CI, 1.64-3.67). In the association of LEL with PF, the mean (SE) decrease in PF score was greatest among survivors of colorectal cancer (-21.8 [2.6]) compared with survivors of endometrial cancer (-13.3 [2.7]) and ovarian cancer (-12.8 [5.2]). Additionally, among survivors of colorectal cancer, LEL was associated with increased odds of needing help with ADLs (OR, 3.59; 95% CI, 1.94-6.66), while there was no such association among survivors of endometrial cancer or ovarian cancer. However, there were no interaction associations between LEL and cancer type for either outcome. Additionally, the overall mean (SE) difference in PF between women with and without LEL was greater among those aged 80 years and older (-19.4 [2.6] points) vs those aged 65 to 79 years (-14.9 [2.2] points). However, among survivors of colorectal cancer, the mean (SE) difference in PF score was greater among women aged 65 to 79 years (-22.9 [3.7] points) vs those aged 80 years or older (-20.8 [3.7] points) (P for 3-way interaction = .03).

Conclusions and Relevance

This study found that nearly one-third of older female survivors of colorectal, endometrial, or ovarian cancer experienced LEL and that LEL was associated with decreased PF and increased odds of needing help with ADLs. These findings suggest that clinicians may need to regularly assess LEL among older survivors of cancer and provide effective interventions to reduce LEL symptoms and improve PF for this population.

Evidence-Based Practice Guideline for the Management of Lymphedema Proposed by the Japanese Lymphedema Society

Background: Secondary lymphedema mostly occurs as an aftereffect of cancer treatment, and it is estimated that 100,000-150,000 patients are affected in Japan. An estimated 3500 patients, develop lymphedema of the lower and upper extremities each year secondary to uterine and breast cancer treatment. Medical reimbursement was first instituted in April 2008 by the Ministry of Health, Labour and Welfare in Japan. Since 2008, we have developed guidelines regarding treatment options for patients with lymphedema based on scientific evidence. This is the third edition of the guidelines established by the Japanese Lymphedema Society (JLES), published in 2018. The JLES Practice Guideline-Making Committee (PGMC) developed 21 clinical questions (CQs). Methods and Results: A review of these 15 CQs was performed in accordance with the methodology for establishing clinical guidelines. The 15 recommendations for each of these CQs were developed and discussed until consensus by the PGMC was reached. Moreover, outside members who had no involvement in these guidelines evaluated the contents using the Appraisal of Guidelines for Research and Evaluation (AGREE) II reporting checklist. Conclusion: These guidelines have been produced for the adequate management of lymphedema by doctors and other medical staff on the lymphedema management team of medical institutes, including nurses, physical technicians, and occupational therapists.

Postural differences in the immediate effects of active exercise with compression therapy on lower limb lymphedema

PURPOSE

Although regarded as an important treatment for lymphedema, the therapeutic effects of active exercise with compression therapy (AECT) are supported by little evidence. The purpose of this study was to determine the relative benefits of AECT with different postures for patients with lower limb lymphedema (LLL).

METHODS

Eighteen women with LLL secondary to surgical treatment of gynecological cancer, completed (1) AECT in a seated position (seated AECT), (2) AECT in a supine position (supine AECT), and (3) compression-only therapy in a supine position (CT) in this randomized, controlled, crossover trial. AECT was performed on a bicycle ergometer while wearing elastic compression bandages. Each intervention was performed for 15 min, and the three conditions were separated by a 1-week washout period. Lower-limb volumes were evaluated using a Perometer^TM sensor (Pero-system, Wuppertal, Germany), and symptom severity was assessed before and after each intervention using a visual analog scale (pain, heaviness) and palpation (pitting, stiffness). The effects of the interventions were estimated using linear mixed-effect models.

RESULTS

The magnitude of limb volume decreases differed significantly among the interventions, with a greater decrease after supine AECT than after CT. Pre-intervention pitting severity and skin stiffness were significantly correlated with the magnitude of volume decrease after all interventions and after AECT in the supine position, respectively.

CONCLUSIONS

Supine AECT using a bicycle ergometer has marked immediate effects to decrease the fluid volume of severe LLL.

CLINICAL TRIAL REGISTRATION

UMIN clinical trial registry (UMIN-CTR; ID000020129) by CONSORT 2010, TRN R000023253, December 9, 2015.

Feasibility of a Pilot Randomized Controlled Trial Examining a Multidimensional Intervention in Women with Gynecological Cancer at Risk of Lymphedema

There is limited knowledge on non-invasive lymphedema risk-reduction strategies for women with gynecological cancer. Understanding factors influencing the feasibility of randomized controlled trials (RCTs) can guide future research. Our objectives are to report on the design and feasibility of a pilot RCT examining a tailored multidimensional intervention in women treated for gynecological cancer at risk of lymphedema and to explore the preliminary effectiveness of the intervention on lymphedema incidence at 12 months. In this pilot single-blinded, parallel-group, multi-centre RCT, women with newly diagnosed gynecological cancer were randomized to receive post-operative compression stockings and individualized exercise education (intervention group: IG) or education on lymphedema risk-reduction alone (control group: CG). Rates of recruitment, retention and assessment completion were recorded. Intervention safety and feasibility were tracked by monitoring adverse events and adherence. Clinical outcomes were evaluated over 12 months: presence of lymphedema, circumferential and volume measures, body composition and quality of life. Fifty-one women were recruited and 36 received the assigned intervention. Rates of recruitment and 12-month retention were 47% and 78%, respectively. Two participants experienced post-operative cellulitis, prior to intervention delivery. At three and six months post-operatively, 67% and 63% of the IG used compression ≥42 h/week, while 56% engaged in ≥150 weekly minutes of moderate-vigorous exercise. The cumulative incidence of lymphedema at 12 months was 31% in the CG and 31.9% in the IG (p = 0.88). In affected participants, lymphedema developed after a median time of 3.2 months (range, 2.7-5.9) in the CG vs. 8.8 months (range, 2.9-11.8) in the IG. Conducting research trials exploring lymphedema risk-reduction strategies in gynecological cancer is feasible but challenging. A tailored intervention of compression and exercise is safe and feasible in this population and may delay the onset of lymphedema. Further research is warranted to establish the role of these strategies in reducing the risk of lymphedema for the gynecological cancer population.

Comprehensive Decongestive Therapy as a Treatment for Secondary Lymphedema of the Lower Extremity and Quality of Life of Women After Gynecological Cancer Surgery

Background

Lymphedema is a clinical manifestation of lymphatic system failure, caused by an imbalance between the transport capacity of the lymphatic system and the volume of the produced lymph. Lymphedema is complication and significantly worsens quality of life (QoL).

Material/Methods

There were 50 patients diagnosed with secondary lymphedema of the lower extremities after gynecological cancer followed by radiotherapy included in this study. The average age was 57.76 years (standard deviation±10.08). Patients were treated at the Department of Physiotherapy, Balneology and Medical Rehabilitation, in hospital NsP in Bardejov. During therapy, we applied manual lymphatic drainage, instrumental lymphatic drainage, multilayer bandage, vascular gymnastics (with loaded external compression), hydrotherapy, and patient education on the adjustment necessary for a life-long regimen. The circumference of the limb was measured using the Kuhnkes disk method, QoL was assessed using the LYMQOL LEG questionnaire, and for assessment of pain the Visual Analogue Scale (VAS) was used.

Results

After treatment, we found a reduction in lymphedema (P<0.001), an increase in QoL (P<0.001), and a reduction in pain (P<0.001). We found a significant relationship between QoL change and pain in the domains of symptoms, function, and overall QoL (P<0.005). The results showed that reduction of lymphedema was not a significant predictor of QoL (P>0.001).

Conclusions

We found a positive effect in the treatment of secondary lymphedema of the lower extremity on the QoL of women after uterine cancer surgery, and also found that reduction of lymphedema and age were not predictors of improvement in QoL.

Exercise Guidelines for Cancer Survivors: Consensus Statement from International Multidisciplinary Roundtable

PURPOSE

The number of cancer survivors worldwide is growing, with over 15.5 million cancer survivors in the United States alone-a figure expected to double in the coming decades. Cancer survivors face unique health challenges as a result of their cancer diagnosis and the impact of treatments on their physical and mental well-being. For example, cancer survivors often experience declines in physical functioning and quality of life while facing an increased risk of cancer recurrence and all-cause mortality compared with persons without cancer. The 2010 American College of Sports Medicine Roundtable was among the first reports to conclude that cancer survivors could safely engage in enough exercise training to improve physical fitness and restore physical functioning, enhance quality of life, and mitigate cancer-related fatigue.

METHODS

A second Roundtable was convened in 2018 to advance exercise recommendations beyond public health guidelines and toward prescriptive programs specific to cancer type, treatments, and/or outcomes.

RESULTS

Overall findings retained the conclusions that exercise training and testing were generally safe for cancer survivors and that every survivor should "avoid inactivity." Enough evidence was available to conclude that specific doses of aerobic, combined aerobic plus resistance training, and/or resistance training could improve common cancer-related health outcomes, including anxiety, depressive symptoms, fatigue, physical functioning, and health-related quality of life. Implications for other outcomes, such as peripheral neuropathy and cognitive functioning, remain uncertain.

CONCLUSIONS

The proposed recommendations should serve as a guide for the fitness and health care professional working with cancer survivors. More research is needed to fill remaining gaps in knowledge to better serve cancer survivors, as well as fitness and health care professionals, to improve 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.

Role of a Structured Physical Activity Pathway in Improving Functional Disability, Pain and Quality of Life in a Case of Breast and Gynecological Cancer Survivorship

Physical activity (PA) interventions can improve physical functioning, treatment-related symptoms and quality of life (QoL) in cancer survivors. Most investigations have been conducted in breast cancer survivors, while studies on PA interventions in gynecological cancer survivors are scant. Here, we report for the first time the possible benefits of a structured PA pathway (i.e., eight weeks of adapted PA followed by twelve weeks of adapted fitness) on physical side effects, pain and QoL in an uncommon case of survivorship of both primary breast and gynecological cancers. For this purpose, a 69-year-old woman was assessed by functional test battery (shoulder-arm mobility, range of motion, back flexibility) at baseline and after the structured PA pathway. QoL and surgical shoulder, back and lower limb pain intensity were evaluated by Short Form-12 (SF-12) and numerical rating scale questionnaires, respectively. Lower limb circumference was also assessed. Improvement in upper limb function, reduction of lower limb edema and pain perception, as well as an increase in overall QoL were achieved after the completion of structured PA intervention. Our findings suggest that a PA intervention tailored to individual characteristics may represent an effective countermeasure to reduce post-treatment functional disability and pain, and thus to improve QoL in breast and gynecologic cancer survivors.

Translation, reliability, and validation of the Turkish version of the Lymphedema Quality-of-Life tool in Turkish-speaking patients with lower limb Lymphedema

The aim of this study was to translate the original English version of the Lymph Quality-of-Life Questionnaire (LYMQoL) into Turkish language and test its reliability and validity in patients with lower limb lymphedema (LLL). A total of 119 patients (86 women and 33 men) with LLL were enrolled in this study. The Turkish version of the Nottingham Health Profile was used to evaluate the criterion validity of related domains in LYMQoL. The LYMQoL was performed after seven days to evaluate its test-retest reliability. Cronbach's alpha value was found to be 0.94 for internal consistency, and the intraclass correlation coefficient score for test-retest reliability was found to be 0.95. The intraclass correlation coefficient score of domains ranged between 0.83 and 0.92. For the criterion validity, "functional aspects" and "symptoms" domains moderately correlated significantly with the Nottingham Health Profile total score. Kappa values ranged from 0.356 to 0.715. According to the factor analysis, four factors that explain the 71% of the cumulative variance were found. In conclusion, this study indicates that the Turkish version of the LYMQoL is a reliable valid tool for the evaluation of disease-specific health-related quality of life in patients with LLL. It can be safely used in both clinical routine and research.

Effects of Aqua-Lymphatic Therapy on Lower Extremity Lymphedema: A Randomized Controlled Study

BACKGROUND

The purpose of this study is to investigate the effects of the aqua-lymphatic therapy (ALT) on unilateral lower extremity lymphedema in the maintenance phase.

MATERIALS AND METHODS

This is a randomized controlled trial with a blinded assessor. The study was completed with 30 ALT and 27 control group participants. Foot volume was assessed by a water displacement device, limb volume by circumference measurements, functional capacity by a 6-minute walk test, quality of life by Short Form-36, and social appearance by Social Appearance Anxiety Scale and hopeless by Beck Hopeless Scale. The ALT and the control group had group sessions twice in a week for 6 weeks directed by a physiotherapist.

RESULTS

The mean age of ALT patients was 44.50 ± 13.69 years, whereas that of the control patients was 47.66 ± 16.82 years. After the intervention, both groups' measurement of edema, functional level, quality of life, as well as social and future concerns improved significantly but this improvement was higher in the ALT group (p < 0.05, p ≤ 0.001).

CONCLUSIONS

ALT was found to be a safe effective method for unilateral lower extremity lymphedema patients during the maintenance phase of Complex Decongestive Physiotherapy.

Lower Extremity Lymphedema Management after Gynecologic Cancer Surgery: A Review of Current Management Strategies

Lymphedema can be described as an accumulation of protein-rich fluid in interstitial spaces. It affects patients in multiple aspects. Gynecologic cancer survivors might experience lower extremity lymphedema after cancer surgery or treatment. In literature, most of the studies have been performed on upper extremity lymphedema. As gynecologic cancer malignancies have increased in the recent years, treatment options and related complications have been gaining attention in studies. In this manner, this review focused on the management of lower extremity lymphedema after gynecologic surgery. Studies indicated that the incidence of lower extremity lymphedema ranges between 2.4% and 41% after pelvic lymph node dissection in patients with gynecologic malignancies. Thus, management of lower extremity lymphedema in patients after gynecologic cancer surgery is an important issue. Complex decongestive therapy method is still the gold standard of lymphedema management. Controlling, evaluating, and preventing the risk factors are also substantial points; hence, it is very important to provide accurate knowledge in the management of lower extremity lymphedema.

Immediate effects of active exercise with compression therapy on lower-limb lymphedema

Purpose

Active exercise with compression therapy (AECT) is a standard treatment for gynecological cancer-related lower-limb lymphedema (LLL) in clinical situations. However, there is insufficient evidence regarding the immediate effects of the use of AECT on LLL. The purpose of this study was to evaluate the immediate effects of AECT on LLL.

Methods

Participants in this randomized controlled crossover trial comprised 23 women with LLL who completed high-load AECT, low-load AECT, and compression-only therapy (CT). AECT was performed on a bicycle ergometer with short stretch bandages. Each intervention was performed for 15 min, with successive interventions separated by a 1-week washout period. Lower-limb volume was assessed using a Perometer™ sensor (Pero-system, Wuppertal, Germany). General symptoms (pain and heaviness) and skin symptoms (pitting and stiffness) were assessed using a visual analog scale and palpation, respectively. Measurements were taken before and after each intervention. Analysis of variance using linear mixed-effect modeling was used for statistical analyses.

Results

Volume decrement differed significantly between all three interventions (P < 0.05). Lower-limb volume was significantly reduced after high-load AECT compared to that after CT. General symptoms and skin symptoms were similar across the three interventions, but severity of pre-intervention skin symptoms correlated significantly with volume decrement after high- and low-load AECT. High-load AECT using the bicycle ergometer was more effective than CT for decreasing lower-limb volume.

Conclusions

These results suggest that high-load AECT has marked effects on severe LLL.

Association between Body Mass Index and Physical Function among Endometrial Cancer Survivors

Objectives

We sought to quantify the relationship between body mass index (BMI) and physical function among endometrial cancer survivors. Understanding this relationship would help healthcare providers target efforts to refer obese endometrial cancer survivors to weight loss and exercise interventions.

Methods

We conducted a survey of 213 endometrial cancer survivors who received cancer care at an academic l health system between 2006 and 2010. Physical function subscale was quantified using physical functional component score from the SF-12 questionnaire. We compared physical function of endometrial cancer survivors to population-based age-standardized normative values.

Results

Among the 213 patients, 16% were normal weight (BMI ≤25 kg/m²), and 52% were obese (≥30 kg/m²). Higher BMI categories were associated with lower physical function (P_trend = 0.003), as a continuous variable each 5kg/m² higher BMI, physical function score was lower by 0.15 points (β = -0.15; P = 0.045). Compared to population-based age-standardized normative values, patients <75yrs reported lower physical function, whereas patients ≥75yrs reported better physical function. BMI was the only covariate associated with differences in physical function between survivors and age-standardized normative values (P = 0.039).

Conclusions

Among endometrial cancer survivors, higher BMI is associated with lower physical function. Younger endometrial cancer survivors report lower physical function compared to age-standardized normative values. Healthcare providers should be aware that younger, obese endometrial cancer survivors may particularly benefit from interventions such as exercise and weight loss to increase or preserve physical function.

Cardiometabolic Health Among Cancer Survivors: A 13-Week Pilot Study of a Combined Aerobic and Resistance Training Program

PURPOSE/OBJECTIVES

To explore the feasibility of combined aerobic and resistance training (CART) as a safe method of improving cardiometabolic health among cancer survivors.
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DESIGN

Descriptive and longitudinal pilot study for exercise intervention.
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SETTING

University campus in Los Angeles, California.
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SAMPLE

A multiethnic population of cancer survivors (N = 11) was recruited by convenience sampling and physician referral. 
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METHODS

Consenting participants were prescribed CART for one hour per day, three days per week for 13 weeks.
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MAIN RESEARCH VARIABLES

Components of cardiometabolic health were measured, including resting heart rate (HRrest), blood pressure, body mass index, waist circumference, body fat percentage, and android fat percentage at baseline and after 13 weeks of training. Fasting blood glucose, insulin, adiponectin, leptin, tumor necrosis factor alpha, and C-reactive protein (CRP) also were assessed at baseline and after 13 weeks of training.
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FINDINGS

More than half of the participants reported living with at least two other chronic diseases or conditions in addition to a cancer diagnosis. Five of six African American and Hispanic participants reported the presence of at least two risk factors for metabolic syndrome, compared to one of five Caucasian participants. After 13 weeks of training, participants experienced an average decrease in waist circumference. Decrease in waist circumference was associated with a decrease in CRP. A relationship also was suggested between number of exercise sessions attended and improvement in HRrest. 
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CONCLUSIONS

A CART intervention among cancer survivors should continue to be explored in a larger sample to establish efficacy and effectiveness at improving cardiometabolic health. Because of the higher risk of comorbidity among cancer survivors in comparison to cancer-free adults, improving cardiometabolic health is as important as monitoring cancer recurrence. A need exists for increased attention to the post-treatment cardiometabolic health of cancer survivors and also for examining potential cardiometabolic health disparities among non-Caucasian cancer survivors.
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IMPLICATIONS FOR NURSING

CART may be a plausible alternative to reduce the risk of metabolic syndrome and improve cardiometabolic health among cancer survivors. Additional studies that continue to explore the efficacy and effectiveness of CART may provide more information to help nurses and physicians determine whether the cancer survivorship care plan should include an exercise-based alternative to intervene on cardiometabolic health.

Training-related improvements in musculoskeletal health and balance: a 13-week pilot study of female cancer survivors

Cancer survivors often experience poor post-treatment musculoskeletal health. This study examined the feasibility of combined aerobic and resistant training (CART) for improving strength, skeletal health and balance. Cancer survivors (n = 24) were identified by convenience sampling in Los Angeles County with 11 survivors consenting to 13 weeks of CART. Pre- and post-intervention assessments of bone mineral density (BMD), strength, flexibility and biomarker analysis were performed. Paired t-test analysis suggested increases in lower and upper body strength. The average T-score for BMD at the femoral neck improved from -1.46 to -1.36 and whole body BMD improved from -1.65 to -1.55. From baseline to follow-up, participants also displayed decreases in sway velocity on the eyes open (7%) and eyes closed (27%) conditions. Improvement in lower body strength was associated with increases in lean body mass (LBM) (r = 0.721) and an inverse association was observed between sway velocity and LBM (r = 0.838). Age and time since last treatment were related with biomarkers of anabolic growth (IGF-1, IGFbp-3) and bone (DPD, BAP). In summary, observed physiological changes were consistent with functional improvements, suggesting that isometric and dynamic exercise prescription may reduce the risk for falls and fall-related fractures among survivors.

Symptoms: Lymphedema

Lymphedema is one of the main late effects from breast cancer treatment affecting 3-60% of breast cancer survivors. Primarily occurring in the hand, arm, and/or affected breast, symptoms of lymphedema include swelling, pain, redness, restriction of arm/hand movement, tightness and feelings of fullness. These symptoms not only may limit physical functioning but also negatively affect quality of life, body image, social functioning, and financial status of breast cancer survivors with lymphedema. Unfortunately, there are no standardized methods for prevention, diagnosis, and treatment of breast cancer-related lymphedema. Despite its prevalence and lack of clinical guidelines, lymphedema is one of the most poorly understood, relatively underestimated, and least researched complications of cancer treatment. This chapter reviews the current problem of breast cancer-related lymphedema by investigating prevention and risk reduction strategies, diagnosis, and treatment. In addition, this chapter identifies future research opportunities focusing on prevention and risk reduction strategies, quality of life and physical function, surveillance, patient education, cost, diagnosis, and treatment. Challenges and recommendations for future research in these areas, particularly among underserved populations, are discussed.

Evaluation of inter-rater reliability of subjective and objective criteria for diagnosis of lymphedema in upper and lower limbs

BACKGROUND: The diagnosis of lymphedema can be obtained objectively by measurement methods, and also by subjective methods, based on the patient's complaint. OBJECTIVE: To evaluate inter-rater reliability of objective and subjective criteria used for diagnosis of lymphedema and to propose a lymphedema cut-off for differences in volume between affected and control limbs. METHODS: We studied 84 patients who had undergone lymphadenectomy for treatment of cutaneous melanoma. Physical measures were obtained by manual perimetry (MP). The subjective criteria analyzed were clinical diagnosis of lymphedema in patients' medical records and self-report of feelings of heaviness and/or increase in volume in the affected limb. RESULTS: For upper limbs, the subjective criteria clinical observation (k 0.754, P<0.001) and heaviness and swelling (k 0.689, P<0.001) both exhibited strong agreement with MP results and there was moderate agreement between MP results and swelling (k 0.483 P<0.001), heaviness (k 0.576, P<0.001) and heaviness or swelling (k 0.412, P=0.001). For lower limbs there was moderate agreement between MP results and clinical observation (k 0.423, P=0.003) and regular agreement between MP and self-report of swelling (k 0.383, P=0.003). Cut-off values for diagnosing lymphedema were defined as a 9.7% difference between an affected upper limb and control upper limb and a 5.7% difference between lower limbs. CONCLUSION: Manual perimetry, medical criteria, and self-report of heaviness and/or swelling exhibited better agreement for upper limbs than for lower limbs for diagnosis of lymphedema.

Physical activity, daily walking, and lower limb lymphedema associate with physical function among uterine cancer survivors

PURPOSE

We sought to quantify the proportion of uterine cancer survivors who self-report poor physical function. We then sought to quantify the association of poor physical function with physical activity (PA), walking, and lower limb lymphedema (LLL), among women with a history of uterine cancer.

METHODS

Physical function was quantified using the Medical Outcomes Study 12-Item Short-Form Health Survey (SF-12) questionnaire. PA, walking, and LLL were measured using self-report questionnaire. PA was calculated using metabolic equivalent hours per week (MET-h week(-1)), and walking was calculated using blocks per day (blocks day(-1)). Logistic regression estimated odds ratios (OR) and 95 % confidence intervals (95 % CI).

RESULTS

Among the 213 uterine cancer survivors in our survey (43 % response rate), 35 % self-reported poor physical function. Compared to participants who reported <3.0 MET-h week(-1) of PA, participants who reported ≥18.0 MET-h week(-1) of PA were less likely to have poor physical function (OR 0.03, 95 % CI 0.01-0.10; P trend  < 0.0001). Compared to participants who reported <4.0 blocks day(-1) of walking, participants who reported ≥12.0 blocks day(-1) of walking were less likely to have poor physical function (OR 0.07, 95 % CI 0.03-0.19; P trend  < 0.0001). Compared to participants who did not have LLL, participants with LLL were more likely to have poor physical function (OR 5.25, 95 % CI 2.41-11.41; P < 0.0001).

CONCLUSION

Higher levels of PA and walking associate with a lower likelihood of reporting poor physical function. The presence of LLL associates with a higher likelihood of reporting poor physical function. These findings are hypothesis-generating and should be evaluated in future prospective studies.

Physical activity and lower limb lymphedema among uterine cancer survivors

PURPOSE

Physical activity (PA) is known to provide physical and mental health benefits to uterine cancer survivors. However, it is unknown if PA is associated with lower limb lymphedema (LLL), an accumulation of protein-rich fluid in the lower limbs. Therefore, we sought to examine the association between PA and LLL in uterine cancer survivors, with a focus on walking.

METHODS

We conducted a cross-sectional study using mailed surveys among uterine cancer survivors who received care at a university-based cancer center. We asked about PA, walking, and LLL symptoms using validated self-report questionnaires. PA was calculated using MET-hours per week, and walking was calculated using blocks per day.

RESULTS

The response rate to our survey was 43%. Among the 213 uterine cancer survivors in our survey, 36% were classified as having LLL. Compared with participants who reported <3 MET · h · wk of PA, participants who reported ≥ 18.0 MET · h · wk of PA had an odds ratio of LLL of 0.32 (95% confidence interval, 0.15-0.69; P trend = 0.003). Stratified analyses suggested the association between PA and LLL existed only among women with body mass index (BMI) <30 kg · m (P trend = 0.007) compared with women with BMI ≥ 30 kg · m (P trend = 0.47). Compared with participants who reported <4.0 blocks per day of walking, participants who reported ≥ 12 blocks per day of walking had an odds ratio of LLL of 0.19 (95% confidence interval, 0.09-0.43; P trend < 0.0001). Stratified analyses suggested the association between walking and LLL was similar among women with BMI <30 kg · m (P trend = 0.007) and women with BMI ≥ 30 kg · m (P trend = 0.03).

CONCLUSION

Participation in higher levels of PA or walking is associated with reduced proportions of LLL in dose-response fashion. These findings should be interpreted as preliminary and should be investigated in future studies.

The prevalence of lymphedema symptoms among survivors of long-term cancer with or at risk for lower limb lymphedema

OBJECTIVE

The aim of this study was to identify commonly reported symptoms in the lower limbs among those with or at risk for developing lower limb lymphedema (LLL).

DESIGN

The authors surveyed survivors of long-term cancer using the Pennsylvania State Cancer Registry. They inquired about demographics, cancer treatment history, knowledge about LLL, and symptoms experienced since completing cancer treatment. They invited all participants for an in-person clinical assessment to better identify and characterize the symptoms associated with LLL.

RESULTS

The response rate to the study survey was 57.2%. Among the 107 participants who answered the study survey, 37 (34.5%) reported one or more symptoms associated with LLL. Many reported a combination of symptoms that included difficulty walking (n = 37; 100%), aching (n = 32; 86%), puffiness (n = 28; 76%), and pain (n = 27; 73%) on one side of the body since cancer treatment. The in-person clinical assessment among a subsample of 17 participants revealed 10 participants with no evidence of LLL and 5 and 2 participants with grade 1 and 2 LLL, respectively. The in-person clinical assessment identified three cases of previously undiagnosed LLL.

CONCLUSIONS

One third of the survivors of cancer surveyed reported experiencing new symptoms in the lower limbs since cancer treatment. Cases of symptomatic, undiagnosed LLL may exist in the population.

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.

Comparison of tai chi vs. strength training for fall prevention among female cancer survivors: study protocol for the GET FIT trial

Background

Women with cancer are significantly more likely to fall than women without cancer placing them at higher risk of fall-related fractures, other injuries and disability. Currently, no evidence-based fall prevention strategies exist that specifically target female cancer survivors. The purpose of the GET FIT (Group Exercise Training for Functional Improvement after Treatment) trial is to compare the efficacy of two distinct types of exercise, tai chi versus strength training, to prevent falls in women who have completed treatment for cancer. The specific aims of this study are to: 1) Determine and compare the efficacy of both tai chi training and strength training to reduce falls in older female cancer survivors, 2) Determine the mechanism(s) by which tai chi and strength training each reduces falls and, 3) Determine whether or not the benefits of each intervention last after structured training stops.

Methods/Design

We will conduct a three-group, single-blind, parallel design, randomized controlled trial in women, aged 50–75 years old, who have completed chemotherapy for cancer comparing 1) tai chi 2) strength training and 3) a placebo control group of seated stretching exercise. Women will participate in supervised study programs twice per week for six months and will be followed for an additional six months after formal training stops. The primary outcome in this study is falls, which will be prospectively tracked by monthly self-report. Secondary outcomes are maximal leg strength measured by isokinetic dynamometry, postural stability measured by computerized dynamic posturography and physical function measured by the Physical Performance Battery, all measured at baseline, 3, 6 and 12 months. The sample for this trial (N=429, assuming 25% attrition) will provide adequate statistical power to detect at least a 47% reduction in the fall rate over 1 year by being in either of the 2 exercise groups versus the control group.

Discussion

The GET FIT trial will provide important new knowledge about preventing falls using accessible and implementable exercise interventions for women following chemotherapy for cancer. ClinicalTrials.gov NCT01635413

Implementing the exercise guidelines for cancer survivors

In 2009, the American College of Sports Medicine convened an expert roundtable to issue guidelines on exercise for cancer survivors. This multidisciplinary group evaluated the strength of the evidence for the safety and benefits of exercise as a therapeutic intervention for survivors. The panel concluded that exercise is safe and offers myriad benefits for survivors including improvements in physical function, strength, fatigue, quality of life, and possibly recurrence and survival. Recommendations for situations in which deviations from the US Physical Activity Guidelines for Americans are appropriate were provided. Here, we outline a process for implementing the guidelines in clinical practice and provide recommendations for how the oncology care provider can interface with the exercise and physical therapy community.

Exercise guidelines for adults with cancer: a vital role in survivorship

Cancer survivors face many challenges as a result of their cancer diagnosis and treatment, most importantly the maintenance of physical well-being. Nurses and other health professionals strive to address the needs of cancer survivors, including providing appropriate health-promotion information for a physically active lifestyle. Cancer survivors are at greater risk for recurrence and for developing second cancers because of treatment effects, unhealthy lifestyle behaviors, or risk factors that contributed to the first cancer. In light of those concerns, guide-lines aimed at understanding and preventing secondary disease, recurrence, and the late and long-term effects of treatment are essential.

Exercise in patients with lymphedema: a systematic review of the contemporary literature

BACKGROUND

Controversy exists regarding the role of exercise in cancer patients with or at risk for lymphedema, particularly breast. We conducted a systematic review of the contemporary literature to distill the weight of the evidence and provide recommendations for exercise and lymphedema care in breast cancer survivors.

METHODS

Publications were retrieved from 11 major medical indices for articles published from 2004 to 2010 using search terms for exercise and lymphedema; 1,303 potential articles were selected, of which 659 articles were reviewed by clinical lymphedema experts for inclusion, yielding 35 articles. After applying exclusion criteria, 19 articles were selected for final review. Information on study design/objectives, participants, outcomes, intervention, results, and study strengths and weaknesses was extracted. Study evidence was also rated according to the Oncology Nursing Society Putting Evidence Into Practice® Weight-of-Evidence Classification.

RESULTS

Seven studies were identified addressing resistance exercise, seven studies on aerobic and resistance exercise, and five studies on other exercise modalities. Studies concluded that slowly progressive exercise of varying modalities is not associated with the development or exacerbation of breast cancer-related lymphedema and can be safely pursued with proper supervision. Combined aerobic and resistance exercise appear safe, but confirmation requires larger and more rigorous studies.

CONCLUSIONS

Strong evidence is now available on the safety of resistance exercise without an increase in risk of lymphedema for breast cancer patients. Comparable studies are needed for other cancer patients at risk for lymphedema.

IMPLICATIONS FOR CANCER SURVIVORS

With reasonable precautions, it is safe for breast cancer survivors to exercise throughout the trajectory of their cancer experience, including during treatment.