Priorities for women with lymphoedema after treatment for breast cancer: population based cohort study

Unmet care needs of women who have undergone breast cancer surgery: A scoping review

AIM

To summarize the evidence regarding the unmet care needs of women who have undergone breast cancer surgery and identify research gaps.

DESIGN

A scoping review.

DATA SOURCES

This review entailed a systematic search in EMBASE, Medline via PubMed, CINAHL Complete, APA PsycINFO, Cochrane Library, Web of Science and Scopus (up until 30 July 2023).

REVIEW METHODS

This review was guided by Arksey and O'Malley's Framework (2005) and the Preferred Reporting Items for Systematic Reviews and Meta-analysis-Scoping Review extension (PRISMA-ScR).

RESULTS

Twenty-five studies that included 4914 participants were retrieved. Fourteen studies employed quantitative designs, eight used qualitative methods, two were mixed-methods studies and one used a qualitative meta-synthesis. Women who have undergone breast cancer surgery experience a wide range of complex and multifaceted unmet care needs. The informational/educational and psychological/emotional domains were the most frequently reported among the identified domains. Meanwhile, the sexual and spiritual/religious beliefs domains remained relatively underexplored. Furthermore, none of the assessment tools used in these studies captured the entirety of the possible domains of unmet care needs.

CONCLUSION

Needs assessment should be integrated into the routine care of women who have undergone breast cancer surgery. Interventions should be developed to address the unmet informational/educational and psychological/emotional needs of women. Future studies should employ high-quality mixed-methods approaches to explore women's sexual and spiritual/religious concerns.

IMPACT

This review provides a comprehensive overview of the unmet care needs of women who have undergone the breast cancer surgery. These findings will contribute to the development of tailored interventions. This review also informs future studies to explore distinct domains of unmet care needs.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

The Role of Patient Awareness and Knowledge in Developing Secondary Lymphedema after Breast and Gynecologic Cancer Surgery

Background: This study aimed to compare the effects of awareness and knowledge on demographic and clinical factors in patients with breast cancer-related lymphedema (BCRL) and gynecologic cancer-related lymphedema (GCRL) in the oncologic rehabilitation setting. Methods and Results: A total of 506 female patients with upper or lower extremity lymphedema, were evaluated for lymphedema education in their postoperative period. Only 74 survivors (25%) with BCRL and 34 survivors (16.83%) with GCRL reported that they had received information about lymphedema by physicians/primary health care providers. In breast cancer survivors, the time of diagnostic delay for lymphedema was shorter in the informed group (p < 0.001), and there was a higher rate of cellulite attacks in uninformed patients (p = 0.021). Duration between surgery and lymphedema was longer and duration of diagnostic delay for lymphedema was shorter in the informed group than uninformed group in gynecologic cancer survivors (p = 0.019, p < 0.001). There was a higher rate of cellulite history in the uninformed patients than informed patients in gynecologic cancer survivors (p < 0.001). In gynecologic cancer survivors who were educated about lymphedema were at an earlier stage than noneducated patients (p = 0.024). Conclusion: The rate of awareness about lymphedema among patients with a history of surgery for gynecologic malignancies is lower compared with those for breast cancer. In female cancer survivors, awareness and knowledge about lymphedema may lead to a later onset of lymphedema, lower lymphedema grades, and fewer infection.

The ALERT model of care for the assessment and personalized management of patients with lymphoedema

BACKGROUND

This study documents the development and evaluation of a comprehensive multidisciplinary model for the assessment and personalized care of patients with lymphoedema.

METHODS

The Australian Lymphoedema Education Research and Treatment (ALERT) programme originated as an advanced clinic for patients considering surgery for lymphoedema. The programme commenced liposuction surgery in May 2012 and then introduced lymph node transfer in 2013 and lymphovenous anastomosis (LVA) in 2016. An outpatient conservative treatment clinic was established in 2016. ALERT commenced investigations with indocyanine green (ICG) lymphography in late 2015, leading to the creation of a diagnostic assessment clinic offering ICG in 2017.

RESULTS

Since 2012, 1200 new patients have been referred to ALERT for assessment of lymphoedema for a total of 5043 episodes of care. The introduction of ICG lymphography in 2015 initially allowed better screening for LVA, but is now used not only to guide surgical options, but also as a diagnostic tool and to guide manual lymphatic drainage massage. The total number of new patients who attended the surgical assessment clinic to December 2018 was 477, with 162 patients (34·0 per cent) undergoing surgery.

CONCLUSION

The ALERT programme has developed a multidisciplinary model of care for personalized lymphoedema treatment options based on clinical, imaging and ICG lymphography. Patients are selected for surgery based on several individual factors.

A Feasibility Study to Examine the Role of Acupuncture to Reduce Symptoms of Lymphoedema after Breast Cancer: A Randomised Controlled Trial

Objective

To determine the feasibility, acceptability and safety of using acupuncture to treat arm lymphoedema in women following treatment for breast cancer.

Methods

We conducted a randomised controlled trial of acupuncture compared with treatment as usual. Twenty women with stable unilateral intransient lymphoedema present for at least 6 months were recruited from Sydney, Australia. The women received 12 acupuncture treatments administered to body and arm points on the non-lymphoedematous limb over 8 weeks, twice weekly for 4 weeks then once weekly for 4 weeks. Outcome measures included an assessment of interest to participate in the trial, identification of successful recruitment strategies, the appropriateness of eligibility criteria and compliance with treatment attendance. Clinical outcomes were assessed at baseline and 8 weeks and included extracellular fluid, lymphoedema symptoms, well-being and safety.

Results

Acupuncture was an acceptable intervention in women with upper limb lymphoedema. Compliance with the treatment protocol was high, with nine women completing all 12 treatments. Outcome forms were completed by 17 women at 8 weeks. No major adverse occurrences, as defined by the study protocol, were reported from the acupuncture group although one woman found the needling uncomfortable, and no study participant experienced an increase in swelling of >10%. There was no change in extracellular fluid or any patient-reported outcome measurement.

Conclusions

Lymphoedema is a persistent symptom experienced by women recovering from breast cancer. Our study suggests that acupuncture may stabilise symptoms and no major safety concerns were identified, so further research is needed.

Trial Registration Number

Australian New Zealand Clinical Trials Registry, http://www.anzctr.org.au ACTRN12612000607875.

Yoga, breast cancer-related lymphoedema and well-being: A descriptive report of women's participation in a clinical trial

AIMS AND OBJECTIVES

To describe the experiences of women taking part in a yoga intervention trial for breast cancer-related lymphoedema.

BACKGROUND

Around 20% of women will experience lymphoedema as a consequence of treatment for breast cancer. Specialist lymphoedema clearing, along with self-management, remains the mainstay of therapy. Yoga, an increasingly popular complementary therapeutic practice, may provide another tool to augment self-management.

DESIGN

A qualitative, descriptive design.

METHODS

Interviews were conducted with 15 women with stage one breast cancer-related lymphoedema who had completed an 8-week yoga intervention trial. The intervention consisted of a weekly teacher-led 1.5-hr yoga class and a daily home practice using a 45-min DVD. Interviews were audio-taped and transcribed. These data were then analysed using an iterative-thematic approach.

RESULTS

Participants reported improved well-being, increased awareness of their physical body as well as improved physical, mental and social functioning. They gained from being part of the yoga group that also provided a forum for them to share their experiences. Nine women felt empowered to describe their yoga participation as a transformative journey through illness.

CONCLUSION

When safe to do so, the holistic practice of yoga may augment and provide additional benefit to current self-management and treatment practices for women with breast cancer-related lymphoedema.

RELEVANCE TO CLINICAL PRACTICE

Patients with breast cancer-related lymphoedema may seek advice and guidance from nurses and other healthcare professionals on a range of complementary therapies to help relieve symptoms and promote recovery. Patients who choose to augment their treatment of breast cancer-related lymphoedema by practicing yoga should be carefully assessed, be taught an appropriate technique by a qualified yoga teacher/therapist and its impact monitored by their yoga teacher/therapist, breast care nurse, lymphoedema therapist or treating clinician.

Total saponins of panaxnotoginseng promotes lymphangiogenesis by activation VEGF-C expression of lymphatic endothelial cells

ETHNOPHARMACOLOGICAL RELEVANCE

Lymphatic system plays an important role in maintaining the fluid homeostasis and normal immune responses, anatomic or functional obstruction of which leads to lymphedema, and treatments for therapeutic lymphangiogenesis are efficiency for secondary lymphedema. Total saponins of panaxnotoginseng (PNS) are a mixture isolated from Panaxnotoginseng (Burkill) F.H.Chen, which has been used as traditional Chinese medicine in China for treatment of cardio- and cerebro-vascular diseases. The aim of this study was to determine the effect and mechanism of PNS on lymphangiogenesis.

METHODS

The Tg (fli1: egfp; gata1: dsred) transgenic zebrafish embryos were treated with different concentrations of PNS (10, 50, 100μM) for 48h with or without the 6h pretreatment of the 30μM Vascular endothelial growth factors receptor (VEGFR)-3 kinase inhibitor, followed with morphological observation and lympangiogenesis of thoracic duct assessment. The effect of PNS on cell viability, migration, tube formation and Vascular endothelial growth factors (VEGF)-C mRNA and protein expression of lymphatic endothelial cells (LECs) were determined. The role of phosphatidylinositol-3 (PI-3)-kinase (PI3K), extracellular signal-regulated kinase (ERK)1/2 pathways, c-Jun N-terminal kinase (JNK) and P38 mitogen activated protein kinases (MAPK) signaling in PNS-induced VEGF-C expression of LECs by using pharmacological agents to block each signal.

RESULTS

PNS promotes lymphangiogenesis of thoracic duct in zebrafish with or without VEGFR3 Kinase inhibitor pre-impairment. PNS promotes proliferation, migration and tube formation of LECs. The tube formation induced by PNS could be blocked by VEGFR3 Kinase inhibitor. PNS induce VEGF-C expression of LEC, which could be blocked by ERK1/2, PI3K and P38MAPK signaling inhibitors.

CONCLUSION

PNS activates lymphangiogenesis both in vivo and in vitro by up-regulating VEGF-C expression and activation of ERK1/2, PI3K and P38MAPK signaling. These findings provide a novel insight into the role of PNS in lymphangiogenesis and suggest that it might be an attractive and suitable therapeutic agent for treating secondary lymphedema or other lymphatic system impairment related disease.

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.

Review of the evidence of lymphedema treatment effect

Lymphedema treatment aims to alleviate symptoms, prevent progression, and reduce risk for skin infection. Mainstream treatment options have been investigated in more than 160 studies. Findings from these studies have been included in at least 1 of more than 20 literature reviews. A critique of these reviews was undertaken to summarize efficacy findings. The quality of the reviews was evaluated, and gaps in the research were identified to better guide clinical practice. Overall, there was wide variation in review methods. The quality of studies included in reviews, in study design and reporting overall, has been poor. Reviews consistently concluded that complex physical therapy is effective at reducing limb volume. Volume reductions were also reported after the use of compression garments, pumps, and manual lymphatic drainage. However, greatest improvements were reported when these treatments formed a combined treatment program. Large, well-designed, evaluated, and reported randomised, controlled trials are needed to evaluate and compare treatments. Consistent outcome measures will allow better quality reviews and meta-analysis in the future.

Exercise barriers self-efficacy: development and validation of a subcale for individuals with cancer-related lymphedema

BACKGROUND

No tool exists to measure self-efficacy for overcoming lymphedema-related exercise barriers in individuals with cancer-related lymphedema. However, an existing scale measures confidence to overcome general exercise barriers in cancer survivors. Therefore, the purpose of this study was to develop, validate and assess the reliability of a subscale, to be used in conjunction with the general barriers scale, for determining exercise barriers self-efficacy in individuals facing lymphedema-related exercise barriers.

METHODS

A lymphedema-specific exercise barriers self-efficacy subscale was developed and validated using a cohort of 106 cancer survivors with cancer-related lymphedema, from Brisbane, Australia. An initial ten-item lymphedema-specific barrier subscale was developed and tested, with participant feedback and principal components analysis results used to guide development of the final version. Validity and test-retest reliability analyses were conducted on the final subscale.

RESULTS

The final lymphedema-specific subscale contained five items. Principal components analysis revealed these items loaded highly (>0.75) on a separate factor when tested with a well-established nine-item general barriers scale. The final five-item subscale demonstrated good construct and criterion validity, high internal consistency (Cronbach's alpha = 0.93) and test-retest reliability (ICC = 0.67, p < 0.01).

CONCLUSIONS

A valid and reliable lymphedema-specific subscale has been developed to assess exercise barriers self-efficacy in individuals with cancer-related lymphedema. This scale can be used in conjunction with an existing general exercise barriers scale to enhance exercise adherence in this understudied patient group.

Lymphedema following breast cancer: regions affected, severity of symptoms, and benefits of treatment from the patients' perspective

Limited high-quality research has focused on the efficacy of lymphedema treatments and symptomatic relief. With that in mind, the authors conducted a cross-sectional survey to describe the presentation of breast cancer-related lymphedema, treatment modalities used, and perceived effectiveness. An electronic validated questionnaire to assess the presentation of lymphedema, severity of swelling and discomfort, number of modalities tried, and the benefits gained from treatment was completed by the Review and Survey Group of the Breast Cancer Network of Australia. Thirty-five percent of participants reported the presence of lymphedema, a majority of which reported it to be mild or moderate for magnitude of swelling and for discomfort. The correlation was weak between magnitude of swelling and discomfort. Compression, massage, and exercise were the most commonly used modalities in these patients. Notably, chest wall or breast lymphedema--about which research is lacking--was as common as hand lymphedema. Women experienced discomfort and physical changes, although the severity of the two was not related. Some benefit was reported for all modalities, but no particular modality was considered extremely helpful. Oncology nurses are ideally positioned to monitor women for early signs of swelling and to advise women on the range of treatments available.

Prevalence, intensity, and predictors of the supportive care needs of women diagnosed with breast cancer: a systematic review

OBJECTIVE

The assessment of supportive care needs is a crucial step in the development of appropriate interventions that may improve the quality of life of cancer patients. This review describes and analyzes the prevalence and predictors of the unmet supportive care needs of breast cancer (BC) patients and survivors and suggests paths for further research.

METHOD

Multiple databases were searched, considering only quantitative studies using validated needs assessment instruments and focusing uniquely on women diagnosed with BC.

RESULTS

Out of 761 hits, 23 studies answered to all eligibility criteria. Nineteen were cross-sectional, and the remaining four were longitudinal. Most included patients at different moments along the BC trajectory, from diagnosis to decades into survivorship, with the major proportion of patients under treatment. Only five concentrated on the posttreatment phase into extended survivorship. The concerns of women diagnosed with BC clustered around psychological and information needs, with the top concern being 'fear of the cancer returning'. Predictors of higher levels of needs included advanced disease stage, greater symptom burden, shorter time since diagnosis, higher levels of distress, and younger age. Prevalence differed between cultures with Asian women reporting greater information needs and lower psychological needs compared with Western women.

CONCLUSIONS

Revealing which needs BC patients consider most urgent and the factors related to greater needs will permit the development of improved and targeted supportive care. Future research should comprise longitudinal designs concentrating on women at specific moments along the BC trajectory for a dynamic understanding of these needs.

Lymphedema and therapeutic lymphangiogenesis

Lymphedema is a disorder of the lymphatic vascular system characterized by impaired lymphatic return and swelling of the extremities. Lymphedema is divided into primary and secondary forms based on the underlying etiology. Despite substantial advances in both surgical and conservative techniques, therapeutic options for the management of lymphedema are limited. Although rarely lethal, lymphedema is a disfiguring and disabling condition with an associated decrease in the quality of life. The recent impressive expansion of knowledge on the molecular mechanisms governing lymphangiogenesis provides new possibilities for the treatment of lymphedema. This review highlights the lymphatic biology, the pathophysiology of lymphedema, and the therapeutic lymphangiogenesis using hepatocyte growth factor.