Development of a core outcome set for breast cancer-related lymphedema: a Delphi study

PURPOSE

For breast cancer survivors (BCS) living with breast cancer-related lymphedema (BCRL), what outcome domains (OD) should be measured to assess the burden of the disease and efficacy of interventions? A Core Outcome Set (COS) that promotes standardized measurement of outcomes within the constraints of time influenced by work environments is essential for patients and the multidisciplinary professionals that manage and research BCRL.

METHODS

Using Delphi methodology, a multidisciplinary group of BCRL experts (physical and occupational therapists, physicians, researchers, physical therapist assistants, nurses, and massage therapist) completed two waves of online surveys. BCRL expert respondents that completed the first survey (n = 78) had an average of 26.5 years in practice, whereas, respondents who completed the second survey (n = 33) had an average of 24.9 years. ODs were included in the COS when consensus thresholds, ranging from 70% to 80%, were met.

RESULTS

A total of 12 ODs made up the COS. Reaching a minimum consensus of 70%; volume, tissue consistency, pain, patient-reported upper quadrant function, patient-reported health-related quality of life, and upper extremity activity and motor control were recommended at different phases of the BCRL continuum in a time-constrained environment. Joint function, flexibility, strength, sensation, mobility and balance, and fatigue met an 80% consensus to be added when time and resources were not constrained.

CONCLUSION

The COS developed in this study thoroughly captures the burden of BCRL. Using this COS may reduce selective reporting, inconsistency in clinical use, and variability of reporting across interdisciplinary healthcare fields, which manage or research BCRL.

Development of a core set of outcome measures to be applied toward breast cancer-related lymphedema core outcome domains

PURPOSE

For breast cancer survivors (BCS) living with breast cancer-related lymphedema (BCRL), what outcome measures (OMs) are recommended to be used to measure standardized outcome domains to fully assess the burden of the disease and efficacy of interventions? An integral component of a standardized core outcome set (COS) are the OMs used to measure the COS.

METHODS

A supplemental online survey was linked to a Delphi study investigating a COS for BCRL. OMs were limited to a maximum of 10 options for each outcome domain (OD). There were 14 ODs corresponding to the International Classification of Functioning, Disability, and Health (ICF) framework and respondents rated the OMs with a Likert level of recommendation. The feasibility of the listed OMs was also investigated for most outpatient, inpatient, and research settings.

RESULTS

This study identified 27 standardized OMs with a few ODs having 2-3 highly recommended OMs for proper measurement. A few of the recommended OMs have limitations with reliability due to being semi-quantitative measures requiring the interpretation of the rater.

CONCLUSION

Narrowing the choices of OMs to 27 highly recommended by BCRL experts may reduce selective reporting, inconsistency in clinical use, and variability of reporting across interdisciplinary healthcare fields which manage or research BCRL. There is a need for valid, reliable, and feasible OMs that measure tissue consistency. Measures of upper extremity activity and motor control need further research in the BCS with BCRL population.

Safety and effectiveness of a novel nonpneumatic active compression device for treating breast cancer-related lymphedema: A multicenter randomized, crossover trial (NILE)

OBJECTIVE

Advanced pneumatic compression devices (APCDs) have been shown to be an effective intervention for lymphedema when used as part of a self-care maintenance treatment regimen. However, adherence to self-care has been poor, and APCDs require patients to be immobile during treatment. We evaluated the safety and efficacy of a novel nonpneumatic compression device (NPCD) for treating lymphedema vs an APCD.

METHODS

A randomized, crossover head-to-head investigation was performed at five U.S. sites in 2021. The patients had been randomized to either the NPCD or a commercially available APCD. The patients used the randomly assigned initial device for 28 days with a 4-week washout period before a comparable 28-day use of the second device.

RESULTS

Data from 50 adult women with unilateral breast cancer-related lymphedema were analyzed. Compared with the APCD, the NPCD was associated with a greater mean reduction in the limb edema volume (64.6% vs 27.7%; P < .001), significantly greater mean improvements in quality of life scores, greater adherence (95.6% vs 49.8%; P < .001), and greater satisfaction with the device (90% vs 14%; P < .001). The patients indicated that use of the NPCD facilitated exercise and was convenient for travel. No adverse events were reported.

CONCLUSIONS

The results have shown that the novel NPCD is an effective maintenance treatment for reducing the limb volume in patients with breast cancer-related lymphedema. The NPCD device was more effective than an APCD and resulted in greater adherence to self-care interventions and greater patient satisfaction.

Uncovering Family Treatment Decision-Making Processes: The Value and Application of Case Study Methods to Family Research

Research on how and why family processes influence phenomena is essential to advancing many areas of science. Case study methods offer an approach that overcomes some of the sampling and analysis obstacles researchers face when studying families. This article aims to illustrate the benefits of case study methods for studying complex family processes using an example from treatment decision-making in sickle cell disease. Using survey, observation, and interview data from various family members within multiple family units, we detail our application of the following analytic strategies: (a) proposition-building, (b) pattern-matching, and (c) cross-case synthesis. Incorporating propositions from a conceptual framework assisted us in study development, data collection, and analysis. Development of graphs and matrices to create thematic family profiles uncovered how and why treatment decision-making occurred as a family process in a pediatric chronic illness. Case study methods are an established, but innovative approach to investigating various phenomena in families.

Clinical Evaluation of a Novel Wearable Compression Technology in the Treatment of Lymphedema, an Open-Label Controlled Study

A diagnosis of lymphedema comes with a lifetime requirement for careful self-care and treatment to control skin deterioration and the consequences of excessive fluid and protein buildup leading to abnormal limb volume and an increased risk of infection. The burden of care and psychosocial aspects of physical disfiguration and loss of function are associated with compromised quality of life (QoL). The current standard therapeutic intervention is complex decongestive therapy with manual lymph drainage and frequent wearing of compression garments. With insurance limitations on therapy visits and the time and travel required, additional home treatment options are needed. Pneumatic compression pumps that mimic the manual massage pressure and pattern are sometimes prescribed, but these are bulky, difficult to apply, and require immobility during treatment. An open-label pilot study in 40 subjects was performed to evaluate the QoL and limb volume maintenance efficacy of a novel wearable compression system (Dayspring™) that is low profile, easy to use, and allows for mobility during treatment. After 28 days of use, subjects had a statistically significant 18% (p < 0.001) improvement in overall QoL as measured by the Lymphedema Quality-of-Life Questionnaire compared with baseline. Individual QoL domains, and limb volume improved with therapy. Adherence was 98% over the course of the study. Results of the clinical evaluation suggest the Dayspring wearable compression device is safe and effective and improves QoL and limb volume. The novel, low-profile device is easy to use and allows for mobility during treatment, addressing a potential barrier to adherence with pneumatic compression devices.

A Systematic Review of Missouri Lymphedema Symptom Assessment Tools in Original Research and Review Articles

Despite advances in cancer treatment, many survivors face a significant challenge of cancer-related lymphedema, together with aging. Aging results in structural changes in the lymphatic system. Beginning in 1998, tools have been developed at the University of Missouri to assess symptoms of lymphedema in cancer patients. The objective of this review was to synthesize evidence regarding use of Missouri lymphedema symptom assessment tools in original research and review articles. A search of six electronic databases was conducted for articles published within 1998 and 2018 on review and use of the tools which are Lymphedema and Breast Cancer Questionnaire (LBCQ), Melanoma and Lymphedema Questionnaire (MELQ), and Gynecologic Cancer and Lymphedema Questionnaire (GCLQ). In all, 210 articles were retrieved, and 32 full-text articles meeting the inclusion criteria were reviewed. The studies reported a cumulative number of 5,872 study participants. Most manuscripts (70.97%) reported data on breast cancer lymphedema, 19.35% on gynecological cancer lymphedema, 3.23% on breast cancer and melanoma lymphedema, and 6.45% on melanoma. The use of LBCQ was reportedly more than the use of GCLQ and MELQ. Tool reliability ranged from r = 0.785 - 0.82 for LBCQ and 0.95 for internal reliability for GCLQ. The tools have been used in many countries including the United States of America. The importance of using valid and reliable quantitative measures in lymphedema symptom assessment across diverse populations and sites cannot be overstated. The tools have been modified and used over the past 20 years in various settings and across languages and cultures.

GOG 244-The lymphedema and gynecologic cancer (LEG) study: Incidence and risk factors in newly diagnosed patients

OBJECTIVES

To evaluate the incidence and risk factors for lymphedema associated with surgery for gynecologic malignancies on GOG study 244.

METHODS

Women undergoing a lymph node dissection for endometrial, cervical, or vulvar cancer were eligible for enrollment. Leg volume was calculated from measurements at 10-cm intervals starting 10 cm above the bottom of the heel to the inguinal crease. Measurements were obtained preoperatively and postoperatively at 4-6 weeks, and at 3-, 6-, 9-, 12-, 18-, and 24- months. Lymphedema was defined as a limb volume change (LVC) ≥10% from baseline and categorized as mild: 10-19% LVC; moderate: 20-40% LVC; or severe: >40% LVC. Risk factors associated with lymphedema were also analyzed.

RESULTS

Of 1054 women enrolled on study, 140 were inevaluable due to inadequate measurements or eligibility criteria. This left 734 endometrial, 138 cervical, and 42 vulvar patients evaluable for LVC assessment. Median age was 61 years (range, 28-91) in the endometrial, 44 years (range, 25-83) in the cervical, and 58 years (range, 35-88) in the vulvar group. The incidence of LVC ≥10% was 34% (n = 247), 35% (n = 48), and 43% (n = 18), respectively. The peak incidence of lymphedema was at the 4-6 week assessment. Logistic regression analysis showed a decreased risk with advanced age (p = 0.0467). An exploratory analysis in the endometrial cohort showed an increased risk with a node count >8 (p = 0.033).

CONCLUSIONS

For a gynecologic cancer, LVC decreased with age greater than 65, but increased with a lymph node count greater than 8 in the endometrial cohort. There was no association with radiation or other risk factors.

GOG 244 - The LymphEdema and Gynecologic cancer (LEG) study: The association between the gynecologic cancer lymphedema questionnaire (GCLQ) and lymphedema of the lower extremity (LLE)

OBJECTIVE

To explore whether patient-reported lymphedema-related symptoms, as measured by the Gynecologic Cancer Lymphedema Questionnaire (GCLQ), are associated with a patient-reported diagnosis of lymphedema of the lower extremity (LLE) and limb volume change (LVC) in patients who have undergone radical surgery, including lymphadenectomy, for endometrial, cervical, or vulvar cancer on Gynecologic Oncology Group (GOG) study 244.

METHODS

Patients completed the baseline and at least one post-surgery GCLQ and LVC assessment. The 20-item GCLQ measures seven symptom clusters-aching, heaviness, infection-related, numbness, physical functioning, general swelling, and limb swelling. LLE was defined as a patient self-reported LLE diagnosis on the GCLQ. LVC was measured by volume calculations based on circumferential measurements. A linear mixed model was fitted for change in symptom cluster scores and GCLQ total score and adjusted for disease sites and assessment time.

RESULTS

Of 987 eligible patients, 894 were evaluable (endometrial, 719; cervical, 136; vulvar, 39). Of these, 14% reported an LLE diagnosis (endometrial, 11%; cervical, 18%; vulvar, 38%). Significantly more patients diagnosed versus not diagnosed with LLE reported ≥4-point increase from baseline on the GCLQ total score (p < 0.001). Changes from baseline were significantly larger on all GCLQ symptom cluster scores in patients with LLE compared to those without LLE. An LVC increment of >10% was significantly associated with reported general swelling (p < 0.001), heaviness (p = 0.005), infection-related symptoms (p = 0.002), and physical function (p = 0.006).

CONCLUSIONS

Patient-reported symptoms, as measured by the GCLQ, discerned those with and without a patient-reported LLE diagnosis and demonstrated predictive value. The GCLQ combined with LVC may enhance our ability to identify LLE.

How to use tests for disorders of copper metabolism

In paediatrics, one of our main aims in the diagnostic process is to identify any treatable conditions. The copper metabolism disorder Wilson's disease (WD) is one such condition that is caused by mutations in the ATP7B gene. Delay in treatment could result in irreversible disability or even death. Although liver disease is the most common presenting feature in children, some children may initially present with a subtle neurological presentation only. In patients presenting with dystonia, tremor, dysarthria or with a deterioration in school performance, there should be a high index of suspicion for WD. However, the differential of these clinical presentations is wide and exclusion of WD is difficult. No single diagnostic test can exclude WD and each of the biochemical tests has limitations. In this article, we discuss copper metabolism disorders including WD and Menke's disease. We then discuss the available diagnostic tests and how to investigate children for these rare disorders.

Impact of light exposure on thyroid-stimulating hormone results using the Siemens Advia Centaur TSH-3Ultra assay

Background

Thyroid-stimulating hormone (TSH) is used as the first-line test of thyroid function. Siemens Healthcare Diagnostics recommend that Siemens Centaur reagents must be protected from light in the assay information and on reagent packaging. We have compared the effect of light exposure on results using Siemens TSH-3Ultra and follicle-stimulating hormone reagents. The thyroid-stimulating hormone reagent includes fluoroscein thiocyanate whereas the follicle-stimulating hormone reagent does not.

Methods

Three levels of quality controls were analysed using SiemensTSH-3Ultra and follicle-stimulating hormone reagent packs that had been kept protected from light or exposed to light at 6-h intervals for 48 h and then at 96 h.

Results

Thyroid-stimulating hormone results were significantly lower after exposure of TSH-3Ultra reagent packs to light. Results were >15% lower at all three levels of quality control following 18 h of light exposure and continued to decrease until 96 h. There was no significant difference in follicle-stimulating hormone results whether reagents had been exposed to or protected from light.

Conclusions

Thyroid-stimulating hormone results but not follicle-stimulating hormone results are lowered after exposure of reagent packs to light. Laboratories must ensure that TSH-3Ultra reagents are not exposed to light and analyse quality control samples on every reagent pack to check that there has not been light exposure prior to delivery. The labelling on TSH-3Ultra reagent packs should reflect the significant effect of light exposure compared with the follicle-stimulating hormone reagent. We propose that the effect of light exposure on binding of fluoroscein thiocyanate to the solid phase antibody causes the falsely low results.

Challenges Evaluating Chemotherapy-Induced Peripheral Neuropathy in Childhood Cancer Survivors

Children treated for cancer are exposed to a variety of chemotherapeutic agents with known toxicity to the peripheral nervous system. The side effect of peripheral neuropathy can cause changes in sensation, function, and even cause pain. Although peripheral neuropathy is recognized by pediatric oncology nurses as an important and significant side effect, measuring neuropathy can be quite complex for clinical care and research efforts. With more children surviving a cancer diagnosis today, this issue is increasingly important for childhood cancer survivors. This article has reviewed existing literature examining peripheral neuropathy in childhood cancer survivors with particular interest paid to measurement tools available and needs for future research. It is important for nurses to choose appropriate measures for clinical care and research methods in order to have an impact on patients experiencing this condition.

Prospective Lymphedema Surveillance in a Clinic Setting

The potential impact of breast cancer-related lymphedema (LE) is quite extensive, yet it often remains under-diagnosed until the later stages. This project examines the effectiveness of prospective surveillance in post-surgical breast cancer patients. A retrospective analysis of 49 out of 100 patients enrolled in a longitudinal prospective study at a Midwestern breast center evaluates: (1) time required for completion of bilateral limb measurements and Lymphedema Breast Cancer Questionnaire (LBCQ); (2) referral to LE management with limb volume increase (LVI) and/or LBCQ symptoms; and (3) cost of LE management at lower LVI (≥5%–≤10%) versus traditional (≥10%). Findings revealed a visit timeframe mean of 40.3 min (range = 25–60); 43.6% of visits were ≤30-min timeframe. Visit and measurement times decreased as clinic staff gained measurement experience; measurement time mean was 17.9 min (range = 16.9–18.9). LBCQ symptoms and LVI were significantly (p < 0.001) correlated to LE referral; six of the nine patients referred (67%) displayed both LBCQ symptoms/LVI. Visits with no symptoms reported did not result in referral, demonstrating the importance of using both indicators when assessing early LE. Lower threshold referral provides compelling evidence of potential cost savings over traditional threshold referral with reported costs of: $3755.00 and $6353.00, respectively (40.9% savings).

Is surviving enough? Coping and impact on activities of daily living among melanoma patients with lymphoedema

We assessed the impact of lymphoedema (defined as ≥ 10% limb volume change) on quality of life (QOL), ability to perform activities of daily living (ADLs) and coping in 277 melanoma patients. Limb volume was measured prospectively, pre-operatively and every 3-6 months for 18 months post-operatively using a perometer. Three questionnaires were administered to measure QOL, coping and impact on ADLs. Statistical analyses were conducted using longitudinal logistic regression models. At 18 months, the cumulative incidence of lymphoedema was 31% in patients with upper extremity nodal basin treatment and 40% in lower extremity nodal basin treatment patients. Patients with lower extremity lymphoedema reported lower QOL scores than those with upper extremity lymphoedema. Over 18 months, both groups with mild and moderate lymphoedema showed improvement in coping [odds ratio (OR): 6.67, 95% confidence interval (CI): 3.30-13.47] and performance of ADLs (OR: 7.46, CI: 3.38-16.47). Over the course of 18 months, men were found to have poorer coping scores than women (OR: 2.91, CI: 1.35-6.27). Lymphoedema was associated with improvement in coping over time (P = 0.08) and a higher reported interference with ADLs (OR: 2.53, CI: 1.29-4.97). Patient education about lymphoedema at the time of surgical consent may improve self-efficacy and coping ability. Effective management of lymphoedema may improve patient QOL and reduce interference with ADLs.

The surgical treatment of lymphedema: a systematic review of the contemporary literature (2004-2010)

PURPOSE

A systematic review of the literature was performed to examine contemporary peer-reviewed literature (2004-2010) evaluating the surgical treatment of lymphedema.

METHODS

A comprehensive search of 11 major medical indices was performed. Selected articles were sorted to identify those related to the surgical treatment of lymphedema. Extracted data included the number of patients, specific surgical procedure performed, length of follow-up, criteria for defining lymphedema, measurement methods, volume or circumference reduction, and reported complications.

RESULTS

A total of 20 studies met inclusion criteria; procedures were categorized as excisional procedures (n = 8), lymphatic reconstruction (n = 8), and tissue transfer (n = 4). The reported incidence of volume reduction of lymphedema in these studies varied from 118% reduction to a 13% increase over the follow-up intervals ranging from 6 months to 15 years. The largest reported reductions were noted after excisional procedures (91.1%), lymphatic reconstruction (54.9%), and tissue transfer procedures (47.6%). Procedure complications were rarely reported.

CONCLUSIONS

A number of surgical approaches have demonstrated beneficial effects for select patients with lymphedema. Most of these reports, however, are based on small numbers of patients, use nonstandardized or inconsistent measurement techniques, and lack long-term follow-up. The proposed benefits of any surgical approach should be evaluated in the context of the potential morbidity to the individual patient and the availability of surgical expertise. In addition, although these surgical techniques have shown promising results, nearly all note that the procedures do not obviate the need for continued use of conventional therapies, including compression, for long-term maintenance.

Occurrence of Lymphedema Continues To Increase Twelve to Thirty Months after Breast Cancer Treatment

Introduction:Breast cancer (BC) survivors are at lifetime risk for developing lymphedema (LE), the accumulation of protein-rich fluid in the interstitial spaces of the affected body part due to a blockage or malfunction in the lymph system. This is different than swelling which may occur immediately after surgery and may be present at the post-op visit, and the physical and psychological aspects of the condition greatly impact the daily lives of LE patients (Geller et al., 2003, Hull, 1998). Of those affected by breast cancer, up to 40% will develop LE, potentially comprising 1 to 5 million survivors. However, all breast cancer survivors are considered at risk for the condition (American Cancer Society, 2007).While numerous studies have reported LE incidence during the first 12 months following breast cancer treatment, little is known regarding long-term LE diagnosis. Very few studies have examined LE incidence past 1 year post-treatment, and many that have are retrospective or cross-sectional, not prospective, in nature. In fact, in one analysis of existing literature the study with the shortest follow-up (12 months) reported the lowest LE incidence (Ball et al., 1992) and the study with the longest follow-up (11 years) reported the highest incidence (Schunemann and Willich, 1997).Methods:Participants were enrolled following diagnosis of BC but before treatment and followed every 3 months for 12 months, then every 6 months until 2.5 years post-surgery. Limb volume changes (LVC) were measured using: (a) circumferences via tape measure at 4 cm intervals, (b) infra-red laser perometry, and (c) symptom experience (SS) via interview. Four diagnostic criteria for LE were used: (i) 2 cm circumferential change; (ii) 200 mL perometry LVC; (iii) 10% perometry LVC; and (iv) report of limb heaviness/swelling, 'now' or 'in the past year'. Standard survival analysis methods were applied to identify when the LE criteria were met.Results:At 30 months post-treatment, LE incidence using the four criteria ranged from 41%- 91% and had continued to increase over time, with 2 cm being the highest estimation method and SS the lowest.Conclusions:These preliminary findings provide additional evidence that BC survivors continue to be at risk for developing LE beyond the first year following treatment. LE identification, regardless of the criteria used, continued to increase past the initial 12 months post-treatment. From month 12 to month 30, LE identification increased by an additional 10-27%, depending on the criteria used. While identification of LE via symptom experience in the initial 12 months occurred in 31% of participants, only an additional 10% met the criteria at 30 months, by far the lowest incidence rate among all criteria. Overall, this analysis finds 2 cm criteria as the most liberal definition of LE (91%), while self-report of heaviness and swelling, along with 10% LVC, represent the most conservative definitions (41% and 45%, respectively).

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2070.

Breast Cancer Survivors Often Meet Multiple Criteria for Lymphedema

Introduction:Assessment and diagnosis of lymphedema (LE) has been problematic, in part due to the fact that various measurement approaches and criteria have been applied. This analysis examines four different criteria for diagnosing lymphedema among breast cancer survivors. Recent scientific literature reports that anywhere from 6 to 30 percent (Petrek and Heelan, 1998) or 6 to 62.5 percent (Passik, 1998) of the breast cancer population has LE. The discrepancies among the reported percentages stem from difficulties in measurement, diagnosis, and follow-up (Petrek and Heelan, 1998, Passik, 1998, Rockson, 1998, Meek, 1998, Armer and Stewart, 2005, Hayes et al., 2008). Traditionally, finding &gt;2cm difference in limb girth between the affected and non-affected limbs warranted clinical diagnosis of LE (Callaway, 1988, Armer and Stewart, 2005). Measuring a 200 ml limb volume difference or a 10 percent limb volume change (LVC) from baseline and/or between limbs as well as self-reported signs and symptoms are also documented methods of LE diagnosis (Petlund, 1991, Armer and Stewart, 2005).Methods:Participants were enrolled post-breast cancer diagnosis but pre-surgery, and followed every 3 months for 12 months, then every 6 months until 2.5 years post-surgery. Limb volume changes (LVC) were measured using: (a) circumferences via tape measure at 4 cm intervals, (b) infra-red laser perometry, and (c) symptom experience (SS) via interview. Four diagnostic criteria for LE were used: (i) 2cm circumferential change; (ii) 200 mL perometry LVC; (iii) 10% perometry LVC; and (iv) self-report of limb heaviness/swelling.Results:In this cohort, 84% met at least one criterion to identify lymphedema by 2.5 years post-treatment (Figure 1). The most common single criterion met was 2-cm circumferential change (25%). When examining meeting multiple criteria, 13% of participants met the combination of 200mL LVC, 10% LVC, and 2cm change. In addition, 11% of participants met all four lymphedema criteria by 2.5 years post treatment.Conclusions:This analysis demonstrates breast cancer survivors who develop lymphedema often meet multiple criteria for the condition. We found 62% of those with lymphedema met two or more criteria used in this analysis, and 31% met three or more criteria. The most common criterion to identify lymphedema, either alone or associated with one or more criteria, was 2 cm circumference change (77%), while 10% LVC was least likely to be met (26%).

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2074.

Demystifying lymphedema: development of the lymphedema putting evidence into practice card

Cancer treatment is the leading cause of lymphedema in developed countries. Development and severity of lymphedema have a significant impact on comfort, psychological distress, and overall quality of life. Incidence statistics have ranged from 5%-60%, with onset of symptoms ranging from immediately after treatment to 30 years after treatment. Oncology nurses caring for patients throughout the cancer trajectory have a critical role to play in early assessment of risk, prompt identification of lymphedema, and implementation of evidence-based, individualized treatment plans in collaboration with therapists. As part of an Oncology Nursing Society (ONS) project team, the authors of this article undertook a review of current literature to identify effective interventions for the treatment of secondary lymphedema. Following the guidelines established by the ONS Evidence-Based Practice Resource Team, the authors evaluated current clinical practice guidelines, systematic reviews, and research studies conducted since 1998. The team reviewed and synthesized the literature and developed evidence tables and a Putting Evidence Into Practice(R) (PEP) card. The data were reviewed by experts in the field of lymphedema management. The lymphedema ONS PEP card, a user-friendly, succinct summary of interventions, was released at the 33rd Annual ONS Congress in May 2008.

SELF-REPORTED MANAGEMENT OF BREAST CANCER-RELATED LYMPHOEDEMA

BACKGROUND: Improvements in breast cancer treatment and early diagnosis are leading to increasing numbers of breast cancer survivors, many of whom are experiencing upper limb lymphoedema as a post-treatment outcome. Current management techniques of breast cancer-related lymphoedema produce uneven results, signifying a need for research in this area. AIMS: To assess the symptom management practices of breast cancer survivors experiencing cancer-related lymphoedema by identifying and quantifying self-care management practices. METHODS: The Lymphoedema Breast Cancer Questionnaire (LBCQ) was given to 40 breast cancer survivors with either self- or medical diagnosis of upper limb lymphoedema ipsilateral to the breast treated for cancer. RESULTS: Findings revealed three main themes: recommended management techniques, pharmaceutical treatments, and lay symptom management techniques. Further categorisation suggested that clusters of similar related symptoms (e.g. heaviness, aching, tenderness, and tightness/firmness) tend to be managed or not managed in similar ways. CONCLUSIONS: Healthcare professionals need to recognise the scope and diversity of self-management practices that breast cancer survivors choose in managing their lymphoedema symptoms. A critical next step is the rigorous evaluation of the effectiveness of these self-management modalities.

Upper limb swelling following mastectomy: lymphedema or not?

Having experienced an excisional biopsy, sentinel lymph node biopsy, and mastectomy, BH is at lifetime risk of developing post-breast cancer lymphedema in the arm on the side where her breast cancer was treated. She has two additional risk factors, among those documented in the literature: history of an infection (specifically a systemic infection, significant in that it required hospitalization for intravenous antibiotics) in the postsurgery period, and a moderate increase in bilateral limb volume and weight (body mass index) over the months and years following the breast cancer diagnosis. Further, the patient-reported transient hand swelling on the affected side and gradual weight increase are cues indicating a need for patient vigilance and careful monitoring by the health-care team. Preventing future infections, managing weight at an optimal level, and preventing trauma or injury to the affected arm and chest are important self-management precautions to reduce risk of chronic lymphedema development. BH needs continued support in reviewing evidence-based risk-reduction guidelines and understanding ways to apply them to her lifestyle. In the absence of preoperative baseline or contralateral limb measurements (with circumferences or perometry or water displacement), assessment of limb change at a level identified as diagnostic of lymphedema (commonly, 200-mL volume or 2-cm girth increase from baseline or as compared to the contralateral limb) is very challenging. Without bilateral preop limb measurements for baseline and contralateral limb comparisons, BH might have been diagnosed with lymphedema at postop or at 48 months, when both limbs increased symmetrically. Symptom assessment is also crucial, as symptom report of heaviness and swelling is found to be associated with limb volume changes indicative of lymphedema. Transient hand swelling may be evidence of latent lymphedema and cause for increased risk-reduction education and vigilance in assessment for emergence of nonresolving chronic lymphedema. million American women are breast cancer survivors. According to the American Cancer Society, every person treated for cancer with lymph node removal, surgery, or radiation has a lifetime risk for lymphedema, swelling caused by an increase in protein-rich interstitial fluid. Some will develop lymphedema soon after cancer treatment (within weeks or months) and others may not experience

The cancer and leukemia group B oncology nursing committee (1983-2006): a history of passion, commitment, challenge, and accomplishment

The Cancer and Leukemia Group B (CALGB) Oncology Nursing Committee (ONC) was initially established in 1983 as a working group with the specific aim of promoting protocol compliance through collaboration, communication, and education to enhance the scientific goals of the Group. Due to the efforts of its members, the committee gained full committee status. ONC members now serve as principal investigators and coinvestigators on research studies, continue to sponsor biannual educational sessions individually and in concert with other CALGB committees, and continue to develop tools to enlighten patients about their disease and the clinical trial process. The ONC, an administrative group of 12 members, provides leadership within CALGB. Although ONC members have always acted as liaisons to the disease and modality committees, three positions have recently been designated specifically for doctorally prepared nurse scientists. Since its inception, general nurse membership within the group has more than doubled to a total of more than 500 members.

Home-based Comprehensive Assessment of Rural Elderly Persons: The CARE Project

CONTEXT

Home-based comprehensive geriatric assessment (CGA) has been effective in urban areas but has had little study in rural areas. CGA involves medical history taking, a physical exam, and evaluation of functional status, mental status, cognitive status, gait and balance, medications, vision, extent of social supports, and home safety. We sought to develop and pilot a model of rural home-based CGA to determine whether successful urban models can be adapted to rural areas.

METHODS

This study was a developmental demonstration project with qualitative and quantitative evaluation components of a home-based CGA model using a home health agency and a geriatrician participating from a remote location by teleconference. Findings and recommendations were relayed to patients, caregivers, and primary physicians. The population studied was elderly volunteers (N = 51) aged 75 years and older who did not have a terminal diagnosis or immediate plans to enter a long-term care facility. Survey instruments and focus groups were used with subjects, family members or caregivers, and physicians to generate refinements and outcome measures for the model.

FINDINGS

Among the 51 patients undergoing CGA, Instrumental Activities of Daily Living dependency and balance and gait problems were highly prevalent. Means of 1.1 major problems and 4.9 nonmajor problems were identified per patient. Recommendations were implemented for 32% of major problems and for 35% of nonmajor problems. Primary physicians found recommendations for vaccination and home safety change helpful but were skeptical of physical examination findings by the nurse. Practitioners noted that this study resulted in several positive outcomes: (1) some subjects initiated regular clinic visits; (2) several visually impaired elders began services for the blind; (3) identification of gait and balance problems resulted in physical therapy treatment; and (4) identification of caregiver stress was addressed by social-work intervention. Potential further refinements of the model for rural home-based CGA were identified.

CONCLUSIONS

Home-based CGA identifies important problems of rural older adults. However, modifications are still needed to create a truly effective process.

Age differences in post-breast cancer lymphedema signs and symptoms

This secondary data analysis was designed to explore the age differences in lymphedema (LE) occurrence and self-reported symptoms in post-breast cancer LE. A descriptive-exploratory cross-sectional design was used with a convenience sample composed of 102 women treated and followed for breast cancer at a midwestern cancer center. Sequential circumferential arm measurement was used to estimate limb volume differences. Self-reported symptoms were assessed by the Lymphedema and Breast Cancer Questionnaire (LBCQ) designed and tested by the research team. Lymphedema occurrence was relatively higher (41.2%) in breast cancer survivors younger than 60 than in those older than 60 (30.6%). Six subjectively reported symptoms were found to occur more often (P </= .05) in the younger women with LE: numbness now and in the past year, tenderness in the past year, aching now and in the past year, increased temperature in arm now. Numbness, tenderness, and aching were the most prevalent symptoms among women in both age groups regardless of LE presence. Our findings suggest that younger breast cancer survivors may have increased LE risk and report LE-related symptoms more often. Future research should focus on age differences in LE risk, occurrence, and perceptions of LE-related symptoms in women treated for breast cancer.

Lymphedema following breast cancer treatment, including sentinel lymph node biopsy

To compare the occurrence, signs, and symptoms of lymphedema (LE) the arms of women after axillary lymph node dissection (ALND), sentinel lymph node biopsy (SLNB), combined SLNB and ALND (Both), or neither as part of breast cancer diagnosis and treatment, a concurrent descriptive-comparative cross-sectional four-group design with retrospective chart review was carried out. In a convenience sample of 102 women treated for breast cancer and receiving follow-up care at a midwestern United States cancer center, sequential circumferential measurements at five selected anatomical sites along both arms and hands were used to determine the presence of LE (> or = 2 cm differences between sites). Participants self-reported LE-related signs and symptoms by interview and completion of the Lymphedema and Breast Cancer Questionnaire (LBCQ). Retrospective chart review was carried out to verify lymph node-related diagnostic and treatment procedures. Based on node group, LE occurred as follows: 43.3% (29 of 67) of women who underwent ALND alone; 22.2% (2 of 9) of those who underwent SLNB alone; 25.0% (3 of 12) of those with combined SLNB and ALND; and 22.2% (2 of 9) with neither SLNB nor ALND. LE-related symptoms were reported by women who underwent ALND alone, SLND alone, combined SLNB and ALND, and neither. Among the node groups, three symptoms were more common: larger arm size, firmness/tightness in past year, and numbness in past year. We conclude that circumferential measurements of the upper arm and forearm may be critical for distinguishing LE from no LE. Overall, the proportion of women who experienced LE-related signs and symptoms was higher among women who underwent ALND versus SLNB. However, numbness and tenderness frequently were reported by those undergoing ALND, SLNB or both; and by women without LE. It is possible that some frequently occurring symptoms, such as numbness and tenderness, may be related to breast cancer surgery and not LE. Findings from this study can assist health professionals in educating women with breast cancer about LE risk factors, as well as early detection and management of LE by using the LBCQ and sequential circumferential arm measurements to evaluate limb changes subjectively and objectively concurrent with each breast cancer survivor's follow-up care.

Patients' perceptions of fatigue in response to biochemotherapy for metastatic melanoma: a preliminary study

PURPOSE/OBJECTIVES

To explore patients' perceptions of fatigue in response to biochemotherapy treatment for metastatic melanoma.

DESIGN

A descriptive-correlational, cross-sectional study.

SETTING

A cancer center in the midwestern United States.

SAMPLE

12 adult patients between the ages of 28-70 who received at least one cycle of biochemotherapy treatment for metastatic melanoma (stages III and IV) from the inpatient or outpatient services of a midwestern cancer center.

METHODS

A demographic data sheet and the Revised Piper Fatigue Scale (PFS) were used to collect data at a single point in time after patients received at least one cycle of biochemotherapy.

FINDINGS

The majority of patients who received biochemotherapy reported severe or moderate fatigue. Female patients' total fatigue scores were higher than those of male patients. Fatigue duration varied from hours to months, with a maximum duration of 12 months after biochemotherapy treatment. All of the patients reported that the most direct causes of their fatigue were metastatic melanoma and biochemotherapy treatment.

CONCLUSIONS

Patients who received biochemotherapy treatment for metastatic melanoma reported moderate to severe fatigue. Female patients experienced more intense fatigue than male patients. The findings also supported the multidimensionality of fatigue construct identified in prior fatigue studies. The four dimensions/subscales of fatigue assessed by the Revised PFS were highly correlated to total fatigue scores.

IMPLICATIONS FOR NURSING

Biochemotherapy is a newer treatment modality for metastatic melanoma. Fatigue, one of the severe toxicities from biochemotherapy treatment, necessitates attention from nurses. The findings will assist nurses in teaching patients about fatigue that may be expected during or after biochemotherapy and about self-care strategies to manage fatigue.