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PurposeBreast cancer-related lymphedema (BCRL) represents a significant concern for patients following breast cancer treatment, and assessment for BCRL represents a key component of survivorship efforts. Growing data has demonstrated the benefits of early detection and treatment of BCRL. Traditional diagnostic modalities are less able to detect reversible subclinical BCRL while newer techniques such as bioimpedance spectroscopy (BIS) have shown the ability to detect subclinical BCRL, allowing for early intervention and low rates of chronic BCRL with level I evidence. We present updated clinical practice guidelines for BIS utilization to assess for BCRL.Methods and ResultsReview of the literature identified a randomized controlled trial and other published data which form the basis for the recommendations made. The final results of the PREVENT trial, with 3-year follow-up, demonstrated an absolute reduction of 11.3% and relative reduction of 59% in chronic BCRL (through utilization of compression garment therapy) with BIS as compared to tape measurement. This is in keeping with real-world data demonstrating the effectiveness of BIS in a prospective surveillance model. For optimal outcomes patients should receive an initial pre-treatment measurement and subsequently be followed at a minimum quarterly for first 3 years then biannually for years 4–5, then annually as appropriate, consistent with previous guidelines; the target for intervention has been changed from a change in L-Dex of 10 to 6.5. The lack of pre-operative measure does not preclude inclusion in the prospective surveillance model of care.ConclusionThe updated clinical practice guidelines present a standardized approach for a prospective model of care using BIS for BCRL assessment and supported by evidence from a randomized controlled trial as well as real-world data.

Purpose This study aimed to compare the effects of virtual reality (VR) training and resistance exercises training on lymphedema symptom severity as well as physical functioning and QoL in women with breast cancer–related lymphedema (BCRL). Methods In a single blinded randomized trial, women diagnosed with unilateral BCRL were randomly divided into two groups: the Xbox Kinect group received VR Kinect-based games ( n  = 30) and resistance exercise group received resistance training ( n  = 30). In addition, both groups received complex decongestive physiotherapy (manual lymphatic drainage, compression bandages, skin care, and exercises). The intervention was conducted five sessions per week for 8 weeks. The outcome measures included excessive limb volume, visual analogue scale (VAS), the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire, shoulder range of motion (ROM), shoulder muscles strength, hand grip strength, and Study Short-Form (SF-36). The outcomes were evaluated pre and post intervention (week 8). Results Statistical significant differences were recorded in VAS (pain intensity), DASH, shoulder ROM ( p  < 0.001), bodily pain ( p  = 0.002), general health ( p  < 0.001), and vitality ( p  = 0.006) in favor of the Xbox Kinect group. However, there were statistically significant differences in shoulder flexion strength ( p  = 0.002), external rotation strength ( p  = 0.004), and abduction strength and handgrip strength ( p  < 0.001) in favor of the resistance exercise group. Conclusions The VR training was superior to resistance exercises training in BCRL management. The empirical findings support the VR as a new effective and encouraging intervention modality which can assist in improving physical functioning and quality of life in women with BCRL. Trial registration This study is retrospectively registered at ClinicalTrials.gov (ID: NCT04724356).

Purpose A combined body weight loss and upper body/arm exercise programme is a potential strategy for managing Breast cancer related lymphoedema (BCRL), but there is limited data on the best method for delivery or its potential efficacy. Methods Fifty-seven women with overweight/obesity and BCRL were randomised to a 12 week supervised ( n  = 12) or home-based combined weight loss and upper body/arm exercise programme ( n  = 16), a home-based upper-body arm exercise only programme ( n  = 17) or standard care ( n  = 12). Primary outcomes were uptake, retention and changes in weight and change in Relative Arm Volume Increase (RAVI) using analysis of covariance (ANCOVA). Results Sixteen percent of women invited joined the study and 49 completed the trial (85% retention). Reductions in weight occurred in the supervised and home-based weight control and exercise programmes; Mean (95% CI) change compared to standard care − 1.68 (− 4.36 to − 1.00), − 2.47(− 4.99 to − 0.04) Kg. Reductions in perometer assessed RAVI were seen in the supervised and home-based combined weight control and arm exercise groups and the weight stable home-based arm exercise only group: mean (95% CI) change compared to standard care − 2.4 (− 5.0 to + 0.4),− 1.8 (− 4.3 to + 0.7), − 2.5(− 4.9 to − 0.05)%. Conclusion Women with BCRL and overweight and obesity engaged in diet and exercise weight loss programmes. Both weight loss/arm exercise programmes led to modest changes in weight and BCRL. Comparable reductions in BCRL were reported in the weight stable group undertaking arm exercise only. The independent and combined effects of weight loss and exercise on BCRL need further study. Trial registration ISRCTN86789850 https://doi.org/10.1186/ISRCTN86789850 , registered 2011.

IntroductionUp to one-fifth of breast cancer survivors will develop chronic breast cancer-related lymphoedema (BCRL). To date, complex physical decongestion therapy (CDT) is the gold standard of treatment. However, it is mainly symptomatic and often ineffective in preventing BCRL progression. Lymphovenous anastomosis (LVA) and vascularised lymph node transfer (VLNT) are microsurgical techniques that aim to restore lymphatic drainage. This international randomised trial aims to evaluate advantages of microsurgical interventions plus CDT versus CDT alone for BCRL treatment.Methods and analysisThe effectiveness of LVA and/or VLNT in combination with CDT, which may be combined with liposuction, versus CDT alone will be evaluated in routine practice across the globe. Patients with BCRL will be randomly allocated to either surgical or conservative therapy. The primary end point of this trial is the patient-reported quality of life (QoL) outcome ‘lymphoedema-specific QoL’, which will be assessed 15 months after randomisation. Secondary end points are further patient-reported outcomes (PROs), arm volume measurements, economic evaluations and imaging at different time points. A long-term follow-up will be conducted up to 10 years after randomisation. A total of 280 patients will be recruited in over 20 sites worldwide.Ethics and disseminationThis study will be conducted in compliance with the Declaration of Helsinki and the International Council for Harmonisation-Good Clinical Practice (ICH-GCP) E6 guideline. Ethical approval has been obtained by the lead ethics committee ‘Ethikkommission Nordwest- und Zentralschweiz’ (2023-00733, 22 May 2023). Ethical approval from local authorities will be sought for all participating sites. Regardless of outcomes, the findings will be published in a peer-reviewed medical journal. Metadata detailing the dataset’s type, size and content will be made available, along with the full study protocol and case report forms, in public repositories in compliance with the Findability, Accessibility, Interoperability and Reuse principles.Trial registration number NCT05890677.

Purpose The aim of this study was to evaluate the effect of compression bandage applied with different pressures on the skin and subcutaneous thickness in individuals with breast cancer-related lymphedema (BCRL). Methods 21 individuals with stage 2 unilateral BCRL participated in the study. Individuals were randomly allocated into two groups as low-pressure bandage (20–30 mmHg) ( n : 11) and high-pressure bandage (45–55 mmHg) ( n : 10). Skin and subcutaneous tissue thickness, extremity volume, sleep quality, treatment benefit, and comfort were evaluated by ultrasound from 6 reference points (as hand dorsum, wrist volar, forearm volar, arm volar, forearm dorsum, and arm dorsum), volumetric measurement, Pittsburgh Sleep Quality Index, Patient Benefit Index-Lymphedema, and visual analog scale, respectively. Complex decongestive physiotherapy was applied to both groups. Compression bandage was applied according to their group. Individuals were evaluated at the baseline, 1st session, 10th session, 20th session, and at 3-month follow-up. Results Skin thickness decreased significantly in the volar reference points of the extremity in the high-pressure bandage group ( p  = 0.004, p  = 0.031, and p  = 0.003). Subcutaneous tissue thickness significantly decreased at all reference points in the high-pressure bandage group ( p  < 0.05). In the low-pressure bandage group, skin thickness only decreased in the forearm dorsum and the arm dorsum ( p  = 0.002, p  = 0.035) and subcutaneous tissue thickness changed for all points ( p  < 0.05) except for hand and arm dorsum ( p  = 0.064, p  = 0.236). Edema decreased in a shorter time in the high-pressure bandage group ( p  < 0.001). No significant differences were found in sleep quality, treatment benefit, and comfort for both groups ( p  = 0.316, p  = 0.300, and p  = 0.557, respectively). Conclusion High pressure was more effective in reducing subcutaneous tissue thickness in the dorsum of hand and arm. The usage of high-pressure can be recommended especially in cases which have edema in the dorsum of hand and arm which is difficult to resolve. Also, high-pressure bandage can provide faster edema resolution and can be used in rapid volume reduction as desired. Treatment outcomes may improve with high-pressure bandage without any impairment in comfort, sleep quality, and treatment benefit. Trial registration number and date NCT05660590, 12/26/2022 retrospectively registered.

The objective of this study is to evaluate the effect of Tuina combined with moxibustion on relieving breast cancer–related lymphedema (BCRL). A randomized cross-over controlled trial was conducted at our institution. All patients with BCRL were assigned to 2 groups: Group A and Group B. In the first period (weeks 1-4), tuina and moxibustion were performed in Group A and pneumatic circulation and compression garment in Group B. The washout period took place from weeks 5 to 6. In the second period (weeks 7-10), pneumatic circulation and compression garment were performed in Group A, and tuina and moxibustion in Group B. Therapeutic efficacy was evaluated by measuring the affected arm volume, circumference, and Visual Analog Scale for swelling. Regarding the results, a total of 40 patients were included, and 5 cases were dropped. After treatment, both the traditional Chinses medicine (TCM) treatment and complete decongestive therapy (CDT) was found to reduce the volume of the affected arm (P < .05). At the endpoint (visit 3), compared with CDT, the effect of the TCM treatment was more evident than that of CDT (P < .05). After the TCM treatment, the arm circumference at the elbow crease and proximal 10 cm to elbow crease was reduced, which was statistically different from that before treatment (P < .05). Post-CDT treatment, the arm circumference at proximal 10 cm to wrist crease and the elbow crease and proximal 10 cm to elbow crease decreased, which was statistically different from that before treatment (P < .05). At the endpoint (visit 3), the arm circumference at proximal 10 cm to elbow crease of the patients treated with TCM was less than that of CDT (P < .05). Moreover, the VAS scores for swelling were better after compared with before TCM treatment and CDT (P < .05). At the endpoint (visit 3), the subjective relief of swelling by TCM treatment was greater than CDT (P < .05). Ultimately, tuina combined with moxibustion can alleviate BCRL symptoms, which is primarily reflected in reducing the affected arm volume and circumference and relieving swelling. Trial registration: Chinese Clinical Trial Registry (Registration Number ChiCTR1800016498).

Background The PREVENT randomized control trial monitored progression to chronic breast cancer-related lymphedema (cBCRL) following intervention for subclinical breast cancer-related lymphedema (sBCRL) assessed by bioimpedance spectroscopy (BIS) versus tape-measure (TM). This multi-institutional trial demonstrated a 92% risk reduction of developing cBCRL. This secondary analysis reviews the timing of sBCRL and cBCRL following breast cancer (BC) treatment. Patients and Methods Women at risk of cBCRL ( n = 919) were screened regularly up to 36 months after BC treatment using either BIS or TM. Following diagnosis of sBCRL, patients underwent a 4-week compression sleeve intervention. The time in months from BC treatment to detection was reviewed at 3-month intervals. Results In total 209 patients developed sBCRL (BIS: n = 89, TM: n = 120) and were eligible for intervention. 30 progressed to cBCRL postintervention (BIS: 7, TM: 23). More than half of patients had measurements consistent with sBCRL within 9 months of BC treatment. Patients continued to have initial detections of sBCRL, regardless of screening method, with rates remaining consistent in years two and three ( p > 0.242) post surgery. Additionally, 39 patients progressed to cBCRL without developing sBCRL or receiving intervention across the 3-year period. Conclusions The timing of sBCRL detection demonstrates that patients continue to be at risk years after treatment and may continue to progress to cBCRL years after surgery. Early detection of sBCRL allows for early intervention decreasing the likelihood of progression to cBCRL. Patients should continue to be monitored for a minimum of 3 years following completion of cancer treatment. Specifically, careful targeted monitoring over the initial 9-month period is important.

IntroductionBreast cancer-related lymphedema (BCRL) is a common postoperative complication of breast cancer. It develops in a chronic and vicious cycle. Once lymphedema occurs, it cannot be cured and bring serious physiological, psychological, social and economic burden to patients. Upper limb functional exercises are an effective and convenient intervention for managing lymphedema. However, the optimal exercise sequence remains unclear. Therefore, we aim to compare the effects of exercise sequences under the guidance of commonly used exercise sequences and lymphatic flow theory.MethodsAn exploratory randomised controlled cross-over trial will be conducted. 32 patients with BCRL are randomly allocated into two groups (group A and group B). Group A patients will perform functional exercise from wrist joint to shoulder joint, and the exercise direction of group B is opposite to that of group A, that is, from shoulder joint to wrist joint end. Exercise time is once a day, each 20–30 min, for 2 weeks. After 2 weeks of washout period, A and B groups of exchange exercise sequences (exercise frequency and duration unchanged). The primary outcome is upper limb circumference, and secondary outcomes are upper limb function and lymphedema symptoms.Ethics and disseminationThis study protocol is presented in accordance with the Standard Protocol Items: Recommendations for Interventional Trials guidelines. All participants will sign a written informed consent. The research ethics regional committee of Shanghai Seventh People’s Hospital has approved the study. Regardless of the outcome of this study, the results will be published in open-access journals to ensure public access.Trial registration numberChiCTR2200066463.

Several recent studies have investigated the validity of precautionary practices for lymphedema risk reduction after breast cancer treatment, such as avoidance of blood pressure measurements, skin puncture, blood draws, and use of prophylactic compression during air travel. Other studies have elucidated risk factors for breast cancer-related lymphedema, such as axillary lymph node dissection and skin infection (cellulitis). Combining the current evidence base with the consensus opinion of lymphatic experts assembled at the American Cancer Society/Lymphology Association of North America Summit in October 2023, updated evidence-based risk reduction recommendations are presented for those with or at risk of breast cancer-related lymphedema. Recommendation topics include prospective surveillance, patient education, individual risk factors, exercise, blood pressure, skin care and hygiene, skin puncture and blood draws, surgical procedures, prophylactic compression, air travel, and hot climate and sauna. These recommendations will help inform education and medical choices for individuals treated for breast cancer who are at risk of or diagnosed with breast cancer-related lymphedema. More high-quality evidence is required to allow the development of risk reduction recommendations for other cancer types such as gynecological, melanoma, and head and neck. It is recommended that clinicians and organizations serving people at risk of or with lymphedema align risk reduction guidelines with the evidence-based recommendations provided within this consensus document and companion manuscripts from the American Cancer Society/Lymphology Association of North America Lymphedema Summit: Forward Momentum: Future Steps in Lymphedema Management.