Recent progress in the treatment and prevention of cancer-related lymphedema.

This article provides an overview of the recent developments in the diagnosis, treatment, and prevention of cancer-related lymphedema. Lymphedema incidence by tumor site is evaluated. Measurement techniques and trends in patient education and treatment are also summarized to include current trends in therapeutic and surgical treatment options as well as longer-term management. Finally, an overview of the policies related to insurance coverage and reimbursement will give the clinician an overview of important trends in the diagnosis, treatment, and management of cancer-related lymphedema.

The long-term risk of upper-extremity lymphedema is two-fold higher in breast cancer patients than in melanoma patients.

BACKGROUND AND OBJECTIVES: We assessed the cumulative incidence, symptoms, and risk factors for upper-extremity lymphedema in breast cancer and melanoma patients undergoing sentinel lymph node biopsy or axillary lymph node dissection. METHODS: Patients were recruited preoperatively (time 0) and assessed at 6, 12, and 18 months postoperatively. Limb volume change (LVC) was measured by perometry. Lymphedema was categorized as none, mild (LVC 5-9.9%), or moderate/severe (LVC≥10%). Symptoms were assessed with a validated lymphedema instrument. Longitudinal logistic regression analyses were conducted to identify risk factors associated with moderate/severe lymphedema. RESULTS: Among 205 breast cancer and 144 melanoma patients, the cumulative incidence of moderate/severe lymphedema at 18 months was 36.5% and 35.0%, respectively. However, in adjusted analyses, factors associated with moderate/severe lymphedema were breast cancer (OR 2.0, P = 0.03), body mass index ≥ 30 kg/m(2) (OR 1.6, P = 0.04), greater number of lymph nodes removed (OR 1.05, P < 0.01), and longer interval since surgery (OR 2.33 at 18 months, P < 0.01). CONCLUSIONS: Lymphedema incidence increased over time in both cohorts. However, the adjusted risk of moderate/severe lymphedema was two-fold higher in breast cancer patients. These results may be attributed to surgical treatment of the primary tumor in the breast and more frequent use of radiation.

Is surveillance imaging effective for detecting surgically treatable recurrences in patients with melanoma? A comparative analysis of stage-specific surveillance strategies.

OBJECTIVE: To guide resource utilization, we aimed to determine the impact of routine surveillance imaging for the detection of melanoma recurrences amenable to surgical resection with curative intent. BACKGROUND: The National Comprehensive Cancer Network guidelines for melanoma surveillance are largely consensus based. METHODS: Using single-institution, patient-level data (n = 1600), transition probabilities were calculated for a Markov model simulating the natural history of patients with stage I-III melanoma. As a base estimate, imaging was assumed to detect regional and distant recurrences of which 80% and 20% could be surgically treated with curative intent, respectively. Sensitivity analyses were conducted for all point estimates. For each disease stage, we calculated the number of surgically treatable regional or distant recurrence detected during 5 years per 10,000 patients undergoing computed tomography (CT) or positron emission tomography (PET)/CT scans at 6- or 12-month intervals. The associated positive and negative predictive values and life expectancy were also calculated and compared with clinical examination alone. RESULTS: At 5-year follow-up, CT or PET/CT at 6-month intervals detected surgically treatable regional or distant recurrence in 6.4% of patients with stage I, 18.5% of stage II, and 33.1% of stage III disease; 12-month intervals decreased the rates to 3.0%, 7.9%, and 13.0%, respectively. The high false-positive rates of CT (20%) and PET/CT (9%) resulted in overall low positive predictive values. However, both CT and PET/CT effectively predicted absence of disease. Life-expectancy gains were minimal (≤ 2 months) for all groups. CONCLUSIONS: The effectiveness of routine surveillance imaging for detecting treatable melanoma recurrences is limited. Even in patients with stage III disease, only minimal gains in life expectancy were achieved.

Surgeon symptoms, strain, and selections: Systematic review and meta-analysis of surgical ergonomics.

BACKGROUND: Many surgeons experience work-related pain and musculoskeletal symptoms; however, comprehensive reporting of surgeon ailments is lacking in the literature. We sought to evaluate surgeons' work-related symptoms, possible causes of these symptoms, and to report outcomes associated with those symptoms. MATERIALS AND METHODS: Five major medical indices were queried for articles published between 1980 and 2014. Included articles evaluated musculoskeletal symptoms and ergonomic outcomes in surgeons. A meta-analysis using a fixed-effect model was used to report pooled results. RESULTS: Forty articles with 5152 surveyed surgeons were included. Sixty-eight percent of surgeons surveyed reported generalized pain. Site-specific pain included pain in the back (50%), neck (48%), and arm or shoulder (43%). Fatigue was reported by 71% of surgeons, numbness by 37%, and stiffness by 45%. Compared with surgeons performing open surgery, surgeons performing minimally invasive surgery (MIS) were significantly more likely to experience pain in the neck (OR 2.77 [95% CI 1.30-5.93]), arm or shoulder (OR 4.59 [2.19-9.61]), hands (OR 2.99 [1.33-6.71], and legs (OR 12.34 [5.43-28.06]) and experience higher odds of fatigue (8.09 [5.60-11.70]) and numbness (6.82 [1.75-26.65]). Operating exacerbated pain in 61% of surgeons, but only 29% sought treatment for their symptoms. We found no direct association between muscles strained and symptoms. CONCLUSIONS: Most surgeons report work-related symptoms but are unlikely to seek medical attention. MIS surgeons are significantly more likely to experience musculoskeletal symptoms than surgeons performing open surgery. Symptoms experienced do not necessarily correlate with strain.

Do No Harm, Except to Ourselves? A Survey of Symptoms and Injuries in Oncologic Surgeons and Pilot Study of an Intraoperative Ergonomic Intervention.

BACKGROUND: Occupational symptoms and injuries incurred over a surgical career are under- reported, yet they have an impact on daily surgical practice. We assessed the frequency, consequences, and risk factors for occupational injury in oncologic surgeons and evaluated the feasibility of intraoperative foot mat use to mitigate occupational symptoms. STUDY DESIGN: Oncologic surgeons completed a survey of demographic information and occupational symptoms and injuries. Multivariate logistic regression was used to identify factors associated with occupational symptoms and injuries. A randomized cross-over pilot study of intraoperative foot mat use was conducted. RESULTS: One hundred twenty-seven surgeons completed surveys (response rate: 58%). The most commonly reported symptoms were fatigue, discomfort, stiffness, and back pain. An occupational injury was reported by 27.6% of surgeons. Of those injured, 65.7% received treatment, with 17.4% of those treated requiring surgery for their injury. In multivariate analysis, factors significantly associated with occupational injury were male sex (odds ratio [OR] 3.00, 95% CI 1.08 to 8.38), mean case length of 4 hours or more (OR 2.72, 95% CI 1.08 to 6.87), using a step to operate (OR 3.06, 95% CI 1.02 to 9.15), and neck pain (OR 4.81, 95% CI 1.64 to 14.12). In the foot mat pilot study (n = 20), mat use was associated with discomfort (OR 7.57, 95% CI 1.19 to 48.00), but no significant differences in leg volume change due to mat use were found. CONCLUSIONS: Most oncologic surgeons experience musculoskeletal symptoms from operating. Of the 28% of surgeons with an occupational injury, most required treatment. Intraoperative foot mat use was associated with increased discomfort.

Long-term follow-up for melanoma patients: is there any evidence of a benefit?

As the incidence of melanoma and the number of melanoma survivors continues to rise, optimal surveillance strategies are needed that balance the risks and benefits of screening in the context of contemporary resource use. Detection of recurrences has important implications for clinical management. Most current surveillance recommendations for melanoma survivors are based on low-level evidence with wide variations in practice patterns and an unknown clinical impact for the melanoma survivor.

Improving outcomes in patients with melanoma: strategies to ensure an early diagnosis.

Patients with thin, low-risk melanomas have an excellent long-term prognosis and higher quality of life than those who are diagnosed at later stages. From an economic standpoint, treatment of early stage melanoma consumes a fraction of the health care resources needed to treat advanced disease. Consequently, early diagnosis of melanoma is in the best interest of patients, payers, and health care systems. This review describes strategies to ensure that patients receive an early diagnosis through interventions ranging from better utilization of primary care clinics, to in vivo diagnostic technologies, to new "apps" available in the market. Strategies for screening those at high risk due to age, male sex, skin type, nevi, genetic mutations, or family history are discussed. Despite progress in identifying those at high risk for melanoma, there remains a lack of general consensus worldwide for best screening practices. Strategies to ensure early diagnosis of recurrent disease in those with a prior melanoma diagnosis are also reviewed. Variations in recurrence surveillance practices by type of provider and country are featured, with evidence demonstrating that various imaging studies, including ultrasound, computed tomography, positron emission tomography, and magnetic resonance imaging, provide only minimal gains in life expectancy, even for those with more advanced (stage III) disease. Because the majority of melanomas are attributable to ultraviolet radiation in the form of sunlight, primary prevention strategies, including sunscreen use and behavioral interventions, are reviewed. Recent international government regulation of tanning beds is described, as well as issues surrounding the continued use artificial ultraviolet sources among youth. Health care stakeholder strategies to minimize UV exposure are summarized. The recommendations encompass both specific behaviors and broad intervention targets (eg, individuals, social spheres, organizations, celebrities, governments).

Prospective assessment of lymphedema incidence and lymphedema-associated symptoms following lymph node surgery for melanoma.

We aimed to prospectively assess limb volume change (LVC) and associated symptoms in patients with melanoma undergoing sentinel lymph node biopsy and/or therapeutic lymph node dissection. Limb volume was measured preoperatively and postoperatively at 6 and 12 months using a perometer (1000 mol/l). LVC was calculated and used to define three groups: less than 5%, 5-10%, and greater than 10%. A 19-item lymphedema symptom questionnaire was administered at baseline, 6, and 12 months. One hundred and eighty-two patients were enrolled. Twelve months after axillary surgery, 9% had LVC 5-10% and 13% had LVC greater than 10%. Twelve months after inguinofemoral surgery, 10% had LVC 5-10% and 13% had LVC greater than 10%. There was a significant seven- to nine-fold increase in symptoms for patients with LVC greater than 10% compared with those with LVC less than 5% (P<0.05). On multivariate analysis, therapeutic lymph node dissection versus sentinel lymph node biopsy (odds ratio=3.18; P<0.01) and borderline significance for lower-extremity versus upper-extremity procedures (odds ratio=1.72; P=0.07) were associated with LVC greater than 5%. LVC greater than 5% is common at 12 months following nodal surgery for melanoma and is associated with symptoms. Informed consent for melanoma patients undergoing lymph node surgery should include a discussion of the risks of postoperative lymphedema.

Health-related quality of life in patients with melanoma: overview of instruments and outcomes.

The increasing public health burden of melanoma warrants evaluation of quality-of-life outcomes and the instruments most commonly used to measure quality of life in patients with melanoma. A review of the published literature focusing on quality-of-life outcomes in melanoma patients was performed to appraise the instruments used for assessment and the significant findings. In general, generic instruments continue to be most commonly used in the evaluation of quality of life despite the lack of responsiveness to changes in quality of life in subsets of patients. Cancer-specific and melanoma-specific instruments may be more suited for longitudinal clinical assessments.

Review of diagnostic imaging modalities for the surveillance of melanoma patients.

As melanoma survival rates continue to increase, optimal surveillance strategies for recurrences are needed, as are effective imaging modalities. Therefore, we performed a meta-analysis to evaluate the current state of imaging modalities for surveillance of melanoma in the published medical literature to determine the sensitivity, specificity, and positive predictive values of ultrasonography, computed tomography (CT), positron emission tomography (PET), and CT-PET combined. Ultrasonography was found to be the most sensitive and specific for detecting lymph node metastases, and PET-CT was the most sensitive and specific for detecting distant metastases. In addition to identifying appropriate surveillance methods, future studies should focus on the most effective and cost-effective intervals for performing these tests. In addition, the results from the meta-analysis related to sensitivity and specificity of the tests should be made available to doctors in community practice.

Value-based health care: a surgical oncologist's perspective.

There is ongoing debate on how to reform the health care system. Value-based systems have been proposed to account for both quality and cost. The primary goal of value-based health care is to achieve good health outcomes for patients with consideration of dollars spent. To do so, it is imperative that health care providers define meaningful outcome metrics for specific medical conditions and consider the full cycle of care as well as multiple dimensions of care.

Variability in melanoma post-treatment surveillance practices by country and physician specialty: a systematic review.

There are no evidence-based guidelines for the surveillance of patients with melanoma following surgical treatment. We carried out a systematic review to identify by country and physician specialty the current stage-specific surveillance practices for patients with melanoma. Three major medical indices, MEDLINE, the Cochrane Library database, and Scopus, were reviewed to identify articles published from January 1970 to October 2011 that included detailed information about the surveillance of patients with melanoma after the initial surgical treatment. Data on surveillance intervals and recommended evaluation were extracted and categorized by country and, when reported, physician specialty. One hundred and four articles from 10 countries and four physician specialties (dermatology, surgical oncology, medical oncology, and general practice) fulfilled the inclusion criteria, including 43 providing specific patient-level data. The articles showed a wide variation with respect to the surveillance intervals and recommended evaluations. The variation was greatest for patients with stage I disease, for whom the follow-up frequency ranged from one to six visits per year during years 1 and 2 after treatment. All four physician specialties agreed that for years 1-3, the follow-up frequency should be four times per year for all patients. For years 4 and 5, surgical oncologists recommended two follow-up visits per year, whereas general practitioners, dermatologists, and medical oncologists recommended four visits per year. Recommended imaging and laboratory evaluations were most intense in the UK and most minimalist in the Netherlands. Although general practitioners did not recommend routine laboratory or imaging tests for surveillance, all other specialties utilized both in their surveillance practice. Self skin-examination was recommended for surveillance in all countries and by all practitioner specialties. There are significant intercountry and interspecialty variations in the surveillance of patients with melanoma. As the number of melanoma survivors increases, it will be critical to examine the benefits and costs of various follow-up strategies to establish consensus guidelines for melanoma post-treatment surveillance.