The Appraisal of Clinical Practice Guidelines for Breast Cancer-Related Lymphedema.

Background: Approaches to screening, assessment, and treatment of breast cancer-related lymphedema (BCRL) vary widely. We evaluated overall quality of clinical practice guidelines (CPGs) for managing BCRL using the Appraisal of Guidelines for REsearch and Evaluation II (AGREE II) tool, and relevance of consensus recommendations for the Canadian health context. Methods and Results: We searched electronic databases, gray literature, national lymphedema frameworks, and expert opinions, to identify lymphedema CPGs, printed/published from January 2013 to October 2021. Using AGREE II, six health care professionals reviewed CPGs for consensus. Domain-specific AGREE II quality consensus scores were required (≥70% for Rigor of Development; ≥ 60% for Stakeholder Involvement and Editorial Independence; and ≥50% for Clarity of Presentation, Applicability, Scope, and Purpose). Results and overall recommendations from the CPGs were summarized and synthesized. Nine CPGs met inclusion criteria for review. Wide variability of evidence-based recommendations, and limited clinical considerations were found. Scope and Purpose, and Clarity of Presentation were adequate in six of nine CPGs; Stakeholder Involvement in seven of nine CPGs; and Editorial Independence in three of nine CPGs. Across all CPGs, Applicability was minimally reported. Only the Queensland Health CPG met quality consensus scores for Rigor and Development; however, the focus was limited to compression therapy. Conclusions: No CPG reviewed could be adopted for the Canadian health context. The proposed Canadian BCRL CPG will focus on stakeholder engagement, methodology, and implementation/evaluation. Using AGREE II allowed for assessment of quality of methods used to develop identified CPGs from other countries before consideration of adoption in a Canadian Context.

Exercise Preferences, Barriers, and Facilitators of Individuals With Cancer Undergoing Chemotherapy Before Stem Cell Transplantation: A Mixed-Methods Study.

BACKGROUND: Exercise can help mitigate side effects of hematopoietic stem cell transplantation (HSCT), particularly when initiated before HSCT. However, the exercise-related barriers, facilitators, and preferences of this population remain unclear. OBJECTIVE: This study aimed to explore the patient experience to inform future implementation of a prehabilitation intervention. INTERVENTIONS/METHODS: A 2-phase sequential explanatory mixed-methods study was conducted using (1) cross-sectional survey and (2) focus groups. Survey questions aligned with the Theoretical Domains Framework. Focus group data were analyzed using a directed content analysis approach, followed by inductive thematic analysis to generate themes that represented the exercise-related barriers, facilitators, and preferences of participants. RESULTS: Twenty-six participants completed phase 1 (n = 22 with multiple myeloma). Fifty percent of participants (n = 13) were fairly/very confident in their ability to exercise pre-HSCT. Eleven participants completed phase 2. Exercise barriers included knowledge/skill limitations, inadequate healthcare provider support, and the emotional toll of treatment. Facilitators included social support and goals. Exercise preferences were related to 2 themes: (1) program structure (subthemes: prescription and scheduling, mode of delivery) and (2) support (subthemes: support from personnel, tailoring, and education). CONCLUSION: Key exercise-related barriers included knowledge limitations, disease/treatment effects, and inadequate support. Prehabilitation should be tailored, flexible, and include education and a virtual or hybrid delivery model in this population. IMPLICATIONS FOR PRACTICE: Nurses are well positioned to identify functional limitations and counsel and refer patients to exercise programming and/or physiotherapy services. Including an exercise professional in the pretransplant care team would provide key supportive care assistance for the nursing team.

Update to the Canadian clinical practice guideline for best-practice management of breast cancer-related lymphedema: study protocol.

BACKGROUND: One of the more frequent complications following treatment for breast cancer, lymphedema is a substantial swelling of the arm, breast and chest wall that occurs on the side where lymph nodes were removed. The aim of this work is to update recommendations on the prevention, diagnosis and management of lymphedema related to breast cancer. METHODS: We present the protocol for an update of the 2001 clinical practice guideline on lymphedema from the Steering Committee for Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. We will use a patient-oriented research approach with a focus on self-management and the positive health model to inform the updated guideline development. The methods proposed will be undertaken with consideration of the standards outlined in the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. The literature will be appraised by evaluating existing guidelines from other countries, the evidence from systematic reviews and meta-analyses and direct evidence from clinical studies. We will manage competing interests according to Guidelines International Network principles. Recommendations will be presented using an actionable statement format and will be linked to the level of evidence along with any relevant considerations used in formulation. A draft of the guideline will be produced by the steering committee then sent out to international experts and stakeholder groups for feedback. INTERPRETATION: The primary benefit of this clinical guideline will be to improve the quality of care of women with breast cancer-related lymphedema. Findings will be disseminated at national and international conferences and through webinars and educational videos hosted on the websites of the supporting organizations.

Evaluating implementation and pragmatism of cancer-specific exercise programs: a scoping review.

PURPOSE: Studies in exercise oncology are increasingly evaluating the implementation of cancer-specific exercise programming in real-world settings. Evaluating current implementation efforts and identifying current research gaps may inform future implementation. This scoping review explores studies implementing cancer-specific exercise programs to determine their pragmatic characteristics and evaluate potential for translation into practice. METHODS: A systematic literature search was conducted using five databases (up to July 2020) to identify implementation studies that used qualitative or quantitative methods. Program pragmatism was evaluated using the PRECIS/RE-AIM tool. RESULTS: Fourteen articles were included for review. While programs were moderately pragmatic (average: 3.4; range: 2.8-4.2), variability was observed between scoring domains. Programs scored higher (more pragmatic) in domains typical for effectiveness studies, including participant eligibility, follow-up intensity, primary trial outcome, and analysis of primary outcome. In contrast, programs scored lower (less pragmatic) in domains aligned with implementation science, including intervention flexibility, adoption, implementation, and maintenance. Limited information was reported regarding program fidelity, adaptations, and maintenance/sustainability. CONCLUSION: Researchers should consider the pragmatism of interventions, the nuances of program adoption and implementation at the setting level, and the transition and integration of programming into the healthcare system. Future studies may benefit from the inclusion of decision-makers and implementation experts and shifting focus towards flexible programming. PRECIS/RE-AIM may facilitate the evaluation of programs throughout the study design and implementation process. IMPLICATIONS FOR CANCER SURVIVORS: The implementation of pragmatic exercise programs that are both scalable and sustainable is needed so that cancer survivors can experience exercise-related benefits beyond research settings.

Nighttime compression supports improved self-management of breast cancer-related lymphedema: A multicenter randomized controlled trial.

BACKGROUND: Lymphedema is a prevalent long-term effect of breast cancer treatment associated with reduced quality of life. This study examined the efficacy of nighttime compression as a self-management strategy for women with chronic breast cancer-related lymphedema. METHODS: Th authors conducted a parallel 3-arm, multicenter, randomized trial. Women were recruited from 3 centers in Canada and randomized to group 1 (daytime compression garment alone [standard care]), group 2 (daytime compression garment plus nighttime compression bandaging), or group 3 (daytime compression garment plus the use of a nighttime compression system garment). The primary outcome was the change in excess arm volume from the baseline to 12 weeks. Participants from all groups used a nighttime compression system garment from weeks 13 to 24. RESULTS: One hundred twenty women were enrolled, 118 completed the randomized trial, and 114 completed the 24-week follow-up. The rates of adherence to nighttime compression were 95% ± 15% and 96% ± 11% in the compression bandaging and nighttime compression system groups, respectively. After the intervention, the addition of nighttime compression was found to be superior to standard care for both absolute milliliter reductions (P = .006) and percentage reductions (P = .002) in excess arm lymphedema volume. Significant within-group changes were seen for quality of life across all groups; however, no between-group differences were found (P > .05). CONCLUSIONS: The trial demonstrated a significant improvement in arm lymphedema volume from the addition of nighttime compression whether through the application of compression bandaging or through the use of a nighttime compression system garment. LAY SUMMARY: Lymphedema is swelling that occurs in the arm on the side of the surgery for breast cancer. Lymphedema occurs in approximately 21% of women. Lymphedema tends to worsen over time and can result in recurrent infections in the arm, functional impairment, and pain. Currently, treatment consists of intensive treatments to reduce the swelling followed by regular use of a compression sleeve during the day. This study examined and found a benefit from the addition of nighttime compression (whether through self-applied compression bandaging or through the use of a nighttime compression system garment) to the use of a daytime compression sleeve.

Cancer-related fatigue in head and neck cancer survivors: Energy and functional impacts.

BACKGROUND: Survivors with head and neck cancer (HNC) report cancer-related fatigue (CRF) as a devastating, prevalent health issue that limits activity engagement and adversely influences quality of life. OBJECTIVE: To explore HNC survivors' written responses and descriptors regarding CRF, and offer potential healthcare strategies based on findings. METHODOLOGY: In written format, similar to responses on intake forms in outpatient-clinics, 25 HNC survivors provided descriptions of their CRF experiences and their perspectives on its impact. An exploratory descriptive research design was utilized, drawing on social theory for content analysis and thematic development. RESULTS: Two main themes regarding CRF arose from the data: (1) CRF as a barrier to daily function; and (2) uncontrollable and unpredictable energy fluctuations. CONCLUSIONS: To enhance outcomes of CRF symptom management in HNC survivors, a healthcare approach that targets the functional implications of CRF, and utilizes energy cultivation strategies when communicating about the negative impacts of CRF (including limited function and fluctuating energy levels) may be beneficial for HNC survivors. Further research into the effects of CRF on function for HNC survivors is warranted.

Resistance Exercise and Art Therapy on Body Image in Breast Cancer: A Scoping Review.

Background: Treatments for breast cancer are invasive, causing visible changes such as loss of the breast, body weight change, and hair loss. These changes in conjunction with the pressure for women to conform to societal beauty standards may lead to body image disturbance in breast cancer survivors (BCS). The aims of this scoping review were to explore the nature, characteristics, and extent of the literature examining resistance exercise or art therapy on body image in BCS; and examine how body image is defined and measured across the studies. Methods: We searched the literature up to January 2020, which included conducting electronic searches of three major databases and checking references of screened articles. Results: Ninety-three articles were identified, 28 underwent full-text screening, with 8 studies eligible for inclusion in the review. Five randomized control trials, one hybrid effectiveness-implementation trial, and two single group studies were found. All studies showed significant within-group difference in body image scores, with two studies showing a between-group difference in favor of resistance exercise. No studies were found combining resistance exercise and art therapy. None of the studies defined the aspect of body image they wished to measure, and only one used theory to inform their research. Discussion: Preliminary evidence supports the benefit of resistance exercise and art therapy as single interventions to improve body image perception among BCS. Findings suggest the need for closer attention to the delivery format of interventions. Future research is needed that is theory-informed, with a clear definition of the aspect of body image of interest, and with body image as the primary outcome.

Uncertainty and sense-of-self as targets for intervention for cancer-related fatigue.

Cancer-related fatigue (CRF) can be a devastating consequence of cancer and cancer treatments, negatively impacting 50%-90% of cancer patients regardless of age, sex or diagnosis. Limited evidence and research exist to inform effective patient-centred interventions. To target symptom management, there must first be a broader understanding of the symptoms and the lived experience of the persons experiencing CRF and those caring for them, from a supportive as well as a healthcare perspective. This study set out to consider whether components of the language used or descriptors reported by patients, family members, and/or healthcare professionals may provide new insights for potential targets for intervention development. Descriptors from 84 responses (n = 84) from cancer survivors, family members and healthcare professionals were analysed for content. The descriptors reiterate the physical, emotional and functional consequences of CRF, but also reflect two new potential targets for intervention to mitigate the impacts of CRF: uncertainty and sense-of-self.

Physical Rehabilitation and Occupational Therapy.

Head and neck cancer and associated treatments can have debilitating effects on patient physical function and quality of life. The American Cancer Society's Head and Neck Cancer Survivorship Care Guidelines recommend that all patients receive an assessment after their treatment to address complications that may impact long-term recovery and function. Evidence supports the role of physical activity, exercise, physical therapy, and occupational therapy to decrease symptom burden after treatment and improve strength, endurance, and function. Physical therapy can play an important role in optimizing jaw, neck and shoulder function and occupational therapy can optimize return to work.