Risk Factors for Breast Cancer-Related Lymphedema: An Umbrella Review.

BACKGROUND: Identification of risk factors facilitates the prevention of breast cancer-related lymphedema (BCRL). Several published systematic reviews have already addressed the risk factors for BCRL. This study aimed to systematically identify potential risk factors for BCRL and evaluate the quality of evidence. METHODS: The study followed methodologic guidance from the Joanna Briggs Institute, and the Cochrane Handbook. The following electronic databases were systematically searched from inception to 15 November 2022: PubMed, Embase, CINAHL, Web of Science, Scopus, CNKI, SinoMed, Wanfang, JBI Database, Cochrane Database, ProQuest, and PROSPERO. Two authors independently screened studies, extracted data, and assessed methodologic quality using AMSTAR2, risk of bias using ROBIS, and evidence quality using GRADE. The study evaluated overlap, assessed the small-study effect, and calculated the I2 statistic and Egger's P value as needed. RESULTS: The study included 14 publications comprising 10 meta-analyses and 4 systematic reviews. The authors identified 39 factors and 30 unique meta-analyses. In the study, 13 innate personal trait-related risk factors, such as higher body mass index (BMI) and axillary lymph nodes dissection, showed statistically significant associations with BCRL incidence. Breast reconstruction was found to be a protective factor. The methodologic quality was low or critically low. The majority of the systematic reviews and/or meta-analyses were rated as having a high risk of bias. Evidence quality was low for 22 associations and moderate for 8 associations. CONCLUSIONS: The currently identified risk factors for BCRL all are innate personal trait-related factors. Future well-designed studies and robust meta-analyses are needed to explore potential associations between behavioral-, interpersonal-, and environmental-related factors and BCRL, as well as the role of genetic variations and pathophysiologic factors.

Financial toxicity experienced by patients with breast cancer-related lymphedema: a systematic review.

PURPOSE: To perform a systematic review on financial toxicity of breast cancer-related lymphedema. METHODS: Seven databases were searched on September 11, 2022. Eligible studies were identified, analyzed, and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Empirical studies were appraised by the Joanna Briggs Institute (JBI) tools. The Mixed Methods Appraisal Tool version 2018 was used to assess the mixed method studies. RESULTS: A total of 963 articles were identified, but only 7 articles reporting on 6 studies met the eligibility criteria. A 2-year treatment for lymphedema was approximately USD$14,877 to USD$23,167 in America. In Australia, the average out-of-pocket costs ranged from A$207 to A$1400 (USD$156.26 to USD$1056.83) per year. Outpatient visits, compressed clothing, and hospital admissions were the dominant costs. The financial toxicity was associated with the severity of lymphedema, and patients with heavy financial burden had to reduce other expenses or even forgo the treatment. CONCLUSION: Breast cancer-related lymphedema aggravated the economic burden of patients. The included studies showed great variation in the methods used and therefore differences in cost results. The national government should further improve the healthcare system and increase the insurance coverage of lymphedema treatment to alleviate this burden. More research is needed to focus on financial toxicity experience of breast cancer patients with lymphedema. IMPLICATIONS FOR CANCER SURVIVORS: The cost of the ongoing treatment of breast cancer-related lymphedema influences patients' economic situation and quality of life. Survivors need to be informed early about the potential financial burden associated with lymphedema treatment.

Risk factors of breast cancer-related lymphoedema: protocol of an umbrella review.

INTRODUCTION: Breast cancer-related lymphoedema (BCRL) is a progressive and debilitating complication post-breast cancer treatment. Identifying potential risk factors facilitates the prevention and management of BCRL. Multiple systematic reviews have been conducted to address the variables correlated with the occurrence of BCRL. This study aims to identify and examine factors predicting the development of BCRL, to clarify the predicting mechanism of these factors, as well to determine the credibility of risk factors for BCRL. METHODS AND ANALYSIS: This umbrella review will be conducted with the methodological guidance of the Joanna Briggs Institute and the Cochrane handbook. A comprehensive systematic search will be performed in ten databases: PubMed, Embase, CINAHL, Web of Science, Scopus, CNKI, SinoMed, Wangfang database, the JBI Database of Systematic Reviews, Cochrane Database of Systematic Reviews. The search for unpublished studies will include ProQuest and the PROSPERO register. Reference lists will also be hand searched. Two reviewers will independently screen the studies, extract data and assess the methodological quality using the Methodological Quality of Systematic Reviews-2 and the Risk of Bias in Systematic Reviews. The degree of overlap between included reviews will be assessed by calculating the Corrected Covered Area. The credibility of the associations between risk factors and lymphoedema will be graded into four classes: convincing, highly suggestive, suggestive and weak, referring to the classification system of recent umbrella reviews. A descriptive, narrative synthesis and suggestions for clinical practice and future research will be made based on included systematic reviews, considering the quality of the evidence. ETHICS AND DISSEMINATION: Ethical approval is not required for this umbrella review. We will seek to submit the results for publication in a peer-reviewed journal or present it at conferences. PROSPERO REGISTRATION NUMBER: CRD42022375710.

Risk factors of unilateral breast cancer-related lymphedema: an updated systematic review and meta-analysis of 84 cohort studies.

PURPOSE: To review and update the incidence and risk factors for breast cancer-related lymphedema based on cohort studies. METHODS: The study was guided by the Joanna Briggs Institute methodology and the Cochrane handbook for systematic reviews. PubMed, EMBASE, CINAHL, Scopus, Web of Science, The Cochrane Library, CNKI, SinoMed, and Wan Fang Database were searched from inception to November 15, 2021. Cohort studies reported adjusted risk factors were selected. PRISMA guideline was followed. Study quality were evaluated using the Newcastle-Ottawa scale. Random-effects models were adopted. The robustness of pooled estimates was validated by meta-regression and subgroup analysis. Lymphedema incidence and adjusted risk factors in the multivariable analyses with hazard / odds ratios and 95% CIs were recorded. RESULTS: Eighty-four cohort studies involving 58,358 breast cancer patients were included. The pooled incidence of lymphedema was 21.9% (95% CI, 19.8-24.0%). Fourteen factors were identified including ethnicity (black vs. white), higher body mass index, higher weight increase, hypertension, higher cancer stage (III vs. I-II), larger tumor size, mastectomy (vs. breast conservation surgery), axillary lymph nodes dissection, more lymph nodes dissected, higher level of lymph nodes dissection, chemotherapy, radiotherapy, surgery complications, and higher relative volume increase postoperatively. Additionally, breast reconstruction surgery, and adequate finance were found to play a protective role. However, other variables such as age, number of positive lymph nodes, and exercise were not correlated with risk of lymphedema. CONCLUSION: Treatment-related factors still leading the development of breast cancer-related lymphedema. Other factors such as postoperative weight increase and finance status also play a part. Our findings suggest the need to shift the focus from treatment-related factors to modifiable psycho-social-behavioral factors.