Reducing Decisional Conflict and Enhancing Satisfaction with Information among Women Considering Breast Reconstruction following Mastectomy: Results from the BRECONDA Randomized Controlled Trial

Background: Deciding whether or not to have breast reconstruction following breast cancer diagnosis is a complex decision process. This randomized controlled trial assessed the impact of an online decision aid [Breast RECONstruction Decision Aid (BRECONDA)] on breast reconstruction decision-making. Methods: Women (n = 222) diagnosed with breast cancer or ductal carcinoma in situ, and eligible for reconstruction following mastectomy, completed an online baseline questionnaire. They were then assigned randomly to receive either standard online information about breast reconstruction (control) or standard information plus access to BRECONDA (intervention). Participants then completed questionnaires at 1 and 6 months after randomization. The primary outcome was participants' decisional conflict 1 month after exposure to the intervention. Secondary outcomes included decisional conflict at 6 months, satisfaction with information at 1 and 6 months, and 6-month decisional regret. Results: Linear mixed-model analyses revealed that 1-month decisional conflict was significantly lower in the intervention group (27.18) compared with the control group (35.5). This difference was also sustained at the 6-month follow-up. Intervention participants reported greater satisfaction with information at 1- and 6-month follow-up, and there was a nonsignificant trend for lower decisional regret in the intervention group at 6-month follow-up. Intervention participants' ratings for BRECONDA demonstrated high user acceptability and overall satisfaction. Conclusions: Women who accessed BRECONDA benefited by experiencing significantly less decisional conflict and being more satisfied with information regarding the reconstruction decisional process than women receiving standard care alone. These findings support the efficacy of BRECONDA in helping women to arrive at their breast reconstruction decision

Axillary versus sentinel-lymph-node dissection for micrometastatic breast cancer

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Toward the breast screening balance sheet : cumulative risk of false positives for annual versus biennial mammograms commencing at age 40 or 50

This study aimed to:(1) Estimate cumulative risk of recall from breast screening where no cancer is detected (a harm) in Australia; (2) Compare women screened annually versus biennially, commencing age 40 versus 50; and (3) Compare with international findings. At the no-cost metropolitan program studied, women attended biennial screening, but were offered annual screening if regarded at elevated risk for breast cancer. The cumulative risk of at least one recall was estimated using discrete-time survival analysis. Cancer detection statistics were computed. In total, 801,636 mammograms were undertaken in 231,824 women. Over 10 years, cumulative risk of recall was 13.3% (95% CI 12.7-13.8) for those screened biennially, and 19.9% (CI 16.6-23.2) for those screened annually from age 50-51. Cumulative risk of complex false positive involving a biopsy was 3.1% (CI 2.9-3.4) and 5.0% (CI 3.4-6.6), respectively. From age 40-41, the risk of recall was 15.1% (CI 14.3-16.0) and 22.5% (CI 17.9-27.1) for biennial and annual screening, respectively. Corresponding rates of complex false positive were 3.3% (CI 2.9-3.8) and 6.3% (CI 3.4-9.1). Over 10 mammograms, invasive cancer was detected in 3.4% (CI 3.3-3.5) and ductal carcinoma in situ in 0.7% (CI 0.6-0.7) of women, with a non-significant trend toward a larger proportion of Tis and T1N0 cancers in women screened annually (74.5%) versus biennially (70.1%), X²=2.77, p=0.10. Cancer detection was comparable to international findings. Recall risk was equal to European estimates for women screening from 50 and lower for screening from 40. Recall risk was half of United States' rates across start age and rescreening interval categories. Future benefit/harm balance sheets may be useful for communicating these findings to women.11 page(s

Psychological distress and streamlined BreastScreen follow-up assessment versus standard assessment

Objectives: To establish whether altered protocol characteristics of streamlined StepDown breast assessment clinics heightened or reduced the psychological distress of women in attendance compared with standard assessment. Willingness to attend future screening was also compared between the assessment groups. Design: Observational, prospective study of women attending either a mammogram-only StepDown or a standard breast assessment clinic. Women completed questionnaires on the day of assessment and 1 month later. Participants and setting: Women attending StepDown (136 women) or standard assessment clinics (148 women) at a BreastScreen centre between 10 November 2009 and 7 August 2010. Main outcome measures: Breast cancer worries; positive and negative psychological consequences of assessment (Psychological Consequences Questionnaire); breast cancer-related intrusion and avoidance (Impact of Event Scale); and willingness to attend, and uneasiness about, future screening. Results: At 1-month follow-up, no group differences were evident between those attending standard and StepDown clinics on breast cancer worries (P=0.44), positive (P =0.88) and negative (P =0.65) consequences, intrusion (P=0.64), and avoidance (P =0.87). Willingness to return for future mammograms was high, and did not differ between groups (P =0.16), although higher levels of unease were associated with lessened willingness to rescreen (P=0.04). Conclusions: There was no evidence that attending streamlined StepDown assessments had different outcomes in terms of distress than attending standard assessment clinics for women with a BreastScreen-detected abnormality. However, unease about attending future screening was generally associated with less willingness to do so in both groups; thus, there is a role for psycho-educational intervention to address these concerns.5 page(s

Sexual concerns of women diagnosed with breast cancer-related lymphedema

Purpose: Lymphedema is a common side effect of breast cancer treatment that may negatively impact on a woman's physical and psychological well-being. This study aimed to understand the impact of breast cancer-related lymphedema on women's sexual functioning, and to identify key concerns of these women regarding sexual issues. Methods: Purposive sampling recruited 17 women aged 38-67 years with mild to severe lymphedema. Telephone interviews concerning sexual issues were transcribed verbatim and thematic analysis undertaken. Results: Women perceived sexual concerns arising from lymphedema to exacerbate concerns arising from breast cancer. Four interrelated factors determined the extent of lymphedema's sexual impact: (a) swelling severity and location, (b) needing to wear a compression garment, (c) body image concerns raised by lymphedema and breast cancer treatment, and (d) their sexual partner's acceptance and supportiveness. In particular, a supportive partner was instrumental in assisting women to overcome sexual issues caused by severe swelling and/or body image concerns. Few women reported being asked about sexual issues by any health professional, and most women indicated that they were unwilling to discuss sexual concerns with health professionals, friends, or family. Conclusions: Lymphedema had the potential to accentuate sexual issues caused by breast cancer, but most women were reluctant to discuss issues with anyone other than their partner. These findings are relevant to health professionals designing breast cancer psychosexual interventions and future research addressing lymphedema-specific sexual concerns.11 page(s

"You're naked, you're vulnerable" : sexual well-being and body image of women with lower limb lymphedema

Lower-limb lymphedema is an incurable illness manifesting as visible swelling enlarging the leg(s) and/or feet, buttocks, and genitals. This study used semi-structured interviews and thematic analysis to explore sexual well-being among women with primary (congenital) lymphedema (n=11) or secondary lymphedema associated with gynecological cancer (n=8). Five themes (subthemes) summarized women's responses, with Attractiveness and Confidence (Publicly Unattractive, Privately Unconfident, Lymphedema or Aging?) describing women's central concern. These body image-related concerns accounted for sexual well-being in association with Partner Support (Availability of Support, Languages of Support, Fears About Support) and the degree of Functional Interruptions (Lymphedema in Context, Enduring Impacts, Overcoming Interruptions). Successful Lymphedema Coping (Control, Acceptance) and self-perceived ability to fulfill a valued Sexual Role also affected sexual well-being. Few differences between women with primary versus secondary lymphedema were evident. Lymphedema clinicians should screen for sexual concerns and have referral options available.12 page(s

Work experiences of Australian cancer survivors with lymphoedema: A qualitative study

Our qualitative study addresses a significant gap in the scholarship on return-to-work after cancer by examining the impact of secondary lymphoedema on individuals in paid employment. We undertook an Interpretive Phenomenological Analysis of interviews with 14 cancer survivors (13 women) with secondary lymphoedema in Sydney, Australia. Our interviewees were engaged in paid employment during and after their lymphoedema diagnosis. In addition to difficulties with tasks involving manual or repetitive labour, interviewees highlighted the importance of work for maintaining their identity. They also outlined the critical role that significant others at work, such as supervisors and colleagues, play in maintaining that identity. At the same time, their need for privacy and control over to whom they disclosed their lymphoedema diagnosis emerged strongly from our interviews. Finally, we present the coping mechanisms that our interviewees utilised to manage their lymphoedema in the workplace, including covering the affected limb with long sleeves, changing the tasks they completed, or even changing employers. In addition to our contribution to the scholarship, we highlight implications for employers, future research, and policy makers

Liposuction for Advanced Lymphedema: A Multidisciplinary Approach for Complete Reduction of Arm and Leg Swelling

Purpose: This research describes and evaluates a liposuction surgery and multidisciplinary rehabilitation approach for advanced lymphedema of the upper and lower extremities. Methods: A prospective clinical study was conducted at an Advanced Lymphedema Assessment Clinic (ALAC) comprised of specialists in plastic surgery, rehabilitation, imaging, oncology, and allied health, at Macquarie University, Australia. Between May 2012 and 31 May 2014, a total of 104 patients attended the ALAC. Eligibility criteria for liposuction included (i) unilateral, non-pitting, International Society of Lymphology stage II/III lymphedema; (ii) limb volume difference greater than 25 %; and (iii) previously ineffective conservative therapies. Of 55 eligible patients, 21 underwent liposuction (15 arm, 6 leg) and had at least 3 months postsurgical follow-up (85.7 % cancer-related lymphedema). Liposuction was performed under general anesthesia using a published technique, and compression garments were applied intraoperatively and advised to be worn continuously thereafter. Limb volume differences, bioimpedance spectroscopy (L-Dex), and symptom and functional measurements (using the Patient-Specific Functional Scale) were taken presurgery and 4 weeks postsurgery, and then at 3, 6, 9, and 12 months postsurgery. Results: Mean presurgical limb volume difference was 45.1 % (arm 44.2 %; leg 47.3 %). This difference reduced to 3.8 % (arm 3.6 %; leg 4.3 %) by 6 months postsurgery, a mean percentage volume reduction of 89.6 % (arm 90.2 %; leg 88.2 %) [p < 0.001]. All patients had improved symptoms and function. Bioimpedance spectroscopy showed reduced but ongoing extracellular fluid, consistent with the underlying lymphatic pathology. Conclusions: Liposuction is a safe and effective option for carefully selected patients with advanced lymphedema. Assessment, treatment, and follow-up by a multidisciplinary team is essential.8 page(s