You are here

Impact of lower limb lymphedema on quality of life in gynecologic cancer survivors after pelvic lymph node dissection

European Journal of Obstetrics & Gynecology and Reproductive Biology, September 2015, Pages 31 - 36

Abstract

Objective

To evaluate the impact of lower limb lymphedema (LLL) on quality of life (QOL) in cervical, ovarian, and endometrial cancer survivors after pelvic lymph node dissection.

Study design

A cross-sectional case-control study was performed using the Korean version of the Gynecologic Cancer Lymphedema Questionnaire (GCLQ-K) and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30). In total, 25 women with LLL and 28 women without LLL completed both questionnaires.

Results

The GCLQ-K total symptom score and scores for swelling-general, swelling-limb, and heaviness were significantly higher in the LLL group than in the control group. In the EORTC QLQ-C30, the LLL group reported more financial difficulties compared to the control group (mean score, 16.0 vs. 6.0; P = 0.035). Global health status was poorer in the LLL group with borderline statistical significance (mean score, 62.7 vs. 71.4; P = 0.069). Spearman's correlations suggested that global health status in the EORTC QLQ-C30 correlated with the GCLQ-K total symptom score (in the LLL group, R = −0.64, P = 0.001; in the control group, R = −0.42, P = 0.027).

Conclusions

QOL decreases due to LLL-related symptoms and financial difficulty in women with LLL. Well-designed prospective studies are required to confirm these findings.

Keywords: Gynecologic cancer, Lymphedema, Quality of life.

Introduction

In 2014, gynecologic cancer is expected to account for 11.7% (94,990) of all new cancers and 10.4% (28,790) of all cancer deaths among women in the United States [1] . In Korea, incidence of gynecologic cancer is continuously increasing, especially endometrial cancer and ovarian cancer with the annual percent changes of 6.9% and 1.5%, respectively [2] . For gynecologic cancer, pelvic lymph node dissection (LND) is performed during staging and/or to reduce tumor burden in gynecologic cancer surgeries. Lower limb lymphedema (LLL) is common after pelvic LND as a result of damage to the lymphatic system [3] and [4]. LLL could limit mobility and daily activity, and have a negative effect on the psychological and social wellbeing [5] . Recently, Beesley et al. reported that 13% of patients treated with endometrial cancer experienced LLL [6] . Our previous study also showed that even in early-stage ovarian cancer cases, about four of every 10 patients reported past and/or current lower extremity edema and related symptoms after surgical staging including pelvic LND [7] .

In survivorship planning in gynecologic cancer patients, LLL after pelvic LND is one of the important issues [8] . Gynecologic Oncology Group (GOG) trials are currently underway to elucidate the incidence, natural course, complications, and impact of LLL after primary treatment for gynecologic cancers [9] and [10]. However, the impact of LLL after pelvic LND on the quality of life (QOL) in gynecologic cancer patients has not been well investigated. Lymphedema and its debilitating effects on QOL have only been extensively assessed in breast cancer survivors, and these studies have focused on uncomfortable symptoms, as well as physical, psychological, and social functioning [11], [12], [13], [14], [15], and [16].

Therefore, the aim of the study was to evaluate the impact of LLL on QOL in gynecologic cancer patients after pelvic LND.

Materials and methods

This cross-sectional case-control study was conducted after obtaining the approval by the Institutional Review Board of National Cancer Center (NCCNCS-13-794).

Between October 2012 and January 2013, gynecologic cancer survivors (cervical cancer, ovarian cancer, and endometrial cancer) who visited the outpatient clinic of National Cancer Center were screened for eligibility. Eligibility criteria were the same as in our previously published study which developed and validated of the Korean version of the Gynecologic Cancer Lymphedema Questionnaire (GCLQ-K) [17] . Patients with age over 18 years, who underwent pelvic lymph node dissection in gynecologic cancer surgery, whose interval from surgery to survey was more than 6 weeks, and who agreed with the written informed consent were included. Patients with the following conditions were excluded from this study: edema with unclear cause, active thrombosis, tumors or local infection in their lower extremity, uncontrolled diabetes mellitus, severe cardiac dysfunction, renal insufficiency, and auto-immune vasculitis. Pregnant or lactating patients, alcohol or drug abusers, and long-term users of systemic corticosteroids were also excluded.

Among the 67 gynecologic cancer patients who met these criteria, patients with LLL were identified clinically through physical examination and limb volume measurement by various methods such as perometry, lymphoscintigraphy, magnetic resonance imaging (MRI), and computed tomography (CT) [17] and [18]. All patients with swollen lower extremities were evaluated using limb sonography or CT venography to exclude deep vein thrombosis. By this way, 33 patients were verified to have LLL, while the remaining 34 patients did not have LLL.

Two individual questionnaires were conducted in telephone survey: the GCLQ-K and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30). Patients were requested to answer the items, and both questionnaires were completed in 25 out of 33 patients (75.8%) with LLL (LLL group) and in 28 out of 34 patients (82.4%) without LLL (control group).

The Gynecologic Cancer Lymphedema Questionnaire (GCLQ) is a simple, effective, and time-efficient screening method to identify gynecologic cancer patients with lymphedema [19] . The questionnaire consists of a total of 20 items that are distributed over seven symptom clusters: six items for deteriorated physical functioning (weakness and limited movement), four items for numbness, three items for swelling-general, three items for infection-related, one item for heaviness, one item for aching, and two items for swelling-limb. Each item is scored as 0 or 1, which stands for “no” and “yes”, respectively, within the previous 4 weeks. The GCLQ was modified and validated for Korean population, and termed GCLQ-K [17] .

The EORTC QLQ-C30 was developed to assess cancer patients’ general QOL and has been used widely in various studies [20] and [21]. Integrating 30 items of cancer-specific questions, this questionnaire displays five functional scales (physical, role, emotional, cognitive, and social), three symptom scales (fatigue, pain, and nausea and vomiting), single-items about additional symptoms common in cancer patients (dyspnea, insomnia, appetite loss, constipation, and diarrhea), global health status scale, and the perceived financial difficulties. All of the scales and single-item measures in score with range from 0 to 100. In a functional scale, a high score represents a high/healthy level of function. A high score for the functional and global health status scales represents a high QOL. In contrast, a high score for a symptom scale or single-item means a high level of problems due to a symptom [20] and [21]. The Korean version of the EORTC QLQ-C30 has been also validated [22] , and was used to assess patients’ QOL in this study.

Patient characteristics and questionnaire scores between two groups were investigated to determine the differences. Student's t test and Mann–Whitney U test were used to compare continuous variables. Pearson's chi-squared test, Fischer's exact test, and Kruskal–Wallis test were used to compare categorical variables. Spearman's test was used to evaluate correlations between total symptom score or scores of symptom clusters in the GCLQ-K and global health status in the EORTC QLQ-C30 of both groups. R statistical software (version 2.12.) was used for statistical analysis. A P value <0.05 was considered statistically significant.

Results

The clinico-pathologic characteristics of the patients are presented in Table 1 . The proportion of cervical cancer, ovarian cancer, and endometrial cancer cases was 48.0%, 24.0%, and 28.0%, respectively, in the LLL group and 39.3%, 46.4%, and 14.3%, respectively, in the control group, without significant differences between the two group (P = 0.861). The following factors were not statistically different between the LLL group and the control group: FIGO stage, age at diagnosis (mean, 45.5 vs. 46.9 years), age at the time of survey (mean, 49.5 vs. 51.9 years), and the time interval from diagnosis to survey (mean, 56.0 vs. 62.2 months). All patients of the two groups received pelvic LND at the time of surgeries. Additional para-aortic LND was performed in 64.0% of the LLL group and in 57.1% of the control group (P = 0.610). The mean harvested numbers of lymph nodes were 30.6 and 25.0 in the LLL group and the control group, respectively (P = 0.358).

Table 1 Patient characteristics in the LLL group and the control group.

Characteristics LLL group (n = 25) Control group (n = 28) Total (n = 53) P
  N % N % N %  
Type of cancer 0.861
 Cervical cancer 12 48.0 11 39.3 23 43.4  
 Ovarian cancer 6 24.0 13 46.4 19 35.8  
 Endometrial cancer 7 28.0 4 14.3 11 20.8  
Stage (FIGO) 0.781
 I 11 44.0 16 57.1 27 50.9  
 II 4 16.0 1 3.6 5 9.4  
 III 10 40.0 10 35.7 20 37.7  
 IV 0 0.0 1 3.6 1 1.9  
Age at diagnosis
 Mean ± SD (years) 45.5 ± 9.85 46.9 ± 8.69 46.3 ± 9.19 0.572
Age at survey
 Mean ± SD (years) 49.5 ± 9.96 51.9 ± 8.23 50.8 ± 9.08 0.332
 28–35 years 2 8.0 1 3.6 3 5.7  
 36–50 years 9 36.0 9 32.1 18 34.0  
 51–65 years 11 44.0 16 57.1 27 50.9  
 66–80 years 3 12.0 2 7.1 5 9.4  
Time interval from diagnosis to survey
 Mean ± SD (months) 56.0 ± 32.54 62.2 ± 48.29 59.3 ± 41.34 0.590
 At least 5 years 9 36.0 9 32.1 18 34.0  
 3–5 years 8 32.0 10 35.7 18 34.0  
 1–3 years 8 32.0 8 28.6 16 30.2  
 Less than 1 year 0 0.0 1 3.6 1 1.9  
Lymphadenectomy 0.610
 PLND only 9 36.0 12 42.9 21 39.6  
 PLND + PALND 16 64.0 16 57.1 32 60.4  
Retrieved LNs (No.)
 Mean ± SD (range) 30.6 ± 19.95 (4–100) 25.0 ± 12.22 (6–57) 27.8 ± 16.54 (4–100) 0.358
LN involvement
 Pathologically proven 10 40.0 6 21.4 16 30.2 0.142
Adjuvant treatment 0.180
 Surgery only 6 24.0 9 32.1 15 28.3  
 Chemotherapy 6 24.0 13 46.4 19 35.8  
 Radiation therapy 7 28.0 0 0.0 7 13.2  
 Concurrent chemoradiation therapy 6 24.0 6 21.4 12 22.6  

FIGO, International Federation of Gynecology and Obstetrics; LLL, lower limb lymphedema; LN, lymph node; PLND, pelvic lymph node dissection; PALND, para-aortic lymph node dissection; SD, standard deviation.

Scores of GCLQ-K symptom clusters are shown in Table 2 . Total symptom score was higher in the LLL group than in the control group (mean, 5.32 vs. 1.86; P < 0.001). Among the seven GCLQ-K symptom clusters, scores for swelling-general (P < 0.001), swelling-limb (P < 0.001), and heaviness (P = 0.007) were significantly higher in the LLL group. However, scores for physical functioning, infection-related, aching and numbness were not significantly different between the two groups.

Table 2 Distributions of patients according to GCLQ-K symptom clusters and total score.

  Score (n, %) 0 1 2 3 4 5 6 P
Physical functioning LLL group (n = 25) 13 (52.0%) 10 (40.0%) 1 (4.0%) 1 (4.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0.741
  Control group (n = 28) 17 (60.7%) 9 (32.1%) 2 (7.1%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%)  
  OR 1 1.5 1.3 a          
  (95% CI)   (0.46–4.61) (0.16–10.56)          
 
Swelling-general LLL group (n = 25) 3 (12.0%) 11 (44.0%) 11 (44.0%) 0 (0.0%)       <0.001
  Control group (n = 28) 26 (92.9%) 1 (3.6%) 1 (3.6%) 0 (0.0%)        
  OR 1 95.3 95.3 a          
  (95% CI)   (8.9–1020.25) (8.9–1020.25)          
 
Infection-related LLL group (n = 25) 20 (80.0%) 3 (12.0%) 2 (8.0%)         0.156
  Control group (n = 28) 27 (96.4%) 1 (3.6%) 0 (0.0%)          
  OR 1 6.8 b            
  (95% CI)   (0.73–62.4)            
 
Numbness LLL group (n = 25) 10 (40.0%) 7 (28.0%) 2 (8.0%) 2 (8.0% 4 (16.0%)     0.302
  Control group (n = 28) 12 (4.29%) 12 (42.9%) 3 (10.7%) 0 (0.0%) 1 (3.6%)      
  OR 1 0.7 0.8 7.2 c        
  (95% CI)   (0.20–2.45) (0.11–5.77) (0.74, 70.2)        
 
Swelling-limb LLL group (n = 25) 10 (40.0%) 11 (44.0%) 4 (16.0%)         <0.001
  Control group (n = 28) 27 (96.4%) 1 (3.6%) 0 (0.0%)          
  OR 1 29.7 b            
  (95% CI)   (3.38–260.61)            
 
Heaviness LLL group (n = 25) 12 (48.0%) 13 (52.0%)           0.007
  Control group (n = 28) 24 (85.7%) 4 (14.3%)            
  OR 1 6.5            
  (95% CI)   (1.74–24.27)            
 
Aching LLL group (n = 25) 12 (48.0%) 13 (52.0%)           0.099
  Control group (n = 28) 20 (71.4%) 8 (28.6%)            
  OR 1 2.7            
  (95% CI)   (0.87, 8.42)            
    Mean SE Median P
GCLQ-K total symptom score LLL group (n = 25) 5.32 0.68 5 <0.001
  Control group (n = 28) 1.86 0.35 1  
  Cohen's D 1.26      

a Score 2 or higher were combined to calculate the OR compared to score 0.

b Score 1 or higher were combined to calculate the OR compared to score 0.

c Score 3 or higher were combined to calculate the OR compared to score 0.

GLCQ-K, The Korean version of the Gynecologic Cancer Lymphedema Questionnaire; LLL, lower limb lymphedema; OR, odds ratio; CI, confidence interval; SE, standard error.

In the survey of EORTC QLQ-C30 ( Table 3 ), the scores of five functional scales (physical, role, emotional, cognitive, and social), three symptom scales (fatigue, pain, and nausea and vomiting), and five items of symptoms (dyspnea, insomnia, appetite loss, constipation, and diarrhea) were not statistically different between the two groups. However, financial difficulty was more commonly observed in the LLL group than in the control group (mean, 16.0 vs. 6.0; P = 0.035). In addition, global health status was poorer in the LLL group with borderline statistical significance (mean, 62.7 vs. 71.4; P = 0.069).

Table 3 Comparison of EORTC QLQ-C30 scale scores between groups.

Dimension LLL group (n = 25) Control group (n = 28) P
Scale score Mean SD Mean SD  
Functional scales Physical functioning 82.1 8.5 84.0 10.9 0.485
Role functioning 82.7 21.8 83.3 19.2 0.906
Emotional functioning 78.7 20.7 78.6 18.6 0.986
Cognitive functioning 80.7 15.7 83.9 16.7 0.468
Social functioning 77.3 24.0 85.7 19.6 0.168
 
Symptoms scales Fatigue 25.8 18.6 19.8 17.5 0.237
Nausea and vomiting 1.3 4.6 1.2 4.4 0.908
Pain 18.0 23.0 10.7 15.9 0.182
 
Additional symptoms Dyspnea 6.7 16.7 1.2 6.3 0.132
Insomnia 18.7 21.7 13.1 18.9 0.322
Appetite loss 4.0 11.1 6.0 15.9 0.610
Constipation 9.3 18.1 6.0 13.0 0.434
Diarrhea 2.7 9.2 1.2 6.3 0.496
 
Financial difficulties 16.0 19.5 6.0 13.0 0.035
Global health status 62.7 18.0 71.4 16.3 0.069

EORTC QLQ-C30, The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30; LLL, lower limb lymphedema; SD, standard deviation.

Spearman's correlations were performed to determine associations between the results of the GCLQ-K and those of the EORTC QLQ-C30 in the LLL group ( Table 4 ). Global health status of the EORTC QLQ-C30 was associated with total score of the GCLQ-K (R = −0.64, P = 0.001). Specifically, global health status decreased with increasing scores of physical functioning (R = −0.46, P = 0.021), swelling-general (R = −0.56, P = 0.004), and heaviness (R = −0.48, P = 0.014). Each functional scale of the EORTC QLQ-C30 was associated with symptoms reported in the GCLQ-K.

Table 4 Spearman's correlations between GCLQ-K and EORTC QLQ-C30 in the LLL group.

      GCLQ-K
      Physical functioning Swelling-general Infection-related Numbness Swelling-limb Heaviness Aching Total score
EORTC QLQ-C30 No. of items 6 3 3 4 2 1 1 20
Functional scales Physical function 5 −0.39 −0.09 −0.08 −0.47 * −0.15 −0.27 −0.24 −0.46 *
Role function 2 −0.39 −0.32 −0.55 * −0.56 * −0.16 −0.33 −0.11 −0.63 *
Emotional function 4 −0.61 * −0.02 −0.09 −0.19 −0.14 −0.25 −0.15 −0.41 *
Cognitive function 2 −0.14 −0.29 0.02 0.06 −0.10 −0.08 −0.10 −0.20
Social function 2 −0.73 * −0.26 −0.35 −0.41 * −0.37 −0.46 * −0.32 −0.72 *
Symptoms scales Fatigue 3 0.27 0.25 −0.03 0.29 0.14 0.29 −0.17 0.35
Nausea and vomiting 2 0.11 0.07 0.19 0.34 −0.10 −0.01 0.28 0.31
Pain 2 0.09 −0.03 0.50 * 0.56 * 0.21 0.29 0.61 * 0.59 *
Additional symptoms Dyspnea 1 0.29 0.08 0.02 0.25 0.07 0.17 0.00 0.31
Insomnia 1 0.02 0.02 0.06 0.08 −0.41 * 0.04 0.25 0.08
Appetite loss 1 0.32 −0.02 0.10 0.07 0.11 0.35 −0.14 0.16
Constipation 1 0.03 0.11 0.13 0.33 0.34 0.13 0.18 0.39
Diarrhea 1 −0.01 −0.34 −0.15 0.14 −0.33 −0.01 0.28 −0.09
Financial difficulties 1 0.13 0.23 −0.01 0.35 0.21 0.23 0.08 0.41 *
Global health status 2 −0.46 * −0.56 * −0.24 −0.38 −0.26 −0.48 * −0.03 −0.64 *

* P < 0.05.

All values are described in R-values; EORTC QLQ-C30, The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30; GCLQ-K, The Korean version of the Gynecologic Cancer Lymphedema Questionnaire; LLL, lower limb lymphedema.

The results of Spearman's correlations in the control group also showed a correlation between global health status of the EORTC QLQ-C30 and total score of the GCLQ-K (R = −0.42, P = 0.027) ( Table 5 ). Scores for physical functioning (R = −0.45, P = 0.016) and numbness (R = −0.45, P = 0.015) were associated with decreased global health status.

Table 5 Spearman's correlations between GCLQ-K and EORTC QLQ-C30 in the control group.

      GCLQ-K
      Physical functioning Swelling-general Infection-related Numbness Swelling-limb Heaviness Aching Total score
EORTC QLQ-C30 No. of items 6 3 3 4 2 1 1 20
Functional scales Physical function 5 −0.51 * 0.18 0.24 −0.44 * −0.34 −0.13 −0.33 −0.41 *
Role function 2 −0.41 * −0.27 0.18 −0.46 * −0.37 −0.21 −0.09 −0.44 *
Emotional function 4 −0.41 * −0.30 −0.32 −0.26 −0.06 −0.18 −0.03 −0.42 *
Cognitive function 2 −0.56 * −0.07 0.23 −0.11 −0.05 −0.11 −0.34 −0.36
Social function 2 −0.38 * 0.22 0.15 −0.05 −0.22 −0.07 −0.16 −0.15
Symptoms scales Fatigue 3 0.49 * 0.36 −0.24 0.29 0.34 0.17 0.03 0.41 *
Nausea and vomiting 2 0.30 −0.08 −0.05 −0.07 0.69 * −0.11 0.13 0.12
Pain 2 0.05 −0.23 −0.16 0.04 0.31 −0.09 0.45 * 0.09
Additional symptoms Dyspnea 1 −0.15 −0.05 −0.04 0.10 −0.04 −0.08 −0.12 −0.06
Insomnia 1 0.13 0.08 −0.14 0.02 0.24 0.18 0.06 0.11
Appetite loss 1 0.07 0.28 −0.08 −0.12 0.45 * −0.17 0.18 0.14
Constipation 1 0.05 −0.13 −0.09 −0.20 −0.09 −0.19 −0.09 −0.21
Diarrhea 1 0.36 −0.05 −0.04 0.30 −0.04 −0.08 0.30 0.30
Financial difficulties 1 0.40 * −0.13 −0.09 0.14 0.41 * 0.08 0.12 0.21
Global health status 2 −0.45 * 0.02 0.01 −0.45 * −0.12 −0.15 −0.13 −0.42 *

* P < 0.05.

All values are described in R-values; EORTC QLQ-C30, The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30; GCLQ-K, The Korean version of the Gynecologic Cancer Lymphedema Questionnaire; LLL, lower limb lymphedema.

Comments

In the current study, we evaluated the impact of LLL on QOL in cervical, endometrial, and ovarian cancer survivors after pelvic LND. Scores for LLL-related symptoms estimated by the GCLQ-K were higher in women with LLL than in women without LLL in terms of swelling-general, swelling-limb, and heaviness. In addition, QOL in terms of financial difficulty was aggravated in the LLL group.

Unlike to gynecologic cancer area, the impact of lymphedema on survivors’ QOL has been well investigated in breast cancer area [11], [12], [13], [14], [15], and [16]. Among these studies, Hormes et al. assessed QOL in terms of psychological and social problems including intrusive thoughts, distorted body image and decreased sexual drive, which were adversely impacted by arm lymphedema (AL) and related arm symptoms, such as pain, heaviness, tightness, numbness, and difficulty writing [12] . Moreover, the total number of AL-related arm symptoms was significantly associated with a decrease in physical and social functioning [12] . This dose–response relation between the number of arm symptoms and patients’ QOL was also found in a large cohort study by Ahmed et al. [13] . Similarly, in the current study, the GCLQ-K total symptom score, which was significantly higher in patients with LLL, was strongly associated with global health status in the EORTC QLQ-C30.

Previously, Pyszel et al. reported that breast cancer survivors with AL had a significantly greater mean score of pain in the EORTC QLQ-C30 symptom scales than patients did without AL (P = 0.001) [14] . However, in the current study, the score of pain in the same survey tool, the EORTC QLQ-C30, was not statistically different between the LLL group and the control group (P = 0.182). Score of aching (pain) in the GCLQ-K was not different between the groups, either (P = 0.099). The inconsistent results of the previous study and this study may be explained by the following reasons: (1) pain was not measured quantitatively, rather the presence or absence of pain was reported by the patients; and (2) patients in the control group may have experienced pain from other causes such as intraoperative nerve damage during pelvic LND, neural pain from chemotherapy, or general pain from progressive disease, which were not considered in the analyses [23] . Thus, quantitative measurement of pain and efforts to find out the cause of pain are necessary to confirm these findings in further investigations.

Gynecologic cancer patients with LLL after pelvic LND reported poorer global health status than did the control group patients, with borderline statistical significance (P = 0.069). In the EORTC QLQ-C30, global health status was assessed by two items: “How would you rate your overall health during the past week?” and “How would you rate your overall quality of life during the past week?” These two comprehensive self-reported questions appear useful to assess patients’ global QOL at a glance. However, evaluation of QOL should be considered and interpreted along with other much more specific items [24] . In the current study, other components of the EORTC QLQ-C30 such as cancer related symptoms, and the scales for physical, emotional, role, cognitive, and social functioning were not significantly different between the two groups. This result may be explained in part by the influence of adjuvant treatments such as chemotherapy or radiation therapy in both groups.

Previously, Dunberger et al. reported adverse effects of LLL on daily life functioning in gynecologic cancer survivors [25] . Physical functions and housework were limited in 45% and 29% of patients with LLL, respectively, and 27% and 20%, respectively, of these patients also experienced reluctance to social activities and meeting friends [25] . Combinations of the difficulty walking, aching, puffiness, and pain were manifested in cancer survivors with LLL [26] . Recently, the Australian National Endometrial Cancer Study Group conducted the questionnaire survey with the Medical Outcomes Study Short Form-12 Health Survey among the patients after treatment, and reported that LLL was associated with reductions in physical QOL [27] . Thus, QOL should be evaluated more specifically, and the clinical environment, especially adjuvant treatments after pelvic LND, should be considered as well.

In the current study, the LLL group reported more financial difficulties compared to the control group (P = 0.035). This result is consistent with that of a previous study in breast cancer survivors using the same questionnaire [14] . Although no definitive method has been proven efficacious in the management of LLL, the patients frequently receive manual lymphatic drainage, compression bandaging, or leg exercise as rehabilitation treatment which results in additional cost [5] . Furthermore, development of LLL may cause physical disability in gynecologic cancer patients [28] . Limitation in normal range of knee movement can interrupt activities such as walking, standing, or heavy lifting. In addition, LLL-induced psychological distress and social isolation can hinder a patient from working or living a normal life. Therefore, a LLL patient may experience decreased ability to work and may be unable to continue their employment, resulting in financial difficulties. However, detailed physical disability and job status were not evaluated in this study. In breast cancer survivors with AL, Beaulac et al. measured grip strength and range of shoulder movement (flexion, abduction, and rotation) to assess arm function [15] . Similarly, measurement of leg strength and range of hip and/or knee movement would be useful to evaluate function in gynecologic cancer patients.

There were some limitations in the present study. First, this study was a cross-sectional case-control study, and unavoidable issues such as selection bias are inevitable. Second, since the current study was conducted based on self-reported patient survey, questionnaire-related issues may confound the results. Third, there was no information on sequential changes of the symptoms of LLL. Sequential data on the presence and extent of LLL-related symptoms and changes in patients’ QOL could provide comprehensive insight into the natural course of LLL. Lastly, the most weakness point would be small number of enrolled patients. However, the LLL group was assigned by clinical diagnosis of LLL with a clear definition rather than based on self-reporting edema, and any statistical differences in characteristics including the mean harvested numbers of lymph nodes were not founded between the LLL group and the control group.

Even with these limitations, the current study has a unique and distinctive approach: survey results of two individual questionnaires were paired, and integrated for insightful interpretation. Thus, this study could role as the pilot study for further studies to elucidate the impact of LLL on QOL in gynecologic cancer patients who underwent pelvic LND.

In conclusion, QOL decreases in terms of LLL-related symptoms and financial difficulty in gynecologic cancer patients with LLL after pelvic LND. This study provides clinical significance of LLL in cancer survivors. During cancer treatment and post-treatment surveillance, patients and clinicians should be aware of LLL-related symptoms and make an effort to detect them early. Further large cohort studies are encouraged, especially based on quantitative measurement of patients’ LLL-related symptoms and financial difficulties as well as prevention and management of LLL.

Conflict of interest

The authors have no conflicts of interest.

Acknowledgements

This work was supported by grants from the Korean National Cancer Center (1210510). This study was conducted as a pilot study of a randomized controlled trial, which is currently in the recruitment step (Available at: http://clinicaltrials.gov/show/NCT01849224 ).

References

  • [1] R. Siegel, J. Ma, Z. Zou, A. Jemal. Cancer statistics, 2014. CA Cancer J Clin. 2014;64:9-29
  • [2] M.C. Lim, E.K. Moon, A. Shin, et al. Incidence of cervical, endometrial, and ovarian cancer in Korea, 1999–2010. J Gynecol Oncol. 2013;24:298-302
  • [3] V. Beesley, M. Janda, E. Eakin, A. Obermair, D. Battistutta. Lymphedema after gynecological cancer treatment: prevalence, correlates, and supportive care needs. Cancer. 2007;109:2607-2614
  • [4] N.R. Abu-Rustum, K. Alektiar, A. Iasonos, et al. The incidence of symptomatic lower-extremity lymphedema following treatment of uterine corpus malignancies: a 12-year experience at Memorial Sloan-Kettering Cancer Center. Gynecol Oncol. 2006;103:714-718
  • [5] A. Finnane, S.C. Hayes, A. Obermair, M. Janda. Quality of life of women with lower-limb lymphedema following gynecological cancer. Expert Rev Pharmacoecon Outcomes Res. 2011;11:287-297
  • [6] V.L. Beesley, I.J. Rowlands, S.C. Hayes, et al. Incidence, risk factors and estimates of a woman's risk of developing secondary lower limb lymphedema and lymphedema-specific supportive care needs in women treated for endometrial cancer. Gynecol Oncol. 2015;136:87-93
  • [7] M.C. Lim, J.S. Lee, B.H. Nam, S.S. Seo, S. Kang, S.Y. Park. Lower extremity edema in patients with early ovarian cancer. J Ovarian Res. 2014;7:28
  • [8] R. Salani. Survivorship planning in gynecologic cancer patients. Gynecol Oncol. 2013;130:389-397
  • [9] GOG. Studying the physical function and quality of life before and after surgery in patients with stage I cervical cancer. (, 2014) http://clinicaltrials.gov/ct2/show/NCT01649089
  • [10] GOG. Lymphedema after surgery in patients with endometrial cancer, cervical cancer, or vulvar cancer. (, 2014) http://clinicaltrials.gov/ct2/show/NCT00956670
  • [11] W. Kwan, J. Jackson, L.M. Weir, C. Dingee, G. McGregor, I.A. Olivotto. Chronic arm morbidity after curative breast cancer treatment: prevalence and impact on quality of life. J Clin Oncol. 2002;20:4242-4248
  • [12] J.M. Hormes, C. Bryan, L.A. Lytle, et al. Impact of lymphedema and arm symptoms on quality of life in breast cancer survivors. Lymphology. 2010;43:1-13
  • [13] R.L. Ahmed, A. Prizment, D. Lazovich, K.H. Schmitz, A.R. Folsom. Lymphedema and quality of life in breast cancer survivors: the Iowa Women's Health Study. J Clin Oncol. 2008;26:5689-5696
  • [14] A. Pyszel, K. Malyszczak, K. Pyszel, R. Andrzejak, A. Szuba. Disability, psychological distress and quality of life in breast cancer survivors with arm lymphedema. Lymphology. 2006;39:185-192
  • [15] S.M. Beaulac, L.A. McNair, T.E. Scott, W.W. LaMorte, M.T. Kavanah. Lymphedema and quality of life in survivors of early-stage breast cancer. Arch Surg. 2002;137:1253-1257
  • [16] S.A. Dominick, L. Natarajan, J.P. Pierce, H. Madanat, L. Madlensky. The psychosocial impact of lymphedema-related distress among breast cancer survivors in the WHEL Study. Psychooncology. 2014;23:1049-1056
  • [17] M.C. Lim, J.S. Lee, J. Joo, et al. Development and evaluation of the Korean version of the Gynecologic Cancer Lymphedema Questionnaire in gynecologic cancer survivors. Gynecol Oncol. 2014;133:111-116
  • [18] K. Kerchner, A. Fleischer, G. Yosipovitch. Lower extremity lymphedema update: pathophysiology, diagnosis, and treatment guidelines. J Am Acad Dermatol. 2008;59:324-331
  • [19] J. Carter, L. Raviv, K. Appollo, R.E. Baser, A. Iasonos, R.R. Barakat. A pilot study using the Gynecologic Cancer Lymphedema Questionnaire (GCLQ) as a clinical care tool to identify lower extremity lymphedema in gynecologic cancer survivors. Gynecol Oncol. 2010;117:317-323
  • [20] P.M. Fayers, N.K. Aaronson, K. Bjordal, et al. EORTC QLQ-C30 scoring manual. 3rd ed. (, 2001) http://groups.eortc.be/qol/eortc-qlq-c30 Available at:
  • [21] P.M. Fayers. Interpreting quality of life data: population-based reference data for the EORTC QLQ-C30. Eur J Cancer. 2001;37:1331-1334
  • [22] Y.H. Yun, Y.S. Park, E.S. Lee, et al. Validation of the Korean version of the EORTC QLQ-C30. Qual Life Res. 2004;13:863-868
  • [23] S. Quasthoff, H.P. Hartung. Chemotherapy-induced peripheral neuropathy. J Neurol. 2002;249:9-17
  • [24] M.A. Sprangers. Quality of life assessment in oncology. Acta Oncol. 2002;41:229-237
  • [25] G. Dunberger, H. Lindquist, A.C. Waldenstrom, T. Nyberg, G. Steineck, E. Avall-Lundqvist. Lower limb lymphedema in gynecological cancer survivors—effect on daily life functioning. Support Care Cancer. 2013;21:3063-3070
  • [26] J.C. Brown, C.S. Chu, A.L. Cheville, K.H. Schmitz. The prevalence of lymphedema symptoms among survivors of long-term cancer with or at risk for lower limb lymphedema. Am J Phys Med Rehabil. 2013;92:223-231
  • [27] I.J. Rowlands, V.L. Beesley, M. Janda, et al. Quality of life of women with lower limb swelling or lymphedema 3–5 years following endometrial cancer. Gynecol Oncol. 2014;133:314-318
  • [28] S.M. Hammer, J.C. Brown, S. Segal, C.S. Chu, K.H. Schmitz. Cancer-related impairments influence physical activity in uterine cancer survivors. Med Sci Sports Exerc. 2014;46:2195-2201

Footnotes

a Center for Uterine Cancer, Research Institute and Hospital, National Cancer Center, Gyeonggi-do, Republic of Korea

b Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea

c Gynecologic Cancer Branch, Research Institute and Hospital, National Cancer Center, Gyeonggi-do, Republic of Korea

d Biometric Research Branch, Research Institute and Hospital, National Cancer Center, Gyeonggi-do, Republic of Korea

e Rehabilitation Medicine, Research Institute and Hospital, National Cancer Center, Gyeonggi-do, Republic of Korea

Corresponding author at: Center for Uterine Cancer and Gynecologic Cancer Branch, Research Institute and Hospital, National Cancer Center, 323, Ilsan-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do 410-769, Republic of Korea. Tel.: +82 31 920 1760; fax: +82 31 920 1238.


Search this site

Stay up-to-date with our monthly e-alert

If you want to regularly receive information on what is happening in Quality of Life in Oncology research sign up to our e-alert.

Subscribe »

QOL (Quality of Life) newsletter e-alert

NEW! Free access to the digital version of a new publication in Cancer Supportive Care


Cancer cachexia: mechanisms and progress in treatment

Authors: Egidio Del Fabbro, Kenneth Fearon, Florian Strasser

This book was supported by an educational grant from Helsinn Healthcare SA.

Featured videos

Quality of Life promotional video

Made possible by an educational grant from Helsinn

Helsinn does not have any influence on the content and all items are subject to independent peer and editorial review

Society Partners

European Cancer Organisation Logo

Share