BACKGROUND:Skeletal muscle thickness, echo intensity, and quality are important morphological properties; however, little is known how these variables compare between the affected and unaffected forearms in breast cancer-related lymphedema (BCRL). METHODS:Using B-mode ultrasound, we recorded the raw radiofrequency data of the affected and unaffected forearms of women (n = 20) with Stage 2 BCRL, and in a control group of 20 women with no lymphedema. The data were converted into images and measurements of skin, subcutaneous fat, and muscle thickness were obtained. Within a designated region of interest, muscle echo intensity was assessed using computer graded grey scale and muscle thickness was measured using ImageJ2. Handgrip strength was measured using standard dynamometry. RESULTS:We found no differences in muscle thickness among affected, unaffected, and control forearms. The affected arm had significantly lower (p ≤ 0.025) muscle quality than controls but similar to values found in the unaffected arms. The affected arm had higher muscle echo intensity than the unaffected (p ≤ 0.013) and control (p ≤ 0.001) arms. Muscle echo intensity was related to subcutaneous fat thickness (r = 0.45; p ≤ 0.05) and arm circumference (r = 0.47; p = 0.04) in the affected arm in women with lymphedema. CONCLUSIONS:Lymphedema does not negatively affect forearm muscle thickness. The elevated levels of muscle echo intensity of the affected arm does not influence muscle quality in BCRL. The functional relevance of an elevated muscle echo intensity in the affected arm and its relationship with arm circumference and subcutaneous fat thickness needs to be further explored.

This educational piece about lymphedema (chronic edema) was developed by the medical advisory committee of the Canadian Lymphedema Framework and is intended specifically to inform Canadian healthcare professionals. Lymphedema is an incurable, chronic inflammatory condition requiring early diagnosis and life-long management. It may lead to complications like cellulitis and can result from obesity or cancer treatments. Treatment entails cleansing, exercise, self-management education, and potential surgical interventions, with resources available through the Canadian Lymphedema Framework.

Cancer-related lymphedema (CRL) lacks internationally accepted definition and diagnostic criteria. The accurate incidence of CRL is therefore a challenge and the condition is likely underreported. Patients treated for cancer can develop CRL as a result of surgery, chemotherapy, and/or radiotherapy, which can lead to considerable psychosocial and physical morbidity, and decreased quality of life. Determining CRL incidence is crucial to inform care access and resource allocation, to best support patients affected by this lifelong condition. This review aimed to provide the latest CRL incidence estimates. Using four core databases (MEDLINE, Embase, Web of Science Core Collection, Cochrane Library), a literature search was performed to capture publications dated between 2015 and 2023. A total of 48 articles (33 prospective studies, 15 systematic reviews) met inclusion criteria, providing a sample size of 234,079 cancer patients. Findings revealed CRL incidence across cancer types varied, reported 2–74

For over 2 decades, the mainstay of lymphedema treatment has been complete decongestive therapy, however, surgical options are available when conservative treatment is not successful in reducing lymphedema. Standardized pre-surgical and post-surgical guidelines for candidates are not readily available. As part of the 2023 Lymphedema Summit that was sponsored by the American Cancer Society, and the Lymphology Association of North America, an expert consensus workgroup was formed and developed an expert consensus which affirms the importance of pre-surgical guidelines for candidates with lymphedema. The workgroup recommended that guidelines should be tailored to four major end-user groups: (1) patients, (2) referring physicians, (3) allied health professionals, and (4) surgeons.

Physician-administered euthanasia (Medical-Aid-in-Dying or MAiD) has been legally available in Canada since 2016, with ever-widening indications. Most palliative care physicians in Canada do not provide MAiD themselves but will refer to colleagues who provide this procedure. The author was involved in a qualitative research project on MAiD, looking at the views of Montreal-based palliative care physicians regarding their role. One interesting finding from that project is that our own individual personal views (i.e., what I would want for myself when I will inevitably face my own death) versus my professional views as a palliative care physician (i.e., the kind of end-of-life care that I am ready to provide, or what I think patients should receive) may radically differ. We teach our trainees (and the community beyond) that dying can have meaning up to the end of one’s natural life. Patients facing terminal illness commonly express a fear of becoming a burden to others. Yet we teach that this sentiment is often not well-founded, based on the expressed views of the patient’s loved ones. And yet dying can be difficult, even when patients receive the best available palliative care. Our professional view of what constitutes a dignified end-of-life and what patients and families (and I, eventually) will experience may be different. This presentation will spark reflection regarding this dichotomy. What feelings might this inner split provoke, when our professional and personal views conflict with each other? Am I being a dishonest physician? And yet…

It is vitally important to know the prevalence and impact of a condition to justify the allocation of health care resources. Chronic edema/lymphedema continues to be poorly recognized and poorly treated. Even within the lymphedema community, some basic questions still need to be answered. How do we define lymphedema? What diagnostic methods should be used? What volume differences? We have no accepted international guidance on this. In estimating prevalence, do we only include stages 2 and 3, ignoring those in earlier stages who might only have limb swelling and/or feel heaviness at the end of the day? For the purposes of the current exercise, we have only considered those with established chronic edema/ lymphedema; however, those with early signs also need preventive advice and treatment.

Little is known about skeletal muscle thickness, echogenicity, and muscle quality (handgrip strength /muscle thickness) in breast cancer-related lymphedema (BCRL). Using B-mode ultrasound, we recorded the raw radiofrequency data of the affected (AA) and unaffected (UA) arms of women (n=20) with BCRL, and in 20 control women with no lymphedema (CA). The data were converted into images and measurements of skin, subcutaneous fat and muscle thickness were obtained. Within a designated region of interest, muscle echo-intensity was assessed using computer graded grey scale and muscle thickness was measured using ImageJ2. Handgrip strength was measured using standard dynamometry. We found that forearm muscle thickness was similar among AA, UA, and CA. When compared to the unaffected and control arms, the affected arm had a significantly higher (p 0.013) muscle echo-intensity. When compared to the AA, handgrip strength was similar to UA (p 0.401) but lower than CA (p 0.05). We conclude that the use of B-mode ultrasound is a reliable method to assess muscle thickness and EI in BCRL. When comparing AA to UA, the elevated levels of muscle EI in AA did not influence strength or muscle quality. The elevated EI in AA is a marker of abnormal health that needs to be further explored.

Objective: Breast cancer treatment often causes the removal of or damage to lymph nodes of the patient's lymphatic drainage system. This side effect is the origin of Breast Cancer-Related Lymphedema (BCRL), referring to a noticeable increase in excess arm volume. Ultrasound imaging is a preferred modality for the diagnosis and progression monitoring of BCRL because of its low cost, safety, and portability. As the affected and unaffected arms look similar in B-mode ultrasound images, the thickness of the skin, subcutaneous fat, and muscle have been shown to be important biomarkers for this task. The segmentation masks are also helpful in monitoring the longitudinal changes in morphology and mechanical properties of tissue layers. Methods: For the first time, a publicly available ultrasound dataset containing the Radio-Frequency (RF) data of 39 subjects and manual segmentation masks by two experts, are provided. Inter- and intra-observer reproducibility studies performed on the segmentation maps show a high Dice Score Coefficient (DSC) of $0.94\pm 0.08$ and $0.92\pm 0.06$ , respectively. Gated Shape Convolutional Neural Network (GSCNN) is modified for precise automatic segmentation of tissue layers, and its generalization performance is improved by the CutMix augmentation strategy. Results: We got an average DSC of $0.87\pm 0.11$ on the test set, which confirms the high performance of the method. Conclusion: Automatic segmentation can pave the way for convenient and accessible staging of BCRL, and our dataset can facilitate development and validation of those methods. Significance: Timely diagnosis and treatment of BCRL have crucial importance in preventing irreversible damage.

Abstract The revised edition of Crossing Over is a book of stories—narratives of giving and receiving palliative care in the context of end of life. It is not a textbook that portrays ideal palliative care or that prescribes specific management techniques. Instead, it presents stories of actual patients and families who have experienced terminal illness with the support of hospice or palliative care teams. The narratives are derived from a three-year, qualitative, ethnographic study of the experiences of patients, families, and caregivers. Since the first edition of Crossing Over appeared, changes have occurred in healthcare and in society at large that have altered the environment in which people give and receive palliative care, including effects of the COVID-19 pandemic, the opioid crisis, changes in social welfare policy, the rise of the internet, the evolution of palliative care as a field, increased emphasis on advance care planning, and, in some jurisdictions (including all of Canada), legalization of medical aid in dying. The Authors’ Comments following each narrative pinpoint specific decisions and choices of patients, families, and clinicians where today’s changed context may be particularly relevant.

Abstract The revised edition of Crossing Over is a book of stories—narratives of giving and receiving palliative care in the context of end of life. It is not a textbook that portrays ideal palliative care or that prescribes specific management techniques. Instead, it presents stories of actual patients and families who have experienced terminal illness with the support of hospice or palliative care teams. The narratives are derived from a three-year, qualitative, ethnographic study of the experiences of patients, families, and caregivers. Since the first edition of Crossing Over appeared, changes have occurred in healthcare and in society at large that have altered the environment in which people give and receive palliative care, including effects of the COVID-19 pandemic, the opioid crisis, changes in social welfare policy, the rise of the internet, the evolution of palliative care as a field, increased emphasis on advance care planning, and, in some jurisdictions (including all of Canada), legalization of medical aid in dying. The Authors’ Comments following each narrative pinpoint specific decisions and choices of patients, families, and clinicians where today’s changed context may be particularly relevant.

There is limited knowledge on non-invasive lymphedema risk-reduction strategies for women with gynecological cancer. Understanding factors influencing the feasibility of randomized controlled trials (RCTs) can guide future research. Our objectives are to report on the design and feasibility of a pilot RCT examining a tailored multidimensional intervention in women treated for gynecological cancer at risk of lymphedema and to explore the preliminary effectiveness of the intervention on lymphedema incidence at 12 months. In this pilot single-blinded, parallel-group, multi-centre RCT, women with newly diagnosed gynecological cancer were randomized to receive post-operative compression stockings and individualized exercise education (intervention group: IG) or education on lymphedema risk-reduction alone (control group: CG). Rates of recruitment, retention and assessment completion were recorded. Intervention safety and feasibility were tracked by monitoring adverse events and adherence. Clinical outcomes were evaluated over 12 months: presence of lymphedema, circumferential and volume measures, body composition and quality of life. Fifty-one women were recruited and 36 received the assigned intervention. Rates of recruitment and 12-month retention were 47% and 78%, respectively. Two participants experienced post-operative cellulitis, prior to intervention delivery. At three and six months post-operatively, 67% and 63% of the IG used compression ≥42 h/week, while 56% engaged in ≥150 weekly minutes of moderate-vigorous exercise. The cumulative incidence of lymphedema at 12 months was 31% in the CG and 31.9% in the IG (p = 0.88). In affected participants, lymphedema developed after a median time of 3.2 months (range, 2.7–5.9) in the CG vs. 8.8 months (range, 2.9–11.8) in the IG. Conducting research trials exploring lymphedema risk-reduction strategies in gynecological cancer is feasible but challenging. A tailored intervention of compression and exercise is safe and feasible in this population and may delay the onset of lymphedema. Further research is warranted to establish the role of these strategies in reducing the risk of lymphedema for the gynecological cancer population.

Purpose: Physiotherapists have an important role to play in the early detection and treatment of lymphedema, a chronic inflammatory condition characterized by excess interstitial protein-rich fluid, which is estimated to affect more than one million Canadians. Obesity has been identified both as an important cause of and as a risk factor for developing lymphedema of various aetiologies. Little is currently known about obesity in Canadians affected by lymphedema. The objective of this study was to report on the prevalence of overweight and obesity in a Canadian lymphedema clinic population and the relationships among BMI; demographic, medical, and lymphedema characteristics; and cellulitis history. Method: We conducted a retrospective electronic record review of the clinical data collected from new patients evaluated for suspected lymphedema at a specialized Canadian hospital-based clinic over a 2-year period. We used descriptive analyses to characterize the sample and one-way analysis of variance and χ 2 tests for comparative analyses. Results: Of the 178 patients whose records were reviewed, 36.5% were classified as overweight and 39.3% as obese. Patients with non-cancer diagnoses had a higher mean BMI than those with cancer-related diagnoses ( p < 0.001). A higher BMI was associated with a longer time since lymphedema onset ( p < 0.001), bilateral lymphedema ( p = 0.010), and history of cellulitis ( p < 0.001). Conclusions:Obesity is prevalent in the Canadian population with lymphedema and is associated with delayed referral and increased cellulitis rates. Early detection and tailored management strategies are needed to address obesity in patients with lymphedema and the complexities associated with these two related conditions.

Objectives In 2015, the Province of Quebec, Canada passed a law that allowed voluntary active euthanasia (VAE). Palliative care stakeholders in Canada have been largely opposed to euthanasia, yet there is little research about their views. The research question guiding this study was the following: How do palliative care physicians in Quebec position themselves regarding the practice of VAE in the context of the new provincial legislation? Methods We used interpretive description, an inductive methodology to answer research questions about clinical practice. A total of 18 palliative care physicians participated in semistructured interviews at two university-affiliated hospitals in Quebec. Results Participants positioned themselves in opposition to euthanasia. Their justifications were framed within their professional commitment to not hasten death, which sat in tension with the value of patients' autonomy to choose how to die. Participants described VAE as unacceptable if it impeded opportunities to evaluate and alleviate suffering. Further, they contested government rhetoric that positioned VAE as a way to improve end-of-life care. Participants felt that VAE would diminish the potential of palliative care to relieve suffering. Dilemmas were apparent in their narratives, about reconciling respect for patient autonomy with broader palliative care values, and the value of accompanying and not abandoning patients who make requests for VAE while being committed to neither prolonging nor hastening death. Conclusions This study provides insight into nuanced positions of experienced palliative care physicians in Quebec and confirms expected tensions between an important stakeholder and the practice of VAE as guided by the new legislation.

Lymphoedema is an oedematous condition with a specific and complex tissue biology. In the clinical context of cancer, the pathogenesis of lymphoedema ensues most typically from the modalities employed to stage and treat the cancer (in particular, surgery and radiotherapy). Despite advances in cancer treatment, lifelong lymphoedema (limb swelling and the accompanying chronic inflammatory processes) affects approximately one in seven individuals treated for cancer, although estimates of lymphoedema prevalence following cancer treatment vary widely depending upon the diagnostic criteria used and the duration of follow-up. The natural history of cancer-associated lymphoedema is defined by increasing limb girth, fibrosis, inflammation, abnormal fat deposition and eventual marked cutaneous pathology, which also increases the risk of recurrent skin infections. Lymphoedema can substantially affect the daily quality of life of patients, as, in addition to aesthetic concerns, it can cause discomfort and affect the ability to carry out daily tasks. Clinical diagnosis is dependent on comparison of the affected region with the equivalent region on the unaffected side and, if available, with pre-surgical measurements. Surveillance is indicated in this high-risk population to facilitate disease detection at the early stages, when therapeutic interventions are most effective. Treatment modalities include conservative physical strategies that feature complex decongestive therapy (including compression garments) and intermittent pneumatic compression, as well as an emerging spectrum of surgical interventions, including liposuction for late-stage disease. The future application of pharmacological and microsurgical therapeutics for cancer-associated lymphoedema holds great promise.

Breast cancer-related lymphedema is a consequence of a malfunctioning lymphatic drainage system resulting from surgery or some other form of treatment. In the initial stages, minor and reversible increases in the fluid volume of the arm are evident. As the stages progress over time, the underlying pathophysiology dramatically changes with an irreversible increase in arm volume most likely due to a chronic local inflammation leading to adipose tissue hypertrophy and fibrosis. Clinicians have subjective ways to stage the degree and severity such as the pitting test which entails manually comparing the elasticity of the affected and unaffected arms. Several imaging modalities can be used but ultrasound appears to be the most preferred because it is affordable, safe, and portable. Unfortunately, ultrasonography is not typically used for staging lymphedema, because the appearance of the affected and unaffected arms is similar in B-mode ultrasound images. However, novel ultrasound techniques have emerged, such as elastography, which may be able to identify changes in mechanical properties of the tissue related to detection and staging of lymphedema. This paper presents a novel technique to compare the mechanical properties of the affected and unaffected arms using quasi-static ultrasound elastography to provide an objective alternative to the current subjective assessment. Elastography is based on time delay estimation (TDE) from ultrasound images to infer displacement and mechanical properties of the tissue. We further introduce a novel method for TDE by incorporating higher order derivatives of the ultrasound data into a cost function and propose a novel optimization approach to efficiently minimize the cost function. This method works reliably with our challenging patient data. We collected radio frequency ultrasound data from both arms of seven patients with stage 2 lymphedema, at six different locations in each arm. The ratio of strain in skin, subcutaneous fat, and skeletal muscle divided by strain in the standoff gel pad was calculated in the unaffected and affected arms. The p -values using a Wilcoxon sign-rank test for the skin, subcutaneous fat, and skeletal muscle were 1.24×10-5 , 1.77×10-8 , and 8.11×10-7 respectively, showing differences between the unaffected and affected arms with a very high level of significance.

Background: Lymphedema is an irreversible inflammatory condition caused by accumulated lymph fluid and is associated with chronic swelling and increased risk of cellulitis. Our objectives were to: (1) describe the patient population referred to a Canadian lymphedema center and (2) compare lymphedema characteristics between patients with cancer and patients with noncancer diagnoses.Methods and Results: A retrospective cohort study was conducted of new patients referred for suspected lymphedema to a hospital-based center over a 2-year period. The mean age of the patients (n = 429) was 61.4 years; 85% were female and 81% had a history of cancer. Lymphedema characteristics were primary (7%) versus secondary (92%); upper body (51%) versus lower body (45%); unilateral (74%) versus bilateral (25%); and history of cellulitis (22%). Patients with noncancer diagnoses (n = 82) were more likely than patients with cancer diagnoses (n = 347) to have a history of cellulitis (44% vs. 17%), to have bilateral (61% vs. 16%) and lower limb (89% vs. 37%) lymphedema, and to experience a long delay between symptom onset and referral (14.0 vs. 3.5 years) (p < 0.001).Conclusion: Most patients referred to our lymphedema center were female with a history of cancer. However, patients with noncancer diagnoses were more likely to have bilateral lower body lymphedema with an important history of cellulitis; this subgroup is at great risk of missed and delayed diagnoses in the medical setting and of experiencing long-term issues with mobility, recurrent hospitalizations, and poor quality of life.

Purpose: Malignant lymphedema is an accumulation of interstitial fluid caused by tumour infiltration or compression of lymphatic vessels. Our objective is to describe self-management strategies for malignant lymphedema using a case report. Client Description: A 50-year-old woman with advanced breast cancer was referred to our centre with a 3-month history of unexplained left-arm edema, subsequently diagnosed as malignant lymphedema caused by tumour compression of the axillary lymph nodes. Intervention: She undertook a physiotherapist-guided, modified lymphedema treatment programme, with self-management interventions including self-bandaging and exercise. Limb volumes and leisure exercise levels were measured over a 1-year period. Data were collected from her follow-up visit 4 years post-diagnosis of lymphedema. Measures and Outcome: Within the first month, the patient's excess limb volume reduced from 26.8% to 5.9% and, 1 year later, remained stable at 3%. Over time, her exercise levels increased (1-year follow-up: 33.5 MET-hours per week). At 4 years, her excess limb volume was 9.7%, and exercise levels were at 36 MET-hours per week. Implications: A woman with moderate malignant arm lymphedema caused by advanced breast cancer successfully adhered to a guided self-management programme and benefited from reduced swelling and improved self-reported physical function in the long term. This case provides oncology health professionals with knowledge about self-management options for malignant lymphedema.

This article explores the prevalence of lymphedema and chronic edema in Canada, emphasizing the challenges in obtaining accurate estimates due to diverse causes and complex diagnostic criteria. Authors Keast and Towers address multiple prevalence factors, particularly highlighting the significant role of obesity, which surpasses cancer as the primary contributor to lymphedema cases in Canada. Additional risk factors include chronic venous insufficiency, reduced mobility, and certain types of surgeries. While prevalence estimates vary, conservative figures suggest over a million Canadians may be affected. The authors advocate for improved prevention, screening, and management strategies and call for greater research to refine prevalence data and inform healthcare policy.

The Canadian Society of Palliative Care Physicians recently listed potential roles for the specialty of palliative medicine in the context of decriminalized euthanasia. These roles included the reduction of harm to patients and to other individuals who may be negatively impacted, including physicians (CSPCP 2015). The aim of this ongoing qualitative study is to shed light on the roles that palliative care physicians play in decision-making processes about euthanasia in the post-decriminalization context in Québec. The research question guiding this study was: How is the enactment of the law on medical aid in dying in Québec redefining the roles of palliative care providers? We conducted semi-structured interviews with 18 palliative care physicians at a university-affiliated hospital in Montréal, Québec. Verbatim transcripts were analyzed with discourse analysis to explore how participants describe and justify their roles in these decisions. Physicians expressed significant uncertainty and fear regarding their actual and imagined roles in decisions about euthanasia. Physicians’ positions ranged along the spectrum of conscientious opposition to any participation, procedural non-participation, and non-interference. It appears that a position of complete non-involvement is untenable given a terminally-ill patient population that commonly wishes to discuss end-of-life care options. Palliative care providers therefore become a source of information about the law that was enacted, and also adopt a strong advocacy role in calling for access to adequate palliative care services. The roles of palliative care providers in decision-making processes about euthanasia are currently being defined as the law is implemented, and warrant further investigation. The decriminalization of euthanasia in Québec appears to have an impact on the practice of palliative providers, even though participants expressed conscientious objection to their involvement in these decisions. Support for involved professionals is important and should be built into the implementation process.

Arm morbidity (AM) arising from breast cancer (BC) treatment can detrimentally impact quality of life; often limiting a survivor’s ability to participate in valued activities. The present study explored (a) the developmental time course of AM [restricted range of motion (ROM), pain, and arm volume changes], negative affect, and perceived disability in the immediate years post-surgery, and (b) the mediating role of perceived disability on the relationship between AM and negative affect over time. In this 5-year longitudinal study, BC survivors from four Canadian oncology clinics (n = 431) completed five annual clinical assessments, where differences in ROM (shoulder abduction, external rotation) and arm volume between the affected and non-affected arm were measured. The profile of mood states (POMS), disability of arm, shoulder, hand, and McGill Pain Questionnaire-Short form were completed. Results from general linear modeling showed that AM, negative affect, and perceived disability were greatest 1-year post-surgery, declined, and with the exception of arm volume changes, were significantly lower 5 years later. Negative affect was significantly associated with restrictions in shoulder abduction and external rotation (average r = −0.15; p < 0.05) and present arm pain (average r = 0.28, p < 0.01) at most assessments. The mediating role of perceived disability on the relationship between AM and negative affect was statistically significant in a majority of assessments. Perceived disability is the underlying factor driving the relationship between AM and mood disturbance over time. Rehabilitative therapy to improve survivors’ functional well-being might mitigate the negative impacts of AM on emotional health.