Asian Oncol Nurs AON Asian Oncology Nursing 2287-2434 2287-447X Korean Oncology Nursing Society 10.5388/aon.2017.17.1.20 Original Article Lower Limb Lymphedema and Quality of Life in Gynecologic Cancer Patients Yu Sun Young 1 Kim Jeong Hye 2 Department of Nursing, Asan Medical Center, Seoul, Korea. Department of Clinical Nursing, University of Ulsan, Seoul, Korea. Address reprint requests to: Kim, Jeong Hye. Department of Clinical Nursing, University of Ulsan, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea. Tel: +82-2-3010-5335, Fax: +82-2-3010-5332, kimjh@amc.seoul.kr 03 2017 31 03 2017 17 1 20 28 30 11 2016 03 01 2017 21 03 2017 © 2017 Korean Oncology Nursing Society 2017 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Purpose

The purpose of this study was to identify the lower limb lymphedema (LLL) and quality of life in gynecologic cancer patients.

 Methods

A sample of 143 patients who have received pelvic lymphadenectomy and/or para-aortic lymphadenectomy recruied in the descriptive study. The instruments used were the Korean Version of the Gynecologic Cancer Lymphedema Questionnaire (GCLQ-K) and the European Organization for Research and Treatment of Cancer QOL Questionnaire-C30 (EORTC QLQ C-30).

 Results

The level of LLL for all patients was 4.31±3.86. The level of GCLQ-K score was higher in the LLL group than the non LLL group (8.38±2.92 vs 1.76±1.41). The all functional scale score was lower in the LLL group than the non LLL group, and all symptom scale score except for appetite loss and financial difficulties was higher in the LLL group than the non LLL group. The global health status score was lower in the LLL group than the non LLL group.

 Conclusion

The above results show that in the LLL patients after pelvic and/or para-aortic, lymphadenectomy was common. The quality of life was lower in the LLL group than the non LLL group. It is important to develop nursing intervention regarding prevention and management about LLL in gynecologic cancer patients.

 Gynecology Lower Extremity Lymphedema Quality of Life

The article is a revision of the first author's mater's thesis from Ulsan University.

 National Cancer Center, Korea Central Cancer Registry Annual report of cancer statistics in Korean 2013 [Internet] Accessed December 10, 2015 Available from: http://ncc.re.kr/cancerStatsList.ncc?searchKey=total&searchValue=&pageNum=1 Brearley SG Stamataki Z Addington-Hall J Foster C Hodges L Jarrett N The physical and practical problems experienced by cancer survivors: a rapid review and synthesis of the literature Eur J Oncol Nurs 2011 15 204 212 Dunberger G Lindquist H Waldenström AC Nyberg T Steineck G Åvall-Lundqvist E Lower limb lymphedema in gynecological cancer survivors--effect on daily life functioning Support Care Cancer 2013 21 3063 3070 McGarvey AC Osmotherly PG Hoffman GR Chiarelli PE Lymphoedema following treatment for head and neck cancer: impact on patients, and beliefs of health professionals Eur J Cancer Care (Engl) 2014 23 317 327 Köhler C Klemm P Schau A Possover M Krause N Tozzi R Introduction of transperitoneal lymphadenectomy in a gynecologic oncology center: analysis of 650 laparoscopic pelvic and/or paraaortic transperitoneal lymphadenectomies Gynecol Oncol 2004 95 52 61 Achouri A Huchon C Bats AS Bensaid C Nos C Lécuru F Complications of lymphadenectomy for gynecologic cancer Eur J Surg Oncol 2013 39 81 86 Beesley V Janda M Eakin E Obermair A Battistutta D Lymphedema after gynecological cancer treatment : prevalence, correlates, and supportive care needs Cancer 2007 109 2607 2614 Brown JC Chu CS Cheville AL Schmitz KH 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 Brown JC John GM Segal S Chu CS Schmitz KH Physical activity and lower limb lymphedema among uterine cancer survivors Med Sci Sports Exerc 2013 45 2091 2097 Carter J Raviv L Appollo K Baser RE Iasonos A Barakat RR 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 Finnane A Hayes SC Obermair A Janda M Quality of life of women with lower-limb lymphedema following gynecological cancer Expert Rev Pharmacoecon Outcomes Res 2011 11 287 297 Kang SH Hwang KH Sim YJ Jeong HJ Lee TH Kim SH The prevalence and risk factors of lower limb lymphedema in the patients with gynecologic neoplasms Korean J Obstet Gynecol 2009 52 815 820 Yang HS Lee K Kim DS Sim YJ Jeong HJ Kim GC The association of social support and quality of life in gynecological cancer related of lymphedema in a hospital: a pilot study Korean J Obstet Gynecol 2011 54 355 360 Hyun HY Yeom CH Lee HR The treatment effect of the complex lymphatic therapy for lymphedema J Korean Acad Fam Med 2002 23 646 651 Cho MO Jung HM Jun JY Sohn SK Yoo YJ No MY A study on self-care among the lymphedema patients J Korean Acad Adult Nurs 2003 15 383 392 Rowlands IJ Beesley VL Janda M Hayes SC Obermair A Quinn MA Quality of life of women with lower limb swelling or lymphedema 3-5 years following endometrial cancer Gynecol Oncol 2014 133 314 318 Erickson VS Pearson ML Ganz PA Adams J Kahn KL Arm edema in breast cancer patients J Natl Cancer Inst 2001 93 96 111 Lockwood-Rayermann S Lymphedema in gynecologic cancer survivors: an area for exploration? Cancer Nurs 2007 30 E11 E18 Lim MC Lee JS Joo J Park K Yoo HJ Seo SS Development and evaluation of the Korean version of the Gynecologic Cancer Lymphedema Questionnaire in gynecologic cancer survivors Gynecol Oncol 2014 133 111 116 Hammer SM Brown JC Segal S Chu CS Schmitz KH Cancer-related impairments influence physical activity in uterine cancer survivors Med Sci Sports Exerc 2014 46 2195 2201 Yun YH Park YS Lee ES Bang SM Heo DS Park SY Validation of the Korean version of the EORTC QLQ-C30 Qual Life Res 2004 13 863 868 Kim SI Lim MC Lee JS Lee Y Park K Joo J Impact of lower limb lymphedema on quality of life in gynecologic cancer survivors after pelvic lymph node dissection Eur J Obstet Gynecol Reprod Biol 2015 192 31 36 Abu-Rustum NR Alektiar K Iasonos A Lev G Sonoda Y Aghajanian C 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 Scott NW Fayers PM Aaronson NK Bottomley A de Graeff A Groenvold M EORTC QLQ-C30 reference values Brussels EORTC Quality of Life Group 2008 Yang GH Shim JY The diagnosis and treatment of lymphedema J Korean Med Assoc 2013 56 1115 1122 Langbecker D Hayes SC Newman B Janda M Treatment for upper-limb and lower-limb lymphedema by professionals specializing in lymphedema care Eur J Cancer Care (Engl) 2008 17 557 564 Fu MR Chen CM Haber J Guth AA Axelrod D The effect of providing information about lymphedema on the cognitive and symptom outcomes of breast cancer survivors Ann Surg Oncol 2010 17 1847 1853 Ryan M Stainton MC Slaytor EK Jaconelli C Watts S Mackenzie P Aetiology and prevalence of lower limb lymphoedema following treatment for gynaecological cancer Aust N Z J Obstet Gynaecol 2003 43 148 151 General Characteristics of Participants (<italic>N</italic>=143)
Variables Categories n (%) or M ± SD
Age (year) ≤40 18 (12.6)
41~50 42 (29.4)
51~60 62 (43.3)
≥61 21 (14.7)
51.1 ± 9.9
Education ≤Middle School 23 (16.1)
High School 69 (48.2)
≥College 51 (35.7)
Economic status (10,000 won/month) (n=133) ＜100 15 (11.3)
100~499 77 (57.9)
≥500 41 (30.8)
Type of cancer Ovarian 103 (72.0)
Endometrial 11 (7.7)
Cervical 20 (14.0)
Others 9 (6.3)
Stage of cancer (n=141) Stage I 29 (19.9)
Stage II 24 (17.0)
Stage III 62 (44.0)
Stage IV 27 (19.1)
Cancer recurrence Yes 93 (65.0)
No 50 (35.0)
Time period since surgery (month) ≤12 62 (43.3)
13~24 39 (27.3)
≥25 42 (29.4)
17.18 ± 11.94
Number of removal lymphnode (n=142) 42.51 ± 23.10
Node metastasis (n=142) Yes 89 (62.7)
No 53 (37.3)
Type oflymphadenectomy PLND 95 (66.4)
PLND & PALND 48 (33.6)
Chemotherapy Yes 139 (97.2)
No 4 (2.8)
Radiotherapy Yes 21 (14.7)
No 122 (85.3)
Comorbodity Yes 36 (25.2)
No 107 (74.8)
Lower limb lymphedema Yes 55 (38.5)
No 88 (61.5)

PLND= Pelvic lymphadenectomy: PALND= Pelvic & Para-aortic lymphadenectomy.

 Lower Limb Lymphedema of Participants (<italic>N</italic>=143)
Subscale Item number Items n (%) or M ± SD
Physical function 1 Limited movement of your hip 16 (11.2)
2 Limited movement of your knee 22 (15.4)
3 Limited movement of your ankle 18 (12.6)
4 Limited movement of your foot 25 (17.5)
5 Limited movement of your toes 33 (23.1)
6 Leg or foot feels weak 85 (59.4)
Swelling [general] 8 Experienced swelling 47 (32.9)
9 Experienced swelling with pitting 25 (17.5)
20 Experienced pockets of fluid 1 (0.7)
Infection 10 Experienced redness 15 (10.5)
11 Experienced blistering 5 (3.5)
13 Experienced increased temperature in the leg 27 (18.9)
Neuropathy 7 Experienced tenderness 22 (15.4)
12 Experienced firmness/tightness 39 (27.3)
15 Experienced numbness 35 (24.5)
16 Experienced stiffness 51 (35.7)
Swelling [limb] 18 Experienced hip swelling 10 (7.0)
19 Experienced groin swelling 24 (16.8)
Heaviness 14 Experienced heaviness 60 (42.0)
Ache 17 Experienced aching 56 (39.2)
Lower Limb Lymphedema according to General Characteristics (<italic>N</italic>=143)
Variables Categories LLL (n=55) Non LLL (n=88) χ2 or t (p)
n (%) or M ± SD n (%) or M ± SD
Age (year) ≤40 7 (12.7) 11 (12.6) 2.51 (.473)
41~50 14 (25.5) 28 (31.8)
51~60 28 (50.9) 34 (38.6)
≥61 6 (10.9) 15 (17.0)
50.6 ± 9.3 51.3 ± 10.3 0.41 (.683)
Education ≤Middle school 11 (20.0) 12 (13.6) 2.07 (.356)
High school 28 (50.9) 41 (46.6)
≥College 16 (29.1) 35 (39.8)
Economic status (10,000 won/month) (n=133) <100 7 (13.5) 8 (9.9) 0.43 (.808)
100~499 29 (55.8) 48 (59.2)
≥500 16 (30.7) 25 (30.9)
Type of cancer Ovarian 38 (69.1) 65 (73.9) 1.35 (.717)
Endometrial 4 (7.3) 7 (7.9)
Cervical 10 (18.2) 10 (11.4)
Others 3 (5.4) 6 (6.8)
Stage of cancer (n=141) Stage I 11 (20.4) 17 (19.5) 3.33 (.344)
Stage II 6 (11.1) 18 (20.7)
Stage III 28 (51.8) 34 (39.1)
Stage IV 9 (16.7) 18 (20.7)
Cancer recurrence Yes 40 (72.7) 53 (60.2) 2.33 (.151)
No 15 (27.3) 35 (39.8)
Time period since surgery (month) ≤12 22 (40.0) 40 (45.4) 0.58 (.750)
13~24 15 (27.3) 24 (27.3)
≥25 18 (32.7) 24 (27.3)
18.04 ± 12.42 16.65 ± 11.67 −0.68 (.501)
Number of removal lymphnode (n=142) 47.31 ± 23.38 39.47 ± 22.54 −1.99 (.049)
Node metastasis (n=142) Yes 39 (70.9) 50 (57.5) 2.60 (.114)
No 16 (29.1) 37 (42.5)
Type of lymphadenectomy PLND 16 (29.1) 22 (25.0) 0.29 (.698)
PLND & PALND 39 (70.9) 66 (75.0)
Chemotherapy Yes 54 (98.2) 84 (95.5) 0.75 (.649)
No 1 (1.8) 4 (4.5)
Radiotherapy Yes 12 (21.8) 9 (10.2) 3.63 (.087)
No 43 (78.2) 79 (89.8)
Comorbidity Yes 15 (27.3) 21 (23.9) 0.21 (.694)
No 40 (72.7) 67 (76.1)

LLL= Lower Limb Lymphedema; PLND= Pelvic lymphadenectomy; PALND= Pelvic & Para-aortic lymphadenectomy.

 Level of Lower Limb Lymphedema and Quality of Life (<italic>N</italic>=143)
Variables Categories Total LLL (n=55) Non LLL (n=88) t (p)
M ± SD M ± SD M ± SD
Level of LLL 4.31 ± 3.86 8.38 ± 2.92 1.76 ± 1.41 −15.67 (<.001)
Quality of life Functional scale
 Physical functioning 73.75 ± 16.10 62.54 ± 15.42 80.75 ± 12.10 7.44 (<.001)
 Role functioning 70.16 ± 24.69 54.84 ± 23.71 79.73 ± 20.12 6.71 (<.001)
 Emotional functioning 74.35 ± 21.21 66.81 ± 23.43 79.07 ± 18.30 3.49 (.001)
 Cognitive functioning 77.97 ± 18.72 73.63 ± 21.44 80.68 ± 16.35 2.22 (.028)
 Social functioning 65.38 ± 26.76 56.06 ± 26.71 71.21 ± 25.23 3.42 (.001)
Symptom scales
 Fatigue 38.22 ± 20.24 49.69 ± 21.58 31.06 ± 15.63 −5.56 (<.001)
 Nausea and vomiting 16.90 ± 23.73 24.54 ± 26.99 12.12 ± 20.17 −2.94 (.004)
 Pain 24.35 ± 26.14 38.18 ± 28.44 15.71 ± 20.42 −5.09 (<.001)
 Dyspnea 20.97 ± 27.02 32.12 ± 31.40 14.01 ± 21.27 −4.11 (<.001)
 Insomnia 30.30 ± 31.37 40.60 ± 34.36 23.86 ± 27.65 −3.20 (.002)
 Appetite loss 24.24 ± 28.30 29.69 ± 31.21 20.83 ± 27.65 −1.84 (.068)
 Constipation 25.40 ± 30.11 38.78 ± 33.80 17.04 ± 24.23 −4.15 (<.001)
 Diarrhea 12.12 ± 22.21 18.18 ± 28.55 8.30 ± 16.18 −2.33 (.009)
 Financial difficulties 25.40 ± 29.59 29.69 ± 29.86 22.72 ± 29.27 −1.37 (.171)
Global health status/QOL
 Global health status 58.68 ± 22.37 50.45 ± 21.60 63.82 ± 21.40 3.62 (<.001)

LLL= Lower Limb Lymphedema; QOL= quality of life.

 Correlation between Lower Limb Lymphedema and Quality of Life (<italic>N</italic>=143)
Variables Categories Total LLL (n=55) Non LLL (n=88)
r (p) r (p) r (p)
Functional scale Physical functioning −.64 (<.001) −.42 (.001) −.36 (.001)
Role functioning −.53 (<.001) −.17 (.216) −.39 (<.001)
Emotional functioning −.24 (.004) .04 (.761) −.10 (.359)
Cognitive functioning −.31 (<.001) −.26 (.056) −.38 (<.001)
Social functioning −.32 (<.001) −.16 (.254) −.22 (.043)
Symptom scale Fatigue .46 (<.001) .15 (.274) .21 (.054)
Nausea and vomiting .29 (<.001) .32 (.019) −.15 (.175)
Pain .48 (<.001) .32 (.019) .19 (.075)
Dyspnea .35 (<.001) .07 (.600) .30 (.004)
Insomnia .30 (<.001) .25 (.068) .01 (.925)
Appetite loss .21 (.012) .19 (.162) .11 (.327)
Constipation .34 (<.001) .15 (.284) .01 (.939)
Diarrhea .26 (.002) .20 (.136) .02 (.847)
Financial difficulties .21 (.012) .21 (.130) .24 (.022)
Global health status/QOL Global health status Quality of life −.34 (<.001) −.06 (.644) −.34 (.001)

LLL= Lower Limb Lymphedema; QOL= Quality of life.