Recurrence of Lymphedema and Related Characteristics in Discharged Breast Cancer Patients During The COVID-19 Pandemic: A Multicenter, Cross-Sectional Survey

Recurrence of Lymphedema and Related Characteristics in Discharged Breast Cancer Patients During The COVID-19 Pandemic: A Multicenter, Cross-Sectional Survey | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Recurrence of Lymphedema and Related Characteristics in Discharged Breast Cancer Patients During The COVID-19 Pandemic: A Multicenter, Cross-Sectional Survey Xin PENG, Renwang Chen, Zhenli Rao, Yi Yang, Yunli Yan, Ying Xia, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-836567/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background To evaluate recurrence of lymphedema and its influencing factors in discharged breast cancer patients with treated lymphedema during the COVID-19 pandemic and to propose feasible improvements. Methods A multicenter, cross-sectional, hospital-based survey of discharged breast cancer patients was conducted during the COVID-19 pandemic in eight first-class hospitals in Wuhan city, China. Norman Questionnaire was used for assessing lymphedema, and multivariable binary logistic regression was performed to risk factors of moderate or severe lymphedema. Difference in living characteristics, anxiety and depression between no or mild group and moderate or severe group were compared. Preference in management of lymphedema were collected. Results 202 valid patients were included. 191 participants reported recurred lymphedema (prevalence: 94.6%, 95%CI 90.5% to 97.3%). 134 of them was mild and 57 were moderate/severe. In the 191 patients, the main symptom was swelling (140, 69.3%) and pain (56, 27.7%). Multivariable regression showed that age (odds ratio, 1.06, 95%CI: 1.02-1.10), radical surgery (OR=4.35, 95%CI: 1.54-12.50) and fully complete radiotherapy (OR=2.62, 95%CI: 1.17-5.87, P=0.019) was associated with the risk of moderate or severe lymphedema. No significant difference in lifestyles was observed but moderate or severe group experienced higher rate of anxiety and depression. patients preferred treatment in hospital and self-care at home equally. Conclusion The high recurrence rate of lymphedema in breast cancer patients with during COVID-19 should draw our great attention, continuous efforts should be made to identify patient at risk of lymphedema and distribute feasible guidance and education for self-management for these patients. Cancer Biology Oncology COVID-19 breast cancer lymphedema PROs Norman Questionnaire Background Anatomically and physiological, the breast has fifteen to 20 lobes that contain glands responsible for milk production in response to hormone stimulation, however, uncontrolled growth of cells in the breast can lead to tumors [ 1 ] . Breast cancer had become the world’s most prevalent cancer in women based on the global cancer statistics 2020 [ 2 ] . The breast tumor tends to spread lymphatically and hematologically, the axillary lymph nodes are often the first to be affected when breast cancer spreads. During treatment for breast cancer, some or all of the axillary lymph nodes under the arm are dissected and flow of lymph may be disrupted, the patients are at a high risk of lymphedema for the rest of their life. Meanwhile, possible regional lymph node radiation treatment may cause scarring and blockages in the under arm lymph nodes, which can further increase the risk of lymphedema. A review including 19 studies and 3035 breast cancer patients showed that 711 (23.43%) developed breast cancer related lymphedema (BCRL) [ 3 ] . Moreover, the disturbing recurrence of BCRL could be not ignored [ 4 ] . BCRL has been one of the serious complications that affect both quality of life and postoperative psychological status [ 5 – 6 ] . Early identification and treatment of lymphedema is important. Self-reported symptoms were considered as suitable instrument of early detection of BCRL [ 4 ] . Without timely treatment for lymphedema, the swelling will worsen, meanwhile, skin sores, infection in affected area or other problems can develop, all of which greatly deteriorate prognosis of breast cancer [ 7 ] . In December 2019, the first case of Coronavirus disease 2019 (COVID-19) was identified in Wuhan city which was the epicenter of the COVID-19 outbreak in China. The COVID-19 spread rapidly and globally within a short period, which had been recognized as a global pandemic by the WHO [ 8 – 9 ] . At the beginning of the outbreak, the medical resources were limited with shortage of personal protection equipment and a large number of patients infected with COVID-19. About 51 local hospitals in Wuhan city were transformed into designated hospitals for patients infected with COVID-19, so patients with other diseases were delayed to get adequate and timely treatment, which also included breast cancer patients [ 10 – 11 ] . The delay due to the outbreak will cause overdue diagnosis and treatment of lymphedema. Meanwhile, a high prevalence of depression and anxiety were observed among general population during the pandemic [ 12 ] . A literature review showed that psychosocial issues were associated with breast cancer-related lymphedema [ 13 ] . So, it is of great significance to understand status of lymphedema and demands among the breast cancer patients with treated lymphedema. Breast cancer patients in Wuhan city experienced a long city lockdown and a passive delay of treatments. Therefore, they could provide valuable information. In this study, we performed a multicenter cross-sectional survey in eight first-class hospitals from Wuhan city to investigate the status of lymphedema and demands in breast cancer patients with previous and cured lymphedema during the early pandemic. It can help to arrange optimal nursing plan and treatment for potential lymphedema in breast cancer patients during the ongoing global COVID-19 pandemic. Materials And Methods Study Design, Setting, Participants From May 27, 2020 to June 10, 2020, a multicenter, cross-sectional, hospital-based survey was conducted in eight first-class hospitals in Wuhan city, China. This study was reviewed and approved by the ethical review of Tongji Medical College of Huazhong University of Science and Technology. A convenient sampling method was adopted to select accessible breast cancer patients. Patients were eligible for the inclusion if they: 1) female patients who were diagnosed with breast cancer before COVID-19; 2) discharged after treatment; 3) has lymphedema before COVID-19 pandemic and the lymphedema had been effectively treated and affected limbs had recovered to normal before January 2020; 4) lymphedema-related intervention was interrupted during COVID-19 from January to April 2020; 5) agreed the informed consent and was volunteer to participate in this study. The exclusion criteria were 1) infection with COVID-19; 2) new recurrence or metastasis of breast cancer. Data Collection A self-administered electronic questionnaire was designed to collect data. A structural and unified instructions was prepared to explain the purpose, meaning and filling method of the questionnaire. The link embed in a QR code was distributed through WeChat (a famous online communication tool in China). One WeChat account could only fill out the questionnaire once, and consumed time was recorded for further validation. The questionnaire consisted of general characteristics, diagnostic questionnaire for lymphedema, patient-reported outcomes and preference in management of lymphedema. In the demographic characteristics, we collected age, height, weight, educational level, surgery (yes/no) and type of surgery, radiotherapy (yes/no), use of taxane drugs or hormones in the past 6 months(yes/no), knowledge level of lymphedema. Moreover, we queried participants’ physical activity (yes/no), special protection for the affected limb (yes/no), emotional status and need for treatment after the lymphedema reappeared during COVID-19 pandemic. Secondly, to assess whether the patients have lymphedema symptoms by phone, a reliable and validated Norman Questionnaire was applied [ 14 ] . The researchers converted contents of phone assessment into easy-to-understand text, repeated proofreading and comparison to guarantee the consistent meaning. It queried about any swelling in 3 parts (the hand, forearm and upper arm) in the past 3 months. For each part, its score ranged from 0 to 3, 0 indicated no swelling, 1 score indicated a slight swelling where only the patient could perceive, 2 score indicated a moderate swelling where patients’ acquaintances could notice in daily life, 3 score indicated a serious swelling where any stranger could notice. Finally, the scores of the three parts were summed. No lymphedema was developed if the sum equaled to 0, a total score of 1 to 4 scores indicated a mild lymphedema, 4 points or more implied a moderate to severe lymphedema. The symptoms of lymphedema were structurally assessed according to a review on patient reported outcomes for breast cancer [ 15 ] . We collected whether the patient reported swelling, pain, heaviness, numbness, stiffness or movement restriction in affected limbs. Finally, the participants’ anxiety and depression were assessed using 7 items in the hospital anxiety and depression scale(HADS) [ 16 ] . Each item scored from 0 to 3 points, giving a total of 21 points. A total score greater than 8 suggested the presence of anxiety and depression which required medical attention. Statistical analysis Data were extracted from the online questionnaire system and exported to SPSS software for statistical analysis. We first performed statistical description and group comparisons. Mean and standard deviation was used to describe continuous variables, and student’s t test was performed for comparison between groups. Categorical variables were described using frequencies and percentages and were compared using chi-square test or Fisher’s exact test. Participants were classified into none or mild lymphedema group and moderate to severe lymphedema group, a multivariable binary logistic regression was conducted to explored potential and independent risk factors, odds ratio and corresponding 95% confidence interval (95% CI) were presented. Two-sided P values of less than 0.05 were considered statistically significant. Results General characteristics A total of 228 questionnaires were collected, All but 16 participants were excluded for taking less than 90 seconds; no logical error was found. Finally, 202 records were included for final analysis. The included patients presented a mean age of 51.34 years old and a mean BMI 23.43 Kg/m 2 , and the majority of them (70.8%) reported a more than 10-years education background. 144 patients (71.8%) had received radical surgery. Affected by COVID-19 pandemic, only 10 (5.0%) underwent radiotherapy, while 71 (35.1%) did not receive radiotherapy and 121 (59.9%) experienced interrupted radiotherapy. 55 (22.3%) used taxane or hormone therapy in the past 6 months. Seen Table 1 . Table 1 demographic characteristic of discharged breast cancer patients during COVID-19 Variable Description Age, years, mean+/SD 51.34 ± 10.07 BMI, kg/m 2 , mean+/SD 23.43 ± 3.08 Years of education, years, n(%) ≤ 6 11(5.4%) 7–9 48(23.8%) 10–12 66(32.7%) > 12 77(38.1%) Type of surgery, n(%) Radical surgery 145(71.8%) Others 57(28.2%) Radiotherapy situation, n(%) Never 71(35.1%) Fully completed 121(59.9%) Interrupted 10(5.0%) Medication, n(%) Used 45(22.3%) Never used 121(59.9%) Unknow 36(17.8%) COVID-19, Coronavirus Disease 2019; BMI, body mass index; Medication, the use of taxane drugs or hormones in the past six months. Prevalence of lymphedema and self-reported symptoms Based on Norman Questionnaire using 8 as cutoff, 191 participants (prevalence: 94.6%, 95%CI 90.5–97.3%) reported recurred lymphedema, 134 of them were mild and 57 were moderate to severe, In the 191 patients, the main symptom was swelling (140, 69.3%), followed by pain (56, 27.7%), heaviness (55, 27.2%), numbness (55, 27.2%), stiffness31 (15.3%), and movement restriction 31 (15.3%). Characteristics associated with degree of lymphedema The participants were classified into two groups, no or mild lymphedema group (134, 66.3%) and moderate or severe lymphedema group (57, 28.2%). Description of two groups were presented in Table 2 . The age was 49.79 ± 10.14 in the no or mild group and 55.30 ± 8.80 in moderate or severe group. After adjustment, increased age was significantly and independently associated with severer lymphedema (OR = 1.06, 95%CI: 1.02–1.10, P = 0.004). The rate of radical surgery was 91.2% in moderate or severe group and 61.1% in another group, Multivariable regression showed that radical surgery methods were associated with a higher risk of severer lymphedema using othres surgery as reference (OR = 4.35, 95%CI: 1.54–12.50, P = 0.006). 42(73.7%) in no or mild group took fully complete radiotherapy, while the figures decreased to 79(54.5%) in moderate or severe group. Using no radiotherapy as reference, fully complete radiotherapy increased the risk of severer lymphedema (OR = 2.62, 95%CI: 1.17–5.87, P = 0.019). However, BMI, the months since surgery and use of drugs or hormones in the past six months were found not to be the risk factors after adjustment. Table 2 Logistic regression analysis on the relationship between risk factors and risk of moderate or severe lymphedema Degree of lymphedema Adjusted OR (95%CI) P None or mild (n = 145) Moderate or severe (n = 57) Age 49.79 ± 10.14 55.30 ± 8.80 1.06(1.02–1.10) 0.004 BMI 23.01 ± 2.99 24.33 ± 3.15 1.08(0.97–1.21) 0.176 Surgery until now(months) 25.34 ± 24.09 41.15 ± 32.51 1.01(0.99–1.02) 0.155 Surgical method Radical surgery 93(61.1%) 52(91.2%) 4.35(1.54–12.50) 0.006 Others 52(35.9%) 5(8.8%) 1.00 Radiotherapy Never 57(59.7%) 14(24.6%) 1.00 Fully completed 79(54.5%) 42(73.7%) 2.62(1.17–5.87) 0.019 Interrupted 9(6.2%) 1(1.8%) 0.60(0.05–6.91) 0.685 Medication Used 38(26.2%) 7(12.3%) 1.00 Never used 81(55.9%) 40(70.2%) 1.46(0.53–3.97) 0.461 Unknown 26(17.9%) 10(17.5%) 1.84(0.51–6.68) 0.353 BMI, body mass index; Medication, the use of taxane drugs or hormones in the past six months; Influence of lymphedema on lifestyle and psychological state During the COVID-19 pandemic, after lymphedema recurred, less than 20% patients increased physical labor and more than 80% took protective measures for affected limbs. Meanwhile, about half of patients took less exercise at home and about one in five patients reported excessive housework during quarantine at home. The rate of accidental injuries, skin allergies and fungal skin infections of the hands were low. No significant differences in these lifestyles were observed between the two groups. However, a significantly higher proportion of both anxiety and depression were observed in moderate or severe group than that in no or mild group, 78.9% vs 54.4%, 24.6% vs 9.7%, respectively, seen Table 3 . Table 3 difference in lifestyles and psychological states between no or mild group and moderate or severe group Parameters Degree of lymphedema P None or mild n(%) Moderate or severe n(%) Manual labor 0.870 No change 78(53.8%) 29(50.9) Increase 26(17.9%) 12(21.1) decrease 41(28.3%) 16(28.1) Protective measures for affected limbs None 24(16.6%) 7(12.3) 0.448 Keep skin clean and intact 87(60.0%) 32(56.1) 0.616 No lift of heavy objects 114(78.6%) 50(87.7) 0.136 Postoperative functional exercise 64(44.1%) 21(36.1) 0.345 Living conditions Exercise less at home 75(51.7%) 36(63.2%) 0.142 Excessive housework 24(16.6%) 10(17.5%) 0.865 Accidental injuries 5(3.4%) 3(5.3%) 0.846 Skin allergies 15(10.3%) 2(3.5%) 0.196 Fungal skin infections of the hands 3(2.1%) 0(0.0%) 0.654 Psychological state anxiety 79(54.4%) 45(78.9%) 0.001 Depression 14(9.7%) 14(24.6%) 0.006 COVID-19, Corona Virus Disease 2019; BMI, body mass index; Patients' needs for treatment of lymphedema during the COVID-19 pandemic The survey showed that 70.8% of patients hoped to get treatment at hospital even though the COVID-19 greatly limited the accessibility. The same rate was observed for the need of self-care at home. Online consultation and family help were the secondary options, accounting for about 35.1% and 32.7%, respectively. About one in five chose community service and only 11.4% of patients were willing to receive door-to-door services. Discussion The COVID-19 was mainly characterized by high contagiousness and rapid spread [ 17 ] . City lockdown and home quarantine were considered as effective measures to prevent the spread of the virus during the early outbreak. Breast cancer patients were also restricted from going out and visiting the hospital, which caused their treatment to be interrupted. In this study, the prevalence of recurred lymphedema during the COVID-19 pandemic was 94.6% which was higher than 14–40% in previous studies. The mainly reported manifestation was swelling and pain, while lymphedema related swelling, infection and dysfunction in limbs could affect the patients’ quality of life seriously [ 18 – 19 ] . Meanwhile, insufficient knowledge about lymphedema and lack of standard and professional guidance in monitoring swelling and implementing lymphedema drainage in the patients might led to further aggravation and decreased quality of life during the home quarantine. The high prevalence of lymphedema should draw our great attention and were required to distribute effective and timely intervention. Prevention of lymphedema in breast cancer patients is more important than treatment, it is of great significance to identify potential risk factors and targeted population. Exercise is important for managing lymphedema by working muscle and increasing the flow of lymph fluid. Generally, the elderly was characterized by decreased physical activity [ 20 ] . In our study, the mean age was about 51 years, and age was found to increase the risk of severer lymphedema. Cancer survivors experienced fatigue and barriers to physical activity in after treatment [ 21 ] . Moreover, home quarantine might make participants reduce exercise. Finally, the decreased activity resulted in increased risk of lymphedema. There were various surgery for breast cancer, including biopsy surgery of sentinel lymph node, breast-conserving surgery, breast reconstruction surgery and others [ 22 ] . Radical mastectomy was a type of surgery that involved the removal of both breast tissue, fatty lymphatic tissue and lymph nodes. Undoubtedly, it cuts off most of the lymphatic pathways in the upper extremities. axillary dissection. Previous study found that complete axillary lymph node dissection increased incidence of lymphedema to 36% [ 23 ] . We also found radiotherapy significantly increased the risk of lymphedema, which was consistent with conclusion of a large cohort study [ 24 ] . Nursing staffs should provide personalized and feasible guidance for functional exercises and prevention, monitoring, treatment and nursing of lymphedema for these patients at high risk. In lymphedema, an inflammatory process was developed progressively in affected limbs. A national study conducted during COVID-19 pandemic showed a higher proportion of infection in cancer patients than the overall incidence of cancer in China (1% vs. 0.29%) [ 26 ] . Nursing managers should pay attention to preventing secondary infection in breast cancer patients. The COVID-19 pandemic was a public health emergency, it not only affected the routine diagnosis and treatment of patients, but also affected the psychology of patients to a certain extent. A systematic review showed that concerns about the risk of infection with COVID-19 led to high rates of symptoms of anxiety and depression [ 25 ] . In our study, 61.4% breast cancer patients suffered from anxiety and 13.9% experienced depression, patients with moderate or severe lymphedema presented higher proportion of both anxiety and depression. The patients worried that delay in treatment would cause symptoms of lymphedema to worsen, meanwhile, presence of lymphedema limited the movements of the affected limbs and affected daily life and self-care ability, such as use of chopsticks, toileting and bathing. These conditions made the patient frustrated and depressed. So, psychological intervention should be carried out timely for breast cancer patients with lymphedema to increase their psychological resistance. Nursing management could conduct remote guidance and apply online courses to increase patients’ self-management ability during the restricted condition. Furthermore, timely diagnosis and treatment of lymphedema were still effective and direct measures. Our study showed that patients preferred treatment in hospital and self-care at home equally. Patients with severe lymphedema or psychological distressed were recommended to go for treatment in professional hospitals. However, immunodeficiency after anti-tumor treatment might make these patients be susceptible to COVID-19 infection. Requirement of frequent nucleic acid and chest CT test make the treatment complex. Self-care at home become the optimal alternative. Patients can develop self-care ability in management of symptoms, treatment and psychosocial adaptation when coping with chronic diseases [ 28 – 30 ] . Considering the ongoing pandemic, nursing education for lymphedema must be distributed for discharged patients. Telemedicine was a promising technology [ 31 ] . After patients mastered basic knowledge of lymphedema and basic nursing methods, healthcare workers could guide remote rehabilitation and online medical treatment through telephone, WeChat, video and other online methods during COVID-19 pandemic [32] . There were several limitations in this study. Firstly, it was a cross-sectional study, no causal inference could be made, but it could be considered that risk factors occurred before the recurred lymphedema which provided clues for the temporal relationship. Secondly, data was collected using an online tool, selection bias might exist since patients who did not use smartphones failed to participate in this study, meanwhile, recall bias and self-reporting problems might influence the precision. Finally, the COVID-19 pandemic was still ongoing, a longitudinal study was required to track breast cancer patients’ new problems and search new solutions. Conclusion During the COVID-19 pandemic, high prevalence of lymphedema was observed in breast cancer patients Age, radical surgery and fully completed radiotherapy were associated with increased risk of severer lymphedema. Meanwhile, the patients with severe lymphedema experienced psychological distress. While the Covid-19 pandemic was still raging, continuous efforts should be made to identify patient at risk of lymphedema and distribute feasible guidance and education for self-management in lymphedema. Declarations Ethical approval This study passed the ethical review of Tongji Medical College of Huazhong University of Science and Technology. Consent for publication Not applicable. Availability of data and materials The data being used and analyzed during the current study are available from the corresponding authors upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors' contributions PX developed the idea, designed the study, and provided financial support for the study. PX and CRW designed the questionnaires and drafted the manuscript. RZL，YY，YYL, XY, WT，WJY, LF, PH, and LF were involved in the acquisition of the data. PX and CRW summarized the data and contributed to data interpretation. CJ and HQ critically revised the manuscript for important intellectual content. The corresponding author had full access to all the data in the study and was responsible for submission for publication. Acknowledgment This study was supported by nursing managers and breast cancer patients in eight hospitals, including the Union Hospital of Tongji Medical College of Huazhong University of Science and Technology. Thanks go to all breast cancer specialist nursing workers for thinking about the treatment and nursing of lymphedema in breast cancer patients in the post-epidemic era. References Ely S, Vioral AN. Breast cancer overview. Plast Surg Nurs. 2007;27(3):128–33, 134–135. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-836567","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":49163338,"identity":"ff96026a-b56a-44c2-b914-e27eb5b93562","order_by":0,"name":"Xin PENG","email":"","orcid":"https://orcid.org/0000-0002-8061-2335","institution":"Wuhan Union Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xin","middleName":"","lastName":"PENG","suffix":""},{"id":49163339,"identity":"a09030e6-5a53-43f4-9c1a-7070619c414a","order_by":1,"name":"Renwang Chen","email":"","orcid":"","institution":"Huazhong University of Science and Technology Tongji Medical College First Clinical College: Wuhan Union Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Renwang","middleName":"","lastName":"Chen","suffix":""},{"id":49163340,"identity":"cf8aaf70-f6f4-45a3-a5fc-df167f62eb81","order_by":2,"name":"Zhenli Rao","email":"","orcid":"","institution":"Huazhong University of Science and Technology Tongji Medical College First Clinical College: Wuhan Union Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Zhenli","middleName":"","lastName":"Rao","suffix":""},{"id":49163341,"identity":"6f37da17-6d01-4daa-ae4f-3fb95a6dbc28","order_by":3,"name":"Yi Yang","email":"","orcid":"","institution":"Hubei Cancer Institute: Hubei Cancer Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yi","middleName":"","lastName":"Yang","suffix":""},{"id":49163342,"identity":"86e7299c-c1a6-4709-a8a0-0d6c6b5743e5","order_by":4,"name":"Yunli Yan","email":"","orcid":"","institution":"Huazhong University of Science and Technology Tongji Medical College First Clinical College: Wuhan Union Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yunli","middleName":"","lastName":"Yan","suffix":""},{"id":49163343,"identity":"7f924e31-6d1e-471f-a870-4218e072fa3e","order_by":5,"name":"Ying Xia","email":"","orcid":"","institution":"Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology Department of Geriatrics","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ying","middleName":"","lastName":"Xia","suffix":""},{"id":49163344,"identity":"7572770f-a951-4080-8243-2f84fc7a3b33","order_by":6,"name":"Ting Wang","email":"","orcid":"","institution":"Medical College of Hubei Institute for Nationalities: Hubei University for Nationalities School of Medical Science","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ting","middleName":"","lastName":"Wang","suffix":""},{"id":49163345,"identity":"1c23f9c3-150b-4ea1-b088-e559149b4bcb","order_by":7,"name":"Jianying Wang","email":"","orcid":"","institution":"Renmin Hospital of Wuhan University: Wuhan University Renmin Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jianying","middleName":"","lastName":"Wang","suffix":""},{"id":49163346,"identity":"1c193fea-c290-4f29-acf0-559e1b4f8ef9","order_by":8,"name":"Fang Lu","email":"","orcid":"","institution":"Wuhan University Zhongnan Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Fang","middleName":"","lastName":"Lu","suffix":""},{"id":49163347,"identity":"50e6f917-8fb5-4ad5-90ea-dfdb171c8415","order_by":9,"name":"Hong Pan","email":"","orcid":"","institution":"The Central Hospital of Wuhan","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hong","middleName":"","lastName":"Pan","suffix":""},{"id":49163348,"identity":"00cc1cfb-7863-434c-af03-34ca516f33ef","order_by":10,"name":"Yan Liu","email":"","orcid":"","institution":"Third People's Hospital of Zhongshan","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Liu","suffix":""},{"id":49163349,"identity":"a680c0ab-ea47-4743-976e-db3e6a29203e","order_by":11,"name":"Qin He","email":"","orcid":"","institution":"Huazhong University of Science and Technology Tongji Medical College First Clinical College: Wuhan Union Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Qin","middleName":"","lastName":"He","suffix":""},{"id":49163350,"identity":"60c10cde-dcf5-412b-bf20-a952644cc08f","order_by":12,"name":"Jing Chen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6ElEQVRIiWNgGAWjYDACCRA2YOBhY2Y++BgswszcQJQWGT52tmRjBgYDoBZGIrQAgY0cP4+ZNFgLAwEt/LObjz2wKLgDdBhbWnVBxZ9o/naglh8V23BbcudYuoGEwTOQX47dnnHGIHfGYcYGxp4zt3FqMZDIMZOQMDgMtuU2b5tBbgNQCzNjGz4t+d+gWnjMikFa5hPWksMG18IM0rKBkBaJG2lwhyVL85wxzt0I1HIQn1/4ZyQ/k5b4c9hevv/wwc88FXK5884fPvjgRwVuLSDALIEucgCveiBg/EBIxSgYBaNgFIxsAAADH0ylB04RHQAAAABJRU5ErkJggg==","orcid":"","institution":"Huazhong University of Science and Technology Tongji Medical College First Clinical College: Wuhan Union Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Jing","middleName":"","lastName":"Chen","suffix":""}],"badges":[],"createdAt":"2021-08-22 19:14:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-836567/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-836567/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":13712485,"identity":"364055f9-4fd2-4bdb-8f37-49b2ac9d70f5","added_by":"auto","created_at":"2021-09-17 14:28:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":410474,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-836567/v1/28b75152-b667-424d-bc53-1425ebe565e7.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eRecurrence of Lymphedema and Related Characteristics in Discharged Breast Cancer Patients During The COVID-19 Pandemic: A Multicenter, Cross-Sectional Survey\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eAnatomically and physiological, the breast has fifteen to 20 lobes that contain glands responsible for milk production in response to hormone stimulation, however, uncontrolled growth of cells in the breast can lead to tumors\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Breast cancer had become the world\u0026rsquo;s most prevalent cancer in women based on the global cancer statistics 2020\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. The breast tumor tends to spread lymphatically and hematologically, the axillary lymph nodes are often the first to be affected when breast cancer spreads. During treatment for breast cancer, some or all of the axillary lymph nodes under the arm are dissected and flow of lymph may be disrupted, the patients are at a high risk of lymphedema for the rest of their life. Meanwhile, possible regional lymph node radiation treatment may cause scarring and blockages in the under arm lymph nodes, which can further increase the risk of lymphedema. A review including 19 studies and 3035 breast cancer patients showed that 711 (23.43%) developed breast cancer related lymphedema (BCRL)\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. Moreover, the disturbing recurrence of BCRL could be not ignored\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. BCRL has been one of the serious complications that affect both quality of life and postoperative psychological status \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Early identification and treatment of lymphedema is important. Self-reported symptoms were considered as suitable instrument of early detection of BCRL\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. Without timely treatment for lymphedema, the swelling will worsen, meanwhile, skin sores, infection in affected area or other problems can develop, all of which greatly deteriorate prognosis of breast cancer\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn December 2019, the first case of Coronavirus disease 2019 (COVID-19) was identified in Wuhan city which was the epicenter of the COVID-19 outbreak in China. The COVID-19 spread rapidly and globally within a short period, which had been recognized as a global pandemic by the WHO \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. At the beginning of the outbreak, the medical resources were limited with shortage of personal protection equipment and a large number of patients infected with COVID-19. About 51 local hospitals in Wuhan city were transformed into designated hospitals for patients infected with COVID-19, so patients with other diseases were delayed to get adequate and timely treatment, which also included breast cancer patients\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. The delay due to the outbreak will cause overdue diagnosis and treatment of lymphedema. Meanwhile, a high prevalence of depression and anxiety were observed among general population during the pandemic\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. A literature review showed that psychosocial issues were associated with breast cancer-related lymphedema\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. So, it is of great significance to understand status of lymphedema and demands among the breast cancer patients with treated lymphedema.\u003c/p\u003e \u003cp\u003eBreast cancer patients in Wuhan city experienced a long city lockdown and a passive delay of treatments. Therefore, they could provide valuable information. In this study, we performed a multicenter cross-sectional survey in eight first-class hospitals from Wuhan city to investigate the status of lymphedema and demands in breast cancer patients with previous and cured lymphedema during the early pandemic. It can help to arrange optimal nursing plan and treatment for potential lymphedema in breast cancer patients during the ongoing global COVID-19 pandemic.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design, Setting, Participants\u003c/h2\u003e \u003cp\u003eFrom May 27, 2020 to June 10, 2020, a multicenter, cross-sectional, hospital-based survey was conducted in eight first-class hospitals in Wuhan city, China. This study was reviewed and approved by the ethical review of Tongji Medical College of Huazhong University of Science and Technology. A convenient sampling method was adopted to select accessible breast cancer patients. Patients were eligible for the inclusion if they: 1) female patients who were diagnosed with breast cancer before COVID-19; 2) discharged after treatment; 3) has lymphedema before COVID-19 pandemic and the lymphedema had been effectively treated and affected limbs had recovered to normal before January 2020; 4) lymphedema-related intervention was interrupted during COVID-19 from January to April 2020; 5) agreed the informed consent and was volunteer to participate in this study. The exclusion criteria were 1) infection with COVID-19; 2) new recurrence or metastasis of breast cancer.\u003c/p\u003e \u003c/div\u003e\n\u003ch2\u003eData Collection\u003c/h2\u003e\n\u003cp\u003eA self-administered electronic questionnaire was designed to collect data. A structural and unified instructions was prepared to explain the purpose, meaning and filling method of the questionnaire. The link embed in a QR code was distributed through WeChat (a famous online communication tool in China). One WeChat account could only fill out the questionnaire once, and consumed time was recorded for further validation.\u003c/p\u003e \u003cp\u003eThe questionnaire consisted of general characteristics, diagnostic questionnaire for lymphedema, patient-reported outcomes and preference in management of lymphedema. In the demographic characteristics, we collected age, height, weight, educational level, surgery (yes/no) and type of surgery, radiotherapy (yes/no), use of taxane drugs or hormones in the past 6 months(yes/no), knowledge level of lymphedema. Moreover, we queried participants\u0026rsquo; physical activity (yes/no), special protection for the affected limb (yes/no), emotional status and need for treatment after the lymphedema reappeared during COVID-19 pandemic. Secondly, to assess whether the patients have lymphedema symptoms by phone, a reliable and validated Norman Questionnaire was applied\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. The researchers converted contents of phone assessment into easy-to-understand text, repeated proofreading and comparison to guarantee the consistent meaning. It queried about any swelling in 3 parts (the hand, forearm and upper arm) in the past 3 months. For each part, its score ranged from 0 to 3, 0 indicated no swelling, 1 score indicated a slight swelling where only the patient could perceive, 2 score indicated a moderate swelling where patients\u0026rsquo; acquaintances could notice in daily life, 3 score indicated a serious swelling where any stranger could notice. Finally, the scores of the three parts were summed. No lymphedema was developed if the sum equaled to 0, a total score of 1 to 4 scores indicated a mild lymphedema, 4 points or more implied a moderate to severe lymphedema. The symptoms of lymphedema were structurally assessed according to a review on patient reported outcomes for breast cancer\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. We collected whether the patient reported swelling, pain, heaviness, numbness, stiffness or movement restriction in affected limbs. Finally, the participants\u0026rsquo; anxiety and depression were assessed using 7 items in the hospital anxiety and depression scale(HADS)\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. Each item scored from 0 to 3 points, giving a total of 21 points. A total score greater than 8 suggested the presence of anxiety and depression which required medical attention.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData were extracted from the online questionnaire system and exported to SPSS software for statistical analysis. We first performed statistical description and group comparisons. Mean and standard deviation was used to describe continuous variables, and student\u0026rsquo;s t test was performed for comparison between groups. Categorical variables were described using frequencies and percentages and were compared using chi-square test or Fisher\u0026rsquo;s exact test. Participants were classified into none or mild lymphedema group and moderate to severe lymphedema group, a multivariable binary logistic regression was conducted to explored potential and independent risk factors, odds ratio and corresponding 95% confidence interval (95% CI) were presented. Two-sided P values of less than 0.05 were considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eGeneral characteristics\u003c/h2\u003e \u003cp\u003eA total of 228 questionnaires were collected, All but 16 participants were excluded for taking less than 90 seconds; no logical error was found. Finally, 202 records were included for final analysis. The included patients presented a mean age of 51.34 years old and a mean BMI 23.43 Kg/m\u003csup\u003e2\u003c/sup\u003e, and the majority of them (70.8%) reported a more than 10-years education background. 144 patients (71.8%) had received radical surgery. Affected by COVID-19 pandemic, only 10 (5.0%) underwent radiotherapy, while 71 (35.1%) did not receive radiotherapy and 121 (59.9%) experienced interrupted radiotherapy. 55 (22.3%) used taxane or hormone therapy in the past 6 months. Seen Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003edemographic characteristic of discharged breast cancer patients during COVID-19\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years, mean+/SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51.34\u0026thinsp;\u0026plusmn;\u0026thinsp;10.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI, kg/m\u003csup\u003e2\u003c/sup\u003e, mean+/SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.43\u0026thinsp;\u0026plusmn;\u0026thinsp;3.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears of education, years, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11(5.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48(23.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u0026ndash;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66(32.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77(38.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of surgery, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadical surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e145(71.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57(28.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadiotherapy situation, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71(35.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFully completed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e121(59.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterrupted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10(5.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedication, n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUsed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45(22.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever used\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e121(59.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36(17.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eCOVID-19, Coronavirus Disease 2019; BMI, body mass index; Medication, the use of taxane drugs or hormones in the past six months.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003ePrevalence of lymphedema and self-reported symptoms\u003c/h2\u003e \u003cp\u003eBased on Norman Questionnaire using 8 as cutoff, 191 participants (prevalence: 94.6%, 95%CI 90.5\u0026ndash;97.3%) reported recurred lymphedema, 134 of them were mild and 57 were moderate to severe, In the 191 patients, the main symptom was swelling (140, 69.3%), followed by pain (56, 27.7%), heaviness (55, 27.2%), numbness (55, 27.2%), stiffness31 (15.3%), and movement restriction 31 (15.3%).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics associated with degree of lymphedema\u003c/h2\u003e \u003cp\u003eThe participants were classified into two groups, no or mild lymphedema group (134, 66.3%) and moderate or severe lymphedema group (57, 28.2%). Description of two groups were presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The age was 49.79\u0026thinsp;\u0026plusmn;\u0026thinsp;10.14 in the no or mild group and 55.30\u0026thinsp;\u0026plusmn;\u0026thinsp;8.80 in moderate or severe group. After adjustment, increased age was significantly and independently associated with severer lymphedema (OR\u0026thinsp;=\u0026thinsp;1.06, 95%CI: 1.02\u0026ndash;1.10, P\u0026thinsp;=\u0026thinsp;0.004). The rate of radical surgery was 91.2% in moderate or severe group and 61.1% in another group, Multivariable regression showed that radical surgery methods were associated with a higher risk of severer lymphedema using othres surgery as reference (OR\u0026thinsp;=\u0026thinsp;4.35, 95%CI: 1.54\u0026ndash;12.50, P\u0026thinsp;=\u0026thinsp;0.006). 42(73.7%) in no or mild group took fully complete radiotherapy, while the figures decreased to 79(54.5%) in moderate or severe group. Using no radiotherapy as reference, fully complete radiotherapy increased the risk of severer lymphedema (OR\u0026thinsp;=\u0026thinsp;2.62, 95%CI: 1.17\u0026ndash;5.87, P\u0026thinsp;=\u0026thinsp;0.019). However, BMI, the months since surgery and use of drugs or hormones in the past six months were found not to be the risk factors after adjustment.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLogistic regression analysis on the relationship between risk factors and risk of moderate or severe lymphedema\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eDegree of lymphedema\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAdjusted OR\u003c/p\u003e \u003cp\u003e(95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNone or mild\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;145)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModerate or severe\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;57)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49.79\u0026thinsp;\u0026plusmn;\u0026thinsp;10.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55.30\u0026thinsp;\u0026plusmn;\u0026thinsp;8.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.06(1.02\u0026ndash;1.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.01\u0026thinsp;\u0026plusmn;\u0026thinsp;2.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.33\u0026thinsp;\u0026plusmn;\u0026thinsp;3.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.08(0.97\u0026ndash;1.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.176\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSurgery until now(months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.34\u0026thinsp;\u0026plusmn;\u0026thinsp;24.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41.15\u0026thinsp;\u0026plusmn;\u0026thinsp;32.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.01(0.99\u0026ndash;1.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.155\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSurgical method\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRadical surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93(61.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e52(91.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.35(1.54\u0026ndash;12.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52(35.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5(8.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eRadiotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57(59.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14(24.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFully completed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79(54.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e42(73.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.62(1.17\u0026ndash;5.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.019\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInterrupted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9(6.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1(1.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.60(0.05\u0026ndash;6.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.685\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMedication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUsed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38(26.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7(12.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNever used\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81(55.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e40(70.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.46(0.53\u0026ndash;3.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.461\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26(17.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10(17.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.84(0.51\u0026ndash;6.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.353\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eBMI, body mass index; Medication, the use of taxane drugs or hormones in the past six months;\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eInfluence of lymphedema on lifestyle and psychological state\u003c/h2\u003e \u003cp\u003eDuring the COVID-19 pandemic, after lymphedema recurred, less than 20% patients increased physical labor and more than 80% took protective measures for affected limbs. Meanwhile, about half of patients took less exercise at home and about one in five patients reported excessive housework during quarantine at home. The rate of accidental injuries, skin allergies and fungal skin infections of the hands were low. No significant differences in these lifestyles were observed between the two groups. However, a significantly higher proportion of both anxiety and depression were observed in moderate or severe group than that in no or mild group, 78.9% vs 54.4%, 24.6% vs 9.7%, respectively, seen Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003edifference in lifestyles and psychological states between no or mild group and moderate or severe group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eParameters\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eDegree of lymphedema\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNone or mild\u003c/p\u003e \u003cp\u003en(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModerate or severe\u003c/p\u003e \u003cp\u003en(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eManual labor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.870\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78(53.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29(50.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIncrease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26(17.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12(21.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003edecrease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41(28.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16(28.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eProtective measures for affected limbs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24(16.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7(12.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.448\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKeep skin clean and intact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87(60.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32(56.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.616\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo lift of heavy objects\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e114(78.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50(87.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.136\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostoperative functional exercise\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64(44.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21(36.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.345\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eLiving conditions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExercise less at home\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75(51.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36(63.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.142\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExcessive housework\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24(16.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10(17.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.865\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAccidental injuries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(3.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3(5.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.846\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSkin allergies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15(10.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2(3.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.196\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFungal skin infections of the hands\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(2.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0(0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.654\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePsychological state\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eanxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79(54.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45(78.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14(9.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14(24.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eCOVID-19, Corona Virus Disease 2019; BMI, body mass index;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePatients' needs for treatment of lymphedema during the COVID-19 pandemic\u003c/h2\u003e \u003cp\u003eThe survey showed that 70.8% of patients hoped to get treatment at hospital even though the COVID-19 greatly limited the accessibility. The same rate was observed for the need of self-care at home. Online consultation and family help were the secondary options, accounting for about 35.1% and 32.7%, respectively. About one in five chose community service and only 11.4% of patients were willing to receive door-to-door services.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe COVID-19 was mainly characterized by high contagiousness and rapid spread\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. City lockdown and home quarantine were considered as effective measures to prevent the spread of the virus during the early outbreak. Breast cancer patients were also restricted from going out and visiting the hospital, which caused their treatment to be interrupted. In this study, the prevalence of recurred lymphedema during the COVID-19 pandemic was 94.6% which was higher than 14\u0026ndash;40% in previous studies. The mainly reported manifestation was swelling and pain, while lymphedema related swelling, infection and dysfunction in limbs could affect the patients\u0026rsquo; quality of life seriously\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. Meanwhile, insufficient knowledge about lymphedema and lack of standard and professional guidance in monitoring swelling and implementing lymphedema drainage in the patients might led to further aggravation and decreased quality of life during the home quarantine.\u003c/p\u003e \u003cp\u003eThe high prevalence of lymphedema should draw our great attention and were required to distribute effective and timely intervention.\u003c/p\u003e \u003cp\u003ePrevention of lymphedema in breast cancer patients is more important than treatment, it is of great significance to identify potential risk factors and targeted population. Exercise is important for managing lymphedema by working muscle and increasing the flow of lymph fluid. Generally, the elderly was characterized by decreased physical activity\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. In our study, the mean age was about 51 years, and age was found to increase the risk of severer lymphedema. Cancer survivors experienced fatigue and barriers to physical activity in after treatment\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. Moreover, home quarantine might make participants reduce exercise. Finally, the decreased activity resulted in increased risk of lymphedema. There were various surgery for breast cancer, including biopsy surgery of sentinel lymph node, breast-conserving surgery, breast reconstruction surgery and others\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e. Radical mastectomy was a type of surgery that involved the removal of both breast tissue, fatty lymphatic tissue and lymph nodes. Undoubtedly, it cuts off most of the lymphatic pathways in the upper extremities. axillary dissection. Previous study found that complete axillary lymph node dissection increased incidence of lymphedema to 36% \u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. We also found radiotherapy significantly increased the risk of lymphedema, which was consistent with conclusion of a large cohort study\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e. Nursing staffs should provide personalized and feasible guidance for functional exercises and prevention, monitoring, treatment and nursing of lymphedema for these patients at high risk. In lymphedema, an inflammatory process was developed progressively in affected limbs. A national study conducted during COVID-19 pandemic showed a higher proportion of infection in cancer patients than the overall incidence of cancer in China (1% vs. 0.29%)\u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e. Nursing managers should pay attention to preventing secondary infection in breast cancer patients.\u003c/p\u003e \u003cp\u003eThe COVID-19 pandemic was a public health emergency, it not only affected the routine diagnosis and treatment of patients, but also affected the psychology of patients to a certain extent. A systematic review showed that concerns about the risk of infection with COVID-19 led to high rates of symptoms of anxiety and depression\u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e. In our study, 61.4% breast cancer patients suffered from anxiety and 13.9% experienced depression, patients with moderate or severe lymphedema presented higher proportion of both anxiety and depression. The patients worried that delay in treatment would cause symptoms of lymphedema to worsen, meanwhile, presence of lymphedema limited the movements of the affected limbs and affected daily life and self-care ability, such as use of chopsticks, toileting and bathing. These conditions made the patient frustrated and depressed. So, psychological intervention should be carried out timely for breast cancer patients with lymphedema to increase their psychological resistance. Nursing management could conduct remote guidance and apply online courses to increase patients\u0026rsquo; self-management ability during the restricted condition. Furthermore, timely diagnosis and treatment of lymphedema were still effective and direct measures.\u003c/p\u003e \u003cp\u003eOur study showed that patients preferred treatment in hospital and self-care at home equally. Patients with severe lymphedema or psychological distressed were recommended to go for treatment in professional hospitals. However, immunodeficiency after anti-tumor treatment might make these patients be susceptible to COVID-19 infection. Requirement of frequent nucleic acid and chest CT test make the treatment complex. Self-care at home become the optimal alternative. Patients can develop self-care ability in management of symptoms, treatment and psychosocial adaptation when coping with chronic diseases\u003csup\u003e[\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e. Considering the ongoing pandemic, nursing education for lymphedema must be distributed for discharged patients. Telemedicine was a promising technology\u003csup\u003e[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/sup\u003e. After patients mastered basic knowledge of lymphedema and basic nursing methods, healthcare workers could guide remote rehabilitation and online medical treatment through telephone, WeChat, video and other online methods during COVID-19 pandemic \u003csup\u003e[32]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThere were several limitations in this study. Firstly, it was a cross-sectional study, no causal inference could be made, but it could be considered that risk factors occurred before the recurred lymphedema which provided clues for the temporal relationship. Secondly, data was collected using an online tool, selection bias might exist since patients who did not use smartphones failed to participate in this study, meanwhile, recall bias and self-reporting problems might influence the precision. Finally, the COVID-19 pandemic was still ongoing, a longitudinal study was required to track breast cancer patients\u0026rsquo; new problems and search new solutions.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eDuring the COVID-19 pandemic, high prevalence of lymphedema was observed in breast cancer patients Age, radical surgery and fully completed radiotherapy were associated with increased risk of severer lymphedema. Meanwhile, the patients with severe lymphedema experienced psychological distress. While the Covid-19 pandemic was still raging, continuous efforts should be made to identify patient at risk of lymphedema and distribute feasible guidance and education for self-management in lymphedema.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study passed the ethical review of Tongji Medical College of Huazhong University of Science and Technology.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe data being used and analyzed during the current study are available from the corresponding authors upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePX developed the idea, designed the study, and provided financial support for the study. PX and CRW designed the questionnaires and drafted the manuscript. RZL，YY，YYL,\u0026nbsp;XY,\u0026nbsp;WT，WJY,\u0026nbsp;LF, PH,\u0026nbsp;and LF were involved in the acquisition of the data. PX and CRW summarized the data and contributed to data interpretation. CJ and HQ critically revised the manuscript for important intellectual content. The corresponding author had full access to all the data in the study and was responsible for submission for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was supported by nursing managers and breast cancer patients in eight hospitals, including the Union Hospital of Tongji Medical College of Huazhong University of Science and Technology. Thanks go to all breast cancer specialist nursing workers for thinking about the treatment and nursing of lymphedema in breast cancer patients in the post-epidemic era.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEly S, Vioral AN. Breast cancer overview. Plast Surg Nurs. 2007;27(3):128\u0026ndash;33, 134\u0026ndash;135.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021;71(3):209\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnson AR, Kimball S, Epstein S, Recht A, Lin SJ, Lee BT, et al. Lymphedema Incidence After Axillary Lymph Node Dissection: Quantifying the Impact of Radiation and the Lymphatic Microsurgical Preventive Healing Approach. Ann Plast Surg. 2019;82(4S Suppl 3):234\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRupp J, Hadamitzky C, Henkenberens C, Christiansen H, Steinmann D, Bruns F. Frequency and risk factors for arm lymphedema after multimodal breast-conserving treatment of nodal positive breast Cancer - a long-term observation. Radiat Oncol. 2019;14(1):39.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRockson SG. Lymphedema after Breast Cancer Treatment. N Engl J Med. 2018;379(20):1937\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTemur K, Kapucu S. The effectiveness of lymphedema self-management in the prevention of breast cancer-related lymphedema and quality of life: A randomized controlled trial. Eur J Oncol Nurs. 2019;40:22\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFu MR. Breast cancer-related lymphedema: Symptoms, diagnosis, risk reduction, and management. 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Impact of treatment delay due to the pandemic of COVID-19 on the efficacy of immunotherapy in head and neck cancer patients. J Hematol Oncol. 2020;13(1):174.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRan L, Wang W, Ai M, Kong Y, Chen J, Kuang L. Psychological resilience, depression, anxiety, and somatization symptoms in response to COVID-19: A study of the general population in China at the peak of its epidemic. Soc Sci Med. 2020;262:113261.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEaton LH, Narkthong N, Hulett JM. Psychosocial Issues Associated with Breast Cancer-Related Lymphedema: a Literature Review. Curr Breast Cancer Rep 2020: 1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNorman SA, Miller LT, Erikson HB, Norman MF, Mccorkle R. Development and validation of a telephone questionnaire to characterize lymphedema in women treated for breast cancer. Phys Ther. 2001;81(6):1192\u0026ndash;205.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTevis SE, James TA, Kuerer HM, Pusic AL, Yao KA, Merlino J, et al. Patient-Reported Outcomes for Breast Cancer. Ann Surg Oncol. 2018;25(10):2839\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStern AF. The hospital anxiety and depression scale. Occup Med (Lond). 2014;64(5):393\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFauci AS, Lane HC, Redfield RR. Covid-19 - Navigating the Uncharted. N Engl J Med. 2020;382(13):1268\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaghian NR, Miller CL, Jammallo LS, O'Toole J, Skolny MN. Lymphedema following breast cancer treatment and impact on quality of life: a review. Crit Rev Oncol Hematol. 2014;92(3):227\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCornelissen A, Kool M, Keuter X, Heuts EM, Piatkowski DGA, van der Hulst R, et al. Quality of Life Questionnaires in Breast Cancer-Related Lymphedema Patients: Review of the Literature. Lymphat Res Biol. 2018;16(2):134\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcphee JS, French DP, Jackson D, Nazroo J, Pendleton N, Degens H. Physical activity in older age: perspectives for healthy ageing and frailty. Biogerontology. 2016;17(3):567\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFrikkel J, Gotte M, Beckmann M, Kasper S, Hense J, Teufel M, et al. Fatigue, barriers to physical activity and predictors for motivation to exercise in advanced Cancer patients. Bmc Palliat Care. 2020;19(1):43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKeim-Malpass J, Doede A, Camacho F, Kennedy C, Showalter SL. Impact of patient health literacy on surgical treatment of breast cancer. Breast J. 2018;24(4):633\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKilmartin L, Denham T, Fu MR, Yu G, Kuo TT, Axelrod D, et al. Complementary low-level laser therapy for breast cancer-related lymphedema: a pilot, double-blind, randomized, placebo-controlled study. Lasers Med Sci. 2020;35(1):95\u0026ndash;105.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWarren LE, Miller CL, Horick N, Skolny MN, Jammallo LS, Sadek BT, et al. The impact of radiation therapy on the risk of lymphedema after treatment for breast cancer: a prospective cohort study. Int J Radiat Oncol Biol Phys. 2014;88(3):565\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXiong J, Lipsitz O, Nasri F, Lui L, Gill H, Phan L, et al. Impact of COVID-19 pandemic on mental health in the general population: A systematic review. J Affect Disord. 2020;277:55\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan. China \u003cb\u003eLancet\u003c/b\u003e. 2020;395(10223):497\u0026ndash;506.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOstby PL, Armer JM, Smith K, Stewart BR. Patient Perceptions of Barriers to Self-Management of Breast Cancer-Related Lymphedema. West J Nurs Res. 2018;40(12):1800\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRidner SH, Dietrich MS, Kidd N. Breast cancer treatment-related lymphedema self-care: education, practices, symptoms, and quality of life. Support Care Cancer. 2011;19(5):631\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRidner SH, Rhoten BA, Radina ME, Adair M, Bush-Foster S, Sinclair V. Breast cancer survivors' perspectives of critical lymphedema self-care support needs. Support Care Cancer. 2016;24(6):2743\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFu MR, Axelrod D, Guth AA, Rampertaap K, El-Shammaa N, Hiotis K, et al. mHealth self-care interventions: managing symptoms following breast cancer treatment. Mhealth 2016, 2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMccarthy MS, Matthews EE, Battaglia C, Meek PM. Feasibility of a Telemedicine-Delivered Cognitive Behavioral Therapy for Insomnia in Rural Breast Cancer Survivors. Oncol Nurs Forum. 2018;45(5):607\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"COVID-19, breast cancer, lymphedema, PROs, Norman Questionnaire","lastPublishedDoi":"10.21203/rs.3.rs-836567/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-836567/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eTo evaluate recurrence of lymphedema and its influencing factors in discharged breast cancer patients with treated lymphedema during the COVID-19 pandemic and to propose feasible improvements. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eA multicenter, cross-sectional, hospital-based survey of discharged breast cancer patients was conducted during the COVID-19 pandemic in eight first-class hospitals in Wuhan city, China. Norman Questionnaire was used for assessing lymphedema, and multivariable binary logistic regression was performed to risk factors of moderate or severe lymphedema. Difference in living characteristics, anxiety and depression between no or mild group and moderate or severe group were compared. Preference in management of lymphedema were collected. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults \u003c/strong\u003e\u003c/p\u003e\u003cp\u003e202 valid patients were included. 191 participants reported recurred lymphedema (prevalence: 94.6%, 95%CI 90.5% to 97.3%). 134 of them was mild and 57 were moderate/severe. In the 191 patients, the main symptom was swelling (140, 69.3%) and pain (56, 27.7%). Multivariable regression showed that age (odds ratio, 1.06, 95%CI: 1.02-1.10), radical surgery (OR=4.35, 95%CI: 1.54-12.50) and fully complete radiotherapy (OR=2.62, 95%CI: 1.17-5.87, P=0.019) was associated with the risk of moderate or severe lymphedema. No significant difference in lifestyles was observed but moderate or severe group experienced higher rate of anxiety and depression. patients preferred treatment in hospital and self-care at home equally.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion \u003c/strong\u003eThe high recurrence rate of lymphedema in breast cancer patients with during COVID-19 should draw our great attention, continuous efforts should be made to identify patient at risk of lymphedema and distribute feasible guidance and education for self-management for these patients.\u003c/p\u003e","manuscriptTitle":"Recurrence of Lymphedema and Related Characteristics in Discharged Breast Cancer Patients During The COVID-19 Pandemic: A Multicenter, Cross-Sectional Survey","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-09-02 19:17:52","doi":"10.21203/rs.3.rs-836567/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4d391cfa-02b4-4e71-a6ea-3c9084ea81cc","owner":[],"postedDate":"September 2nd, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":6895711,"name":"Cancer Biology"},{"id":6895712,"name":"Oncology"}],"tags":[],"updatedAt":"2021-09-02T19:17:54+00:00","versionOfRecord":[],"versionCreatedAt":"2021-09-02 19:17:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-836567","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-836567","identity":"rs-836567","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}