Routine Screening Of Breast Cancer Patients For Symptoms Of Sub-Clinical Lymphoedema Leads To Better Clinical Outcomes

Breast cancer patients should undergo routine surveillance for sub-clinical lymphoedema, concludes a study published in Cancer . The study, which was conducted in US, showed that compression garments introduced early in the course of lymphoedema can be used to effectively treat sub clinical condition. Lymphoedema is an abnormal buildup of fluid, most often in arms or legs; that occurs when lymph vessels or nodes have been damaged or removed. This occurs after breast cancer surgery or lymph node biopsy where removal of lymph nodes and vessels from under arm changes way lymph fluid flows. Breast cancer related lymphoedema is a chronic condition - estimated to affect 33 to 47 % of women following axillary lymph node dissection and 4 to 17 % after sentinel node biopsy. It is a progressive condition that diminishes a womanR! 17; s quality of life and contributes to impairment in range of movements, loss of strength and limits every day activities, such as lifting and reaching. It has previously been reported that changes in interstitial tissue congestion occur before limb swelling becomes visible. Furthermore, it was suggested that earlier detection might result in fewer long term complications.

Stout Gergich and colleagues, from National Naval Medical Center ( Bethesda, Maryland, USA ) set about investigating efficacy of surveillance in patients with early stage breast cancer. The investigators hypothesized that on diagnosis of sub-clinical lymphoedema, a light grade compression garment worn daily would be sufficient to alleviate problem.

Between 2001 and 2006 all women with newly diagnosed unilateral early stage breast cancer ( stage I-III ) were screened by a physical therapist prior to surgery to determine eligibility. Patients were excluded from study if they had a previous history of breast cancer, bilateral breast cancer or if they had suffered severe trauma or surgery to their upper limb.

For the 196 women meeting the study criteria, limb volume was measured pre operatively and at three -month intervals following surgery using a Perometer. The Perometer is a sensitive and standardized device using infrared optoelectronic technology to detect and quantify limb volume changes. If upper limb volume increased by greater than 3% compared with preoperative volume, then a diagnosis of lymphoedema was made. Altogether 43 women were found to have lymphoedema and offered early intervention with a ready made 20 to 30 mmHg compression sleeve that was fitted by a physical therapist and worn for four weeks. Upon reduction of lymphoedema women were advised to wear the garment during periods of strenuous activity, if they experienced symptoms of heaviness or if they saw visible swelling.

Results show that average time to onset of lymphoedema symptoms was 6. 9 months after the operation. The mean affected limb volume increase was 83 mL ( ±119 mL; 6. 5% ± 9. 9% ) at lymphoedema onset ( P = . 005 ) compared with baseline measurement prior to operation. After intervention with the compression sleeve, a statistically significant mean 48 mL ( ±103 mL; 4. 1% ± 8. 8% ) volume decrease was achieved ( P < . 0001 ) . The mean duration of intervention was 4. 4 weeks ( ±2. 9 weeks ) , with volume reduction maintained at follow up of 4. 8 months.

While standard of care for treating and managing clinically apparent lymphoedema is well established, write the authors, there's no standard for the treatment of early-stage, subclinical lymphoedema. " A new classification system is needed to recognize subclinical lymphoedema and encourage early intervention to diminish the negative functional, cosmetic, and psychosocial consequences of lymphoedema. On the basis of our findings, we believe that a more sensitive threshold for diagnosing lymphoedema is warranted and can be quantified by using optoelectronic imaging technologies, " conclude authors.

Few clinical sites currently have access to optoelectronic measurement technology, concede the authors, but suggest that other assessment tools such as water displacement, bioelectrical impedance analysis, and circumferential girth measurements could all be used to diagnose sub clinical lymphoedema.

Preoperative assessment enables early diagnosis and successful treatment of lymphedema. Stout Gergich N L, Pfalzer L A, McGarvey C, Springer B, Gerber L H, Soballe P. Cancer ( online 21 Apri1, 2008, DOI 10. 1002/cncr. 23494 )

Cancer Research Summaries are overviews of important cancer research findings that have been reported in leading cancer publications. The Cancer Research Summaries are provided by Cancer Media Service ( CMS ) in collaboration with Nature Clinical Practice Oncology.

All previous Cancer Research Summaries can be viewed here.

This summary can be reproduced without permission. If reproduced please include following acknowledgement:

" This summary is provided by European School of Oncology's Cancer Media Service. " http: //www. cancerworld. org/mediaservice

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Doxepin: uses

Doxepin is used to treat mental/mood problems such as depression, anxiety and bipolar disorder. It may help improve mood and feelings of well-being, relieve anxiety and tension, help we sleep better, and increase your energy level. Doxepin belongs to a class of medications called tricyclic antidepressants. It works by affecting balance of certain natural chemicals ( neurotransmitters ) in the brain.

Doxepin: how to use

Read Medication Guide available from your pharmacist. Consult your doctor or pharmacist if we have any questions.

Take Doxepin by mouth, usually 1 to 3 times daily or as directed by your doctor. If you take it only once a day, take it at bedtime to help reduce daytime sleepiness. The dosage is based on your age, medical condition and response to therapy. Your doctor may start you at a low dose and gradually increase your dose over several weeks. Follow your doctor's instructions carefully.

Use dropper that comes with medication to measure out the prescribed amount. Just before taking, mix drug with half a glass ( 4 ounces or 120 milliliters ) of water, whole/skim milk, or orange, grapefruit, tomato, prune or pineapple juice, and drink all of the mixture. Do not mix with soda or other carbonated beverages. If we are taking Doxepin in combination with liquid methadone, you may mix both drugs with lemonade, orange juice, sugar water, orange drink mix, or plain water, but not grape juice. Mix only what we need for each dose. Don't prepare a supply for future use.

Doxepin doesn't work right away. It may take up to 2 to 3 weeks before you experience the full benefits.

Use Doxepin regularly in order to get the most benefit from it. To help we remember, take it at same times each day.

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Doxepin: other used

This section contains uses of Doxepin that are not listed in approved professional labeling for the drug but that may be prescribed by your health care professional. Use Doxepin for a condition that's listed in this section only if it has been so prescribed by your health care professional.

If directed by your doctor, Doxepin may also be used to treat certain types of pain ( e. g. , peripheral neuropathy, neuropathic pain ) and trouble sleeping.

Doxepin: side effects

See also the Warning section.

Drowsiness, dizziness, dry mouth, blurred vision, constipation, fast heartbeat, nausea, vomiting, loss of appetite, changes in taste, weight gain, or trouble urinating may occur while use Doxepin. If any of these effects persist or worsen, notify your doctor or pharmacist promptly.

To relieve dry mouth, suck on ( sugarless ) hard candy or ice chips, chew ( sugarless ) gum, drink water, or use a saliva substitute.

Remember that your doctor has prescribed Doxepin because he or she has judged that benefit to we is greater than risk of side effects. Many people using Doxepin don't have serious side effects.

Tell your doctor immediately if any of these unlikely but serious side effects occur:

Tell your doctor immediately if any of these rare but very serious side effects occur:

A very serious allergic reaction to Doxepin is unlikely, but seek immediate medical attention if it occurs. Symptoms of a serious allergic reaction may include:

This isn't a complete list of possible side effects. If we notice other effects not listed above, contact your doctor or pharmacist.

Doxepin: precautions

See also Warning section.

Before taking Doxepin, tell your doctor or pharmacist if you're allergic to it, or to other tricyclic antidepressants ( e. g. , amitriptyline ) , or if we have any other allergies.

Doxepin should not be used if we have certain medical conditions. Before using this medicine, consult your doctor or pharmacist if you have:

Before using Doxepin, tell your doctor or pharmacist your medical history, especially of:

Doxepin may make we drowsy or dizzy or cause blurred vision; use caution engaging in activities requiring alertness or clear vision such as driving or using machinery. Limit alcoholic beverages.

To minimize dizziness and risk of fainting, get up slowly when rising from a sitting or lying position.

Before having surgery, tell your doctor or dentist that we are taking Doxepin.

Doxepin may make we more sensitive to sun. Avoid prolonged sun exposure, tanning booths, and sunlamps. Wear sunblock ( SPF 30 or greater ) and a hat when outdoors.

If we have diabetes, Doxepin may increase your blood sugar levels. Check your blood sugar levels regularly as directed by your doctor. Tell your doctor immediately if we have symptoms such as increased thirst/urination, shakiness, unusual sweating, or hunger. Your anti-diabetic medication or diet may need to be adjusted.

Depression can lead to thoughts/attempts of suicide. Tell your doctor immediately if you have any suicidal thoughts, worsening depression, or any other mental/mood changes ( including new or worsening anxiety, agitation, panic attacks, trouble sleeping, irritability, hostile/angry feelings, impulsive actions, severe restlessness, rapid speech ) . Keep all medical appointments so your doctor can monitor your progress closely and adjust your medication if needed.

Caution is advised when using Doxepin in elderly because they may be more sensitive to its side effects, especially dizziness, drowsiness, confusion, and difficulty urinating.

Caution is advised when using Doxepin in children. ( See also Warning section. ) Doxepin should be used only when clearly needed during pregnancy. Discuss the risks and benefits with your doctor.

Doxepin passes into breast milk and may have undesirable effects on a nursing infant. Breast-feeding while using Doxepin isn't recommended. Consult your doctor before breast-feeding.

Doxepin: interactions

Your healthcare professionals ( e. g. , doctor or pharmacist ) may already be aware of any possible drug interactions and may be monitoring we for it. Do not start, stop or change the dosage of any medicine before checking with them first.

Doxepin should not be used with following medications because very serious ( possibly fatal ) interactions may occur:

Avoid taking MAO inhibitors within 2 weeks before and after treatment with Doxepin. In some cases a serious, possibly fatal drug interaction may occur while use Doxepin.

If we are currently using any of these medications listed above, tell your doctor or pharmacist before starting Doxepin.

Other drugs besides Doxepin that may affect heart rhythm ( QT prolongation in EKG ) include disopyramide, cisapride, halofantrine, pimozide among others. Before taking Doxepin, report all medications we are currently using to your doctor or pharmacist. QT prolongation can infrequently result in serious ( rarely fatal ) fast/irregular heartbeat and other symptoms ( e. g. , severe dizziness, fainting ) that require immediate medical attention. Ask your doctor or pharmacist for more details and for instructions on how we may reduce the risk of this effect.

Before using Doxepin, tell your doctor or pharmacist of all prescription and nonprescription/herbal products we may use, especially of:

If we have been taking fluoxetine, wait at least 5 weeks after stopping fluoxetine before starting Doxepin.

Cigarette smoking decreases blood levels of this medication. Tell your doctor if you smoke or if you have recently stopped smoking.

Tell your doctor or pharmacist if you also take drugs that cause drowsiness such as:

Check labels on all your medicines ( e. g. , cough-and-cold products ) because they may contain drowsiness-causing ingredients. Ask your pharmacist about safe use of those products.

Also report use of drugs which might increase seizure risk ( decrease seizure threshold ) when combined with Doxepin such as bupropion, isoniazid ( INH ) , theophylline, or tramadol, among others. Consult your doctor or pharmacist for details.

This document does not contain all possible interactions. Therefore, before using Doxepin, tell your doctor or pharmacist of all products you use. Keep a list of all your medications with you, and share the list with your doctor and pharmacist.

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