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.