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This study aimed to identify the predictors of quality of life related to lower limb lymphedema among women who had undergone gynecological cancer surgery. Additionally, the association between fatigue and the quality of life was examined.
A cross-sectional design with a convenience sample was adopted. Participants included 200 women with lymphadenectomy following gynecological cancer surgery. Demographic data, quality of life related to lower limb lymphedema, and fatigue symptoms were collected.
Of the 200 participants, 60 percent (n =120) reported a mild to severe impact on quality of life related to lower limb lymphedema, with the main impact on the function of mobility and physical symptoms. Age less than 55 years (β = 0.706, OR = 2.027, p = 0.017), a diagnosis of ovarian cancer (β = 0.804, OR = 2.235, p = 0.048), undergoing chemotherapy (β = 0.616, OR = 1.854, p = 0.046), time after surgery (β = -0.833, OR = 0.435, p = 0.05), and fatigue (β = 0.055, OR = 1.06, p < 0.001) were independently associated with quality of life related to lower limb lymphedema. Hierarchical multiple regression demonstrated that fatigue was significantly associated with quality of life related to lower limb lymphedema after controlling for age, types of cancer, time after surgery, and chemotherapy. Fatigue explained 11% of the variance in the quality of life.
More than half of the women with gynecological cancer requiring lymphadenectomy experienced an impact on quality of life related to lower limb lymphedema. Effective interventions are warranted to improve the quality of life related to lower limb lymphedema among women with gynecological cancer, particularly those who present with fatigue.
Chronic fatigue has a negative impact on women’s QoL during treatment phases and illness stages, and fatigue is associated with depression, sleep disturbance, and cognition dysfunction during cancer-related treatments among patients with cancer.
Although lethargy is a common symptom and negatively impacts the QoL among women with gynecological cancer, the association of fatigue or lethargy with QoL related to lymphedema has not been studied.
One systematic review of 23 studies identified the risk factors for lower limb lymphedema development, including the extent of lymphadenectomy, the number of lymph nodes removed, and adjuvant radiotherapy. Other factors included increased age, advanced cancer staging, higher body mass index, and insufficient physical activity.
Despite the emphasis on the symptoms and management of lymphedema, QoL related to lower limb lymphedema in women after gynecological cancer surgery has not been studied extensively. Little is known about the determinants of the QoL related to limb lymphedema and the association between fatigue and the QoL among women after gynecological cancer surgery.
This study aimed to identify the health-related determinants of QoL related to lower limb lymphedema in women with gynecological cancer who had undergone lymphadenectomy. Additionally, the associations between fatigue and the QoL related to lymphedema were examined.
Study design and participants
This study was conducted using a cross-sectional correlational design. To quickly collect data from the readily available subjects, convenience sampling was used to recruit participants from the gynecology outpatient clinic of a medical center in southern Taiwan. The eligibility criteria for participants included women at least 20 years of age diagnosed with gynecological cancer who had undergone cancer surgery with lymphadenectomy. Women were excluded if they reported heart failure, renal failure, cardiovascular accident, lower limb infection, drug abuse, or psychological disorders.
The sample size was calculated by G*Power software version 22.214.171.124. A sample size of 166 was determined using multiple linear regression with the assumption of α = 0.05, power level = 0.9, predictors = 14, as well as a medium effect size of 0.15 as a reference. Considering the 20% attrition rate of subjects, this study planned to recruit 200 women.
Quality of life related to lower limb lymphedema
A Chinese version of the Lymphedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphedema (Lymph-ICF-LL_C) was used to assess the participants’ QoL related to lower limb lymphedema in the past two weeks
. The scale includes five domains used to measure the daily function related to lower limb lymphedema: physical function (6 items), mental function (6 items), general/household tasks (3 items), mobility (7 items), and life/social life (6 items). For example, the physical domain illustrates the severity of edema symptoms. A total of 28 items are included in the scale. Each item is rated on an 11-point Likert scale (0 = no problem, 10 = very severe problem). Of the 28 items, nine have a non-applicable option if the condition of the question is inapplicable to respondents. The total score of the Lymph-ICF-LL ranges from 0 to 100, with a higher score indicating a lower QoL related to lymphedema.
The scores in each domain and the total scale are calculated with the following formula: the sum of the item scores divided by the number of questions answered, then multiplied by 10. Based on the total scores of the scale and each domain, the QoL related to lower limb lymphedema can be categorized as no impact or dysfunction (0–4), mild impact or dysfunction (5–24), moderate impact or dysfunction (25–49), severe impact or dysfunction (50–95), and very severe impact or dysfunction (96–100).
In the current study, a substantial impact or dysfunction related to lymphedema was defined as a score ≧ 5 of the total score or each domain of the Lymph-ICF-LL Chinese version. The construct validity of the Lymph-ICF-LL has been confirmed by a significant association with the SF-36; the internal consistency of the scale has been validated with Cronbach’s alphas ranging from 0.89 to 0.97 in the domains and 0.96 for the total score in patients with gynecological or prostate cancers.
The psychometric properties of the Chinese version of Lymph-ICF-LL have been demonstrated in women with gynecological cancer by the scale’s construct validity and internal reliability (Cronbach’s alphas = 0.84–0.95).
Using a tape measure, six lower leg circumferences were obtained at the (1) metatarsal-phalanges joint, (2) ankle, (3) peroneus longus, (4) femoral epicondyle, (5) 10 cm above the patella, and (6) 20 cm above the patella.
The relative circumference difference between the bilateral lower limbs was calculated as [ABS (R circumference–L circumference)/the smallest circumference of the bilateral limbs]. The presence of lower limb lymphedema was defined as equal to or greater than 7% of the relative circumference difference.
Three research assistants were trained to evaluate the circumference measurements. The intraclass correlation coefficients (ICCs) of limb circumference measurement for intra- and inter-rater reliability were 0.98–1.0 and 0.96–0.99, respectively.
The Chinese version of the Lee Fatigue Scale-Short (C-LFS-SF), a 7-item self-rated scale, was used to assess physical fatigue in the evening.
Participants were asked to rate each item based on how they felt before going to bed, from 0 (not fatigued) to 10 (extremely fatigued), with a higher score indicating greater severity of fatigue. The English version of LFS-SF has been used to assess fatigue in women after breast cancer surgery.
The Cronbach’s alpha for the C-LFS-SF total score was 0.88 in the current study.
Social demographic and health-related data
Socio-demographic data were obtained from participants, while health and clinical information were collected from their medical records. The health and clinical information included cancer location and the FIGO stage (International Federation of Gynecology and Obstetrics), body weight, surgery date and type, site and number of lymph nodes removed, postoperative chemotherapy, and radiation therapy.
Data collection occurred during patients’ clinical visits at the outpatient departments of gynecological oncology of a medical center in southern Taiwan. Physicians and nurses referred potential participants to research assistants. When potential participants met the inclusion criteria, they were given verbal information about the study and asked to provide written informed consent before participation. The participants completed the self-administered questionnaires in a private clinical room, and their limb circumferences were measured. The clinical room contained the necessary equipment to provide participants with a comfortable and convenient environment to complete their questionnaires and the measurement of limb circumferences, such as a medical exam table, desk, and chairs. Participants took 10–15 mins to complete the questionnaires, and the measurement of the limb circumferences was completed within 8–10 mins. After that, the research assistants reviewed participants’ medical records to obtain their health and medical information All participants received a gift equivalent to NT$100 when they completed all research measurements. Participants were recruited from February 2016 to November 2017.
Data were analyzed using SPSS version 22.0 (IBM Corp, Armonk, NY, USA). Cases with missing data were excluded if 20% of the items in the Lymph-ICF-LL or the C-LFS-SF were incomplete. Descriptive analysis was used to depict the features of QoL related to lower limb lymphedema. Univariate logistic regressions were performed to determine the associations of socio-demographic variables, health-related variables, and fatigue with QoL. Hierarchical logistic regression was then performed to examine the impact of fatigue on QoL related to lymphedema after controlling for socio-demographic and health-related factors. For the regression analysis, cases with significant outliers in the Lymph-ICF-LL were excluded. A p-value < 0.05 indicated statistical significance.
The Institutional Reviewed Board of the National Cheng Kung University Hospital in southern Taiwan approved this study (IRB number: A-ER-103-425). Potential participants were informed about the purpose of the study, voluntary participation, confidentiality of study process as well as the right to withdraw at any time without repercussions. All participants were asked to provide written informed consent before participation.
Of the 216 women who agreed to participate, 200 provided complete data. Half of the participating women (n = 102, 51%) were under 55 years old, with a mean age of 54.4 years (SD = 10.6, range = 23–85). Nearly three-quarters of the participants were married (72%, n = 144) and employed (74%, n = 148). One quarter (n = 52) reported having completed senior high school, and 34% (n = 68) had a college level of education.
Nearly half had a normal body mass index (BMI) (45%, n = 90), 26% (n = 52) had obesity, and 6.5% (n = 13) were underweight. Most women had been diagnosed with ovarian (42.0%, n = 84) or endometrial cancer (36.5%, n = 73). Other diagnoses included vulvar, vaginal, and peritoneal cancers (3%, n = 6). Over half of the women’s cancers were at FIGO Stage I (57%, n = 114), with 28% (n = 56) at Stage III. Over half of the participants had experienced bilateral pelvic lymphadenectomy (58%, n = 116) and received adjuvant chemotherapy (68%, n = 135) without adjuvant radiotherapy (91%, n =182). The median time after surgery was 15 months (range = 1–240 months). Regarding the time since surgery, nearly 50 percent of the participants (n = 93) had undergone cancer surgery with lymphadenectomy within one year, and 13% (n = 26) had undergone surgery five years before. The majority of the participants had either completed their chemotherapy (n = 96, 48%) or never undergone chemotherapy (n = 65, 32.5%). Only 20% of the participants (n = 38) received chemotherapy, and 9% (n = 18) previously completed radiotherapy.
Nearly 60% of the participants (n = 116) underwent bilateral pelvic lymph node removal, and 39% of the participants (n = 78) underwent bilateral with para-aortic lymph node removal. The mean number of lymph nodes dissected was 18 (SD = 10, range = 1–55). Thirty-five (17%) of the 200 participants had a circumferential difference ≧ 7% between the lower limbs.
Description of the quality of life related to lower limb lymphedema
Figure 1 presents the descriptive analysis for QoL related to lower limb lymphedema. The total mean score of the Lymph-ICF-LL measuring QoL was 13.3 (SD = 15.48, range = 0–90.7) out of a possible 100. The mobility domain had the highest mean score (mean = 18.0, SD = 21.97), followed by the physical domain (mean = 13.4; SD = 17.10). The mental, household and social domains had low and similar mean scores.
Of the 200 participants, 61% (n = 121) reported an impact of lower limb lymphedema on QoL, with 82 women (41%)) reporting their impact as mild and 33 (15%) as moderate. Six women (3%) reported that lower limb lymphedema had severely impacted their QoL. Across the five domains of QoL, over half of the women (57%, n = 114) reported an impact on physical aspects, while 59% (n = 118) reported an impact on mobility. Nearly half (46%, n = 91) reported that lymphedema had negatively impacted their mental health.
Quality of life determinants related to lower limb lymphedema
Before conducting logistic regressions, outliers were analyzed, resulting in two subjects being deleted (see Table 1). Data from 198 women were thus used for the univariate and multiple logistic analyses. Table 2 shows the results of the univariate binary logistic regressions. The univariate logistic regressions identified four variables as significant predictors of QoL: age (<55 years) (β = 0.706, OR = 2.027, 95% CI: 1.14–3.61, p = 0.017), ovarian cancer (β = 0.804, OR = 2.235, 95% CI: 1.01–4.96, p = 0.048), chemotherapy (β = 0.616, OR = 1.854, 95% CI: 1.01–3.39, p = 0.04), and fatigue (β = 0.055, OR =1.06, 95% CI: 1.03–1.09, p < .001). However, the time after surgery of over five years had a borderline significance (β = -0.833, OR = 0.435, 95% CI: 0.19–1.00, p = 0.05). Younger women diagnosed with ovarian cancer who had recent surgery and chemotherapy were more likely to report poor QoL related to lower limb lymphedema. For the time after surgery, the impact of lower limb lymphedema on QoL significantly decreased at five years after the surgery. Women reporting greater fatigue were more likely to report a lower QoL due to lower limb lymphedema. However, the relative circumference difference was not associated with QoL related to lower limb lymphedema.
Table 1Demographic and health-related characteristics of women with gynecological cancer (n=200).
≧ 55 years
≦ Junior High School
Senior High School
Others: Vulva, vagina cancer
Cancer Stage (FIGOb)
Time since surgery (year)
< 1 year
> 5 years
Pelvic lymph nodes removed
Bilateral with para-aortic
Lymph nodes removed (n)
Limb circumference difference
Note:a BMI: Body Mass Index; bFIGO: International Federation of Gynecology Obstetrics.
Table 3 presents a hierarchical logistic regression with three blocks containing five predictive variables entered as independent variables. First, age was entered in Block One, accounting for a 4% variance of QoL. Next, types of cancer, time since surgery, and chemotherapy were entered in Block Two. Apart from age (OR = 1.87, p = .043), none of the second-order variables were significantly associated with QoL, and these variables only accounted for 4% of the variance of QoL. Finally, fatigue was entered in Block Three, and it significantly contributed to QoL (OR = 1.052, p < .001). The Hosmer and Lemeshow test indicated a good fit of the multivariate model (Chi-square = 9.626, p = 0.292), which explained 19% of the total variance in the QoL related to lower limb lymphedema, with fatigue accounting for 11% variance of the QoL related to lower limb lymphedema.
Table 3The Hierarchical logistic regression analysis examining the relationship between fatigue and QoL related to LLL.
Age (Ref =≧55 years old)
Cancer Types (Ref = cervical cancer)
Chemotherapy (Ref= No)
Time since surgery (years)
Note: B: unstandardized coefficients, SE: standard error, β: standardized coefficients *: p < 0.05; **: p < 0.01; ***: p < 0.001.
This study revealed that six out of every 10 women who underwent lymphadenectomy during gynecological cancer surgery experienced a decrease in QoL due to postoperative lower limb lymphedema. The mobility and physical restrictions were the most substantial impacts on the QoL related to lower limb lymphedema. The findings confirm the results from previous studies; limitation in mobility is common in patients with lower limb lymphedema.
Recently, a longitudinal study of physical activity following gynecological cancer surgery revealed that lymphedema significantly contributed to the decrease in physical activity from before to two years after surgery.
Mobility is a representative indicator of QoL related to lower limb lymphedema. Therefore, future research is needed to evaluate physical activity and the barriers for women after gynecological cancer surgery with lymphadenectomy.
The results of the present study revealed that younger adult (<55 years old) women reported poorer QoL related to lower limb lymphedema. Our results are consistent with those of prior studies that reported that younger adult women were more vulnerable to the QoL impact related to lower limb lymphedema than older women.
A possible reason for the poor QoL in younger adult women is that they may be more involved in their jobs and social activities. Thus, they may perceive more restrictions in role performance due to lower limb lymphedema. A prior study of patients with endometrial cancer and lower limb lymphedema reported a significant positive association between a woman’s age and their physical and role functions
. Future studies should explore the physical-socio-psychological dimensions of young adult women with lower limb lymphedema.
This study reported that health-related factors, such as chemotherapy, ovarian cancer, and short term after cancer surgery, contribute significantly to poor QoL related to lower limb lymphedema. Women with ovarian cancer reported a poorer QoL than those with other gynecological cancers. A previous study found that over half of ovarian cancer patients developed lower limb lymphedema. Patients with ovarian cancer require extensive lymph node removal and adjuvant chemotherapy, placing those women at a higher risk of developing lower limb lymphedema, which leads to poor QoL.
In this regard, these mechanisms may explain why chemotherapy is a determinant of QoL related to lymphedema. The study’s findings indicated that time after cancer surgery has a borderline association with the QoL. Prior studies have also indicated that QoL in patients with lower limb lymphedema improves over time as patients gradually recover from surgery.
Several studies have identified the onset of lymphedema occurring within the first two years after cancer surgery in most patients, from 32–68% within the first year to 69–83% within the first two years after surgery.
As noted above, lower limb lymphedema may be a hassle in a woman’s daily life in the first few years after surgery; subsequently, QoL is less impacted after five years of surgery because women may gradually learn how to manage the daily life dysfunctions caused by lower limb lymphedema.
Current findings revealed a greater level of fatigue corresponding to a more significant impact on the QoL related to lymphedema. This finding is congruent with the theories of fatigue, which indicate that fatigue symptoms affect mobility function, and the activation of inflammation elicits fatigue symptoms. Additionally, fatigue symptoms, such as tiredness and the inability to function, are usually due to the deterioration patient’s functional status and musculoskeletal condition.
It is possible that most women in the current study had a mild degree of lymphedema, and only 18% of the participants had prominent LCD (≥7%), which may have resulted in a non-significant influence on the QoL. The current study failed to show an association between BMI and the QoL, However, previous studies have reported that overweight or obese women with gynecological cancer were more likely to develop lower limb lymphedema.
Future studies should examine the QoL related to lower limb lymphedema in the obese population.
The findings from the current study can be applied to clinical practice. Postoperatively, health care providers should assess the symptoms of lower limb lymphedema and the impact on QoL in women who have undergone gynecological cancer surgery with lymphadenectomy. Health care providers need to pay attention to the vulnerable population who may have poor QoL due to lymphedema, such as younger women with recent ovarian cancer surgery with lymphadenectomy, who have received chemotherapy and have a high level of fatigue. The assessment of the QoL related to lymphedema should be comprehensive and include physical and psychosocial domains, particularly the physical symptoms and the function of mobility. Furthermore, fatigue symptoms should be assessed. Tailored interventions for this vulnerable population should contain pre- and postoperative counseling, education, and strategies to minimize physical symptoms and psychosocial impact due to lower limb lymphedema.
One of this study’s strengths is the number of participants with various gynecological cancers that represent a wider gynecological cancer population, as well as a comprehensive assessment of the QoL related to lower limb lymphedema, including physical, psychosocial, and daily life functions.
This study has some limitations. The findings are limited to a convenience sample with gynecological cancer, and the findings may not apply to other populations with different types of limb lymphedema. Due to the study’s cross-sectional design, changes in QoL related to lower limb lymphedema and fatigue symptoms were not evaluated.
In summary, more than half of the women with gynecological cancer surgery reported an albeit mild impact of QoL related to limb lymphedema. The mobility and physical restrictions were the most substantial impacts. Fatigue contributed to lower QoL related to lymphedema. Further research on interventions is needed to determine the best practice on ameliorating physical symptoms, mobility dysfunction, and fatigue.
Yu-Yun Hsu: Conceptualization, design, funding acquisition, data analysis; manuscript writing and review.
Chia-Yu Liu: Data collection, subject recruitment, and data analysis and draft writing of the results.
Chien-Liang Ho: design, subject recruitment and writing review.
Keng-Fu Hsu: subject recruitment and writing review.
This study was approved by the Institutional Reviewed Board of the National Cheng Kung University (IRB number: A-ER- 103-425).
Declaration of Interests
Personal relationships that could have appeared to influence the work reported in this paper.
We would like to thank the women who agreed to participate in this study. We also thank Prof. Wei-ming Luh at the Institute of Education, National Cheng Kung University, for her helpful advice on statistical analysis, and Yi-Chien Tsai, who assisted in data collection.
Complications of lymphadenectomy for gynecologic cancer.