Using convenient sampling method, 195 patients with lymphedema treated in a hospital in Guangzhou from June 2021 to December 2022 were selected for questionnaire survey. Inclusion criteria: ① according to the differentiation and diagnosis of lymphedema [12] , all patients were patients with lymphedema and underwent comprehensive detumescence treatment; ② Age ≥ 18 years old; ③ Normal cognitive and communication skills, able to cooperate with the investigation; ④ The patients had informed consent and were willing to participate in this study. Exclusion criteria: ① combined with other system tumors or severe liver and kidney dysfunction; ② Tumor recurrence and distant metastasis; ③ Accompanied by ascites, limb edema, serous cavity effusion, etc.; ④ People with mental illness or personality disorder.

In this study, 200 questionnaires were distributed and 195 valid questionnaires were recovered, with an effective recovery rate of 97.5%.

The total score of stigma was (60.36 ± 11.08). The results showed that the score of social exclusion was the highest (21.07 ± 3.80), followed by economic discrimination (15.65 ± 3.94), social isolation (15.56 ± 3.05), and internal stigma (8.09 ± 1.86). See Table 1.

According to the difference of patients’ general data, single factor ANOVA test was carried out. The results showed that family monthly income, personality and family relationship had an impact on the level of stigma in patients with lymphedema. The difference was statistically significant (P < 0.05). Among them, the family with low monthly income has a high score of stigma, and the introverted personality and family relationship are poor or the general score of stigma is high. See Table 2.

The total score of alexithymia was (56.53 ± 8.43). The results showed that the score of extraversion thinking was the highest (22.71 ± 3.03), followed by the score of lack of ability to recognize emotion (20.02 ± 4.57), and the score of lack of ability to describe emotion was the lowest (13.80 ± 2.55). See Table 3.

In order to further clarify and predict the influencing factors of stigma, the total score of stigma was taken as the dependent variable, and the family monthly income, personality, family relationship and alexithymia with statistical differences in single factor analysis were analyzed by multiple linear regression. The independent

Note: R = 0.360, R² = 0.347.

** At the level of 0.01, the correlation is significant. * At the level of 0.05, the correlation is significant.

variables entering the equation are alexithymia and family relationship. ANOVA test results f = 26.722, P = 0.000, indicating that the proposed regression equation model has statistical significance. The independent variables (alexithymia, family relationship) explained 34.7% of the variation of the dependent variable (stigma). The results are shown in Table 4.

The results showed that alexithymia was positively correlated with stigma (r = 0.510, P < 0.01). See Table 5.

Alexithymia has a serious impact on the treatment, physical and mental health and quality of life of cancer patients. It is often manifested in physical symptoms. Patients with lymphedema are one of the common complications after malignant tumor surgery. At present, lymphedema cannot be cured, which brings significant mental stimulation and psychological trauma to patients. However, clinical medical staff ignore the impact of alexithymia on the occurrence, development, treatment effect and prognosis of lymphedema to some extent. The results of this survey show that the total score of alexithymia is (56.53 ± 8.43), of which the score of extraversion thinking is the highest, which is (22.71 ± 3.03), followed by the score of lack of ability to identify emotion, which is (20.02 ± 4.57), and the score of lack of ability to describe emotion is the lowest, which is (13.80 ± 2.55). The total score is basically consistent with the score (57.07 ± 9.50) of alexithymia in cancer patients less than 3 months after operation by Gritti [16] , indicating that alexithymia in patients with lymphedema is obvious and at the upper middle level. The reason may be that cancer and surgery have a serious impact on the body and mind of patients. Postoperative lymphedema disease, abnormal swelling of affected limbs, changes in life, worry about other people’s views, affect social interaction, affect self-esteem, and fear of being discriminated against, so as to close themselves, suppress their feelings and not express them to the outside world. Some patients also need radiotherapy and chemotherapy after operation. Multiple stress makes it difficult for patients to identify between physical discomfort and psychological discomfort. They are more sensitive to their own diseases, worry about losing family and love, and can not truly express their feelings.

Patients with lymphedema also face the psychological challenge of long-term adherence to treatment and the comprehensive treatment of the original disease after operation. If they cannot adjust and deal with it in time, they are prone to negative emotions and affect their physical and mental health. It shows that medical staff should timely understand the current situation of alexithymia in patients with lymphedema and intervene in time to reduce alexithymia and improve their physical and mental health.

The results showed that the total score of stigma was (60.36 ± 11.08). The score of social exclusion was the highest (21.07 ± 3.80), followed by economic discrimination (15.65 ± 3.94) and social isolation (15.56 ± 3.05), and the score of internal stigma was the lowest (8.09 ± 1.86). It is basically consistent with the systematic review and research of Reynolds LM et al. [17] on the stigma of cancer patients after physical and mental trauma. Possible reasons for the highest score of social exclusion in this study: most of the patients in this study are women and in-service personnel, who pay too much attention to the external image, because the treatment of lymphedema requires bandage compression and bandage, which is exposed and cannot be concealed, which affects social and work, and the stability of work is impacted and challenged. The second highest score is economic discrimination and social segregation. For patients with lymphedema, it is a protracted battle to insist on self-treatment every day. When limb lymphedema occurs, they have to use compressed clothes or pressure treatment. Patients say they feel constantly reminding themselves of cancer and causing a sense of stigma [18] . For the exposed bandage, I feel a stigma and guilty. I feel that I am labeled with a different label. I am too sensitive, exaggerate the social view of myself, reduce social interaction, and lead to social isolation. Therefore, the sense of stigma affects the social activities of patients with lymphedema. In addition, the reason for economic discrimination may be that the treatment materials required by patients with lymphedema need to be used for a long time. At present, the treatment materials and treatment expenses have not been included in the scope of medical insurance reimbursement, and patients need to pay at their own expense. The economic pressure caused may cause negative emotions of patients.

In order to further clarify the influencing factors of stigma, the total score of stigma was taken as the dependent variable, the statistically significant ones in univariate analysis and the statistically different family monthly income, personality, family relationship and alexithymia in univariate analysis were taken as the independent variables for regression analysis. The results of this study showed that alexithymia and family relationship were the main influencing factors of stigma in patients with lymphedema. The treatment of lymphedema is a long-term process. Girgis et al. [18] showed that patients with lymphedema hope to obtain information about lymphedema and its related treatment and care during the treatment process. For the treatment of patients with lymphedema, lymphedema therapists focus more on how to heal the patient’s mind and improve the patient’s social cognition. Long-term bandage makes the patient reduce social contact. Patients often choose to avoid and can’t carry out good self-management, resulting in the further aggravation of lymphedema symptoms. Therefore, the high cost and the lack of social role also directly affect family relations and social support. Therefore, professional lymphedema therapists are needed. We should adjust the mentality in time, reduce the occurrence of negative emotions, help patients improve their self-treatment and nursing skills at home, overcome psychological obstacles, do their own emotional management, and eliminate or slow down their sense of stigma. Encourage patients to communicate with each other and greet each day with a positive attitude. Family participation can timely understand the psychological needs of patients, so as to alleviate the psychological stigma, which plays a positive role.

The results of this study show that alexithymia is an influencing factor in patients with lymphedema. Alexithymia was positively correlated with the total score of stigma. The higher the level of alexithymia, the stronger the sense of stigma. Multi layer bandage compression bandage is one of the important steps in the comprehensive detumescence treatment of lymphedema. Although it can reduce or control the symptoms of lymphedema, it also brings physical and mental effects and social adaptation to patients. With the guidance and help of professional lymphedema therapists and the support of family members, we can provide patients with a comprehensive way of rehabilitation; Improve physical function, provide regular follow-up and psychological adjustment, help patients recover physically and mentally, and eliminate the sense of stigma. The emergence of lymphedema is undoubtedly worse for patients, and they are worried about cancer recurrence. They will have a negative attitude towards themselves and deny their own value. Worry about becoming a burden on family members and social exclusion, which affects social activities [1] . This study further confirmed the correlation between alexithymia and stigma, suggesting that lymphedema therapists should take appropriate psychological counseling to reduce the degree of stigma. Therefore, medical staff should provide a follow-up platform for patients with malignant tumors after operation, conduct regular follow-up, timely psychological adjustment, guide them out of negative mood, help patients choose their own lifestyle and work mode, and reflect their social value.