Peripheral inserted central catheters and totally implantable vascular access ports are commonly used for CT treatment in patients with breast cancer [5, 6]. The use of PICC as an alternative to traditional chest-ports has increased over the last 2 decades, due to greater safety, ease of insertion and removal, and reduced waiting time [7]. Though, PICCs are more visible, they potentially may interfere with daily activities (e.g., bathing and showering) and are at a greater risk of dislodgement [8].

PICC-port is a particular type of arm TIVAP, inserted according to the current state-of-the-art of PICC insertion—ultrasound (US)-guided venipuncture of deep veins of the arm, micro-puncture kits, proper location of the tip preferably by intracavitary electrocardiogram (IC-ECG)—with placement of the reservoir at mid-arm [19]. The consistent adoption of these strategies has led to a considerable improvement in terms of safety and reliability of these devices, and recently, PICC-ports have been advocated as an alternative to chest TIVAPs to reduce complications and improve patients’ acceptance and QoL [28]. In fact, clinical studies reported positive clinical outcomes with the use of PICC-ports. In 418 adult patients with breast cancer undergoing chemotherapy [19], authors reported PICC-port failure rate of 2.6%, similar or even inferior to the same outcome reported for chest-ports in the recent literature [29,30,31]. Another more recent retrospective study [20] confirmed favorable clinical outcomes of PICC-ports in a very large cohort (4480) of cancer and non-cancer patients. In fact, over 80% of PICC-ports were removed because of the end of use, and severe adverse event (mainly infections requiring removal) occurred only in 1.1% of cases. Also, the rate of symptomatic thrombosis was 2%, requiring removal only in 0.02% of cases. Despite these encouraging clinical outcomes, PICC-ports’ QoL is not consistently considered among primary outcomes.

Breast cancer is the most frequent female tumor occurring in a relatively young and socially active population [1]; psychological/relationship needs and family/working habits represent unmet needs that must be considered [22]. Only one study [28] compared arm-ports to PICCs in terms of QoL in patients with colon and breast cancer. In their study, Burbridge and coworkers found that, despite pain scores associated with device implantation and device access for therapy were greater with ports compared to PICCs, overall, a significantly higher proportion of subjects with a PICC versus a port reported changes in the way they dressed, difficulty with showering or bathing, and having people comment on the presence of their device in the survey performed at baseline and at 3 months.

In our study, we found no differences between PICCs and PICC-ports in terms of pain at the insertion of the devices and in terms of discomfort associated with treatment. In particular, no significant differences were reported at the connection and disconnection of the infusion line to the two different devices, despite the positioning and removal of the Huber needle may be theoretically more painful [32].

On the other hand, in terms of QoL, PICC-ports were preferred over PICCs. By a greater extent compared to PICC-ports, patients carrying a PICC experienced the need to cover the device with clothing. In fact, patients may feel uncomfortable on showing their PICC to other people, as well as may feel anxious on possible dislodgement. Moreover, more patients with PICC were worried of the possibility of the device to be blocked. Also, a greater proportion of patients in the PICC group were bothered by the device when they shower, bathe, or perform personal hygiene or during social activities. In general, the degree of satisfaction was greater with PICC-ports. In fact, a significantly greater number of patients with PICC-port reported to be satisfied by the insertion of the device. Interestingly, those differences between PICC and PICC-port were even more pronounced in women under the age of 60. This is easily explainable by the fact that women of that age usually still work and are more socially active. Therefore, an external device such as a PICC may represent a limitation for their daily activities. Moreover, the more frequent (weekly) PICC’s maintenance compared to PICC-port (monthly or bimonthly) may make a difference for many women.

In terms of complications, a significantly greater incidence of ecchymosis, but not of hematoma, occurred in the PICC-port group, which is not surprising. As a matter of fact, PICC-port insertion, despite being less invasive than a chest-port, is a more invasive procedure than a PICC insertion [12]. Also, it must be considered that at the beginning, when we started inserting PICC-ports, pocketing the reservoir at the arm represented a technical challenge, which was easily overcome by practice. In fact, we progressively observed a reduction in the incidence of ecchymosis as the clinicians improved their technical skills. Nevertheless, ecchymosis, despite may alarm the patient, is a benign phenomenon, with a favorable outcome without any treatment.

Overall incidence of symptomatic catheter-related thrombosis (CRT) was low (3%), and no significant differences were found between the two groups, despite a significantly greater proportion of PICC-ports had a bigger diameter than PICC (5 fr vs 4 fr). This is basically due to the consistent adoption by our group of a CRT prevention protocol, both for PICC and PICC-port insertion, encompassing four strategies: (a) US-guided venipuncture, which limiting the number of attempts, reduces endothelial trauma and the consequent CRT risk; (b) attention to catheter-to-vein ratio, which, rather than catheter diameter per se, is one of the most important factors for determining the risk of CRT [33]; (b) the extensive use of catheter tunneling, which allows puncturing proximally to the axilla, where normally veins are larger; (d) accurate, intra-procedural tip location with intracavitary ECG [34]. As a matter of fact, recent meta-analysis demonstrated that, if those strategies are all consistently adopted, the risk of symptomatic PICC-associated CRT risk is very low and the risk of pulmonary embolism minimal or absent [35, 36].

Incidence of infection was very low. Only two cases of infection were recorded: one local (pocket) infection and one CRBSI—none of them requiring device removal—occurred in the PICC-port group, and none in the PICC group, with no statistical significance. This favorable outcome can be due to the scrupulous application of infection prevention strategies, as prescribed by the international guidelines [27, 37, 38].

This study has some limitations. First, it was carried out on patients with breast cancer undergoing neoadjuvant CT, and the results may not be representative of all patients with breast cancer. Hopefully, the role of PICC-ports in terms of QoL in other stages of breast cancer, and in other type of tumors, and in other healthcare systems (e.g., lower income countries) will be addressed by further research. Second, the experience with PICC-port implantation, especially at the beginning, was very scarce for the staff, but improved over time during the study period. This may have influenced the duration of the procedure and the incidence of complications. Third, some patients openly asked for a PICC-port to be implanted, and this may have influenced their attitude toward these devices.

In conclusion, in women with breast cancer undergoing neoadjuvant chemotherapy, PICC-port, compared to PICC, showed to interfere less with daily life activities, to be associated less with psychological and social concerns and to be associated with less anxiety for device being blocked or dislodged. In this population, and especially in youngers, PICC-port is overall better accepted than PICC in terms of QoL, with similar risks of complications.