Best practice screening and management for breast cancer-related lymphoedema

One in five breast cancer patients who undergo axillary lymph node dissection (ALND) will develop secondary lymphodema.(¹⁾ This risk is significantly increased when surgery is combined with radiation therapy and may also be increased by chemotherapy drugs, either alone or in combination with radiation(^2,3). The primary healthcare practitioner plays an important role in the management of breast cancer patients, as lymphoedema can develop weeks, months or years following treatment.

Importance of early detection and intervention

Clinical lymphoedema is preceded by a subclinical or latent stage, where the lymphatic system is impaired, but swelling is not yet obvious. As there is no cure for established clinical lymphoedema, the earlier lymphoedema is detected in a sub-clinical stage, the better it can be managed to prevent progression to clinical signs and symptoms.

Without early intervention, patients who experience progression to moderate or severe lymphoedema face an increased risk of secondary complications including cellulitis, lymphorrhoea and wounds(⁴⁾. Studies have found that patients with untreated lymphoedema are three times more likely to develop cellulitis which requires hospitalisation and antibiotic therapy compared to those receiving active treatment(^5,6).

International research has shown that regular screening, education, early detection and intervention of lymphoedema can assist in reducing the long-term impacts caused by the progression of the condition and improve a patient’s commitment to self-care(^7,8). This demonstrates the importance of increasing local access to lymphoedema screening and management for the Australian community.

Screening for breast cancer-related lymphoedema

Traditionally, lymphoedema assessment has been conducted using a number of different methods, including limb volume measurement, water displacement method, circumferential limb measurement, perometry and bioimpedance(⁹⁾. Bioimpedance spectroscopy (BIS) is a recent advancement in lymphoedema screening and offers a non-invasive approach. BIS uses resistance to electrical currents to measure a patient’s total body water, extracellular and intracellular fluid volumes – informing a baseline L-Dex score and allowing clinicians to monitor lymphoedema progression(¹⁰⁾.

Icon Cancer Centre offer complimentary lymphoedema screening through the SOZO device, which uses BIS technology, as part of our lymphoedema screening and early intervention service for local breast cancer patients. The service is delivered in partnership with an accredited lymphoedema therapist and includes both baseline screening to identify the patient’s risk of developing lymphoedema and follow-up monitoring. Patients are asked to stand on the SOZO device, similar to a bathroom scale, and screening is performed in less than two minutes.

Strategies for lymphoedema management and treatment

The goal of lymphoedema management and treatment is to restore function, reduce side effects and prevent the progression of lymphoedema and associated complications. Best practice management of lymphoedema, as defined by the International Lymphoedema Framework, includes(⁹⁾:

• Exercise/movement – to improve lymphatic and venous flow
• Swelling reduction and maintenance – to reduce limb size/volume, improve subcutaneous tissue consistency and maintain improvements through compression and/or massage
• Skin care – to improve skin condition, treat complications and reduce the risk of cellulitis/erysipelas
• Risk reduction
• Pain and psychosocial management

If subclinical lymphoedema is detected through screening at the Icon Cancer Centre, a referral will be made to an accredited lymphoedema therapist who specialises in lymphoedema therapy and management, including education around self-management programs. When detected early, the implementation of education, short term compression therapy and exercise can reduce progression of lymphoedema by 95%(¹¹⁾. Regular consultation with a lymphoedema therapist and routine lymphoedema screening are encouraged within best practice guidelines to improve patient outcomes(⁹⁾.

Multidisciplinary support for breast cancer patients

The optimal management of patients with breast cancer requires the expertise of multidisciplinary specialists, including general practitioners. Through clinical practice, general practitioners can have a significant impact on the incidence and progression of breast cancer-related lymphoedema through patient education on the importance of early detection and support in accessing lymphoedema screening and early intervention services.

References:

1. DiSipio T, Rye S, Newman B, Hayes S.  Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis. Lancet Oncol. 2013;14(6):500-515. doi:10.1016/S1470-2045(13)70076-7
2. Boyages, John & Vicini, Frank & Shah, Chirag & Koelmeyer, Louise & Nelms, Jerrod & Ridner, Sheila. (2020). The Risk of Subclinical Breast Cancer–Related Lymphedema by the Extent of Axillary Surgery and Regional Node Irradiation: A Randomized Controlled Trial. International Journal of Radiation Oncology*Biology*Physics. 109. 10.1016/j.ijrobp.2020.10.024.
3. Zhu W, Li D, Li X, et al. Association between adjuvant docetaxel-based chemotherapy and breast cancer-related lymphedema. Anticancer Drugs. 2017;28(3):350-355. doi:10.1097/CAD.0000000000000468
4. https://emedicine.medscape.com/article/1087313-overview#a8
5. Vignes S, Arrault M, Dupuy A. Factors associated with increased breast cancer-related lymphoedema volume. Acta Oncol 2007;46:1138-42
6. Shih Y, Xu Y, Cormier JN, Giordano S,Ridner SH, Buchholz TA, et al. Incidence, treatment costs and complications of lymphedema after breast cancer among women of working age: a 2-year follow-up study. J Clin Oncol 2009 Apr;27(12):2007-14.
7. Koelmeyer LA, Borotkanics RJ, Alcorso J, Prah P, Winch CJ, Nakhel K, et al. (2019) Early surveillance is associated with less incidence and severity of breast cancer–related lymphedema compared with a traditional referral model of care. Cancer. 125(6):854–62.
8. National Comprehensive Cancer Network. (2020). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Breast Cancer and Survivorship. Retrieved 20 August 2021 https://www.impedimed.com/wp-content/uploads/2021/01/PM-104-Rev-G-NCCN_flashcard_DIGITAL.pdf
9. International Lymphoedema Network. (2006). Best Practice for the Management of Lymphoedema. Retrieved 14 October 2021 from https://www.lympho.org/portfolio/best-practice-for-the-management-of-lymphoedema/
10. Warren AG, Janz BA, Slavin SA, Borud LJ. The use of bioimpedance analysis to evaluate lymphedema. Ann Plast Surg. 2007 May;58(5):541-3. doi: 10.1097/01.sap.0000244977.84130.cf. PMID: 17452840.
11. Ridner, Sheila H., Mary S. Dietrich, Koelmeyer, L, John Boyages et al. (2019). A randomized trial evaluating bioimpedance spectroscopy versus tape measurement for the prevention of lymphedema following treatment for breast cancer: interim analysis. Annals of surgical oncology 26, no. 10: 3250-3259.