Risks have been reduced, but condition remains problematic Breast cancer-related lymphedema remains an ongoing challenge. "We know there are certain risk factors for lymphedema," said Vered Stearns, MD, co-director of the Breast and Ovarian Cancer Program at the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins. "Patients who either have a lymph node dissection in the axilla, or patients who have radiation to the axilla, and particularly if a patient has both radiation and lymph node dissection are at greater risk for lymphedema." In 2014 The American Society of Clinical Oncology issued guidelines (reaffirmed in 2016)recommending that women without sentinel lymph node metastases, as well as women with one to two metastatic sentinel lymph nodes who are planning to undergo breast-conserving surgery with whole-breast radiotherapy, should not undergo axillary lymph node dissection. Sentinel node biopsy can be offered to women with operable breast cancer and multicentric tumors, with ductal carcinoma in situ who will undergo mastectomy, who previously underwent breast and/or axillary surgery, or who received preoperative/neoadjuvant systemic therapy. "So, most patients with early breast cancer today have a sentinel node evaluation and their risk for lymphedema is very small, and even if they develop lymphedema, it's relatively mild," Stearns told MedPage Today. "When we discuss with the patient the different approaches to treatment then we talk about the pros and cons of radiation versus surgery -- and again, some patients will need both," she said. "And then one thing we advocate for is prehabilitation" -- that is, maximizing patients' physical functioning prior to treatment. Under these types of programs patients are educated about the procedure they are undergoing, as well as lymphedema risk reduction principles. In addition, they will be assessed by specialists, such as physical therapists, and equipped with exercise regimens that patients will begin working on prior to surgery with the hope, said Stearns, "of decreasing the risk of long-term complications of lymphedema." In addition to treatment-related risk factors for lymphedema, there are non-treatment risk factors as well, including a high BMI at the time of diagnosis, weight fluctuations during and after treatment, and cellulitis. If lymphedema can't be entirely avoided, it needs to be diagnosed and treated in a timely manner. "There is growing data that suggests that if you can detect lymphedema at an early point, and then intervene with a treatment, you can prevent the development of chronic lymphedema," said Chirag Shah, MD, director of breast radiation oncology and clinical research, Cleveland Clinic, Ohio. "And that's important because chronic lymphedema is thought to be a condition that can be irreversible and lead to quality of life altering changes like infections and hospitalization, and other morbidities." In this study, for example, investigators monitored women at high risk for lymphedema with bioimpedance spectroscopy and compared them to a control group where women were monitored with circumferential arm measurements. Patients diagnosed with subclinical lymphedema received short-term physical therapy, compression garments, and education about exercise, elevation, infection precautions, BMI, and hand usage. They found that monitoring patients with bioimpedance spectroscopy allowed for early detection and timely intervention for lymphedema, which reduced the incidence of clinical lymphedema from 36.4% to 4.4%. "The conventional ways of detecting lymphedema include patient-reported symptoms like arm heaviness and rings not fitting, as well as techniques like circumference or tape measurement where you measure one limb, then the other, and compare them," Shah told MedPage Today. "And then there are other techniques which are less commonly used, things like water displacement and perometry." Bioimpedance spectroscopy is a technique that evaluates lymphedema by measuring tissue resistance to an electric current to determine extracellular fluid volume. At the annual meeting of the American Society of Breast Surgeons in May researchers presented results of an interim analysis of the PREVENT trial, a randomized trial evaluating bioimpedance spectroscopy versus tape measurement in the prevention of lymphedema following treatment for breast cancer. In this study, investigators, who included Shah, enrolled 509 patients prior to cancer treatment who were undergoing either mastectomy, or lymph node-related breast cancer surgeries and/or radiation. Patients were randomly assigned to either bioimpedance spectroscopy or tape measure groups. Shah and his colleagues found that, of the tape measure patients whose assessments triggered interventions (compression therapy), 14.7% progressed to clinical lymphedema requiring complex decongestive therapy. This compared to just 4.9% in the bioimpedance spectroscopy group, and represented a a 67% relative reduction and a 9.8 percentage-point absolute reduction when measuring with bioimpedance spectroscopy. "Traditional diagnostics like circumference or tape measurements aren't highly sensitive, while bioimpedance spectroscopy represents a highly sensitive diagnostic technique for lymphedema," said Shah. There is no cure for lymphedema, so treatments will focus on reducing swelling and controlling pain. "The most common thing people use is compression sleeves, which puts pressure on the limb, and helps mobilize drainage," said Shah. "When people develop more symptomatic lymphedema then we start getting into more aggressive interventions like complex decongestive physiotherapy." There is also a movement towards surgical treatment, Shah pointed out. These include treatments such as vascularized lymph node transfer, lymphaticovenous anastomosis, and lymphaticolymphatic bypass. While no drug therapies have been approved for treatment of lymphedema, two early-stage clinical trials led by Stanford University researchers have shown that lymphedema patients who took the anti-inflammatory drug ketoprofen demonstrated a reduction in skin thickness as well as improved measures of histopathology. Source
