The standard of care since 2003, sentinel lymph node biopsy has dramatically reduced the risk of lymphedema in early breast cancer, but more than 6% of patients still develop the condition. At the ASCO20 Virtual Education Program, Nicole L. Stout, DPT, CLT-LANA, FAPTA, Research Assistant Professor at West Virginia University Cancer Institute, Morgantown, discussed strategies for early detection and management to help mitigate risk.1
“By standardizing the process with which we follow patients, we will detect the earliest sensory symptoms as well as subclinical measurable changes indicative of emerging swelling,” said Dr. Stout. “There are also strategies we can employ to reduce risk, such as prescribing exercise and encouraging patients with self-manual lymphatic drainage techniques.”
Nicole L. Stout, DPT, CLT-LANA, FAPTA
Prospective Surveillance Model
As Dr. Stout reported, the risk factors for developing lymphedema have been well characterized in the literature. They include having more lymph nodes removed, having multiple surgeries to the chest or more extensive surgery, being overweight or obese, and receiving radiation therapy. With respect to the latter, a greater risk of developing lymphedema is associated with an increased area of radiation.
However, simply identifying risk factors is not enough, according to Dr. Stout. Effective intervention requires prospective monitoring of patients to recognize the earliest signs of clinically meaningful change. All of this comes together in the framework of the prospective surveillance model, which was developed through an international consensus of stakeholders, with details published in 2012.2 The model begins with a baseline clinical assessment at the time of cancer diagnosis to identify normal lifestyle behaviors and physical activity level. The baseline examination also includes screening the upper quadrant and assessing limb volume and tissue.
The model continues with interval surveillance visits at designated time points throughout the course of care. When clinically meaningful change is identified through screening, a specialist in lymphedema management or in rehabilitation follows up with a more detailed assessment.
Screening Questions and Tools
According to Dr. Stout, screening is as simple as asking patients whether they have experienced arm swelling since the diagnosis of breast cancer—even if it’s gone away completely. Sensory changes, including heaviness, tingling, and fatigue in the upper extremity, are also predictive of the onset of lymphedema. A ‘yes’ response to those screening questions should be referred for more detailed assessment, which involves circumferential measures (5% volume change from baseline) and bioimpedance spectroscopy. Tissue dielectric constant is another emerging diagnostic tool used to identify the earliest tissue changes consistent with swelling.
“Each of these tools is excellent, with strong reliability, validity, and repeatability, and each can be used to measure changes over time to promote early detection,” said Dr. Stout. “The key point is we must standardize our methodology of screening and assessment and do that prospectively.”
Right Intervention at the Right Time
Dr. Stout and colleagues encourage all patients to perform self lymphatic massage and manual lymphatic drainage along with deep breathing and daily stimulation to the neck and unaffected node beds. Exercise three to five times per week for a total of 150 minutes is also recommended. In addition, patients are educated to monitor for early signs and symptoms associated with soft-tissue infection.
“It’s critical to catch lymphedema at an early stage, even a subclinical stage,” said Dr. Stout. “If we can identify and manage it in a subclinical stage, we can prevent progression to a more severe and chronic condition. If lymphedema is not managed, it will progress to more significant tissue changes over time.”
If there is measurable change and/or self-reported symptomatology, said Dr. Stout, compression therapy is prescribed per guidelines. Patients are given a compression garment to wear daily for approximately 4 to 6 weeks, with no restrictions on their activities and no nighttime wear.
Dr. Stout and colleagues then reassess to determine whether limb volume has decreased, stabilized, or increased. Patients who do not experience reduction in limb volume with the early compression garment should then begin a complete decongestive therapy program implemented by a lymphedema specialist.
According to Dr. Stout, a number of guidelines have incorporated early detection and monitoring strategies to identify and manage early lymphedema. The most recent updates to the National Comprehensive Cancer Network (NCCN®) Clinical Practice Guidelines in Oncology: Breast Cancer, for example, provide detailed definitions of the progressive stages of lymphedema and note that symptom assessment should occur with regular frequency.
Moreover, said Dr. Stout, the prospective surveillance model is considered a rehabilitative care service, which is an essential component of comprehensive cancer care. “By monitoring your patients with interval screening over the course of treatment, you are helping your hospital health system or cancer center meet compliance with the Commission on Cancer standards,” she explained.
Despite the effectiveness of the prospective surveillance model, which has been demonstrated in multiple randomized clinical trials, Dr. Stout acknowledged there is still risk of developing lymphedema—even for a small number of lymph nodes. Ultimately, assessment is more about risk reduction than prevention.
“We may not be able to prevent lymphedema entirely, but by using a prospective surveillance approach and empowering patients to identify early changes, we can reduce risk and prevent the progression of lymphedema to more severe stages in the long term,” Dr. Stout concluded.
DISCLOSURE: Dr. Stout has received honoraria from BSN Medical Essity, MedBridge, and Survivorship Solutions LLC and has received royalties from Jones and Bartlett.
2. Stout NL, Andrews K, Binkley JM, et al: Stakeholder perspectives on dissemination and implementation of a prospective surveillance model of rehabilitation for breast cancer treatment. Cancer 118(8 suppl):2331-2334, 2012.