Early detection and treatment of lymphedema: recommendations
Breast cancer-related lymphedema (BCRL) has become an increasingly important clinical issue as noted by the recent update of the 2015 NCCN breast cancer guidelines which recommends to “educate, monitor, and refer for lymphedema management as early as possible”.
But how do we implement those guidelines cost-effectively in daily practice?
BCRL can lead to complications including pain and infections as well deterioration in QoL through a reduction in function of the affected limb.
Since there is a reversible subclinical phase without fibrosis, the potential exists for detection and treatment of BCRL at this phase of the process. However, older diagnostic tests have limited ability to detect subclinical BCRL reducing the potential for early detection and therefore early intervention.
This review describes new diagnostic techniques and timely interventions effective in preventing subclinical BCRL to become chronic.
The number of long-term breast cancer survivors continues to increase secondary to improved cancer treatment outcomes over the past several decades. This growing population of patients has resulted in an increased focus on survivorship and the management and prevention of acute and chronic toxicities.
One such concern is breast cancer-related lymphedema (BCRL). BCRL can have a significant, detrimental impact on the quality of life of breast cancer survivors. With the increased use of multimodality therapy including surgery, local-regional radiation therapy, and certain systemic chemotherapeutic agents, the number of cases of BCRL may continue to increase. Recent data still demonstrate rates of 10–30% at 2 years.
But, who and how and when do we screen, and who and how do we treat patients with subclinical lymphedema?
What is the evidence and what are the costs of diagnostics and treatment?
Diagnostics:
Traditionally, the diagnosis of BCRL has been based on several techniques including circumferential arm measurements, water displacement, and patient surveys. Newer techniques are evolving, including 1) optoelectronic perometry, which uses infrared light to measure limb volume, 2) dual-energy X-ray absorptiometry and 3) bio-impedance spectroscopy (BIS). BIS uses electrical current to detect the volume of the extracellular space that can then be converted into a measurement index with a validated cutoff.
Screening:
Prospective surveillance programs of high risk patients at 3, 6, 12, 18, 24, and 36 months following treatment will capture 89% of the BCLR diagnoses.
High-risk patients may include (1) those undergoing ALND, (2) regional nodal irradiation, and/or (3) taxane-based chemotherapy. Similarly, data have demonstrated a high risk of significant BCRL in patients with increased BMI and/or a history of cellulitis, both of which may be included into surveillance inclusion criteria.
Treatment:
Early intervention usually consists of early education, administering self massage techniques and provision of compression sleeves.
Costs:
Apart from improving QoL, early surveillance and detection could also reduce costs; A recent analysis compared a prospective surveillance model with traditional “impairment-based care” and found that while the cost was estimated to be $636 per year to place patients in the prospective surveillance model, for patients using the traditional model, the cost was $3,124 per year to manage BCRL.
New diagnostic modalities offer the ability to provide clinicians with standardized objective cut points to initiate therapy, providing early intervention to prevent chronic lymphedema and associated costs and reduction of QoL.
What is your current standard of care? Can you implement these guidelines in your daily practice?
> From: Shah et al., Cancer Med (2016) (Epub ahead of print). All rights reserved to The Author(s). Click here for the Pubmed summary.
