Aggressive research continues on techniques to assess the risk of arm lymphedema after breast cancer diagnosis and treatment and in ways to prevent it.
From the research available, it would seems appropriate that a multifocal approach would be the best practice. This multifocal approach would include The use of sentinel node biopsy versus axillary node biopsy, exploration in the use of the small needle biopsy; assessment of tissue type which includes fluid dynamics of the arm; lymph node mapping, diet; exercise; early diagnosis and finally after diagnosis immediate intervention if lymphedema is detected.
Statistics indicate a range of 35% to 40% of breast cancer survivors will at some time in their life experience lymphedema as a complication of breast cancer treatment and diagnosis. We must utilize all methods possible to drastically reduce this morbidity.
June 3, 2008
ARTEmIS–The Online Magazine of The Breast Center At Johns Hopkins
Issue: July 2008
The study, conducted by the National Naval Medical Center (NNMC) and the National Institutes of Health (NIH) and in collaboration with the University of Michigan-Flint and George Mason University, was published in the journal Cancer.
The authors demonstrated the effectiveness of a surveillance program that included pre-operative limb volume measurement and interval post-operative follow-up to successfully detect and treat lymphedema, a chronic and often irreversible condition that can cause significant swelling of the upper and lower extremities due to the build-up of excess lymph fluid.
“This study is significant for several reasons, but none more so than it showing that detection and management of lymphedema at early stages may prevent the condition from progressing to a chronic, disabling stage and may enable a more cost-effective, conservative intervention,” said American Physical Therapy Association (APTA) spokesperson and the study's lead author, Nicole L Stout Gergich, PT, MPT, CLT-LANA, of the National Naval Medical Center (NNMC) Breast Care Center, in Bethesda, Maryland.
Breast cancer related lymphedema is associated with decreased arm function, disability and diminished quality of life. If the condition is not diagnosed early and managed, it can progress to a situation where the patient is at risk for infection and further shoulder complications. The swelling is disfiguring and many times prohibits patients from finding clothes that fit properly.
Stout noted that the baseline pre-operative assessment of 196 patients with breast cancer participating in the study - which was conducted from 2001 to 2005 - included basic strength, range of motion, limb volume, and physical activity level. “To measure limb volume, we employed infra-red technology that scans the limbs using beams and sensors, providing us with very accurate information,” she said. All study participants were monitored one month post-surgery and at three-month intervals thereafter for one year even if they exhibited no swelling. “Using both the pre- and post-operative assessments enabled us to diagnose lymphedema before it became visible, which is an unprecedented accomplishment,” Stout noted.
Once lymphedema was diagnosed in 43 of the patients participating in the study, the condition was managed using a conservative compression garment, atypical of lymphedema treatment, observed Stout. A light-grade compression sleeve and gauntlet, fitted by the physical therapist, were prescribed for daily wear. “Lymphedema is normally treated with more aggressive and often costly and time-consuming techniques, such as complete decongestive therapy, which requires the patient to attend daily therapy sessions for weeks and wear bulky compression bandages. This study clearly demonstrates that the condition can be managed with a more conservative treatment option when it is diagnosed at its earliest presentation, which will be good news to breast cancer patients,” she added.
“What we hope to garner from publicizing this study is that it will encourage patients with breast cancer to ask the questions that need to be asked regarding their treatment, as well as galvanize physicians, surgeons, oncologists and other physical therapists to make early intervention and conservative treatment of lymphedema the standard of care in breast cancer care,” Stout concluded.
SOURCES: Cancer, April 25, 2008
Lymphology. 2008 Mar
Hayes S, Janda M, Cornish B, Battistutta D, Newman B. Institute of Health and Biomedical Innovation, School of Public Health, Faculty of Health, Queensland University of Technology, Kelvin Grove, Australia. firstname.lastname@example.org
Research on secondary lymphedema primarily uses indirect methods for diagnosis. This paper compares prevalence and cumulative burden following breast cancer surgery, as well as personal, treatment, and behavioral characteristics associated with lymphedema, using different assessment techniques. Lymphedema status was assessed at three-monthly intervals between six- and 18-months post-surgery in a population-based sample of Australian women with recently diagnosed, unilateral, invasive breast cancer, using three methods: bioimpedance spectroscopy (BIS), difference between sum of arm circumferences (SOAC) and self-report. Depending on the method, point prevalence ranged between 8 to 28%, with 1 in 5 to 2 in 5 women experiencing lymphedema at some point in time. Of those with lymphedema defined by BIS, almost 40%-60% went undetected, and 40%-12% were misclassified as having lymphedema, based on self-report and SOAC, respectively. The choice of measure also had significant implications for identified risk factors. Over 10 characteristics were associated with lymphedema, however only one, experiencing other upper-body symptoms at baseline, influenced odds of lymphedema across all three methods. These findings highlight that secondary lymphedema poses a significant public health problem. Utilizing the most accurate and reliable method for assessment is crucial to advance our understanding of preventive and treatment strategies.
Acta Oncol. 2008
Nesvold IL, Dahl AA, Løkkevik E, Marit Mengshoel A, Fosså SD. Department of Cancer Rehabilitation-Physiotherapy, Rikshospitalet, University of Oslo: Division The Norwegian Radium Hospital, Montebello, Oslo, Norway. email@example.com
INTRODUCTION: The objective of this study was to compare the prevalence of late effects in the arm and shoulder in patients with breast cancer stage II who had radical modified mastectomy (RM) or breast-conserving therapy (BCT) followed by loco-regional adjuvant radiotherapy with or without chemotherapy/anti-oestrogen.
MATERIAL AND METHODS: All patients had axillary lymph node dissection. At a median of 47 months (range 32-87) post-surgery, 263 women (RM: n=186, BCT: n=77) were seen during an outpatient visit and had their arm and shoulder function and the presence of lymphedema assessed by a clinical examination, interview and self-rating. Volume calculation was used to measure lymphedema.
RESULTS: In the RM group 20% had developed arm lymphedema versus 8% in the BCT group (p=0.02). In multivariate analysis lymphedema was associated with a higher number of metastatic axillary lymph nodes [OR1.14, p=0.02], RM [OR 2.75, p=0.04] and increasing body mass index (BMI) [OR 1.11, p<0.01]. In the RM group 24% had a restricted range of motion in shoulder flexion compared to 7% in the BCT group (p<0.01). Shoulder pain was reported by 32% in the RM group and by 12% in the BCT group (p=0.001). Increasing observation time, RM, and increasing BMI were significantly associated with impaired arm/shoulder function.
DISCUSSION: Arm/shoulder problems including lymphedema were significantly more common after RM compared to BCT in irradiated breast cancer patients who have undergone axillary lymph node dissection. The performance of BCT should be encouraged when appropriate, to ensure a low prevalence of arm/shoulder morbidity including lymphedema.
Lymphat Res Biol. 2008
Moseley A, Piller N. Department of Surgery and Lymphedema Assessment Clinic, Flinders University and Medical Centre, South Australia, Australia.
Abstract Background: Measuring the female breast, especially after breast cancer treatment, is problematic due to breast size, texture, and patient positioning. However, being able to accurately measure changes in the breast is important, as it may help in the earlier diagnosis and treatment of early breast edema and later lymphedema.
Methods: 14 women who had undergone breast conserving surgery for breast cancer (> 12 months ago) were recruited to assess the between subject reproducibility of tonometry and bioimpedance spectroscopy (BIS). With the participant supine, two repeat measurements of the resistance of the tissues to compression (tonometry) and fluid levels (BIS) of the treated and normal breast were taken for each of the four quadrants of the breast.
Results: The between subject reproducibility for both measurement techniques was high, with covariance ranging from 1.29% to 3.25% for tonometry and 0.20-0.86% for BIS.
Conclusions: The reliability of these two measurement techniques provides an opportunity for researchers and clinicians to easily quantify breast tissue and fluid changes which in turn may lead to the earlier diagnosis and targeted treatment of breast edema and lymphedema.
J Clin Nurs. 2008 Jun
Park JH, Lee WH, Chung HS. College of Nursing, Ajou University, Seoul, Korea. firstname.lastname@example.org
AIM: The purpose of this study was to examine the incidence of lymphoedema and to identify risk factors of lymphoedema in patients with breast cancer undergoing mastectomy in Korea. BACKGROUND: Lymphoedema is a serious problem for many breast cancer survivors. Although the potential impact of lymphoedema is extensive, it is largely unrecognised.
METHODS: Women with breast cancer (n = 450) receiving mastectomy were recruited from outpatient breast cancer clinics of two university hospitals in Seoul, Korea from October 2004 to May 2005. Lymphoedema was defined by circumferential measurement. This study examined the risk factors associated with lymphoedema through the literature review. A descriptive design was used for this study and data were collected using structured questionnaire. Data were analysed by chi-square test and multiple logistic regression.
RESULTS: Among the 450 cases of breast cancer, 24.9% had developed lymphoedema. There were significantly increased risks of lymphoedema if women were with higher staging, had modified radical mastectomy, had axillary lymph node dissection, received axillary radiotherapy and were with body mass index greater than 25 kg/m(2). A significantly decreased risk of lymphoedema was found in women who exercised regularly, received pretreatment education of lymphoedema and had performed preventive self-care activities.
CONCLUSIONS: Lymphoedema is recognised as an unpleasant and uncomfortable consequence of breast cancer-related treatment. Patients should be advised of the risk of lymphoedema and educated to detect its symptoms. Relevance to clinical practice. It is of importance to recognise breast cancer patients at risk for lymphoedema. Nurses should inform patients with breast cancer about their risk for lymphoedema and guidelines to reduce the risk and to emphasise self-care activities for prevention.
also includes (1) Retroperitoneal Lymph Node Dissection and (2) Laparoscopic Retroperitoneal Lymph Node Dissection