Strategies for lymphoedema management and treatment

A leading radiation oncologist outlines best-practice screening and management for breast cancer-related lymphoedema.

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One in five breast cancer patients who undergo axillary lymph node dissection will develop secondary lymphoedema.¹ 

This risk is significantly increased when surgery is combined with radiation therapy and may also be increased by chemotherapy drugs, particularly when axillary surgery and/or radiation is given.^2,3 The primary healthcare practitioner plays an important role in the management of patients with breast cancer, 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 subclinical 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, ulcers and, in rare cases, lymphangiosarcoma.⁴ Studies have found that patients with untreated lymphoedema are three times as likely to develop cellulitis that requires hospitalisation and antibiotic therapy as 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 several different methods, including limb volume measurement, water displacement, 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 

Professor John Boyages, a radiation oncologist at Icon Cancer Centre in New South Wales and one of the principal investigators in Australia of the international “PREVENT” study, recently found that patients having regular screening with BIS had a 7.9% progression to clinical lymphoedema requiring complex lymphoedema therapy including a compression sleeve, compared with 19.2% for patients being screened with a tape measure (p=0.016). A 2021 study by Professor Boyages had also shown that patients having radiation to the supraclavicular fossa had a higher risk of subclinical lymphoedema (33.3%) than if the SCF was not treated (12.9%) after a sentinel node biopsy (p=0.03).¹²

Many centres, including the Icon Cancer Centres, offer complimentary lymphoedema screening as part of an early intervention service for breast cancer patients. The service includes both baseline screening to identify the patient’s risk of developing lymphoedema and follow-up monitoring. Patients are asked to stand on a device that uses bioimpedance spectroscopy (known as a SOZO), similar to a bathroom scale, and screening is performed in less than two minutes (Figure 1).  

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, a referral can 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, GPs 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.

For further information about lymphoedema screening at Icon Cancer Centre, visit our website here: What is lymphoedema? | Icon Cancer Centre. 

Professor John Boyages is an internationally recognised radiation oncologist, breast cancer specialist and author committed to the expert care of patients with breast disease.

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.
12. Boyages, J., Vicini, F. A., Shah, C., Koelmeyer, L. A., Nelms, J. A., & Ridner, S. H. (2021). 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(4), 987-997.