Early screening after breast cancer treatment essential to reduce impact of lymphedema
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Lymphedema occurs in around 20% of breast cancer survivors depending on the treatment course, but growing knowledge of risk factors and the importance of early screening can improve these odds.
Lymphedema occurs when disruption to the lymphatic system prevents adequate drainage from lymphatic vessels, leading to excess fluid that causes swelling in the breast, trunk or extremities. Axillary surgery is the greatest risk factor for breast cancer-related lymphedema. Patients who undergo axillary lymph node dissection carry a risk of 25% to 30%, and those who undergo sentinel node biopsy have a risk of 8% to 10%, according to Alphonse Taghian, MD, PhD, director of the breast cancer-related Lymphedema Research Program at Massachusetts General Hospital and professor of radiation oncology an Harvard Medical School.
!["We know that it's important we start screening [for lymphedema] early but that we continue to screen these patients because the risk doesn't go away." - Cheryl Brunelle, PT, MS, CCS, CLT](/~/media/slack-news/hemonc/content-bundles/resource-centers/navigating-survivorship-rc/2022/hot_ns0122lymphedema_taghian_graphic_01.jpg?w=800)
Taghian said that, nationwide, lymphedema will affect approximately one in five breast cancer survivors, although this can vary depending on the practice, the techniques used for treatment, how advanced the cancer may be and other patient factors, such as BMI.
“When it comes to cancer, whichever treatment is needed takes priority,” he told Healio. “The main cause of lymphedema is lymph node dissection, but when that treatment is needed, it’s needed; you cannot get around it.”
The focus for Taghian and other lymphedema specialists has, therefore, been to better understand how to lower the risks during treatment and catch it as early as possible.
Understanding the risks
Among patients who require the highest-risk factor treatment of axillary lymph node dissection, Taghian said that the risk grows from 25% to 30% if regional lymph node radiation also is used. Another risk factor is BMI of 25 kg/m2 or more at the time of breast cancer diagnosis.
“If you have the combination of lymph node dissection, nodal radiation and high BMI, the risk increases even further,” he said. “Now, how can we decrease it while we maintain same treatment success?”
He continued that, rather than immediately proceeding to lymph node dissection after a positive sentinel lymph node biopsy, recent data have shown that it may be safe to substitute the lymph node dissection by lymph node radiation if there are only one or two positive sentinel lymph nodes.
“The risk for lymphedema then goes down from 30% to 10%, and this is a huge benefit for the patient,” he said.
In a study published in Gland Surgery, Taghian and colleagues provided a comprehensive review of the current evidence regarding breast cancer-related lymphedema risk factors. Besides axillary dissection, nodal irradiation and comorbid factors such as elevated BMI and cellulitis, the researchers identified areas of data that require further investigation.
Specifically, emerging evidence indicates that a lack of breast reconstruction may be a treatment-related risk, with some studies showing that immediate reconstruction significantly reduces the risk for lymphedema.
In contrast, the literature is unclear regarding the risk posed by taxane-based chemotherapy, with only some studies demonstrating an increased risk for lymphedema after receipt of docetaxel-based chemotherapy. Moreover, the effect of neoadjuvant chemotherapy on risk is also unclear.
Because the knowledge surrounding lymphedema and the best way to measure for it and to treat it once it is established are still developing, Taghian said his focus turned to improving screening.
Timing is key
Historically, clinicians have largely been unsuccessful in curing lymphedema once it’s been established.
“The whole story is that, when I came to the field of lymphedema, it was driven by impairment-based treatment or policies,” Taghian said. “This means that, when I saw the patient had lymphedema, I would send the patient to physical therapy, and that’s it.”
Instead, Taghian wanted to switch from this impairment-based model to one focused on screening and early identification model. The lymphedema screening program at Massachusetts General Hospital began in 2005 and uses perometer measurements to monitor patients for arm volume changes.
“We have a screening program in which we screen patients for lymphedema starting before their breast cancer surgery and then routinely after their breast cancer surgery for a goal of 4 to 5 years,” Cheryl Brunelle, PT, MS, CCS, CLT, associate director of the Lymphedema Research Program at Massachusetts General Hospital, told Healio in an interview.
In a paper published in International Journal of Radiation Oncology, Biology, Physics, Brunelle and colleagues evaluated the timing of lymphedema onset based on different types of breast cancer treatment. Results showed that patients who had node dissection were most likely to develop lymphedema early, between 6 and 12 months after surgery. For patients who underwent sentinel lymph node biopsy with radiation, the risk for lymphedema appeared greatest between 36 and 48 months after surgery.
“From that data, we know that it’s important we start screening early but that we continue to screen these patients because the risk doesn’t go away,” Brunelle said. “Even though the patients with the highest risk were likely to develop lymphedema early, we still saw patients presenting at 2, 3 or even 5 years, so we can’t say that a patient is clear after even 1 year of screening.”
The lymphedema screening program at Massachusetts General Hospital has screened more than 6,000 patients since it began.
“We know by looking at data in our screening program that, in absence of a preoperative baseline measurement, we’re misdiagnosing lymphedema about 50% of the time,” Brunelle said. “Addressing this can be as simple as telling a patient at the end of their preop appointment that there’s one more thing to do and to take those arm measurements then.”
An overwhelming effect
The importance of understanding risks and screening patients to ensure early detection is crucial when considering the devastating effect lymphedema can have on a patient’s quality of life.
“The reason I moved into the field of lymphedema as a radiation oncologist was that I had a patient who had two mastectomies, then reconstruction, a local failure, removed the reconstruction, chemotherapy — a patient who had been in treatment for years,” Taghian said. “She was incredibly graceful, she accepted whichever treatment was recommended or needed next, but from the excessive treatments she underwent, she developed bilateral lymphedema. One day I was passing by and just asked her how she was doing, she said that she didn’t mind the mastectomies or other surgeries, the only thing she could not deal with and brought her down was the lymphedema. This was a huge red flag for me.”
Taghian said other patients had admitted that they would “rather have the cancer come back” or from a husband who said lymphedema had “taken the life out of my wife and therefore our family.”
Brunelle said that although screening for lymphedema is recommended as standard of care by several associations, including the International Lymphedema Framework, the National Comprehensive Cancer Network and the National Lymphedema Network, not many programs exist and many challenges surround establishing programs.
“Any health care provider seeing patients with breast cancer needs to understand lymphedema,” she said. “They need to take the time to do the reading, what it is, what risk factors the patient in front of you has and how to educate them. Screening should begin early, continue through their treatment and after, so that we can manage and possibly prevent progression. It’s no longer good enough to say in the clinic that we don’t have time.”
References:
- Brunelle C, et al. J Pers Med. 2015;doi:10.3390/jpm5020153.
- Gillespie TC, et al. Gland Surg. 2017;doi:10.21037/gs.2017.11.04.
- McDuff SGR, et al. Int J Radiat Oncol Biol Phys. 2019;doi:10.1016/j.ijrobp.2018.08.036.
For more information:
Cheryl Brunelle, PT, MS, CCS, CLT, can be reached at cbrunelle@mgh.harvard.edu.
Alphonse Taghian, MD, PhD, can be reached at ataghian@mgh.harvard.edu.
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