From assessment to management, how best to care for cancer survivors at risk for lymphedema
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Lymphedema — swelling in the limbs or trunk caused by excess fluid that can arise following cancer treatment — can be extremely detrimental to survivors’ quality of life.
Because lymphedema can be such an overwhelming complication for survivors to face, it is important for all health care providers involved in their care to be aware of the basics of lymphedema assessment and what steps to take for management should it develop.
“Essentially any patient who has had lymph nodes removed or treated with radiation is at risk for lymphedema,” Sarah A. McLaughlin, MD, professor of surgery at Mayo Clinic in Jacksonville, Florida, told Healio in an interview. “Really, the assessment, education and discussion about those risks should happen before the treatment occurs.”
It is also important to consider the risk for lymphedema prior to treatment in order to weigh cancer treatment options that are less likely to cause the complication.
“There is a lot working in this field right now and the first step to prevent lymphedema is to only assess the lymph nodes if we really need to,” McLaughlin said.
Healio spoke with lymphedema experts about how best to assess survivors for the development of this debilitating effect of cancer treatment, its optimal management and cancer treatment options that may lower risk for lymphedema.
Assessment
Experts with whom Healio spoke agreed that baseline measurements and regular screening are essential for the timely diagnosis and management of lymphedema.
In a related article, Healio spoke with Alphonse Taghian, MD, PhD, professor of radiation oncology at Harvard Medical School and director of the Lymphedema Research Program at Massachusetts General Hospital, about the institute’s lymphedema screening program that has seen more than 6,000 patients.
Unfortunately, such programs with lymphedema specialists and lymphedema-certified physical therapists are not widely available in the U.S. or internationally. In absence of such specialists, Taghian provided some key knowledge that any provider should keep in mind for patients with breast cancer at risk for lymphedema.
“Part of my mission is to spread awareness about this complication to providers,” he said.
“Providers need to know that even though the risk is low with sentinel node biopsy, it can cause lymphedema,” he added. “Other things that can increase the risk for lymphedema include high BMI, seromas and cellulitis.”
Patients at risk should undergo baseline limb measurements, which are then repeated every 6 to 12 months for at least 2 to 3 years.
“The best information we can get is baseline assessment of the patient’s arm volume and differences between one arm and the other, so we are able to follow those measurements over the course of treatment,” McLaughlin said. “In other words, measurement changes at postoperative visits are less meaningful without baseline measurements. We naturally have variations in our arms, so by getting those baseline assessments, you are able to control for things like weight changes over the course of treatment.”
In addition to measuring arm circumference, clinicians should calculate the relative volume change when diagnosing breast cancer-related lymphedema, using either a control arm for comparison in the case of unilateral surgery or a weight-adjusted change equation for patients who underwent bilateral surgery.
Methods for doing so may include objective measurements like bio-impedance, perometry or circumferential tape measures at different locations, but subjective assessments also are important, McLaughlin said.
“When the patient comes back postoperatively and we ask if they are experiencing any symptoms, if they feel like their arms are heavier, or shirt sleeves or jewelry they wear on that arm is feeling tighter, all may be indications that they have some arm swelling,” she said.
McLaughlin said the third component of assessment is a physical exam, in which clinicians look at the quality and texture of the skin to check for pitting or dimpling.
“Ideally, the goal is to identify the early stage of lymphedema before the patient has significant changes or symptoms, so one can intervene and prevent progression of that swelling,” she said. “That’s why we want to make sure the next thing after those baseline measurements and discussions is education, so patients know what symptoms they should be on the lookout for.”
Alternative treatment options
In addition to conducting baseline measurements and screening, reducing the frequency of lymph node dissection is another important means of reducing lymphedema risk.
Several studies have addressed the varying range of risk for lymphedema based on which breast cancer surgical procedures and techniques are used. Specifically, axillary lymph node dissection presents one of the highest risks compared with sentinel lymph node biopsy.
Because of these risks, researchers have looked to develop assessment procedures to better identify who absolutely requires axillary lymph node dissection and who may be safely treated with alternative procedures.
“We are pushing the envelope, identifying certain cancers in elderly women with small tumors who might not need their lymph nodes assessed at all and they can just have the tumor removed,” McLaughlin explained. “If we do have to remove the lymph nodes, we want to remove as few as possible. We continue to look for opportunities to safely extend the indications for sentinel node biopsy, as opposed to doing an axillary dissection for every single patient with a positive lymph node.”
She said that there are also two surgical techniques being evaluated to try to prevent lymphedema. The first is axillary reverse mapping, orARM, in which dye is injected into the upper extremity to identify the lymphatic channels draining the arm. The patients is also given a radiotracer in the breast to identify the lymphatics and lymph nodes draining the breast.
“The goal is then to identify and protect the blue lymphatics from the arm and remove only the identified lymph nodes draining the breast,” she said.
The other technique is known as the Lymphatic Microsurgical Preventative Healing Approach, or LYMPHA.
“Once you identify the lymphatics draining from the upper extremity, one can prophylactically connect the divided lymphatic to a nearby blood vessel so that the lymphatic flow is not interrupted and continues to drain into the venous system despite lymph node removal,” McLaughlin said.
Management once established
Once lymphedema is established and especially if it has reached a point of significant swelling, treatment can be difficult and there may be a limit to how much reduction can be achieved.
“The cornerstone of therapy is getting these patients connected with a lymphedema physical therapist,” McLaughlin said. “They assess the patient and start doing what is called complex decongestive therapy, which is a combination of different interventions, education and techniques to try to reduce the volume within the arm.”
Taghian also mentioned sleeve treatment, often handled by a physical therapist, which can help maximize reduction after draining or other treatments.
Once the maximum reduction is achieved, the physical therapist and others on the patient’s care team can work to maintain that reduction over time. Patients can also be educated on how to perform manual lymphatic draining and bandaging at home.
“There are a few types of surgeries that can be done at certain points,” Taghian said. “Liposuction is very successful once lymphedema is clearly established. A problem is that there are not a lot of lymphatic surgeons in the country, even internationally. If you can get to one, the surgeon may be able to perform a lymphatic bypass or have lymph nodes implanted from another area.”
“Ultimately, it’s a personalized strategy and the time it takes to manage the lymphedema will vary from patient to patient,” McLaughlin continued. “It is important that these decisions are made in the setting of a multidisciplinary team with surgeons, with the lymphatic therapist or physical medicine and rehab physician who can help guide some of these discussions. Then, once we’re clear about how we are going to evaluate upfront, we know how we are going to treat them going forward with which interventions.”
References:
- Gillespie TC, et al. Gland Surg. 2017;doi:10.21037/gs.2017.11.04.
- McLaughlin SA, et al. J Clin Oncol. 2020;doi:10.1200/JCO.19.02896.
For more information:
Sarah A. McLaughlin, MD, can be reached at Mayo Clinic, 4500 San Pablo Road S, Jacksonville, FL 32224.
Alphonse Taghian, MD, PhD, can be reached at ataghian@mgh.harvard.edu.
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