Consensus recommendations aim to prevent breast cancer-related lymphedema
Click Here to Manage Email Alerts
Multinational Association of Supportive Care in Cancer published the first set of consensus guidelines intended to prevent lymphedema among patients who underwent surgery for breast cancer.
A panel of 64 experts from 16 countries reviewed data from randomized controlled trials that included more than 60,000 patients with breast cancer-related arm lymphedema to identify risk factors and optimal prevention strategies.
“There has been new research evidence providing more guidance on the most effective prevention strategies for lymphedema,” co-senior author Raymond J. Chan, RN, PhD, GAICD, FACN, FAAN, deputy vice-chancellor of research and Matthew Flinders professor of cancer care, systems and policy at Caring Futures Institute at Flinders University in Australia, told Healio. “It was, therefore, important for the international community to reach consensus on risk factors and prevention strategies, enabling consistency in practice across the globe. It is important for us to articulate what optimal care should be offered if resources allow.”
Prioritizing high-risk patients
Lymphedema — which involves accumulation of fluid in the arms — results from damage or removal of lymph nodes during breast cancer treatment.
“Lymphedema occurs in up to 20% of [patients with breast cancer] after anticancer treatments,” Chan said. “Lymphedema can cause swelling, recurring infection, restricted range of movement and hardening of the skin, and [it] can affect the patient’s appearance and self-image.”
Approximately half of patients with breast cancer-related arm lymphedema develop the condition 12 to 30 months postoperatively, Chan said. However, the condition can emerge many years after surgery.
There is a major unmet need for strategies to prevent the condition because there are no effective strategies to eradicate it once it reaches a chronic state, Chan and colleagues wrote.
Some strategies, including prophylactic lymphatic reconstruction and surveillance programs, have shown potential promise. However, practice differs greatly based on variations in organizational standards, clinician preference and local resources, according to the authors.
The guideline panel — which included experts involved in breast cancer treatment and research — reviewed randomized controlled trial and evidence review data published from 2018 through 2022.
Through this analysis, they identified multiple risk factors associated with breast cancer-related arm lymphedema. These included axillary lymph node dissection, receipt of postoperative radiotherapy, increase in relative arm volume 1 month after surgery, higher number of lymph nodes dissected and high BMI.
“Oncologists need to communicate the potential development and consider the risk factors for developing this condition prior to treatment,” Chan said. “It is paramount that patients who are at higher risk for developing this condition get prioritized for local resources, interventions and support.”
‘Partners in care’
This effort is the first to offer guidance on frequency and length of surveillance, approaches to early detection of lymphedema, and types of treatments to offer.
Among the key recommendations:
Prospective surveillance programs should be utilized to screen for and decrease risk for breast cancer-related arm lymphedema where resources permit.
Providers should offer prophylactic compression sleeves, axillary reverse mapping and prophylactic lymphatic reconstruction as options to patients at risk for breast cancer-related arm lymphedema.
Routine axillary lymph node dissection should not be offered to patients with clinical T1-2 node-negative disease with one or two positive sentinel lymph nodes who undergo breast conservation therapy.
In the same group of patients who undergo mastectomy, axillary radiation should be offered instead of axillary lymph node dissection.
Ideally, these recommendations should be considered and implemented in collaboration with patients, caregivers and the entire oncology care team, Chan said.
“Patients and their family members should be treated as partners in care,” Chan said. “Communication and support are essential in implementing these recommendations. Oncology nurses should also play a role in patient counselling and self-management.”
For more information:
Raymond J. Chan, RN, PhD, GAICD, FACN, FAAN, can be reached at Flinders University, College of Nursing and Health Sciences, Sturt Campus, Sturt Road, Bedford Park SA 5042, Australia; email: raymond.chan@flinders.edu.au.
Perspective
Back to Top
Chirag Shah, MD
Breast cancer-related lymphedema (BCRL) represents a dreaded complication of breast cancer therapy with the potential for a significant impact on quality of life for breast cancer survivors. The Multinational Association of Supportive Care in Cancer (MASCC) practice guideline looks to provide consensus recommendations for key questions facing clinicians, including which patients need BCRL surveillance, how to provide surveillance, and how to intervene.
With regard to risk factors for BCRL, the guideline supports increased risk for BCRL for those undergoing axilliary lymph node dissection with greater than 15 nodes removed and those receiving lymph node radiation with additional risk factors identified. This allows clinicians to know which patients may require additional BCRL counseling and surveillance when possible based on resources available.
The MASCC guideline supports prospective BCRL surveillance when resources are available. This is clinically significant and consistent with other guidelines that support that clinicians should work to ensure that patients receive prospective surveillance for BCRL. With regard to BCRL surveillance, the guideline supports use of bioimpedance spectroscopy when possible, with alternatives being arm circumference or lymphangiography, providing clinicians multiple ways to provide BCRL surveillance. Targeted treatment with a compression sleeve is a key clinical intervention for those requiring it (L-Dex > 6.5 increase or 5-10% increase in volume) and clinically actionable. With regards to timing of BCRL surveillance, the guideline suggests surveillance should start within 3 months of surgery and continue for at least 24 months, an important point as clinicians should counsel patients on the need for long-term BCRL follow-up.
Finally, a key take away is conversations between clinicians and patients with breast cancer regarding BCRL risk, surveillance and intervention should be taking place as part of shared decision-making during and after breast cancer treatment.
Collapse
Click Here to Manage Email Alerts