Breast cancer-related lymphoedema: Prospective surveillance or prophylactic approach?

This MOH Talk was co-moderated by Dr Mohamed Omar Elfarok, consultant vascular and endovascular surgeon at the General Organization of Teaching Hospitals and Institutes in Cairo, Egypt, and Bethanie Noll, clinical specialist for SIGVARIS GROUP USA. The second speaker, Dr Vincent Singh Paramanandam,  qualified cancer case specialist and certified lymphedema therapist at the University of Sydney, Australia, highlighted the advantages of combining two methods used to prevent chronic lymphedema: the prospective surveillance method and the prophylactic approach. 

Prospective surveillance is used to detect arm swelling at a subclinical stage and to intervene early, usually with compression sleeves. In the prophylactic approach compression is applied immediately following breast cancer surgery to prevent arm swelling in women at high risk. 

Does participation in prospective surveillance and early management reduce the risk of developing chronic edema? Dr Paramanandam presented results from a systematic literature review and meta-analysis, indicating that participation in prospective surveillance with early management reduces the risk of chronic breast cancer related arm lymphedema. However, these results should be interpreted with caution due to heterogenous methods used to detect arm lymphedema in the included studies. Dr Paramanandam emphasised the need for high quality studies and standardised methods to detect early lymphedema. He pointed out that the prospective surveillance method is resource intensive, requiring trained people, a bioimpedance device, and regular monitoring. It is doubtful that prospective surveillance is feasible in a low resource setting. 

In the prophylactic approach, compression sleeves are applied irrespective of whether the patient has edema or not. Dr Paramanandam presented results from a blinded randomised controlled parallel group trial that was conducted to determine whether prophylactic use of compression sleeves prevents arm swelling in women who had undergone axillary lymph node dissection for breast cancer surgery. A total of 307 adult women referred for breast cancer surgery were randomly assigned to either an intervention or control group. In addition to standard postoperative care, the intervention group received a pair of compression sleeves (20-25 mmHg) to wear postoperatively at least 8 hours per day until 3 months after completion of adjuvant treatments. The estimated cumulative incidence of arm swelling at one year was lower in the intervention group compared to the control group based on bioimpedance spectroscopy (42% vs 52%; HR 0.61, 95% CI 0.43-0.85; p=0.004) and ≥10% increase from baseline in relative arm volume (14% vs 25%; HR 0.56, 95% CI 0.33-0.96; p=0.034).The prophylactic use of compression sleeves not only reduced the incidence, but also delayed the onset of arm swelling and did not negatively impact quality of life, physical function and symptoms in breast or arms. 

Since some women developed arm swelling even with prophylactic compression sleeves, Dr Paramanandam proposed using prophylactic compression in addition to self-surveillance. Thus, it is paramount to educate women about lymphedema symptoms so that they can identify arm swelling early and seek help. 

Take home messages:

• Arm swelling is common following axillary lymph node dissection due to breast cancer treatment.  
• Participation in prospective surveillance with early management reduces the risk of chronic breast cancer related arm lymphedema. 
• The prophylactic use of compression sleeves reduced the incidence of arm swelling, delayed the onset of arm swelling and did not negatively affect quality of life, physical function and breast or arm symptoms in a randomized, controlled clinical trial. 
• A combined approach of educating women about lymphedema symptoms and prophylactic use of compression sleeves may prove beneficial for patients in low resource settings.