Advancing BCRL Management: The Role of Compression Therapy in Prevention and Maintenance
This MOH Focus presents the benefits of compression therapy in the maintenance and prevention of post-surgical BCRL. This paper is available in English, French, German, Italian and Spanish.
Breast cancer-related lymphedema (BCRL): Background
This introduction to the background of BCRL is based on references 1-17.
Definition
BCRL is a swelling of the arm, chest wall, and breast on the surgical side, and is one of the most frequent complications of breast cancer treatment. It results from a disruption of the lymphatic system, causing lymph fluid to accumulate in the interstitial space.
Risk factors
Axillary lymph node dissection (ALND), sentinel lymph node biopsy, radiation therapy of the axilla, or a combination.
Incidence
20% at one year, 40% at ten years, cumulative incidence of 28%.
Symptoms
Can include swelling, pain, numbness, heaviness, tightness, stiffness, decreased coordination and mobility, limb fatigue or weakness, recurrent infections in the limb, negative changes in self-image, increased anxiety, and poorer quality of life.
BCRL management
Education, skin care, exercise, compression therapy and manual lymphatic drainage. Early detection and treatment of subclinical BCRL can prevent progression to its chronic stage and decrease the need for costly treatments.
Compression & Prevention
Paramanandam et al., 2022
Aim
To determine whether compression sleeves reduce the incidence of arm swelling in women having undergone ALND for breast cancer surgery.
Experimental procedure
Primary endpoint: arm swelling (bioimpedance spectroscopy, BIS****)
Secondary endpoints: arm swelling (tape measurement), quality of life
Results
BCRL incidence after one year
- Significantly lower BCRL incidence in the sleeve group. (As BIS quantifies extracellular fluid, a higher incidence of swelling detected by BIS is expected.)
- No significant differences between treatment groups for quality of life
Take-home message
Compression sleeves combined with education on arm care and exercise substantially reduce the incidence of BCRL in patients having undergone axillary lymph node dissection.
Ochalek et al., 2017
Aim
To determine whether compression sleeves reduce the incidence of arm swelling in women having undergone ALND for breast cancer surgery.
Experimental procedure
Primary endpoint: arm volume (tape measurement)
Secondary endpoint: quality of life
Results
BCRL incidence after one year
• Significantly less edema in the sleeve group
• High sleeve compliance (10+h/d in 22 out of 23 patients)
• No sleeve discomfort, no donning and doffing difficulties
• Significant improvement in quality of life with sleeves after two years (4)
Take-home message
In patients having undergone axillary lymph node dissection, compression sleeves prevent postsurgical arm swelling, reduce the incidence of BCRL and have a positive impact on quality of life.
*Education, skin, drain care, shoulder exercises; **SIGVARIS GROUP compression sleeve (20-25mmHg, min. 8h/day), until three months after completion of adjuvant treatments ***compression sleeve (15-21mmHg, 8-10h/day); ****BIS measures extracellular fluid within the arm
Compression & Maintenance
McNeely et al., 2021
Aim
To determine the efficacy of nighttime compression (compression bandages or wraps) on arm lymphedema volume maintenance in women with post-surgical BCRL.
Experimental procedure
Patients had completed all primary and adjuvant cancer treatments for at least one month before they were randomized into the following groups:
Primary endpoint: arm volume measured with a perometer****
Secondary endpoint: quality of life
Results
Compliance
Night discomfort
Excess arm volume over time [mL]
Absolute [mL] and percentage [%] volume reduction (week 0 to week 12)
• With nighttime compression (CB or wraps): significant volume reduction over time
• With nighttime compression (CB or wraps): significantly more volume reduction than without compression
• Improvement in quality of life across all groups
• At week 12, cross-over of all patients to the nighttime wrap group: patients from the "no compression group" benefited the most and showed a significant decrease in arm volume at week 24.
Take-home message
Nighttime compression is beneficial as a self-management strategy for chronic BCRL. These results are in accordance with a study showing that nighttime use of wraps offers benefits to patients during the maintenance phase of lymphedema treatment and enhances patients’ autonomy (16). This seems to be especially true in patients that have no previous experience in bandaging (3).
*sleeve (12h/day), skin care, exercise, body weight maintenance; **multi-layered compression bandages; ***sigvaris Medaform Standard Arm; ****a perometer uses infrared technology to quantify limb volume
References
(1) Paramanandam, Vincent, et al. "Prophylactic use of compression sleeves reduces the incidence of arm swelling in women at high risk of breast cancer-related lymphedema: a randomized controlled trial" Journal of Clinical Oncology (2022): JCO-21.
(2) Ochalek, Katarzyna, Tomasz Gradalski, and Hugo Partsch. "Preventing early postoperative arm swelling and lymphedema manifestation by compression sleeves after axillary lymph node interventions in breast cancer patients: a randomized controlled trial." Journal of pain and symptom management 54.3 (2017): 346-354.
(3) McNeely, Margaret L., et al. "Nighttime compression supports improved self-management of breast cancer–related lymphedema: A multicenter randomized controlled trial." Cancer (2021).
(4) Ochalek, Katarzyna, et al. "Do compression sleeves reduce the incidence of arm lymphedema and improve quality of life? Two-year results from a prospective randomized trial in breast cancer survivors." Lymphatic research and biology 17.1 (2019): 70-77.
(5) Klassen, Anne F., et al. "Development and psychometric validation of a patient-reported outcome measure for arm lymphedema: the LYMPH-Q upper extremity module." Annals of Surgical Oncology 28.9 (2021): 5166-5182.
(6) Pappalardo, Marco, et al. "Breast Cancer-Related Lymphedema: Recent Updates on Diagnosis, Severity and Available Treatments." Journal of Personalized Medicine 11.5 (2021): 402.
(7) Rebegea, L., et al. "The incidence and risk factors for occurrence of arm lymphedema after treatment of breast cancer." Chirurgia (Bucur) 110.1 (2015): 33-7.
(8) DiSipio, Tracey, et al. "Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis." The lancet oncology 14.6 (2013): 500-515.
(9) Campbell, Kristin L., et al. "A prospective model of care for breast cancer rehabilitation: function." Cancer 118.S8 (2012): 2300-2311.
(10) Paskett, Electra D., et al. "Cancer-related lymphedema risk factors, diagnosis, treatment, and impact: a review." Journal of Clinical Oncology 30.30 (2012): 3726-3733.
(11) Asdourian, Maria S., et al. "Association between precautionary behaviors and breast cancer–related lymphedema in patients undergoing bilateral surgery." Journal of Clinical Oncology 35.35 (2017): 3934.
(12) Ezzo, Jeanette, et al. "Manual lymphatic drainage for lymphedema following breast cancer treatment." Cochrane Database of Systematic Reviews 5 (2015).
(13) Leysen, Laurence, et al. "Risk factors of pain in breast cancer survivors: a systematic review and meta-analysis." Supportive Care in Cancer 25.12 (2017): 3607-3643.
(14) Wernicke, A. Gabriella, et al. "Complication rates in patients with negative axillary nodes 10-years after local breast radiotherapy following either sentinel lymph node dissection or axillary clearance." American journal of clinical oncology 36.1 (2013): 12.
(15) McEvoy, Maureen P., et al. "Prevention of breast cancer-related lymphedema." Clinical breast cancer (2021).
(16) Mestre, S., et al. "Interest of an auto-adjustable nighttime compression sleeve (MOBIDERM® Autofit) in maintenance phase of upper limb lymphedema: the MARILYN pilot RCT." Supportive Care in Cancer 25.8 (2017): 2455-2462.
(17) Chowdhry, Muhammed, Warren Matthew Rozen, and Matthew Griffiths. "Lymphatic mapping and preoperative imaging in the management of post-mastectomy lymphoedema." Gland surgery 5.2 (2016): 187.