Management of breast cancer lymphedema: An evidence-based and practical approach
Breast cancer treatment is the leading cause of secondary lymphedema, an accumulation of high or low protein fluid in consequence of lymphatic dysfunction. The underlying pathophysiology includes lymph drainage failure and hemodynamic imbalance. Both, arterial and venous components can be affected in arms with lymphedema. In her engaging presentation within the MOH Talk “Navigating the challenges of lymphedema in cancer care: expert insights” on October 28, 2023, Dr Linda T. Miller discussed new evidence on breast cancer lymphedema and clinical applications for its management.
This online 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 first speaker, Dr Linda T. Miller, founder and clinical director of the Breast Cancer Physical Therapy Center in Philadelphia, USA, shared her expertise in the management of breast cancer lymphedema.
As morphologic tissue changes occur as a result of chronic edema and inflammation, reducing fluid volume alone is not enough to achieve a sustained tissue change. Therefore, a comprehensive breast cancer lymphedema programme intents to soften fibrous tissue by applying compression, to decrease excess accumulated tissue fluid by changing tissue pressure, and to minimise excess filtration to maintain limb size and shape via supportive compression treatment and tissue pressure changes.
Dr Miller provided an overview of evidence that impacts treatment choices and applications. As the bulk of mobile tissue fluid is located in the deeper subcutaneous tissue, some treatment techniques may require higher pressure in order to actually impact not only volume reduction but also tissue texture changes. Experience has taught her that patient compliance is going to increase with the best technique that makes a difference. In this context, compression using multi-layer bandages or garments represents one of the cornerstones of lymphedema management.
Applied multi-layer bandages change tissue pressure and increase tissue fluid resorption, especially in combination with active muscle contraction. The high effectiveness in decreasing limb volume using multi-layer bandaging is supported by systematic reviews. While multi-layer bandages are often used in the treatment phase of lymphedema, studies revealed that patients who continue to wear a bandage for at least 3 nights a week achieve better long-term results.
Likewise, compression garments are considered a very effective treatment in multiple systematic reviews. They can be used to treat lymphedema or to maintain outcomes once the limb volume has been successfully reduced. A recent randomised clinical trial demonstrated significant improvement in arm lymphedema volume with additional nighttime compression, either with bandages or nighttime compression garments. Since exercise is also beneficial to enhance lymphatic return by changing tissue pressure, exercise while wearing compression garments is a critical part of the management programme.
Further, intermittent fluid compression (IPC) achieves volume reduction by decreasing overall tissue fluid load. It helps to control excess filtration. Literature suggests that IPC increases lymph flow velocity at higher pressures, whereby faster cycle times improve tolerance to higher pressures. Dr Miller advised to always consider the thickness of the tissue to determine the appropriate IPC pressure. IPC can be used as an effective adjunct to decrease limb volume and the speed of reduction.
Take Home Messages:
- Edemas consist of a lymphatic and a venous component
- The most effective treatment programme should include
- softening fibrous tissue
- decreasing excess accumulated tissue fluid
- minimizing excess filtration to maintain limb size and shape
- Appropriately applied compression using various modalities and textiles reduces limb volumes, impacts fibrosis and filtration and, in consequence, tissue texture and limb size.
- Best short-term and long-term outcomes will be achieved by addressing skin fibrosis and managing filtration.