1. Carlson, Robert H.

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MIAMI BEACH-Early intervention in lymphedema can result in substantial savings for breast cancer patients after surgery, both financially and in quality of life. That was the word here at the Miami Breast Cancer Conference from Sarah McLaughlin, MD, Associate Professor of Surgery at Mayo Clinic, Jacksonville.


"Identification of lymphedema after breast cancer surgery is important because early interventions can reverse swelling," she said.


"What we know about lymphedema is that it is a long-term, chronic side effect of surgery; it is common but under-reported, it is a fiscal burden, and it has a negative impact on patient quality of life.


"What we don't know, though, is much more," she continued. "We really don't know what the mechanism of action is or the pathophysiology, or even have an accurate measure of the incidence of breast cancer-related lymphedema.


"Recent randomized controlled trials all use different follow-up and different definitions of lymphedema, so there is a wide variation in the reported incidence," she said, noting, though, that a recent meta-analysis suggests that 21 percent of women will develop lymphedema after treatment for breast cancer.


Detecting Subclinical Lymphedema

Today there is a strong emphasis on detection of subclinical lymphedema, McLaughlin said. "It is only recently understood that mild, early swelling may be reversible, but when early swelling is left untreated there is a 50 percent risk that it will progress to more severe forms."


There are several measuring techniques, she said, and they are all reasonable as long as the same method is used throughout treatment and follow-up.


But measurements do not take the place of an office exam, she stressed. "In an ideal world we would be able to identify which of our patients are at risk for developing lymphedema."


In her own practice, she said, she stratifies patients with baseline, six-month, and one-year measurements, but this has only shown that it is not possible to predict who will develop the condition.


"Because we can't identify who is at risk for progressing to lymphedema, it is our responsibility as clinicians to educate all of our patients. And we need to educate them because they really worry about developing lymphedema, and they start worrying early."


Although women who have had sentinel lymph node dissection have a far lower risk than women who had axillary node dissection, they all seem to want to follow precautionary behaviors, McLaughlin said.


There are dozens of reported risk-reducing behaviors patients may want to follow, from not carrying children to avoiding racquet sports to not having their IV draws or blood pressure taken. "But studies show that the only real behavior to avoid is sauna use," she said.


On the other hand there are good data on resistance exercise, and she said she tells patients to go back to their regular exercises after therapy. "Whatever they were doing beforehand, they can go back to after surgery."


Cornerstone of Treatment

The cornerstone of treatment, McLaughlin said, remains CDT-complex decongestive therapy-which includes both reductive and maintenance phases.


CDT results in limb reductions of 25 to 75 percent, she said. But it is cumbersome and requires constant care, which is both expensive and time consuming on a daily basis.


"What is getting a lot of buzz now is whether surgery will correct the underlying pathophysiology of lymphedema," McLaughlin said. Surgery is gaining renewed interest with the adoption of microvascular surgical techniques, and lymphovenous anastomosis and lymph node transfer are showing promising results.


But, McLaughlin concluded, educating patients about their individual risk is key to developing tailored risk-reducing strategies.