1. Samson, Kurt

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ORLANDO, FL-The incidence of breast cancer-related lymphedema could be significantly reduced or even eliminated using a special device to monitor lymphatic fluid and counseling patients to manually massage swollen areas as soon as they are detected, a researcher reported at the the American Society of Breast Surgeons Annual Meeting (Abstract 404018).

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Regular screening of lymphatic function using bioimpedance spectroscopy (BIS) combined with use of a compressive sleeve and a simple massage of the affected area is highly effective in reversing subtle lymphatic changes before they become permanent, said Lyndsey Kilgore, MD, a resident in the Department of Surgery at the University of Kansas Cancer Center in Kansas City.


BIS is a relatively new technique that measures tissue resistance to an electric current in order to determine extracellular body fluid volume. It is highly effective in evaluating early-stage lymphedema due to impeded lymphatic draining in the arm.


Typically, breast cancer-related lymphedema (BCRL) is not diagnosed before it reaches the stage that it cannot be reversed. BIS uses electrical current to evaluate body fluid volume and is highly effective in detecting early extracellular lymphatic fluid retention, Kilgore told a press briefing.


In the prospective study, she and her colleagues tested a home intervention involving self-massage of areas as soon as swelling appeared or was detected by BIS. Out of 146 women, BIS revealed 49 who developed subclinical lymphedema by elevated BIS scores and were directed to use self-massage of the affected area at home. Lymphedema rates for similarly treated patients range from 20 percent to 40 percent in the study; lymphedema was resolved in 82 percent after home therapy.


"We hope this study will help usher in a new protocol involving precise, highly controlled monitoring and immediate intervention to reverse early lymphatic changes prior to damage that leads to chronic, irreversible lymphedema," Kilgore stated.


Current National Comprehensive Cancer Network guidelines support baseline measurements with prospective assessment of breast cancer patients to allow for early diagnosis and treatment of BCRL, she noted, and BIS has a CPT code and more than 60 percent of private insurers and Medicare cover exams.


"This study shows that early intervention is crucial in addressing lymphatic changes before they reach clinically apparent levels that are likely to become permanent," she told a press briefing. "A woman may not notice the swelling yet, but the whole point is we're detecting it sooner so we can intervene sooner."


Methods, Results

The study involved patients with unilateral disease and undergoing treatments at high risk for BCRL at a single institution evaluated from November 2014 to December 2017. The researchers defined high-risk treatments as axillary lymph node dissection with regional nodal irradiation and/or taxane chemotherapy.


All patients received baseline BIS measurements prior to surgery, followed by serial post-operative measurements following a routine surveillance model, with all individuals having at least 1-year post-operative follow-up.


Patients with subclinical lymphedema diagnosed by a BIS result of two standard deviations above baseline from preoperative assessment were started on at-home conservative interventions of a compression sleeve garment and patient-directed self-massage for a period of 4-6 weeks. Post-intervention measurements were taken to assess for improvement.


Although 82 percent of the lymphedema cases were resolved, 6 percent continued to exhibit elevated measurements and were referred to outpatient complete decongestive therapy. These women had significant nodal burden on final surgical pathology, with eight of the nine (89%) having N2 or N3 disease, and of these nine patients, six have since died secondary to breast cancer, Kilgore stated.


A majority of patients with persistent lymphedema were obese and had significantly more positive lymph nodes on final surgical pathologies.


"Identifying the appropriate patients at the appropriate time is imperative. After the disease has progressed, more complex, costly interventions are necessary with less potential for resolving to the baseline measurements," she noted.



Sarah Blair, MD, a breast surgeon at the University of California San Diego, commented on the findings.


"Lymphedema remains a significant clinical problem, although rates are decreasing as fewer full axillary node dissections are performed," she said. "These results are encouraging and should pave the way for larger studies with longer follow-up to examine this early detection and intervention paradigm."


The findings contribute to the growing body of evidence supporting prospective monitoring, early detection, and dedicated interventions help reduce the rates of persistent BCRL requiring CDT in a high-risk group of breast cancer patients, said Sarah McLaughlin, MD, Associate Professor of Surgery at the Mayo Clinic, in Jacksonville, Fla.


There is no doubt in her mind that more women should be screened for lymphedema earlier. "Screening for lymphedema should be part of the routine assessment for patients and consist of both preoperative and routine post-operative assessments."


Clinicians should also advise patients to be wary of lymphedema symptoms and be informed of this treatment, as well as prospective screening and risk-stratified interventions. "However, in practice, I suspect this discussion is variable and the information provided is inconsistent across medical and surgical disciplines and across practices/institutions. This clearly presents an opportunity for improvement in patient care," McLaughlin told Oncology Times.


"Oncologists need to acknowledge lymphedema risks, and openly and proactively discuss prevention and treatment strategies with patients, and to participate in active and early referral to knowledgeable lymphedema specialists and therapists."


Kurt Samson is a contributing writer.