Lymphedema is a side effect of cancer treatment that often requires lifelong management for many patients. But prospective surveillance programs that identify evidence of lymphedema early, before it starts to affect someone's day-to-day life, and refer patients to early treatment for it may offer clinicians the opportunity to slow or prevent the condition. Now, a new review article concludes that evidence to date shows such programs do significantly reduce the number of patients with breast cancer who go on to develop chronic breast cancer-related arm lymphedema (J Clin Oncol 2022; doi: 10.1200/JCO.21.01681).
"The call to integrate prospective surveillance for lymphedema into cancer care pathways is building momentum to enable early intervention and prevent the progression of the condition," the review's authors noted in the paper. "The findings suggest that participation in prospective surveillance with early management reduces the risk of chronic breast cancer-related arm lymphedema."
In an interview with Oncology Times, the paper's lead author Bolette Rafn, PT, PhD, a physical therapist researcher in the Cancer Survivorship and Treatment Late Effects Research Unit of the Department of Oncology at Copenhagen University Hospital, shared her thoughts on the research.
1 Why did you and your colleagues conduct and write this review now about prospective surveillance for lymphedema in patients with breast cancer?
"There has been an increasing number of studies that have utilized a prospective surveillance approach for lymphedema. We have contributed to the evidence ourselves and, therefore, understood that there was a need to condense the evidence to evaluate the effectiveness of this approach in preventing chronic lymphedema.
"There is interest in evaluating if a proactive approach to identification of lymphedema can facilitate earlier treatment and hinder the progression, such that the lymphedema remains/reduces to a subclinical or mild stage that only has minimal impact on patients' everyday lives. The alternative to a surveillance program is the traditional care model where patients either self-identify symptoms of lymphedema and seek care, or it is identified by a health care professional who then initiates referral to lymphedema treatment.
"Depending on how prompt the patient and/or the professional reacts to the onset of lymphedema symptoms, then this approach may be associated with a delayed start of treatment that then becomes less effective because the changes are already irreversible."
2 What were the key findings from the review?
"This is the first meta-analysis in this field and demonstrates that there is a significantly reduced risk of developing chronic arm lymphedema among patients with breast cancer. However, this result is based on two small, randomized trials and more robust trials are needed to confirm this finding. In addition, we demonstrate that only a minority (6%) of patients are at high risk of developing lymphedema after participating in a prospective surveillance program with early management. This is markedly lower than the expected incidence of 20 percent in this group.
"I was surprised that only 6 percent of high-risk breast cancer patients develop chronic arm lymphedema. This is an important finding that really speaks to the benefit of this approach. I was also surprised that we only identified one study that included patients with other cancers than breast cancer. This calls for more work to detect and treat lymphedema more broadly among patients with cancer."
3 What are the implications for practicing oncologists and cancer care providers, and what's the next step of this work?
"Prospective surveillance and early management with compression garments seems to be effective in reducing the risk of chronic lymphedema.
"Our manuscript provides specific recommendations based on the literature on how clinicians could structure a surveillance program, specifically the timing and frequency of assessment, duration of surveillance program, and what measurement tool to use and patients to include in such programs.
"We are currently doing a multi-center trial in Denmark called PROTECT that will test the effectiveness of a self-managed prospective surveillance program versus usual care on the development of chronic lymphedema. In this trial, the patients are measuring their own arms at home. If demonstrated effective, then this approach to surveillance will provide an alternative to routine measurements by health care professionals and overcome the associated barriers of access and cost."