What is Lymphedema?
Lymphedema is a known complication of breast cancer treatment, and one that can not only last after treatment, but through a patient’s lifetime. The incidence of lymphedema after treatment can range up to 21% (Koelmeyer et al). The condition is described in literature as the improper drainage of lymphatic vessels and accumulation of protein-rich fluid within the various compartments of the body, most commonly the arms (Sayegh et al). There are certain risks to developing chronic lymphedema, including the type of surgical treatment, cellulitis, radiation, obesity, and weight fluctuations (Sayegh et al). Lymphedema can be a particularly painful and debilitating disease that can affect your quality of life and can even result in various skin infections.

Early Detection is Preventative
Early detection and intervention of lymphedema can prevent progression of symptoms that can become irreversible. There are various stages of lymphedema ranging from subclinical phases with edema reversed through treatment and progressive edema that is chronic, complicated by infection. Lymphedema Stage 0 and 1 are described as pitting edema that can be reduced by treatment or limb elevation. Stages 2 and 3 are irreversible. At these stages edema is non-pitting and does not reduce with treatment methods. Stage 3 lymphedema is associated with infection and progression of the disease. Lymphedema associated with breast cancer treatment was defined by researchers as a difference in greater than 10% of arm volume changes (Ridner). In the past, your doctor would obtain a baseline measurement of the upper extremities using a tape measure before starting treatment for your breast cancer. This form of screening and prevention was subjective and did not detect subclinical lymphedema.

Subclinical lymphedema is often missed, up to 50% of the time, leading researchers to find a more effective way of diagnosis (McLaughlin et al). Recent studies, including the PREVENT trial looked at the difference of detecting lymphedema at the subclinical stage with standard tape measuring compared to bioimpedance spectroscopy (BIS). In this study, 1200 patients were followed over 3 years with either tape measuring or BIS to detect subclinical lymphedema. BIS directly measures tissue resistance to an electrical current that measures fluid accumulation in the arm, which decreases the movement of the electric current (Kilgore et al). The measurements from BIS are more accurate and quicker, compared to tape measure (McLaughlin et al). Through BIS, subclinical lymphedema is more accurately diagnosed, allowing for decreased progression to chronic lymphedema with intervention (Ridner). With a more accurate diagnosis, BIS also places fewer patients into treatment for their subclinical lymphedema compared to tape measure, (Ridner). The researchers of the PREVENT trial concluded that BIS screening should be denoted the standard approach for prospective breast cancer-related lymphedema surveillance (Ridner). Testing with BIS requires a conversation with your cancer care team.

Treatment
Various treatments exist for reversible lymphedema. Many patients seek out a lymphedema therapist or clinic to help with the various symptoms of the disease. In the initial stages of lymphedema, therapists will focus on the reduction of fluid through different modes including compression sleeves, exercise, education and skin care (Mclaughlin et al). To maintain and limit the progression of lymphedema, patients often wear compression sleeves and garments, self-manual lymphatic drainage techniques, exercise and skin care (Mclaughlin et al). Weightlifting through slow, progressive movements at a lymphedema facility were noted to decrease overall lymphedema by about 35% (Mclaughlin).

Chronic lymphedema requires more aggressive treatment modes such as decongestive therapy, manual lymphatic drainage, self-bandaging, and surgery. Surgical options exist for chronic lymphedema but remain in the preliminary stages of development. One approach, lymphovenous anastomosis (LVA), creates a channel between the lymph and venous systems, allowing drainage of lymphatic fluid that would otherwise be stuck in various compartments of the body. LVA has been shown to be more beneficial in earlier stages of lymphedema before lymphatic channels become firm and unmalleable (Scaglioni et al). For later stages of lymphedema, surgeons are using the vascularized lymph node transfer technique. This technique transfers lymph nodes from other sites within the body, like the groin, neck, mouth, and stomach, to improve drainage of the lymphatics in the edematous arm (Scaglioni et al). In later stages of lymphedema, a debulking procedure may be added to the lymph node transfer to improve drainage in up to 60% of patients (Scaglioni et al).

It is important to talk to your breast surgeon about lymphedema to learn the signs and symptoms and screening programs for subclinical lymphedema. If, during your cancer treatment you notice signs and of lymphedema, inform your cancer care team to advise you on surgical and nonsurgical treatment options for lymphedema, including how to find a local certified lymphedema therapist. Through early diagnosis, prevention and treatment, the debilitating effects of lymphedema can be minimized and lead you to a healthy life uninhibited by the disease.

References

• Kilgore, L. J., Korentager, S. S., Hangge, A. N., Amin, A. L., Balanoff, C. R., Larson, K. E., … & Wagner, J. L. (2018). Reducing breast cancer-related lymphedema (BCRL) through prospective surveillance monitoring using bioimpedance spectroscopy (BIS) and patient directed self-interventions. Annals of surgical oncology, 25(10), 2948-2952.
• Koelmeyer, L. A., Borotkanics, R. J., Alcorso, J., Prah, P., Winch, C. J., Nakhel, K., … & Boyages, J. (2019). Early surveillance is associated with less incidence and severity of breast cancer–related lymphedema compared with a traditional referral model of care. Cancer, 125(6), 854-862.
• McLaughlin, S. A., Brunelle, C. L., & Taghian, A. (2020). Breast cancer–related lymphedema: risk factors, screening, management, and the impact of locoregional treatment. Journal of Clinical Oncology, 38(20), 2341.
• McLaughlin, S. A., Staley, A. C., Vicini, F., Thiruchelvam, P., Hutchison, N. A., Mendez, J., … & Feldman, S. M. (2017). Considerations for clinicians in the diagnosis, prevention, and treatment of breast cancer-related lymphedema: recommendations from a multidisciplinary expert ASBrS panel. Annals of surgical oncology, 24(10), 2818-2826.
• Ridner, S. H., Dietrich, M. S., Boyages, J., Koelmeyer, L., Elder, E., Hughes, T. M., … & Shah, C. (2022). A Comparison of Bioimpedance Spectroscopy or Tape Measure Triggered Compression Intervention in Chronic Breast Cancer Lymphedema Prevention. Lymphatic Research and Biology.
• Sayegh, H. E., Asdourian, M. S., Swaroop, M. N., Brunelle, C. L., Skolny, M. N., Salama, L., & Taghian, A. G. (2017). Diagnostic methods, risk factors, prevention, and management of breast cancer-related lymphedema: past, present, and future directions. Current Breast Cancer Reports, 9(2), 111-121.
• Scaglioni, M. F., Arvanitakis, M., Chen, Y. C., Giovanoli, P., Chia‐Shen Yang, J., & Chang, E. I. (2018). Comprehensive review of vascularized lymph node transfers for lymphedema: outcomes and complications. Microsurgery, 38(2), 222-229.
• Shah, C., Arthur, D. W., Wazer, D., Khan, A., Ridner, S., & Vicini, F. (2016). The impact of early detection and intervention of breast cancer‐related lymphedema: a systematic review. Cancer medicine, 5(6), 1154-1162.