Screening for lymphoedema

21 May 2008

Routine screening of breast cancer patients for symptoms of sub-clinical lymphoedema leads to better clinical outcomes

Breast cancer patients should undergo routine surveillance for sub-clinical lymphoedema, concludes a study published in Cancer. The study, which was conducted in the US, showed that compression garments introduced early in the course of lymphoedema can be used to effectively treat the sub clinical condition. Lymphoedema is an abnormal buildup of fluid, most often in the arms or legs; that occurs when lymph vessels or nodes have been damaged or removed. This occurs after breast cancer surgery or lymph node biopsy where removal of lymph nodes and vessels from under the arm changes the way lymph fluid flows. Breast cancer related lymphoedema is a chronic condition - estimated to affect 33 to 47 % of women following axillary lymph node dissection and 4 to 17 % after sentinel node biopsy. It is a progressive condition that diminishes a woman’s quality of life and contributes to impairment in the range of movements, loss of strength and limits every day activities, such as lifting and reaching. It has previously been reported that changes in interstitial tissue congestion occur before limb swelling becomes visible. Furthermore, it was suggested that earlier detection might result in fewer long term complications.

Stout Gergich and colleagues, from the National Naval Medical Center ( Bethesda, Maryland, USA) set about investigating the efficacy of surveillance in patients with early stage breast cancer. The investigators hypothesized that on diagnosis of sub-clinical lymphoedema, a light grade compression garment worn daily would be sufficient to alleviate the problem.

Between 2001 and 2006 all women with newly diagnosed unilateral early stage breast cancer (stage I-III) were screened by a physical therapist prior to surgery to determine eligibility. Patients were excluded from the study if they had a previous history of breast cancer, bilateral breast cancer or if they had suffered severe trauma or surgery to their upper limb.

For the 196 women meeting the study criteria, limb volume was measured pre operatively and at three-month intervals following surgery with a Perometer; a sensitive and standardized device which uses infrared to detect and quantify limb volume changes. If the upper limb volume increased by greater than 3% compared with the preoperative volume, then a diagnosis of lymphoedema was made. Altogether 43 women were found to have lymphoedema and offered early intervention with a ready made 20 to 30 mmHg compression sleeve that was fitted by a physical therapist and worn for four weeks. Upon reduction of lymphoedema women were advised to wear the garment during periods of strenuous activity, if they experienced symptoms of heaviness or if they saw visible swelling.

Results show that the average time to onset of lymphoedema symptoms was 6.9 months after the operation. The mean affected limb volume increase was 83 mL (±119 mL; 6.5% ± 9.9%) at lymphoedema onset (P = .005) compared with the baseline measurement prior to the operation. After intervention with the compression sleeve, a statistically significant mean 48 mL (±103 mL; 4.1% ± 8.8%) volume decrease was achieved (P < .0001). The mean duration of the intervention was 4.4 weeks (±2.9 weeks), with volume reduction maintained at the follow up of 4.8 months.

While the standard of care for treating and managing clinically apparent lymphoedema is well established, write the authors, there is no standard for the treatment of early-stage, subclinical lymphoedema. “A new classification system is needed to recognize subclinical lymphoedema and encourage early intervention to diminish the negative functional, cosmetic, and psychosocial consequences of lymphoedema. On the basis of our findings, we believe that a more sensitive threshold