For some women with breast cancer, their experience goes beyond the disease and its treatment. They may develop breast cancer-related lymphedema (BCRL), a serious and common adverse effect, after treatment with surgery or radiation. In fact, 20% to 30% of women with breast cancer develop lymphedema, most often as a result of surgery, but it can also develop from radiation and even chemotherapy. Lymphedema causes heightened stress for the patient as it triggers pain, swelling, and leads to diminished use of the affected arm. As the condition progresses, it can wear a person down physically and psychologically, and may also increase the risk of infection.1
The best way to prevent BRCL from worsening is to detect the condition in its subclinical state, before it progresses and requires treatment with complex decongestive physiotherapy (CPD). Even though CPD can be effective, it is not always easy to access. Qualified therapists are often not readily available outside of major cities and medical centers.
The traditional, low-tech method for evaluating a patient’s risk of developing lymphedema is simply to measure volume (circumference) of the arm with a tape measure. Although readily available, portable, and economical, tape measure may not provide the most accurate assessment of lymphedema progression. Fortunately, the breast cancer clinical armamentarium now includes bioimpedance spectroscopy (BIS), a painless and noninvasive modality for subclinical detection of fluid. To assess the potential risk for clinical lymphedema with BIS, a technician runs an electronic signal through the body, similar to the way electronic monitors determine body mass index.
The availability of BIS has made earlier detection of BCRL possible, thus enabling early stage treatment with interventions that are less intensive, less invasive, and less expensive than CPD. Caught early, subclinical lymphedema is responsive to the use of compression sleeves and gauntlets to reduce lymphatic fluid in the affected arm.
Sensitivity Is Key
Sheila H. Ridner, PhD, RN, FAAN, of Vanderbilt University School of Nursing in Nashville, Tennessee, and her multi-institute team reported on a randomized trial to evaluate the 2 methods as part of PREVENT, an international ongoing controlled trial that began in 2014. The primary goal is to compare BIS with tape measure and evaluate whether its use could detect rate of extracellular fluid accumulation, allowing for early intervention that may reduce the need for CDP. The team found that monitoring with BIS led to a 10% reduction in rates of progression. Dr Ridner explained that BIS is more sensitive to changes in lymphatic fluid compared with tape measure. “The bioimpedance device measures lymphatic fluid, and the tape measures much more than that. It takes more lymphatic fluid to make your whole arm volume change than it does to make volume changes the device will detect,” she explained.
The Vanderbilt-based trial included 508 women with newly diagnosed breast cancer who were followed for at least 1 year after undergoing surgery. The participants were average age 59 years; average BMI, 27.9; and 77% were white. Inclusion criteria included undergoing an axillary lymph node dissection or sentinel lymph node biopsy with removal of more than 6 nodes, mastectomy, taxane-based chemotherapy, or axillary radiation.
Although 8% of patients had had minor arm surgery previously, cardiovascular disease was the most frequently reported comorbidity (44% of patients). Diagnoses at baseline were stage I breast cancer (56.7%) and stage II/III breast cancer (39%). There were no significant differences in demographics, clinical, or baseline treatment characteristics between the tape measure and BIS groups.
The researchers provided compression sleeves (class 2; 23-32 mmHg) and gauntlets to women found to have increasing fluid volume. For this protocol, the patients wore the devices 12 hours a day for 4 weeks to prevent progression to lymphedema. The women who went on to develop lymphedema reached their trial end point, and staff referred them for complex decongestive physiotherapy.