Breast cancer related lymphedema (BCRL), a common and painful, yet underreported side effect of surgery and radiation, is getting fresh attention, courtesy of new guidelines from internationally recognized breast surgeons. Their recommendations, published in the Annals of Surgical Oncology, tackle BCRL, which causes permanent swelling of the arm.
Sheldon M. Feldman, M.D., Chief of the Division of Breast Surgery and Surgical Oncology, and Director of Breast Cancer Services at Montefiore Einstein Center for Cancer Care, the clinical arm of the NCI-designated Albert Einstein Cancer Center, is a senior author of the guidelines and has served as a principal investigator for research on techniques to prevent and treat BCRL.
“Breast cancer related lymphedema is a debilitating side effect of treatment that is caused by the accumulation of lymph fluid in the arm,” says Dr. Feldman, who is also the Immediate Past President of the American Society of Breast Surgeons. “The swelling, which can impair arm mobility, frequently happens just when people are starting to regain their energy and resume their lives following breast cancer treatment.”
According to the National Cancer Institute, by 2024, there will be four million breast cancer survivors in the United States and nearly two million diagnosed worldwide. An estimated 25 percent of women who have undergone breast cancer treatment will develop BCRL three to five years following surgery, representing a significant burden to global public health.
Establishing Baseline Measurements & Simple Tools for Diagnosis BCRL is largely misunderstood in the medical community due to inconsistent measurement and disagreement in how to define it. The consensus recommendations were approved by the American Society of Breast Surgeons under Dr. Feldman’s leadership, giving clinicians clear BCRL guidelines for the first time. The guidelines include establishing surveillance plans with baseline measurements at diagnosis to prevent BCRL progression by ensuring proper follow up.
Dr. Feldman emphasizes that “the ideal screening tools are objective, cost efficient and easy to use, so we suggest at minimum, a simple tape measurer be used in early diagnosis to establish a baseline measurement and to be used sequentially, as long as all sides of a patient’s arms are measured equally.”
Bioimpedence spectroscopy, which sends currents through the body to measure fluids, and perometry, a technique using an infrared scanner to calculate the volume of an affected arm, are also beneficial in diagnosing pre-clinical lymphedema at an earlier stage. Additionally, the panel strongly recommends that cancer survivorship care plans include exercise and education about BCRL. Gene expression related to acute inflammation, immune response and wound healing should be studied further.Techniques for BCRL Treatment
On the treatment side, the panel agreed that more patients should undergo “axillary reverse mapping”. This minimally invasive technique preserves healthy lymph nodes (glands that carry fluid, nutrients and waste material between the body tissue and blood stream) in the armpit, as only breast cancer specific lymph nodes are impacted by surgery. Montefiore offers this procedure and has established a prospective database to monitor its success.
Lymphatic Microsurgical Preventative Healing Approach (LYMPHA), which reconnects lymph vessels to the circulatory system during the same operation that lymph nodes are removed, utilizing a combination of image guidance and microsurgery techniques, was also in the recommendations as a promising technique to effectively reduce clinical lymphedema. Dr. Feldman was the first in the United States to study and employ the procedure.
Vascularized lymph node transfer, involving harvesting healthy lymph nodes from unaffected areas and transplanting them into the arm, was also cited as a promising procedure to re-establish draining of excess lymphatic fluid.
“As more people have successful breast cancer care, there needs to be a global focus on the quality of their survivorship and opportunities to avoid side effects that require life-long treatments like compression therapy, and possibly recurrent hospitalizations for infections, both which are commonly associated with BCRL,” says Dr. Feldman. “We hope that these new guidelines raise awareness of lymphedema among clinicians and patients – and are a significant step forward towards reducing the prevalence of this complicated treatment side effect.”
Other authors of these guidelines include Sarah M. McLaughlin, M.D., Department of Surgery, Mayo Clinic (lead author); Alicia C. Staley, MBA, MS, BC; patient advocate at Akari Health; and Frank Vicini, M.D., FACR, FABC, Clinical Professor, Radiation Oncology at UCLA School of Medicine. A comprehensive list of authors can be found by visiting the Annals of Surgical Oncology website.