Screening for Lymphedema After Breast Cancer

Cheryl Brunelle, PT, MS, CCS, CLT, is the Associate Director of the Lymphedema Research Program and a Physical Therapy Clinical Specialist at Massachusetts General Hospital in Boston. Cheryl’s clinical focus is on the evaluation and treatment of patients during and after breast cancer treatment, for issues such as surveillance and early intervention for lymphedema, shoulder morbidity and deconditioning resulting from breast cancer and its treatment. Cheryl’s main research interests include risk factors, prospective surveillance, symptoms and early intervention for breast cancer-related lymphedema.

Many people don’t realize that lymphedema is a side effect of breast cancer treatment. We asked Cheryl to explain more about risk factors and the importance of screening.

What should patients know about lymphedema before, during and after breast cancer treatment?
Lymphedema is a side effect of breast cancer treatment. It is not caused by anything a patient has or has not done. Risk factors include lymph node surgery (axillary lymph node dissection or sentinel lymph node biopsy), regional lymph node radiation, body mass >25 kg/m2 at the time of breast cancer diagnosis and early volume increases in the arm.^1–3

Lymphedema screening should begin with a pre-operative arm measurement.⁴ Patient education becomes imperative after surgery, when individual lymphedema risk factors are known. The oncology team should discuss individual risk factors and symptoms. Patients who report a change in arm size, swelling or heaviness are more likely to develop lymphedema.^5,6 Small pockets of swelling in the hand or at the elbow can be early signs of lymphedema. If patients experience new symptoms or signs of swelling, they should discuss this with their oncology team and pursue treatment.

Lymphedema is progressive and best treated in its early stages. Although lymphedema risk is lifelong, it is most likely to occur within the first four years after breast surgery.⁷

What does lymphedema screening mean?
Lymphedema screening should be standard of care for all patients undergoing breast cancer surgery. Pre-operative arm measurement is necessary for an accurate lymphedema diagnosis.⁴ After surgery, patients should be screened for symptoms and arm changes at regular intervals for at least four to five years. At Massachusetts General Hospital (MGH), we take an arm volume measurement, inquire about symptoms and perform clinical examination, as needed, during oncology follow-up visits.⁸ If we see changes that may indicate developing lymphedema, we refer the patient to a certified lymphedema therapist (CLT). In between screening visits, patients should be looking for any new signs or symptoms of swelling and reporting these to their oncology team immediately.

Generally speaking, how important is screening and early intervention of lymphedema?
Early symptoms and signs of lymphedema are subtle. Screening allows for measurements that may identify early swelling before a patient perceives it. Evidence is emerging that supports treatment for early swelling to prevent lymphedema progression. However, larger, randomized controlled trials should be completed before this is standard of care. Early intervention should be considered for patients at high risk of lymphedema progression. All patients with early arm volume increases should be monitored closely. In summary, lymphedema screening after breast cancer treatment is essential and without it, accurate lymphedema diagnosis and early intervention is impossible.

References

1. Naoum GE, Roberts S, Brunelle CL, et al. Quantifying the impact of axillary surgery and nodal irradiation on breast cancer-related lymphedema and local tumor control: Long-term results from a prospective screening trial. J Clin Oncol. 2020;38(29):3430-3438. doi:10.1200/JCO.20.00459
2. Jammallo LS, Miller CL, Singer M, et al. Impact of body mass index and weight fluctuation on lymphedema risk in patients treated for breast cancer. Breast Cancer Res Treat. 2013;142(1):59-67. doi:10.1007/s10549-013-2715-7
3. Bucci, LK; Brunelle, CL; Bernstein, MC; Shui, AM; Gillespie, TC; Roberts, SA; Naoum, GE; Taghian A. Subclinical Lymphedema After Treatment for Breast Cancer: Risk of Progression and Considerations for Early Intervention. Ann Surg Oncol. 2021;In Press.
4. Sun F, Skolny MN, Swaroop MN, et al. The need for preoperative baseline arm measurement to accurately quantify breast cancer-related lymphedema. Breast Cancer Res Treat. 2016;157(2):229-240. doi:10.1007/s10549-016-3821-0
5. Armer JM, Radina ME, Porock D, Culbertson SD. Predicting breast cancer-related lymphedema using self-reported symptoms. Nurs Res. 2003;52(6):370-379. doi:10.1097/00006199-200311000-00004
6. Brunelle CL, Roberts SA, Horick NK, et al. Integrating Symptoms Into the Diagnostic Criteria for Breast Cancer–Related Lymphedema: Applying Results From a Prospective Surveillance Program. Phys Ther. 2020;100(12):2186-2197. doi:10.1093/ptj/pzaa162
7. Petrek JA, Senie RT, Peters M, Peterrosen P. Lymphedema in a cohort of breast carcinoma survivors 20 years after diagnosis. Cancer. 2001;92(6):1368-1377. doi:10.1002/1097-0142(20010915)92:6<1368::AID-CNCR1459>3.0.CO;2-9
8. Brunelle C, Skolny M, Ferguson C, Swaroop M, O’Toole J, Taghian AG. Establishing and sustaining a prospective screening program for breast cancer-related lymphedema at the Massachusetts General Hospital: Lessons Learned. J Pers Med. 2015;5(2):153-164.

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