Pat W. Whitworth1, Chirag Shah2, Frank Vicini3 and Andrea Cooper1. Front Oncol. 2018 Jun 12;8:197

Main findings

• 93 subjects.
• Preoperatively, patients had an L-Dex measurement as well as BCRL education. Subsequently, post-operatively, patients underwent L-Dex measurements at 1.5 weeks and then at 3, 6, 9, and 12 months post-operatively followed by bi-annual measurements.
• At any time point, patients were considered to have an elevated L-Dex score if the score increased by at least 10 points from baseline. Patients having an increase of more than 10 units were subsequently instructed to utilize an over the counter (OTC) compression sleeve for 4 weeks followed by re-assessment, consistent with current guidelines and prospective data. Patients with persistent elevation in spite of compression garment utilization or those that developed clinical BCRL were considered for complex decongestive physiotherapy (CDP).
• Median follow up was 24 months.
• The results of the current analysis add to the growing body of outcomes-based evidence that prospective BCRL surveillance and early intervention using BIS is associated with very low rates of progression to chronic BCRL. Of the 93 high-risk patients treated with ALND and prospectively followed and managed in this structured BCRL protocol, only 10.8% required CDP. More importantly, only three of these patients (3%) went on to require additional therapies and 97% remain without evidence of chronic BCRL.
• The concept of prospective surveillance is driven by the idea that identifying BCRL at the subclinical phase of the process and initiating early, conservative intervention reduces chronic morbidity and the need for invasive and costly procedures.
• The suggestion is to target patients at high risk of BCRL so they can be provided with the most effective prospective surveillance, while offering clinicians and clinics less intensive options for lower risk patients (ex. less frequent surveillance, clinical surveillance only). These results support this approach for high-risk patients as 35% has elevated L-Dex levels and 11% required CDP. Moving forward, such a strategy would allow for the effective and efficient assessment of BCRL, providing a potential for cost savings compared with delayed detection and intervention, which has been associated with high cost.
• It is important to note that all patients that required CDP were identified with an elevated L-Dex score with the majority of the patients treated with an OTC compression sleeve for 4 weeks. One observation may be that those that progressed to CDP may not have if preventative intervention had been applied earlier. One strategy to allow for even earlier detection would be to reduce the threshold for intervention. This is supported by growing data that support the use of a 2 SD threshold (L-Dex > 7) to initiate intervention as compared to the traditional 3 SD threshold that has been used in the past. The emerging available data suggest a higher sensitivity to detect mild to moderate volume changes, would facilitate even earlier BCRL treatment.
• The data for this study was collected prospectively, but the ALND subgroup analyses were performed retrospectively and as such are limited by the biases of such an approach.