Abstract

Which are the best conservative interventions for lymphoedema after breast cancer surgery?

Martijn M Stuiver, Associate professor, Marieke R ten Tusscher, physiotherapist, Margaret L McNeely, associate professor. BMJ 2017; 357

What you need to know

An estimated 20% of women who have been treated for breast cancer will develop lymphoedema

Advise patients to watch for early symptoms such as swelling, feelings of heaviness, or tension in the skin of the arm or the breast

Lymphoedema might be prevented or treated using one or more conservative approaches including patient education, physical exercise, manual lymphatic drainage, and compression therapy

Evidence for the effectiveness of any of these interventions, alone or in combination, is limited

Lymphoedema is a common complication of breast cancer surgery with or without adjuvant cancer treatments.1 Fluid accumulates because of damage to the lymphatic system, most commonly after axillary lymph node dissection. Box 1 shows factors associated with lymphoedema. Swelling is commonly in the arm but can involve the chest or back; it can result in pain, dysfunction, and disturbance of body image.3

Box 1: Risk factors for breast cancer related lymphoedema with reported ranges of odds ratios (OR)

• Factors related to disease and treatment
• Higher number of metastatic lymph nodes: OR 1.1-2.8
• Axillary lymph node dissection: OR 1.3-6.7
• Greater number of lymph nodes dissected: OR 1.0-2.1
• Mastectomy: OR 2.7-7.4
• Radiotherapy: OR 1.7-3.8
• Chemotherapy: OR 1.6-2.0
• Other factors
• High BMI: OR 0.1-5.5 per point increase
• Lack of participation in regular physical activity: OR 2.1-6.1
• Development of an infection in the limb at any time after breast cancer treatment: OR 2.17; 95% confidence interval: 0.93-5.082

Nearly 1 in 5 women who survive breast cancer develops lymphoedema within two years of diagnosis or surgery, with the incidence increasing with time.13 In recent years, sentinel lymph node biopsy has been implemented as standard care and has greatly reduced the incidence of lymphoedema. This means that women with clinically positive lymph nodes undergo the higher risk axillary lymph node dissection, but others can avoid the procedure.