Considerations for Clinicians in the Diagnosis, Prevention, and Treatment of Breast Cancer-Related Lymphedema: Recommendations from a Multidisciplinary Expert ASBrS Panel

Part 1: Definitions, Assessments, Education, and Future Directions

Sarah A. McLaughlin, Alicia C. Staley, Frank Vicini, Paul Thiruchelvam, Nancy A. Hutchison, Jane Mendez, Fiona MacNeill, Stanley G. Rockson, Sarah M. DeSnyder, Suzanne Klimberg, Michael Alatriste, Francesco Boccardo, Mark L. Smith, and Sheldon M. Feldman. Ann Surg Oncol, Aug 2017.

Main findings

The American Society of Breast Surgeons (ASBrS) convened an international, multidisciplinary expert panel to review current data and guidelines on all aspects of lymphedema diagnosis and management to acknowledge the gravity of this public health issue facing breast cancer survivors. The Panel sought to collate clear and meaningful recommendations for providers regarding lymphedema diagnosis, treatment, and prevention. Diagnosis, education, and future directions were discussed in Part 1.

Defining and diagnosing lymphedema: objective and subjective assessments

  • The ideal anthropometric measuring tool should be easy to use, noninvasive, hygienic, cost effective, reliable, reproducible, and quantifiable. Each method has advantages and disadvantages.
  • No head-to-head comparison trials are currently available that validate one technique over another, although a few studies are ongoing.
  • The panel agrees that clinicians should establish a surveillance plan because early diagnosis leads to early treatment and increases the likelihood for limited disease burden.
  • The panel agrees that baseline and follow-up measurements of the ipsilateral and contralateral arms of all breast cancer patients are critical. All measurement techniques have advantages and disadvantages that should be considered when a comprehensive measurement strategy is developed that includes a combination of objective and subjective measures.
  • BCRL should be evaluated with patient-reported outcomes (PRO) and an objective measure because health-related quality-of life (HRQOL) impact does not directly correlate with measured limb volume, and BCRL is a multifaceted condition.
  • Many patients with clinical lymphedema do not have subjective symptoms, suggesting that at-risk patients without symptoms still need to be screened.

Risk factors

  • The panel agrees that clinicians should practice personalized medicine strategies to minimize axillary surgery, should question the routine use of postmastectomy or regional nodal irradiation, and should use genomic tests to guide the use of chemotherapy to collectively minimize the additive effects of multimodality therapy. Patients should maintain a healthy body weight/BMI.

Need for education

  • Guidelines emphasize the crucial role of patient education in encouraging risk-reducing lifestyle changes and early self-detection because when these are combined with prompt interventions, significant improvements in outcomes and quality of life are achievable.
  • Clinicians must raise awareness of the lifetime risk for lymphedema, especially in the 3–5 years after surgery. They should inform patients of concerning early signs and symptoms (unilateral/ipsilateral aching, heaviness, tightness, fullness, or stiffness) that often precede visible swelling and should ask about clothing or jewellery becoming tighter or patient-perceived swelling.
  • Second, clinicians should educate patients on critical risk-reducing strategies that are practical and evidence based.
  • Finally, clinicians should provide patients with a reliable specialist as a point of contact should they experience symptoms.
  • A 10 year follow-up study showed that patients with a diagnosis of low-volume/early lymphedema had better long-term outcomes.
  • The panel agrees that surgeons should admit and accept that lymphedema risks exist and educate themselves and their patients about these risks at preoperative and follow-up visits. Education should continue into survivorship and be incorporated into survivorship care plans.

New research, promising targets, and future directions

  • To acknowledge the pathophysiology of lymphedema as a mechanical insufficiency alone is likely simplistic. Lymphatic obstruction, inflammation, immune response, complement activation, wound healing, and fibrosis to the development of lymphedema. Therapeutic lymphangiogenesis and targeted inflammatory inhibition may aid structural and functional lymphatic improvement.