Early Surveillance Is Associated With Less Incidence and Severity of Breast Cancer-Related Lymphedema Compared With a Traditional Referral Model of Care

Louise A. Koelmeyer, BAppSc (OT)1; Robert J. Borotkanics, MPH, MS, DrPH2; Jessica Alcorso, MPH, PhD1; Philip Prah, MSc2; Caleb J. Winch, M Psychol (Clin)1; Kristine Nakhel, B Human Sc1; Catherine M. Dean, BAppSc, MA, PhD3*; and John Boyages, MBBS, FRANZCR, PhD1. Cancer Month 0, 2018

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Early Surveillance Is Associated With Less Incidence and Severity of Breast Cancer-Related Lymphedema Compared With a Traditional Referral Model of Care

Louise A. Koelmeyer, BAppSc (OT)1; Robert J. Borotkanics, MPH, MS, DrPH2; Jessica Alcorso, MPH, PhD1;  Philip Prah, MSc2; Caleb J. Winch, M Psychol (Clin)1; Kristine Nakhel, B Human Sc1;  Catherine M. Dean, BAppSc, MA, PhD3*; and John Boyages, MBBS, FRANZCR, PhD1.  Cancer  Month 0, 2018

BACKGROUND: Bioimpedance spectroscopy (BIS) has enabled the early identification of breast cancer-related lymphedema. In this study, differences in health service metrics and in the incidence of breast cancer-related lymphedema are evaluated in an early surveillance model of care compared with a traditional referral model of care.

METHODS: In a retrospective analysis of data from 753 women who underwent BIS measures between January 1, 2007 and December 31, 2016, 188 women were assigned to the “early surveillance” group if they began lymphedema monitoring presurgery (n = 121) or within 90 days postsurgery (n = 67), and 285 women were assigned to the “traditional referral” group if they began monitoring after 90 days postsurgery. Health service metrics were calculated as the time to the first BIS measure after 90 days postsurgery, the median follow-up, and the number of health care visits. Lymphedema was diagnosed based on BIS measures. RESULTS: Women in the early surveillance group received lymphedema care significantly earlier than those in the traditional referral group. However, there was no difference in the number of visits per year to the clinic between groups. Significantly more women in the traditional referral group were diagnosed with clinical lymphedema (stage I-III, 39 % vs 14%; P < .001) and with greater severity (stage II-III, 24%) compared with those in the early surveillance group (4%).

CONCLUSIONS: The current findings support the adoption of an early prospective surveillance model of care using BIS for the early detection and management of breast cancer-related lymphedema. Cancer 2018;0:1-9. © 2018 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, dis

Main findings

  • Eligible women (n = 473) were categorized into 2 groups. The early surveillance group (n = 188) was made up of those whose surveillance and intervention commenced presurgery (n = 121) or within 90 days postsurgery (n = 67) and continued for at least 90 days thereafter. The traditional referral group included 285 participants.
  • The current results indicate that women who underwent early surveillance received lymphedema care almost 2 years earlier than women in the traditional referral group without any difference in number of visits to the lymphedema clinic.
  • The early surveillance group had a significantly lower incidence of clinical lymphedema than the traditional referral group, and those who were diagnosed had significantly less severe lymphedema.
  • For women who were diagnosed with lymphedema, BIS scores increased slowly over time, but the rate of increase was less for patients who underwent early surveillance.
  • There are strengths and limitations of this study. The main strength is the volume of data available for analysis collected in the same clinic using the same method over a decade of practice. The data were recorded routinely as part of normal practice by 1 therapist.
  • Second, the number of women and baseline characteristics for both groups were very similar, and these women were at greater risk for developing clinical lymphedema.
  • In regards to limitations, the 2 groups were not randomly assigned. Although both groups were similar, the number of women who never developed lymphedema is likely under-represented in the traditional referral group because, historically, they only sought treatment when they had developed a clinical symptom or need. Although a larger proportion of women in the early surveillance group had been prescribed taxane-based chemotherapy, this group had a lower incidence of clinical lymphedema at diagnosis compared with the traditional referral group.
  • Regular clinic visits to monitor extracellular fluid present an opportunity for therapists to provide risk management education, psychological support, physical rehabilitation, empowerment, and survivorship care.
  • The findings from the current study support the use of BIS as part of an early prospective surveillance model of care that results in significantly earlier detection of lymphedema over time. Furthermore, the earlier detection of lymphedema will lead to lower health care costs if it results in the effective management of symptoms and prevents progression to severe clinical lymphedema.