A Review of Treatment for Breast Cancer–Related Lymphedema: Paradigms for Clinical Practice
Posted: Thursday, December 1, 2016
Lymphedema is a major yet common complication of breast cancer surgery, with incidence rates ranging from 2% to 65% depending on the treatment approach used (eg, surgery, radiation, systemic therapy) and host factors. More aggressive local therapy (mastectomy vs breast conservation), axillary surgery (axillary dissection vs sentinel node biopsy), radiation therapy (regional nodal irradiation), and use of systemic therapies are all associated with an increased risk of breast cancer–related lymphedema. Moreover, the incidence of breast cancer–related lymphedema is approximately 10% to 40% with regional nodal irradiation and 10% to 50% with axillary dissection.
The International Society of Lymphology created a useful clinical classification system that categorizes the severity of breast cancer–related lymphedema from stage 0 to III based on two factors: the “softness” or “firmness” of the limb and the outcome after elevation.
This literature review was conducted over a 10-year period to provide guidance to clinicians. Noninvasive strategies for lymphedema include compression therapy, manual lymphatic drainage, and complex decongestive therapy; invasive modalities include liposuction and lymphatic bypass/lymph node transfer. Results were presented from 45 studies.
Compression therapy typically involves repetitive and/or prolonged application of low-stretch compressive bandages wrapped tightly around the edematous limb to promote the flow of excess interstitial fluid out of the extremity. Alternative methods use compression arm sleeves and gloves, intermittent pneumatic compression devices, or kinesiology compression tape.
Manual lymphatic drainage is a noninvasive massage therapy technique involving stationary circular, pumping, scooping, and rotary movements with various degrees of pressure.
Complex decongestive therapy is a noninvasive multimodality treatment that includes manual lymphatic drainage, skin care, compression bandaging, and exercises.
Liposuction represents a reductive technique that involves insertion of a cannula through a small incision in the affected arm followed by circumferential vacuum-assisted removal of fibrofatty tissue, which accumulates during periods of prolonged lymphostasis. Liposuction is sometimes considered a symptom-management tool.
Lymphatic bypass is a surgical intervention that involves localization of the damaged lymphatic vasculature in the extremity, harvesting of healthy lymph nodes and vessels, and either anastomosis of lymphatic vessels distal to the obstruction with healthy lymphatics or veins proximal to the obstruction.
Most studies demonstrated the short-term efficacy of breast cancer–related lymphedema treatments in reducing lymphedema volumes. Of the noninvasive treatments, complex decongestive therapy was the most comprehensively studied and most efficacious compared with baseline. As such, complex decongestive therapy has been regarded as the standard noninvasive treatment for low-stage breast cancer–related lymphedema.
Studies evaluating the efficacy of invasive treatments generally demonstrated favorable outcomes with greater long-term reductions in volume, circumference, and fluid stasis. Nevertheless, the complication profile of lymph node transfer is rather striking compared with liposuction, as well as with the noninvasive treatments, which should prompt frank discussion with patients.
The stage of disease is an essential component of selection criteria: irreversible fibrotic changes associated with higher-stage breast cancer–related lymphedema are incompatible with noninvasive therapies or successful lymphatic bypass/lymphovenous anastomosis procedures, which require an intact lymphatic vasculature.
The authors concluded that complex decongestive therapy is an effective treatment modality for early-stage breast cancer–related lymphedema, whereas for more advanced breast cancer–related lymphedema, lymph node transfer has demonstrated efficacy. Comparison of breast cancer–related lymphedema treatments, including comparative costs, will require further study.