The importance of prevention of lymphoedema in breast cancer-related lymphoedema: How and when?

If left untreated, functional disability, psychosocial problems, and impaired quality of life can be observed in patients with breast cancer-related lymphoedema (BCRL). Previous studies indicated that the costs related to prevention and early diagnostic programmes are lower than those of treating lymphoedema. “Therefore, prevention strategies are essential,” Dr Pinar Borman, professor of physical medicine and rehabilitation at the University of Health Sciences in Ankara, Turkey, emphasised in her talk at the 9th online event of the global MOH series, which was co-moderated by Drs Andrzej Szuba, professor of medicine at Wroclaw Medical University, Poland and Sylvain Gaillard, Head of Corporate Medical Marketing at SIGVARIS GROUP in Switzerland.

When should prevention of BCRL begin? Ideally, patient education about risk factors and prevention strategies should be initiated before breast cancer treatment. Generally, prevention strategies are performed after treatment in a prospective surveillance approach, which includes regular monitoring of limb volume and patients’ subjective complaints. Objective assessments of BCRL include circumferential measurements, water displacement, bioelectrical impedance and perometer. Since many patients report lymphoedema symptoms without obvious arm excess volume or arm oedema, early detection and identification is important. In this context, Prof Borman discussed the pros and cons of the different assessment methods of BCRL. Several studies are currently being conducted to investigate the value of imaging modalities in early diagnosis.

How can BCRL be prevented? Awareness, education, information, meticulous skin care to avoid infections, compression garments, exercise, weight control, and minimising stress are the most important measures in the prevention of this condition. Awareness and education are needed for both healthcare professionals and patients. Patients should be well informed about their risk of developing BCRL and preventive actions. Therefore, monitoring and providing a preventive self-management programme is important. Self-management includes compression garments, which Prof Borman identified as a neglected part of lymphoedema prevention due to the limited number of published studies. Accordingly, compression garments should be prescribed to all patients at risk of BCRL. For prevention, pressures of 18-21 mmHg are sufficient and sleeves from wrist or metacarpophalangeal joint in circular knit can be chosen. A daily wearing time of 8 h is recommended.

Randomised controlled trials demonstrated the effectiveness of compression sleeves following breast cancer surgery, especially in the first 3 to 12 months. Literature reviews indicated the benefits of lymphoedema prevention programmes with compression garments in addition to general precautions such as education and exercise. Prophylactic compression sleeves not only prevented lymphoedema, but also increased functionality and quality of life. The adherence of patients to compression was the most important aspect of prevention. Correspondingly, the incidence of BCRL was significantly lowered in patients who adhered to daily use of compression garments, especially in the first 3 months during two years of surveillance.

The subsequent lively discussion, which was joined by panellist Dr Vincent Paramanandam (Australia), Orsi Kokai (Australia), Nouf Aldhwayan (Saudi Arabia) and Prof Margaret McNeely (Canada), touched the importance of education, preventive measures, barriers to surveillance and prescribing compression garments in different countries as well as use of compression at night.

Take Home Messages:

• BCRL is a serious and concerning complication after treatment of breast cancer, leading to functional disability, limiting daily living activities, and impairing quality of life.
• Patients should be well informed and aware of their BCRL risk.
• Surveillance, offering early intervention and prevention to the patients at risk is feasible.
• Prophylactic intervention and self-management techniques can help to prevent and reduce BCRL.
• In addition to education, skin care and exercises, pressure garments are useful and effective in the prevention of BCRL.
• As patient adherence plays an important role in preventing BCRL, long-term follow-up is important and should be considered.