Annals of Surgical Oncology

, Volume 21, Issue 11, pp 3481–3489 | Cite as

Proactive Approach to Lymphedema Risk Reduction: A Prospective Study

  • Mei R. Fu
  • Deborah Axelrod
  • Amber A. Guth
  • Francis Cartwright
  • Zeyuan Qiu
  • Judith D. Goldberg
  • June Kim
  • Joan Scagliola
  • Robin Kleinman
  • Judith Haber
Breast Oncology



Advances in cancer treatments continue to reduce the incidence of lymphedema. Yet, many breast cancer survivors still face long-term postoperative challenges as a result of developing lymphedema. The purpose of this study was to preliminarily evaluate The Optimal Lymph Flow program, a patient-centered education and behavioral program focusing on self-care strategies to enhance lymphedema risk reduction by promoting lymph flow and optimize body mass index (BMI).


A prospective, longitudinal, quasi-experimental design with repeated-measures was used. The study outcomes included lymph volume changes by infrared perometer, and BMI by a bioimpedance device at pre-surgery baseline, 2–4 weeks after surgery, 6-month and 12-month follow-up. A total of 140 patients were recruited and participated in The Optimal Lymph Flow program; 134 patients completed the study with 4 % attrition rate.


Fifty-eight percent of patients had axillary node dissection and 42 % had sentinel lymph node biopsy (SLNB). The majority (97 %) of patients maintained and improved their preoperative limb volume (LV) and BMI at the study endpoint of 12 months following cancer surgery. Cumulatively, two patients with SLNB and two patients with axillary lymph node dissection had measurable lymphedema (>10 % LV change). At the 12-month follow-up, among the four patients with measurable lymphedema, two patients’ LV returned to preoperative level without compression therapy but by maintaining The Optimal Lymph Flow exercises to promote daily lymph flow.


This educational and behavioral program is effective in enhancing lymphedema risk reduction. The study provided initial evidence for emerging change in lymphedema care from treatment-focus to proactive risk reduction.


Sentinel Lymph Node Biopsy Lymphedema Compression Garment Limb Volume Sentinel Lymph Node Biopsy Group 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



This study was supported by the Avon Foundation, National Institute of Health (National Institute on Minority Health and Health Disparities Project No. P60 MD000538-03), Judges and Lawyers for Breast Cancer Alert, and the Vital Fund. Dr. Judith D. Goldberg was partially supported by NYU School of Medicine Cancer Center Support Grants National Cancer Institute 5 P30 CA16087-32. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. Partial findings were presented at the 2012 Breast Cancer Symposium, San Francisco, CA, USA (13–15 September 2012).

Statement of Financial Interest

Mei R. Fu, Deborah Axelrod, Amber A. Guth, Francis Cartwright, Zeyuan Qiu, Judith D. Goldberg, June Kim, Joan Scagliola, Robin Kleinman, and Judith Haber have no financial interest or commercial association with information submitted in manuscript.

List of Products Used

No products, devices, or drugs were used or identified in the manuscript.


  1. 1.
    Fu MR, Ridner SH, Hu SH, et al. Psychosocial impact of lymphedema: a systematic review of literature from 2004 to 2011. Psychooncol. 2013;22(7):1466-84.CrossRefGoogle Scholar
  2. 2.
    Chachaj A, Malyszczak K, Pyszel K, et al. Physical and psychological impairments of women with upper lymphedema following breast cancer treatment. Psychooncol. 2009;19:299–305.CrossRefGoogle Scholar
  3. 3.
    Petrek JA, Senie RT, Peters M, Rosen PP. Lymphedema in a cohort of breast carcinoma survivors 20 years after diagnosis. Cancer. 2001;92(6):1368–77.PubMedCrossRefGoogle Scholar
  4. 4.
    Armer JM, Stewart BR, Shook RP. 30-month post-breast cancer treatment lymphoedema. J Lymphoedema. 2009;4(1):14–18.PubMedPubMedCentralGoogle Scholar
  5. 5.
    International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema. Consensus document of the International Society of Lymphology. Lymphology. 2003;36:84–91.Google Scholar
  6. 6.
    Stanton AW, Modi S, Mellor RH, et al. Recent advances in breast cancer-related lymphedema of the arm: lymphatic pump failure and predisposing factors. Lymphat Res Biol. 2009;7(1):29–45.PubMedCrossRefGoogle Scholar
  7. 7.
    Brorson H, Aberg M, Svensson H. Chronic lymphedema and adipocyte proliferation: clinical therapeutic implications. The Lymphatic Continuum. National Institutes of Health, Bethesda, USA, 2002. Lymphat Res Biol. 2003;1:88.Google Scholar
  8. 8.
    Mak SS, Yeo W, Lee YM, et al. Predictors of lymphedema in patients with breast cancer undergoing axillary lymph node dissection in Hong Kong. Nurs Res. 2008;57:416-25.PubMedCrossRefGoogle Scholar
  9. 9.
    Kwan ML, Darbinian J, Schmitz KH, et al. Risk factors for lymphedema in a prospective breast cancer survivorship study: the Pathways Study. Arch Surg. 2010;145:1055–63.PubMedCrossRefPubMedCentralGoogle Scholar
  10. 10.
    Ahmed RL, Schmitz KH, Prizment AE, et al. Risk factors for lymphedema in breast cancer survivors, the Iowa Women’s Health Study. Breast Cancer Res Treat. 2001;130:981–91.CrossRefGoogle Scholar
  11. 11.
    Paskett ED, Naughton MJ, McCoy TP, et al. The epidemiology of arm and hand swelling in premenopausal breast cancer survivors. Cancer Epidemiol Biomarkers Prev. 2007;16:775–82.PubMedCrossRefGoogle Scholar
  12. 12.
    Ruocco V, Schwartz RA, Ruocco E. Lymphedema: an immunologically vulnerable site for development of neoplasms. J Am Acad Dermat. 2002;47:124–7.CrossRefGoogle Scholar
  13. 13.
    Fu MR, Chen C, Haber J, et al. The effect of providing information about lymphedema on the cognitive and symptom outcomes of breast cancer survivors. Ann Surg Oncol. 2010;17(7):1847–53.PubMedCrossRefGoogle Scholar
  14. 14.
    Cemal Y, Pusic A, Mehrara BJ. Preventative measures for lymphedema: separating fact from fiction. J Am Coll Surg. 2011;213(4):543–51.PubMedCrossRefPubMedCentralGoogle Scholar
  15. 15.
    Nielsen I, Gordon S, Selby A. Breast cancer-related lymphoedema risk reduction advice: a challenge for health professionals. Cancer Treat Rev. 2008;34(7):621–8.PubMedCrossRefGoogle Scholar
  16. 16.
    Stout NL, Binkley JM, Schmitz KH, Andrews K, Hayes SC, Campbell KL, et al. A prospective surveillance model for rehabilitation for women with breast cancer. Cancer. 2012;118(8 Suppl):2191–200.PubMedCrossRefGoogle Scholar
  17. 17.
    Armer JM, Stewart BR. A comparison of four diagnostic criteria for lymphedema in a post-breast cancer population. Lymphat Res Biol. 2005;3:208–17.PubMedCrossRefGoogle Scholar
  18. 18.
    McLaughlin SA, Bagaria S, Gibson T, et al. Trends in risk reduction practices for the prevention of lymphedema in the first 12 months after breast cancer surgery. J Am Coll Surg. 2013:216:380–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Lasinski BB, Thrift KM, Squire D, et al. A systematic review of the evidence for complete decongestive therapy in the treatment of lymphedema from 2004 to 2011. PM R. 2012;4(8):580–601.PubMedCrossRefGoogle Scholar
  20. 20.
    American Cancer Society. Breast Cancer Facts & Figures 2013-2014. Atlanta: American Cancer Society, Inc.; 2013.Google Scholar
  21. 21.
    Shih YC, Xu Y, Cormier JN, et al. Incidence, treatment costs, and complications of lymphedema after breast cancer among women of working age: a 2-year follow-up study. J Clin Oncol. 2009;27(12):2007–14.PubMedCrossRefGoogle Scholar
  22. 22.
    McLaughlin SA, Wright MJ, Morris KT, et al. Prevalence of lymphedema in women with breast cancer 5 years after sentinel lymph node biopsy or axillary dissection: objective measurements. J Clin Oncol. 2008;26(32):5213–19.PubMedCrossRefPubMedCentralGoogle Scholar
  23. 23.
    Fitzmaurice G, Laird N, Ware J. Applied longitudinal data analysis. New Jersey: John Wiley & Sons; 2004.Google Scholar

Copyright information

© Society of Surgical Oncology 2014

Authors and Affiliations

  • Mei R. Fu
    • 1
  • Deborah Axelrod
    • 2
    • 3
  • Amber A. Guth
    • 2
    • 3
  • Francis Cartwright
    • 3
  • Zeyuan Qiu
    • 4
  • Judith D. Goldberg
    • 5
  • June Kim
    • 5
  • Joan Scagliola
    • 3
  • Robin Kleinman
    • 3
  • Judith Haber
    • 1
  1. 1.College of NursingNew York UniversityNew YorkUSA
  2. 2.Department of SurgeryNew York University School of MedicineNew YorkUSA
  3. 3.NYU Clinical Cancer CenterNew YorkUSA
  4. 4.New Jersey Institute of TechnologyNewarkUSA
  5. 5.Division of BiostatisticsNew York University School of MedicineNew YorkUSA

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