Reducing Breast Cancer-Related Lymphedema (BCRL) Through Prospective Surveillance Monitoring Using Bioimpedance Spectroscopy (BIS) and Patient Directed Self-Interventions

Abstract

Background

Breast cancer-related lymphedema (BCRL) is a chronic progressive disease that results from breast cancer treatment and nodal surgery. NCCN guidelines support baseline measurements with prospective assessment for early diagnosis and treatment. We sought to determine if baseline measurement with bioimpedance spectroscopy (BIS) and serial postoperative evaluations provide early detection amenable to conservative interventions that reduce BCRL.

Methods

Breast cancer patients with unilateral disease high-risk for BCRL from a single institution were evaluated from November 2014 to December 2017. High risk was defined as axillary lymph node dissection with radiation and/or taxane chemotherapy. Patients received preoperative baseline BIS measurements followed by postoperative measurements with at least two follow-ups. Patients with BIS results that were 2 standard deviations above baseline (10 + points) started home conservative interventions for 4–6 weeks. Postintervention measurements were taken to assess improvement.

Result

A total of 146 patients high-risk for BCRL were included. Forty-nine patients (34%) developed early BCRL and started self-directed treatment. Forty patients (82%) had elevated BIS measurements return to normal baseline range. Nine (6%) patients had persistent BCRL requiring referral for advanced therapy. Patients with persistent BCRL had significant nodal burden on surgical pathology; eight (89%) had N2/N3 disease. Six (76%) with BCRL refractory to conservative measures died of their breast cancer.

Conclusion

Our results demonstrated that early conservative intervention for breast cancer patients high risk for BCRL who were prospectively monitored by utilizing BIS significantly lowers rates of BCRL. These findings support early prospective screening and intervention for BCRL. Early detection with patient-directed interventions improves patient outcomes and decreases the risk of persistent BCRL.

This is a preview of subscription content, log in to check access.

References

  1. 1.

    Ashikaga T, Krag DN, Land SR, et al. Morbidity results from the NSABP B-32 trial comparing sentinel lymph node dissection versus axillary dissection. J Surg Oncol. 2010;102(2):111–8.

    Article  PubMed  PubMed Central  Google Scholar 

  2. 2.

    Hayes S, Di Sipio T, Rye S, et al. Prevalence and prognostic significance of secondary lymphedema following breast cancer. Lymphatic Res Biol. 2011;9(3):135–41.

    Article  Google Scholar 

  3. 3.

    Whitworth PW, Cooper A. Reducing chronic breast cancer-related lymphedema utilizing a program of prospective surveillance with bioimpedance spectroscopy. Breast J. 2018;24(1):62–5.

    CAS  Article  Google Scholar 

  4. 4.

    Kaufman DI, Shah C, Vicini FA, Rizzi M. Utilization of bioimpedance spectroscopy in the prevention of chronic breast cancer-related lymphedema. Breast Cancer Res Treat. 2017;166(3):809–15.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  5. 5.

    Zou L, Liu FH, Shen PP, et al. The incidence and risk factors of related lymphedema for breast cancer survivors post-operation: a 2-year follow-up prospective cohort study. Breast cancer (Tokyo, Japan). 2018;25(3):309–14.

    Article  Google Scholar 

  6. 6.

    Tengrup I, Tennvall-Nittby L, Christiansson I, Laurin M. Arm morbidity after breast-conserving therapy for breast cancer. Acta Oncol (Stockholm, Sweden). 2000;39(3):393–7.

    CAS  Article  Google Scholar 

  7. 7.

    Armer JM, Stewart BR. A comparison of four diagnostic criteria for lymphedema in a post-breast cancer population. Lymphatic Res Biol. 2005;3(4):208–17.

    Article  Google Scholar 

  8. 8.

    Beaulac SM, McNair LA, Scott TE, LaMorte WW, Kavanah MT. Lymphedema and quality of life in survivors of early-stage breast cancer. Arch Surg (Chicago, Ill.: 1960). 2002;137(11):1253–7.

    Article  Google Scholar 

  9. 9.

    Deutsch M, Land S, Begovic M, Sharif S. The incidence of arm edema in women with breast cancer randomized on the National Surgical Adjuvant Breast and Bowel Project study B-04 to radical mastectomy versus total mastectomy and radiotherapy versus total mastectomy alone. Int J Radiat Oncol Biol Phys. 2008;70(4):1020–4.

    Article  Google Scholar 

  10. 10.

    Francis WP, Abghari P, Du W, Rymal C, Suna M, Kosir MA. Improving surgical outcomes: standardizing the reporting of incidence and severity of acute lymphedema after sentinel lymph node biopsy and axillary lymph node dissection. Am J Surg. 2006;192(5):636–9.

    Article  Google Scholar 

  11. 11.

    Kopec JA, Colangelo LH, Land SR, et al. Relationship between arm morbidity and patient-reported outcomes following surgery in women with node-negative NSABP protocol B-32. J Support Oncol. 2013;11(1):22–30.

    PubMed  PubMed Central  Google Scholar 

  12. 12.

    Iyigun ZE, Duymaz T, Ilgun AS, et al. Preoperative lymphedema-related risk factors in early-stage breast cancer. Lymphatic Res Biol. 2018;16(1):28–35.

    Article  Google Scholar 

  13. 13.

    Hahamoff M, Gupta N, Munoz D, et al. A lymphedema surveillance program for breast cancer patients reveals the promise of surgical prevention. J Surg Res. 2018. https://doi.org/10.1016/j.jss.2017.10.008.

  14. 14.

    Cornish BH, Chapman M, Hirst C, et al. Early diagnosis of lymphedema using multiple frequency bioimpedance. Lymphology. 2001;34(1):2–11.

    CAS  PubMed  Google Scholar 

  15. 15.

    Reichart K. Lymphedema: improving screening and treatment among at-risk breast cancer survivors. Clin J Oncol Nurs. 2017;21(1):21–5.

    Article  Google Scholar 

  16. 16.

    Soran A, Ozmen T, McGuire KP, et al. The importance of detection of subclinical lymphedema for the prevention of breast cancer-related clinical lymphedema after axillary lymph node dissection; a prospective observational study. Lymphatic Res Biol. 2014;12(4):289–94.

    Article  Google Scholar 

  17. 17.

    Norman SA, Localio AR, Potashnik SL, et al. Lymphedema in breast cancer survivors: incidence, degree, time course, treatment, and symptoms. J Clin Oncol. 2009;27(3):390–7.

    Article  PubMed  PubMed Central  Google Scholar 

  18. 18.

    Seward C, Skolny M, Brunelle C, Asdourian M, Salama L, Taghian AG. A comprehensive review of bioimpedance spectroscopy as a diagnostic tool for the detection and measurement of breast cancer-related lymphedema. J Surg Oncol. 2016;114(5):537–42.

    Article  Google Scholar 

  19. 19.

    Shah C, Vicini F, Beitsch P, et al. The use of bioimpedance spectroscopy to monitor therapeutic intervention in patients treated for breast cancer related lymphedema. Lymphology. 2013;46(4):184–92.

    CAS  PubMed  Google Scholar 

  20. 20.

    Vicini F, Shah C, Lyden M, Whitworth P. Bioelectrical impedance for detecting and monitoring patients for the development of upper limb lymphedema in the clinic. Clin Breast Cancer. 2012;12(2):133–7.

    Article  Google Scholar 

  21. 21.

    Fu MR, Cleland CM, Guth AA, et al. L-dex ratio in detecting breast cancer-related lymphedema: reliability, sensitivity, and specificity. Lymphology. 2013;46(2):85–96.

    CAS  PubMed  PubMed Central  Google Scholar 

  22. 22.

    Torres Lacomba M, Yuste Sanchez MJ, Zapico Goni A, et al. Effectiveness of early physiotherapy to prevent lymphoedema after surgery for breast cancer: randomised, single blinded, clinical trial. BMJ (Clin Res ed.). 2010;340:b5396.

    Article  Google Scholar 

  23. 23.

    Stout Gergich NL, Pfalzer LA, McGarvey C, Springer B, Gerber LH, Soballe P. Preoperative assessment enables the early diagnosis and successful treatment of lymphedema. Cancer. 2008;112(12):2809–19.

    Article  Google Scholar 

  24. 24.

    Shah C, Vicini FA, Arthur D. Bioimpedance spectroscopy for breast cancer related lymphedema assessment: clinical practice guidelines. Breast J. 2016;22(6):645–50.

    Article  Google Scholar 

  25. 25.

    Ridner SH, Shih YC, Doersam JK, Rhoten BA, Schultze BS, Dietrich MS. A pilot randomized trial evaluating lymphedema self-measurement with bioelectrical impedance, self-care adherence, and health outcomes. Lymphatic Res Biol. 2014;12(4):258–66.

    Article  Google Scholar 

  26. 26.

    Laidley A, Anglin B. The Impact of L-Dex((R)) Measurements in assessing breast cancer-related lymphedema as part of routine clinical practice. Front Oncol. 2016;6:192.

    Article  PubMed  PubMed Central  Google Scholar 

  27. 27.

    Clark B, Sitzia J, Harlow W. Incidence and risk of arm oedema following treatment for breast cancer: a three-year follow-up study. QJM. 2005;98(5):343–8.

    CAS  Article  Google Scholar 

  28. 28.

    Kuwajerwala NK, Feczko C, Dekhne N, et al. Comparison of lymphedema in patients with axillary lymph node dissections to those with sentinel lymph node biopsy followed by immediate and delayed ALND. Am J Clin Oncol. 2013;36(1):20–3.

    Article  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Jamie L. Wagner DO.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Kilgore, L.J., Korentager, S.S., Hangge, A.N. et al. Reducing Breast Cancer-Related Lymphedema (BCRL) Through Prospective Surveillance Monitoring Using Bioimpedance Spectroscopy (BIS) and Patient Directed Self-Interventions. Ann Surg Oncol 25, 2948–2952 (2018). https://doi.org/10.1245/s10434-018-6601-8

Download citation

Keywords

  • Breast Cancer-related Lymphedema (BCRL)
  • Bioimpedance Spectroscopy (BIS)
  • Lymphedema (LE)
  • Axillary Lymph Node Dissection (ALND)
  • Taxane Chemotherapy