Breaking the Silence: The Underrated Struggle of Lymphedema After Breast Cancer

By Steven Chen, MD, MBA

With rates of cancer survivorship climbing, the long-term impact of complications such as lymphedema that are associated with cancer treatment merits additional attention.

Lymphedema is a common but underdiscussed issue experienced by cancer survivors. Lymphedema describes a condition in which usual lymphatic drainage is interrupted, creating an accumulation of protein-rich lymph fluid in the interstitial space. In some cases, lymphedema may develop into a chronic condition, impairing patients’ immune systems and placing them at greater risk of infection. Its negative effects on patients include poor physical functioning, impaired ability to engage in normal activities of daily living, and increased psychological distress, according to the National Cancer Institute.

Of particular concern is breast cancer-related lymphedema (BCRL), which can affect approximately 20% of patients treated for breast cancer, according to a review in the journal Gland Surgery with rates depending on the type and intensity of treatments. BRCL may result from procedures that have removed lymph nodes, radiation to lymph nodes, and certain types of chemotherapy, as well as other factors.

BCRL also has negative economic implications, as a systematic review by Bian, et al., estimated that the two-year cost of treatment for lymphedema ranged from $14,877 to $23,167. As a result, patients who are diagnosed with late-stage BCRL often experience not only physical discomfort but financial burdens.

Lymphedema prevention and intervention

While success of treatment is understandably defined primarily by survival and recurrence metrics, lymphedema risk should also be a consideration in the treatment. The appropriate use of newer surgical strategies such as avoiding lymphatic surgery altogether in some low-risk patients, sentinel node biopsies, avoiding axillary dissections in lower risk patients, and lymphatic surgery techniques such as reverse axillary mapping or lymphatic bypass can play a part in decreasing the incidence of lymphedema.  Similarly, careful attention to radiation techniques and consideration of risks of various chemotherapies may also reduce the risk of lymphedema. Despite all of these advances, lymphedema risk can never truly be eliminated.

Once treatment is initiated, it can be challenging to identify patients with early stage BCRL because the patient has not yet experienced visible damage and has few, often very subtle, symptoms. However, prior to these more obvious changes, subclinical disease, in the form of increased extracellular fluid, can be developing. Therefore, finding subclinical disease before unprompted patient complaints is essential to facilitating early intervention, and ideally, turning around the process before it develops into a chronic condition.

Better BCRL detection and risk management

To decrease the risk of BCRL becoming a chronic condition, healthcare providers can adopt numerous approaches and tactics that focus on early detection, prevention, and efficient management of the disease. Finding BCRL starts with a careful history and listening for patients’ concerns about how their arms feel and function.  This should be supplemented with using objective measurements of arm swelling.  Volume measurements have been the historical backbone of identifying lymphedema. This can be done via circumferential tape measurements or volume displacement tanks or perometry. While important for detecting lymphedema that is not grossly symptomatic, tape measurements can be difficult to perform accurately especially when done by different people at different times.

Another option is the use of Bioimpedance Spectroscopy (BIS), which is a noninvasive straightforward way of measuring total body water, extracellular and intracellular fluids. BIS works by sending a small electrical current through electrodes on the skin and measuring the resulting voltage. Then, based on the different electrical properties of each type of tissue, BIS can distinguish between different tissues, such as cells, blood, and fluid. As it relates to lymphedema, BIS can often detect early fluid buildup before visible symptoms appear, enabling providers to intervene and treat the disease more quickly than traditional volume methods.

Whatever the method of detection, the next step after detection should be intervention. Compression garments and devices that apply controlled pressure to the affected limb to reduce fluid in the limb while being used continues to be shown to be an effective method of symptom relief, and when done early enough, can reverse the progression of lymphedema to the point where compression no longer is necessary.

Another option is customized exercise programs with trained therapists, whether provided digitally or in-person, to maintain limb mobility and function to reduce the likelihood of disease progression. Digital platforms represent an efficient way of delivering educational resources, exercise programs, and tools for self-monitoring, which promote greater adherence to lymphedema prevention and management practices.

Because BCRL has such a dramatic effect on patients’ quality-of-life and financial well-being, it is crucial that we take a comprehensive management strategy to the disease. That includes the integration of numerous tactics, from advanced technologies like BIS, emerging digital platforms, new approaches to patient education, and customized care. Working together across the entire multidisciplinary team of breast cancer to identify lymphedema as early as possible so that treatment can be initiated provides the best chance for patients to avoid having life-long impacts. With early therapy being so important (and cost effective!), all breast cancer patients should know about their risks and all team members should be a part in taking away the fear of lymphedema and making it a core part of the survivorship plan just as we do for the long-term effects of any of our other treatments.

Steven Chen, MD, MBA, serves as the Chief Medical Officer of ImpediMed, a pioneer in the field of medical technology.  Most recently, Dr. Chen was the Chief Medical Officer for Avelas Biosciences. He has also served as the Chief of Breast Surgery at UC Davis Medical Center, followed by a position as an Associate Professor of Surgery and as the associate program director of the surgical oncology training program at City of Hope National Medical Center in Duarte, California. Dr. Chen is a past President of the American Society of Breast Surgeons and serves on committees for a number of professional societies including the American Medical Association, the Society of Surgical Oncology, and the American College of Surgeons. He is also a practicing surgeon in San Diego, California, and the Director of Surgical Oncology at OasisMD.