Prospective Surveillance for Breast Cancer–Related Arm Lymphedema: A Systematic Review and Meta-Analysis

Abstract

PURPOSE The call to integrate prospective surveillance for lymphedema into cancer care pathways is building momentum to enable early intervention and prevent the progression of the condition. We offer a critical evaluation of the literature on prospective surveillance and early management for cancer-related lymphedema and evaluate the effect of such programs in preventing chronic lymphedema (CRD42019137965). METHODS Five databases and two registries were searched for randomized controlled trials or observational studies that assessed the incidence or prevalence of lymphedema associated with participation in a prospective surveillance program, published until February 26, 2021. Numbers triggered for early lymphedema management, resolved, and chronic lymphedema were extracted. Pooled relative risk (trials) and pooled rate (cumulative incidence; observational studies) of chronic lymphedema was calculated. Subgroup analyses assessed the effect of study design, length of follow-up, and extent of axillary surgery. RESULTS Twenty-three studies were included, of which 21 studies evaluated breast cancer–related arm lymphedema (BCRaL). Participation in prospective surveillance with early management reduced the risk of chronic BCRaL versus usual care (relative risk 0.31; 95% CI, 0.10 to 0.95; two randomized controlled trials; N = 106). The pooled rate of chronic BCRaL was 4% (95% CI, 3 to 6; 15 observational studies; N = 3,545), and 6% (95% CI, 4 to 9) when restricted to participants with axillary lymph node dissection (12 studies; N = 1,527). CONCLUSION The findings suggest that participation in prospective surveillance with early management reduces the risk of chronic BCRaL. Only a minority of patients at high risk of lymphedema because of axillary surgery developed chronic lymphedema. More robust research is needed to determine whether prospective surveillance with early management can reduce the risk of chronic lymphedema, particularly among cancer survivors other than breast cancer.

Prediction of breast cancer-related lymphedema by dermal backflow detected with near-infrared fluorescence lymphatic imaging

“…The exact time frame between development of clinically measurable edema and irreversible changes that are not responsive to complete decongestive therapy (CDT) or reparative microsurgeries is unknown, but dermal backflow may be an effective and objective measure of lymphatic dysfunction at very early stages of BCRL progression. Significantly, these findings support the importance of early monitoring to implement physiotherapy to reverse dysfunction and restore fluid homeostasis, as suggested by non-imaging studies [ 14 , 35 ] and shown by imaging in a NIRF-LI study of early head and neck cancer-related lymphedema treated with pneumatic compression therapy, in which dermal backflow disappeared or was reduced with physiotherapy [ 36 ].…”

“…No diagnostic method has been universally accepted for accurate detection of early changes in lymphatic function before the onset of irreversible BCRL tissue changes, yet early diagnosis may lead to the best chance of treatment efficacy [ 14 – 17 ]. Instead, the objective, albeit non-standardized, diagnostic criterion for cancer-acquired lymphedema is an increase in arm volume, which is typically measured no earlier than 3–6 months after locoregional treatment to avoid the transient swelling attributable to surgery and RT [ 18 ].…”

Cancer treatment and survivorship statistics, 2022

“…It has been estimated that the condition occurs in at least one‐fifth of patients after axillary lymph node dissection (ALND) and in approximately 6% of patients after sentinel lymph node biopsy 41 . However, the risk of chronic arm lymphedema may be greatly reduced through prospective surveillance and early management of the condition; in one meta‐analysis that examined the efficacy of this approach, the cumulative incidence of chronic arm lymphedema among women who underwent ALND was only 6% 42 . Cancer rehabilitation can reduce the risk and lessen the severity of the chronic condition 43,44 .…”

“…41 However, the risk of chronic arm lymphedema may be greatly reduced through prospective surveillance and early management of the condition; in one meta-analysis that examined the efficacy of this approach, the cumulative incidence of chronic arm lymphedema among women who underwent ALND was only 6%. 42 Cancer rehabilitation can reduce the risk and lessen the severity of the chronic condition. 43,44 In large part because of limited access to these services, women of lower socioeconomic status are disproportionately burdened by the condition.…”

Evaluation of the External Jugular Vein Overlying the Sternocleidomastoid Muscle as Venous Lymph-Node Flap

“…Breast-cancer-related surgeries are one of the most common iatrogenic causes for lymphedema. For example, Rafn et al recently published a systematic review and meta-analysis and found that the pooled rate of chronic lymph edema after breast cancer surgery has a pooled rate of 4–6% [ 4 ].…”