With advances in technology, lymphoedema is now considered an unnecessary evil for breast cancer patients post-treatment. General practitioners have an important role to play in reducing their risk of lymphoedema through increased patient awareness, proper precautions and timely detection.
Before the twentieth century, the radical Halsted mastectomy was considered the gold standard in the treatment of breast cancer. Patients may have survived, but they did not live well as many were left scarred with disfiguring wounds and significant morbidities.
These women suffered a profound, debilitating impact on their affected chests and the functions of their shoulders and arms, resulting in persistent suffering of pain, numbness and swelling with little means of relief.1 It was an ironic reminder of their socalled victory over cancer, or the ‘necessary evil’.
In recent years, there has been a paradigm shift in the aims of breast cancer treatment – to not merely achieve the best oncological outcomes but also focus on improved quality of life for cancer survivors in tandem.
A potential morbidity of any lymph node surgery is lymphoedema, the swelling of the draining limb due to disruption of lymph flow.
As axillary surgery is an integral part of staging and providing locoregional control of breast cancer, it is almost routinely performed. Lymphoedema is estimated to affect up to 20% of breast cancer patients and occurs within the first few years of treatment.
Most cases of lymphoedema present with mild symptoms and are potentially reversible, but in advanced cases, it can cause severe limitations to the function of the affected breast and limb, resulting in pain, swelling or recurrent infections.
A patient with a swollen arm due to lymphoedema (Figure 1) not only has a higher risk of cellulitis and other debilitating symptoms such as pain or numbness, but also experiences inconvenience in many aspects of daily living such as finding fitting clothes or wearing jewellery.
Figure 1 A patient with a marked swollen right arm due to breast cancer related lymphoedema, who can only wear jewellery on the unaffected wrist.
These patients may need:
Ongoing manual lymphatic drainage
To wear compression garments which are extremely uncomfortable in our warm climate
To undergo surgical procedures to restore lymphatic flow and minimise damage from chronic lymphoedema
This potential health burden is often given much less consideration during the initial stages of cancer diagnosis and in the treatment decision-making process.
With our improved understanding of cancer biology, doing ‘more’ does not always lead to better results. In fact, by choosing the right treatment strategy, we could see an overall improved quality of life with decreased morbidities, and have similar long-term survival outcomes.
From axillary clearance to sentinel lymph node biopsy
Traditionally, axillary clearance (AC) was performed to remove all the lymph nodes in the axilla regardless of whether there was disease in the draining nodes. However, it was quickly apparent that it did not convey survival benefits in patients who did not appear to have cancer in the axilla.
A less invasive yet accurate procedure of sentinel lymph node (SLN) biopsy quickly replaced AC as the gold standard procedure for such patients.
Omitting AC in favour of radiotherapy
When cancer was detected in any of the SLN, an AC was still routinely performed to eradicate cancer in the nodal basin.
However, this practice was also challenged when the results of the landmark trials such as the American College of Surgeons Oncology Group (ACOSOG) Z0011 trial and the AMAROS trial showed that we could reliably avoid axillary dissection in favour of radiotherapy for a subset of patients with early, low-risk breast cancer and limited nodal disease – without causing any difference in survival benefits, and yet lowering the incidence and severity of lymphoedema.2,3
Neoadjuvant chemotherapy to test tumour biology – to avoid AC in complete responders
In patients with established nodal disease, another strategy to de-escalate axillary surgery in breast cancer management involves the use of neoadjuvant chemotherapy (NACT). This is particularly suitable for cancer subtypes known to respond favourably to it, such as:
Figure 2 shows an enlarged pathological lymph node (A) which was marked with a sonographically visible clip and showed shrinkage (B) after NACT. The clipped lymph node was then identified by ultrasound localisation and retrieved as SLN, which corresponds to the node with blue (C) and fluorescent indocyanine green (D) uptake.
Targeted axillary lymph node dissection to spare patients from AC
Targeted axillary lymph node dissection (TALND) is a modified axillary staging technique which combines the conventional SLN biopsy with pretreatment localisation of the involved nodes.
Should there be good clinical response after NACT such that no obvious nodal disease remains, this targeted approach would spare the patient from the morbidity of a traditional AC, and have similar efficacy in terms of axillary staging and long-term survival outcomes.
Omission of axillary staging if it does not affect management
Lastly, in situations whereby additional axillary staging information may not influence prognosis or treatment, the decision to omit axillary surgery can be undertaken safely after discussion in a multidisciplinary setting with input from treating medical and radiation oncologists.
This may be applicable to a small proportion of patients with otherwise very favourable tumours, or patients with poorer prognosis and who would unlikely benefit from any other adjuvant systemic therapy and/or radiotherapy.
It is advisable to take the necessary preventative measures for at-risk limbs. Risk factors like a raised BMI and recurrent arm infections should be addressed.
This is especially since any form of axillary surgery, chemotherapy and radiation to the lymph nodes could increase the patients’ chances of developing lymphoedema and put them at risk.
The unnecessary evil of misinformation
However, when there is frequent association of certain practices and lymphoedema, a causal relationship becomes falsely perpetuated by anecdotal or poor-quality evidence. The perceived threat or unwarranted restrictions could also become an unnecessary evil.
For instance, some patients and clinicians may caution about developing lymphoedema from air travel, physical activity, compression garments, blood pressure taking, venepuncture – and the list goes on.
A literature review conducted by the Changi General Hospital Health Services Research department showed that there was very little evidence-based literature regarding many of such advice to avoid physical activity, carrying heavy things or putting on compression garments during air travel. In fact, those that demonstrated positive associations were not without significant bias.
We recommend three easy and evidence-based principles to safeguard against lymphoedema for those at risk (adopted from the National Lymphedema Network Position statement)5.
1. Appropriate skin care to avoid trauma and injury to the at-risk limb to reduce infection risk, if possible
Applying moisturisers to prevent chapping/chafing of the skin and paying attention toenail care
Wearing protective garments when doing activities that may cause injuries (e.g., washing dishes, gardening or working with tools/chemicals)
If any scratches or punctures should occur, attending to the wound appropriately (e.g., washing with water and soap and observing for signs of infection)
Seeking medical attention early if there are signs of possible infection such as fever, swelling, redness or pain
Avoiding excessive or prolonged constriction – including from poor-fitting blood pressure cuffs or garments, or extremes of temperature that can result in tissue injury
2. Maintaining a healthy weight
A high BMI is a known risk factor for developing lymphoedema. Patients should always adopt regular exercise and a healthy diet in their lifestyles and build up the duration and intensity of activity safely. There is no physical limitation to what an at-risk limb is allowed to do.
3. Regular surveillance for lymphoedema
Report any changes to your at-risk limb such as an increase in size or a change in sensation, colour, temperature or skin condition.
While there may be variations in healthcare policies among various medical facilities regarding the at-risk limb, every healthcare professional should make a reasonable attempt to protect any limb that the patient identifies as being at risk.
If, however, in a medical emergency or when there is no uninvolved limb, healthcare professionals should address the medical priority, take reasonable precautions to address patients’ concerns properly and take appropriate actions to monitor for swelling.
Looking out for signs and symptoms
Early detection is another key to the management of lymphoedema.
The majority of cases occur within the first few years of surgery. When detected in its early stages, the condition tends to be reversible and cause less detriment to quality of life. It is hence recommended to screen for the signs and symptoms of lymphoedema (Table 1).
Taking pre-treatment limb measurements
Pre-treatment limb measurements are recommended to be taken as a baseline and at regular intervals, either by treating clinicians or trained lymphoedema assessors.
The surveillance strategy can be done through:
Cost-effective methods such as taking the arm circumference
Using specialised tools such as:
A perometer which calculates limb volume
Bioimpedance spectroscopy which analyses the composition of fluid compartment in the body to detect early lymphoedema in the at-risk limb
With an increased awareness about lymphoedema, we can educate patients, the community and healthcare professionals to better manage this potential complication brought about by breast cancer treatment.
In conclusion, it is time to not only rethink about the priorities of cancer treatment, but also to weigh the value of every treatment against its potential harms, and be aware of the strategies to avoid the unnecessary evil as much as possible.
Plesca M, Bordea C, El Houcheimi B, Ichim E, Blidaru A. Evolution of radical mastectomy for breast cancer. J Med Life. 2016;9(2):183-186.
Krag DN, Anderson SJ, Julian TB, et al. Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically nodenegative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncol. 2010;11(10):927-933.doi:10.1016/S1470-2045(10)70207-2
Giuliano AE, Ballman KV, McCall L, et al. Effect of Axillary Dissection vs No Axillary Dissection on 10-Year Overall Survival Among Women With Invasive Breast Cancer and Sentinel Node Metastasis: The ACOSOG Z0011 (Alliance) Randomized Clinical Trial. JAMA. 2017;318(10):918–926. doi:10.1001/jama.2017.11470
Donker M, van Tienhoven G, Straver ME, et al. Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS): a randomised, multicentre, open-label, phase 3 non-inferiority trial. Lancet Oncol. 2014;15(12):1303-1310. doi:10.1016/S1470-2045(14)70460-7
National Lymphoedema Network Position Statements, Available at https://lymphnet.org/position-papers
Clinical Assistant Professor Jeffrey Hing Jun Xian is a Consultant Breast Surgeon at Changi General Hospital (CGH). He completed his overseas fellowship in Korea and Japan where he trained under various pioneers in the field of minimally invasive and oncoplastic breast surgery. He believes in supporting his patients to make balanced and well-informed decisions in their treatment journey and delivering the best possible outcome with every surgery.
He is appointed Clinical Assistant Professor at Duke-NUS Medical School and is the clinical lead for students from the Lee Kong Chian School of Medicine in CGH General Surgery.
GPs can call the SingHealth Duke-NUS Breast Centre for appointments at the following hotlines or click here to visit the website:
Singapore General Hospital: 6326 6060 Changi General Hospital: 6788 3003 Sengkang General Hospital: 6930 6000 KK Women's and Children's Hospital: 6692 2984 National Cancer Centre Singapore: 6436 8288
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