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- Lymphedema Prevention and Early Detection Go Arm in Arm
Lymphedema Prevention and Early Detection Go Arm in Arm
To understand lymphedema, picture a highway construction project. Machinery and roadblocks interrupt the usual flow of traffic, so construction crew members divert drivers on to side roads to keep traffic moving. Without a detour, cars would continue to back-up, resulting in a jam.
Our bodies have a network of lymph vessels and lymph nodes that function as part of the immune system. The vessels carry oxygen and other nutrients to the cells, and carry away waste like carbon dioxide that flows from the cells. The lymph nodes act as filters for the vessels' content. Nodes that have been removed during cancer surgery can leave the vessel fluid with nowhere to go, a lymph fluid traffic jam. In breast cancer patients, the result is chronic, debilitating swelling of the arm.
Lymphedema occurs in up to 40% of breast cancer patients postsurgery. Between 1 and 5 lymph nodes are removed for a sentinel lymph node biopsy, and more than 10 are typically removed for an axillary lymph node dissection. The condition often goes undiagnosed until it’s clinically apparent, when it cannot be reversed.
The Women's Cancer Center at The University of Kansas Cancer Center focuses on breast and gynecologic cancers and improving the delivery of cancer care. Its Lymphedema Prevention Clinic, of which there are only a few in the country, centers on lymphedema prevention, early identification and treatment with routine surveillance. Every breast cancer patient is scheduled to visit with a lymphedema specialist. In 2017, the clinic’s specially trained nurses treated about 2,000 patients.
Jamie Wagner, DO, FACOS, division chief, breast surgical oncology, points out that because lymphedema is a chronic, progressive disease, the patient population grows year-over-year. Despite its high incidence rate, it has been an understudied side effect of breast cancer treatment.
“When I started practicing surgery and treating breast cancer patients, my patients were more concerned about removal of lymph nodes than their breasts,” says Dr. Wagner. “It’s a huge patient concern that motivated me to better understand lymphedema from a scientific perspective.”
To start, Dr. Wagner and surgery chief resident Lyndsey Kilgore, MD, looked at the outcomes model for mammograms, which emphasizes and demonstrates the importance of early detection. They also analyzed previous lymphedema studies and noticed that baseline measurements of the swelling were rarely taken. The team hypothesized that early identification of lymphedema would result in less extensive treatment and improved outcomes.
These factors became the pillars of a clinical trial aimed at identifying the earliest signs of lymphedema and then intervening and reducing progression. Using The University of Kansas Cancer Center’s database, which contains the details of thousands of breast cancer patients treated at the center, the team narrowed down to a group of 146 women at highest risk for developing lymphedema.
Quick test, simple strategy
All participants were measured pre- and postsurgery using bioimpedance spectroscopy, a tool that uses electrical current to detect tissue resistance to flow. Sticky electrode pads connected to a machine affix to the patient’s arm and leg. Minutes later, results are available. The team also took physical arm measurements, which is the current standard of care.
“The bioimpedance spectroscopy tool can detect subtle changes in a patient’s extracellular fluid volume before it’s ever detectable via arm measurements,” Dr. Kilgore says. “It even senses buildup at the subclinical level, before the patient notices.”
Participants with altered measurements indicating lymphedema were prescribed easy at-home methods to reduce progression. This included wearing compression sleeves and patient-directed self-massage.
This intervention proved to be highly effective in preventing breast cancer-related lymphedema: 82% of the women diagnosed with early-stage lymphedema returned to their normal pretreatment measurements. The results, which were presented at the 2018 annual American Society of Breast Surgeons meeting, made national headlines.
The findings not only support interventions that are convenient and easy to follow, they also support the case for insurance companies to broaden lymphedema coverage. Compression sleeves, for example, are rarely fully insured and can cost $1,000 or more.
The team is already thinking about how to make this straightforward yet life-changing approach to a wider patient group. The second generation of the bioimpedance spectroscopy omits the sticky pads, eliminating the need for a 1-on-1 appointment with a specially trained nurse to administer the test. Nurses remain a critical part of the process as they interpret test results and follow-up with patients.
“The new detection devices are embedded in the machine. You literally stand on a pad with bare hands and the results are generated,” Dr. Kilgore says. “It provides so many opportunities in terms of making this technology available to rural parts of Kansas.”
One in 8 women will develop breast cancer in her lifetime, and a large percentage of those with cancer will be at increased risk of developing lymphedema. That’s why Dr. Wagner continues to push research efforts that aim to increase our understanding of it.
“In clinical research, you’re always thinking of the next phase of your idea. I hope to take this beyond the walls of our own institution by developing a multicenter trial that can be conducted at sites across the country,” Dr. Wagner says. “This is cutting-edge research that could really make a difference in a patient’s quality of life. And it started here at The University of Kansas Cancer Center.”
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Speaker 1: Welcome to Bench to Bedside, a weekly series of live conversations about recent advances in cancer from the research bench to treatment at the patient's bedside. And now, your host and the Director of the University of Kansas Cancer Center, Dr. Roy Jensen.
Dr. Jensen: Hi. I'm Dr. Roy Jensen. Thanks for joining us today for today's episode of Bench to Beside. With me is Dr. Jamie Wagner, a Breast Surgical Oncologist at the Women's Cancer Center at the University of Kansas Cancer Center, and Clinical Nurse Coordinator and Lymphedema Prevention and Treatment Specialist, Sabrina Korentager. October is Breast Cancer Awareness Month, so it's an ideal time to call attention to advances in breast cancer surgical care and lymphedema treatment. Today we're going to focus our discussion on lymphedema prevention and its impact on patient care and quality of life for breast cancer patients everywhere. Sabrina, could you tell us what exactly is lymphedema?
Sabrina Korentager: Lymphedema is swelling usually of an arm or a leg, that's caused by the disruption of the normal lymphatic flow. In our breast cancer patients, lymphedema most often will occur as a result of treatment for breast cancer, whether that's removal of a lymph node or radiation treatment. So, those areas that affected can have a disruption in that flow. It's a necessary part of their treatment, but it can have a side effect.
Dr. Jensen: What causes lymphedema to occur in breast cancer? Sabrina Korentager: When I'm working with a patient, I explain that lymphedema can occur with ... you think about how a construction site happens. If you're traveling on a highway and you come across road construction, there's a part of the road that's disrupted. In the body, when we remove a lymph node, it's causing a disruption in the normal flow, much like road construction. If the body can't find a new pathway and isn't able to get around the detour, then the fluid that normally routes is unable to route. If that happens over time, just like a lot of cars will back up, a lot of fluid will back up. Over time, this leads to swelling. Chronic swelling may lead to other things such as pain, infection, inability to do your daily activities of living, decreased range of motion, and it really can impede a woman's quality of life.
Dr. Jensen: So, Dr. Wagner, why is lymphedema such a concern, particularly among breast cancer patients?
Dr. Wagner: Well, in particular for invasive breast cancer patients, they all have to undergo some type of nodal procedure, whether it's a sentinal lymph node biopsy when we're sampling just those very first few lymph nodes that drain the breast, or with more advanced disease that has now invaded into the lymph nodes. Some of those women have to have a complete axillary lymph node dissection, where we're taking out well more than ten lymph nodes within the axilla. As a result, we know that women have a risk of lymphedema, whether it's five to ten percent with just those few lymph nodes removed. But we also have a risk of 20 to 40% in those women that have to have much more extensive surgery. So, we are putting all of these invasive cancer patients at least at a risk for developing lymphedema.
Dr. Jensen: Mm-hmm (affirmative). What, exactly, are our breast cancer specialists, namely, the both of you, doing to combat this issue?
Dr. Wagner: We have taken more of an education, prevention, and early identification approach, very similar to the accomplishments we have made with mammography screening where we know that early identification allows us to identify breast cancers at earlier stages, and that requires treatment to be successful in the treatment. That is the approach that we have now taken with lymphedema. So getting a baseline measurement, we know first and foremost is the most important aspect of what we do for our patients. So, before we ever implement any treatment, whether it's surgery, chemotherapy, or radiation, we want to know what is normal for them. So we get that baseline measurement. Then, after their treatment, we continue to follow them on a very routine basis, again, very similar to mammography, where we recommend that be done every year, we're doing the same thing, but on a very routine basis, much closer in timeframe in the beginning and then, eventually, we will spread that timeframe out just to be annual. But we follow them. What that has allowed us to do is identify the early stages of lymphedema at what is considered subclinical stages. So, before a patient can even identify it, before the older methods of tape measure, circumferential measurement had been identifying it, we are identifying this at subclinical stages. That has now allowed us to implement very modest lifestyle changes and modest treatments, most of which we can teach the patient at home. That has allowed us to get patients back down to that baseline normal measurement, and it prevents them from going on to have progression of that lymphedema to a point that does impact their quality of life, as Sabrina had explained.
Dr. Jensen: So, that's really incredible. It's fantastic. If you're just joining us, we are here with Breast Surgical Oncologist, Dr. Jamie Wagner, and Clinical Nurse Coordinator, Sabrina Korentager, discussing lymphedema treatment in breast cancer patients. If you have any questions for our experts, you can post them in the comments section. Remember to share this link with people you think might benefit from our discussion. Use the hashtag benchtobedside. Dr. Wagner, studies show that patients achieve the best outcomes when they obtain treatment in large volume academic medical centers. Why does that make such a difference, particularly for breast cancer patients?
Dr. Wagner: Well, in particular, in these larger, such as NCI designated cancer centers that we have the opportunity be a part of here at the University of Kansas Cancer Center, we know that those patients are being treated by subspecialists, physicians and even nurses that are subspecialty trained within that specific disease treatment site. With that, we understand that there is a broader aspect of treatment that's being implemented. We're looking at truly the multi-disciplinary approach. And, through the many years of research that we have, especially for breast cancer patients, we understand that that subspecialty training and the multi-disciplinary approach of a team coming together to tailor that treatment strategy and that treatment plan for each individual patient and their specific tumor type really has the best outcomes.
Dr. Jensen: Mm-hmm (affirmative). So that's very exciting. As we approach the end of today's program, what would you say would be the key take away that you want to give our audience to remember?
Dr. Wagner: I think it's very important for patients to seek out the highest level of care with a very subspecialized, multi-disciplinary approach because we know that patients treated at NCI designated cancer centers actually have a change in the breast cancer diagnosis by 46%, by recent studies. And early identification across the board, whether it be their actual breast cancer treatment through good screening mammography performed annually starting at the age of 40, all the way to prevention and early identification for lymphedema. Prevention is the best method for best outcomes and survival.
Dr. Jensen: Well, thank you, Dr. Wagner and Sabrina. That's it for today. Thank you for joining us. We invite you to tune in next week, always Wednesday at 10 a.m., where we will have yet another topic from the KU Cancer Center. Thanks for watching.