Lymphedema Prevention and Early Detection Go Arm In Arm

Jamie Wagner, DO, Lyndsey Kilgore, MD

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 percent of breast cancer patients post-surgery. Between one and five lymph nodes are removed for a sentinel lymph node biopsy, and more than ten 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 Wagner. “It’s a huge patient concern that motivated me to better understand lymphedema from a scientific perspective.”

To start, 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 KU 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 post-surgery using a bioimpedence 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 bioimpedence spectroscopy tool can detect subtle changes in patient’s extracellular fluid volume before it’s ever detectable via arm measurements,” Kilgore says. “It even senses build-up at the sub-clinical 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 percent of the women diagnosed with early-stage lymphedema returned to their normal pre-treatment measurements. The results, which were presented at the 2018 annual American Society of Breast Surgeons (ASBrS) 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 a thousand or more dollars.

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 bioimpedence spectroscopy omits the sticky pads, eliminating the need for a one-on-one 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,” Kilgore says. “It provides so many opportunities in terms of making this technology available to rural parts of Kansas.”

One in eight 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 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 multi-center trial that can be conducted at sites across the country,” 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 KU Cancer Center.”