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Fighting Lymphedema Through Surveillance and Early Intervention

Jamie Wagner, DO

October 31, 2019

Many breast cancer patients have a lifelong risk of developing lymphedema, which is a buildup of fluid in soft body tissues that causes painful swelling.

Lymphedema occurs when lymph nodes are surgically removed, much like intersections being closed during construction. When this happens, fluid can’t move through the body and out because lymph system pathways are gone. If alternate routes can’t be found, then fluid backs up and the arm begins to swell. Patients who have had breast surgery, lymph node removal or radiation are at highest risk for lymphedema, which can cause an arm to swell up to 4 times its normal size.

Surveillance of lymphedema

Early detection allows for early treatment, which can provide the most benefit to breast cancer patients.

After breast cancer treatment, we schedule lymphedema assessments at key intervals just before or after oncology follow-up appointments. This makes it as easy as possible for all patients to come in for assessments.

During this time, we provide patients with education about lymphedema signs, symptoms and prevention tactics. This may include diet, exercise, self-massage, self-care, support groups, garments and referrals to resources.

As part of our comprehensive breast cancer program, The University of Kansas Cancer Center has established lymphedema prevention clinics. Our clinics are located at the Richard and Annette Bloch Cancer Care Pavilion in Westwood and The University of Kansas Hospital in Overland Park. At the clinics, we use painless devices to monitor breast cancer patients for the first signs of lymphedema.

Lymphedema diagnosis and treatment

To ensure we catch lymphedema before it starts, we use a perometer to measure arm circumference before and periodically after breast cancer surgery. This allows us to provide a baseline so we can detect subtle circumference changes early. The rectangular device passes over each of the patient’s arms in a single round-trip, using infrared light beams to measure arm volume.

We also use a state-of-the-art, FDA-approved technology known as L-Dex, which is specifically designed to diagnose lymphedema. L-Dex technology detects extracellular fluid accumulation of the upper extremity that results when the lymphatic system is compromised. The noninvasive exam is easily performed in our clinic. Estimating body composition using low-frequency electrical current, also called Bioimpedance surveillance, we can detect lymphedema 3 to 4 months earlier than traditional methods of assessment.

Once detected, treatment can include at-home programs of stretching, use of a compression sleeve and patient self-massage on the affected side. With the help of these techniques, many patients return to normal exams and never develop lymphedema.

Surgical treatment for lymphedema

For patients who need it, we offer lymphatic surgery to alleviate pain and symptoms. Our plastic surgeons use sophisticated surgical procedures, such as vascularized lymph node transfer and lymphovenous bypass, to effectively treat lymphedema.

These advances offer patients new hope to manage their condition.

Jamie Wagner, DO, breast surgical oncologist, and Sabrina Korentager, RN, clinical nurse coordinator and lymphedema prevention and treatment specialist, discuss breast cancer surgical care and lymphedema treatment.

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 Korenta: 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 Korenta: 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.

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