Evidence
Alert

Screening for lymphoedema after breast cancer surgery could identify women likely to benefit from compression sleeves

Some women having breast cancer surgery would benefit from screening to pick up lymphoedema (swelling of the arm that can become long-term). This can develop as a complication of surgery if lymph nodes are removed.

Lymph nodes under the arm normally drain fluid from the breast. They may be removed during breast cancer surgery to prevent further spread of the disease. But after this treatment, some patients develop lymphoedema. It can cause arm pain and heaviness, and reduce quality of life. 

Healthcare professionals are advised to screen breast cancer patients who have had lymph nodes removed. But there is no agreed standard method of identifying lymphoedema. This study compared two different ways of diagnosing the condition.  

The study also examined which groups of patients are most likely to develop lymphoedema, and which benefit most from treatment. Treatment is often with compression sleeves, which apply pressure to the arm to reduce pain and swelling. Researchers found that only those women who had an increase in arm volume of 5% or more had improved quality of life after this treatment. 

What’s the issue?

Lymphoedema can develop after lymph nodes are removed as an essential part of breast cancer surgery. The complication may be painful and may reduce women’s quality of life. It increases the risk of infections and can cause patients to worry their cancer has returned. 

Screening for lymphoedema after breast cancer surgery is recommended, but there is no standard diagnostic test or agreed criteria for the condition. An early diagnosis of lymphoedema means treatment can be started straight away to reduce discomfort and improve quality of life. 

There are several ways of detecting lymphoedema:

  • some doctors rely on patients reporting symptoms such as tingling, numbness or swelling in the arm
  • arm measurements can be taken using a tape measure 
  • an infrared test called perometry measures changes in arm volume and may be a more reliable way of diagnosing lymphoedema than a standard tape measure 
  • another method, called bioimpedance spectroscopy (BIS) involves passing a small electric current through the body to compare the amount of fluid in the operated arm with the other arm. BIS is most often used in the US to detect lymphoedema early, after surgery. It is used in a handful of NHS centres. 

The usual treatment for lymphoedema is compression sleeves, but it is not known which patients find them helpful. This treatment may be unnecessary for some people. 

What’s new?

Researchers compared the performance of the two diagnostic tools, perometry and BIS, in 1100 women who had recently had breast cancer surgery.  The women’s arms were measured before and after surgery and they were followed up five years later. 

The study found:

  • lymphoedema was associated with poorer quality of life
  • using perometry to find an increase in arm volume of more than 10% after surgery was the most accurate indicator of lymphoedema 
  • BIS overestimated lymphoedema and led to unnecessary treatment
  • obesity, defined as having a BMI of more than 30, increased the risk of developing long-term lymphoedema 
  • patients with an increase in arm volume of more than 5% had improved quality of life after treatment with compression sleeves 
  • compression sleeves did not improve quality of life for women with an increase in arm volume of less than 5%. 

Why is this important?

Screening for lymphoedema after breast cancer surgery is recommended but is not currently standard of care. There are no universal diagnostic criteria for lymphoedema. 

This study suggests that BIS, which is often used to screen for the condition especially in the US, over-diagnoses lymphoedema. This could lead to treatment that will not benefit patients and unnecessary costs for the NHS. 

The research suggests perometry is a more accurate way of diagnosing lymphoedema than BIS and provides a more standardised way of measuring than a tape measure. But if perometry is unavailable, tape measurements are an alternative to calculate volume changes.

A high BMI increases the risk of developing long-term lymphoedema. Doctors should help obese patients to lose weight if they need to have breast cancer surgery.  

What’s next?

Screening for lymphoedema using perometry could become standard practice before and after breast cancer surgery. A NICE review found BIS is less effective at diagnosing lymphoedema than measurement of arm circumference with a tape measure but could potentially detect lymphoedema before patients have symptoms.

You may be interested to read

The full paper: Bundred NJ, and others. Increases in arm volume predict lymphoedema and quality of life deficits after axillary surgery: a prospective cohort study. British Journal of Cancer. 2020;123;17–25. Available at:

A study on the prevalence of lymphoedema after breast cancer: DiSipio T, and others. Incidence of unilateral arm lymphedema after breast cancer: a systematic review and meta-analysis. Lancet Oncology. 2013;14; 500–515

An opinion piece on the study: Brunelle CL, and others. Lymphoedema screening: setting the standard. British Journal of Cancer. 2020;123;1–2.

An article on the importance of incorporating weight management strategies into breast cancer care: Vagenas D, and others. Weight and weight change following breast cancer: evidence from a prospective population based breast cancer cohort study. BMC Cancer. 2015;15;28.

Funding

The trial was funded by the NIHR Programme Grant for Applied Research.

Commentaries

Study author

Lymphoedema is a significant public health problem and causes major quality of life deficits. We wanted to see if we could identify people who were going to develop it early and find the best test to detect it.

What became apparent is that two-thirds of the people who develop lymphoedema had a high BMI. We want the NHS and surgeons to identify the people who might get complications and intervene to try and prevent lymphoedema by advising them to lose weight.

Nigel Bundred, Professor of Surgical Oncology, University of Manchester

Researcher

These findings have the potential to improve the care of women after breast cancer surgery. They support a policy of objective measurement of arm volume before surgery – something that only happens in a few oncology centres in the UK. The study also gives clear guidelines on the type of follow-up needed after surgery. The potential increase in costs from measuring arm volumes after surgery are likely to be offset by savings from overtreatment with sleeves. More accurate risk assessment would reduce patients’ anxiety and the burden of treatment.

There are real nuggets of sensible advice here for managing lymphoedema patients and it will be valuable for training the next generation of breast care nurses, lymphoedema specialist nurses, physiotherapists, and oncology doctors.

Rhian Noble-Jones, Vice Chair of the Scientific Committee of the British Lymphology Society

Conflicts of Interest

None declared.