An algorithm for screening and treatment of breast cancer-related lymphedema.

Abstract

256 Background: Currently, there is no clear-cut regimen for the treatment of breast cancer related lymphedema. There is evidence advocating both conservative and micro surgical therapy, with treatment effectiveness being dependent on the lymphedema stage. We propose a multidisciplinary screening program with the aim of preventing breast cancer related lymphedema progression and ensure disease regression by early identification and treatment initiation. This approach would ultimately reduce the negative functional, psychosocial and cosmetic consequences resulting from (chronic) lymphedema. Methods: All women with early stage breast cancer are included in this screening program. We use preoperative and sequential postoperative bilateral upper limb circumference measurements and patient perception to identify lymphedema. A difference of > 2cm between post-operative and baseline circumference and patient perception of (refractory) swelling constitutes a diagnosis of lymphedema. Upon lymphedema diagnosis, patients are referred to a lymph therapist for initiation of conservative therapy in the form of complex decongestive physiotherapy. Therapy effect is evaluated after 1 month. In case of unsatisfactory symptom or limb circumference reduction, the patient is considered for surgical treatment. A plastic surgeon evaluates the possibility of microsurgical lymph vessel repair in the form of lymphatic-venous anastomoses or lymphatic-venous-lymphatic anastomoses. This minimal invasive surgery can improve lymph flow in the affected limb. If despite this, symptom improvement and patient satisfaction remains minimal, autologous lymph node transplantation is considered. Results: The aimed outcome parameters are 1) limb circumference reduction, 2) perceived symptom improvement: (refractory) swelling, 3) quality of life improvement, 4) limb range of motion improvement, 5) strength and sensory improvement, 6) restoration/improvement of lymph flow visualized by lymphoscintigraphy. Conclusions: A structured approach for a multidisciplinary treatment of breast cancer related lymphedema is proposed to reduce the negative functional, psychosocial and cosmetic consequences resulting from (chronic) lymphedema.