Lymphedema can be a debilitating side effect of breast cancer treatment. To diagnose and treat the condition early, when it may be reversible, a program at The University of Texas MD Anderson Cancer Center identifies and screens patients at high risk for lymphedema.
Breast cancer surgery sometimes requires the removal of some or all of the axillary lymph nodes, and radiation therapy to the regional lymph nodes (which include the internal mammary, axillary, and supraclavicular lymph node beds) can damage the lymphatic system. When the body is unable to drain lymph, fluid can build up in the patient’s extremities; in breast cancer patients, this tends to occur in the arms.
“Lymphedema affects quality of life for our patients. Patients end up with arms that are much larger than normal and feel heavy and painful. Sometimes it’s difficult for these patients to fit into their clothes and to do their regular activities,” said Simona Shaitelman, M.D., an assistant professor in the Department of Radiation Oncology. “Unfortunately, if lymphedema is not diagnosed early, it’s nearly impossible to completely reverse the condition.”
Dr. Shaitelman encourages patients who are at high risk for lymphedema (i.e., those whose breast cancer treatment includes axillary lymph node dissection or radiation therapy to the regional lymph nodes) to see a physical therapist for an educational session right after treatment. She said, “Physical therapists can teach patients preventive exercises that they can do at home to reduce their risk of lymphedema, which really empowers patients.” Dr. Shaitelman also makes sure patients who are at high risk for lymphedema are included in long-term follow-up through the lymphedema screening initiative.
Lymphedema screening initiative
Dr. Shaitelman and her colleagues have established a lymphedema screening initiative at MD Anderson to diagnose this debilitating condition as early as possible. At the Breast Center, pretreatment arm measurements are taken via perometer for patients who will undergo any type of treatment to the lymph nodes. When high-risk patients return to MD Anderson for follow-up visits, arm measurements are included with the workup for other vital signs. If the arm measurement increases, the patient is referred to physical therapy.
Refining perometer use
To reduce measurement errors, two medical assistants are dedicated to lymphedema screening in the Breast Center and have been trained to use perometers, which employ infrared technology to measure arm volume and may enable detection of lymphedema earlier than standard tape measurements. However, after starting the initiative, Dr. Shaitelman and her colleagues found that the perometer measurements were not as reliable as had been expected.
“We wanted to make sure that our results were reproducible so that we didn’t misdiagnose patients,” Dr. Shaitelman said. Toward this goal, she worked with Parviz Kheirkhah, Ph.D., a senior health care systems engineer in the Office of Performance Improvement, to optimize the perometer measurements. They added handlebars of different heights to the machine and to the wall near the machine; these handlebars help patients to remain stable and optimize their positioning for the measurements. The handlebars have decreased variability in perometer measurements by 28%.
Patients at MD Anderson who have lymphedema are seen by physical therapists who are certified by the Lymphedema Association of North America. These patients typically undergo complete decongestive therapy, which includes manual lymph drainage and the use of compression garments. When complete decongestive therapy cannot control a patient’s lymphedema, the patient is referred to a plastic surgeon. Mark Schaverien, M.D., Edward Chang, M.D., and Matthew Hanasono, M.D., are among the faculty members in the Department of Plastic Surgery who specialize in microvascular techniques that can improve lymph drainage to relieve lymphedema.
“We’re working to improve our screening program so that we can begin to triage patients and systematically determine who should be referred to plastic surgery earlier,” Dr. Shaitelman said. “We’d like to take better advantage of the specialized skill set of our plastic surgeons and let patients know that this treatment option is available.” Ongoing research is expected to improve these screening and triage efforts.
Sarah DeSnyder, M.D., an assistant professor in the Department of Breast Surgical Oncology, is the principal investigator at MD Anderson for a multicenter clinical trial (2014-0911) to determine whether bioimpedance spectroscopy, which measures extracellular fluid, can detect subclinical lymphedema earlier than standard tape measurements, resulting in treatment at earlier stages and a lower rate of progression. The trial will also investigate factors associated with lymphedema progression (such as body mass index, seroma, smoking status, age, and air travel), evaluate time until progression requires complete decongestive therapy, and determine whether subclinical lymphedema detection and early intervention improve symptoms and quality of life compared with tape measurements and later intervention. The trial is enrolling patients who plan to undergo surgery for invasive breast cancer or ductal carcinoma in situ.
In another clinical trial, Drs. Shaitelman and DeSnyder along with Elizabeth Mittendorf, M.D., Ph.D., an associate professor in the Department of Breast Surgical Oncology, and Melissa Aldrich, Ph.D., an assistant professor in the Center for Molecular Imaging at The University of Texas Health Science Center at Houston, will investigate immune and inflammatory markers for lymphedema (2016-0170). The trial will soon begin enrolling patients with locally advanced breast cancer who will undergo axillary lymph node dissection and radiation to the regional lymph nodes. Using fluorescence imaging with microdose amounts of dye to visualize the lymph nodes in the patients’ arms, the trial aims to determine whether early changes in the lymphatic system are correlated with serum immune or inflammatory markers.
“We hypothesize that lymphedema is an autoimmune reaction,” Dr. Shaitelman said, adding that this hypothesis is supported by data from multiple fields. “Discovering immune-related biomarkers for lymphedema could help us further refine which patients are at high risk, counsel patients to reduce their risk of lymphedema, and find therapeutic targets.”
The findings from these trials, if validated, will be incorporated into the lymphedema screening initiative. Dr. Shaitelman said, “We want our initiative to be flexible and science based. With advances in technology for detecting and treating lymphedema, we hope to diagnose and treat patients early to reverse this condition.”
While current lymphedema screening and research programs focus on improving quality of life for breast cancer survivors, findings from these efforts could have applications for other cancer sites. As long-term data become available on the outcomes of breast cancer patients who participate in the lymphedema screening initiative, the program may be adapted to screen for lymphedema in patients with head and neck cancers, melanoma, or gynecological malignancies.
For more information, contact Dr. Simona Shaitelman at 713-563-8491.
OncoLog, September 2016, Volume 61, Issue 9