Benefits of early intervention

There is a chance of preventing or at least mitigating lymphedema
after breast cancer surgery. The key to success is detecting it as
early as the subclinical stage. The focus is on high-risk patients. If
subclinical lymphedema is detected, preventive measures and
subsequent compression therapy as part of secondary prevention
can help ensure women’s recovery and quality of life after the
procedure. Two experts from Madrid reported on experiences from
their lymphological practices.

Dr. Belén Alonso Álvarez, Specialist in Rehabilitation as well as
Treatment of Lymphedema and Lipedema at Hospital Ramon y
Cajal in Madrid, spoke about the current model project
“Prospective Surveillance and Early Intervention for Breast Cancer-
Related Lymphedema (BCRL)”. This project’s driving factor is early
intervention, i.e. at the first signs of lymphedema in breast cancer
patients. But what does ‘early’ mean?
Ideally, breast cancer-related lymphedema should be detected as
early as the subclinical stage, meaning when lymphatic
performance is already impaired, yet no swelling is visible,
explained Dr. Alonso Álvarez. This is aimed particularly at women
with risk factors, such as a high number of axillary lymph node
dissections, regional lymph node radiation, chemotherapy with
taxanes, or a BMI over 25.

Volume and splash
The speaker referred to a study¹ conducted in 2013 according to
which lymphedema continued to develop into a clinical stage after
a relative volume change of more than 10 percent. If the relative
volume change was between 5 and 10 percent three months after
surgery, a significantly increased risk of progression into the
clinical stage was detected. This is therefore when intervention needs to happen. Bioimpedance measurements have proven
superior in detecting the risk of subclinical lymphedema compared
to circumference measurements. However, Dr. Alonso Álvarez
pointed out that not every hospital is equipped with the relevant
technology. Lymphography with indocyanine green has been more
sensitive in early diagnostics compared to volume measurement.
The splash pattern, a typical contrast agent distribution pattern, is
the earliest finding in patients who are still asymptomatic. It can
therefore be regarded as a sign of subclinical lymphedema.

First treatment, then self-management
She named three objectives for the pilot project being conducted
for high-risk patients at Hospital Ramon y Cajal: prevention of
breast cancer-related lymphedema, improvement in quality of life,
and, ultimately, saving money, for patients as well. There are
currently 45 participants in this model project. The treatment
regimen includes a basic examination of all patients. Identified
high-risk cases are then checked every three months during the
first year, other patients every six months. With risk cases,
lymphography with indocyanine green is additionally performed in
the sixth month. The hospital has also set up a “Lymphedema
School” which, in addition to information about the condition, offers video tutorials for self-management, exercises, bandaging
techniques, and compression products. The Spanish model project
has not yet been completed. Dr. Alonso Álvarez promised to
present the results during the next Lymphology Workshop.

Before and after the procedure
Further treatment and self-management of patients after breast
cancer surgery is crucial to prevent the development of
lymphedema, for example, or to keep control of its progression. This
is what Irene del Olmo Domingo, Director at Centro Vodder de Fisioterapia in Madrid, spoke about in her presentation. She also demonstrated how the Godoy & Godoy Method is being incorporated into the treatment concept in her Specialist Center for Oncological
Physiotherapy as well as Lymphedema and Lipedema Therapy.

Lymphedema prevention starts even before surgery. Patients are
prepared for the procedure with breathing, strengthening, and
lymphokinetic exercises. After surgery, focus is on mobilizing the
shoulder girdle and working on range of motion as well as the
axillary fasciae. Treatment of scars and lymph vessels, adapted to
the individual case, is also added. Patients should also strengthen
their muscles as early as possible. Irene del Olmo Domingo pointed out that this would not lead to the edema increasing in volume.

What to do in six hours?
The method developed by Jose María and Fatima Godoy in Brazil
combines manual and mechanical lymphatic drainage. A study
with Centro Vodder’s own patients substantiated that the Godoy
Method resulted in greater reduction in edema volume by 24.5
percent, compared to the procedure according to Vodder. Starting
with manual treatment (intermittent compression therapy for
secondary lymphedema) and cervical therapy, machine-based
treatment of the upper and lower extremities follows. For this
method, the patients remain for a period of one to six hours in a
machine that moves them passively, i.e. without using the force of
their own muscles. The mechanical stimulation of the lymph
vessels promotes removal of macro molecules from the
interstitium, which counteracts fibrosis. Compression is also part
of this treatment. Irene del Olmo Domingo mentioned the versatile treatment options using VenoTrain curaflow in this context. Finally, the
speaker highlighted the immense value of a supported training
program which should transition into the patients’ own training
program to be consistently followed.
In the subsequent discussion, machine treatment and the
extensive duration of six hours raised a lot of questions. According
to Irene del Olmo Domingo, nearly all patients become relaxed and fall
asleep during mechanical therapy, although there is a very small
percentage who have some trouble getting used to the machine.

¹ Specht MC, Miller CL, Russell TA et al. (2013). Defining a
threshold for intervention in breast cancer-related lymphedema:
what level of arm volume increase predicts progression? Breast
Cancer Research and Treatment, 140, 485–494.

Pictures: Andreas Wetzel, Bauerfeind AG, Adobe Stock Image