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State of Chest and Breast Lymphedema:

By Lesli R. Bell, PT CLT-LANA

A Brief Compilation of Lymphedema Research

Over the past 15 years, Breast Conserving Therapy (BCT) has supplanted mastectomy to an ever-increasing extent. In BCT, the resection is limited to removing the tumor from the breast, followed by either a formal axillary lymph node dissection or a sentinel lymph node biopsy. The role played by radiotherapy is greater with this treatment than following mastectomy. The results of BCT with respect to survival — and to disease-free-survival — are at least as good as those achieved by mastectomy. However, after BCT (with or without radiotherapy) or mastectomy, twenty to forty percent of women develop chronic lymphedema at an average time of three years following treatment. Depending on the severity, the lymphedema can impede, to a greater or lesser extent, the woman's return to her normal activities. Her quality of life both at home and at work can be affected. Possible physical complications of lymphedema of the breast and chest wall include: asymmetry of the breasts, impairment of scar formation, fibrosis, chronic pain in the breast and axilla, and (rarely) plexopathies.

In her article, "Seroma and Other Factors Influencing the Development of Breast Cancer and Edema Following Breast Cancer Treatment", Barbara Martlew cites a 1998 study of 250 patients with lymphedema and no evidence of local recurrence who had been treated with varying types of axillary dissection from sampling to complete. What she found was that 25% exhibited lymphedema confined to the trunk or breast with little or no arm edema. This was an increase of 20% over her observations the prior year. In 1992 a study by Moffat noted that breast edema developed in 21% of women undergoing post-operative radiation therapy to the breasts and or lymph nodes.

The most comprehensive data on lymphedema resulting from breast cancer treatment appears to be a set of studies compiled by the National Health and Medical Research Council (NHMRC) in Australia. However, these studies focused on arm lymphedema, which is much more commonly recognized. While the extent of chest region edema remains hard to assess, the NHMRC clearly called for more comprehensive and conclusive research and an increase in education regarding the condition.

The various studies reviewed by the NHMRC showed that there were a significant number of women who suffered lymphedema as a result of breast cancer treatment, including both axillary dissection and axillary radiation. In one of the studies considered methodologically stronger by the NHMRC, the prevalence of lymphedema following full axillary dissection was estimated as ranging from 12% to 60%, with a consensus that over a third of patients experience lymphedema.

We were only able to find five studies of lymphedema in women treated with axillary sampling followed by axillary radiation. These studies were considered to be weaker methodologically and indicated lymphedema rates lower than those following full dissection at between 6% and 32%. The study on axillary radiation reported a lymphedema rate of 32%, with a milder edema reported.

These complications are sub-chronic to chronic in nature. At present, manual lymphatic drainage (MLD) and or complete decongestive therapy (CDT) treatment for lymphedema of the breast, chest wall or extremity is very effective, but has a temporary effect without adequate maintenance measures.

Extensive experience and research has clearly shown that MLD and CDT may cause the complaints to disappear in 20% to 60% of patients. Even with the chronic character of the lymphedema, the response to MLD treatment occurs relatively quickly, in an average of 5 to 10 treatments.

The question therefore arose as to how the result achieved could be maintained in the breast and chest wall. It is been documented that the use of a compression garment prevents the re-accumulation of fluid in tissues affected by lymphedema, by increasing the hydrostatic pressure from the outside. However, compression garments have only been designed for the upper and lower extremities.

Since compression is the accepted treatment for maintenance of the extremities, it makes sense that compression would also work for the breast and chest wall. Many therapists do indeed recommend athletic bras for the control of swelling and pain. However, sizing and fit are a problem. Most athletic bras are not available in larger sizes, and therefore leave little to no compressive bra options for the larger patient. Athletic bras also do not cover all of the areas that are commonly problematic. They are difficult to get on and off, especially for the post-operative patient. Other options such as custom-made compression vests may be more than what the patient needs.

Most compression garments are custom-fit for involved extremities. However, based on the athletic bra's success in providing compression that prevents vertical motion of the breasts, and the reported comfort of said bras, it is conceivable that with adjustability of girth and the normal sizing of a bra, comfortable compression could be achieved for the breast and chest wall lymphedema patient without custom fitting.

Therefore, a compressive bra that covers high-risk areas, and that has an adjustable girth, a front closure to ease the difficulty of getting it on, a longer silhouette to avoid putting pressure on the areas that naturally drain lymphatic fluid, and wider and padded adjustable straps, would be an asset to patients and the therapists who are helping with long term lymphedema management.

Study References:

1. Kissin MW, Querci-della-Rovere G, Easton D, Westbury G. "Risk of lymphoedema following the treatment of breast cancer". British Journal of Surgery 1986;73:580-4.

2. Hoe AL, Iven D, Royle GT, Taylor I. "Incidence of arm swelling following axillary clearance for breast cancer". British Journal of Surgery 1992;79:261-2.

3. Aitken RJ, Gaze MN, Rodger A, Chetty U, Forrest APM. "Arm morbidity within a trial of mastectomy and either nodal sample with selective radiotherapy or axillary clearance". British Journal of Surgery 1989;76:568-71.

4. Olsen NK, Pfeiffer P, Mondrup K, Rose C. "Radiation-induced brachial plexus neuropathy in breast cancer patients". Acta Oncologica 1990;29:885-90.

5. Larson D, Weinstein M, Goldberg I, Silver B, Recht A, Cady B et al. "Edema of the arm as a function of the extent of axillary surgery in patients with stage I-II carcinoma of the breast treated with primary radiotherapy". International Journal of Radiation Oncology, Biology, Physics 1986;12:1575-82.

6. Chiverton SG, Perry PM. "Morbidity after surgery for breast cancer". British Journal of Surgery 1987;74:1166.

7. Gerber L, Lampert M, Wood C, Duncan M, D'Angelo T, Schain W et al. "Comparison of pain, motion, and edema after modified radical mastectomy vs local excision with axillary dissection and radiation". Breast Cancer Research and Treatment 1992; 21:139-45.

8. Liljegren G, Holmberg L. "Arm morbidity after sector resection and axillary dissection with or without post-operative radiotherapy in breast cancer stage I. Results from a randomised trial. Uppsala-Orebro Breast Cancer Study Group". European Journal of Cancer 1997;33:193-9.

9. Bates TD. "The 10-year results of a prospective trial of post-operative radiotherapy delivered in 3 fractions per week versus 2 fractions per week in breast carcinoma". British Journal of Radiology 1988;61:625-30.

10. Segerström K, Bjerle P, Graffman S, Nyström A. "Factors that influence the incidence of brachial oedema after treatment of breast cancer". Scandinavian Journal of Plastic & Reconstructive Surgery & Hand Surgery 1992;26:223-7.

11. Göltner E, Gass P, Haas JP, Schneider P. "The importance of volumetry, lymphscintigraphy and computer tomography in the diagnosis of brachial edema after mastectomy". Lymphology 1988;21:134-43.

12. Siegel BM, Mayzel KA, Love SM. "Level I and II axillary dissection in the treatment of early-stage breast cancer. An analysis of 259 consecutive patients". Archives of Surgery 1990;125:1144-7.