Lymphedema is a serious complication of breast cancer treatment, and lymphatic distribution and fluid transposition into the interstitial area are caused by either cancer invasion to the lymph nodes or concurrent surgery, radiation exposure. Patients may have symptoms such as heaviness or fullness and may present lymphedema clinical signs such as with swelling in the hand, arm, breast, chest wall or trunk. Consequently, the physical and psychological and emotional well-being is significantly deteriorated. Women who have obvious arm swelling, motion limitations, skin lesions like hyperkeratosis, nodules, and open wounds experience emotional dissatisfaction with their bodies (1). Up to 40% of patients with breast cancer face the inevitable breast cancer related lymphedema (BCRL) (2). Although a multidisciplinary approach is the foundation of breast cancer treatment, there may be a higher risk of BCRL as a result of surgical management, radiation, and systemic therapies.
The article published in Journal of Clinical Oncology recently enlightens us about how BCRL might be delayed or reduced in high-risk women using current data, which is the main reason why we found it to be quite interesting and insightful (3). The primary endpoint was arm swelling based on bioimpedance spectroscopy (BIS). It is important to note that in all cases of this study, arm swelling was observed less frequently in the compression group (38%) than in those in the control group (53%) and significantly postponed symptoms (HR: 0.61; 95% CI, 0.43 to 0.85; P=0.004). Furthermore, due to BIS, the approximate incidence of arm swelling was relatively different; 42% (95% CI, 34% to 51%) in the compression group and 52% (95% CI, 44% to 61%) in the control group). On the other hand, when comparison settled by relative arm size, the results qualitatively resemble, whereas they occurred less frequently and developed later (HR: 0.56; 95% CI, 0.33 to 0.96; P=0.034). Overall, these results indicate that the aggregate incidence of arm swelling was found approximately 10% lower with compression sleeves: 14% (95% CI, 9% to 22%) in the comparison group and 25% (95% CI, 19% to 33%) in the control group. In addition, the authors observed that a multivariate Cox model identified older age and neoadjuvant chemotherapy as variables that were remarkably connected to the time to the beginning of arm size increasement, but the authors also proved that approaches with sleeves remained a compelling factor after alteration for these variables (HR: 0.57; 95% CI, 0.34 to 0.97; P=0.038). Small sample size and baseline differences in significant risk factors between groups make it difficult to draw firm conclusions about the efficacy of preventive compression sleeves. Nevertheless, in this study, with a prospective design, a considerable number of participants who were over 18 years old and operated with unilateral breast mass were evaluated. Additionally, based on the findings in this study, compression sleeves augment safe, appropriate, and preferable use in women, with significant positive effects on self-reported general health and physical functioning. On the other hand, it is not known whether similar results in incidences will remain in BCRL in 5 years’ time.
Theoretically, advancements in oncoplastic surgery, including minimally invasive techniques, fewer axillary interventions, better systemic therapy agents, earlier symptom diagnosis, and more effective prevention strategies, should reduce the risk ratio of BCRL. As mentioned in the article, studies are heterogeneous and unresolved, therefore defining standardized indications for conservative interventions is challenging. The authors stated that prophylactic use of compression garments is advantageous in detection and intervention in inhibiting symptoms related to lymphedema at a high-risk profile because the terms and management of subclinical lymphedema remains not clear. Indeed, indocyanine green lymphography (ICG_L) is a tool to identify dermal backflow before clinical swelling occurs. Nowadays, centers like us implement ICG_L for the early diagnosis of lymphedema and personalized treatment such as manual lymphatic drainage, pressure adjustment of compression sleeve and compression pump (2,4).
In our daily practice, as one of the busiest breast surgery and lymphedema centers in the USA, we recommend high-risk patients wear a low-pressure (15–20 mmHg) compression sleeve before clinical signs of lymphedema occur (5). High-risk patients for lymphedema are those who had their axillary lymph nodes dissected, had ≥5 sentinel lymph nodes removed, had a Ldex of >7 units (or a change of 7 units between two measurements), and experienced lymphedema symptoms including heaviness and fullness (6).
In conclusion, this topic covers more than simply the narrow idea of having important tools for educating lymphedema and close follow-ups. In addition, an alternative strategy might provide high-risk women for lymphedema with an effective and efficient preventative measure.
Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Palliative Medicine. The article did not undergo external peer review.
Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-22-1094/coif). AS receives consulting fees from KONA medical. The other author has no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
- Taghian NR, Miller CL, Jammallo LS, et al. Lymphedema following breast cancer treatment and impact on quality of life: a review. Crit Rev Oncol Hematol 2014;92:227-34. [Crossref] [PubMed]
- Aldrich MB, Rasmussen JC, DeSnyder SM, et al. Prediction of breast cancer-related lymphedema by dermal backflow detected with near-infrared fluorescence lymphatic imaging. Breast Cancer Res Treat 2022;195:33-41. [Crossref] [PubMed]
- Paramanandam VS, Dylke E, Clark GM, et al. Prophylactic Use of Compression Sleeves Reduces the Incidence of Arm Swelling in Women at High Risk of Breast Cancer-Related Lymphedema: A Randomized Controlled Trial. J Clin Oncol 2022;40:2004-12. [Crossref] [PubMed]
- Koelmeyer LA, Thompson BM, Mackie H, et al. Personalizing Conservative Lymphedema Management Using Indocyanine Green-Guided Manual Lymphatic Drainage. Lymphat Res Biol 2021;19:56-65. [Crossref] [PubMed]
- Ochalek K, Partsch H, Gradalski T, et al. Do Compression Sleeves Reduce the Incidence of Arm Lymphedema and Improve Quality of Life? Two-Year Results from a Prospective Randomized Trial in Breast Cancer Survivors. Lymphat Res Biol 2019;17:70-7. [Crossref] [PubMed]
- Isik A, Soran A, Grasi A, et al. Lymphedema After Sentinel Lymph Node Biopsy: Who Is at Risk? Lymphat Res Biol 2022;20:160-3. [Crossref] [PubMed]