Lymphedema continues to plague women after breast cancer treatment. The cosmetic deformity cannot be disguised with normal clothing; physical discomfort and disability are associated with the enlargement; and recurrent episodes of cellulitis and lymphangitis may be expected. Added to the physical symptoms is the distress caused unintentionally by clinicians, who are more interested in cancer recurrence and often trivialize the nonlethal nature of lymphedema.
In five reports published within the last 10 years, the incidence of lymphedema was almost 20%.[1-5] Incidence ranged from 16% to 25.5% of study populations measured with arm circumferences or volumetric equipment. The similarity in lymphedema incidence is notable since these patients underwent different breast cancer procedures in three different countries.
Paradoxically, the incidence of lymphedema in modern times has not decreased despite less extensive breast cancer surgery. This may be due to scatter from breast irradiation, which can be absorbed at the level of the axillary lymphatic trunks; also, irradiation is known to be synergistic with surgical dissection in producing lymphedema. Precise and meticulous radiation planning, therefore, is necessary when treating patients who have undergone axillary dissection.
Since controlling lymphedema is onerous and may require daily attention, emphasis must be placed on prevention. Nevertheless, until the causative factors are defined and understood, prevention is unlikely. Despite the human cost, lymphedema has not been systematically studied perhaps for two reasons. First, since lymphedema usually is not due to cancer recurrence, and rather, is a quality of life issue, it has not generated comprehensive research in the past. In addition, there is often a lengthy time interval to the onset of lymphedema, necessitating prolonged follow-up.
Factors Associated With Lymphedema Being Studied
Because there are no published prospective studies on lymphedema, we embarked on such a study. Between January 1988 and June 1990, we enrolled 122 patients prior to axillary lymph node dissection and took preoperative measurements of arm circumferences. In a multivariate logistic- regression analysis, 19 variables were evaluated. These included clinical characteristics, surgical/pathologic considerations, and events in subsequent years pertaining to arm factors and overall health. Unfortunately, two variables that may be most important are not amenable to study: the precise surgical technique at the level of the lymphatic trunks and the congenital individual lymphatic variations. Although not statistically significant in this early multivariate analysis with a mean follow-up of only 6.4 years, the factors most predictive of lymphedema were age, obesity, seroma duration, and breast field radiation. Lymphedema formation was constant over the years of the study period.
With Department of Defense funding, we are also currently studying the incidence of and factors associated with lymphedema in the long-term survivors of a cohort of consecutively treated breast cancer patients. Our population consists of 1,216 patients who were enrolled in a study unrelated to lymphedema from 1976 to 1978 and who have undergone active follow-up for that study. We are studying the same variables as were analyzed in the prospective study.
There is no "cure" for lymphedema. The list of diverse multiple operations attempted for this disabling condition in the past decades suggests what is the fact: none is successful. Scientific examination of lymphedema treatment is urgently needed in order to make the best individual decisions for the legions of women living with this often disabling condition.
Exact Role of CLT Requires Further Study
This descriptive study by Boris and colleagues shows that comprehensive lymphedema therapy (CLT) is impressively effective in consecutive lymphedematous patients at a center specializing in this technique. The 100% compliance of large numbers of patients is unexplained, but may be related to motivation, especially in those who are not reimbursed by insurance plans and who must pay for therapy out of their own pocket.
It is clear that CLT has a permanent position in the armamentarium of this chronic disease. The exact role of CLT is unknown, however, and must await studies designed to compare CLT to conventional and more modest therapies.