On 14-15 September 2023, some members of CarEdOn were present at ICPTO in Amsterdam. This is an international congress for physical therapists working in the domain of oncology.
As you can see in the first picture, it was really an amazing venue (the EYE Film Institute). In the second picture, you can see that we really had a good time during the congress.
Hereunder you may find three summaries of presentations on the topic of lymphoedema.
Dr. Bolette Rafn (from Denmark) presented about prospective surveillance of breast cancer patients to prevent the development of breast cancer-related arm lymphedema. Lymphedema is a progressive condition feared by many breast cancer patients. Her research questions were ‘Are prospective surveillance programs effective in reducing the risk of developing cancer-related lymphedema, how does the program have to be structured, who should be included, how do we have to measure patients and what treatment should be delivered?’
She performed a systematic review to answer these questions. This resulted in 23 studies: only 4 RCTs of which 2 RCTs used another prospective surveillance as comparator, 9 prospective, 9 retrospective cohort studies and 1 case-control study. Based on 2 RCTs there was a reduced risk of developing chronic breast cancer-related lymphedema associated with the prospective surveillance (overall risk ratio was 0.31 (with CI 0.10-0.95 and p= 0.04). In these studies, the incidence rate of chronic arm lymphedema was only 4% and in the high-risk patients (i.e. patients receiving axillary clearance) it was only 6%. This was remarkably lower than the 20% that is reported in most other studies.
Then she discussed the question of ‘how the program should be structured’. In the studies, the researchers started the assessments pre-surgery and the first postoperative assessment was performed within or at three months post-surgery. Twelve studies (57%) performed prospective surveillance and early management for more than 1 year. The duration of the follow-up was at least 12 months.
Of the 23 studies, 21 studies looked to development of breast cancer related arm lymphoedema, 1 study to breast lymphoedema and 1 to lower limb lymphoedema after gynecological cancer.
In the 23 studies, 8 different measurement methods and 25 different diagnostic criteria were used to detect early breast cancer-related arm lymphoedema that triggered intervention. Bioimpedance spectroscopy (BIS) was most frequently used (n=10 studies, 48%) using six different diagnostic criteria. To assess chronic breast cancer-related arm lymphoedema, five different measurement methods and 16 criteria were applied.
The applied intervention to prevent the development of BCRL was in many studies wearing a compression garment (n=17 or 81%). However, the majority of these studies did not specify whether the compression garments were fitted, the level of compression used, and the duration of compression used.
Her take home message for organizing a surveillance program was:
This systematic review was published in 2022 in Journal of Clinical Oncology: https://pubmed.ncbi.nlm.nih.gov/35077194/.
Dr. Vincent Paramanandam performed an RCT about the prophylactic use of a compression sleeve in patients at risk of developing breast cancer-related lymphedema in India.
Only patients receiving an axillary lymph node dissection were included (n=307). All patients received education about exercises and lymphoedema. The intervention group received additionally a pair of Sigvaris advanced compression sleeve CCL2 and was asked to wear the compression sleeve from the first postoperative day until 3 months after the completion of the adjuvant treatment. All patients were followed up for one year following breast cancer surgery. The family members were trained to perform arm circumference measurements and to register subjective symptoms. To evaluate compliance with the treatment, patients were asked to complete a diary. The primary outcome was the incidence rate of arm swelling measured with the BIS ratio. Secondary outcomes were 1) incidence rate of arm swelling determined from arm circumferences, 2) quality of life, and 3) feasibility and acceptability of wearing the compression garment. Only 3 patients in each group dropped out during the trial.
What was the result of the study?
To investigate the preventive effect of the compression sleeve, time-to-event analyses were performed and this for arm swelling based on BIS ≥ 2SD (upper picture) and relative arm volume increase ≥ 10% (RAVI).
52% of the patients in the control group had developed arm swelling compared to 42% of the compression group. You also see in the picture that patients started developing arm swelling fast after the lymph node dissection, particularly in the control group.
According to a more severe criterion (RAVI ≥ 10%), 25% of the patients in the control group had developed arm swelling compared to 14% of the compression group. If this more severe criterion is used, patients seemed to develop the arm swelling at a later time after surgery.
Dr. Vincent Paramanandam emphasized also that nevertheless that patients had to wear a compression sleeve, they experienced a similar quality of life compared to patients who did not have worn a compression sleeve.
This randomized controlled trial was also published in 2022 in Journal of Clinical Oncology: https://pubmed.ncbi.nlm.nih.gov/35108031/
A reflection from Prof. Nele Devoogdt:
Did a compression sleeve create really a preventive effect, meaning that it results in the recovery of the lymphatic system, or do you ‘treat’ day-by-day the small accumulation of lymph with the compression sleeve? Maybe, patients will develop lymphoedema at a later stage, when the compression sleeve is not worn anymore. Food for future research!
At the second day, our colleague Prof. Nele Devoogdt took the stage to discuss the question ‘To MLD or not to MLD!?’
The presentation of Nele Devoogdt addressed a controversial topic that caused debate for many years: “Is manual lymph drainage an effective treatment for secondary cancer-related lymphoedema?” Nele and her colleagues, including Tessa De Vrieze, conducted a comprehensive study called the EfforT-BCRL trial several years ago, which they presented to the audience.
The different techniques of manual lymphatic drainage were first briefly discussed, as well as the results of other studies in this field. Nele then elaborated on the EfforT-BCRL study, explaining the study protocol to show how they had proceeded.
Based on the results of the EfforT-BCRL trial and other studies thé question was answered: Manual lymphatic drainage is not effective to treat secondary cancer-related lymphedema. However, this does not mean that physiotherapists cannot contribute to the treatment of lymphoedema, as there are other proven effective treatment techniques, such as exercise, elevation, education, manual techniques and compression techniques.
After Nele's presentation, a panel discussion took place with other speakers on the topic of lymphoedema. Here, they shared their perspectives and knowledge on various questions. Some questions on the role of manual lymphatic drainage were asked by the attendees in the room, who had to get used to the conclusion. All in all, the congress was again informative and engaging!
by Nele Devoogdt and Kaat Verbeelen