Opinion

Pat Whitworth MD/

Lymphedema: Urgent Opportunity Lost?

The American Society of Breast Surgeons (ASBrS) leadership is requesting comments regarding their Lymphedema Expert Panel Report presented by Sarah McLaughlin MD at the 2017 ASBrS annual meeting in Las Vegas in April. The 10-minute presentation to the membership provided no guidance regarding the technologies that detect breast cancer related lymphedema (BCRL) before tissue elasticity is compromised, namely perometry and bio-impedance spectroscopy (BIS). This much anticipated report failed to emphasize that waiting until changes are detectable by tape measures (standard surveillance) is inadequate and only detects lymphedema after it is a already a chronic clinical problem. Though guidelines have encouraged prospective screening and intervention for BCRL, standard methods can not detect tissue changes at a preventable stage, before extracellular compartment elasticity is compromised. With "standard" methods the diagnosis is simply bad news, "You have lymphedema; now let's try to manage it as best we can." More sensitive technologies make early detection, simple intervention and prevention of clinical BCRL possible. It is the responsibility of the entire breast care community to inform women about this advance. With the large attendance of breast care physicians who will treat many thousands of patients at risk for BCRL and the opportunity to reduce lymphedema by as much as two-thirds, it was very disappointing that the panel did not recommend either of these early-detection tools and simply encouraged the ineffective status quo. The ASBrS request for comments states:

Dear Members, The Society held an expert panel discussion on lymphedema during the 18th annual meeting last week in Las Vegas and gave a report at the meeting summarizing current care of patients and their recommendations for physicians. As the panel refines their recommendations, we are soliciting feedback on the attached recommendations that the panel made for their consideration.  The full presentation is available by clicking here. Please review and let us know if you have any comments by Monday, May 13. Comments may be emailed to: lymphedema@breastsurgeons.org

We at BCN welcome your comments on this matter of great importance to breast cancer patients.

At Nashville Breast Center we have used BIS for over 7 years and our clinical lymphedema rate in over 550 patients (80% with high-risk features) with 17 months follow-up is 3%. This compares very favorably to any modern series and is quite a bit better than the 7% rate at 12 months in the mostly low-risk patients in the Z10 trial. We are convinced that pre-clinical detection is helping us prevent lymphedema. In fact our therapists express very pleasant surprise at the very low rates of CDT required by our patients. The slide below documents an example of early detection via BIS.

Alison L. Laidley MD FACS of Texas Breast Specialists in Dallas Texas, a leading breast surgeon and a former member of the ASBrS board, reports a similar experience, "I incorporated BIS into my practice when it first came out. My results are published and reflect the same low rate of lymphedema with 1-2% for patients with sentinel node surgery and 8-10% for axillary node dissection. Kimberli Cox MD (Comprehensive Breast Center of Arizona, Paradise Valley), breast surgical oncologist, points out that "the vast majority of our patients are not in large regional centers, nor can they travel to places where lymph node transfer or LV anastomoses are routinely performed. BIS is so easy to do and to have available to our patients; they really should have highlighted that."

 

Disclosure: Impedimed (the BIS, “L-Dex” company) is one of our supporters for our yearly TME BreastCareNetwork roundtable symposia, and was a major supporter of the ASBrS this year. None of the TME BCN leadership holds any equity interest or any paid position with the company.

Pat Whitworth MD @WhitworthMD

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