Developing a Breast Cancer-Related Lymphedema Program: The William Beaumont Hospital Experience

Abstract

The incidence of breast cancer in the United States is approximately 200,000 cases per year with an estimated prevalence of 2.4 million women (1). As early detection and improved therapies result in increased long-term survival of women with breast cancer, management of the side effects of cancer treatment assumes increasing importance. Currently, up to 800,000 women have some form of breast cancer related lymphedema (BCRL) based on incidence and prevalence rates of breast cancer and averaged rates of BCRL (2). While local therapies have evolved, estimates of the incidence and prevalence of BCRL are highly variable due to significant discrepancies in reported incidence rates of BCRL from 2% with lumpectomy alone to 65% with axillary lymph node dissection and radiation therapy (2-4). BCRL can lead to physical, emotional, and psychological challenges and is a constant and devastating reminder of breast cancer and the treatments incurred (5). Other sequelae and side effects can also occur including shoulder dysfunction, muscle tightness, restricted range of motion, as well as axillary cording and webbing. At this time, limited data are available regarding programs designed to address both BCRL and the other morbidities of breast cancer treatment.In conjunction with the Beaumont Cancer Institute, the Breast Care Center at William Beaumont Hospital, Royal Oak, Michigan established a lymphedema clinic in 2004 to evaluate and treat women. The goal was to use education and early management techniques to decrease the incidence of BCRL and related post treatment complications, to diagnose BCRL at the subclinical and early stages of the disease to avoid its chronic complications, and to educate referring physicians (including primary care physicians, breast surgeons, medical oncologists, and radiation oncologists) on the goals and outcomes of early, pro-active BCRL management.At the inception of the clinic, the majority of patients presented with a primary complaint of lymphedema (86.2%) with the second most common complaint being related to shoulder/rotator cuff complaints (11.5%). Of the 87 patients initially presenting to the clinic, none presented electively for BCRL prevention. Overall, 90.8% of all patients seen had clinically evident BCRL at presentation. Five years following the inception of the clinic, significantly more patients were seen for elective counseling (18.9% versus 0%, p < 0.001); in addition, more patients were seen for primary shoulder complaints (30.7% versus 11.5%, p < 0.001) whereas less patients were seen for primary lymphedema complaints (33.8% versus 86.2%, p < 0.001). Of the patients presenting with a primary complaint of lymphedema, the majority were managed with complex decongestive physiotherapy (69.3%) whereas those with less severe LE were managed with compression sleeves (20.0%). With regard to shoulder dysfunction, 27.6% of patients had decreased range of motion at presentation whereas 74.7% had some form of shoulder weakness. The majority of these patients 86.2% were managed with a comb...