Prevention of Breast Cancer-Related Arm Lymphoedema (BCRAL)

Publication Date: January 31, 2024
Last Updated: February 29, 2024

Summary of Recommendations

Risk factors for breast cancer related arm lymphoedema

  • When there are resource constraints, patients who present with a higher BMI (BMI ≥30 kg/m2) should be prioritised over patients with BMI <30 kg/m2 when selecting patients for prophylactic management of lymphoedema.
  • The timing of chemotherapy (neoadjuvant versus adjuvant) may impact the subsequent risks of lymphoedema but should not be a major determining factor on selecting patients for prophylactic management of lymphoedema until more studies are available.
  • The type of chemotherapy (taxane versus non-taxane) a patient receives may impact the subsequent risks of lymphoedema, but should not be a major determining factor on selecting patients for prophylactic management of lymphoedema until more studies are available.
  • When there are resource constraints, patients who had ≥15 axillary lymph nodes removed in axillary dissection should be prioritised over patients who had less lymph nodes removed when selecting patients for prophylactic management of lymphoedema.
  • When there are resource constraints, patients who received axillary radiation should be prioritised over patients who receive radiation to the breast/chest wall ± the supraclavicular fossa when selecting patients for prophylactic management of lymphoedema.

Prospective surveillance programs

  • A prospective surveillance program is recommended to reduce risks of chronic lymphoedema after breast cancer surgery where feasible and resources allow.
  • Bioimpedance spectroscopy is one of the more commonly used methods in the literature for early lymphoedema detection in prospective surveillance programs and can be an option before more prospective studies are available to suggest the preferred method of assessment.
  • In a prospective surveillance program, arm circumference (or volumetric) or lymphangiography/lymphoscintigraphy measurement is an alternative method to identify patients with subclinical/early stage lymphoedema for early treatment when bioimpedance spectroscopy is not available or there are resource limitations.
  • In a prospective surveillance program, treatment is triggered when the bioimpedance spectroscopy score shows an increase of L-Dex ≥6.5 compared to pre-surgical values.
  • In a prospective surveillance program, treatment can be triggered when a difference in volume measurements of ≥5 but <10% is seen compared to pre- surgery values.
  • In a prospective surveillance program, treatment should be triggered by any patient- reported arm symptoms (e.g., swelling, heaviness, tightness, and numbness).
  • In a prospective surveillance program, more intensive treatment is indicated (e.g., complete decongestive therapy) when a difference in bioimpedance spectroscopy scores is L-Dex >10 compared to pre-surgery values.
  • In a prospective surveillance program, more intensive treatment (e.g., congestive decompressive therapy) is indicated when a difference in volume measurements is ≥ 10% compared to pre-surgery values.
  • In a prospective surveillance program, the diagnosis of chronic lymphoedema is made when there are persistent symptoms despite initial treatments.
  • Prospective surveillance is recommended to start within 3 months after surgery.
  • Pre-surgical assessment of lymphoedema is required in a prospective surveillance program for better comparison of measurements after surgery.
  • The surveillance interval for a prospective surveillance program is recommended to be every 3–4 months in the first year then every 6–12 months thereafter where feasible and resources allow.
  • The total duration of surveillance in a prospective surveillance program is recommended to be at least 24 months from surgery where feasible and resources allow.
  • In a prospective surveillance program, healthcare professionals should conduct the prospective surveillance where feasible and resources allow.
  • In a prospective surveillance program, patients or family members who receive adequate training should conduct the prospective surveillance where resources are limited.
  • When subclinical/early stage lymphoedema is detected in a prospective surveillance program, compression garment are recommended for initial treatment.
  • When subclinical/early stage lymphoedema is detected in a prospective surveillance program, compression sleeves are suggested to be prescribed for at least 4–6 weeks. A longer duration can be considered depending on clinical response and the individual judgement of the treating therapist.

Prophylactic compression sleeves

  • Prophylactic compression sleeves should be offered as an option to prevent breast cancer- related arm lymphoedema.
  • For patients at high risk of lymphedema who wish to consider prophylactic arm sleeves, the sleeves should be applied from the first post- operative day until 3 months after the completion of adjuvant treatments (excluding hormonal treatments).
  • The daily use of prophylactic arm sleeves is suggested to be at least 8 h. The duration should be individualized depending on patients' preferences and comfort while wearing the sleeves.
  • The pressure of the prophylactic arm sleeve should be reviewed regularly and adjusted to patients' risks and needs.
  • Patients should be assessed every 6 months for any lymphoedema while using prophylactic compression sleeves.
  • Patients should be assessed for breast cancer related arm lymphoedema using bioimpedance testing while using prophylactic compression sleeves.
  • Patients should be assessed for breast cancer related arm lymphoedema using relative volume measurements while using prophylactic compression sleeves.
  • When prophylactic compression sleeves are used, clinical lymphoedema diagnosed by bioimpedance testing or increase in relative arm volume by ≥ 10% should trigger subsequent treatments.

Axillary radiation instead of axillary lymph node dissection for positive sentinel lymph node biopsy

  • Axillary lymph node dissection should not be routinely offered to breast cancer patients with clinical T1 or T2, node-negative disease who are found to have 1 to 2 positive sentinel lymph nodes and received breast conservation therapy.
  • Axillary radiotherapy instead of axillary lymph node dissection can be considered in breast cancer patients with clinical T1 or T2, node-negative disease who are found to have 1 to 2 positive sentinel lymph nodes and received mastectomy.
  • Axillary lymph node dissection should be offered instead of axillary radiation in breast cancer patients with clinical T1 or T2, node-negative disease who are found to have more than 2 positive sentinel lymph nodes.
  • For clinical T1 or T2, node- negative breast cancer patients with high risk tumour biology (e.g., triple negative, grade 3) who are found to have 1 to 2 positive sentinel lymph nodes, an individualized decision should be made with the patient whether to perform axillary dissection or give axillary radiation.
  • In clinical T1 or T2, node- negative disease who are found to have positive sentinel lymph nodes with less than 2 lymph nodes removed or having extra- nodal extension, an individualized decision should be made with the patient whether to perform axillary dissection or give axillary radiation.
  • When axillary radiation is recommended in clinical T1-2 node negative breast cancer with a positive sentinel lymph node, the decision to include internal mammary chain in the radiation volumes should be individualized depending on factors such as location of primary tumour and presence of cardiac risk factors.
  • While there are concerns that axillary radiotherapy is associated with a relatively higher incidence of second primary cancers, the decision to offer radiotherapy should not be affected if indicated.
  • In accordance with international guidelines, moderate hypofractionation (40–42.5 Gy in 15–16 fractions) is preferred over 50 Gy in 25 fractions when axillary radiotherapy is given to clinical T1 or T2, node-negative patients with a positive sentinel lymph node biopsy.

Prophylactic lymphatic reconstruction

  • Where expertise is available and resources allow, prophylactic lymphatic reconstruction is an option to reduce risks of chronic breast cancer related lymphoedema in patients who require extensive axillary lymph node dissection for large or multiple clinically positive lymph nodes.

Axillary reverse mapping

  • Where expertise is available and resources allow, axillary reverse mapping is an option for patients indicated for axillary lymph node dissection to reduce risks of chronic breast cancer related lymphoedema.
  • Axillary reverse mapping should not be offered in patients at high risk of axillary recurrence (e.g., multiple clinically positive lymph nodes, T4 primary).

Recommendation Grading

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Prevention of Breast Cancer-Related Arm Lymphoedema (BCRAL)

Authoring Organization

Multinational Association of Supportive Care in Cancer

Publication Month/Year

January 31, 2024

Last Updated Month/Year

April 1, 2024

Supplemental Implementation Tools

Document Type

Consensus

Country of Publication

Global

Document Objectives

Developing strategies to prevent breast cancer-related arm lymphoedema (BCRAL) is a critical unmet need because there are no effective interventions to eradicate it once it reaches a chronic state. Certain strategies such as prospective surveillance programs and prophylactic lymphatic reconstruction have been reported to be effective in clinical trials. However, a large variation exists in practice based on clinician preference, organizational standards, and local resources. The objective of this modified Delphi consensus process was to develop recommendations on evidence-based interventions to prevent BCRAL when there are resource limitations.

Inclusion Criteria

Female, Adult, Older adult

Health Care Settings

Ambulatory, Outpatient

Intended Users

Nurse, nurse practitioner, physical therapist, physician, physician assistant

Scope

Management, Prevention

Keywords

Lymphoedema, breasy camcer, BCRAL, Arm Lymphoedema

Source Citation

Wong HCY, Wallen MP, Chan AW, Dick N, Bonomo P, Bareham M, Wolf JR, van den Hurk C, Fitch M, Chow E, Chan RJ; MASCC BCRAL Expert Panel and the Oncodermatology and Survivorship Study Groups. Multinational Association of Supportive Care in Cancer (MASCC) clinical practice guidance for the prevention of breast cancer-related arm lymphoedema (BCRAL): international Delphi consensus-based recommendations. EClinicalMedicine. 2024 Feb 2;68:102441. doi: 10.1016/j.eclinm.2024.102441. PMID: 38333542; PMCID: PMC10850412.

Methodology

Number of Source Documents
63
Literature Search Start Date
February 26, 2023
Literature Search End Date
May 24, 2023