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Robert Millett meets a Belfast-based physiotherapist who is conducting a pioneering study into lymphoedema screening.

Survival rates for breast cancer are continually improving, with surgery and treatments such as chemotherapy often proving successful.

But patients who have undergone breast surgery may still be at risk of developing lymphoedema – a chronic, incurable and potentially progressive condition that often requires long-term care and can blight patients’ quality of life.

Lymphoedema often presents as a swelling in the tissue of the arm, due to a build-up of lymph fluid that has accumulated as a result of a failure in the lymphatic system.

It can lead to distressing symptoms such as pain, fatigue, a decreased range of motion, psychological distress and an increased risk of persistent infection.

Patients who have had breast cancer are especially at risk because the lymphatic system can be impaired by breast surgery, the removal of lymph nodes under the arm and radiotherapy.

In fact, research suggests that around 25 per cent of breast surgery patients go on to develop lymphoedema.

Yet, despite it being a relatively common complication for patients who have had breast cancer, there is no standard measurement technique in the UK that enables reliable and early identification of the condition or the accurate detection of patients who might be at ‘high risk’.

This may soon change, however, thanks to groundbreaking research that is currently being conducted by a physiotherapist in Belfast.

Janine Blaney is based in the physiotherapy department in the Northern Ireland Cancer Centre, part of Belfast Health and Social Care Trust.

She is investigating the potential benefits of a breast cancer-related lymphoedema screening programme.

‘Evidence has shown that the ability to detect and treat lymphoedema early is vital.

‘Early intervention may reduce the need for intensive treatment and rehabilitation and lead to a reduction in morbidities and diminished quality of life,’ explains Dr Blaney.

Around 1,200 people are newly-diagnosed with breast cancer in Northern Ireland every year, and these figures are projected to increase by three per cent each year. But, as yet, lymphoedema screening programmes are relatively rare.

‘The normal care pathway is reliant on the patient noticing changes in their arm and presenting with symptoms such as pain, limb swelling or heaviness,’ explains Dr Blaney.

Once lymphoedema progresses beyond the early stages, it requires intensive therapist-led interventions – including manual lymphatic drainage, multilayer bandaging and daily compression.

Initially, at least,  patients can attend hospital up to five times a week. In severe cases, patients require long-term maintenance and lifelong follow-up.

However, if identified early enough, the condition can be prevented from becoming chronic and patients can monitor themselves, without the need for daily compression garments.

If services were able to identify lymphoedema at an early stage then the condition could be treated before chronic tissue changes occur – and this is at the crux of Dr Blaney’s research.

‘As there is no standard approach in measurement techniques or definition of the presence of lymphoedema we are seeking to establish the most appropriate screening tool to identify early stage lymphoedema,’ says Dr Blaney.

Technology versus tape

In the UK the most widely used method for diagnosing and monitoring patients with breast cancer-related lymphoedema is circumferential measurement of the upper limb.

A tape is used to measure the circumference of the arm every 4cm from the wrist to the axilla, where the arm connects to the shoulder.

These measurements are used to calculate the limb volume and, when lymphoedema has already developed, to fit compression garments.

However, in recent years concerns about the sensitivity of this method have arisen, says Dr Blaney. As a result her research aims to compare the technique with a promising new approach.

The alternative  is a new technology  called  bioimpedance analysis  that may ensure accurate and standardised assessment of lymphoedema.

‘Bioimpedance analysis devices measure the lymphatic fluid in the body whereas the tape just measures limb volume,’ explains Dr Blaney.

‘It specifically targets the lymphatic compartments and can pick up increased fluids in the tissues, so it’s considered to be more accurate.’

‘Bioimpedance analysis looks promising in being able to identify more cases of early stage lymphoedema in comparison to circumferential measurement techniques, but the efficacy of implementing one screening tool over the other has yet to be established ,’ says Dr Blaney.

As a result, her research is not only seeking to ascertain which of the two measurement techniques is the most efficient, but also which could be most suitable in clinical settings.

The benefits of screening

Dr Blaney began recruiting female patients who were newly diagnosed with breast cancer at stages I to III last April.

A total of 125 participants were recruited and since December 2012 the study has been underway at two sites – the City Hospital in Belfast and Ulster Hospital in Dundonald, with Dr Blaney managing referrals at both sites.

All the volunteers are screened pre-surgery and undergo an upper limb assessment in order to establish their normal arm measurements.

This data is acquired using both circumferential measurements and bioimpedance analysis. The patients are then followed-up and screened post-surgery at three month intervals over a 12-month period. The collected measurements are used to ensure that any evidence of early stage lymphoedema is identified.  

Any patients who are found to have developed the condition are immediately referred for management to a lymphoedema specialist team in their local trust.

Dr Blaney says no conclusions can yet be reached but, anecdotally at least, patients are already responding positively to the screening process and a number of early cases of lymphoedema have been identified.

All the patients  identified as having lymphoedema displayed no subjective symptoms. Without the screening programme it is likely their condition would have progressed and gone unnoticed for some time.

Participants have also reported that being part of the screening programme has reduced their anxieties, as they feel confident that if they do develop lymphoedema it will be detected early.

‘The benefit of screening can be clearly seen as the patients identified to date may have gone undetected within the normal care pathway,’ says Dr Blaney.

Clinically and cost effective

The idea for the research project came from Jane Rankin, lead oncology physiotherapist at the Cancer Centre and lead for the Lymphoedema Network Northern Ireland.

It was prompted by her awareness that similar projects were being conducted internationally. In particular, a surveillance model for breast cancer currently being adopted in the USA is proving to be both clinically and cost effective.

Mrs Rankin explains that a cost evaluation of the USA study (see reference below) showed that the cost of managing early stage breast cancer-related lymphoedema using the screening model was $636 (around £400) for one patient each year.

This compares to the cost of managing late stage lymphoedema using the traditional non-screening model which was found to be  $3124 (around £1,945) per patient.

‘Lymphoedema screening is a more cost effective way of lymphoedema management,’ says Mrs Rankin.

‘So teams in the UK  should begin to focus on reducing incidence rates by increasing awareness and enabling early access to acute conditions so that we can affect an overall change in prevalence and chronicity.’

Dr Blaney’s data collection will continue for a year and she will prepare the results for publication in March 2014.

The findings will enable researchers to calculate the number of participants required to ensure statistical significance for similar definitive studies.

‘The results of this study will also go some way toward providing an insight for commissioners and healthcare authorities as to how such a service could be of benefit to patients and a cost-effective service for the NHS,’ says Dr Blaney.

‘It will  provide physiotherapists with some degree of evidence as to which, if any, measurement technique is better able to identify early stage lymphoedema as well as identifying which group of patients should be targeted and screened routinely as part of routine care and how a screening programme can fit within clinical practice.’

If the results confirm the conclusions of earlier studies, Dr Blaney and Mrs Rankin hope the screening programme will be rolled out across Northern Ireland and even more widely.

‘There’s no reason why this couldn’t be replicable everywhere,’ says Mrs Rankin. fl

For more information

  • To download copies of CSP’s Cancer and Lymphoedema Physiotherapy works, visit: www.csp.org.uk
  • The Association of Chartered Of Physiotherapists in Oncology and Palliative Care (ACPOPC): www.acpopc.csp.org.uk

Reassurance ‘helps allay fears’

Breast cancer patient Stella Kelly joined the study last August, prior to having a mastectomy.

‘I just thought if there’s anything I can do to help in any way then I will,’ says Mrs Kelly.

‘If I can do something that can prevent a bigger problem later on then that’s great – and being able to be proactive in a situation like this is really important.’

Two weeks after her mastectomy, Mrs Kelly underwent further surgery to remove the lymph nodes on her affected side.

‘Having my lymph nodes removed was really painful – and it’s taken me longer to recover from that than from the breast surgery,’ she says.

Mrs Kelly was given physiotherapy exercises to help restore strength to the arm that was operated on and is undergoing a series of chemotherapy treatments at Belfast City Hospital.

Mrs Kelly, who meets Dr Blaney every three months for lymphoedema screening, describes the screening sessions as providing a welcome source of mental and emotional support.

‘I think when you’re in a situation like this any reassurance that you can be given really helps you,’ says Mrs Kelly.

‘Just knowing there’s someone there looking after you is really reassuring because you go through so many emotions and it can affect you a lot.

But if someone is there who can answer your questions it can allay so many fears.’

Fellow breast cancer patient Paula Creighton is half-way through a six session course of chemotherapy.

She had a mastectomy and additional reconstructive surgery last September and had her first appointment with Dr Blaney shortly before her first operation.

Like Mrs Kelly she finds the lymphoedema screening reassuring and says attending the programme has not proven to be an inconvenience.

‘It wasn’t really something I knew about but the cancer care nurses really encouraged me to join and I was happy to get involved.’

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