Prospective surveillance

All people at risk of BCRL should have access to prospective surveillance (screening) for BCRL, including pre-operative baseline measurements (such as arm volume and/or bioimpedance spectroscopy measurements) and regular follow-up based on individual risk. Every person at risk needs instruction in self-monitoring. Screening for signs and symptoms of BCRL includes the limb(s), breast, and trunk on the side(s) of breast cancer treatment. Ideally, screening would continue for five years post-surgery as most people who develop BCRL do so within this timeframe [2, 3]. Prospective surveillance for BCRL has been well described in the literature and allows for early diagnosis and treatment and therefore decreased risk of later stage lymphedema, which is more challenging to treat than subclinical or early stage lymphedema [2]. Timely referral to a certified lymphedema therapist is essential to initiate treatment when necessary.

Education

Pre-operative and post-operative patient education should be tailored to the individual’s level of understanding. For all people with or at risk of BCRL, the discussion should include individual risk factors and signs and symptoms of BCRL. If any signs or symptoms are noted between screening visits, the individual should contact the treating team.

Individual risk factors

Risk factors for BCRL include axillary lymph node dissection [2, 4,5,6,7], body mass index ≥ 25 kg/m2 at the time of breast cancer diagnosis [2, 3, 5,6,7,8], regional lymph node radiation [5, 6, 8], certain chemotherapy regimens, skin infection [5, 7, 9] at or near the affected breast, axillary web syndrome (cording) [10], seroma [8], and Black race and Hispanic ethnicity [11].

Axillary lymph node dissection is the greatest known risk factor for lymphedema of the arm after breast cancer surgery [4]. Sentinel node biopsy, a less invasive surgical procedure, imparts lower, but not negligible, BCRL risk [2, 4].

Exercise

Supervised, slowly progressive resistance and aerobic exercise training is safe in people with or at risk of BCRL [12, 13] and is recommended in current exercise guidelines for people who have been treated for breast cancer.

Blood pressure

Isolated blood pressure (BP) measurements in the at-risk arm do not increase arm volume in those at risk of BCRL [6, 7, 9]. Best practice supports the avoidance of BP measurement in the affected arm of those with BCRL when possible. The effect of repetitive or cycling BP measurements, such as in the operating room, has not specifically been studied. When repetitive or cycling BP monitoring is required, best practice supports preferential use of the non-at-risk arm.

Skin care and hygiene

Skin infection has been shown to increase lymphedema risk [6,7,8]. Skin hygiene and protection of the area at risk of BCRL help reduce lymphedema onset and progression through the avoidance of infection. The area at risk of BCRL is defined as the breast, trunk, arm, and hand on the side of breast cancer surgery. Skin protection of these areas includes daily washing, moisturizing, and the use of sunscreen and insect repellent. Skin trauma, such as cuts, insect bites, and burns, requires first aid (e.g., cleansing the wound, applying an antibiotic ointment and a sterile dressing). The wound and surrounding area should be monitored for infection and new onset or worsening of swelling. In the event of an infection, immediate medical attention is required as these infections can spread quickly. Signs and symptoms of cellulitis infection include localized redness, swelling, and pain, and may include lymphorrhea or blistering. In advanced cases, fever, chills, and sepsis may be present.

Skin puncture and blood draws

Isolated blood draws [6, 7, 9] and skin puncture for injection or aspiration [6, 7, 9, 14] in the at-risk arm have not been shown to increase arm volume in people at risk of BCRL. In contrast, the effect of skin punctures, blood draws, and injections on individuals with lymphedema has not been studied, and therefore, best advice supports avoidance of blood draws and injections in the arm with BCRL.

Surgical procedures

Studies regarding the effect of surgical procedures on the upper extremity at risk of or with BCRL are limited to small sample sizes and case reports. Although surgery, such as elective hand surgery, has not been associated with BCRL onset or exacerbation, some people may experience a temporary limb volume increase following surgery. People who may require elective surgery on the limb at risk of or with lymphedema are advised to discuss the risks and benefits of surgery with their treatment team, weighing the necessity of surgery and risk of BCRL exacerbation. People should be provided with close prospective surveillance and/or ongoing intervention for BCRL throughout the pre- and post-operative time periods as indicated.

Prophylactic compression

One study has shown that prophylactic use of compression sleeves post-operatively for individuals at high risk of lymphedema (with axillary lymph node dissection) may reduce and delay lymphedema onset in the first year after surgery for breast cancer [15]. Post-operative prophylactic compression may be considered for people at high risk following axillary lymph node dissection.

Air travel

Air travel has not been found to be a significant risk factor for those at risk of BCRL onset [6, 7, 14].

As consistent compression is best practice for maintenance, those with BCRL should wear their compression garments during air travel. Any compression garments worn during air travel should be well-fitted, as poorly fitting garments may cause discomfort or swelling.

Hot climate and sauna

Hot climate has not been found to be a significant risk factor for those at risk of BCRL but may transiently affect limb measurements and perceived swelling in those with BCRL [14, 16, 17].

Sauna use may be a risk factor for the onset or progression of BCRL [9]. People are encouraged to self-monitor when exposed to high temperatures.