Prevention and Early Intervention Protocols

Prevention and Early Intervention Protocols

PEP Topic 
Lymphedema
Description 

Prevention and early intervention protocols involved the implementation of prophylactic patient assessment and monitoring and relevant interventions to attempt to prevent a symptom and identify early stages of symptom development. Tes approach for symptom management was evaluated in patients with cancer for prevention and management of lymphedema.

Likely to Be Effective

Research Evidence Summaries

Boccardo, F.M., Ansaldi, F., Bellini, C., Accogli, S., Taddei, G., Murdaca, G., . . . Campisi, C. (2009). Prospective evaluation of a prevention protocol for lymphedema following surgery for breast cancer. Lymphology, 42(1), 1–9pr

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Study Purpose:

To determine the effects of a specific protocol of prophylactic measures on the development of secondary lymphedema

Intervention Characteristics/Basic Study Process:

The preventive protocol included preoperative upper-limb lymphscintigraphy, principles for lymphedema risk minimization, and early management of lymphedema. The positive lymphscintigraphy group underwent a microsurgical operation of lymphatic-venous multiple anastomoses at the same time of axillary nodal dissection. When postoperative lymphscintigraphy revealed disruption of blockage of arm lymphatic drainage before the onset of limb swelling, the preventive protocol group underwent early use of elastic sleeves, manual lymphatic drainage, prophylactic external compression, and remedial exercises. In case of appearance or worsening of lymphedema notwithstanding the physical methods, the patients underwent early microsurgical operation. In the control group, once a volume abnormality was determined, the standardized diagnostic and therapeutic procedures to assess and non-operatively treat lymphedema were carried out. Time points of evaluation were preoperatively and at 1, 3, 6, 12, and 24 months postoperatively.

Sample Characteristics:

  • The study sample (N = 49) was comprised of a preventive protocol group (n = 25) and control group (n = 24) of female patients diagnosed with breast cancer. 
  • Mean age was 53.4 and 54.6 years for the preventive protocol and control groups, respectively.

Setting:

The study took place at the University of Genoa S. Martino Hospital in Italy.

Study Design:

The study used a prospective randomized controlled design.

Measurement Instruments/Methods:

  • Arm volume was measured using water displacement.
  • Lyphatic patterns of the upper limb were displayed using lymphscintigraphy.

Results:

Of the 49 women with unilateral breast cancer surgery who were measured at 24 months, 10 (21%) were identified with secondary lymphedema with an incidence of 8% in the preventive protocol group and 33% in the control group. At 12 months and 24 months, the number of patients with arm volume increases was significantly lower in the preventive protocol group ( p = 0.038 and p = 0.012, respectively). There were no differences between groups at six months and no significant differences between groups at baseline in terms of risk factors.

Conclusions:

The prophylactic strategies appear to reduce the development of secondary lymphedema and alter its progression in comparison to the control group.

Limitations:

  • The sample size was small, with less than 100 participants.
  • The study had only one site.

Nursing Implications:

The study indicates that healthcare professionals, including nurses, should inform patients with breast cancer of risk for developing lymphedema and help them understand signs and symptoms for early lymphedema. Healthcare professionals also need to examine whether patients develop lymphedema at every clinic visit. Anytime lymphedema is noted, patients should be referred for lymphedema treatment by certified lymphedema therapists or knowledgeable physical therapists. Strategies for prevention appear to be effective in the longer term.

Gergich, N.L.S., Pfalzer, L.A., McGarvey, C., Springer, B., Gerber, L.H., & Soballe, P. (2008). Preoperative assessment enables the early diagnosisand successful treatment of lymphedema, Cancer 112, 2809–2819.

doi: 10.1002/cncr.23494
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Study Purpose:

To investigate the efficacy of a surveillance method for the diagnosis and management of subclinical lymphedema in patients with early-stage breast cancer

Intervention Characteristics/Basic Study Process:

Diagnostic criteria for lymphedema included a volume increase of 3% in the affected upper limb compared with the patient’s preoperative measurement and with consideration of the contralateral limb volume changes. When lymphedema was diagnosed, garments were prescribed for daily wear. No activity limitations were placed for the duration of the intervention. At follow-up, when limb volume decreased, women were advised to continue wearing the garment only when completing strenuous exercise or activity, during air travel, with symptoms of heaviness, or if visible swelling appeared. Time points of evaluation were the preoperative visit and 1, 3, 6, 9, 12, and 18 months postoperatively.

Sample Characteristics:

  • The study sample (N = 86) was comprised of a subclinical lymphedema (n = 43) group and control group (n = 43).
  • Mean age was 55.3 and 53.4 years for the subclinical lymphedema and control groups, respectively. 
  • All patients were female with newly diagnosed, unilateral, early-stage breast cancer (stage I–III).
  • Patients were excluded if they had a previous history of breast cancer, bilateral breast cancer, or severe trauma or surgery of the affected upper limb.

Setting:

The study took place at the National Naval Medical Center Breast Care Center in Bethesda, MD.

Study Design:

The study used a case-control design.

Measurement Instruments/Methods:

  • Measurements for both upper limbs were taken using a Perometer.
  • Upper-limb volume was calculated by using 80% of the total limb length, which was measured from the ulnar styloid process to the tip of the acromion for standardization.
  • Body weight was recorded at each visit to control for weight change.

Results:

The time to onset of lymphedema averaged 6.9 months postoperatively. The subclinical lymphedema group had significantly higher upper-limb volume than the control group when the compression intervention was introduced. After the intervention, a statistically significant mean 48 ml volume decrease was realized (p < 0.0001) in the subclinical lymphedema group with activity-related garment wear only compared with 2.3 ml decrease in the control group. The mean duration of the intervention was 4.4 weeks. Volume reduction was maintained at an average follow-up of 4.8 months after the intervention.

Conclusions:

Preoperative assessment in the context of a prospective surveillance model enables the early detection and management of subclinical lymphedema. An early intervention protocol reduces the affected limb volume to near baseline measures and prevents progression to a more advanced stage of lymphedema for at least the first year postoperatively.

Limitations:

The study does not use a randomized controlled design.

Nursing Implications:

Preoperative baseline measurement is vital to successfully diagnosing subclinical lymphedema. However, currently, physical therapists in clinical practice rely on an impairment-based model for diagnosing and treating lymphedema. The paradigm is inadequate and a shift in the current practice pattern in favor of surveillance models is necessary. Further research is warranted to confirm the long-term clinical and cost effectiveness of this surveillance model compared with a traditional impairment-based model in treating breast cancer-related lymphedema.


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