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.

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

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.

• 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.

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

The study used a case-control design.

• 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.

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.

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.

The study does not use a randomized controlled design.

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.