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

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

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.

• 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.

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

The study used a prospective randomized controlled design.

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

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.

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

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

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.