Reducing the economic burden of breast cancer-related lymphoedema

 

Breast cancer-related lymphoedema (BCRL) is an inflammatory condition resulting in swelling, fibrosis, fatty tissue deposition and infections known as cellulitis (Al-Niaimi & Cox 2009, Mohammad Azhar et al 2020).

‘Lymphoedema, which can be a debilitating sequela to breast cancer treatment, is characterised by an abnormal accumulation of lymph in the arm, shoulder, breast, or thoracic area’ (Fu et al 2009).

BCRL is internationally recognised as one of the most dreaded morbidities following breast cancer treatment, imposing ‘a tremendous financial burden for patients and society’ (De Vrieze et al 2020, Fu 2014).

‘It may appear gradually or suddenly and although it usually develops within three years of a breast cancer diagnosis, it can arise much later’ with survivors remaining at lifetime risk (Fu et al 2009).

Unfortunately there is lack of diagnostic criteria for BCRL and the reported incidence varies from less than five per cent to more than 50 per cent (Gillespie 2018).

Research published in 2019 from Harvard Medical School found that 31.2 per cent of patients developed lymphoedema within five years after receiving common breast cancer treatments, including an axillary lymph node dissection and regional lymph node radiation (McDuff 2019).

The most commonly quoted statistic publicly advertised on websites such as the Australian Government’s Cancer Australia website (Cancer Australia 2013) is one in every five patients (20 per cent) is at risk.

Millions of Australian public healthcare dollars every year are invested into treating lymphoedema and its complications, particularly cellulitis.

A systematic review published in 2020 assessed the economic burden and costs associated with the treatment of BCRL (De Vrieze et al 2020).

An included study by Bilir and colleagues (2012) found that the total one-year economic impact with direct and indirect costs for the care of 627 patients was the equivalent of more than A$2.5 million (US$1,984,529) for standard assessment and lymphoedema treatment in the US (Bilir et al 2012).

In 2015–16 the cost of admission to a NSW public hospital for a patient with cellulitis as the primary diagnosis and lymphoedema as a secondary diagnosis was A$6193 per admission with an average length of stay of 5.53 days (ACI 2018).

Physiotherapy can reduce the economic burden of BCRL by two means.

The first is by halting the progressive nature of the condition by providing early education and treatment services for breast cancer patients before lymphoedema develops (Stout et al 2012a, Shah et al 2020).

Every patient with breast cancer should be seen and screened before breast cancer treatment starts (ALA 2019). Those at high risk of developing lymphoedema should continue to be seen every 3–6 months for the first five years.

Cost savings have been shown equating to A$3230 per patient per year in direct treatment costs (US$3125 for late care vs US$636 for early care) for services that implement early screening and treatment programs (Stout et al 2012b).

There are further direct cost savings such as decreased staff burden and patient-related healthcare expenses when offering early care.

The other means is reducing the likelihood of breast cancer-related cellulitis by providing compression garments for diagnosed lymphoedema.

‘There is a benefit to the health system with the cost of compression garments being less than unnecessary admissions (ACI 2018).

'Compression should start as soon as fluid levels become abnormal but before the arm or breast become visibly swollen to the eye (known as Stage Zero lymphoedema).

'If a patient presents to a physiotherapist with an obviously swollen arm or breast (known as Stage One, Two or Three lymphoedema) then compression therapy and further physiotherapy interventions are warranted.'

March is Lymphoedema Awareness Month. Keep an eye out for the CANdetect online course on cpd4physios.com.au available from March 2021.

Current and evidence-based, this course features videos by Flinders University lymphologist Professor Neil Piller and provides education on early care for patients at risk of developing lymphoedema as a result of breast cancer treatments.

If you wish to learn more about the assessment and treatment of lymphoedema, the CANtreat upper limb and breast online course will also help you learn more.

References

Al-Niaimi F, Cox N. Cellulitis and lymphoedema: a vicious cycle. J Lymphoedema. 2009;4(2):38-42.
Mohammad Azhar SH, Lim HY, Tan BK, Angeli V. The unresolved pathophysiology of lymphedema. Frontiers in Physiology. 2020;11:137.
Fu MR, Ridner SH, Armer J. Post-breast cancer lymphedema: part 1. AJN The American Journal of Nursing. 2009 Jul 1;109(7):48-54.
De Vrieze T, Nevelsteen I, Thomis S, De Groef A, Tjalma WA, Gebruers N, Devoogdt N. What are the economic burden and costs associated with the treatment of breast cancer-related lymphoedema? A systematic review. Supportive Care in Cancer. 2020 Feb 1:1-1.
Fu MR. Breast cancer-related lymphedema: Symptoms, diagnosis, risk reduction, and management. World journal of clinical oncology. 2014 Aug 10;5(3):241.
Gillespie TC, Sayegh HE, Brunelle CL, Daniell KM, Taghian AG. Breast cancer-related lymphedema: risk factors, precautionary measures, and treatments. Gland Surgery. 2018 Aug;7(4):379. 
McDuff SG, Mina AI, Brunelle CL, Salama L, Warren LE, Abouegylah M, Swaroop M, Skolny MN, Asdourian M, Gillespie T, Daniell K. Timing of lymphedema after treatment for breast cancer: When are patients most at risk?. International Journal of Radiation Oncology* Biology* Physics. 2019 Jan 1;103(1):62-70.
Australian Government, Cancer Australia, Lymphoedema - What you need to know.  https://www.canceraustralia.gov.au/publications-and-resources/cancer-aus.... Accessed 23rd January 2021
Bilir SP, DeKoven MP, Munakata J. Economic benefits of BIS-aided assessment of post-BC lymphedema in the United States. The American journal of managed care. 2012 May;18(5):234-41.
Agency for Clinical Innovation. Guide For Clinical Services. https://www.aci.health.nsw.gov.au/resources/chronic-care/lymphoedema/lym.... Accessed 23 January 2021
Stout NL, Binkley JM, Schmitz KH, Andrews K, Hayes SC, Campbell KL, McNeely ML, Soballe PW, Berger AM, Cheville AL, Fabian C. A prospective surveillance model for rehabilitation for women with breast cancer. Cancer. 2012 Apr 15;118(S8):2191-200.
Shah C, Zambelli-Weiner A, Delgado N, Sier A, Bauserman R, Nelms J. The impact of monitoring techniques on progression to chronic breast cancer-related lymphedema: a meta-analysis comparing bioimpedance spectroscopy versus circumferential measurements. Breast Cancer Research and Treatment. 2020 Nov 27:1-32.
Australasian Lymphology Association. Early detection of breast cancer-related lymphoedema. Position Statement. Updated 2019. http://www.lymphoedema.org.au/public/7/files/Position%20Statements/ALA%2... Accessed 23rd Jan 2021.
Stout NL, Pfalzer LA, Springer B, Levy E, McGarvey CL, Danoff JV, Gerber LH, Soballe PW. Breast cancer–related lymphedema: comparing direct costs of a prospective surveillance model and a traditional model of care. Physical therapy. 2012 Jan 1;92(1):152-63.

 

 

 

 

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