Postmastectomy Lymphedema: Laser Treatments May be the Answer for Some

Abstract & Commentary

Synopsis: In a prospective, placebo-controlled trial, the use of 2 cycles of low-level laser therapy in women with postmastectomy lymphedema was shown to result in objective benefit in approximately one-third of cases. If further research confirms this finding, a new inexpensive and effective treatment modality will be available for this heretofore refractory consequence of breast cancer management.

Source: Carati CJ, et al. Cancer. 2003;98:1114-1123.

Postmastectomy lymphedema remains a significant cause of morbidity for breast cancer patients, affecting up to 30% of patients who have received axillary node dissections and adjunctive radiotherapy.1 Traditional treatments for this condition have included compression bandaging, manual lymphatic drainage, and extended limb elevation, but with only modest success.2 In the current report from South Australia, Carati and colleagues explore the potential use of laser therapy in a randomized, placebo-control trial in patients with postmastectomy lymphedema. A total of 61 women were enrolled in the study—28 in the placebo group and 33 in the active treatment group. One treatment cycle consisted of 9 sessions (active laser or control) in which treatment was administered 3 times per week for 3 weeks. Briefly, for treatment, there was a grid with 17 points centered at 2-cm intervals placed in the axilla. The laser treatment head was held in contact with the skin adjacent to each point in the grid and switched on for 1 minute at each point (total treatment time each session, 17 minutes). The total energy applied at each point was 300 mJoules for a total of 5.1 Joules over the 17 points on the grid, or 1.5 Joules/cm2.

The outcome measures included an assessment of limb volume (perimetry), fluid distribution (bioimpedance), induration (tonometry), shoulder range of motion (goniometry), and a panel of subjective markers including self-reported symptoms, quality of life, and function.

There was no significant improvement immediately after treatments. However, by 1 month or 3 months of follow-up after 2 cycles of active laser treatment, 31% of subjects had a clinically significant reduction in arm volume (> 200 ccs). No effect was observed in the placebo treatment group or after only 1 cycle of laser treatment. The extracellular fluid index (by bioimpedance) of the affected and unaffected arms and torso were reported to be significantly reduced at 3 months after 2 cycles of laser therapy, and there was a significant softening of the tissues in the affected arm. Treatment did not appear to improve range of movement in the affected arm. With regard to the subjective measures, mean perceptual scores of symptoms and the index of activities of daily living demonstrated improvement after treatment in all groups (including placebo), and there was no difference found between active treatment and placebo in any of the measures except an improved quality of life score at 3 months after 2 cycles of treatment.

Thus, 2 cycles of laser treatment were found to be effective in reducing the volume of the affected arm, extracellular fluid, and tissue hardness in approximately one-third of patients with postmastectomy lymphedema at 3 months after treatment.

Comment by William B. Ershler, MD

The common appearance of lymphedema is frequently associated with physical discomfort (pain, heaviness), impaired function, and reduced quality of life. Standard approaches have offered only modest improvements, and the introduction of a new treatment modality with promise for success in one-third of patients would be a significant clinical advance. The current trial included a relatively small number of patients, but the design of the study was solid (prospective, randomized, placebo controlled), and the results clearly demonstrate benefit for some patients. As Carati et al acknowledge, a great deal more research will be needed to determine the optimal treatment dose and schedule, the duration of effect, and whether there is any long-term negative consequence.

Certainly, additional research should also be directed at determining the mechanisms involved in producing reduced lymphedema. Laser treatment for other conditions has been shown to affect fibroblast proliferation,3 macrophage and lymphocyte functions,4,5 and, perhaps most importantly in this context, to stimulate lymphangiogenesis.6 It is conceivable that these or other mechanisms yet to be described are involved in the treatment responses. Furthermore, it is also conceivable that laser treatment may activate dormant metastatic cells, and very careful analysis in larger trials will be required to determine the overall safety of this approach.

With regard to feasibility, it should be pointed out that the equipment required is relatively inexpensive (estimated to be approximately US $5000) and the treatments administered are of short enough duration that an economic analysis would likely show the overall costs to be low.

Thus, an intriguing new approach to a long-standing problem in cancer management has recently been introduced. The use of low-level laser therapy for the treatment of postmastectomy lymphedema deserves vigorous exploration.

Dr. Ershler is INOVA Fairfax Hospital Cancer Center, Fairfax, VA; Director, Institute for Advanced Studies in Aging, Washington, D.C.

References

1. Petrek J, Heelan M. Cancer. 1998;83:2776-2781.

2. Foldi E, et al. Angiology. 1985;36:171-180.

3. Boulton M, et al. Lasers Life Sci. 1986;1:125-134.

4. Young S, et al. Lasers Surg Med. 1989;9:497-505.

5. Tadakuma T. Keio J Med. 1993;42:180-182.

6. Lievens P. Lasers Med Sci. 1991;6:193-199.