Prevention has focused on taking what we know causes lymphedema and developing risk reduction strategies. Most importantly, sentinel lymph node dissection (SLND) has now replaced full axillary lymph node dissection (ALND) where possible, reducing the risk of lymphedema. Infection prevention and education about precautionary guidelines (Armer et al. 2013; Paskett et al. 2012; Bernas 2013; Bernas et al. 2010; Erickson et al. 2001; Golshan and Smith 2006; Shah and Vicini 2011; Shah et al. 2012a; Soran et al. 2012; Stout et al. 2013) have not been tested as risk reducing strategies, although risk and prevention messages have been targeted to both providers—in terms of risk and how to reduce it, minimize risk of infection (i.e., draw blood only from untreated side) (Armer et al. 2013; Bernas 2013; Bernas et al. 2010; Shah and Vicini 2011; Soran et al. 2012; Shah et al. 2012b; Cassileth et al. 2013; O’Toole et al. 2013; Rourke et al. 2010; Schwartz 2012; Stout Gergich et al. 2008; Tam et al. 2012; Fu et al. 2012)—and survivors—to recognize early signs, and understand methods of risk reduction (Soran et al. 2012; Schwartz 2012; McLaughlin et al. 2013; Meneses et al. 2007; Sherman and Koelmeyer 2011). More recently, physical activity (Ahmed et al. 2006; Brennan and Miller 1998; Jammallo et al. 2013; Jonsson and Johansson 2009; Katz et al. 2010; McNeely et al. 2010; Schmitz 2010; Schmitz et al. 2009, 2010) and weight reduction have been explored as prevention options with results still pending; however, some studies show no harm with physical activity (Ahmed et al. 2006; Cormie et al. 2013; Courneya et al. 2007). The use of compression garments for air travel is still controversial (Graham 2002; Kilbreath et al. 2010) and has yet to be evaluated.

Uncertainties about diagnostic measures for lymphedema exist because current methods vary greatly in their validity, reliability and acceptability to both women and providers/clinics. Methods studied include: water displacement (Sagen et al. 2009), lymphoscintigraphy (Moshiri et al. 2002; Szuba et al. 2002), high-frequency ultrasound (Adriaenssens et al. 2012), bioimpedance (Cornish et al. 2001; Ward et al. 1992), arm circumference (Deutsch et al. 2008; Chen et al. 2008), and self-report (Czerniec et al. 2010). Each method has strengths and weaknesses; however, the fact that there are so many tools reduces the ability of common estimates of lymphedema to be valid and reliable. A summary of diagnostic methods are presented in Table 8.2. In addition, because there is no commonly accepted measurement tool, the ability of any tool to be used for early detection, when early treatment can eliminate or cure early signs of lymphedema (Deutsch et al. 2008; Stout et al. 2011; Johansson and Branje 2010), is limited. A new area of promise is surveillance where all women at risk are screened, and, if diagnosed with early-stage BCRL, they receive intervention and treatment. Significant cost savings were found using this surveillance model vs. impairment-based care (Stout et al. 2012).

While there is no cure for lymphedema, there are many treatment strategies, some tested and others utilized but with varying efficacy (Park et al. 2012; Sayko et al. 2013; Norman et al. 2009; Cormier et al. 2010; Sierla et al. 2013). The most common treatment regimens are Complete Decongestive Therapy (CDT) (including bandaging, compression garments, and manual lymphatic drainage), pneumatic compression, low-level laser therapy (LLLT), and surgery. Newer treatments include exercise, stem cell transplant, and shock wave therapy. Recent studies have shown that guided, gradual exercise may increase arm function (Cormie et al. 2013); however, the impact of exercise on the prevention and/or reduction of swelling needs to be further investigated. Evidence from randomized controlled trials (RCTs) shows conflicting evidence on the efficacy of CDT on both arm volume/function and quality of life (King et al. 2012; Badger et al. 2000; Dayes et al. 2013; Huang et al. 2013; Vignes et al. 2013). Pneumatic compression used at home has only been tested in one study and was found to significantly reduce arm volume (Fife et al. 2012). LLLT shows some promise, but no RCTs have been conducted for surgery as a treatment modality. For the newer treatments, only extra-corporeal shock wave therapy has demonstrated promise but it has only been tested in one small study (Bae and Kim 2013). Thus, treatment modalities for lymphedema are woefully understudied. A summary of treatment methods are presented in Table 8.3.

While common risk factors for lymphedema, such as ALND, infection and obesity, have emerged, an improved understanding of how these risk factors interact, particularly in underserved populations (e.g., racial/ethnic minorities, urban/rural residents, the elderly, the poor, and persons with disabilities), is desperately needed (Dominick et al. 2013; Meeske et al. 2009; DiSipio et al. 2010). There is a paucity of information about disparities in lymphedema risk and incidence, as well as treatment characteristics, among underserved populations, but it is certainly plausible that lymphedema disparities mirror the trend generally observed in health and health care (i.e., higher incidence and mortality). For example, African Americans have a higher rate of obesity compared to their white counterparts (Ogden et al. 2012), and BMI is a known risk factor for lymphedema. Minority women, particularly African Americans and Hispanics, are also more likely to present with later stage disease and larger tumors (Dehal et al. 2013; American Cancer Society 2013), increasing the likelihood of undergoing ALND (Arrington et al. 2013), which increases the risk for lymphedema.

Another underserved population includes those living in non-urban areas, who have increased odds of undergoing ALND (OR for rural area = 2.06), with non-urban areas lagging 2 years behind urban areas with respect to the use of SLND (Arrington et al. 2013). Not only do those living in non-urban areas undergo ALND more often, they also have limited access to trained lymphedema specialists, who are primarily located in urban centers.

There are very few prevention strategies being tested, thus this area is ripe for further investigation (Armer et al. 2011, 2013; Shah et al. 2012a; Soran et al. 2012; Stout et al. 2013; O’Toole et al. 2013; Fu et al. 2012). What makes prevention studies difficult to conduct, however, is the need for long-term follow-up of women which can be difficult and costly. Future interventions should explore the extent to which compression garments should be worn during exercise, the timing of exercise after curative treatment, the varying usefulness of exercise across the clinical progression of BCRL, and the type of safety monitoring needed during exercise among this population (Tam et al. 2012). To incorporate exercise rehabilitation into cancer survivorship care, there is a need to inform both practitioners and patients of the risks and benefits associated with exercise (including strength training), and to provide healthcare providers with streamlined resources to promote the integration of physical rehabilitation into the supportive care paradigm (Meneses et al. 2007). Another unstudied research topic is whether losing weight after breast cancer treatment reduces BCRL risk. If so, post treatment weight loss could be a risk reduction strategy for survivors.

There are two areas where clinical practice can be impacted regarding BCRL risk reduction—the provider and the patient. Providers frequently counsel patients regarding BCRL risk based on the presence of previously reported risk factors like injury, infection, BMI, age, and surgery. However, recommendations based solely on these factors are unreliable, as evidenced by the multiple studies presenting conflicting data. This suggests that an individualization of risk reduction strategies is needed. Barriers to this approach include lack of time and provider training to discuss individualized risk factors and strategies with patients. Best practice guidelines need to be updated to include baseline measurements prior to treatment, and continued routine measurements should be part of routine survivorship care.