Breast cancer-related lymphedema (BCRL): Should we be doing more or less for the axilla?

Breast cancer mortality has declined steadily over the years with breast cancer screening and improvement in diagnostic and therapeutic regimens. Despite cancer survivors living longer, breast cancer-related lymphedema (BCRL) is a significant complication after major breast surgery that can impact quality of life adversely. The incidence of BCRL reported ranges from 10.1% to 42.2%1-5 with risk factors that include higher body mass index, larger number of dissected nodes, taxane-based regimen, total mastectomy, larger irradiation field, and conventional fractionation.5 To mitigate the risk of BCRL, de-escalating axilla surgery and axilla radiotherapy in place of axillary dissection are increasingly recognised as the new standard of care in recent years for early breast cancer with sentinel lymph node positive.6 Surgical innovation and advancements have also led to proponents of immediate lymphatic reconstruction to decrease the incidence of BCRL.7 However, immediate lymphatic reconstruction is a costly additional procedure and whether it constitutes value-based care to recommend this as a routine procedure in relation to the prevalence of lymphedema in Singapore is an important decision that requires careful deliberation by the breast cancer surgical community.