Pre-emptive Versus Reactive Models of Care

Pre-emptive Care Model

Prospectively Managing Lymphedema in Breast Cancer Patients

Reactive Care

Patients are often referred only after visible swelling and symptoms are apparent.
In current clinical practice, a tape measure is most likely used to verify a 2 cm or 200 -300 ml difference between limbs. At this point irreversible change might have already occurred. The tape measure is neither standardised nor objective. It has only a 5% sensitivity for early detection when compared to the standardised metric of BIS [3]
At these levels, irreversible changes due to fibrosis and lipid deposition have already occurred. A 10 year follow up study of breast cancer patients diagnosed with lymphedema using water displacement (200 ml or 8% to 11% volume difference) showed that none of these patients returned to normal levels, and had at least Stage 2 lymphedema even after being treated for up to ten years. [1]
Due to the difficulty of use and lack of confidence in the tape measure few surgeons/radiologists take a pre-emptive care approach. Consequently, a multi-disciplinary approach is seldom implemented to identify pre-clinical lymphedema. Patients are simply referred to physical therapy after swelling is apparent and the often life long chronic care begins, impacting the patient’s quality of life, and burdening the healthcare payer with major costs

“Patients with breast cancer–related lymphoedema (BCRL) have been found to have a lower quality of life, a higher level of anxiety or depression, a higher likelihood of chronic pain & fatigue, & greater difficulty functioning socially & sexually compared with BC women without lymphoedema” [2]

A recent study from MD Anderson looked at the cost of treating breast cancer patients in a reactive model over a two year period in matched cohorts with and without lymphedema. The study showed a $14,000 to $23,000 higher cost associated with those who had developed lymphedema. [2]
If we continue to react to lymphedema, we’ll continue to negatively impact the survivors of cancer whose quality of life should be protected as a key clinical objective. In addition, to pay the considerable costs associated with chronic care, which can include weeks of intensive physical therapy, pneumatic compression pumps, depression, social withdrawal and disability is less than ideal.

Pre-emptive Care

What is the best option to provide patients the best possible clinical outcome at the lowest cost?

Bioimpedance spectroscopy (BIS) can aid a physician in the clinical assessment of unilateral lymphedema of the arm in female breast cancer patients. [3] It is the first device to offer a clinical aid in measuring directly the extracellular fluid differences of the arms.
The groundbreaking study conducted by the National Institutes of Health (NIH) [4] has demonstrated the importance of pre-emptive coordinated care in protecting patients from potentially progressing to irreversible lymphedema. Using pre-operative and post operative surveillance, the investigators identified lymphedema in an early, pre-clinical fluid state. The study was highly successful in returning patients back to pre-operative baseline measurements. Other randomized control trials have shown the importance of early intervention and a preventative approach. [5]
Reimbursing quarterly pre-emptive care at $200 could save a health insurance plan covering 5 million lives an estimated $2.3 million dollars, (36%) in the first two years while protecting women’s quality of life. [6] Applying the same model to the US Medicare population would save an estimated $81.4 million dollars while protecting the quality of life of over 21,000 women.
Pre-emptive care brings the surgeon, oncologist/radiologist and therapist together to educate patients about lymphedema risk while employing pre- and post-operative care to identify pre-clinical lymphedema when it can be most cost effectively and efficiently treated.
Early intervention appears to prevent progression in the vast majority of patients. [4] The one area that seems consistent as a mantra, across all health care providers in this field, is that early treatment leads to better clinical outcomes.

Lymphedema can devastate the life of not just the patient but also a spouse, family member or caregiver who then needs to assist the patient for the rest of her life. Breast cancer affects one in eight women in the United States. If it affects someone you know, would you be satisfied with a reactive model or would you want a pre-emptive model of care? Comparative effectiveness supports the use of BIS and early intervention to affect better outcomes. [2]

References

Cancer