Breaking the drought: rural management of breast cancer-related lymphoedema

This six-month joint project implemented a lymphoedema screening clinic, providing comprehensive treatment for lymphoedema in the Lachlan Health Service.

It involved a cross discipline collaboration between project leaders Dianne Green, McGrath Breast Care Nurse, and Rochelle Smith, senior physiotherapist. Responsibility was shared for these patients following breast cancer surgery.

This project aimed to meet a range of Australasian Lymphology Association (ALA) guidelines, which promote the early detection and intervention in lymphoedema after breast cancer surgery.

Previously there were no dedicated staff to provide this service. This project team enabled compliance with the guidelines by sharing staff responsibilities across chemotherapy, physiotherapy and breast cancer nursing.

Aim

The goal was for 100% of patients with breast cancer in the Lachlan Health Service to be:

• screened for lymphoedema pre-surgery
• screened for lymphoedema every three to six-months, post-surgery, over a two year period
• treated for lymphoedema if required.

Benefits

• Screenings increased: With 98% of patients screened, compared with 63% prior to the project.
• Early detection took place: Fourteen people were identified with lymphoedema.
• Treatment was provided: Extensive treatment for lymphoedema was provided to these consumers.
• Staff knowledge increased: A majority of project staff (75%) completed two Health Education and Training Institute (HETI) online education modules in lymphoedema.
• Project satisfaction: Project satisfaction was reported qualitatively by all participating consumers.

Background

An average of 64 people each year are treated for breast cancer within the Lachlan Health Service. Of those, approximately 16 people have, or will develop, lymphoedema.

Before this project began, there were insufficient numbers of staff within the Lachlan Health Service with appropriate qualifications to effectively meet the needs of lymphoedema treatment. Yet best practice requires the early detection, prevention and management of lymphoedema that develops after breast cancer surgery.

The ALA's Position Statement on Monitoring for Early Detection of Breast Cancer-Related Lymphoedema advises that lymphoedema should be screened pre-surgery and every three to six months for at least two-years, post surgery; in every person who has had breast cancer.¹

Before this project, Lachlan Health Service showed only 63% of people who met this screening criteria were screened over the previous two year period.

The impact of lymphoedema is significant and early detection is vital. Research shows that approximately 25% of people develop lymphoedema following breast cancer surgery. This is a result of damage to the lymphatic system that often occurs with cancer-related treatments. Once diagnosed, lymphoedema is a life-long condition which can have a significant impact on quality of life for breast cancer survivors.

Implementation

Step one: the creation of a project team

To address the lack of a comprehensive, evidence-based, best practice lymphoedema service a project team was created. It comprised a McGrath breast care nurse, three physiotherapists, a physiotherapy assistant and two oncology nurses.

Step two: identification of contributing factors and solutions

Once formed, this team identified several contributing factors to be addressed, as follows.

Challenge 1

Lack of documented procedures were available in relation to lymphoedema screening for the Lachlan Health Service area.

Solutions 1

• The development of an effective breast cancer patient database for those diagnosed within the last two years. This was to alert, monitor and collect patient data.
• The development of a patient assessment sheet, in line with the ALA guidelines. This includes circumferential measurements, L-Dex reading, and exploratory questions that target the signs and symptoms associated with lymphoedema.

Challenge 2

Minimal lymphoedema-trained staff, and limited staff hours, were made available to screen for lymphoedema. This meant that patients waited between six to eight weeks for treatment.

Solutions 2

• The development of a joint partnership between a McGrath Breast Care Nurse and the physiotherapy departments across several sites within Lachlan Health Service. The goal of this partnership was to provide monthly screening clinics and treatment for breast cancer-related lymphoedema.
• The successful application for a grant from Slade Health which resulted in a McGrath Breast Care Nurse completing a Level One Lymphoedema Certification through the Australian Lymphoedema Education, Research and Treatment (ALERT) program at Macquarie University.
• This increased work capacity by one day each week over six months. This additional day was set aside for the McGrath Breast Care Nurse to focus solely on best practice lymphoedema screening, early detection and treatment.
• Staff participation took place by studying lymphoedema modules Lymphoedema Awareness and Lymphoedema Early Intervention through the Health Education and Training Institute. This applied to chemotherapy, nursing and physiotherapy staff to support the early detection of lymphoedema.
• Professional development took place for lymphoedema therapists to support garment prescription for patients with lymphoedema.

Challenge 3

Patient education on lymphoedema was given only at initial diagnosis, and not as an ongoing initiative.

Solutions 3

• Post screening consumer consultation took place via interview and questionnaires to identify further patient education opportunities.
• At two separate intervals in the screening process, written education was given to consumers about the risk of lymphoedema, the reasons for, and benefits of, early detection.

Status

Implementation: The initiative is ready for implementation, is currently being implemented, piloted or tested.

Temporary funding for the treatment of lymphoedema was secured through Slade Health to last until 30 June 2019.

Lymphoedema screening clinics in the region continued within the Lachlan Health Service Area until this date, and further funding is required to ensure best practice lymphoedema, early intervention and treatment.

Dates

April 2018 to June 2019

Implementation sites

Parkes, Forbes, Condobolin, outreach sites Peak Hill, Trundle, Tullamore, Tottenham

Partnerships

• Slade Health
• McGrath Foundation
• Clinical Excellence Committee Clinical Leadership Program
• Lachlan Health Service
• Clinical Cancer Stream Western NSW Local Health District

Results

In six months, through the benefit of one extra day of staffing, the following results emerged.

• at least 98% of people were screened, to reflect the ALA Position Statement on Monitoring for Early Detection of Breast Cancer-Related Lymphoedema (2012).
• Twenty-three per cent of people were identified with lymphoedema.
• These people received 118 hours of treatment for lymphoedema.
• At least 77% of staff completed two HETI online education modules in lymphoedema.
• Patients commented that they felt cared for, part of a team, and that the process had shown how to manage their lymphoedema.

Lessons learnt

The importance of involving a variety of stakeholders and high level sponsors was apparent, to help ensure the completion of a project when obstacles occur.

References

1. Australasian Lymphology Association. Position Statement on monitoring for early detection of breast cancer-related lymphoedema. Beaumaris: ALA; 2012.

Further reading

• Breast Cancer Network Australia. Lymphoedema. Camberwell, Vic: BCNA.
• Cancer Council. Lymphoedema. Cancer Council: 2017.
• Hayes SC, Janda M, Cornish B, et al. Lymphedema after breast cancer: incidence, risk factors, and effect on upper body function. J ClinOncol. 2008 Jul 20;26(21):3536-42.
• Health Education and Training Institute
• Macquarie University Health Sciences Centre. Lymphoedema Accreditation Course. North Ryde: Macquaire University; 2019.
• Shah C, Arthur D, Wazer D, et al. The impact of early detection and intervention of breast cancer-related lymphoedema: a systemic review. Cancer Medicine 2016: 5 (6)

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