Carpal Tunnel Syndrome Management in Breast Cancer Survivors at Risk for Lymphedema: A Markov Model

Plast Reconstr Surg. 2018 May;141(5):689e-696e. doi: 10.1097/PRS.0000000000004318.

Abstract

Background: Breast cancer survivors that have undergone axillary lymph node dissection have an increased risk of developing same-side upper extremity lymphedema. Patients with carpal tunnel syndrome in the ipsilateral limb may not receive appropriate surgical therapy (carpal tunnel release) because of concerns that it may trigger or worsen lymphedema.

Methods: A state transition cohort model was used to evaluate the treatment options for breast cancer survivors at risk of upper extremity lymphedema presenting with carpal tunnel syndrome. The model reflected three treatment strategies: (1) early surgical intervention, (2) delayed surgical intervention, or (3) nonsurgical management. Both life-years and quality-adjusted life-years were modeled over a 30-year time horizon.

Results: Over a 30-year time horizon, the preferred strategy was delayed surgery, which resulted in 21.41 quality-adjusted life-years. Early surgery and nonsurgical management yielded 20.42 and 21.06 quality-adjusted life-years, respectively. The model was robust and was not sensitive to variation in any of the parameters within the clinically plausible ranges.

Conclusions: Based on this decision analytic model, the optimal choice for breast cancer survivors with mild carpal tunnel syndrome who are at risk for lymphedema would be delaying surgery until severe symptoms develop. This strategy balances the potential increased risk of lymphedema following carpal tunnel release with the decreased long-term risk of severe carpal tunnel syndrome. The model comprehensively assesses a controversial area in the breast cancer and hand surgery literature to inform decision-making for patients and clinicians.

MeSH terms

  • Axilla / surgery
  • Breast Neoplasms / mortality
  • Breast Neoplasms / surgery*
  • Cancer Survivors*
  • Carpal Tunnel Syndrome / diagnosis
  • Carpal Tunnel Syndrome / surgery*
  • Clinical Decision-Making
  • Cohort Studies
  • Female
  • Humans
  • Lymph Node Excision / adverse effects*
  • Lymphedema / etiology
  • Lymphedema / prevention & control*
  • Markov Chains
  • Middle Aged
  • Severity of Illness Index
  • Time Factors
  • Upper Extremity / surgery