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

Retrouvey, Helene, M.D.C.M.; Krahn, Murray, M.D., M.Sc.; Baltzer, Heather, L., M.Sc., M.D.

Plastic and Reconstructive Surgery: May 2018 - Volume 141 - Issue 5 - p 689e–696e
doi: 10.1097/PRS.0000000000004318
Hand/Peripheral Nerve: Original Article

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.

Toronto, Ontario, Canada

From the Division of Plastic and Reconstructive Surgery, University of Toronto; and the Toronto Health Economics and Technology Assessment Collaborative, Toronto General Hospital.

Received for publication September 13, 2017; accepted November 21, 2017.

Presented at Gallie Day, in Toronto, Ontario, Canada, April 28, 2017.

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

Heather L. Baltzer, M.Sc., M.D., Division of Plastic and Reconstructive Surgery, University of Toronto, 399 Bathurst Street, East Wing, 2nd Floor, Room 422, Toronto, Ontario M5T 2S8, Canada, heather.baltzer@uhn.ca

©2018American Society of Plastic Surgeons