Breast Cancer & Lymphoedema
After surgery for breast cancer, many women suffer from lymphedema, a chronic swelling of the arm due to impaired lymph drainage. Lymphedema is often defined as an increase in the arm circumference measurement on the affected side of > 2 cm over the unaffected side, but women often report changes in sensation and experience of reduced range of arm motion before they display significant swelling.
INTRODUCTION — Lymphedema is swelling caused by a build up of lymph fluid, usually in the arm in women who have been treated for breast cancer. Lymphedema is one of the most troubling complications that can develop after breast cancer surgery. Many women find that lymphedema worsens the physical and emotional strain of dealing with breast cancer.
Between 9 and 25 percent of women develop lymphedema after surgery for breast cancer. The risk of developing lymphedema depends upon the extent of surgery, the time since surgery, and if radiation therapy was used. Generally, people who undergo more extensive surgery, have many lymph nodes removed, or have radiation therapy to the axilla after surgery are more likely to develop lymphedema. Most women who develop lymphedema do so within four years after their operation.
WHAT IS LYMPHOEDEMA? — Lymph is a clear fluid that contains mostly protein and white blood cells (the blood cells that fight infection). The lymphatic system drains the body's tissues and organs into a series of tubes or ducts. The fluid is filtered through lymph nodes (also called glands) and eventually drains into the bloodstream.
Lymphedema can develop if the lymph vessels are interrupted. This interruption can be caused by:
- Surgery, particularly removal of the lymph glands in the armpit (also called the axilla)
- Radiation treatment to the axilla
Women who have multiple lymph nodes removed (a full axillary node dissection) are more likely to develop lymphedema than those who have only sentinel lymph node biopsy. Women who have both surgery and radiation treatment are at even higher risk.
Lymph node biopsy and dissection are discussed in detail in a separate topic review.
SYMPTOMS — The initial symptoms of lymphedema may include
- A heavy sensation or an aching discomfort in the arm
- Swelling of the affected arm or upper chest
- Difficulty moving the arm
- Stiffness, weakness, or numbness
In some cases, these symptoms develop before swelling is noticeable. Let your healthcare provider know as soon as possible if you develop any of these symptoms; recognizing and treating lymphedema in the early stages may prevent or slow its worsening over time.
HOW IS LYMPHEDEMA DIAGNOSED? — Most women will know if they have lymphedema because they have one or more of the symptoms listed above. Other ways to diagnose lymphedema include measuring the circumference of the arm (the distance around the arm) at several predetermined points or by using a device called a volumeter. A volumeter is a device that measures the size of the arm when it is immersed in water. The size of the affected arm (near the breast treated for cancer) is then compared to the size of the unaffected arm.
A water displacement arm volumeter device has been designed for home use. The device can be made using widely available polyvinyl chloride (PVC) pipes that are sold in hardware stores.
The size or volume of the arm is often monitored over time to detect changes and measure response to treatment.
PREVENTING PROGRESSION OF LYMPHEDEMA — Women with lymphedema can do several things to prevent the condition from getting worse over time. Expert groups recommend the following:
- Avoid trauma and injury to the affected arm. Injections and acupuncture should not be given in the affected arm, if at all possible. Blood drawing and intravenous lines are allowed, but caution is needed to minimize pressure and avoid infection.
- Avoid constriction in the affected arm. Tight fitting clothing, prolonged blood pressure monitoring, or any activity that could interfere with lymph flow should be avoided.
- Try to prevent infection. Practice careful skin and nail hygiene. Use skin moisturizers to prevent dry, cracked skin. Use an antibiotic cream or ointment on small skin cuts, such as paper cuts. Use protective gloves for household work and gardening. Use an electric razor rather than a razor blade to remove hair in the armpit.
- Avoid heavy exercise and lifting heavy objects with the affected arm immediately after surgery. Moderate to heavy exercise of the limb may increase blood flow, which can worsen edema. Gentle stretching and range of motion exercises, provided by the surgeon, may be used immediately after surgery. Check with a healthcare provider before resuming an exercise program after breast cancer treatment.
- Avoid extreme temperature changes during bathing or washing dishes. Hot tubs, steam baths, and spending time in hot climates can worsen lymphedema in some women.
- Some women notice worsening of their lymphedema during air flight. In the past, many health care providers suggested that women who use compression sleeves wear them during the flight, but this is now controversial. At least one study suggests that short-duration flights (less than 5 hours) do not worsen lymphedema, and that wearing a sleeve during a short flight may actually increase arm swelling.
- Maintain an ideal body weight. Obesity can worsen lymphedema and may limit the effectiveness of compression pumps or sleeves.
- Avoid resting the arm below the heart or sleeping on the arm for prolonged periods.
- Contact a healthcare provider if the affected arm develops a rash, becomes red, blistered, or warm, or if a fever develops (temperature greater than 100.4ºF or 38ºC). These symptoms could signal the beginning or worsening of lymphedema.
- Patients who develop lymphedema many years after surgery or who have lymphedema that is increasing should be evaluated for a possible recurrence of their breast cancer.
TREATMENT — There is no cure for lymphedema. The main goals of treatment are to control swelling, relieve symptoms, and prevent edema from worsening over time. Treatment should begin as soon as possible after lymphedema is diagnosed. Women who are treated in the early stages are more likely to have a positive outcome.
Treatment should address the all of the symptoms of lymphedema, including swelling, discomfort, difficulty moving the arm, and psychological distress. A healthcare provider or program with expertise in treating lymphedema can be especially helpful.
Because drugs are of little benefit and can sometimes be harmful, the most common approaches are nonpharmacologic (ie, they do not involve medications).
Nonpharmacologic therapy — Several nonpharmacologic treatment modalities are effective.
Arm elevation — Although elevation of the arm is not an effective treatment by itself, it may be recommended in conjunction with other therapies [2].
Exercise — After the immediate recovery phase, moderate exercise is recommended. If the arm begins to hurt, lie down and elevate the arm. Walking, swimming, light aerobics, bike riding, and yoga are all recommended to improve lymph flow and reduce swelling. Avoid repetitive movements against resistance with the affected arm, such as scrubbing or pushing/pulling heavy objects.
Some clinicians recommend avoiding certain forms of exercise, including rowing, tennis, golf, skiing, squash, racquetball, or other vigorous repetitive movements. However, there is no evidence that these activities promote or worsen lymphedema.
Compression garments — Applying pressure to the arm can encourage fluid movement and ultimately reduce swelling. Pressure can be applied by using an elastic lymphedema sleeve or by wrapping the arm in elastic bandages. Some people require a custom-made garment if a standard size sleeve does not fit.
A lymphedema sleeve is preferred to bandaging because it provides increased pressure at the wrist, which gradually lessens towards the axilla; this helps to move fluid better than bandages, which have equal pressure at all points along the arm. Whichever method is used, proper fit is important to avoid worsening edema in any one area of the arm.
Some clinicians recommend the garment be used for up to 24 hours per day, while others recommend use only during waking hours or exercise. Compression garments should be replaced every four to six months, or when they begin to lose their elasticity.
Massage therapy — Another method to mobilize lymph fluid is massage or manual lymphatic drainage (MLD). MLD applies light pressure to the arm and torso to mobilise fluid from the fingers and hand to the upper arm and chest. It is thought that MLD of the skin and subcutaneous tissue may help open gaps or collateral channels between lymphatic ducts, enhancing the flow of fluid through the lymphatic system.
Massage is usually used in conjunction with compression garments and therapeutic exercise. Whenever possible, patients should be referred to practitioners trained in MLD. Patients and family members can also be trained in massage techniques, allowing therapy to continue after formal treatment with a therapist. Mild lymphedema may resolve in two to three weeks, but more severe cases usually require longer treatment.
Complex decongestion therapy — This is a multimodality approach that uses a combination of massage, skin care, exercise, and compression garments. It is considered an effective treatment for lymphedema that is unresponsive to compression therapy alone. A physical therapist directs the treatment. The treatment is done intensively until arm swelling is improved (several weeks to months), followed by a maintenance program that continues indefinitely.
Women with certain conditions should not use complex physical therapy of the arm, including those with infections of the affected arm, severe heart failure, or a deep vein thrombosis (blood clot in the arm).
External pneumatic compression — External pneumatic compression may be used for patients who do not respond to massage or pressure garments. This treatment uses a sleeve that is intermittently inflated, beginning at the lower end of the arm and progressing towards the shoulder.
Currently, pneumatic compression is recommended only for patients who have not improved with other therapies (massage, compression garments, exercise). It is not useful as a sole form of therapy, but is usually combined with complex physical therapy.
Drug treatment — Drug therapy is usually ineffective and in some cases, can be harmful.
- Diuretics — Diuretics eliminate excess fluid from the body. Although they are often used to treat edema that develops as a result of heart failure, diuretics are not effective for lymphedema.
- Antibiotics — Antibiotics are used to treat infection; continued or preventive antibiotic therapy does not improve lymphedema. However, oral antibiotics may rarely be recommended for extended periods of time to prevent infection in people who have chronic or recurrent infections.
Surgery — Surgery is rarely performed to treat lymphedema following breast cancer therapy. When surgery is necessary, the preferred approach includes removal of subcutaneous fat and fibrous tissue with liposuction. The effectiveness of this approach has not been studied, and there is concern that lymphedema will eventually return after surgery.
Some specialized centers have performed lymphatic microsurgery, which involves draining lymph fluid into blood vessels. A newer technique, microsurgical lymph node transplantation, is currently being studied.
IMPACT OF LYMPHEDEMA — While lymphedema is not a life-threatening condition, it can have a major impact on a person's lifestyle and quality of life. A change in the appearance of the arm often leads to concerns about body image.
- After breast cancer surgery, many women are already self-conscious about their appearance; arm edema can heighten this concern.
- Psychologic symptoms can occur, such as anxiety, depression, avoiding social situations, and lack of interest in sex.
- If lymphedema affects the ability to use the arm, this can impact quality of life, particularly if it is the patient's dominant arm (eg, right arm if the person is right-handed).
- Lymphedema can reduce tissue healing and occasionally causes chronic pain. For these reasons, prevention strategies and early treatment of lymphedema are strongly recommended.
