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Breast Cancer & Lymphoedema

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:

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

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:

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.

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.

     Axillary lymph nodes