Lymphoedema after Breast Cancer Treatment

Lymphoedema is a chronic swelling of the limb, caused by a primary congenital condition, or a secondary trauma or surgery to the lymphatic structures. Lymphoedema of the arm is a common side effect of breast cancer treatment (1,2), with varying incidence depending on the type of treatment received.

Not all men and women who undergo treatment for breast cancer will develop lymphoedema, but it is important to know how to reduce the risk of developing this condition and what signs and symptoms to look out for. There is currently no cure for lymphoedema, but it is a condition that can be managed effectively if identified at an early stage.

The main responsibilities of the lymphatic system are immunity and maintaining a fluid balance in the body. When there is damage to the lymphatics, the ability to transport lymphatic fluid back into the circulation is affected, sometimes leading to a build-up of fluid in the limb. This fluid is rich in protein and makes an ideal environment for bacteria to thrive, which could lead to serious infections like cellulitis. The limb becomes larger and heavier over time if not managed effectively, leading to pain and loss of function (3).

Breast cancer related lymphoedema causes

In relation to breast cancer treatment, certain treatments can damage the lymphatics

  • Surgery- removal of lymph nodes, the number of lymph nodes removed, and scarring
  • Post-surgical complications- e.g. seroma, infection
  • Radiation- radiation skin changes and radiation fibrosis
  • Chemotherapy

Significant predisposing factors are Obesity (BMI greater than 30), and a sedentary lifestyle (4). Recent studies have shown 150 minutes of moderate intensity exercise, every week, can reduce the recurrence of breast cancer by 40%. (5,6)

Signs and symptoms

  • a feeling of heaviness in the arm, stiffness in the joints, skin changes, numbness and or pins and needles, clothes feeling tighter
  • obvious swelling anywhere in the arm
  • clinically a circumference measurement difference of 2cm is significant, or a volume difference of 10% (7).

Treatment

According to the International Society of Lymphology Classification, there are varying stages of lymphoedema depending on the size of the limb and skin changes. This is helpful when classifying the severity of the condition and deciding what management strategies are required. (8)

It is important that you see a certified lymphoedema therapist as soon as possible if you suspect you may have lymphoedema. DO NOT WAIT to see if the swelling will go away. It may appear to be better the next morning, BUT this is an indication that the lymphatic system is not coping with the fluid demand and requires help.

Treatment usually consists of an Intensive Phase to reduce the limb size and volume, followed by a Maintenance Phase where the patient is taught techniques to manage the condition daily.

Complete Decongestive Therapy consists of 4 important factors:

  1. Compression- bandaging and compression garments
  2. Manual Lymphatic Drainage
  3. Exercise- General exercise, including resistance and aerobic training, has been shown to decrease lymphoedema symptoms. (9)
  4. Skin care

There are some surgical treatment options that could be considered if all conservative management options fail. Lymphoedema is a chronic condition that requires daily intervention for successful management, even after surgery to improve lymphatic function. Compression garments must be worn daily to manage lymphoedema effectively.

Risk Reduction

If you know you will be having, or have undergone treatment for breast cancer, it is important that you try to reduce the risk of developing lymphoedema.

  • Exercise- guided exercises started soon after surgery have been shown to decrease the incidence of lymphoedema. (10) These are specific exercises which you should get from your physiotherapist. Ask your surgeon to refer you to someone who is experienced in working with oncology patients. Gradually return to normal or new activities after surgery.
  • Education- Have a pre-treatment baseline assessment with a lymphoedema therapist who will provide you with information regarding signs and symptoms of lymphoedema and tips on caring for the arm
  • Skin care is a vital risk reduction strategy. Always try to reduce infection, trauma and inflammation to the arm. Moisturise and care for your skin daily. Avoid wearing tight clothing and jewellery. No blood pressure monitors or injections to the affected arm.

Most people will develop lymphoedema within 2-3 years after their treatment for breast cancer. (11) However this is not a rule and lymphoedema may appear decades later. Therefore these risk reduction strategies must be applied for the duration of life.

For further information on reducing the risk of developing lymphoedema, have a look at the National Lymphoedema Network Risk-reduction Guidelines. (12)

References:

  1. Armer, J.; Stewart, B. Post-breast cancer lymphedema: Incidence increases from 12 to 30 to 60 months. Lymphology 2010, 43, 118–122.
  2. Radina, M.E.; Armer, J.M.; Stewart, B.R. Making self-care a priority for women at risk of breast cancer-related lymphedema. J. Fam. Nurs. 2014, 20, 226–249.
  3. Fu, M.R.; Rosedale, M. Breast Cancer survivors’ experiences of lymphedema-related symptoms. J. Pain Symptoms Manag. 2009, 38, 849–859.
  4. Dominick, S.A.; Madlensky, L.; Natarajan, L.; Pierce, J.P. Risk factors associated with breast cancer-related lymphedema in the WHEL study. J. Cancer Survivorship 2012, 7, 115–123.
  5. Holmes, MD et al. Physical activity and survival after breast cancer diagnosis. JAMA. 25 May 2005. 293(20):2479–86.
  6. Holick CN, Newcomb PA, Trentham-Dietz A et al. Physical activity and survival after diagnosis of invasive breast cancer. Cancer Epidemiol Biomarkers Prev. 2008.(17):379–386.
  7. Armer, J.M. The problem of post-breast cancer lymphedema: Impact and measurement issues. Cancer Investig. 2005, 23, 76–83.
  8. International Society of Lymphology Executive Committee. The diagnosis and treatment of peripheral lymphedema: 2013 Consensus Document of the International Society of Lymphology. Lymphology 2013, 46, 1–11.
  9. Schmitz, K.H.; Ahmed, R.L.; Troxel, A.; Cheville, A.; Smith, R.; Lewis-Grant, L.; Greene, Q.P. Weight lifting in women with breast cancer-related lymphedema. N. Engl. J. Med. 2009, 261, 664–673.
  10. Testa A, Iannace C, Di Libero L. Strengths of early physical rehabilitation programs in surgical breast cancer patients: results of a randomised controlled study. Eur J Phys Rehabil Med. 2014. 50:275-84.
  11. Petrek, J.A.; Senie, R.T.; Peters, M.; Rosen, P.P. Lymphedema in a cohort of breast carcinoma survivors 20 years after diagnosis. Cancer 2001, 92, 1368–1377.
  12. Position statement of the National Lymphedema Network. Available online: http://www. lymphnet.org/ category/position-papers

By Candice Kuschke
Physiotherapist and Lymphoedema Therapist