Lymphedema after breast cancer surgery

Patient information: Lymphedema after breast cancer surgery

Authors
Emile R Mohler, III, MD
Tammy E Mondry, DPT, MSRS, CLT-LANA
Section Editor
Daniel F Hayes, MD
Deputy Editors
Don S Dizon, MD, FACP
Susan E Pories, MD, FACS

Disclosures

LYMPHEDEMA OVERVIEW — Lymphedema is swelling caused by a build-up of 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.

The risk of developing lymphedema depends upon the type of surgery you had, the time since surgery, and if radiation therapy was used. Generally, women who undergo more extensive surgery, have many lymph nodes removed, or have radiation therapy to the axilla (arm pit) after surgery are more likely to develop lymphedema. Most women who develop lymphedema do so within four years after their surgery.

More detailed information about lymphedema is available by subscription. (See “Lymphedema: Etiology, clinical manifestations, and diagnosis” and “Lymphedema: Prevention and treatment”.)

WHAT IS LYMPHEDEMA? — Lymph is a clear fluid that contains mostly protein and white blood cells (the blood cells that fight infection). Lymph vessels drain lymph from the body’s tissues and organs. The fluid is filtered through lymph nodes (also called glands) and eventually drains into the bloodstream (figure 1).

Lymphedema can develop if surgery or radiation treatment affects the lymph vessels.

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. (See “Patient information: Surgery for breast cancer — Mastectomy and breast conserving therapy”.)

LYMPHEDEMA 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 doctor or nurse 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.

PREVENTING WORSENING OF LYMPHEDEMA — Women with lymphedema can do several things to prevent it from getting worse over time. Expert groups recommend the following:

Avoid trauma and injury to the affected arm. Blood draws, IV lines, injections, and acupuncture should be avoided in the affected arm, if at all possible. Avoid tight fitting clothing, prolonged blood pressure monitoring, or any activity that could interfere with lymph flow in the affected arm.
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 arm pit.
Avoid heavy exercise and lifting heavy objects with the affected arm immediately after surgery. These activities may increase blood flow, which can worsen edema. Gentle stretching and range of motion exercises, provided by a healthcare professional, may be used immediately after surgery. Check with your doctor 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 may worsen lymphedema.
Some women notice worsening of their lymphedema during air flight. In the past, many healthcare 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 compression sleeve during a short flight may actually increase arm swelling.
Keep your weight under control. Obesity can worsen lymphedema and may limit the effectiveness of compression pumps or sleeves.
Avoid resting your arm below your heart or sleeping on your arm for prolonged periods.
Contact your doctor or nurse if the affected arm develops a rash, becomes red, blistered, or warm, or if you get a fever (temperature greater than 100.4ºF or 38ºC). These symptoms could signal the beginning or worsening of lymphedema.
If you develop lymphedema many years after surgery or have worsening lymphedema, contact your doctor or nurse immediately.
LYMPHEDEMA TREATMENT — There is no cure for lymphedema. The main goals of treatment are to control swelling, relieve symptoms, and prevent the swelling from worsening over time. Treatment should begin as soon as possible. A healthcare provider or program with expertise in treating lymphedema can be especially helpful.

Because medicines are of little benefit and can sometimes be harmful, the most common approaches do not involve medicines. Instead, a therapy program which combines massage, skin care, exercise, and compression garments (elastic bandages or a lymphedema sleeve) is recommended.

IMPACT OF LYMPHEDEMA — While lymphedema is not a life-threatening condition, it can have a major impact on your quality of life. A change in how your arm looks can be distressing.

After breast cancer surgery, many women are worry about how they look; having a swollen or misshapen arm can make this worse.
If lymphedema affects the ability to use your arm, this can affect your quality of life, particularly if it is your dominant arm (eg, right arm if you are right-handed).
Lymphedema can reduce tissue healing and occasionally causes chronic pain. For these reasons, prevention and early treatment of lymphedema are recommended.
CLINICAL TRIALS — Progress in treating breast cancer requires that better treatments be identified through clinical trials, which are conducted all over the world. A clinical trial is a carefully controlled way to study the effectiveness of new treatments or new combinations of known therapies.

One example of a clinical trial that is investigating ways to reduce the incidence of lymphedema after breast cancer therapy is called CALGB 70305. This trial is currently enrolling women to determine if a combination of education, use of light arm weights with exercise, a light compression sleeve with vigorous activity, and regular breathing exercises can reduce the risk or severity of lymphedema after axillary lymph node dissection. Women are encouraged to enroll if possible. More information can be found online at www.cancer.gov/clinicaltrials/CALGB-70305.

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

 

Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient Level Information:

Patient information: Surgery for breast cancer — Mastectomy and breast conserving therapy

Professional Level Information:

Lymphedema: Etiology, clinical manifestations, and diagnosis
Lymphedema: Prevention and treatment

The following organizations also provide reliable health information.

National Cancer Institute
1-800-4-CANCER
(www.nci.nih.gov)

People Living With Cancer: The official patient information website of the American Society of Clinical Oncology

(www.cancer.net/portal/site/patient)

National Comprehensive Cancer Network
(www.nccn.com)

American Cancer Society
1-800-ACS-2345
(www.cancer.org)

National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)

Susan G. Komen Breast Cancer Foundation
(www.komen.org)

National Lymphedema Network
(www.lymphnet.org)

Patient support — There are a number of online forums where patients can find information and support from other people with similar conditions.

About.com Breast Cancer Forum
(file://breastcancer.about.com/forum)

REFERENCES
Brennan MJ, Miller LT. Overview of treatment options and review of the current role and use of compression garments, intermittent pumps, and exercise in the management of lymphedema. Cancer 1998; 83:2821.
Lette J. A simple and innovative device to measure arm volume at home for patients with lymphedema after breast cancer. J Clin Oncol 2006; 24:5434.
Langer I, Guller U, Berclaz G, et al. Morbidity of sentinel lymph node biopsy (SLN) alone versus SLN and completion axillary lymph node dissection after breast cancer surgery: a prospective Swiss multicenter study on 659 patients. Ann Surg 2007; 245:452.
Bertelli G, Venturini M, Forno G, et al. An analysis of prognostic factors in response to conservative treatment of postmastectomy lymphedema. Surg Gynecol Obstet 1992; 175:455.
Rockson SG, Miller LT, Senie R, et al. American Cancer Society Lymphedema Workshop. Workgroup III: Diagnosis and management of lymphedema. Cancer 1998; 83:2882.