What Is Lymphedema?
Some women who have been treated for breast cancer are at risk for lymphedema, or arm swelling. Our bodies have a network of lymph nodes and lymph vessels that carry lymph fluid to all parts of the body, similar to the way blood vessels circulate blood.
During surgery for breast cancer, it is customary to remove at least one of the lymph nodes from the underarm area to see if the cancer has spread. Some lymph vessels that carry fluid from the arm to the rest of the body will also be removed because they are intertwined with the nodes. Removing lymph nodes and vessels from the underarm as well as the scarring that results changes the way the lymph fluid flows. At times, this may make it more difficult for fluid in the arm to circulate to other parts of the body. If the remaining lymph vessels cannot filter enough of the fluid, the fluid builds up in the arm and causes swelling, or lymphedema. Lymphedema of the breast can also occur when the breast fluid is not able to properly drain. Radiation treatment to the lymph nodes in the underarm can also affect the flow of lymph fluid in the arm and breast area, increasing the risk for lymphedema.
Lymphedema usually develops slowly over time. The swelling can range from mild to severe, and it may develop at any time following surgery or radiation therapy. The risk of developing lymphedema increases depending on the number of lymph nodes removed, but it may occur with the removal of only one lymph node. The risk of lymphedema developing is approximately 5-8% after a sentinel node biopsy, and can be as high as 20-25% after full axillary node dissection. We do not fully understand why some women develop lymphedema while others do not, although obesity, extent of breast cancer surgery, injury, and other factors may play a role.
Historically, women were advised to restrict arm movements after breast cancer surgery. In addition, it has long been recommended to avoid having blood pressure checks, blood draws, intravenous lines, and injections. Patients have been told never to have their cuticles cut and to avoid heavy lifting. However, a lot of these “rules” have recently been called into question.
I encourage my patients to resume normal range of motion as soon as possible after surgery. If you have undergone reconstruction, please check with your plastic surgeon as they may have some restrictions. But in general, normal activities including showering, fixing meals, and washing hair are no problem. I also encourage the gradual return to regular exercise, including light weight lifting. There are many booklets and websites that have exercise and stretching routines that may be help. Like with most things, I usually recommend keeping it simple – the important thing is that you move your arm, not to the point of significant pain, but enough to give a gentle stretch. “Move it or lose it” certainly applies here! The key is to gradually increase your range of motion, and gradually resume a more formal exercise program. The goal should not be to get back to “normal” as quickly as possible – recovery from breast cancer surgery does take time.
There is limited good quality data regarding the role of puncture wounds (such as blood draws, IV, and injections) on the development of lymphedema. So in patients who are at risk, rather than a long list of “don’t do”, I think a more common sense approach is appropriate. Try to avoid blood draws and blood pressure checks on the arm. Try to avoid cuts and scrapes on that arm. You can still get your nails done – just be careful.
It is not unreasonable to use a compression sleeve when flying, but realize that it may not help prevent lymphedema – again, the results from studies are mixed.
It is important to emphasize the role of weight gain and obesity – these factors are associated with the development of lymphedema. All patients should evaluate their diet and lifestyle, including exercise routine. In addition to being associated with lymphedema, weight gain and inactivity are associated with an increased risk of cancer recurrence. And of course it’s important to remember the association with cardiac disease, which accounts for more deaths among women in the United States than breast cancer.
Finally, have a low threshold for seeking medical attention – if you notice new or worsening swelling, redness of the arm or red streaks on your arm – see your physician right away. Infections may progress quickly, and may become very severe, to the point that hospitalization for intravenous antibiotics is required – don’t let it get to that point.
This information applies to patients without clinical signs of lymphedema. If you have already developed swelling, you do need to use extra caution as repeated trauma can lead to worsening of the swelling as well as infection. You should be evaluated by a physical therapist who specializes in lymphedema therapy.
Up until recently, we have only been able to detect the development of lymphedema through physical signs, such as tightening of the skin of the hand and forearm, difficulty putting on or taking off rings and watches, and changes in arm measurements. Unfortunately by the time swelling becomes obvious, it is more difficult to treat.
There is currently a method of non-invasive assessment, called bioimpedence spectroscopy, that can more precisely evaluate a patient for early evidence of lymphedema, before tightness and swelling develops. The good news is that with early detection and intervention, studies have shown that we can potentially halt and even reverse the progression of lymphedema. The test is non-invasive, painless, and takes approximately 5 minutes to complete – it is similar to having an EKG reading performed.
Usually the test will be performed prior to surgery to obtain a baseline reading, and then at various intervals after surgery. Periodic testing will help us determine if fluid is building up even before the obvious physical signs of lymphedema have developed. If it is noted that the fluid content is increasing, early referral to physical therapy will result in more effective treatment. Bioimpedence spectroscopy is the only FDA-cleared device specifically for the detection of lymphedema.
Dr. Attai does not provide online medical advice. The information provided is for general information only.
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