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Lymphedema risk after breast cancer treatment

By Patricia Nicholson

Women who have undergone treatment for breast cancer may be at risk of developing lymphedema – an accumulation of fluid that results from an inability to drain lymph fluid from tissues. In addition to swelling, lymphedema can cause pain, hardening of tissue and infection.

In breast cancer patients, lymphedema most commonly occurs in the arm on the side of the affected breast, but it can also affect the chest, hand, back or the underarm.

Most women will experience some swelling immediately following breast cancer surgery. This swelling is a normal part of post-surgical recovery.

The lymphatic system’s job is to carry protein molecules back to the heart that are too big to fit into the veins.  During treatment for breast cancer these vessels are injured by surgery or radiation.  After surgery these vessels can knit together again under the right circumstances, but sometimes there is too much damage to allow for healing. If these vessels are injured so badly that they can no longer carry fluid away from an area, the protein-rich fluid stays in the arm.  This is called lymphedema, explains Tania Obljubek, physiotherapist with Women’s College Hospital’s Lymphedema Treatment Clinic. 

Lymphedema can set in anytime after surgery, from months to years after.

“The challenge with lymphedema is once somebody has it, you cannot turn it off; it’s about self- managing it,” Obljubek says. “The earlier you seek treatment the better.”

The lymphatic system

The lymphatic system not only plays a role in balancing fluids in the body, but is also an important part of the immune system.

About 90 per cent of the fluid in the body is carried through the blood vessels. The other 10 per cent of fluids are carried by the lymph system. This protein-rich fluid is called lymph fluid. The lymphatic system is a complex series of vessels, and these vessels end in small glands called nodes.

“Nodes are kind of the brains of the system,” Obljubek explains. They analyze lymph fluid to determine if there’s a virus or bacteria in our system, and then respond. “That’s why when you have a cold, your glands swell: that’s your lymph system.” Every part of the body drains lymph fluid to a specific lymph node. Breasts drain to the nodes underneath the arm. That’s why doctors may need to remove some of these nodes to see if breast cancer has begun to move to other parts of the body.

“It’s an important part of cancer treatment to remove some of these nodes, but at the same time it disrupts the lymph system,” Obljubek says. “Because here you have these vessels coming up and all of a sudden, they’re not terminating at a node anymore, because that node is missing.”

That can leave lymph fluid with nowhere to go, leading to the buildup in tissue that can cause lymphedema.

Reducing risk

Naffisa Nathwani, occupational therapist with the Women’s College Hospital Lymphedema Treatment Clinic, notes that it’s impossible to predict who will develop lymphedema, or when.

“Not everyone who has a node dissection is going to get it,” she says, adding that some women develop the condition within a few months of breast cancer treatment, and other cases don’t develop until years later.

Some of the major risk factors for lymphedema include having lymph nodes removed, having radiation treatment, and being obese.

Because lymphedema can’t be predicted or cured, Nathwani and Obljubek counsel all women undergoing breast cancer treatment about risk reduction. Factors that can help reduce the risk of developing lymphedema include:

  • knowing your risk!
  • seeing a lymphedema therapist to learn risk reduction education strategies
  • maintaining a healthy body weight, following Canada’s food guide and keeping well hydrated
  • using the opposite arm for medical procedures such as blood pressure measurement and IV lines
  • avoiding cuts and scrapes on the arm, and cleaning any cuts or abrasions immediately
  • protecting skin on the arm with moisturizer, sunscreen and insect repellant to avoid dry skin, sunburn, rashes and bug bites
  • avoiding extreme heat, such as hot tubs, saunas and hot yoga
  • exercising (although it’s important to build up exercise levels very slowly following breast cancer surgery)
  • avoiding constrictive items like snug jewelry or heavy shoulder bags on the affected side

The reason for taking special care of the skin on the arm, and taking steps to avoid cuts, punctures and scratches, is that an infected cut can make lymphedema worse.

“There are always bacteria on your skin,” Obljubek explains. A break in the skin – particularly a dirty cut like a gardening scrape or an insect bite – gives bacteria a way in, where they find a buildup of lymph fluid. “That protein-rich fluid is like candy for bacteria, so they just grow exponentially.”

Any cuts on the affected arm should be cleaned thoroughly with alcohol and treated with antibacterial cream. Nathwani notes that lymphedema patients should carry a small first aid kit with alcohol swabs and antibacterial ointment.

Up in the air

There is some controversy about lymphedema risks associated with air travel. If you’ve ever noticed that your feet swell on airplanes, that’s because of the changes in cabin pressure while flying. But the relationship between flying and lymphedema risk is unclear.

Nathwani recommends that women who already have lymphedema wear their compression sleeve.

“That’s if they already have lymphedema,” she says. “If they don’t and they want to use it as a prevention strategy, there’s no study suggesting yes you should or no you shouldn’t. This is a decision to discuss with your lymphedema therapist."

Obljubek points out that the airplane flight may be only one factor in a series of stressors that may affect lymphedema risk.

“It’s what leads up to the airplane flight,” she says, explaining that most people work until the very last minute before a trip. They get home late, cook dinner, care for their kids, and then wind up packing until very late at night. Then they can’t sleep because they’re thinking about remembering their passport.

“So you’re tired. You’ve already overloaded your system. Then you’re pulling these heavy bags. And then you get on the plane,” Obljubek says. The plane lands in a tropical destination where it’s really hot, and heat can contribute to swelling.

“So it just tips people over the edge,” she says. “People want to blame the airplane for the development of the lymphedema, but we know lymphedema is not just one event. It’s the series of events.”

Treatment and management

In addition to swelling, the signs and symptoms of lymphedema can include a heavy or full feeling in the arm or chest area, redness, clothes fitting differently than they used to, and jewelry feeling tighter than usual. Some patients report a sensation of warmth or of pins and needles in the affected area.

Early detection and treatment of lymphedema is important, so breast cancer survivors should contact their healthcare provider as soon as possible if these symptoms occur, regardless of how long ago they were treated for breast cancer.  

The Lymphedema Treatment Clinic at WCH uses an approach called Complete Decongestive Therapy. This approach has five components:

  • patient education
  • manual lymph drainage
  • exercise
  • compression
  • self-massage

Manual lymph drainage is a special type of gentle massage that helps to move lymph fluid and reroute it away from areas with damaged or missing lymph nodes.

“We’re teaching the body to move the fluid to other lymph nodes,” Obljubek says. The fluid can be redirected to healthy nodes such as those in the opposite arm or those in the spine. “The idea is to stimulate the lymph system. We know from research it actually stimulates it by 30 times, gets it moving faster.”

In addition to having manual lymph drainage performed by a healthcare professional, patients are taught a method of self-massage that enables them to do their own manual lymph drainage.

Patients are also taught to use a special type of short-stretch bandage on the affected arm. This “active bandaging” helps move lymph fluid by pushing back against muscles during activity.

Patients are encouraged to build up physical activity gradually and regularly, and to be cautious about overusing the affected arm, or doing strenuous activities they aren’t used to. Physical fitness and regular exercise may help improve pain and quality of life in lymphedema patients.

Once a lymphedema patient has responded to treatment and the swelling has reduced, the patient is fitted for a compression sleeve. The sleeve is worn daily to keep the swelling from returning.

A major component of the program is educating patients about how to self-manage their condition and reduce risk of future swelling.

Living with lymphedema

Although lymphedema is a chronic condition, it is manageable.

There may be times when swelling or pain associated with lymphedema may make some tasks more challenging, especially for patients who use an assistive device such as a walker.

“It does affect what we call activities of daily living,” Nathwani says. Things like dressing, bathing, opening containers and using a keyboard may be more difficult when one arm is swollen. As an occupational therapist, Nathwani helps patients find solutions to these challenges, while also working with them to improve their range of motion and reduce swelling.

Most patients with lymphedema can eventually return to activities they did before they developed the condition. However, they will have to start slowly and increase gradually.

“You can go back to what you were doing previously,” Nathwani says. “It’s just going to take time and you have to build up to it.”

The Lymphedema Clinic at WCH is about empowering people with knowledge to self-manage their chronic condition.

 

This information is provided by Women’s College Hospital and is not intended to replace the medical advice of your doctor or healthcare provider. Please consult your healthcare provider for advice about a specific medical condition. This document was last reviewed on: Oct. 22, 2015

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