Prevention of Post Mastectomy Lymphedema—Part 1 of 2
Advances in screening and treatment have led to a significant increase in breast cancer survival, but my experience and studies show that a survivor’s long-term sequelae from treatment have a major impact on the quality of his or her life. One sequela is arm lymphedema, a condition in which a protein-enriched fluid is unable to enter the lymphatic system to be transported back into the circulatory system due to proximal lymphatic obstruction. Arm swelling may result in severe functional impairment, pain, and sensory loss, with a predisposition for cellulitis (skin infections).Lymphedema is attributed to several factors which include local radiation, number of lymph nodes removed, extent of surgery, delayed wound healing, and obesity. The extent of the problem is illustrated by current studies that show the incidence of lymphedema associated with various breast cancer treatments. For example, lymphedema is associated with sentinel lymph node biopsy (2 or 3 lymph nodes), 5%-7%; axillary lymph node dissection, 14%-16%; and, the rate highest in those who undergo full axillary lymph node dissection and radiation, (40% to 50%). These numbers gradually increase with time due to chronic inflammatory changes from radiation, surgery, and subsequent lymphatic fibrosis.
Because of the pervasiveness of lymphedema associated with breast cancer treatment, an all-out effort should be made to prevent this sequela. I must emphasize that there are no studies that show that one mode of prevention is better than another or even if preventive measures work at all. Primary prevention is focused on limiting the use of axillary radiation therapy and axillary surgical dissection. Incorporation of sentinel lymph node (SLN) biopsy techniques, perfected in the 1990s has resulted in fewer axillary lymph node dissections being performed. As a result, the incidence of lymphedema is lower but still occurs in 5% to 7% of patients who have SLN biopsy alone. Secondary preventive efforts are largely directed toward early recognition and treatment to minimize the degree of edema following therapy to prevent its progression. A patient must be vigilant in identifying and reporting arm swelling because lymphedema can occur at any time during his or her life span.
There are four primary goals in a preventive strategy: avoidance of trauma or injury to the arm, avoidance of arm constriction, prevention of infection, and limitation of the amount of arm exercise. There is, however, no scientific evidence supporting the efficacy of any of these approaches.
The following are specific recommendations for a preventive strategy. To begin with, meticulous skin hygiene and nail care should be maintained to prevent a portal of entry for infection. Avoid cuts, pinpricks, insect bites, pet scratches, and burns to the affected extremity. Patients should use skin moisturizers, and any small skin breaks should be covered with a topical antibiotic ointment immediately. Protective gloves should be worn for household work and gardening. Moderate to heavy activity of the limb in which a recent lymph node dissection has been performed may cause shunting of blood to that area, with a possible increase in lymph production. However, stretching exercises of the arm to restore full range of motion are encouraged and are not harmful. Patients should not maintain the limb in a dependent position for prolonged periods, including while sleeping. Avoid tight-fitting clothing which can cause a tourniquet effect and obstruct lymph flow. Patients should avoid medical procedures such as vaccinations, blood pressure monitoring, acupuncture, and venography (vein x-ray) in the affected arm. However, most experts feel that it is not necessary to avoid blood drawing or intravenous lines on the side of the axillary dissection, provided the arm is not swollen and the intravenous fluids are not irritating to the veins. It is recommended that blood pressure be taken in the opposite arm if the patient is undergoing surgery and has had an axillary node dissection. There are conflicting reports about airline flight causing or worsening lymphedema. The use of compressive sleeves for domestic air travel is probably not necessary (for flights under 4 _ hours) and may actually be counterproductive, unless lymphedema is already present. Finally, maintenance of ideal body weight is encouraged. Weight loss of only 7 lbs has been associated with a significant reduction in arm lymphedema. Besides being a contributory factor for the development of lymphedema, obesity may also limit the effectiveness of compressive pumps and sleeves in a treatment program, which will be discussed in greater detail next month.
