Lymphoedema

Damage to the lymphatic system can be caused by radiotherapy to the breast or lymphatics in the axilla and patients who have had surgery to remove lymph nodes are also at risk of lymphoedema.

Additional risk factors are being overweight and high BMI^14,24,5,8,1 and having post-operative infection or cellulitis^26,3,10.

The incidence of lymphoedema increases with the number of nodes dissected^{8,23,18,12,3,6}. Radiotherapy^8,33 and chemotherapy^{11,8,18,6,1,26} also increase incidence.

Patients who have all their lymph nodes removed will be at higher risk than those who have only had a few lymph nodes removed.  Arm lymphoedema is estimated to affect approximately 20-25% of patients who have had an axillary node clearance (ANC) and approximately 5-6% after sentinel node biopsy (SNB)^{12,11,17,26,29,8}. There is less data on the incidence of breast oedema following treatment for breast cancer but breast oedema is now regularly seen in lymphoedema practices and may be more common as a result of the standard use of breast conserving surgery with concurrent radiotherapy in early stage breast cancer²⁶.

Patients should look out for a swelling that persists. They may notice that sleeves or jewellery are tighter. They should notify their breast/oncology team or GP so they can receive advice and potentially be referred to a lymphoedema service. They should seek attention immediately if they develop signs of an infection as they may require antibiotics. Signs include such as feeling unwell, redness, heat or pain on the affected side.

It is important for people receiving breast cancer treatment to be aware of the things they can do to help minimise their risk of developing Lymphoedema and to know how to identify it. Education is often given at the time of surgery or radiotherapy. It is important to tailor the information as some patients are at higher risk than others. Consideration should be given to not over burdening or heightening the anxiety of those at lower risk.

Risk reduction advice should include recommendation to:

• Maintain a healthy weight^14,24,5,8,1
• Participate in regular physical activity^{28,29,32,20,19,27,8}

Both of these factors have the strongest evidence in the literature.

• Participate in post op exercises to help regain movement of the shoulder after surgery^21,7 and continue until they are pain free and have full movement back. If undergoing radiotherapy, it is also recommended they continue shoulder exercises during and for a while afterwards as radiotherapy can lead to further tightness of the tissues and shoulder restrictions
• Ensure good skin care which includes moisturising the arm and hand regularly. Try to avoid infection including preventing insect bites by using an insect repellent. Try to prevent burns and scratches to the affected arm which may introduce infection
• Avoid injections and infusions whenever possible, particularly for those who have had a full axillary node clearance. The current available evidence suggests that simple blood draws are likely to be safe but there is insufficient evidence for infusions/injections^1,10,30,3,16.

Patients should also be advised that:

• Flying is considered safe^13,30,10,1
• Exercise is safe for people who have been treated for breast cancer and can help manage consequences of cancer treatment including fatigue, reduced strength and lymphoedema^{32,20,19,27,28,29,8,31}. There is also some evidence that being physically active may also reduce the risk of breast cancer recurrence³⁴
• Blood pressures can be taken in the affected arm^10,1
• A single study found saunas and hot tubs are a risk factor. Would suggest caution until more evidence is available³⁰.

Research shows that early management of lymphoedema can optimise outcomes^32,15. Patients should be aware to contact their nurse specialist or GP if they have swelling on the affected side that is not settling.

Patients with early swelling can be advised on good skin care, exercise and elevation of the limb at rest on a pillow/armrest may be suggested. Patients can also be given advice to perform gentle massage of the tissues towards the unaffected lymph nodes. More detail is available below. If the swelling is not settling, referral on to a lymphoedema specialist for further advice and management is recommended. Teams should consider the need for further investigations/tests to rule out issues such as disease recurrence/DVT’s prior to referring on.

Concurrent referral to MSK physiotherapy is recommended for patients with co-existing shoulder morbidity on the affected side.

A Lymphoedema practitioner/specialist will carry out a comprehensive assessment including assessment of the skin, tissues, movement, circulation and limb volumes. The severity and complexity of the swelling will be determined and a plan for management will be discussed and agreed with the patient using patient- centred goals. A supported self-management approach is usually promoted but patients may also require more intensive periods of treatment.

Skin care advice

Moisturising, cellulitis prevention and management following the British Lymphology Society and Lymphoedema Support Network guidelines on the management of cellulitis in Lymphoedema is recommended and can be accessed at LSN website⁴.

Exercise

Has been determined to be safe with adequate warm up and graduated progression^28,29. There is not one specific type of exercise that should be recommended but it should be something a person enjoys, and fluid limb movements are preferable to static postures as they encourage lymph flow via the muscle pump. Active exercises of the limb are beneficial and if unable to participate in formal exercise patients can be encouraged to consider ways to be generally more physically active. Consideration may need to be given for what stage of treatment patients are at since they may have some post operative precautions for the first few weeks and activities such as swimming may need to be delayed until after chemotherapy or radiotherapy.

Compression

Compression is an effective means of reducing or controlling lymphoedema^2,25. It may be carried out in the form of compression sleeves, gloves or bras. The type and style are selected by the Lymphoedema practitioner based on their assessment.

Patients may require an intensive period of treatment involving compression bandaging. Traditional multilayer bandaging involves the application of layers of short stretch bandage over a padding layer. Alternatively, a 2-layer Coban 2 bandaging system can be selected. This is less bulky and needs less frequent changing. Velcro wraps are a useful alternative to bandaging as they can be adjusted or removed which is beneficial to the individual e.g, to allow for showering and it is considerably less time consuming for the practitioner.

Massage

Simple lymphatic drainage (SLD) involves learning a sequence of self-massage strokes which direct the swelling usually towards intact lymphatics in the opposite axilla or down towards the groin nodes. Light strokes with a flat hand and skin on skin contact are used. The massage is typically carried out 1-2 times a day.  It should not be carried out in the presence of infection. 

Manual lymphatic drainage (MLD) should be carried out by a practitioner who has been trained to provide this complex massage technique for people after cancer. NHS therapists often have limitations on their service and may not be able to offer this as regularly as they would like/or at all but there are some private trained practitioners who can be located at the MLDUK website.

Other Treatment Options

In addition to the four cornerstones of treatment described above there are other management options which may be selected. Kinesiotape is a useful adjunct commonly used in NHS settings.

Although conservative management of lymphoedema is standard there are some emerging surgical options including lymphovenous anastamosis (LVA), lymph node transfer (LNT) and liposuction. These surgical options are very limited in their availability. In Scotland liposuction is currently only available in Tayside and the other surgeries are not currently available on the NHS. Some patients may be keen to explore private options but it is worth knowing that not all patients are suitable candidates and the surgeries do not always have the outcomes patients’ desire. Liposuction for example will reduce the volume of fatty tissue in a limb but the individual is still at risk of swelling and requires ongoing use of compression garments.

Breast oedema can cause discomfort and heaviness of the breast. Swelling and asymmetry can also contribute to body image concerns and psychological distress. Treatment principles for lymphoedema affecting the breast are similar to those used to manage oedema of the arm but there are a few additional considerations. Massage can be a useful management technique for breast oedema to help reduce swelling and soften tissues. Compression is usually provided in the form of a well fitting, supportive bra. These may be traditional style bras or sports bras and if a more specialist bra is required there are some medical options. Foam or lymph pads can also be inserted into the bra to help soften tissues. Overnight support in the form of lighter bras/bra tops are often suggested and kinesiotape is a useful adjunct to treatment.

The following are additional consequences of breast cancer treatment that can be problematic for patients and can also have an impact on lymphoedema:

• Tight breast scars
• Limited shoulder range of motion and problems such as frozen shoulder
• Cording AKA axillary web syndrome.

Referral to physiotherapy should be considered to help manage these issues if problematic.

Lymphoedema can be distressing to many individuals and this is often in addition to the stress they have already experienced with their cancer diagnosis and treatment. It is important to consider the need for psychological support which can be provided by nurse specialists, organisations such as Maggie’s and Macmillan Cancer Centres as well as clinical psychologists.

Lymphoedema onset typically occurs within the first four years after breast cancer treatment^22,23. If it is much later than this a review by the breast team is usually good practice to ensure any suspicions of recurrence can be ruled out.

Lymphorrhoea can often result in palliative situations where lymph fluid leaks out of the tissues. This can be a risk for infection and usually benefits from limb elevation, absorbent dressings and light compression.

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