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Life After Cancer A Roadmap for Cancer Survivors

Lymphedema
Modified from Everyone's Guide for Cancer Supportive Care

John P. Cooke, MD, PhD, Andrzej Szuba, MD, PhD, Alexandra Andrews, and Ernest H. Rosenbaum, MD


Lymphedema is swelling caused by buildup of fluid (lymph) in the soft tissues of the limbs. The lymphatic vessels no longer drain lymph fluid efficiently from the extremities, resulting in a swollen limb. This buildup often occurs after surgical removal of lymph nodes, or radiotherapy to lymph nodes (because of blockage of the lymphatic system), and sometimes after chemotherapy.

Lymphedema is a chronic problem that may cause distress, pain, loss of function, disfigurement with self-image problems, and anxiety. It may develop soon after surgery or radiotherapy or even months or years after therapy; it is most often seen after breast surgery and/or radiotherapy. After breast cancer treatment 15-30% of women may develop lymphedema. Other malignancies that present a risk for lymphedema include malignant melanoma, ovarian, cervical, testicular, or prostate cancers. Use of sentinal node biopsy treatment rather than axillary lymph node dissection has helped reduce the incidence of lymphedema. Also, new advanced radiotherapy treatment planning has improved, minimizing the extent of the radiotherapy field, thus minimizing collateral damage.

Unfortunately, it is not possible to predict which patients will acquire lymphedema problems; therefore, all patients should be advised of this possible treatment complication. They should also be advised about what may promote fluid buildup and the consequences if not properly treated. For example, constriction of an affected limb, through use of a blood pressure cuff, or tight clothing or jewelry, can damage tiny lymphatic vessels and trigger a build up of tissue lymph fluid. Other triggers for fluid buildup are strenuous exercise, heavy lifting, excessive limb heat, or vigorous massage. Importantly, the affected limb is prone to infections (cellulitis). Infection may begin suddenly and progress rapidly; even a minor cut or bruise can trigger this. Oral antibiotics usually can cure the infection, but in severe cases, hospitalization for IV antibiotics might be necessary.

In some instances, lymphedema may become permanent and it may lead to disability and disfigurement. Emotional problems associated with lymphedema are not uncommon and are often neglected by physicians. The need to address the psychological aspects of long-term disfigurement, especially with adolescent patients, cannot be overemphasized.

Decongestive physiotherapy is currently the gold standard treatment for lymphedema.
The two objectives are:
1. Reduce the size of the arm through manual lymphatic massage and use of non-elastic compression bandages, as well as skin care and exercise.
2. Maintain limb reduction size through a compression garment, exercise, and wrappings at night as needed. No Ace Bandages!

Managing lymphedema can be a lifelong process. The following precautions will help survivors avoid infections and support their lymphedema program:
Avoid limb injuries, especially cuts, bruises, and animal scratches.
Keep extremities dry and clean.
Keep skin lubricated with moisturizing creams (for example Eucerin® cream) or oils to prevent chafing of skin.
Protect skin from excessive sunlight (use sun screens and insect repellents).
Protect your fingers; for example, wear gloves to avoid injury especially when gardening or doing manual work.
Avoid cutting your cuticles and use extra care when cutting your nails.
Use an electric razor rather than a blade for shaving the affected limb to avoid nicks and skin irritation.
Avoid blood draws and injections of the affected limb if possible.
See your physician if limb is red, or if rash, swelling, pain, or fever occur.
Avoid the use of blood pressure cuffs on the affected limb.
Take care of cuts or injuries to the limbs; see your physicians for treatment if you have any questions; a minor injury may lead to a major lymphedema problem.
Avoid wearing jewelry on affected arm or leg.
Avoid heavy lifting.
Avoid prolonged heat exposure (>15 Minutes) - for example, hot tubs and saunas.
Baths should be less than 102 degrees.
Dishwashing - It is important to avoid putting the affected arm in hot water since excessive heat might increase swelling. Try to wash dishes with the unaffected arm. Let the dirty dishes soak in hot water then scrub and rinse them with tepid water.
Clean small wounds with warm soapy water and apply antibiotic ointment under a Band-Aid. Change dressings (bandages) often.

Regular exercise appears to stimulate lymphatic drainage and reduce lymphedema as long as elastic support (or hydrostatic pressure) is applied. Swimming is a particularly good activity because the surrounding hydrostatic pressure of the water means compressive support isn't needed. In addition, studies have shown that exercise programs (for example, isometrics and gentle stretching exercises) carefully monitored by a physical therapist who specializes in lymphedema, do not aggravate a limb swelling.

When traveling in airplanes, support the affected limb with a compression garment. Decreased air pressure in airplane cabins can increase tissue fluids, causing the onset of lymphedema. Prophylactically wearing a compression garment can be helpful.

For more information on decongestive lymphatic therapy, please refer to Everyone's Guide to Cancer Survivorship (available in bookstores since October/November 2007) or www.cancersupportivecare.com.




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