Early Intervention to Prevent Lymphedema

Introduction

The information in this article is based on the results of a study supported by the National Navel Medical Center in 2008. The results were promising in demonstrating steps that have the potential of preventing the development of lymphedema soon after treatment for breast cancer.

Any woman, who suffers from the pain and lowered quality of life due to lymphedema, will agree that there is an urgent need for a public education program to make women, physicians, surgeons, and oncologists aware of the simple steps that can prevent the development of lymphedema.

The Goal of This Study

Breast cancer treatment commonly includes surgery, the removal of lymph nodes near the affected breast, and usually radiation. These treatments, which are effective in treating the breast cancer, disrupt the functioning of the lymphatic system and cause from 7 to 47 percent of all breast cancer patients to develop the chronic condition known as lymphedema.

The purpose of this study was to prove that lymphedema could be prevented through early detection of developing lymphedema, the prompt beginning of treatment, and the ongoing following of the treatment regime.

What is Lymphedema?

Lymphedema is a condition of chronic swelling that cannot be cured. It causes pain, diminishes the patient’s quality of life, impairs the limb’s range of motion, and is controlled only by a daily treatment regimine of massage, wearing compression garments, careful skin care, weight control, and exercises.

• Most commonly lymphedema associated with related to breast cancer treatment affects the adjacent arm by causing swelling of the hand, arm, and joints. It also affects the trunk area surrounding where the breast was removed.
• If a lumpectomy was performed, the remaining breast tissue can become swollen, painful, and fibrotic (hardened).
• Because lymphedema is due to the inability of the lymph to drain normally, the fluid in the swollen area consists of protein-rich stagnant lymph. Bacteria thrive in this fluid and, any break in the skin in this area allows pathogens (disease producing bacteria) to enter the tissues, thrive, reproduce, and cause serious infections.
• This abnormal fluid also causes these tissues to deteriorate and become fibrotic (hardened).

The Need for Public Education

Through public education, the lives of many women have been saved by the awareness of the need to detect developing breast cancer at an early stage. These important preventive steps include regular mammograms, plus professional and self-breast examinations. Early detection saves lives!

It is rare for a woman who has not been treated for breast cancer to know what lymphedema is and the risk it presents. Even when diagnosed with breast cancer, few doctors warn their patients that they are now at risk of developing lymphedema and will remain at risk for the rest of their lives. If they develop lymphedema, the newly diagnosed are not aware that they will have to cope with this condition every day because lymphedema cannot be cured.

• In the study being discussed here, the researchers successfully demonstrated that being aware of the risk of developing lymphedema, and taking prompt action, can potentially prevent lymphedema from developing.
• Now one of the greatest challenge to make oncologists and surgeons aware that the initial preventive treatment must be taken before surgery or radiation of the breast cancer is performed.
• Public education is also important so that every woman knows if she is diagnosed with breast cancer she must ask her doctor to initiative these preventive steps in a timely manner.

Step One: Obtaining Baseline Measurements

Baseline measurements must be taken of both arms before any treatment begins.

The easiest and most accurate way to obtain these measurements is through the use of bioimpedance. This is a non-invasive test that measures the composition of body tissues and fluids including lymph. These measurements will be used as the baseline for comparison to detect any changes that can be the first signs of developing lymphedema.

Imp™ XCA (Courtesy of Impedimed)

To date, ImpediMed is the only bioimpedance device cleared by the FDA for use by health care providers to accurately and quickly detect this clinical assessment of an upper limb at risk of developing lymphedema.

These initial tests, and a record of the results are taken at a preoperative visit, can be completed within about five minutes.

Step Two: Follow-up Measurements

• In the study, post-operative measurements were taken at three month intervals. These measurements are compared with the baseline figures and will detect changes in the tissues before any visible signs or symptoms of lymphedema are visible.
• If any indications of lymphedema such as feelings of heaviness, swelling, or pain are observed by the patient before the three month interval, measurements should be taken immediately and the results are compared with the baseline.
• When a post-operative change in the upper limb indicates a change of >3% a diagnosis of subclinical, or stage 0, lymphedema is made.

Prompt Action is Taken!

When lymphedema is diagnosed, or suspected, a physician or lymphedema therapist should be consulted immediately and a conservative compression intervention should be started. The following are the steps that were taken during the study.

• The patient wore a ready-made knit Jobst garment of 20-30 mm HG compression. (The abbreviation HG stands for mercury and this is a measurement of the amount of pressure the sleeve places on the affected limb.)
• These garments consist of a sleeve and a gauntlet. A gauntlet is a style of compression for the hand that is a partial glove that leaves with the fingers completely exposed. A thumb stub holds this garment in place.
• These garments should be fitted by a lymphedema therapist; however for some patients it is possible that an “off-the-shelf” garment will fit. The fit of these garments is important. If necessary, it may be necessary to obtain a custom-made garment.
• The garments are worn during waking hours for a period of four weeks only. They are not worn at night because of the risk that the garment could become tangled during sleep and cause a tourniquet-like effect that disrupts circulation.
• At four weeks measurements are taken again.
• If the next measurements indicate that the lymphedema swelling has been reduced to the original (base-line) level, the regimine is changed so that the compression garment and glove are worn only during strenuous activity, air travel, or if symptoms of heaviness develop.
• The patient should continue to return for remeasurement every three months. On the average during the study, volume reduction was maintained at an average follow-up period of 4.8 months. (At this point the study was discontinued.)
• If swelling is not controlled only by garments, the patient should enter a more traditional lymphedema treatment program.

Knit Compression Sleeve  (Courtesy of Juzo USA)	A glove with finger stubs. Courtesy of Juzo USA
	A gauntlet (Juzo USA.)

The Results

Preoperative assessment, and early intervention at the earliest signs of change, significantly reduced the affected limb volume to near baseline measurements and prevented progression to a more advanced state of lymphedema for at least the first year postoperatively.

Ongoing Guidelines for ALL Breast Cancer Patients

Even if you do not have the benefits of early intervention, each breast cancer patient should take these steps to reduce your risk of developing lymphedema.

• Wear a compression sleeve and glove when traveling by air. Changes in cabin pressure can increase the swelling of lymphedema. Also these pressure changes can trigger the initial onset of lymphedema.
• Avoid having a blood pressure reading taken on the at risk limb. The blood pressure cuff can alter or damage lymphatic function within the area.
• Avoid any injection, blood draw, or finger prick in the affected limb. Any treatment that causes a break in the skin can lead to an infection.
• Avoid any IV placement in the affected limb. The needle breaks the skin and the medication can leak into the tissues and irritate them.
• Avoid having acupuncture needles placed in the affected limb. Although these are very fine needles, they still break the skin.
• Protect the affected area to prevent injuries, sunburn, or insect bites that can damage the skin. When outside wear protective clothing, sunscreen, and insect repellent.
• If any break in the “at risk” skin occurs, no matter how minor, see medical attention. Antibiotics may be necessary to prevent infections.
• Maintain normal weight. Being even slightly overweight increases your risk of developing secondary lymphedema.
• Exercise. This helps to maintain your general health, the pumping motion of muscles improves the flow of lymph.

The Study

In 2008, the American Cancer Society published the results of this study titled “Preoperative Assessment Enables the Early Diagnosis and Successful Treatment of Lymphedema.”

This study was supported by the National Navel Medical Center (NNMC) and the study team included Nicole L. Stout Gergich, PT, MPT, CLT-LANA, Lucinda Pfalzer, PT, MA, PhD, Charles McGarvey, PT, DPT, MS, Barbara Springer, PT, PhD, OCS, SCS, Lynn H. Gerber, MD, and Peter Soballe, MD

Additional References

[1] "Preoperative Assesment Enables the Early Diagnosis and Successful Treatment of Lymphema" by N.L. Stout Gergich, PT, MPT, CLT-LANA, L.. Pfalzer, PT, MA, PhD, C. McGarvey, PT, DPT, MS, B. Springer, PT, PhD, OCS, SCS, L. H. Gerber, MD, P. Soballe, MD. Cancer June 15, 2008. Vol 112, #12, pages 809-2819.

[2] "Published Guidelines Further Support Use of Bioimpedance Measurement Technology for Early Assessment of Lymphedema." June 2008.

[3] “Bioimpedance Analysis in the Assessment of Lymphoedema Diagnosis and Management” by S. Rockson, MD. Journal of Lymphoedema Vol 2, No 1, 2007.

[4] “The Use of Bioimpedance Analysis to Evaluate Lymphedema” by A. Warren et. al. Annals of Plastic Surgery, Vol 58, No 5, May 2007.

[5] “Understanding Lymphoedema in the New Millennium” by Professor N. Piller. Journal of Lymphoedema, 2006, Vol 6, No 1, pages 60-65.

[6] "Measuring lymphedema in patients with Breast cancer: go with the flow?" by K.K. Hunt, R. Askew, J.M. Cormier. Breast Cancer Res Treatment January 2009.

© LymphNotes.com 2010.This information does not replace the advice of a qualified health care professional.

Got a question or comment? Post in the 'Are You at Risk for Lymphedema?' forum.
Category: Are You at Risk for Lymphedema? Updated: 2010-11-01