Surgery for breast cancer may include axillary node dissection or the removal and examination of lymph nodes in the underarm area near the affected breast. This procedure allows physicians to determine whether cancer has spread to the lymphatic system.
A common side effect of axillary node dissection is lymphedema, a swelling of the arm and/or hand on the same side as surgery caused by the buildup of lymphatic fluid. For breast cancer patients, lymphedema can occur at any time post-treatment. As such, experts at The Miriam Hospital in Providence, RI, have chosen to focus efforts on the educational aspect of survivorship.
In conjunction with a Nurse Navigator employed by the hospital, physical therapists at the facility's outpatient rehabilitation center educate patients who are at potential risk for developing lymphedema.
"Until recently, the majority of our patients were breast cancer survivors who had already developed the condition in their arms and hands," explained Carrie Marcil, PT, LANA-CLT, outpatient rehabilitation supervisor, The Miriam Hospital.
Now, thanks to heightened awareness on the part of surgeons and oncologists, breast cancer patients are being educated in aggressive preventive techniques, which can curtail the development of lymphedema.
Lymphedema is a swelling of the soft tissues, usually in the leg and ankle, or in the arm and hand, resulting from the buildup of lymphatic fluid. Lymphedema may be primary or, more commonly, secondary to surgery or radiation treatment.
Lymphedema can develop in the legs and feet, often secondary to abdominal or groin surgery. In either case, treatment is the same. Left untreated, the condition can become severe, painful, disfiguring and resistant to treatment. At the first sign of lymphedema, patients should be referred for treatment because early diagnosis and treatment may significantly improve the prognosis.
Recognizing the symptoms of lymphedema and applying early intervention techniques is important to the future health of these patients. There is no way to determine who will develop lymphedema and the condition can occur at any time.
Patients are referred to the program at the outpatient rehabilitation center by any clinician who identifies the condition, typically primary care physicians, oncologists and surgeons.
Ellen Therrien, RN, works as a breast health navigator in the Adele R. Decof Comprehensive Cancer Center at The Miriam Hospital and refers her patients with lymphedema or potential lymphedema to the outpatient rehab center's lymphedema program. Therrien detects lymphedema early and continues to see patients for years to track their progress. This approach is especially important as lymphedema may take years to develop and be detected. Therrien assesses patients for the earliest possible intervention.
Four PTs and one PTA in the outpatient center have been trained in lymphedema education, signs and symptoms of the condition and post-operative exercise. "On a patient's first visit with us, we discuss lymphedema prevention and provide a handout with tips to reference. Our goal is to reach as many patients as possible and to make them aware of the potential," shared Janet Mahoney, PT, The Miriam Hospital.
With the advent of breast sparing surgery, Marcil has observed that physicians may not refer breast cancer survivors to PT when only one node is taken during surgery. Marcil believes that in general, physicians are not referring consistently or only when they see patients who exhibit signs and symptoms.
"Every single patient who has had lymph node dissection surgery followed by radiation needs lymphdema education, whether one node is removed or 10," Marcil said.
Although lymphedema cannot be cured, the condition can be treated and managed.
Marcil takes advantage of every possible opportunity to educate health care professionals, present and former patients, and members of the community of the potential risks for developing lymphedema.
"There is a disconcerting gap in education because patients today see many different health care providers, even to treat one condition or disease," explained Marcil.
As members of the hospital's interdisciplinary cancer committee, Gilstein and Marcil are collaborating on a quality improvement study designed to identify a gap in referrals. The pair are also developing a cancer screening tool that will be used to automatically refer patients to the outpatient center.
"People are more commonly being referred for lymphedema prevention education pre- and post-operatively," said Marcil. "Breast cancer survivors used to only discuss lymphedema with doctors after the condition had been developed."
Lymphedema is an accumulation of lymphatic fluid in the tissues of the body that causes swelling in the arms, legs or trunk. Lymphedema can develop when lymphatic vessels are blocked, causing a "traffic jam" of fluid on the lymphatic pathway and creating swelling in the body below the area of blockage.
Lymphedema is caused by the removal of lymph nodes in the axilla (under the arm) related to breast cancer surgery; radiation of the breast or axilla; or cellulites (infection) of the breast or arm. All breast cancer survivors are at risk for lymphedema. In fact, 6 percent to 40 percent of breast cancer patients will develop lymphedema.
Lymphedema is often debilitating and while there is no known cure for lymphedema, some measures can make the condition easier to live with or possibly prevent it. Women who undergo axillary node dissection should receive education about how to recognize and possibly prevent lymphedema.
The specially trained PTs at The Miriam Hospital use an intensely "hands-on" approach to treat lymphedema. They reduce the volume of the edema and restore the range of motion to affected joints with complete decongestive therapy. Each patient's treatment is carefully and individually tailored.
Research has shown that manual therapy in conjunction with other types of therapies can reduce fluid up to 73 percent in breast cancer patients, according to a review in the Journal of the National Cancer Institute.
The treatment plan for lymphedema patients at The Miriam Hospital may include: manual lymphatic massage to gently direct fluid away from the impaired lymphatic areas; compression bandaging to help prevent fluid from returning to swollen areas; compression pump therapy to facilitate fluid movement toward the heart; and the application of compression garments to maintain reduced limb size.
The PTs teach patients exercises to keep the joints limber and educate about skin care to help patients understand the cause and appropriate treatment.
After lymph node dissection surgery and removal of the drain, patients may start PT. The first focus in PT is shoulder range of motion to get the patient's function back. The PT will help to ensure that scar tissue does not limit ROM and function as time goes by.
"Limited range of motion is the biggest problem," shared Mahoney. "If a patient strains her arm reaching for something too far above her head, she can develop edema."
But edema can occur from anything that causes an inflammatory reaction, such as a mosquito bite or a burn on the limb, according to Marcil. "These problems might create an imbalance in the limb that had the nodes removed. As a result, there is increased fluid in the limb but the fluid cannot go through the nodes. I call this a 'traffic jam' of fluid," she said.
The PTs advise patients to avoid blood pressure tests and flu shots, for example, on the affected limb.
Depending on the patient's level of activity prior to treatment, she may return to low-level strength exercises six weeks following surgery. Marcil advises using gravity, instead of weights, for strength exercises and slowly adding weights.
She believes that as a general rule, these patients should not go above 3-pound weights. If a patient were to pull a muscle or experience muscle soreness during or after a strength program, she may increase her chances of developing lymphedema.
Rebecca Mayer is senior regional editor of ADVANCE and can be reached at firstname.lastname@example.org
According to physical therapists with The Miriam Hospital, there are a few tactics that breast cancer survivors can employ to help reduce their chances of developing lymphedema:
• Keep the affected limb (the arm on the same side as the lymph node dissection) free from burns, rashes and insect bites.
• Never use the affected limb for blood pressure tests or injections, including acupuncture.
• Practice proper hygiene.
• Inspect the affected limb daily.
• Apply a compression arm sleeve during air travel.
• Avoid vigorous repetitive movements, such as scrubbing, pushing and pulling.
• Avoid heavy lifting. Never carry heavy handbags or bags with over-the-shoulder straps on your affected side.
• Don't wear tight jewelry or elastic bands around an affected finger or arm.
• Avoid extreme temperature changes when bathing or washing dishes. Protect your arm from the sun at all times.
• Maintain ideal body weight through a low-sodium, high-fiber diet, and avoid smoking and alcohol.