Breast Cancer & Lymphedema
By Shalene C. Orallo OTR, CBIS, CLT-LANA
Breast cancer affects approximately 1 in 8 women in the United States. In 2022 it is estimated 287,850 new cases of invasive breast cancer will be diagnosed in women in the U.S., along with 51,400 new cases of non-invasive breast cancer. The expected diagnosis of invasive breast cancer in men is about 2,710 new cases (American Cancer Society, 2021). Breast cancer-related lymphedema affects approximately 1 in 5 patients treated for breast cancer and has a significant impact on quality of life (Gillespie et. al, 2018). It is important to understand the factors that influence lymphedema development in order to identify those at risk. Early implementation of protective measures and appropriate treatment are important components in reducing the risk of development and progression of lymphedema.
What is Lymphedema
The lymphatic system is part of the immune system that protects your body from illness, maintains fluid level in the body, absorbs digestive tract fats, and removes cellular waste. Lymphedema is the collection of protein rich fluid (lymph) in the tissue space due to the decreased ability of the lymphatic system to transport the normal production of lymph fluid. This excess fluid builds up and causes abnormal amounts of swelling in the affected body part.
Primary Lymphedema occurs when genetic impairment prevents the lymphatic system from fully developing. Symptoms can be present at birth, or develop sometime through the course of life. It is also known as Hereditary Lymphedema.
Secondary Lymphedema occurs when a healthy lymphatic system becomes damaged. The most common causes for secondary lymphedema include surgery, radiation, trauma, infection, and malignant tumors. Breast cancer-related lymphedema falls under this category.
Signs and Symptoms
Lymphedema is a chronic disease, that if left untreated, will continue to progress through stages. The International Society of Lymphology defines the stages of lymphedema as:
Stage 0: Subclinical or latent
- No swelling present
- Lifelong risk of developing swelling
- May have mild tingling, fatigue, heaviness
- Lymphatics are working overtime
State I: Reversible or mild
- Resolves or reduces with elevation
- May have soft pitting edema
- No fibrosis or tissue changes at this stage
- Reversible with treatment
- No permanent skin changes
Stage 2: Spontaneously irreversible
- Limb volume increases, with less pitting
- Skin folds
- Tissue becomes thicker and harder (fibrosis)
- Infections are common (cellulitis)
- Volume reduction can occur with proper treatment
Stage 3: Lymphostatic elephantiasis
- Increase in volume, lobules, disfigurement
- Fibrosis is thick and firm
- Skin changes: (papilllomas, cysts, hyperkeratosis)
- Infections
- Skin folds deepen
- Ulcerations with impaired wound healing
Risk Factors
Factors that contribute to the development of breast cancer-related lymphedema include invasive cancer diagnosis, dissection of axillary lymph nodes, radiation therapy, chemotherapy, and obesity (Babak, 2022).
Invasive ductal carcinoma Cancer that has spread beyond the breast ducts into the fibrous or fatty tissue is known as invasive ductal carcinoma. It often requires chemotherapy and radiation treatment which cause damage to the lymphatic system.
Axillary lymph node dissection Lymph nodes located in the armpit are known as axillary lymph nodes. Surgical removal of axillary lymph nodes may be called axillary lymph node dissection or axillary lymphadenectomy.
Radiation therapy Radiation therapy, or radiotherapy, is a form of cancer treatment that uses high doses of radiation to kill cancer cells and shrink tumors. External bean radiation is delivered is administered from a linear accelerator. Targeted radiation is delivered internally through a variety of methods.
Chemotherapy Chemotherapy is designed to attack cancer cells at specific phases of the cell cycle by seeking out any rapidly dividing cells in the body (cancerous and non-cancerous).
Obesity The likelihood of developing lymphedema is associated with an increased body mass index, or obesity.
Treatment with Complete Decongestive Therapy
Complete Decongestive Therapy (CDT) is the gold standard approach to treat and manage lymphedema. It is performed by a physical or occupational therapist who is specialized as a Certified Lymphedema Therapist. CDT consists of 4 components: skin care, manual lymphatic drainage, compression therapy, and decongestive exercises.
Skin Care The basic consideration in skin and nail care is the prevention and control of infection and wounds. Patients are instructed in proper cleansing and moisturizing techniques to maintain the health of the skin. Cellulitis is a common bacterial skin infection that, if left untreated, can lead to serious health problems and possibly sepsis. Signs of cellulitis include redness, swelling, and pain in the affected area.
Manual Lymphatic Drainage Manual Lymph Drainage (MLD) is a gentle hands-on technique designed to stretch the walls of lymph vessels to increase their activity in transporting lymph fluid from damaged vessels to healthy vessels.
Compression Compression is applied as either specific bandage materials called short-stretch bandages, compression garments, or a combination of both. Custom-made alternatives may also be used depending on the needs of the patient. Compression maximizes the gains achieved during MLD and prevents the re-accumulation of excess lymph fluid.
Decongestive Exercises Exercise can promote the uptake of fluid from the tissue space into the lymphatic system. Muscle contraction and relaxation will increase the activity of the lymphatic system by providing an increase in tissue pressure to propel the lymph fluid.
Breast cancer-related lymphedema will require life time management but does not have to diminish quality of life. Empowering strategies to prevent or reduce the occurrence of swelling include self-care, adherences to risk reduction practices, optimal weight management, use of compression and exercise, maintaining a healthy lifestyle, and seeking assistance from a Certified Lymphedema Therapist.
PAM Health has outpatient clinics with specialists trained in treating patients with this condition. View our outpatient location listing to view a resource near you.
