Physician's Weekly Article - Lymphedema in Oncology

       Lymphedema is a common treatment-related side effect that occurs in patients with cancer, but clinicians can minimize its effects by recognizing symptoms and providing treatment early.

      Between 3 and 5 million people in the United States suffer from lymphedema, many of whom develop the disease as a consequence of cancer or its treatment. When patients with cancer develop lymphedema, the flow of lymph fluid through the draining lymphatic vessels and lymph nodes is impaired or disrupted. “Lymphedema in patients with cancer usually occurs as a consequence of surgery and/or radiation therapy,” says Brian D. Lawenda, MD. “The most commonly reported context is following breast cancer treatment, but it can also result from interventions for other cancers. If lymphedema isn’t managed appropriately, it can lead to progressive swelling, soft tissue fibrosis, restricted range of motion, discomfort, and an increased risk of skin and nail infections.”

      Spotting the Symptoms

      Early identification of the signs and symptoms of lymphedema is important in the management of patients who have received surgery or radiation, says Dr. Lawenda. “Patients with breast cancer who undergo lymph node dissection and/or radiation therapy to the breast and axilla are at increased risk for developing lymphedema of the upper extremity. They’re also at risk of developing breast edema.” Depending on the type of surgery performed and whether or not it is combined with radiation therapy to the regional lymph nodes, the extent of upper extremity lymphedema may vary. Several risk factors have been identified as potential causes for the development of upper extremity lymphedema after the management of breast cancer (Table 1).

      “It’s important for healthcare providers to be aware of the signs and symptoms that may be precursors to a clinical diagnosis of lymphedema,” says Dr. Lawenda. “Patients with lymphedema may present with feelings of heaviness or tightness, aching or discomfort, restricted range of motion, and swelling in their limbs. Swelling may also be present in the adjacent quadrant of the trunk.”

      Evaluating Lymphedema

      Lymphedema can occur at any point in patients’ lives. The onset may occur when treatment is initiated or it could be delayed for several decades. “If patients present with new onset swelling after undergoing surgery or radiation therapy, they should undergo a thorough history and physical examination to rule out recurrent or metastatic disease that may be causing tumor blockages in the lymphatic system,” Dr. Lawenda says. “These examinations can also help rule out deep vein thrombosis. Once these possibilities are eliminated, patients should be referred to a lymphedema specialist so that a diagnosis of lymphedema can be confirmed and the amount of edema present in the limbs can be quantified.”

      When evaluating patients for lymphedema, clinicians should begin with a thorough medical and surgical history. “Observation of the limb should be performed, noting the skin mobility, tissue consistency, and the presence or absence of fibrosis and whether or not the edema is pitting or non-pitting,” says Dr. Lawenda. “Any neurologic changes should also be noted. Furthermore, measurements of girth and volume are important. Once a diagnosis of lymphedema is confirmed, patients should quickly begin a treatment program, regardless of the stage or severity of the disease. Failure to treat lymphedema will lead to progressive soft tissue changes that can further advance through the various stages of the disorder. The complications of lymphedema can be minimized when treated in the earliest stages, but treatment can be provided at any stage of this condition.”

      Managing the Condition

      When managing lymphedema, efforts to prevent the disorder are paramount. “Preoperative evaluations and prevention education are necessary for all patients who will undergo treatments that put them at risk for lymphedema,” says Dr. Lawenda. “It’s important to measure baseline girth and volume of affected and unaffected limbs. It’s also critical to educate patients about the signs and symptoms of lymphedema, proper skin and nail care, and various factors that increase their risk for developing lymphedema.”

      With regard to treatment, several therapeutic options are available for cancer patients with lymphedema, the gold standard of which is complete decongestive therapy (CDT). “With CDT, there are many components to successful treatment,” explains Dr. Lawenda. “Lymphedema specialists will ensure that patients complete each component appropriately to optimize outcomes. It’s important for clinicians to be aware of the contraindications for CDT [Table 2]. There are several national organizations—including the National Lymphedema Network and the Lymphedema Research Foundation—that provide informative resources for practitioners and patients about lymphedema. They can help patients find reputable lymphedema specialists to help them manage their condition. In addition to identifying and managing lymphedema early, utilizing these resources can help many of our patients maintain their quality of life by minimizing the burden of this complication.”

      Brian D. Lawenda, MD, has indicated to Physician’s Weekly that he has or has had no financial interests to report.