Updated: 27 August 2003

Definition

Lymphedema following treatment for breast cancer is caused by the interruption of axillary lymphatic drainage from the arm. To detect lymphedema, circumferential measurements of both extremities should be taken at the metacarpal-phalangeal joints, the wrists, 10 cm distal and 15 cm proximal to the lateral epicondyles. A difference of 2 cm or greater at any point is clinically significant.

Incidence

After axillary dissection alone, the risk of lymphedema has been reported to be 0 – 25% in different studies. The average rate without regional radiation was 3%. With axillary dissection plus regional radiation, the risk of lymphedema varied from 10 to 54%.  The average risk with regional radiation was 12%.  The addition of regional radiation, therefore, may increase the risk of arm swelling by 5 – 10%.

Lymphedema is likely to be permanent, transient lymphedema can develop in 7% of women. Most women who develop arm edema do so within 4 years of breast cancer treatment .^1,2

Recommendations

• Treatment is most effective when physicians, physical therapists, nurses, massage therapists, and psychosocial counselors work together.
• The early recognition of upper extremity lymphedema is essential because advanced lymphedema is more difficult to control (3). Limb girths should be monitored during follow-up visits.
• Lymphedema treatment must begin with an assessment of severity and limb function. Tumour involvement of the axilla, infection or axillary vein thrombosis should be ruled out (4).
• Avoidance of skin and soft tissue injury to the affected limb should be stressed (5).
• Skin infections, which are usually streptococcal, should be promptly and aggressively treated with penicillin (6).
• Elevation for early lymphedema may reduce swelling and can be used alone or as an adjunct to external compression and/or light massage (5).
• Compression therapy, which includes graded compression garments and pneumatic compression pumps, is useful in controlling lymphedema and is currently the mainstay of lymphedema therapy in North America (5,8).
• Complex Physical Therapy (CPT) or Complex Decongestive Physiotherapy (CDP), a comprehensive treatment regimen available in the US which includes meticulous skin hygiene, manual lymph drainage or treatment (MLD or MLT), bandaging, exercises, and support garments may offer some relief (4,9). MLD is available in Canada and may include bandaging and exercises after massage.
• Pain and discomfort associated with lymphedema should be managed by controlling the lymphedema. Aggravating conditions, such as infection or axillary disease should be looked for and treated (10).
• Exercise involving the affected upper extremity may be beneficial in controlling lymphedema (7). A compression sleeve is highly recommended for wear during exercise.
• Maintenance of ideal body weight should be encouraged (2). Other than a weight reduction diet for obese patients, no nutritional or dietary restrictions are recommended for minimizing lymphedema.
• Because of the psychological morbidity associated with lymphedema, psychosocial issues should be promptly recognized and addressed (11).
• Surgery, apart from removing redundant skin folds after treatment, has had disappointing, inconsistent results and should be avoided (3).
• Drugs, including diuretics and benzopyrones, should be avoided because of their toxicity profile and lack of benefit (12).
• Other therapeutic modalities such as laser treatment, electrical stimulation, microwave and thermal therapy are based on clinical experience and have not been proven to be effective. These modalities need further study. Therapeutic ultrasound to potential metastatic sites is contraindicated because recent animal studies show it can enhance tumour growth (13). Diagnostic ultrasound is safe and can be an useful medical diagnostic tool.

Objective

To provide evidence-based guidelines for the management of lymphedema secondary to breast cancer treatments. The management of lymphedema in women with breast cancer is poorly addressed by practitioners. To identify the most effective treatment protocols, the Breast Tumour Group of the BC Cancer Agency recognized the need for practice guidelines.

Options

External compression, massage, elevation, exercise, psychosocial support, prompt treatment of infection, avoidance of factors which may aggravate lymphedema.

Outcomes

The outcomes considered were:

• early detection of lymphedema to ensure more effective treatment
• effective treatment of chronic lymphedema to improve the quality of life, ability to work, participate in leisure time activities, and perform activities of daily living

Evidence

To develop this guideline, a task force of the BC Cancer Agency, including physical therapists, women living with breast cancer, medical and surgical specialists, was set up by the Breast Tumour Group. After task force consensus was reached, the guidelines were sent for external review.

These guidelines are based on a review of published data and expert opinion from the Cancerlit and Medline databases 1966 -1997 and from recent breast cancer textbooks. Eighty-seven references were reviewed. The treatment guidelines are, whenever possible, evidence-based using Sackett's rules of evidence (14). The guidelines largely reflect case series evidence and often rely on consensus and common sense due to the paucity of clinical research in this area.

Values

The therapeutic nihilism associated with the treatment of lymphedema versus the multitude of empiric, costly and anecdotal remedies leave the health care provider and women living with lymphedema confused and frustrated. These guidelines attempt to address this confusion and try to provide the consumer and her health care provider with rational and potentially effective treatment for lymphedema.

Benefits, Harms and Costs

Safe reduction of lymphedema to restore and maintain function and cosmesis of the affected upper extremity are the primary benefits. Because of the lack of scientific evidence in this area, the time-honored 'Do No Harm' medical credo has been observed in developing these guidelines.

Treatment of lymphedema is costly for a woman and her health care insurers. The cost of a compression sleeve, which lasts about 6 months, is $60. Multiple treatments by a physical therapist to control the lymphedema are usually needed. A compression pump for home use costs well over $4000. Massage therapy (MLD) costs $60 a session and many sessions are required. CPT (complex physical therapy) costs about $7000 US for the recommended 4 week session. When infection occurs, intravenous antibiotics in an emergency department or hospitalization may be required. Early recognition of lymphedema and intervention may help to control some of these costs.

Validation

These guidelines were reviewed by clinical practitioners and by representatives of the College of Physician and Surgeons, the Registered Nurses Association of B.C., the College of Physical Therapists of B.C. and the B.C. Council on Clinical Practice Guidelines. The guidelines were then reviewed by the Breast Tumour Group at the B.C. Cancer Agency for final approval. These guidelines will be revised every two years to reflect new information.

Sponsors

This guideline was developed by a task force set up by the Breast Tumour Group of the BC Cancer Agency. The task force members included:
Sharon Allan (Medical Oncologist)
Carol Dingee (Breast Cancer Surgeon)
Faye Eddy (Physical Therapist)
Susan R.Harris, (Ph.D Physical Therapist, Task Force Co-editor and breast cancer survivor)
Brian Haylock (Radiation Oncologist)
Maria Hugi (Task Force Chair and Co-editor, Emergency Physician and breast cancer survivor with lymphedema)
Winkle Kwan (Radiation Oncologist)
Sherri Niesen (Physical Therapist and Ph.D. Candidate)
Cynthia Webster (Physical Therapist)