Published: Thursday, May 03, 2007

1. Body image after breast cancer surgery
2. Exercises after axillary dissection
3. Axillary web syndrome (AWS)
4. Seroma and how it is treated
5. Recommendations for managing persistent pain after breast cancer treatment
6. Scar massage after breast cancer surgery
7. Lymphedema
8. Decreasing the risk of developing lymphedema
9. Treatment of lymphedema

1. Body image after breast cancer surgery

Breast-conserving surgery (BCS) for early stage breast cancer was developed to improve breast cancer patients' quality of life. Discrepancies in the conclusions of studies comparing the adjustments of women who have had BCS to those that have had mastectomy may be due to the differences in participant or methodologic characteristics. In her article "Psychosocial outcomes of breast-conserving surgery versus mastectomy: A meta-analytic Review"⁵, Anne Moyer found statistical evidence that those who have breast conserving surgery appear to have a small added benefit over those who have mastectomy in terms of five psychological outcomes: psychological adjustment, marital-sexual adjustment, social adjustment, body/ self-image, and cancer-related fears and concerns.

When assessing psychological adjustment, longer term assessments may be more sensitive to potential advantages for BCS. For example, better psychological adjustments are seen in groups receiving breast-conserving surgery 12 months or longer after treatment. However, during the first year post-surgery, adjuvant radiation that often accompanies breast conserving surgery may be a source of psychological distress. Also, women who are treated with different types of surgery may feel distress for different reasons. For example, in one study, "lumpectomy patients were bothered by fatigue and their slow recovery after a small operation; on the other hand, mastectomy patients, who did not expect a swift recovery, found treatment was less difficult than anticipated."⁵

Breast loss and disfigurement can alter intimate and sexual relationships. There is a very small benefit for BCS in terms of marital-sexual adjustment, especially 12 months or more after treatment. "However, depression, anger, and fear during treatment, apart from disfigurement or adjuvant therapy side effects, may contribute to the lack of intimacy."⁵

Women who have BCS seems to have a very small benefit in terms of social adjustment. These benefits may be improved in those who did not have a treatment preference or who are told what surgery to have. As well, those that "participate in clincial trials and receive more attention and support from medical personnel through involvement in the trials, may also benefit more than they would from members of their social network itself. Social network members may minimize the seriousness of a BCS patient's disease because they have undergone less extensive surgery."⁵

Women who have BCS have superior body image adjustment compared to those who have mastectomy. "The principal advantages of BCS may be that it facilitates the fitting of clothes, avoids the inconvenience of a prosthesis, facilitates the viewing or revealing one's nude body, or continuing of sexual relationship. Women who have breast reconstruction have satisfaction with body image in between those who have BCS and mastectomy. Nevertheless, the psychological ramifications of a life-threatening disease may overshadow these smaller benefits when worries about survival supersede cosmetic concerns."⁵ The diagnosis of malignancy causes more distress than the disfigurement of a mastectomy.

In terms of cancer-related fears and concerns, women who have BCS tend to have less anxiety in general. "This advantage was significantly better for longer compared to shorter term assessments. The disfigurement of mastectomy may remind women of the threat of cancer."⁵ Although early research showed that women who had BCS tended to worry more about cancer recurrence, recent research has not replicated this.

Although the psychological benefit for BCS compared to mastectomy are small, health care providers can use this knowledge to help match patients to optimal surgical choices."Particular areas where individual preferences may play a role in satisfaction with and adjustment to treatment include concerns about body image and disfigurement, tolerance for future surgery, beliefs about the efficacy of treatment, and the values and concerns of significant others. Therefore, despite this optimism for treatment with breast-conserving surgery, adequate preparation and support for all breast cancer patients should remain a crucial focus".⁵

2. Exercises after axillary dissection

Please see BC Cancer Agency recommendations for Upper Extremity Rehabilitation after Axillary Dissection for Breast Cancer. Instructions for patients are included in the book The Intelligent Patient Guide to Breast Cancer, which is included in the Breast Cancer Information Kit.

3. Axillary web syndrome (AWS)

Axillary web syndrome is a post axillary lymph node dissection pain syndrome that occurs in approximately 6% of patients.¹ It is characterized by a "visible web of axillary skin overlying palpable cords of tissue that are made taut and painful by shoulder abduction. The web is always present in the axilla and extends down to the antecubital space, and occasionally to the base of the thumb. Typically, there are two or three taut, tender, nonerythematous cords of tissue under the skin."¹ "In the majority of cases these cords extend across the antecubital fossa and into the forearm, occasionally as far as the radial aspect of the wrist at the base of the thumb."¹ It can present as early as seven days post-op, but there is no documentation of it developing more than eight weeks post-op. It often presents after an initial postoperative delay and resolves within three months of onset. It can occur in diverse populations of patients with invasive breast cancers.

The development of AWS appears to be related to an interruption of axillary lymphatics during surgery, although it has been seen in patients with stage IV disease with fixed, matted axillary metastases who have not had surgery. The removal of axillary lymph nodes may promote AWS through multiple mechanisms, and biopsies of axillary webs suggest that lymphovenous injury, stasis, and hypercoaguability contributes to its development. "Lymphovenous injury might occur in the retraction of tissue and patient positioning during ALND. Additionally, the tissue injury from the operation releases tissue factors that could cause hypercoagualability in the surrounding tissues. Stasis of lymphovenous channels would also be expected from the outflow obstruction induced by removal of axillary lymphatics draining the arm."¹ There does not appear to be an association between AWS and an increased rate of positive axillary nodes.

The use of sentinel lymph node biopsy without axillary dissection may result in less disruption of the lymphatics and superficial tissues of the arm and might help reduce the incidence and severity of axillary web syndrome. In patients who have had limited sentinel lymph node biopsy and where AWS did develop, it tended to be less severe and limited to the axilla and medial arm, without extension to the wrist.¹

AWS is usually self-limited, resolving without any specific treatment. Although some patients have been treated with nonsteroidal anti-inflammatories, physical therapy, and range of motion exercises, these treatments do not shorten or change the self-limited course of the syndrome. There are no long term side effects and the rate of lymphedema complications is not increased in those who develop AWS.¹

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4. Seroma and how it is treated

Seroma is a common complication following breast surgery or axillary dissection. By definition, seroma is is an accumulation of serous fluid that develops following the formation of skin flaps during mastectomy or in the axillary dead space after axillary dissection.”² The origin of seroma formation is unclear, but a "large dead space appears to contribute".³ It is not known if the dead space contains lymph-like fluid or exudates, but "in terms of seroma prevention, the key factors appear to be obliteration of the dead space and securing flaps to underlying skin tissues. Additional factors would include minimization of lymph spillage and serum ooze, and a rapid removal of accumulating fluid.” ³

The incidence of seroma increases with older patient age, larger breast size, hypertension, presence of malignant nodes in the axilla, number of malignant nodes, previous surgical biopsy, and the use of heparin.¹

"Seroma formation is more of a nuisance than a complication, but may delay patient recovery and cause unpleasant symptoms"² of swelling and pain. "Physical closure of the dead space appears to reduce seroma rate, but studies have failed to address the issues of cosmesis, movement and acceptability with this technique. The evidence for the use of fibrin glue remains controversial. Thrombin spray, sclerotherapy and mechanical pressure do not reduce the drainage of seroma. Shoulder immobilization is of no advantage to the patient, but delaying shoulder physiotherapy appears to reduce drainage."²

Closed drainage systems can help, but there is no good evidence to support the use of multiple drains. High pressure vacuum drains may be better than low suction in mastectomy wounds by producing good flap apposition. In the axilla, low vacuum drains result in less seroma formation and earlier drain removal."² The value of using no drains following axillary surgery is unproven.

Patients who experience pain and swelling related to seroma formation can have aspiration performed on an out-patient basis. Some women will require several aspirations before the seroma resolves. Occasionally, a seroma may need to be surgically removed. Seroma formation can safely be dealt with on an outpatient basis by aspiration.

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5. Recommendations for managing persistent pain after breast cancer treatment

• There are many reasons why a patient with breast cancer may experience pain. Identifying the cause and understanding the pathophysiology can lead to more effective management
• The nature and severity of pain should be carefully evaluated using the history and physical, psychosocial and emotional assessments. Adequacy of pain relief should be evaluated regularly
• The patient's self-report of pain intensity is the primary source of assessment data in all initial and subsequent evaluations
• The development of a comprehensive, effective pain-management plan includes the education and involvement of the patient and family, together with an interdisciplinary team approach
• The first objective in the management of pain is to identify the cause and treat it whenever feasible
• The first priority of treatment is to control pain rapidly and completely, as judged by the patient
• The second priority is to prevent recurrence of pain
• Analgesic medication should be administered on a regular schedule, around the clock, with additional doses for breakthrough pain when necessary
• When drug therapy is necessary, the World Health Organization's three-step approach to the use of analgesics is recommended. The severity of the individual's pain will determine at which step the treatment regimen is commenced
• The oral route should be the first choice for opioid administration. If the oral route fails, transdermal or rectal administration should be considered. When parenteral administration is necessary, the subcutaneous route is the first choice. Intramuscular administration of opioids is not recommended
• Accurate conversion with careful observation and titration are required when switching from one opioid to another
• When switching from long-term oral use of morphine or hydromorphone to parenteral use, a ratio of 2:1 should usually be used
• After initiating opioid therapy or making any change in dose or route of administration, the dosage should be evaluated after approximately 24 hours
• Tolerance to opioids is not common and must not be confused with addiction. Physical dependence to opioids is common and is not a symptom of addiction
• Adjuvant analgesics should be administered, when necessary, with an opioid or nonopioid analgesic
• Nonpharmacological measures such as psychosocial interventions, physical modalities and complementary therapies may offer relief
• Neuroinvasive procedures can be considered when all other interventions have failed ⁴

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6. Scar massage after breast cancer surgery

Patients with breast cancer often seek information about whether or not they should massage their scars. Although scar massage is a technique advocated by physiotherapists and massage therapists to help pain and healing, there is no clear information about the benefits and risks of performing this maneuver after surgery. A randomized controlled study titled “Does Scar Massage Improve Postoperative Pain And Function After Breast Cancer Surgery?” was recently completed at Vancouver Island Centre to evaluate the effects of scar massage on pain and function after surgery. The results should be published in early 2007.

7. Lymphedema

Lymphedema in women treated for breast cancer is an accumulation of protein-rich fluid in the arm that occurs when axillary lymphatic drainage from the arm is interrupted because of axillary lymph node dissection or axillary radiation, or both. Affected women can experience pain, swelling of the arm, tightness and heaviness in the arm and recurrent skin infections. Lymphedema can be reversible, transient or permanent.

After axillary dissection alone, the risk of lymphedema has been reported to be 0-25% in different studies. The average rate without regional radiation is 3%. With axillary dissection plus regional radiation, the risk of lymphedema varied from 10 to 54%. The average risk with regional radiation is 12%. The addition of regional radiation, therefore, may increase the risk of arm swelling by 5-10%. Most women who develop lymphedema do so within four years of breast cancer treatment.⁶

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8. Decreasing the risk of developing lymphedema

The following suggestions make clinical sense, even though the evidence that supports the suggestions is limited and primarily anecdotal:⁶

• Scrupulous skin care should be encouraged. Patients should avoid cuts, pin pricks, hangnails, insect bites, contact allergens or irritants, pet scratches and burns to the affected extremity. Whenever possible patients should avoid medical procedures such as vaccination, blood drawing, intravenous access, blood pressure monitoring, acupuncture, venography and lymphangiography in the affected arm
• Lymphedema may be exacerbated if women use saunas, steam baths or hot tubs, spend time in hot climates or travel. Many patients report worsening of their lymphedema during flight, which suggests that patients who use compression sleeves should probably use them during air travel
• Exercise involving the affected arm may be beneficial in controlling lymphedema. Although some clinicians have recommended avoidance of rowing, tennis, golf, skiing, squash, racquetball or any vigorous, repetitive movements against resistance, there is no published evidence to suggest that these activities promote or worsen lymphedema. No exacerbation of existing lymphedema or development of new cases of lymphedema occurred in 20 women with breast cancer who competed in the strenuous sport of dragon boat racing
• Some experts have recommended that women with lymphedema wear a compression sleeve during arm exercises
• Maintenance of ideal body weight should be encouraged. Obesity is a contributing factor for the development of lymphedema and may limit the effectiveness of compression pumps or sleeves
• Skin infection, which is often streptococcal, or on rare occasions staphylococcal, should be promptly treated with antibiotics such as a penicillin, a cephalosporin or a macrolide. For recurrent infections, prophylaxis with oral antibiotics or monthly injections of penicillin should be considered. It may be prudent to provide the patient who has recurrent infections with an emergency home supply of an antistreptococcal antibiotic, to be taken at the first sign of infection. A patient travelling to a remote area should be encouraged to take along a supply of antibiotics

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9. Treatment of lymphedema

• Practitioners may want to encourage long-term and consistent use of compression garments by women with lymphedema
• One randomized trial has demonstrated a trend in favour of pneumatic compression pumps compared with no treatment. Further randomized trials are required to determine whether pneumatic compression provides additional benefit over compression garments alone
• Complex physical therapy, also called complex decongestive physiotherapy, requires further evaluation in randomized trials. In one randomized trial no difference in outcomes was detected between compression garments plus manual lymph drainage versus compression garments alone
• Other physical therapy modalities, such as laser treatment, electrical stimulation, transcutaneous electrical nerve stimulation (TENS), cryotherapy, microwave therapy and thermal therapy, have been used for lymphedema in breast cancer patients (level V evidence). However, these modalities need further, rigorous evaluation before recommendations can be made
• Pain and discomfort associated with lymphedema are common and should be managed primarily by controlling the lymphedema
• Because of the psychological morbidity associated with lymphedema, psychosocial issues should be promptly recognized and addressed. Women with lymphedema have been shown to have greater psychiatric morbidity and greater functional disability
• Surgery, diuretics and benzopyrones have not proven to be beneficial in the treatment of lymphedema and are not recommended⁶

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References

1. Moskovitz AH, Anderson BO, Yeung RS, Byrd DR, Lawton TJ, Moe RE. Axillary web syndrome after axillary dissection. American Journal of Surgery 181. 2001: 434-439.

2. Pogson CJ, Adwani A, Ebbs SR. Seroma following breast cancer surgery. European Journal of Surgery. 2003; 29: 711-717.

3. Katsumasa K, Shimozuma K, Taguchi T, Imai H, Yamashiro H, Ohsumi S, Saito S. Pathophysiology of seroma in breast cancer. Breast Cancer. 2005 Oct; 12(4): 288-293.

4. Clinical Practice Guidelines for the Care and Treatment of Breast Cancer., Guideline 10: The management of chronic pain in patients with breast cancer, Rev. Oct. 30, 2001, © 2006 CMA Media Inc. or its licensors.

5. Moyer, Anne. Psychosocial outcomes of breast-conserving surgery versus mastectomy: A meta-analytic review. Health Psychology. 1997: 16(3): 284-298.

6. Clinical practice guidelines for the care and treatment of breast cancer, Guideline 11: Lymphedema, Jan. 23, 2001, © 2006 CMA Media Inc. or its licensors.

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