Watching Out for Lymphedema
Article written by Jenny Bradt, P.T., D.P.T., C.L.T.-LANA
I am a physical therapist who has treated lymphedema for nearly three decades. Lymphedema refers to tissue swelling caused by the accumulation of fluid usually drained through the body’s lymphatic system. Lymph nodes are an important part of the lymphatic system that helps drain this fluid. Lymphedema can be caused by cancer treatments that remove or damage your lymph nodes. A major advancement in lymphedema prevention occurred when the sentinel node biopsy replaced a full axillary dissection for most people undergoing surgery for breast cancer. An axillary dissection (ALND) is more extensive and still necessary for some, removes one or more of the three groups of lymph nodes in the arm pit (axilla). A sentinel lymph node biopsy (SLNB) only samples nodes that are most likely to have cancer cells in them. This prevents the need for more nodes to be sampled, thus a SLNB reduces the risk of developing swelling. Back in 1995, we told people to avoid repetitive movements, including some upper body exercise. We advised against using that arm for any procedure including injections and blood pressure readings. Some patients would even order medical alert bracelets in case they were in an auto accident and unable to ask emergency workers to be cautions of their at-risk arm. We issued sleeves to anyone who was going to travel by air.
So, what about those precautions? Are they theoretical or based on observation? Multiple studies have looked at large groups of women who had injections, blood draws and blood pressure readings in the arm at risk. None of these activities was associated with increased swelling. Other studies have shown no association with flying and the time spent in the air. The most encouraging studies show exercise using the arms such as strength training and rowing, did not increase arm swelling. In fact, people who engaged in regular exercised showed many improvements in mental and physical health. People who were the most at risk of increasing arm size were women who had an ALND, whose body mass index was higher than twenty-five, who had regional node radiation, or suffered at least one episode of cellulitis. Cellulitis is a skin infection often caused by injury to the skin. It causes the skin to become red and hot and needs immediate medical attention. People are more at risk for cellulitis if they have lymphedema.
In 2017, the American Society of Breast Surgeons published recommendations for surveillance and management of lymphedema. The recommendations recognize that surgery involving the lymph nodes increases the risk of lymphedema and emphasize personalized education based on individual risk. They conclude that using the at-risk arm for IVs and blood pressures is fine but everyone with node surgery should know the symptoms of lymphedema so that they can access prompt treatment.
People wonder, do I need to be worried about lymphedema? We know that most people who develop swelling will do so in the first 30 months after axillary surgery. Prompt treatment reduces the risk of progressive lymphedema. Be familiar with your arm and the way it looks and feels, so that if you do notice any changes in size or feeling, you can tell your medical team right away. If you notice any signs or symptoms of cellulitis, have it checked the same day you notice it. Reduce risk when you can. If you have anxiety about developing swelling and it is getting in the way of you doing the things you enjoy, please ask your oncology team for an appointment with a therapist at Mayo Clinic Physical Medicine and Rehabilitation.