Preventing and Managing Treatment-Related Lymphedema

Jennifer Smith, MSN, CNP

Lauren McCaulley, MSN, RN, OCN

Jennifer Smith is a Survivorship Nurse Practitioner at the Louis Stokes Cleveland VA Medical Center, and Lauren McCaulley is the Assistant Nurse Manager for the Women’s Surgical Oncology unit at University Hospitals Seidman Cancer Center in Cleveland, Ohio.

Cancer-related lymphedema can result from the cancer or its treatment. It is an accumulation of protein-rich fluid in an interstitial space which may be the result of surgical resection, lymph node dissection, or radiation therapy.¹ Lymphedema is a chronic condition that impacts all domains of quality of life, including physical, psychological, social, and spiritual. Lymphedema can impair function and cause disabling physical symptoms as a result of the swelling. Anxiety, depression, and distress are commonly associated with lymphedema, and the disfiguring physical changes can have a negative impact on social-wellbeing and relationships.²

The incidence of cancer-related lymphedema ranges from about 1% to as high as 48% (Box).³ Approximately 25% of breast cancer patients who undergo axillary lymph node dissection develop lymphedema the first 3 years following surgery.

The Role of the Oncology Nurse

The oncology nurse plays a major role in the prevention, detection, and management of lymphedema. Identifying patients at risk who need intensive education about self-care strategies to prevent the initial development of lymphedema is the first step in prevention. Patients at risk include those who have undergone surgical procedures, such as tumor debulking with lymph node dissection or radiation therapy involving lymphatic beds. Additional risk factors associated with lymphedema include advancing age, obesity, venous impairment, and comorbid conditions including diabetes.

Nurses can teach patients who are at risk⁴:

• Activities that promote lymph fluid drainage (eg, lymph drainage exercises)
• Appropriate use of preventive compression garments
• Safe practices that avoid trauma to the at-risk area or limb (eg, avoiding heavy use of the extremity, phlebotomy, or blood pressure readings in the affected limb)
• Skin care
• How to identify early signs and symptoms of lymphedema for rapid intervention

Education can begin prior to starting cancer treatment and continue following surgery or throughout radiation therapy. For example, patients who may be candidates for a lymph node dissection should be fitted with a compression garment prior to surgery so that there is no lag time between the surgery and the acquisition of the compression garment. Ongoing assessment and surveillance is recommended 1 month postoperatively and at 3-month intervals for an additional 18 months.⁵

Incidence of Treatment-Related Lymphedema in Survivors³

Breast: 40%

Gynecologic: 20%

Melanoma: 16%

Genitourinary: 10%

Head and Neck: 4%

Teaching patients how to monitor and assess for the early signs and symptoms of lymphedema will increase the chance that patients will seek medical help at the onset. Although there is no cure, early-stage intervention improves the likelihood of response to treatment and minimizes long-term consequences.

Detection of lymphedema is challenging as fluid shifts may be subtle. Both objective measurements and symptom assessment are combined when making the diagnosis.6 Patients expected to undergo lymph node dissection should have preoperative/ treatment measurements taken to document preexisting normal inter-limb variance.⁵

Limb volume measurements need to be done in a consistent manner. Although there are a variety of measurement techniques and tools, limb circumference is the most common technique and is valid and reliable when performed correctly.⁷ A change of >2 cm from baseline at any point along the 2 cm interval measurements of the limb is the criterion for lymphedema.²

Management

The goal of treatment is to slow progression of lymphedema, provide symptom relief, maintain skin integrity and prevent complications or infection, and maintain psychosocial wellbeing.¹ Complete decongestive therapy is the gold standard of treatment according to the international Lymphedema Framework.⁷ Certified therapists perform manual lymph drainage daily for a 3- to 8-week period. During that time, nurses work with physical therapists to teach patients to use compression bandaging and specific exercises to promote drainage from the congested area. Nurse support and reinforcement of the treatment plan promotes adherence for management of this chronic condition.

Oncology nurses play a major role in the prevention, early detection, and treatment of lymphedema— one of the most distressing side effects of certain types of cancer and its treatment. They provide extensive education for prevention, teach patients how to use and care for compression garments, and work with the oncology team for appropriate referral for manual lymphatic drainage.

A multidisciplinary approach to care, utilizing physical therapists, psychologists, and social workers is essential to address the impact of lymphedema on quality of life.

Oncology nurses can increase their knowledge and expertise in managing this symptom and collaborate with other nurses interested in lymphedema by becoming members of the Lymphedema Management Special Interest Group (SIG) of the Oncology Nursing Society

References

• Ryan JC, Cleveland CM, Fu, MR. Predictors of practice patterns for lymphedema care among oncology advanced practice nurses. J Adv Pract Oncol. 2012;3(5):307-318.
• Torres Lacomba M, Yuste Sanchez MJ, Zapico Goni A, et al. Effectiveness of early physiotherapy to prevent lymphedema after surgery for breast cancer: randomised, single blinded, clinical trial. BMJ. 2010;340:b5396-b5404.
• Cormier JN, Askew RL, Mungovan KS, Xing Y., Ross MI, Armer JN. Lymphedema beyond breast cancer: A systematic review and meta-analysis of cancer-related secondary lymphedema. Cancer 2010;116(22):5138- 5149.
• Ridner SH. Pretreatment lymphedema education and identified resources in breast cancer survivors. Patient Educ Couns. 2006;61(1):72-79.
• Stout Gergich NL, Pfalzer L, McGarvey C, Springer B, Gerber LH, Soballe P. Peroperative assessment enables the early diagnosis and successful treatment of lymphedema. Cancer. 2008;112(12):2809-2819.
• McLaughlin SA, Wright MJ, Morris KT, et al. Prevalence of lymphedema in women with breast cancer 5 years after sentinel lymph node biopsy or axiliary dissection: patient perceptions and precautionary behaviors. J Clin Oncol. 2008;26(32):5220-5226.
• Lymphedema Framework. Best Practice for the Management of Lymphedema. International consensus. London: MEP, Ltd; 2006. http://ewma. org/fileadmin/user_upload/EWMA/Wound_Guidelines/Lymphoedema_ Framework_Best_Practice_for_the_Management_of_Lymphoedema.pdf. Accessed November 22, 2013.