Reducing risk of lymphedema after breast cancer treatment

Breast cancer survivors who have undergone radiation treatment or surgery may be at risk of developing lymphedema – an accumulation of lymph fluid that can cause swelling, pain, hardening of tissue and infection.

The most common site for lymphedema in breast cancer patients is in the arm on the side of the affected breast, but it can also affect the chest, hand, back or the underarm.

The lymphatic system is a network of vessels that carry lymph fluid back to the heart. Each vessel ends in a node. Surgery or radiation for breast cancer injures lymph vessels, and lymph nodes are often surgically removed. The vessels may be able to heal again after surgery, but if they are too damaged to carry lymph fluid away from the area, the fluid accumulates, causing lymphedema.

Risk factors

Naffisa Nathwani, occupational therapist with the Women’s College Hospital (WCH) Lymphedema Treatment Clinic, notes that it’s impossible to predict who will develop lymphedema, or when.

“Not everyone who has a node dissection is going to get it,” she says, adding that some women develop the condition within a few months of breast cancer treatment, and other cases don’t develop until years later.

Some of the major risk factors for lymphedema include having lymph nodes removed, having radiation treatment, and being obese.

Because lymphedema can’t be predicted or cured, Nathwani and Tania Obljubek, physiotherapist with WCH’s Lymphedema Treatment Clinic, counsel all women undergoing breast cancer treatment about risk reduction.

Lymphedema risk reduction measures include:

• Know your risk!
• See a lymphedema therapist to learn risk reduction education strategies
• maintaining a healthy body weight, following Canada’s food guide and keeping well hydrated
• using the opposite arm for medical procedures such as blood pressure measurement and IV lines
• avoiding cuts and scrapes on the arm, and cleaning any cuts or abrasions immediately
• protecting skin on the arm with moisturizer, sunscreen and insect repellant to avoid dry skin, sunburn, rashes and bug bites
• avoiding extreme heat, such as hot tubs, saunas and hot yoga
• exercising (although it’s important to build up exercise levels very slowly following breast cancer surgery)
• avoiding constrictive items like snug jewelry or heavy shoulder bags on the affected side

The reason for taking special care of the skin on the arm, and taking steps to avoid cuts, punctures and scratches, is that an infected cut can make lymphedema worse.

“There are always bacteria on your skin,” Obljubek explains. A break in the skin – particularly a dirty cut like a gardening scrape or an insect bite – gives bacteria a way in, where they find a buildup of lymph fluid. “That protein-rich fluid is like candy for bacteria, so they just grow exponentially.”

Any cuts on the affected arm should be cleaned thoroughly with alcohol and treated with antibacterial cream. Nathwani recommends that lymphedema patients carry a small first aid kit with alcohol swabs and antibacterial ointment.

Up in the air

There is some controversy about lymphedema risks associated with air travel. If you’ve ever noticed that your feet swell on airplanes, it’s because of the changes in cabin pressure while flying. But the relationship between flying and lymphedema risk is unclear.

Nathwani recommends that women who already have lymphedema wear their compression sleeve.

“That’s if they already have lymphedema,” she says. “If they don’t and they want to use it as a prevention strategy, there’s no study suggesting yes you should or no you shouldn’t. This is a decision to discuss with your lymphedema therapist.”

Obljubek points out that the airplane flight may be only one factor in a series of stressors that may affect lymphedema risk.

“It’s what leads up to the airplane flight,” she says, explaining that most people work until the last minute before a trip. They get home late, cook dinner, care for their kids, and wind up packing until very late at night. Then they can’t sleep because they’re thinking about remembering their passport.

“So you’re tired. You’ve already overloaded your system. Then you’re pulling these heavy bags. And then you get on the plane,” Obljubek says. The plane lands in a tropical destination where it’s really hot, and heat can contribute to swelling.

“So it just tips people over the edge,” she says. “People want to blame the airplane for the development of the lymphedema, but we know lymphedema is not just one event. It’s the series of events.”