Breast Cancer and Lymphedema – Myth Busting
June is cancer survivor’s month. Just as cancer treatment deserves close and careful attention, celebrating survivorship and ensuring we take all possible measures to maintain good quality of life is equally as important.
The principal aim in cancer treatment is to defeat cancer while also remembering to treat the patient, guide them through treatment and support them through a meaningful survivorship. Cancer survivors face several challenges, disease as well as treatment related. One challenge that is often under-addressed is that of the occurrence of lymphedema after breast cancer treatment.
Due to the damaged lymphatic system, Lymphedema is caused by an accumulation of protein rich fluid in the tissue spaces. This results in the swelling of one’s arm. One in eight women in the United States develop breast cancer over the course of their lifetime, and although the true frequency of lymphedema occurrence is difficult to determine, there are published estimates that state up to 40% of women treated for breast cancer develop lymphedema. 1 This means that three out of eight women with breast cancer will develop this complication. Lymphedema can take several years to develop. However, 90% of women who develop lymphedema usually develop it within three years of breast cancer treatment. 2 As we begin to adopt the mantra “less is more,” when it comes to breast cancer treatment the actual incidence rate of lymphedema is hopefully on the decline.
Treatment of established lymphedema can result in suboptimal results and include various pharmacological drugs and some advanced surgical options, including microsurgical techniques to improve lymphatic function. The current standard of care is the approach of complete decongestive therapy (CDT). 3
Most practitioners will agree that proactive measures are vital to prevent the occurrence of lymphedema, and that outcomes are not always as expected, which has led to varied recommendations over the decades. A paper from MSK, NY attempted to disprove common lymphedema treatment myths by evaluating the recommendations and their scientific background.4
The summarized myths can be found below:
Avoid needle sticks on the affected side. This is adhered to tediously by most patients, as well as clinicians. Even though there is a plethora of evidence both supporting and opposing this recommendation, most of this evidence is of poor scientific quality. 5
Avoid limb constriction. This is based on the hypothesis that increased venous pressure results in edema and that the tightness causes obstruction to the lymphatic flow. Therefore, patients avoid blood pressure monitoring, tight bands or clothing and any measure that increases the pressure in the arm. There is little scientific evidence for this recommendation. There is no universal consensus on this recommendation, and two schools of thought remain due to the management of lymphedema frequently involving the use of a compression sleeve and pneumatic pumps with high pressure.
Elevate the limb. This works well for venous edema in the extremities, but it is probably not equally effective in the setting of protein rich lymphatic fluid. Thus, long standing increases in lymphatic fluid stasis are hypothesized to promote tissue fibrosis and worsen the edema. 6 While this is another logical recommendation, it has insufficient scientific backing.
Avoidances. Other recommendations include avoiding air travel, wearing compressive garments on flights and extreme temperatures (such as ice packs or the sauna). These all have similar levels of evidence.
One recommendation with strong support is maintaining normal body weight. There is clear evidence which shows that obesity is a significant factor in not only the development of lymphedema, but also in determining the severity of the lymphedema as well. However, the actual cellular and molecular mechanisms responsible for this cause and effect are not clearly understood.
One myth that has been scientifically busted and is perhaps the most important is the avoidance of vigorous exercise. The National Cancer Institute recommends that carefully controlled exercise is safe for patients with lymphedema, and multiple studies have shown that exercise results in a better quality of life. Controlled exercise does not exacerbate lymphedema and could reduce the incidence of exacerbations and symptoms of lymphedema. Instead, exercise can increase the strength of those who undertook regular exercise including resistance training. In fact, regular exercise has been shown to be associated with improved survival. 7
The bottom line— there is a positive effect from maintaining normal body weight and engaging in regular exercise.
So move, pick up those weights and eat healthy to stay healthy.