Breast cancer: Post Mastectomy Lymphedema

Lymphedema refers to the accumulation of protein-rich fluid in the interstitial space caused by a compromised lymphatic system. Breast cancer-related lymphedema of the upper limbs is a common complication following breast cancer surgery. The incidence of post-mastectomy lymphedema was approximately 20% in breast cancer survivors who underwent tumour resection with axillary lymph node dissection. Post-mastectomy lymphedema may appear immediately or years post-treatment, with the majority diagnosed during the first 3 years. Lymphedema causes limb and shoulder pain, heaviness, tightness, and decreased range of motion. Also, gross and fine motor skills, daily functions and psychosocial relationship are affected.

Symptoms

The main symptom of lymphedema after breast cancer treatment is the swelling of the arm on the side where lymph nodes have been removed. The amount of swelling may vary. Other symptoms of lymphedema may include:

• Feeling of fullness, heaviness, or tightness in the arm, chest, or armpit area
• Aching or new pain in the arm
• Trouble bending or moving a joint, such as the fingers, wrist, elbow, or shoulder
• Swelling in the hand
• Thickening of or changes in the skin
• Weakness in the arm

Risk factors

Several risk factors are associated with the occurrence of Breast Cancer Related Lymphedema, which includes the following:

• Radiation therapy or chemotherapy
• A higher number of removed axillary lymph nodes/tumour invasion of the lymph nodes
• Arm infection, inflammation, or injury
• overweight or weight gain
• Ageing
• Surgery on the dominant arm/Level of hand use.
• Having received a mastectomy

Stages of lymphedema

Stages of lymphedema includes;

Stage 1– An individual is considered at-risk for lymphedema development due to injury to the lymphatic vessels but does not present with outward signs of edema. It Includes people with breast cancer who have undergone sentinel lymph node biopsy and/or radiation but have not yet developed, swelling. Lymphatic transport capacity has been reduced, which predisposes the patient to lymphatic overload and resultant edema.

Stage 2- A spontaneous increase in fluid in the body, has pitting edema. Swelling at this stage is soft and may respond to just elevation making it easily reversible.

Stage 3– Has tissue fibrosis/induration. Swelling does not respond to elevation. Skin and tissue thickening occur as the limb volume increases. Pitting may be present but may be difficult to assess due to tissue and or skin fibrosis. It cannot be reversed spontaneously.

Stage 4- Marked pitting edema, increased fibrosis, skin changes/discoloration.  During this stage papilloma may form, infections/cellulitis may occur, and the skin becomes dry.

These disease and treatment-related factors cause tissue scarring and fibrosis.

Physiotherapy role

1. Education: The educational program provides information on the lymphatic system, the symptoms and signs of lymphedema, and suggestions for preventing lymphedema, such as engaging in postoperative exercise, modifying activities, massaging the scar tissue, maintaining healthy body weight, and avoiding trauma to or infection or venipuncture of the limb. 
2. Manual lymphatic drainage (MLD): MLD is a light, skin stretching massage that helps promote the movement of lymphatic fluid out of the swollen limb by opening the remaining functioning lymph collectors and move protein and fluid into them, as well as to help speed up lymph fluid flow through the lymphatics. It should not be confused with a traditional massage. Therapy is applied to your unaffected areas first, making it possible for the fluid to move out of the affected area, or “decongest” the region. Deep breathing techniques called diaphragmatic breathing are usually done at the beginning and end of a therapy session to help open the deep lymphatic pathways. It’s not only relaxing, but it helps increase movement of fluid toward the heart.
3. Exercises: improve cardiovascular health and decrease swelling in some cases. The exercise protocols involve endurance training, strengthening, range of motion exercises, resistance exercises and sensorimotor training.

 In addition to the potential benefits on the cardiovascular system, exercising would lead to an increased Quality of Life and independence. Compression garments should be worn during exercise.

• Complex Decongestive Therapy: this treatment technique is for moderate-to-severe lymphedema and mobilizes lymph and dissipate fibrosclerotic tissue. It involves skincare, light lymphatic drainage, range of motion exercises and compression bandaging.
• Bandages: Wearing a compression sleeve or elastic bandage may help to move fluid and prevent the buildup of fluid. During activity, whether exercise or daily activities, the short-stretch bandages enhance the pumping action of the lymph vessels by providing increased resistance. This encourages lymphatic flow and helps to soften fluid-swollen areas.

While there is no cure, treatment may improve outcomes. A physiotherapist has treatments and therapies to help ease the effects of chemotherapy, radiation, mastectomy and reconstructive surgery. Breast cancer and associated treatments can be scary and have far-reaching effects. We at Physio Centers of Africa can help you meet those challenges of the body, mind and quality of life.