• 2/11/2004
  • Tammy Dotts
  • Hem/Onc Today

The lifetime risk for lymphedema is about 20% for patients who receive treatment that interferes with lymph transport. Many oncologists and other physicians, however, know little about the condition or about available treatments, said Christine Rymal, MSN, RN, CS, AOCN, a nurse practitioner at the Karmonos Cancer Institute in Detroit. “Lymphology is a neglected field,” she told Hem/Onc Today. “There aren’t many experts around.”

The lack of experts may explain why some patients feel abandoned by the medical community. Rymal mentioned a 1997 paper in the Oncology Nursing Forum that found a primary theme among women treated for lymphedema was that they received little information from their doctors. “Ideally, oncologists should know enough about the condition to counsel patients before referring them to a therapist,” she said. “But oncologists may not have the time or the knowledge to understand how lymphedema and lymphedema therapy affect the patient. Even primary doctors aren’t that knowledgeable about it.”

Dorland’s Illustrated Medical Dictionary defines lymphedema as chronic accumulation of interstitial fluid as a result of stasis of lymph, which is secondary to obstruction of lymph vessels or disorders of the lymph nodes.

Under normal conditions, Rymal explained, lymph does not typically flow across watersheds that are the boundaries between quadrants of the peripheral lymph transport vasculature. Surgery, radiation or both can compromise lymph transport. This can cause lymph stasis, vessel hypertension, quadrant congestion and lymphedema. Untreated lymphedema can lead to decreased or lost function in the limbs, skin breakdown, chronic infections and irreversible complications. Lymphedema is usually found closest to the affected lymph nodal basin, but other areas within the quadrant may be affected. For example, patients may experience breast swelling following lumpectomy, axillary dissection and radiation.

Acquired lymphedema can develop immediately after treatment or up to years later, according to the National Lymphedema Network. They also note that any I.V. fluid, including chemotherapy, administered to an already affected lymph area where surgery was performed can lead to lymphedema.

Treatment options
The best treatment for lymphedema is comprehensive decongestive treatment, which consists of manual lymph drainage, layered compression bandages, specific exercise and meticulous skin care and arm precautions, Rymal said. When dealing with extremeties, the treatment pulls lymph fluid from the extremity into the quadrant, which has greater capacity for lymph transported from the extremity.

Some doctors may be concerned that lymphedema treatment may promote metastasis since the lymphatic and blood vasculatures are known routes of metastasis, she said. Rymal discounted this myth. Lymph transport takes lymph constituents to the nodes for destruction, she said, adding that “no reports of unusually aggressive disease progression exist among patients with active malignancy who received comprehensive decongestive treatment.”

Knowledge is power
Lymphedema is a chronic condition that may follow cancer treatment. Unfortunately, patients may be reluctant to pursue immediate treatment and many oncologists may not refer patients to lymphedema therapists. Rymal referred to lymphology as an “orphaned” science. Oncologists and other doctors get most of their information about the treatments through meetings or the occasional journal article, she said. To help doctors learn more about the requirements of lymphedema treatment, fitting treatment into existing therapies and lymphology in general, Rymal recommended the following organizations:

* National Lymphedema Network
The organization provides education and guidance on prevention and management of primary and secondary lymphedema to patients, health care professionals and the general public.
* International Society of Lymphology
The society aims to advance and disseminate knowledge in the field of lymphology and allied topics through international meetings and a scientific journal.
* Lymphology Association of North America
Composed of physicians, nurses and massage, physical and occupational therapists, the organization provides certification for lymphedema therapists.

Another concern of doctors is whether their patients can tolerate lymphedema therapy during ongoing cancer treatment. Rymal said doctors should evaluate if their patients have the time and motivation for daily lymphedema therapy. “Patients may have the time but may not have the energy because of ongoing treatment,” she said. “They could be nauseated from chemotherapy or may just not be up for learning something new at that time. Oncologists don’t always know how taxing lymphedema therapy can be.”

The comprehensive decongestive treatment is time and labor intensive. Basic therapy lasts for 2.5 hours each day and continues for two weeks for an arm and at least four weeks for a leg. “If patients are not up to receiving comprehensive treatment, they should consider just wearing a compression sleeve until their other arduous cancer treatment is completed,” she said.

The pneumatic sleeve is a passive therapy. It uses a pump to inflate and deflate sections of the sleeve in sequence from the fingertips to the armpit. It is less effective than comprehensive therapy, but may be an alternative for patients undergoing other treatment. Pneumatic compression requires at least two hours per session. Another option is compression bandages, which need to be left in place for 48 hours or more but do not interfere with activity or rest, Rymal said.

Compression sleeves are not covered by Medicare, she said. The physical therapy aspect of comprehensive decongestive treatment is covered, but supplies are not.

Source: Rymal C., lymphedema therapy during adjuvant therapy for cancer. Clinical Journal of Oncology Nursing. 2003;7:449-455.