How do lifestyle factors and exposure to environmental substances affect our cancer risk?
By Mia James
Lymphedema results from a compromise in the lymphatic system that decreases
its ability to function, including filtering or draining excess fluids, waste,
and toxins from the body. Inadequate drainage can cause swelling, or edema—
called lymphedema in this case because the lymphatic system is involved.
The lymphatic system can be compromised when one or more lymph vessels
or nodes (small organs distributed throughout the body that transport and
filter or trap foreign particles and waste) are surgically removed or stop
working properly due to disease. A common example of lymph node removal is
for the treatment of breast cancer, as this disease may spread to the nodes
under the arm. Lymph nodes, however, are found elsewhere in the body as well,
such as the neck, abdomen, and groin, so other types of surgery can also affect them.
Simply put, according to Lisa Poormon, PT, DPT, MEd, CLT, a physical therapist at
Cancer Treatment Centers of America® (CTCA) in Goodyear, Arizona, lymphedema is a
“messed up plumbing system,” with the culprit being poor drainage. When the “drains”
of the lymphatic system don’t work correctly, excess protein-rich lymph fluid
isn’t pumped out of the tissue and begins to build up.
Excess lymph fluid contains large molecules, including dead cells, bacteria,
and proteins. The body depends on the lymphatic system to remove these
molecules from the tissue. If these proteins are stuck in the tissue, they draw
water toward themselves—a sequence of events that Poormon says “adds insult to
injury,” as increased protein in the tissue leads to more swelling.
Lymphedema occurs in four stages, the last three of which are active. In stage 0,
or latency, the transport capacity of the lymphatic system is reduced due to a
mechanical dysfunction caused by trauma such as surgery, radiation, or missing
lymph nodes, but swelling isn’t visible. If latency progresses to stage 1, mild
lymphedema, some swelling becomes noticeable. By stage 2, moderate lymphedema,
the tissue starts to harden. This is followed by stage 3, severe lymphedema,
where the tissue is harder and the affected limb becomes very large and
swollen, a condition known as elephantiasis.
As lymphedema progresses through active stages, the consequences become
increasingly serious. Poormon explains that frequent infection becomes a
growing risk and that a patient’s ability to function may be jeopardized. “The
larger that limb becomes, the heavier it becomes and the less function you will
have,” she says. With increased weight and girth of the limb, range of motion
can be reduced and ability for self-care and mobility are threatened.
SIGNS AND SYMPTOMS
If you’ve undergone any type of procedure that’s affected your lymphatic system
or have had an illness that involved it, you may be at risk of lymphedema—a
risk that persists for life. Prevention is, of course, essential, as is awareness
of signs and symptoms of the condition.
Poormon says that patients often report report tightness, tingling, numbness, or
heaviness in the affected limb. As well, there may be pain, color, and temperature
variations compared with the other (unaffected) limb. Swelling is of course a symptom
as is a decrease in strength or range of motion. And because lymph node removal can
compromise immunity in the affected limb, skin changes (such as a rash) may indicate
infection and may also signal lymphedema.
ARE YOU AT RISK?
Though surgery for breast cancer is commonly associated with lymphedema, Poormon says
that risk extends to any type of intervention that affects the lymphatic system. This
includes, she explains, “any surgeries, whether in the groin, in the abdomen, under the arm,
or on the head and neck.” As well, radiation or any type of disease that affects
the lymphatic system’s ability to drain results in a risk of lymphedema.
Elvira “Vera” Stabolito of Peoria, Arizona, can attest to the importance of
understanding the risk of lymphedema. She says that when she was diagnosed with
and treated for metastatic breast cancer in 1988, she didn’t really understand
her risk, even though she had nine or 10 involved nodes. As a result of Vera’s
inadequate education 13 years ago, the now-60-year-old took little precaution,
dismissing what she now knows were signs of lymphedema (such as pain and swelling)
as age-related changes. “I guess I was having lymphedema all these years,” she says,
“but it was never explained to me.”
It’s unclear why some people develop lymphedema whereas others
do not. There are, however, a few known factors that may increase your risk,
Poormon says. Obesity, severe fatigue, susceptibility to infection, and heavy
trauma to the lymphatic system (such as multiple surgeries and radiation) can
The key word in lymphedema management, according to Poormon, is early. “Education and
early intervention are huge pieces to lymphedema management,” she says. In other words,
learn about lymphedema before it becomes a risk or an issue.
Victoria Magnan, OTR, CLT, a lymphedema therapist in the Milwaukee, Wisconsin, area, says
prevention can begin before a patient leaves the hospital. For example, she explains that breast
cancer patients can be given a compression sleeve immediately after surgery and educated about how
to use it as well as about other strategies for managing risk.
Air travel, says Magnan, is one area in which patients with a compromised lymphatic system need
to be particularly vigilant. Proactive measures include staying hydrated with water or juice (no
carbonated drinks); avoiding salt before, during, and after the flight; and wearing a compression
garment. “The [air] pressure changes when you fly, so if you’re on a plane, you’re hugely at
risk,” Magnan explains.
In addition to air travel, certain everyday activities can elevate lymphedema risk. For example,
carrying or lifting heavy objects is a risk factor when arms are affected. Magnan advises
patients to always consult their doctor before attempting any activity that involves the upper
body, including exercise programs. Other things to avoid include extreme temperatures and having
blood pressure taken or needle sticks (injections and blood draws) in the affected arm. Skin care
precautions (described further below) should also be taken. Magnan says that anyone at risk of
lymphedema needs to follow these safety measures, as well as the air travel precautions described
above, for life.
According to the National Lymphedema Network, lymphedema therapists may have a background in several
health care fields, including nursing, occupational therapy, and physical therapy, and have additional
training to treat lymphatic disorders. The professional designation CLT, which stands for certified
lymphedema therapist, indicates specialized lymphedema training and certification. The Lymphology
Association of North America offers a further national certification exam to providers who have
met certain educational requirements.
Lymphedema management is a multistep process, with each facet playing an indispensable role. The
protocol, says Poormon, is called complete decongestive therapy (CDT), a program that includes
skin care, manual lymph drainage, compression therapy, and decongestive exercises. Of the importance
of following through with all four elements, Poormon says, “You truly need all four of those things
to manage lymphedema. You can’t do just one thing.”
Here’s a look at the four elements of CDT:
Due to the elevated risk of infection associated with a compromised lymphatic system, meticulous skin
care is a must. This involves keeping limbs very clean, pH balanced, and moisturized. It’s critical to
avoid anything that might carry a risk of introducing bacteria or infection to the limb; examples include
manicures and pedicures, shaving with a razor that can nick the skin (electric is an alternative), and
needle sticks (injections or blood draws) to the affected limb. Poormon also recommends sensible precautions
like wearing gloves while gardening.
Manual lymph drainage (MLD)
This gentle massage technique stretches the skin superficially to stimulate the lymph vessels immediately
under the skin. The slow, rhythmic stretch encourages builtup protein-rich fluid to move toward healthy areas
of the lymphatic system so that it can be taken back into the circulatory system and processed properly
through the body. “I work on awakening the lymph nodes and draining all of that [built-up] fluid,” says
Magnan of a therapist’s role in MLD, though she also explains that patients can learn to perform this
technique themselves. Poormon underscores the importance of MLD, explaining that it’s the only way to mobilize
the proteins that have accumulated in the tissues back into the system.
Compression therapy involves a specific multilayer bandaging technique performed by a therapist as well as
the use of compression garments, including sleeves, hosiery, and gauntlets (for hands). Bandages and garments
won’t, however, mobilize the proteins out of the tissue—MLD is needed to get the solid components moving.
Compression therapy is used to aid the reabsorption of fluid. The combination of MLD and compression therapy
can have near-instant results. “With the MLD and the bandaging, they see results within the first day,” says Magnan.
Compression garments can also be used to manage lymphedema in at-risk limbs during air travel.
Exercise, says Poormon, can help get the lymphatic system working. “There are so many reasons to exercise,”
she explains, citing additional benefits such as increased muscle and decreased fat, both which can help
manage lymphedema. Suggestions for exercise include walking, biking, dancing, and swimming, but you should first
discuss any activity with your doctor. For upper-limb lymphedema, extra precaution should be taken with lifting and
repetitive upper-body motion, as these activities can aggravate lymphedema.
Vera, whose lymphedema was finally identified this year when she was treated for a breast cancer metastasis on
her mediastinum, says that lymphedema therapy has helped her manage symptoms dramatically. Beginning with MLD, she
says, “It was almost immediate relief.” She also says that she feels significantly less pain and is learning
therapeutic exercises as well as what types of activities to avoid (such as repetitive motion like scrubbing
and carrying heavy objects).
The encouraging message about lymphedema is that effective management and skilled experts are available to help you.
Your responsibility, according to Vera, is to educate yourself as soon as possible. “Get informed. Don’t wait for them
to tell you,” she says. This proactive approach can allow you to live well with lymphedema, as Vera explains: “Make
sure that you learn everything you need to continue living a fruitful life.”
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