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Progress in Lymphedema
Lymphedema is an incurable, but manageable, potential side effect of treatment for some cancers. Prevention, and prompt intervention if lymphedema develops, are the keys to avoiding long-term morbidity. Although lymphedema can develop for noncancer-related reasons, the majority of lymphedema cases in the United States are caused by cancer surgery and/or radiation therapy that affects the lymph system.
The lymph system is a network of vessels that drains skin and deep tissues. Like the vascular system, it is composed of capillaries leading to larger vessels (precollectors and lymphatic trunks). Lymph is a protein-rich fluid that transports interstitial fluid back to the venous circulation. Lymphatic vessels pass through lymph nodes which filter particulate matter and bacteria from the lymph. They also produce antibodies and lymphocytes; swollen, tender lymph nodes are a sign of regional infection. Major collections of lymph nodes are found in the neck, axillae, groin, and para-aortic region. When the lymphatic circulation is disrupted by removal or damage to the lymph nodes or damage to the lymphatic vessels, the patient is at increased risk for infection and lymphedema.
The highest incidence of lymphedema in cancer patients is among women who have chest and upper extremity lymphedema as a result of breast cancer surgery. The extent of the surgery and whether it was combined with radiation impacts the incidence. Incidence is also higher in women younger than 60 years and in obese patients. The advent of breast-sparing surgery and sentinel lymph node biopsy may reduce the incidence to as low as 6%, while lymph node dissection and radiation therapy may increase the incidence to 23%.
Lower extremity and genital lymphedema may be an unwanted outcome for both women and men who undergo surgery and radiation therapy to the pelvis and groin. When both treatments are combined in cervical cancer, the reported range of lymphedema is 21-49%. The extent of lymphedema following melanoma surgery in the lower extremities ranges from 1.7-53%, depending on the number of lymph nodes removed.
The first episode of lymphedema typically occurs within three years of treatment, but the patient has a life-long risk. Postoperative rehabilitation, weight control, exercise, and prevention of infection in the at-risk limb are important elements in preventing the development of lymphedema and recurrent flares. Prompt intervention when lymphedema occurs is crucial to slowing progression. Without intervention, permanent protein and adipose tissue deposits result in irreversible increase in size and decrease in function. No curative treatments are available; the goals of treatment are to decrease excess volume, maintain the smallest limb size possible, maintain or increase functionality, and prevent infection. Research with hyperbaric oxygen and low-level laser therapy is currently under way.
The generally preferred intervention is complete decongestive therapy (CDT), which involves manual lymph drainage (or lymphatic massage), compression bandaging, therapeutic exercise, and skin and nail inspection and care. After an initial period of intensive treatment by specially trained therapists, patients and families can be taught to perform manual lymph drainage and bandaging. Exercise using the affected limb, once thought to increase the risk of lymphedema, is now an integral part of self care. It promotes passage of lymph through the vessels and maintains full functionality of the limb. In a study of CDT, patients who adhered to the self-care elements in the maintenance phase for 12 month retained 90% of the original limb size reduction achieved during the treatment phase.
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In the News
Clinical Practice Guidelines
Clinical Practice Guidelines for Quality Palliative Care, 2nd Ed. is now available from the National Consensus Project for Quality Palliative Care for purchase or as a free download.
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Connecticut Challenge 2009
Registration is open for the 2009 Connecticut Challenge bicycle ride on Saturday July 25. This 5th annual ride will raise money for cancer education, research, and survivor care at Yale Cancer Center, the HEROS pediatric survivorship clinic at Yale-New Haven Hospital, and other survivorship programs in Connecticut.
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Journal Watch
Lawenda BD, et al. Lymphedema: a primer on the identification and management of a chronic condition in oncologic treatment. CA: A Cancer Journal for Clinicians. 2009 Jan-Feb;59(1):8-24. (CME, CNE available)
Cheung WY, et al. Comparisons of patient and physician expectations for cancer survivorship care. Journal of Clinical Oncology. 2009 May 20;27(15):2489-95.
Crenshaw J. Palliative sedation for existential pain: An ethical analysis. Journal of Hospice and Palliative Nursing. 2009;11(2):101-106 (CNE).
Freye E. A new transmucosal drug delivery system for patients with breakthrough cancer pain: the fentanyl effervescent buccal tablet. Journal of Pain Research. 2009;2:13-20. (free download)
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Casuccio A, et al. Treatment strategies for cancer patients with breakthrough pain. Expert Opinion on Pharmacotherapy. 2009 Apr;10(6):947-53.
Cruccu G, Truini A. Tools for Assessing Neuropathic Pain. PLoS Medicine. 2009;6(4):1-5. (Open access).
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Landier W. Survivorship Care: Essential Components and Models of Delivery. Oncology Nurse Edition. 2009;23(4)
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Southard NZ, Keller J. The importance of assessing sexuality: a patient perspective. Clinical Journal of Oncology Nursing. 2009; Apr;13(2): 213-217.
Hong JH, eta l. Taste and odor abnormalities in cancer patients. Journal of Supportive Oncology. 2009 Mar-Apr;7(2):58-65. (Open access)
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Chang SH, et al. Acute and chronic pain following breast surgery. Acute Pain. 2009;11(1):1-14.
Hauser JM. Lost in transition: the ethics of the palliative care handoff. Journal of Pain and Symptom Management. 2009;37(5):930-933.
Cheung WY, et al. Comparisons of patient and physician expectations for cancer survivorship care. Journal of Clinical Oncology. 2009;27(15):2489-2495.
Chiechio S, et al. Pregabalin in the treatment of chronic ain: an overview. Clinical Drug Investigation. 2009;29(3):203-213.
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