Prevention
Treatment
        Compression garments
        Drug therapy
        Dietary Management
        Pain Management
        Complications
Psychosocial considerations

Prevention

Patients at risk for lymphedema should be identified early, monitored, and taught self-care. A patient may be more likely to develop lymphedema if he or she eats an inadequate diet, is overweight, is inactive, or has other medical problems. To detect the condition early, the following should be examined:

• Comparison of actual weight to ideal weight.
• Measurements of the arms and legs.
• Protein levels in the blood.
• Ability to perform activities of daily living.
• History of edema, previous radiation therapy, or surgery.
• Other medical illnesses such as diabetes, high blood pressure, kidney disease, heart disease, or phlebitis (inflammation of the veins).

It is important that the patient know about his or her disease and the risk of developing lymphedema. Poor drainage of the lymphatic system due to surgical removal of the lymph nodes or to radiation therapy may make the affected arm or leg more susceptible to serious infection. Even a small infection may lead to serious lymphedema. Patients should be taught about arm, leg, and skin care after surgery and/or radiation (see Considerations for Teaching Patients Prevention and Control of Lymphedema below). It is important that patients take precautions to prevent injury and infection in the affected arm or leg because lymphedema can occur 30 or more years after surgery. Breast cancer patients who follow instructions about skin care and proper exercise after mastectomy are less likely to experience lymphedema.

Lymphatic drainage is improved during exercise; therefore, exercise is important in preventing lymphedema. Breast cancer patients should do hand and arm exercises as instructed after mastectomy. Patients who have surgery that affects pelvic lymph node drainage should do leg and foot exercises as instructed. The doctor decides how soon after surgery the patient should start exercising. Physiatrists (doctors who specialize in physical medicine and rehabilitation) or physical therapists should develop an individualized exercise program for the patient.

Better recovery occurs when lymphedema is discovered early, so patients should be taught to recognize the early signs of edema and to tell the doctor about any of the following symptoms:

• Feelings of tightness in the arm or leg.
• Rings or shoes that become tight.
• Weakness in the arm or leg.
• Pain, aching, or heaviness in the arm or leg.
• Redness, swelling, or signs of infection.

Considerations for Teaching Patients Prevention and Control of Lymphedema

1. Keep the arm or leg raised above the level of the heart, when possible. Avoid making rapid circles with the arm or leg to keep blood from collecting in the lower part of the limb.



2. Clean the skin of the arm or leg daily and moisten with lotion.



3. Avoid injury and infection of the arm or leg.
   • Arms:
     • Use an electric razor for shaving.
     • Wear gardening and cooking gloves.
     • Use thimbles for sewing.
     • Take care of fingernails; do not cut cuticles.
   • Legs:
     • Keep the feet covered when outdoors.
     • Keep the feet clean and dry; wear cotton socks.
     • Cut toenails straight across; see a podiatrist as needed to prevent ingrown nails and infections.
   • Either arms or legs:
     • Suntan gradually; use sunscreen.
     • Clean cuts with soap and water, then use antibacterial ointment.
     • Use gauze wrapping instead of tape; do not wrap so tight that circulation is cut off.
     • Talk to the doctor about any rashes.
     • Avoid needle sticks of any type in the affected arm or leg.
     • Avoid extreme hot or cold such as ice packs or heating pads.
     • Do not overwork the affected arm or leg.



4. Do not put too much pressure on the arm or leg.
   • Do not cross legs while sitting.
   • Wear loose jewelry; wear clothes without tight bands.
   • Carry a handbag on the unaffected arm.
   • Do not use blood pressure cuffs on the affected arm.
   • Do not use elastic bandages or stockings with tight bands.
   • Do not sit in one position for more than 30 minutes.



5. Watch for signs of infection, such as redness, pain, heat, swelling, and fever. Call the doctor immediately if any of these signs appear.



6. Do prescribed exercises regularly as instructed by the doctor or therapist.



7. Keep regular follow-up appointments with the doctor.



8. Check all areas of the arms and legs every day for signs of problems.
   • Measure around the arm or leg at regular intervals as suggested by the doctor or therapist.
   • Measure the arm or leg at the same two places each time.
   • Tell the doctor if the limb suddenly gets larger.



9. The ability to feel sensations such as touch, temperature, or pain in the affected arm or leg may be lessened. Use the unaffected limb to test temperatures for bath water or cooking.

Lymphedema is treated by physical methods and with medication. Physical methods include supporting the arm or leg in a raised position, manual lymphatic drainage (a specialized form of very light massage that helps to move fluid from the end of the limb toward the trunk of the body), wearing bandages or custom-fitted clothing, such as stockings, that apply controlled pressure around the affected limb, and cleaning the skin carefully to prevent infection. Lymphedema may be treated by combining several of these physical methods. This is known as complex physical therapy (or complex decongestive therapy). which consists of manual lymphedema treatment, compression wrapping, individualized exercises, and skin care followed by a maintenance program. Complex physical therapy must be performed by a professional trained in the techniques.

Surgery for treating lymphedema usually results in complications and is seldom recommended for cancer patients.

When pressure garments are used, they should cover the entire area of edema. For example, a stocking that reaches only to the knee tends to become tight and block the lymphatic vessels and veins if there is edema in the thigh. Pumps connected to cuffs that wrap around the arm or leg and apply pressure on and off may be helpful; however, some physicians and therapists feel these pumps are not effective and may make the edema worse. The cuff is inflated and deflated according to a controlled time cycle. This pumping action is believed to increase the movement of fluid in the veins and lymphatic vessels and keeps fluid from collecting in the arm or leg. Compression pumps should be used only under the supervision of a trained health care professional because high external pressure can damage the lymphatic vessels near the skin surface.

Antibiotics may be used to treat and prevent infections. Other types of drugs such as diuretics or anticoagulants (blood thinners) are generally not helpful, and may make the problem worse.

Finding the exact cause of the swelling and treating it correctly is important. Edema often leads to infection, which then increases fluid and protein deposits in the tissues. If an infection is diagnosed, appropriate antibiotics should be given. Blood clots should be ruled out because massage and other therapy techniques to encourage drainage may cause the clots to move through the bloodstream and cause more serious heart or lung problems. If blood clots are found, they should be treated with anticoagulants.

Coumarin is a dietary supplement that has been studied as a treatment for lymphedema. In the United States, dietary supplements are regulated as foods, not drugs. Supplements are not required to be approved by the Food and Drug Administration (FDA) before being put on the market. Because there are no standards for manufacturing consistency, dose, or purity, one lot of dietary supplements may differ considerably from the next.

Coumarin was once used in some foods and medications in the United States. It was found to cause liver damage, and its use in foods and medications in the United States has been banned since the 1950s. Coumarin is available in several countries, but has not been approved for use in the United States or Canada.

The nutritional status of the patient should be evaluated and appropriate dietary recommendations should be made. Blood protein levels and weight should be monitored regularly, and patients should be encouraged to eat protein-rich foods.

Patients with lymphedema may experience pain caused by the swelling and pressure on nerves; loss of muscle tissue and function; or scar tissue causing shortening of muscles and less movement at joints. Pain may be treated with medications, relaxation techniques, and/or transcutaneous electrical nerve stimulation (TENS); however, the most successful treatment is to decrease the lymphedema.

Edema can make tissues less able to take in nutrients and more likely to be damaged if the affected limb is not moved for long periods. Therefore, patients with lymphedema should be monitored for areas of skin breakdown, especially over areas with very little tissue between the skin and bone (i.e., hips, knees, and elbows).

Bladder emptying problems can develop from lymphedema in the pelvic or groin areas. Patients with lymphedema who are also taking opioids may develop bowel problems. Bowel and bladder status should be monitored regularly for any signs of urine retention or constipation.

Because lymphedema is disfiguring and sometimes painful and disabling, it can create mental, physical, and sexual problems. Several studies have noted that women who develop lymphedema after treatment for breast cancer have more mental, physical, and sexual difficulties than women who do not develop lymphedema. The added stresses associated with lymphedema may interfere with treatment that is often painful, difficult, and time-consuming.

Coping with lymphedema in the arm after breast cancer treatment is especially difficult for patients who have little social support. Some patients may react to the problem by withdrawing. Coping is also difficult for patients with painful lymphedema. Patients with lymphedema may be helped by group and individual counseling that provides information about ways to prevent lymphedema, the role of diet and exercise, advice for picking comfortable and flattering clothes, and emotional support.

(See the PDQ summaries on Normal Adjustment and the Adjustment Disorders ¹ and Sexuality and Reproductive Issues ² for more information.

Glossary Terms

ADL. The tasks of everyday life. These activities include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet. Instrumental activities of daily living are activities related to independent living and include preparing meals, managing money, shopping, doing housework, and using a telephone. Also called ADL.

A substance that kills bacteria or stops them from growing and causing disease.

A drug used to treat infections caused by bacteria and other microorganisms.

A drug that helps prevent blood clots from forming. Also called a blood thinner.

The organ that stores urine.

A tissue with red blood cells, white blood cells, platelets, and other substances suspended in fluid called plasma. Blood takes oxygen and nutrients to the tissues, and carries away wastes.

The force of circulating blood on the walls of the arteries. Blood pressure is taken using two measurements: systolic (measured when the heart beats, when blood pressure is at its highest) and diastolic (measured between heart beats, when blood pressure is at its lowest). Blood pressure is written with the systolic blood pressure first, followed by the diastolic blood pressure (for example 120/80).

The long, tube-shaped organ in the abdomen that completes the process of digestion. The bowel has two parts, the small bowel and the large bowel. Also called the intestine.

Cancer that forms in tissues of the breast, usually the ducts (tubes that carry milk to the nipple) and lobules (glands that make milk). It occurs in both men and women, although male breast cancer is rare.

In the body, the flow of blood through the heart and blood vessels, and the flow of lymph through the lymph vessels.

In medicine, a medical problem that occurs during a disease, or after a procedure or treatment. The complication may be caused by the disease, procedure, or treatment or may be unrelated to them.

A condition in which stool becomes hard, dry, and difficult to pass, and bowel movements don’t happen very often. Other symptoms may include painful bowel movements, and feeling bloated, uncomfortable, and sluggish.

A substance used to make drugs that prevent and treat blood clots in blood vessels and treat certain heart conditions. Coumarin is taken from certain plants and can also be made in the laboratory. It is a type of anticoagulant.

The process by which a professional counselor helps a person cope with mental or emotional distress, and understand and solve personal problems.

A disease in which the body does not properly control the amount of sugar in the blood. As a result, the level of sugar in the blood is too high. This disease occurs when the body does not produce enough insulin or does not use it properly.

The process of identifying a disease by the signs and symptoms.

The things a person eats and drinks.

A product that is added to the diet. A dietary supplement is taken by mouth, and usually contains one or more dietary ingredient (such as vitamin, mineral, herb, amino acid, and enzyme). Also called nutritional supplement.

A drug that increases the production of urine.

The amount of medicine taken, or radiation given, at one time.

Any substance, other than food, that is used to prevent, diagnose, treat or relieve symptoms of a disease or abnormal condition. Also refers to a substance that alters mood or body function, or that can be habit-forming or addictive, especially a narcotic.

Swelling caused by excess fluid in body tissues.

An increase in body temperature above normal (98.6 degrees F), usually caused by disease.

Liquid.

Monitoring a person's health over time after treatment. This includes keeping track of the health of people who participate in a clinical study or clinical trial for a period of time, both during the study and after the study ends.

FDA. An agency in the U.S. federal government whose mission is to protect public health by making sure that food, cosmetics, and nutritional supplements are safe to use and truthfully labeled. The Food and Drug Administration also makes sure that drugs, medical devices, and equipment are safe and effective, and that blood for transfusions and transplant tissue are safe. Also called FDA.

The area where the thigh meets the abdomen.

A blood pressure of 140/90 or higher. High blood pressure usually has no symptoms. It can harm the arteries and cause an increase in the risk of stroke, heart attack, kidney failure, and blindness. Also called hypertension.

Invasion and multiplication of germs in the body. Infections can occur in any part of the body and can spread throughout the body. The germs may be bacteria, viruses, yeast, or fungi. They can cause a fever and other problems, depending on where the infection occurs. When the body’s natural defense system is strong, it can often fight the germs and prevent infection. Some cancer treatments can weaken the natural defense system.

Redness, swelling, pain, and/or a feeling of heat in an area of the body. This is a protective reaction to injury, disease, or irritation of the tissues.

One of a pair of organs in the abdomen. Kidneys remove waste from the blood (as urine), produce erythropoietin (a substance that stimulates red blood cell production), and play a role in blood pressure regulation.

A large organ located in the upper abdomen. The liver cleanses the blood and aids in digestion by secreting bile.

One of a pair of organs in the chest that supplies the body with oxygen, and removes carbon dioxide from the body.

A rounded mass of lymphatic tissue that is surrounded by a capsule of connective tissue. Lymph nodes filter lymph (lymphatic fluid), and they store lymphocytes (white blood cells). They are located along lymphatic vessels. Also called lymph gland.

The flow of lymph from an area of tissue into a particular lymph node.

The tissues and organs that produce, store, and carry white blood cells that fight infections and other diseases. This system includes the bone marrow, spleen, thymus, lymph nodes, and lymphatic vessels (a network of thin tubes that carry lymph and white blood cells). Lymphatic vessels branch, like blood vessels, into all the tissues of the body.

A condition in which excess fluid collects in tissue and causes swelling. It may occur in the arm or leg after lymph vessels or lymph nodes in the underarm or groin are removed or treated with radiation.

Surgery to remove the breast (or as much of the breast tissue as possible).

Refers to the practices and procedures used for the prevention, treatment, or relief of symptoms of a diseases or abnormal conditions. This term may also refer to a legal drug used for the same purpose.

A bundle of fibers that receives and sends messages between the body and the brain. The messages are sent by chemical and electrical changes in the cells that make up the nerves.

A chemical compound (such as protein, fat, carbohydrate, vitamin, or mineral) contained in foods. These compounds are used by the body to function and grow.

The taking in and use of food and other nourishing material by the body. Nutrition is a 3-part process. First, food or drink is consumed. Second, the body breaks down the food or drink into nutrients. Third, the nutrients travel through the bloodstream to different parts of the body where they are used as "fuel" and for many other purposes. To give the body proper nutrition, a person has to eat and drink enough of the foods that contain key nutrients.

A substance used on the skin to soothe or heal wounds, burns, rashes, scrapes, or other skin problems. Also called unguent.

A drug used to treat moderate to severe pain. Opioids are similar to opiates such as morphine and codeine, but they do not contain and are not made from opium.

Being too heavy for one’s height. Excess body weight can come from fat, muscle, bone, and/or water retention. Being overweight does not always mean being obese.

PDQ is an online database developed and maintained by the National Cancer Institute. Designed to make the most current, credible, and accurate cancer information available to health professionals and the public, PDQ contains peer-reviewed summaries on cancer treatment, screening, prevention, genetics, complementary and alternative medicine, and supportive care; a registry of cancer clinical trials from around the world; and directories of physicians, professionals who provide genetics services, and organizations that provide cancer care. Most of this information, and more specific information about PDQ, can be found on the NCI's Web site at http://www.cancer.gov/cancertopics/pdq. Also called Physician Data Query.

Having to do with the pelvis (the lower part of the abdomen located between the hip bones).

Inflammation (redness, swelling, pain, and heat) of a vein, usually in the legs. Phlebitis may be caused by infection, injury, or irritation.

A health professional who teaches exercises and physical activities that help condition muscles and restore strength and movement.

The use of exercises and physical activities to help condition muscles and restore strength and movement. For example, physical therapy can be used to restore arm and shoulder movement and build back strength after breast cancer surgery.

Medical doctor.

A doctor who specializes in the care of the foot and ankle.

A molecule made up of amino acids that are needed for the body to function properly. Proteins are the basis of body structures such as skin and hair and of substances such as enzymes, cytokines, and antibodies.

The use of high-energy radiation from x-rays, gamma rays, neutrons, protons, and other sources to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (external-beam radiation therapy), or it may come from radioactive material placed in the body near cancer cells (internal radiation therapy). Systemic radiation therapy uses a radioactive substance, such as a radiolabeled monoclonal antibody, that travels in the blood to tissues throughout the body. Also called radiotherapy and irradiation.

In medicine, a process to restore mental and/or physical abilities lost to injury or disease, in order to function in a normal or near-normal way.

A method used to reduce tension and anxiety, and control pain.

A network of family, friends, neighbors, and community members that is available in times of need to give psychological, physical, and financial help.

A substance that helps protect the skin from the sun's harmful rays. Sunscreens reflect, absorb, and scatter both ultraviolet A and B radiation to provide protection against both types of radiation. Using lotions, creams, or gels that contain sunscreens can help protect the skin from premature aging and damage that may lead to skin cancer.

A procedure to remove or repair a part of the body or to find out whether disease is present. An operation.

An indication that a person has a condition or disease. Some examples of symptoms are headache, fever, fatigue, nausea, vomiting, and pain.

Treatment.

A group or layer of cells that work together to perform a specific function.

TENS. A technique in which mild electric currents are applied to some areas of the skin by a small power pack connected to two electrodes. Also called TENS and controlled low-voltage electrical stimulation.

Fluid containing water and waste products. Urine is made by the kidneys, stored in the bladder, and leaves the body through the urethra.