Lymphedema Therapy During Adjuvant Therapy for Cancer
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July/August 2003, Volume 7, Number 4
Clinical Q&A
Barbara Holmes Gobel, RN, MS, AOCN®, Associate Editor
Christine Rymal, MSN, RN, CS, AOCN®
Question: What is the rationale for whether patients should receive
lymphedema therapy during adjuvant cancer treatment?
Answer: Until recently, active or incompletely treated cancer was
considered a contraindication for lymphedema therapy, and lymphedema
therapy schools warned against the practice. This dictate was not based
on research or anecdotal evidence but rather was inferred from the
known effects of therapy. Because lymphedema therapy increases the
lymph transport rate and restores lymph transport to the blood
vasculature, the therapy was theorized to potentially promote
metastasis and disease progression (Feltman, 1995). Consequently,
well-trained, well-intentioned therapists have declined to treat
patients who had not completed adjuvant therapy, had not achieved
remission, or whose cancer had recurred. "First do no harm" was the
guiding principle. Therapists who did treat this group of patients gave
careful warnings of the potential risk, which frequently discouraged
frightened patients from pursuing therapy. The following will explain
the principles that support the suspicion of metastatic risk and the
current endorsement of therapy (Cheville, 2002; Forbes-Kirby, 1998).
Theoretical and practical considerations will be addressed.
Anatomic and Therapeutic Principles
The peripheral lymph transport vasculature is divided into five major
sections (the head and four quadrants) and subsections, called
territories. Watersheds at the midline and waist are the boundaries of
the quadrants. Each quadrant is comprised of the anterior and posterior
trunk and the adjacent extremity. Lymph is transported through
territories and from the watersheds toward the axillary and inquinal
lymph node basins. Anastamoses between the watersheds and territories
allow interquadrant and interterritory transport. Under normal
conditions, little, if any, lymph flows across these boundaries (Szuba
& Rockson, 1997). However, when lymph production exceeds lymph
transport capacity, causing quadrant congestion or swelling
(lymphedema), these anastamoses are activated. These alternate pathways
provide "overflow relief" and are exploited by certain lymphedema
therapies. Proceeding from the nodal basin, lymph is transported
through lymph deeper vessels and emptied into the blood vasculature
(see Figure 1).
Surgery and/or radiation to a nodal basin compromise lymph transport
within the entire quadrant, potentially causing lymph stasis, vessel
hypertension, quadrant congestion, and lymphedema (Szuba & Rockson,
1997). Congestion limits the quadrant's capacity to receive lymph from
the extremity, contributing to lymphedema and limiting the
effectiveness of therapeutic limb compression (Boris, Weindorf, &
Lasinski, 1998; Ko, Lerner, Klose, & Cosimi, 1998). Although usually
found in the extremity, lymphedema also may occur in other areas within
the quadrant, as seen in breast swelling following lumpectomy, axillary
dissection, and radiation.
Manual lymph drainage (MLD) and limb compression are two components of
comprehensive decongestive therapy (CDT). MLD ("massage" is its
frequent misnomer) decongests the quadrant by stimulating lymph
transport across territory and quadrant boundaries, creating negative
pressure in the vessels of the affected quadrant. This "vacuum" pulls
fluid from the extremity into the quadrant. Thus, the decongested
quadrant has greater capacity for lymph transported from the extremity
(Foldi, Foldi, & Weissleder, 1985; Ko et al., 1998). Even in the
absence of MLD, therapeutic limb compression does transport some lymph
into a congested quadrant, thus increasing the congestion. To relieve
the pressure, the interquadrant anastamoses allow lymph transport
across watersheds, albeit to a lesser degree than that achieved with
MLD. By strict interpretation, therefore, MLD and limb compression each
holds the potential to transport malignant cells to distant sites.
Metastatic Principles
The lymphatic and blood vasculatures are known routes of metastasis
(Scanlon, 1985). Barriers between quadrants may be interpreted as
limiting the distribution of lymph constituents (e.g., bacteria,
malignant cells). Thus, the fluid mobilization described previously
would appear to overcome these protective barriers. However, physiology
indicates the opposite: The purpose of lymph transport is to deliver
lymph constituents to nodes for destruction by lymphocytes and natural
killer cells (Guyton & Hall, 2000). Further, no reports of unusually
aggressive disease progression exist among patients with active
malignancy who received CDT.
Experts in lymphology and oncology have weighed in against the theory
of therapy-aided metastasis. Cheville (2002) reported about MLD studies
that failed to demonstrate the transport of radiotracer across quadrant
boundaries. Citing the tenuous nature of the metastatic process,
Weissleder and Schuchhardt (1997) argued that therapy has no impact on
metastatic spread or growth: "Less than 0.1% of embolized tumor cells
survive or become clinically manifested" (p. 189). Casley-Smith and
Casley-Smith (1997) pointed out that tumor emboli transported to nodes
are destroyed there and that "the condition of metastatic disease is
the danger to the patient, not the manipulation of peripheral lymphatic
fluid [author's emphasis]" (p. 101). The International Society of
Lymphology (1995) concurred: "Only diffuse carcinomatous infiltrates
which have already spread [author's emphasis] to lymph collectors as
tumor thrombi could be mobilized by mechanical compression. At this
stage, the long-term prognosis is already poor. Mobilization of dormant
tumor cells [after breast cancer treatment] by arm compression remains
speculative and thus far unconvincing or unfounded" (p. 116).
Principles of Palliation
Lymphedema compromises quality of life through pain and pressure, limb
bulk, distorted posture, and altered self-image (Carter, 1997; Mirolo
et al., 1995). These symptoms are accentuated in end-stage disease.
Cheville (2002) asserted that effective symptom management is integral
to patient care at all stages of disease and enumerates several
therapeutic benefits: reducing pain, reestablishing patient control,
empowering caregivers, minimizing infection risk, enhancing mobility,
and preventing skin breakdown (Weiss & Spray, 2002)--no small feat for
the healthy and a spectacular success for the dying. Nursing literature
further discusses lymphedema management issues and supports lymphedema
therapy for all patients (Rymal, 2001a; Smith & Zobec, 2001).
Given the absence of evidence to the contrary and the presence of
expert support of therapy during all stages of cancer, depriving
patients of lymphedema symptom relief is unethical. To this day, some
patients seeking treatment remain frustrated by therapists who continue
practices based on unfounded principles. The Lymphedema Association of
North America developed national lymphedema therapist certification to
standardize therapist preparation and ongoing education requirements
(Rymal, 2001b). Some patients, aware only of the outdated warnings,
fail to seek care and are resigned to living with unrelieved swelling,
bulk, and pain. Informed healthcare professionals must advocate for
effective lymphedema therapy for all patients and educate those whose
lack of understanding denies relief for patients suffering from
lymphedema.
Practical Considerations
Practical barriers also may interfere with lymphedema therapy.
Modification of optimal therapy is necessary to accommodate various
circumstances (Kelly, 2002). CDT, the most effective treatment, is time
and labor intensive. CDT combines bandaging, MLD, exercise, and limb
care and requires daily therapy sessions of 1.5-2 hours each for two to
four weeks. Further, patients are not passive with CDT but actively
participate in learning and performing therapeutic techniques for
long-term, daily management. Few patients can engage fully in CDT while
physically and emotionally fatigued (e.g., during adjuvant or
palliative therapy, in the case of advancing disease). Fitting CDT into
a schedule full of testing, therapy, and medical appointments can be
problematic. With an overloaded schedule, fatigued patients risk
treatment failure from missed appointments and lack of mastering
self-care skills. Because insurance carriers may limit the frequency of
lymphedema treatment, abbreviated or ineffective treatment represents a
missed opportunity.
Some patients with new lymphedema initially deny the chronicity of the
condition and hold out hope for spontaneous remission. Delaying
intensive therapy in this situation provides an opportunity for
patients to appreciate the impact of lymphedema, recognize that it is
"here to stay," and, potentially, accept treatment. When the treatment
barriers are time, fatigue, or motivation, patients may be better
served by delaying intervention altogether or applying maintenance
(elastic) compression until they are fully able to participate in
effective therapy.
In cases of severe debility, CDT may be limited to the minimal number
of visits required to achieve patient or caregiver independence in
bandaging. Palliative compression then is applied at patients'
discretion. Properly applied bandages are comfortable, do not interfere
with activity or rest, and may be left in place for 48 hours or more.
Alternatively, pneumatic compression also may provide comfort and
pressure relief with the advantage of in-home instruction requiring
less than 20 minutes. Some find that the modest rewards of pneumatic
compression do not justify the confinement required to achieve the
desired effect (at least two hours per session).
As with all health care, financial considerations determine the mode of
therapy available to patients. CDT is covered as a physical therapy by
most insurance carriers, but bandaging supplies are not. The cost
(approximately $100 for an arm and $400 or more for a leg) is
prohibitive for many. Coverage for pneumatic devices varies widely
according to the type of device and insurers' guidelines. For example,
Michigan Medicaid provides a pneumatic device only after CDT treatment
failure, and Medicare requires treatment failure on a single-chambered
intermittent pump (not recommended for lymphedema therapy) before
providing the sequential multichambered device favored by lymphedema
experts.
Otherwise healthy individuals find lymphedema therapy and long-term
care a daunting endeavor (Boris, Weindorf, & Lasinkski, 1997). The
challenges are compounded greatly by adjuvant therapies disease
progression. The creative application of individualized therapy methods
will prevent challenges from becoming insurmountable barriers to
effective and satisfying therapy.
References
Boris, M., Weindorf, S., & Lasinski, B. (1997). Persistence of
lymphedema reduction after noninvasive complex lymphedema therapy.
Oncology (Huntington), 11, 99-109.
Boris, M., Weindorf, S., & Lasinski, B.B. (1998). The risk of genital
edema after external pump compression for lower limb lymphedema.
Lymphology, 31 (1), 15-20.
Carter, B. (1997). Women's experiences of lymphedema. Oncology Nursing
Forum, 24, 875-882.
Casley-Smith, J.R., & Casley-Smith, J.R. (1997). Problems of
concomitant diseases. In Modern treatment for lymphoedema (5th ed., pp.
101-102). Malverne, South Australia: Lymphodema Association of
Australia.
Cheville, A.J. (2002). Lymphedema and palliative care. LymphLink, 14
(1), 1-4.
Feltman, B. (1995). Massage for lymph drainage. In Comprehensive
decongestive physical therapy lymphedema management [Course syllabus]
(p. 40). Indianapolis, IN: Lifelines Rehabilitation.
Foldi, E., Foldi, M., & Weissleder, H. (1985). Conservative treatment
of lymphoedema of the limbs. Angiology, 36, 171-180.
Forbes-Kirby, G. (1998, September). MLD as a contraindication in active
cancers: Based on fact or fear? In Lymphedema: Uncovering the hidden
epidemic. Paper presented at the National Lymphedema Network
Conference, Orlando, FL.
Guyton, A.C., & Hall, J.E. (2000). Resistance of the body to infection:
Immunity and allergy. In C. Arthur, A.C. Guyton, & J.E. Hall (Eds.),
Textbook of medical physiology (10th ed., pp. 442-457). Philadelphia:
W.B. Saunders.
International Society of Lymphology. (1995). Consensus document: The
diagnosis and treatment of peripheral lymphedema. Lymphology, 28,
113-117.
Kelly, D.G. (2002). A primer on lymphedema. Upper Saddle River, NJ:
Prentice Hall.
Ko, D.S.C., Lerner, R., Klose, G., & Cosimi, A.B. (1998). Effective
treatment of the extremities. Archives of Surgery, 133, 452-458.
Mirolo, B.R., Bunce, I.H., Chapman, M., Olsen, O., Eliadis, P.,
Hennessy, J.M., et al. (1995). Psychosocial benefits of post-mastectomy
lymphedema therapy. Cancer Nursing, 18, 197-205.
Rymal, C. (2001a). Lymphedema management for patients with lymphoma.
Nursing Clinics of North America: Palliative and Supportive Care of
Advanced Cancer, 36, 709-734.
Rymal, C. (2001b, August). Lymphedema therapist certification: History,
development and implementation. Oncology Nursing Society Lymphedema
Management Special Interest Group Newsletter, 12 (2), 5-6.
Scanlon, E.F. (1985). The process of metastasis. Cancer, 55, 1163-1166.
Smith, J.K., & Zobec, A. (2001). Lymphedema. In B.R. Ferrell & N. Coyle
(Eds.), Textbook of palliative nursing (pp. 192-203). New York: Oxford
University Press.
Szuba, A., & Rockson, S.G. (1997). Lymphedema: Anatomy, physiology and
pathogenesis. Vascular Medicine, 2, 321-326.
Weiss, J.M., & Spray, B.J. (2002). The effect of complete decongestive
therapy on the quality of life of patients with peripheral lymphedma.
Lymphology, 35 (2), 72-75.
Weissleder, H., & Schuchhardt, C. (1997). Malignant lymphedema. In
Lymphedema diagnosis and therapy (2nd ed., pp. 180-192). Bonn, Germany:
Kagerer Kommunikation.
Christine Rymal, MSN, RN, CS, AOCN®, is a nurse practitioner in the
Walt Comprehensive Breast Center at Karmanos Cancer Institute in
Detroit, MI.
Author Contact: Christine Rymal, MSN, RN, CS, AOCN®, can be reached at
cry...@earthlink.net.
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Lymphedema People