Recognizing Lymphedema is Vital in Assisting Oncology Patients

From Medscape Medical News 2009 (Jan 21, 2009):

Oncologists who are alert to the signs and symptoms of cancer and cancer-treatment-related lymphedema can have a large impact on its course, because the chronic condition can be minimized if recognized and treated early, according to a review article on lymphedema published in the January/February issue of CA: A Cancer Journal for Clinicians.

However, oncologists are generally too busy to oversee the care of lymphedema themselves, and hence should become familiar with resources that can help connect patients with lymphedema-management specialists, said lead author Brian D. Lawenda, MD, clinical director of radiation oncology at the N aval Medical Center, in San Diego, California.

"We don't have the time to manage the care for lymphedema. Therefore, my colleagues and I recommend that clinicians be aware of referring specialists in their area who are experts in the diagnosis and management of lymphedema," Dr. Lawenda said in an interview with Medscape Oncology.

Dr. Lawenda also noted that oncology patients at risk for lymphedema should receive pretreatment evaluation that includes baseline girth and volume measurements of limbs. He emphasized the importance of prevention education, which includes a discussion of risk factors, and arm and leg care guidelines.

Pretreatment patient evaluation and education are not well utilized by clinicians, suggested Dr. Lawenda.

"Oncology patients are left with a lot of side effects of treatment. We commonly see lymphedema, but unfortunately it does not get a lot of discussion [by oncologists]. As result, it can be a surprise to patients," he said.

The most common causes of lymphedema in the United States are surgery and radiation therapy for the treatment of cancer. The most common etiology is the impaired flow of lymph fluid through the draining lymphatic vessels and lymph nodes, write Dr. Lawenda and his coauthors, Tammy Mondry, DPT, a physical therapist at N ew Horizons Physical Therapy, in San Diego, and an expert on managing the condition, and Peter Johnstone, MD, chair of the Department of Radiation Oncology at the Indiana University School of Medicine, in Indianapolis.

Lymphedema is most commonly reported after breast cancer treatment, but can result from the treatment of cervical, endometrial, vulvar, head and neck, and prostate cancers, and of sarcomas and melanoma. Lack of standardized definitions and measurement techniques for the disorder make an accurate incidence rate of cancer-treatment-related lymphedema difficult to determine, say the authors.

However, the likelihood of lymphedema by cancer type and related treatment has been established.
For instance, with regard to breast cancer, the frequency of breast edema ranges from 6% to 48% when surgery and radiation therapy are combined. The frequencies tend to be at the higher ends of the range when a lymph node dissection and radiation therapy are performed.

Increased body mass index and tumor location in the upper outer quadrant are other factors that have been reported to significantly increase the risk for breast lymphedema. Also, 1 study (Lymphat Res Biol. 2005;3:208-217) found that women older than 60 years had a higher likelihood of lymphedema (41.2%) than women younger than 60 years (30.6%). Approximately 15% of patients with a bra cup size of A or B developed breast edema, whereas approximately 48% of patients with a bra cup size of C, D, or DD presented with edema.

In general, patients tend to be at highest risk for cancer-treatment-related lymphedema when a large number of lymph nodes are removed, radiation and surgery are combined as treatment, or an infection in a limb that has been operated on develops, said Dr. Lawenda.