Lymphedema and Breast Cancer

Help yourself by learning more about it.

Breast cancer related lymphedema affects approximately 1 in 5 patients treated for breast cancer, and it has a significant negative impact on patients’ quality of life after breast cancer treatment. Gland Surg. 2018 Aug; 7(4): 379–403. doi: 10.21037/gs.2017.11.04

Breast cancer is the most frequent type of cancer affecting women all over the world with 1 in 8 women developing breast cancer during her lifetime. However, due to early detection and improved treatment, the number of long-term breast cancer survivors is increasing. Having said that, the challenge to effectively treat lymphedema of the arm - one of the most common and underestimated side effects of breast cancer treatment, has been an uphill battle.

Breast cancer related lymphedema risk associated with axillary surgery largely depends on the number of nodes removed. Radiation to the affected nodes adds additional risk for the development of lymphedema. Breast Cancer Res Treat 2017;162:201-15. 10.1007/s10549-016-4089-0

Lymphedema negatively affects the quality of life in breast cancer survivors and it is not limited to only breast cancer patients. Lymphedema can also occur in the legs after surgery for uterine cancer, vulvar cancer, ovarian cancer, prostate cancer or melanoma. Lymphedema occurs frequently in patients with head and neck cancers due to treatment that commonly includes surgery and radiation.

The lymphatic system is a part of your immune system consisting of a network of tiny vessels and small, bean-shaped organs called lymph nodes that carry a clear, colorless fluid called lymph throughout the body. It helps protect and maintain the fluid balance of your body by filtering and draining lymph and waste products away from each body part. The lymphatic system also helps the body fight infection. When the lymph system is correctly functional, lymph flows through the body and is returned to the bloodstream.

Lymphedema can occur as a result of damage, such as trauma, surgery or radiation for cancer treatment, to the lymph nodes or lymph vessels.

In many cases during breast cancer treatment, some or all of the lymph nodes under the arm are treated with radiation. The lymph nodes under the arm are called the axillary lymph nodes. They drain the lymphatic vessels from the upper arms, from most of the breast, and from the chest, neck, and underarm area. Lymphedema occurs when protein-rich lymphatic fluid accumulates in the interstitial tissue, causing swelling. The extent of nodes removed during surgery and the combined effect of surgery and radiation on the affected regional lymph nodes remain the primary causes of lymphedema development. Recent research has indicated lymphedema development as multifactorial, influenced by local and systemic treatment and likely by the patient’s ability to form collateral lymphatic pathways after injury, as well as certain other risk factors such as body mass index (BMI), advanced age and prior history of arthritis.

Lymphedema may occur right after surgery or radiation, or months or even years later. Breast cancer related lymphedema onset peaks between 12 and 30 months postoperatively.

There are 3 types of lymphedema:

  • A mild type of lymphedema can occur within a few days after surgery and usually lasts a short time.

  • Lymphedema can also occur about 4 to 6 weeks after surgery or radiation and then go away over time.

  • The most common type of lymphedema is painless and may slowly develop 18 to 24 months or more after surgery. It does not get better without treatment.

Depending on the extent of edema, symptoms can include arm tightness, heaviness/fullness, pain, and impaired limb function. Signs of lymphedema development include slow progression of swelling, which typically begins at the far end of your limb (hands) and then moves up the arm. There can be skin pitting (when a finger is pressed into the area the indentation remains).

The stages of lymphedema include:

  • In stage I, the swelling may reduce with elevation. There is pitting in this stage.

  • In stage II, there is progressive hardening of the tissues in the affected area called fibrosis. There is no pitting in this stage.

  • In stage III lymphedema, with increased protein-rich fluid swelling, there is a risk for bacterial growth and infection.

Skin changes may occur with the development of lymphedema.

Local infections, often called "cellulitis," may cause the limb to become red, hot, painful and swollen. This infection can spread quickly, so early diagnosis and treatment is the key to keeping the infection and swelling under control. Hyperkeratosis and papillomas may also be seen in someone with lymphedema.

Hyperkeratosis is an overgrowth of the skin like a very thick callus. Papillomas are raised wart-like growths that can appear on the skin of people with longstanding lymphedema. Apart from increased risk of cellulitis, wounds may heal more slowly on the part of your body that has lymphedema. The joints in the part of the body with lymphedema may feel chronically stiff or sore. The skin overlying the swollen area can feel tingly and sensitive.

Management of lymphedema remains a major challenge for patients and health care professionals.

Talking to your cancer care team about this common side effect prior to starting treatment can help you prepare, lower the chances of getting lymphedema and take steps to reduce its burden. Here’s a list of the earliest signs of lymphedema that you should look out for. It is also available as a handy checklist to help you note any changes on your skin and then address it with your oncologist if required.

  • Swelling of an arm or leg, which may include fingers and toes.

  • A full or heavy feeling in an arm or leg.

  • A tight feeling in the skin.

  • Trouble moving a joint in the arm or leg.

  • Thickening of the skin, with or without skin changes such as blisters or warts.

  • A feeling of tightness when wearing clothing, shoes, bracelets, watches, or rings.

  • Itching of the legs or toes.

  • A burning feeling in the legs.

  • Trouble sleeping.

  • Loss of hair.

There’s no way to know for sure whether you’ll develop lymphedema after breast cancer, but you can help yourself by learning more about it. Know your risk factors, take steps to reduce your risk, and be aware of early symptoms. The next blog will address strategies to help prevent and manage lymphedema.

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Reason to Hope

There is new research from Brigham and Women’s Hospital that indicates a Western-style diet that is rich in red and processed meat, sugar and refined grains/carbohydrates is tied to higher risk of colorectal cancer through the intestinal microbiota.  Gastroenterology, 2022;DOI:10.1053/j.gastro.2022.06.054