Lymphedema Therapy During Adjuvant Therapy for Cancer

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Lymphedema Therapy During Adjuvant Therapy for Cancer

Postby patoco » Wed Aug 23, 2006 8:06 am

Lymphedema Therapy During Adjuvant Therapy for Cancer

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 crymal@earthlink.net.

------- Thanks Silkie :mrgreen: --------

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