Continuing Education

HOURS 2
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Vol. 109, No. 7 ajnonline.com
By Mei R. Fu, PhD, RN, ACNS-BC,
Sheila H. Ridner, PhD, RN, ACNP,
and Jane Armer, PhD, RN, FAAN
The condition affects many and its
impact can be profound, yet diagnostic
criteria are still not standardized.
Part 1 of a two-part article.
OVERVIEW: Lymphedema, which can
be a debilitating sequela to breast
cancer treatment, is characterized by
an abnormal accumulation of lymph in the arm, shoulder,
breast, or thoracic area. It may appear gradually or
suddenly, and although it usually develops within three
years of a breast cancer diagnosis, it can arise much later;
survivors remain at lifetime risk. The condition can cause
physical discomfort and pain, impaired function, and
emotional distress. Its imperative that survivors risk of
lymphedema be reduced and that those who develop it
receive help to manage it. Part 1 of this two-part article
describes postbreast cancer lymphedema and discusses
its diagnosis and measurement. Part 2 (next month) will
discuss risk reduction, treatment, and implications for nurses.
L
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POST BREAST CANCER
I
ts been called one of the most dreaded
sequelae of breast cancer treatment.
1
Said
one breast cancer survivor: Lymphedema is a
constant reminder of my cancer. You cannot
really forget that you have had cancer because
you are reminded every day.
2
Another said:
Its something you have to deal with physically
and you have to deal with mentally. You know,
lymphedema will never go away.
3
Postbreast cancer lymphedema is characterized
by an abnormal accumulation of lymph in the inter-
stitial spaces, leading to persistent swelling in the
affected arm, shoulder, neck, breast, or thoracic
region, or any combination of these. It usually results
from axillary node dissection but sometimes from
Part 1
sentinel node biopsy, radiotherapy, lumpectomy, or
other trauma to the region. (Primary lymphedema is
a hereditary condition; secondary lymphedema can
result from trauma to the lymph system, as occurs
during breast cancer treatment.) Many of the 2.4 mil-
lion breast cancer survivors in the United States
4
are
living with lymphedema. One recent, large prospec-
tive study found that 42%of breast cancer survivors
developed lymphedema within five years of treat-
ment; the authors also noted that other recent
prospective studies have reported three-year incidence
rates of 15% to 54%.
5
(Estimates of its incidence
and prevalence vary widely according to the type of
treatment for breast cancer, the diagnostic definition
of lymphedema used, and the studys duration of
follow-up.
6
) For an overviewof the normal lymphatic
system and the pathophysiology of lymphedema, go
to http://links.lww.com/AJN/A1.
Lymphedema profoundly affects the quality of
survivors lives. Those who develop it have reported
physical discomfort and pain, functional impair-
ment at home and on the job, poor self-image,
reduced self-esteem, interrupted relationships, and
financial burden.
1, 7, 8
Advances in breast cancer treat-
ment have made survival more likely, making it
even more imperative that survivors risk be
reduced and that those who develop it be helped to
manage it. Although studies indicate that lymph-
edema usually develops within three years of
breast cancer diagnosis,
5
it can arise much later; all
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Lymphedema can impede ones ability to perform
chores, fulfill tasks at work, and enjoy hobbies.
One study found that survivors with lymphedema
in their arm had difficulty performing many house-
hold tasks such as vacuuming or grocery shopping,
both because of swelling and pain and because
care recommendations include reducing repetitive
motion and lifting with the affected arm.
10
Lymph-
edema can also interfere with jobs that involve
heavy lifting, gripping, holding, repetitive move-
ment, or fine motor dexterity.
2
Some find they must
give up certain leisure activities such as gardening,
sewing, and sports that involve strenuous upper
body effort (such as golf or tennis) because these
activities aggravate their symptoms.
3
And there can be serious emotional and psy-
chosocial effects. Studies have found that breast
cancer survivors with arm lymphedema tend to
suffer more psychological distress and have more
difficulty coping than do those without this compli-
cation.
8, 11
One study of survivors with lymphedema
found that worries about job performance and
security created daily emotional distress for many.
2
The disfigurement of the affected arm or hand,
as well as the need for compression garments,
can cause social anxiety and fear of stigmatiza-
tion.
2, 3
And there is evidence that lymphedema
imposes an economic burden. Shih and colleagues
found that breast cancer survivors with lymphedema
had significantly higher health care costs than
did those without it.
1
They also spent more days
annually either hospitalized or visiting physicians
offices, which could adversely affect employment.
Despite the substantial impact lymphedema has
on the lives of those who develop it, many providers
seemunaware of the condition. Recent studies indi-
cate that many breast cancer survivors dont receive
adequate education either on their risk of develop-
ing lymphedema or on ways to reduce that risk.
12, 13
This has undoubtedly impeded the development
of effective risk-reduction interventions and of
lymphedema management.
DIAGNOSIS AND MEASUREMENT
Several factors make diagnosing postbreast can-
cer lymphedema clinically challenging: the fact
that there are no universally recognized diagnostic
criteria, clinicians failure to properly evaluate its
symptoms, and the presence of coexisting conditions.
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survivors are at lifetime risk. There is no cure, but
management can often keep the condition from
worsening.
THE IMPACT OF LYMPHEDEMA
Often, the most visible manifestation of postbreast
cancer lymphedema is swelling in the affected areas
(usually the armand hand but occasionally the breast
or trunk) on the treated side. Lymphedema is accom-
panied by distressing symptoms such as pain; fatigue;
decreased range of motion; skin changes; and sensa-
tions of tightness, heaviness, burning, or numbness in
the affected areas. It has also been associated with
fibrosis, cellulitis, lymphangitis, and other compli-
cations.
1, 9
Indeed, Shih and colleagues found that
survivors with lymphedema were twice as likely to
develop cellulitis or lymphangitis as those with-
out it.
1
Figure 1. Lymphedema
Measurement: Water
Displacement
A patients arm being
assessed for edema
using the water dis-
placement method.
Photo Jane Armer.
All rights reserved.
There is no cure for lymphedema,
but management can often keep
it from worsening.
First, its important to rule out other conditions
that might cause similar symptoms; these include
cancer recurrence, deep-vein thrombosis, chronic
venous insufficiency, diabetes, hypertension, heart
disease, heart failure, kidney disease, and liver dis-
ease. Then diagnosis of lymphedema can be achieved
through objective measurement and subjective symp-
toms.
Quantification. Of the various approaches avail-
able, no single measurement has gained prominence;
this makes quantifying lymphedema difficult. The
most widely used methodswater displacement,
circumferential limb measurement, and infrared
perometryinvolve measuring the volume or cir-
cumference (or both) of the affected arm. Bioelectrical
impedance analysis is emerging as a possible alter-
native to these methods.
For diagnostic purposes measurements are
compared, either of the affected limb and the unaf-
fected limb or of the affected limb at baseline and
again at a later time. Lymphedema is often defined as
a 2-cm or greater difference in limb girth, a 200-mL
or greater difference in limb volume, or a 10% or
greater difference in limb volume.
14
There is currently
no method for quantifying lymphedema in the breast,
shoulder, and thoracic regions.
Water displacement, considered the gold stan-
dard for limb volume measurement, is known to be
a sensitive and accurate measure in the laboratory
setting, but it is seldom used in clinical settings
because its cumbersome and messy.
14
Patients
submerge the affected arm in a container filled with
water; the displaced water flows into another con-
tainer and is weighed (see Figure 1). This method
doesnt provide data about localization of the
edema or the shape of the extremity,
15
and its con-
traindicated in patients with open skin lesions.
14
Patients may find it difficult to hold the position
long enough for the displaced water to drain com-
pletely into the overflow container.
Circumferential limb measurement (also called
tape measurement) involves measuring the arm
at several pointsthe hand, proximal to the
metacarpals; the wrist; and then every 4 cm from
the wrist to the axilla (see Figure 2).
16
A flexible,
nonelastic, paper tape measure should be used to
ensure consistent tension over soft tissue and
bony prominences. Although this method is easy
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Figure 2. Lymphedema
Measurement:
Circumferential
Limb Measurement
A research nurse
measures the circum-
ference of a patients
arm at several points
from hand to axilla.
Photo Jane Armer.
All rights reserved.
to perform, it has limited inter- and intrarater
reliability.
14
Infrared perometry (also called optoelectronic vol-
umetry) works in much the same manner as
computed tomography but uses infrared light instead
of X-rays.
17
The volume and shape of the limb can
be measured and volume changes calculated in
seconds (see Figure 3). One study compared the
accuracy of sequential circumferential measurement
and infrared perometry in evaluating limb volume
in women being treated for breast cancer.
14
The
researchers determined that perometry was as reli-
able as or better than sequential circumferential
measurements for discerning limb volume changes
over time.
In bioelectrical impedance analysis, a small, low-
frequency electrical current is passed through the
body and resistance to that current is measured;
different bodily components offer different levels of
resistance, which allows for a calculation of fluid
volume within a structure. This technology was
first used by nutritionists for analyzing body com-
position. It has since been refined so that resistance
of just extracellular fluid can be detected and its
volume estimated.
18, 19
This method has been used
outside the United States for several years for the
early detection of lymphedema and the monitoring
of results of lymphatic massage in clinical set-
tings.
18
In this country it was used only in research
studies until 2007, when the Food and Drug
Administration approved one such device, the Imp
XCA, for use in the clinical assessment of unilat-
eral lymphedema of the arm.
19, 20
Measurement takes
less than five minutes and results are immediate.
The device should not be used in people with
pacemakers or implantable defibrillators. Further
research is needed to establish its reliability and
sensitivity.
Subjective symptoms can include feelings of
swelling, tightness, heaviness, pain, burning, or
numbness in the affected arm, shoulder girdle, or tho-
racic region and limited mobility in the affected
hand, wrist, elbow, and shoulder. Such symptoms
might indicate subclinical lymphedema, in which
no signs are evident.
9
Their presence warrants insti-
tuting early interventions to treat lymphedema; their
periodic reassessment can also serve to indicate
the effectiveness of such treatment.
21, 22
The diag-
nostic importance of such subjective symptoms
cannot be overstated, at least until standardized
Figure 3. Lymphedema Measurement:
Infrared Perometry
A research assistant (foreground) and a
research nurse (rear) demonstrate the
use of an infrared perometer. Photo
Jane Armer. All rights reserved.
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objective measures capable of early detection can
be established.
The Lymphedema and Breast Cancer Ques-
tionnaire (LBCQ), a 19-item self-administered or
structured-interview tool, can be used to assess
such symptoms.
23
The LBCQ has been shown to
have a high degree of testretest reliability and
validity.
2, 23
The tool was developed by one of us
(JA) and can be obtained by contacting the authors.
LYMPHEDEMA ONSET AND STAGING
Onset may be gradual or sudden, and may occur
early (within three years of breast-cancer diagnosis)
or late (more than three years after diagnosis)
24
;
initial onset has been known to occur as long as
30 years after diagnosis.
16
Its still not fully under-
stood why some patients develop lymphedema and
others dont, even when the type and extent of sur-
gery and the dosage and duration of radiotherapy
are similar.
With gradual onset, observable swelling is often
absent at first, although patients may report sensa-
tions of tightness and heaviness in affected areas.
With sudden onset, swelling develops rapidly, usually
within 24 hours of a triggering event. Common trig-
gers may include air travel, infection, or injuries such
as cuts, insect bites, pinpricks, or burns.
24-26
In cases
involving infection (especially cellulitis) or injury, the
patient usually experiences sudden swelling with red-
ness, an elevated white blood cell count, elevated
temperature, or a combination of these.
27, 28
Usually,
immediate administration of oral or IV antibiotics
clears the infection, and elevation of the limb helps
to reduce the swelling. People who experience such
infections are at higher risk for future infections.
A four-stage system is used to classify lymph-
edema in terms of skin condition and degree of
swelling.
9
Table 1 presents detailed criteria for each
of the four stages. Within each stage, it may be
possible to further assess severity based on the dif-
ference in limb volumeeither between affected
and unaffected limbs or the same limb over time
as follows: mild (less than 20% increase), moderate
(a 20% to 40% increase), or severe (greater than
40% increase).
9
M
Mei R. Fu is an assistant professor at the New York University
College of Nursing in New York City. Sheila H. Ridner is an
assistant professor at the Vanderbilt University School of
Nursing in Nashville, TN. Jane Armer is a professor at the
Sinclair School of Nursing, University of MissouriColumbia,
and director of nursing research at the Ellis Fischel Cancer
Center. Contact author: Mei R. Fu, mf67@nyu.edu. The
authors of this article have no significant ties, financial or
otherwise, to any company that might have an interest in the
publication of this educational activity.
REFERENCES
1. Shih YC, et al. Incidence, treatment costs, and complica-
tions of lymphedema after breast cancer among women of
working age: a 2-year follow-up study. J Clin Oncol 2009;
27(12):2007-14.
2. Fu MR. Women at work with breast cancer-related lymph-
oedema. Journal of Lymphoedema 2008;3(1):30-6.
3. Fu MR. Breast cancer survivors intentions of managing
lymphedema. Cancer Nurs 2005;28(6):446-57.
4. American Cancer Society. Breast cancer facts and figures
20072008. Atlanta; 2008.
5. Norman SA, et al. Lymphedema in breast cancer survivors:
incidence, degree, time course, treatment, and symptoms.
J Clin Oncol 2009;27(3):390-7.
6. National Cancer Institute. Lymphedema (PDQ): health
professional version. National Institutes of Health. 2008.
http://www.cancer.gov/cancertopics/pdq/supportivecare/
lymphedema/healthprofessional.
7. Fu MR, et al. Breast-cancer-related lymphedema: informa-
tion, symptoms, and risk-reduction behaviors. J Nurs
Scholarsh 2005;40(4):341-8.
8. Pyszel A, et al. Disability, psychological distress and quality
of life in breast cancer survivors with arm lymphedema.
Lymphology 2006;39(4):185-92.
9. International Society of Lymphology. The diagnosis and
treatment of peripheral lymphedema. Consensus document
of the International Society of Lymphology. Lymphology
2003;36(2):84-91.
For more than 52 additional continuing nursing
education articles related to the topic of cancer,
go to www.nursingcenter.com/ce.
Table 1. Stages of Lymphedema
International Society of Lymphology. Lymphology 2003;36(2):84-91.
Stage Signs and Symptoms
0: Latent (subclinical)
lymphedema
no visible edema
no pitting
sensations of local heaviness
or tightness may be present for
months or years before overt
swelling occurs
1: Early lymphedema visible edema, with or without
pitting
2: Moderate
lymphedema
visible edema, usually with
pitting
hardened, thickened skin and
tissue (as fibrosis worsens,
pitting may disappear)
3: Severe
lymphedema
(lymphostatic
elephantiasis)
visible edema
no pitting
enlargement of the affected
area
hardened, thickened skin and
tissue
lymph leaking through damaged
skin
54 AJN
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10. Radina ME, Armer JM. Post-breast cancer lymphedema
and the family: a qualitative investigation of families coping
with chronic illness. J Fam Nurs 2001;7(3):281-99.
11. Tobin MB, et al. The psychological morbidity of breast
cancer-related arm swelling. Psychological morbidity of
lymphedema. Cancer 1993;72(11):3248-52.
12. Fu MR, et al. Breast-cancer-related lymphedema: informa-
tion, symptoms, and risk-reduction behaviors. J Nurs
Scholarsh 2008;40(4):341-8.
13. Ridner SH. Pretreatment lymphedema education and identi-
fied educational resources in breast cancer patients. Patient
Educ Couns 2006;61(1):72-9.
14. Armer JM, Stewart BR. A comparison of four diagnostic
criteria for lymphedema in a post-breast cancer population.
Lymphat Res Biol 2005;3(4):208-17.
15. Tierney S, et al. Infrared optoelectronic volumetry, the ideal
way to measure limb volume. Eur J Vasc Endovasc Surg
1996;12(4):412-7.
16. Armer J, et al. Lymphedema following breast cancer treat-
ment, including sentinel lymph node biopsy. Lymphology
2004;37(2):73-91.
17. Petlund CF. Volumetry of limbs. In: Olszewski WI, editor.
Lymph stasis: pathophysiology, diagnosis and treatment.
Boston: CRC Press; 1991. p. 444-51.
18. Cornish BH, et al. Early diagnosis of lymphedema using
multiple frequency bioimpedance. Lymphology 2001;
34(1):2-11.
19. Ridner SH, et al. Comparison of upper limb volume mea-
surement techniques and arm symptoms between healthy
volunteers and individuals with known lymphedema.
Lymphology 2007;40(1):35-46.
20. Center for Devices and Radiological Health, U.S. Food
and Drug Administration. ImpediMed Imp XCA with
lymphoedema analysis PC software. U.S. Department of
Health and Human Services; Mar 29, 2007. http://www.
accessdata.fda.gov/cdrh_docs/pdf5/K050415.pdf.
21. Armer J, Fu MR. Age differences in post-breast cancer
lymphedema signs and symptoms. Cancer Nurs 2005;
28(3):200-7.
22. Voogd AC, et al. Lymphoedema and reduced shoulder func-
tion as indicators of quality of life after axillary lymph node
dissection for invasive breast cancer. Br J Surg 2003;90(1):
76-81.
23. Armer J, et al. Predicting breast cancer-related lymphedema
using self-reported symptoms. Nurs Res 2003;52(6):370-9.
24. Petrek JA, et al. Lymphedema in a cohort of breast carci-
noma survivors 20 years after diagnosis. Cancer 2001;
92(6):1368-77.
25. Johansson K, et al. Factors associated with the development
of arm lymphedema following breast cancer treatment: a
match pair casecontrol study. Lymphology 2002;35(2):
59-71.
26. Casley-Smith JR, Casley-Smith JR. Lymphedema initiated by
aircraft flights. Aviat Space Environ Med 1996;67(1):52-6.
27. American Cancer Society. What is lymphedema? In:
Lymphedema: understanding and managing lymphedema
after cancer treatment. Atlanta; 2006. p. 3-16.
28. Fldi M, et al. Complications of lymphedema. In: Fldi M,
et al., editors. Textbook of lymphology for physicians and
lymphedema therapists. Munich: Urban and Fischer Verlag;
2003. p. 267-75.
GENERAL PURPOSE: To present registered professional
nurses with information on postbreast cancer
lymphedema and its diagnosis and manifestations.
LEARNING OBJECTIVES: After reading this article and
taking the test on the next page, you will be able to
discuss its prevalence, etiology, staging, and effects.
summarize the measurement approaches used in
diagnosis and assessment.
outline the various manifestations of lymphedema.
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