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Breast Cancer-related Lymphedema

 

By

Breast Cancer-Related Lymphedema 

Erin Toomey, SPT

Introduction:

The National Cancer Institute, a component of the National Institutes of Health, estimates that one in eight women will develop breast cancer at some time during her life (Altekruse 2010). Those who elect to undergo surgical treatment of breast cancer often require postoperative physical therapy to increase function, mobility, and manage lymphedema. Lymphedema management is of particular importance for clinicians secondary to its relatively high frequency, which is estimated to occur in 8% to 56% of patients at 2 years post surgery (Paskett 2007). Because it commonly appears late in recovery, cancer related lymphedema is becoming more relevant in the outpatient setting and more people are seeking treatment options for this chronic, debilitating side effect. It has been found that 80% of patients experience onset within 3 years of surgery (Petrek 2001). As physical therapists, we play an integral part in early detection of post-operative lymphedema and in reducing the risk of its occurrence. As we continue to learn more about post mastectomy lymphedema dysfunction, there is an increased need to develop best practice strategies and implement effective interventions for its treatments. I believe by providing additional opportunities to explore lymphedema management in our curriculum it will serve to better prepare future clinicians in the management of this condition.

 

Capstone Nuts and Bolts:

VoiceThread

For my Capstone project, I developed an online [VoiceThread]  and  [PowerPoint] exploring the clinical management of post mastectomy lymphedema. It is my intention that this module will be made available to PHYT 710 (Cardiopulm for those of us who don’t do numbers) students and will serve as an adjunct to the breast cancer lecture already offered in the course.

Educational Videos

I promise you, both of these videos are worth a look!! 

This first video demonstrates a typical manual lymphatic drainage (MLD) treatment sequence applied to a patient with breast cancer-related lymphedmea.

[youtube]http://youtu.be/5rR4IHYEdOw[/youtube]

 

The next video is a demonstration of how to apply compression bandages to the upper extremity. Compression bandages are an integral part of lymphedema treatment! This video provides an excellent tutorial highlighting important compression bandaging considerations for patients with lymphedema.

[youtube]http://youtu.be/HdYfiixS0Jg[/youtube]

[*Please do not use these videos for any reason other than the educational purposes of my Capstone. If you wish to use them for any reason outside this module please consult with me first.]

 

Literature Review

Historically, evidence has been divided as to the efficacy of MLD in lymphedema management. Most studies of lymphedema management have focused on the combined effects of Complete Decongestive Therapy (CDT) and have failed to evaluate each component individually. However, rising health care costs and fiscal restraints have fortified a need for cost-effective intervention programs. The relatively high cost of MLD warrants evaluation concerning the potential benefit of this component in treatment of breast cancer-related lymphedema.

According to my review of the evidence, the role of MLD in lymphedema management remains divided, with some studies concluding that MLD is an unnecessary component of breast cancer-related lymphedema treatment in the short-term. As a general conclusion found in many studies reviewed, continued use of compression is usually required to maintain treatment results.

The links below will direct you to my final products.

Any and all references pertaining to my Capstone can be found [here].

 

Oh yea, I want to hear from you too! Fill out my [VoiceThread Evaluation Form]. And please feel free to contact me with any questions: etoomey@med.unc.edu

 

Acknowledgements

I would like to say a special thank you to my committee members, Lisa Massa and Rebecca Crouch, and my project advisor Karen McCulloch for offering their time and guidance throughout the development of this project. Also a much deserved thank you goes to Delane Clark and Beth Koenig, this project would have not been possible without you.

 

Thank you for visiting my Capstone page! 

5 Responses to “Breast Cancer-related Lymphedema”

  1. Erin

    Hi Kendall!

    What an amazing clinical opportunity you have before you. I know the experience that you will gain in working with cancer survivors will be invaluable and undoubtedly rewarding as all get out! Two take home messages from my research that have stuck with me the most are:

    (1) The risk of developing lymphedema does not diminish over time but is a lifelong risk.
    and
    (2) Manual lymphatic drainage alone will not successfully alleviate symptoms of lymphedema long term, compression therapy is generally required to effectively manage edema buildup. (see evidence table I)

    Based on my personal observations, patient education is a MAJOR component and available resources (i.e. financial, social) can significantly affect treatment outcomes. It is always nice to be aware of community resources available that may be of use to this patient population. I know that CMC in Charlotte has an EXCELLENT grant program that assists lymphedema patients with costs and supplies, I would recommend that you also explore the Raleigh area for similar services.

    Finally, since you will likely be working with this population I am going to email you some patient education materials I developed during our first clinical seminar last winter. The handouts guide post surgical patients though self-MLD techniques and highlight important precautions. Feel free to use them to supplement your clinical. They may need a little “doctoring” depending on your patient population/might need a little consideration in regards to health literacy but handouts are always nice to have in your toolbox.

    Best of luck!! I can’t wait to hear all about your clinical!

    Erin

    Reply

  2. Sarah Yancey

    Hi Erin!

    Since you were so awesome in with helping me with my Capstone, I really wanted to look more into your project. Wow I am definitely impressed! You tackled a difficult subject, one that we have not had much instruction on during our entry-level program. My only experience working with breast cancer patients came from my first rotation at an outpatient orthopedic clinic that was part of a large hospital system. During this rotation, I spent one morning at another outpatient clinic in the system shadowing a PT conducting an After Breast Cancer Class. This was a great opportunity and gave me some valuable insight on how important exercise is after breast cancer treatment. I was glad to see that the Lane et al study, referenced in your second evidence table, found that breast cancer survivors post-treatment could participate in upper extremity resistance training without causing lymphedema. I believe range of motion exercises and strengthening is essential for these women post-treatment to decrease fatigue, improve quality of life, and decrease the risk of developing lymphedema.

    While my only experience working with breast cancer patients came from the brief shadowing opportunity, I have not had any exposure to working directly with women who developed lymphedema post-treatment. However, your PowerPoint and evidence table gave me some great information to help me get to know this population better. I especially appreciated the signs and symptoms section of the PowerPoint. Previously, I always thought swelling was the main symptom of lymphedema, but I am happy to now know other signs and symptoms to watch for if I ever end up treating women post breast cancer treatment. In your experience, will most therapists treating breast cancer survivors typically discover lymphedema based on observations, such as swelling or skin changes, or will patients report subjective feelings of heaviness or tightness first? Just curious about the typical presentation for the onset of lymphedema since like you mentioned, it is so important to diagnose and begin treatment early.

    Erin, you did an excellent job on your project! Thank you so much for educating me on a topic I had minimal knowledge on and experience with. You Rock!

    Sarah

    Reply

  3. kendalls

    Hey Erin!

    I wanted to comment on your Capstone project because I was so, very impressed by how much work you put into this research! You’ve produced some incredibly thorough products, and personally, I am very thankful for that! I am going on my last rotation, and turns out, my clinical instructor is a CLT!! Looks like I am going to be encountering this patient population quite a bit, so I will certainly be referencing all your materials!

    I was wondering, if you could provide me with 2-3 clinical pearls to take with me on my clinical in May, based on this Capstone research you’ve worked so hard on, what would they be?

    Again, thank you for all your excellent information! Can’t wait to use this in practice!

    Kendall

    Reply

  4. etoomey

    Hi Paige!

    Thank you for your comments and your interest in my Capstone project. To answer your question simply, because lymphedema evaluation and treatment is within our scope of practice, yes any therapist can bill for components of lymphedema management. HOWEVER, good clinical judgement should be applied in any situation that may require referral to a skilled provider, which in this case might be a CLT. I personally believe (and I know many clinicians that agree) that lymphedema should be managed by a certified therapist.

    To address your second question, there is a website that lists a number of lymphedema therapists in North Carolina. I found it especially helpful that they group the practitioners by county and practice. I will caution you to check with the practice before referring a patient to confirm that the list provided is up to date. The site can be accessed here: http://bcresourcedirectory.org/book/export/html/700

    Hope this helps!

    Reply

  5. ekensrue

    Hi Erin!

    This is all so helpful in learning more about lymphedema management. I thought you provided great learning materials through the powerpoint/voicethread and the evidence tables. It will be a great addition to the content that we get in our cardiopulmonary class! Although I am not personally interested in becoming certified, I think it is always good to be aware of what is out there and the treatments that can help these patients. I actually had a patient in the clinic the other week who had shoulder pain, but also had a previous history of breast cancer and a double mastectomy. Thankfully, she did not have any current complications with lymphedema, but it just goes to show that although you may be in one “specialty” area of physical therapy, you might have a patient come in with multiple issues to address.

    I was astonished to see that the CLT certification process is so expensive! I was also sad to see that there is very little reimbursement for compression stockings for these patients. This seems to be a great treatment option for this condition. I am sure that these patients have already spent a lot on their healthcare management, and this is just one more thing to add to the list. I did have one question regarding reimbursement: Can any therapist bill for lymphedema management, or does the therapist have to be a CLT? Also, have you found any good ways to look up contact information for a therapist with CLT credentials in your area for referral purposes?

    Thanks again for the amazing content! I will certainly keep this for future reference!

    Reply

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