What is Breast Cancer Related Lymphedema? 

Lymphedema after breast cancer is a chronic swelling that can occur from disruption of the lymphatic system. It can affect the arm, the axilla or armpit/underarm, the entire breast, the lateral portion of your torso, as well as your back on the affected side. Symptoms in addition to swelling are heaviness, achiness, nagging, and tightness. It generally is not considered to be a condition that causes severe pain unless the swelling is severe, or there is an infection present.

What makes lymphedema unique from other types of swelling is that it is a protein based swelling. Because of damage to the lymphatic vessels, the tissue in the body, or the space between your cells, is not able to remove protein and other cellular waste and return it to the circulator system.  Consider the lymphatic system your body's waste disposal system. When protein molecules and other cellular waste gets trapped in your arm or affected limb, the protein attracts bacteria to the area which increases the risk of developing a soft tissue infection.

What Causes Breast Cancer Related Lymphedema? 

Lymphedema after breast cancer can be triggered by axillary node dissection in combination with lumpectomy, mastectomy, and radiation therapy or as a consequence of complications like infection or fluid overload from chemotherapy treatments. It can also be triggered by everyday events such as small cuts, bug bites, hang nails, sun burn, or other events. There is no cure for lymphedema but it is a treatable condition. If left untreated, lymphedema can worsen and become more difficult to achieve relief and manage effectively. It is important to seek treatment and manage lymphedema correctly to avoid these risks.

Who Can Get Lymphedema After Breast Cancer? 

The incidence of developing lymphedema after breast varies significantly depending on multiple factors:

The extent of breast cancer surgery influences who will develop lymphedema. The greater the number of axillary lymph nodes removed and the amount of soft tissue removed from around the lymph nodes, the greater the risk for developing lymphedema. The soft tissue sample taken from around the lymph nodes are additional trauma to the lymphatic system since numerous lymphatic vessels feed into each of the lymph nodes. The area in the underarm that is removed or dissected is sent to the pathology lab to determine the exact extent and staging of the cancer if it is present. The staging will help in the planning of the cancer treatment.

The duration and dosage of radiation therapy play a role in the risk for developing lymphedema after breast cancer. When a patient undergoes radiation for breast cancer, the goal is to achieve local eradication of the cancer effectively and quickly. The duration of radiation will vary significantly depending on the stage and type of cancer. Generally, courses of radiation can range from 3 weeks to 6 weeks or more on a Monday through Friday schedule. The specific course of radiation is generally determined by the radiation oncologist, with the calibration of the actual radiation being calculated by a specialist called a medical dosimetrist. The greater the length and doses of radiation, the greater the potential damage to your lymphatic system. Even though each radiation session is only 10-15 minutes of actual treatment delivery, radiation can cause skin redness, burns, peeling, dryness, and tightness, all of which impair the lymphatic system's ability to function.

How smooth your healing journey went after surgery, radiation, and other procedures influences your risk for lymphedema after breast cancer. Many patients have incisions that heal readily within 3-4 weeks after their lumpectomy and axillary node dissection. Mastectomy involves a larger incision, may involve 1 or 2 plastic bulb containers sutured into the breast area to capture excess drainage. If breast reconstruction is planned in the future, a "spacer" implant may be inserted so that your surgeon can help expand your tissue. All of these are factors that challenge the lymphatic system. If healing is delayed, or if a soft tissue infection develops, the possibility of developing the chronic swelling condition increases.

The cumulative procedures performed for your breast cancer treatment additionally will impact your risk for developing lymphedema. According to recent research on incidence, 5-17% of patients who undergo sentinel lymph node biopsy go on to develop lymphedema. If axillary lymph node dissection is performed, the incidence increases to 15-53% that go on to develop lymphedema. When axillary lymph node dissection and radiation therapy are both involved, incidence of breast cancer related lymphedema can be more than 50% of patients.

Obesity has been shown to play a role as well in the likelihood of developing lymphedema after breast cancer. In one study, 17% of patients with a Body Mass Index of greater than 35 developed lymphedema at five years. Alternatively, only 8% patients with a Body Mass Index of less than 25 developed lymphedema at five years.

How to Reduce Your Risk of Lymphedema

There are many ways to minimize the risk of developing breast cancer related lymphedema, or at least catch it early on so that it can be treated effectively. While there is no cure, with proper management, lymphedema can be controlled and the potential complications associated with it minimized.

To reduce your risk, be aware of the following precautions soon after as well as long after you finish you breast cancer treatment:

• Engage in 150 minutes of moderate aerobic activity per week (ie. 20-30 minutes 5-6 x/week) and strength training 2-3x/week
• Keep a healthy body weight, or Body Mass Index between 25.0 and 29.9. You can check your BMI here.
• Drink plenty of water. Water helps your lymphatic system flush the cellular waste from your body so you can function efficiently.
• Wear sunscreen and bug spray if you are outdoors with the skin of your affected arm exposed.
• If you develop a small cut, bug bite, paper cut, or abrasion, keep the area clean, apply antibacterial ointment and keep the area covered to ensure that the area heals as quickly as possible.
• Keep your skin moisturized daily. Depending on the extent of your breast cancer surgery and radiation, and treatment, your skin may be prone to dryness. Dry skin can lead to small skin cracks, which serve as entry points for bacteria.
• If you develop a new onset of skin redness or pink coloration, increasing pain or itching, increased localized or diffuse swelling in your arm, warmth or hotness to the touch of the area, a soft tissue infection called cellulitis may be developing. This is a situation where urgent care is critical to prevent the infection from spreading up the arm, acute worsening of any existing swelling, and having the infection develop into a systemic total body infection called sepsis.

Be sure to discuss your lymphedema risk with your oncologist, radiation oncologist, and breast surgeon, and ask them what your risks of lymphedema are with the given cancer treatment. It is possible that your medical team may not be familiar the condition. It is also possible that your lymphedema could develop many years after all of your cancer therapies are completed. Fortunately, if you are diagnosed with lymphedema, there are treatments available that can help minimize the symptoms and improve your quality of life such as complete decongestive therapy and ongoing manual lymphatic drainage or lymphedema massage.

If you have any concerns about lymphedema after breast cancer, please reach out. If you are in the process of trying to stay mobile and regain your mobility after breast cancer, be sure to check our the free download 7 Simple Tips to Regain Use of Your Arm, Feel Better, and Move Better After Breast Cancer.

The moral of the story is: lymphedema is a risk with breast cancer, but if you develop it, you can seek out proper treatment and management, and you can live a full and active life despite the condition. Don't be afraid to ask for help - we are here for you! Diagnosis is typically made by your breast surgeon, primary care physician, your radiation oncologist or oncologist, or a provider specializing in lymphedema. In the Baltimore area, we are very fortunate to have the lymphedema specialists at the Greater Baltimore Lymphedema Center at Greater Baltimore Medical Center in Towson, MD. The most important part is prevention and awareness of the lymphedema precautions.

If you have questions about your specific condition and would like to speak to a certified lymphedema physical therapist and oncology specialist, contact deBorja Physical Therapy at 410-835-4498 or email info@deborjapt.com.

Dr. Angie deBorja is a Doctor of Physical Therapy and founder of deBorja Physical Therapy in Baltimore. She has been helping patients since 2001. Her clinic specializes in helping adults 40+ in Baltimore, MD after cancer treatment, surgery, and injury, with a gentle approach to overcome pain and stiffness, move better, and get back to the active life they once enjoyed.