Melanie Taylor, APRN, and Mark Lin, APRN, share how they optimize strategies in caring for patients with lymphedema.
Lymphedema treatment is still an undeveloped aspect of cancer care, according to Melanie Taylor, APRN, who added that the mechanisms of the lymphatic system are not often taught very well to nurses who aren’t directly working in lymphedema.1
Taylor, who helps patients manage lymphedema in the outpatient setting, recently gave a presentation on this adverse event alongside Mark Lin, APRN, as part of the University of Miami Sylvester Comprehensive Cancer Center’s 2023 Survivorship Symposium.
In an interview with Oncology Nursing News after their presentation, they talked about which patients are at risk for lymphedema, as well as how new treatment strategies aim to improve the quality of care that nurses can provide for these individuals.
Lymphedema affects a lot of patients with cancer, said Taylor and Lin, and not just patients with breast cancer. For oncology nurses, it is important to be cognizant of this risk and help connect patients to resources early on to help them take hold of their health.
Most people working in oncology recognize that there is a risk of lymphedema associated with breast cancer, they said, adding that breast surgeons have even adopted certain measures to help reduce a patient’s risk, such as revascularizing the lymph node to the vein.
However, any patient who has had lymphatic “trauma” is at risk of lymphedema. Patients with head and neck cancer, for example, are at a high risk of developing lymphedema because of soft tissue complications, and approximately 40% of patients with gynecologic cancer develop lymphedema.
“The most studied cancer population for lymphedema has been breast cancer,” Taylor said. “But any individual that has surgery that affects the lymphatic system or radiation to their lymphatic system are at a high risk of developing lymphedema.”
“Breast cancer is the most studied cause of lymphedema, [perhaps because] when it is in the arms, it is easier to notice,” Lin noted. “There are only so many things that can occur on the arms, whereas for swelling in the legs, it could be a plethora of things. It could be a vascular disease; it could be related to their cardiovascular system.”
“Diet and exercise is so important,” Taylor remarked, noting that one of the largest lymphatic vessels in the body is the thoracic duct, which drains about 75% of the lymph nodes in the entire body. As she explained, the fluid movement is largely tied to breathing; diaphragmatic breathing is the easiest way to help lymphatic fluid moves throughout the lymphatic system, because it changes the intra-abdominal pressures, creating a squeezing effect and stimulating lymphatic flow.
For that reason, exercises like yoga have been shown to be highly effective in improving the quality of life and decreasing discomfort for these patients because it allows them to focus on their breathing.
“I will often refer patients to our yoga specialist within the University of Miami,” Taylor said. “Also, physical therapists can help our patients with manual lymphatic drainage and teach our patients how to breathe properly and promote limb movement.”
Taylor also encourages patients to prioritize a diet that is fibrous fruits and vegetables and filled with anti-inflammatory foods, such as raspberries, cherries, pomegranate, red cabbage, beet root, omega 3, turmeric, garlic, or curry leaves. She also encourages foods with lots of antioxidants, including red and purple vegetables and fruits.
“We tell our patients to make sure their limbs are moisturized as well,” Lin added. “You don’t want the skin to get too dry or cracked, because any opening can increase your risk of developing cellulitis.”
Beyond that, the team works together to regularly monitor how the patient is doing and the severity of their symptoms. One way they do this is through the Lymphedema Life Impact Scale, which asks patients to assess how much their lymphedema is hindering their life, and through the bioimpedance spectrometer, which is a machine that allows the care team to quickly measure the fluid in the patient’s limbs.
“It measures the amount of measurable fluid in that limb compared to their other limbs and keeps track of that number every 3 months to see whether they're progressing,” he said.
There are currently 3 surgical approaches to treat lymphedema: debulking, lymphovenous bypass, and a vascularized lymph node transfer.2
Debulking involves using liposuction to remove lymphatic solids and fatty deposits and is usually only used in patients who are not good candidates for the other surgical approaches. Of note, this is an effective strategy in later stages of treatment.
“Lymphedema is initially an issue with fluid, and then over time, it turns into fat,” Lin explained. “There are 2 procedures that can address the fluid and flow of the fluid, whereas debulking address the fatty deposits.”
“If you think of the lymphatic system almost like a highway, you can think of lymphedema as a bad accident,” he continued. “All the cars are blocking the lanes; you can't get by, and so the fluid can’t go anywhere.”
A lymphovenous bypass, therefore, is akin to creating an exit to divert the cars and help the flow of traffic. In this procedure, local lymphatic channels are connected to nearby veins, redirecting the flow of fluid.
“With the lymphovenous bypass, surgeons connect the lymphatic vessel to the vein, which basically makes a diversion where the lymphatic fluid can drain,” Lin said.
The other major strategy is a vascularized lymph node transfer, where surgeons take an undamaged lymph node and transfer it to the limb that is affected.
“Over time, usually about a year or 2, this causes lymphomagenesis,” Lin said. “At that point, it can form new lymphatic channels and new lymph nodes in the area.”
Taylor shared that in the maintenance setting, the lymphatic or pneumatic pump has been advantageous because it allows patients to manage their symptoms at home. This device is covered by some insurances as a proven, valuable tool for treatment.3
“They place a garment on their limb, and the machine offers some graduated compression or pressure in a sequential matter to drain the lymph fluid,” she explained. “They can do that at home for an hour a day, and it really helps improve their symptoms, and helps improve drainage.”
She shared that for patients with advanced lymphedema, more aggressive interventions are required, but for those in the acute phase, this has been a useful strategy.
“Patients find it nice because they do not have to go to a physical building or to a physical appointment,” she said. “They can manage their symptoms at home.”
“They have gone through so many doctors’ appointment and so many surgeries, that they are exhausted; they want to be home, and they want to be comfortable,” she added. “Anything we can offer them in the comfort of their own home is going to help them not only just comply better, but just heal better.”
Swelling is not always synonymous with lymphedema, Taylor said. Sometimes patients experience swelling, and their lymphatic system hasn’t been injured at all, so it is important to know a patient’s history, and to know if they have a history of cardiovascular, kidney, or liver dysfunction, so that other causes can be ruled out. However, if it does seem like a case of lymphedema, it is important that patients receive treatment right away.
“One thing we tell our patients to look out for is if their wedding rings are not fitting the same, or their watches aren't fitting the same,” Lin said.
“If, after taking off their bracelet, they see an indentation, if their shoes or clothes, feels tighter, or feels tighter on one side, those are some things to pay attention to.”
“Another sign is when patients that develop cellulitis” Taylor added, “Recurrent cellulitis in the same limb is a telltale sign that something is wrong.”
If you have a patient receiving antibiotics, but they keep coming back with cellulitis, that should be a sign to look further and investigator whether there is some lymphatic disruption in that areas, she said.
Nurses can also make an impact by helping promote risk reduction strategies among patients who are at risk. This includes avoiding wearing tight clothing and jewelry, staying vigilant with insect repellant to avoid bites, keep skin hydrated and protected from the sun, and avoiding blood pressure cuffs or unnecessary blood draws on their affected limbs.