Surgical treatment for breast, gynecologic, prostate, lymphoma, melanoma, or head and neck cancers puts patients at risk for developing secondary lymphedema at any point in the remainder of their life. Studies show that as many as 10%–40% of patients with breast cancer may experience breast cancer–related lymphedema.
Cancer treatment-related lymphedema is a chronic, long-term adverse effect that may diminish patients’ quality of life and functional capacity. The ONS GuidelinesTM for Cancer Treatment-Related Lymphedema provide evidence-based recommendations for practitioners to manage the side effect and improve outcomes for their patients. The full guideline by Armer et al. was published in the September 2020 issue of the Oncology Nursing Forum.
Lymphedema in Patients With Cancer
To address a patient’s lifetime risk for lymphedema, practitioners use surveillance and management approaches, Armer et al. explained. About 75% of lymphedema cases occur in the first year after breast cancer surgery. Surveillance is multicomponent and includes measurement, education, exercise, and symptom assessments.
Lymphedema treatments are intense and lifelong. “Current standard of care for lymphedema treatment is complete decongestive therapy (CDT), including intensive lymphedema therapy (phase 1) with a certified lymphedema therapist, followed by lifelong self-management (phase 2) administered by the patient and/or a caregiver,” Armer et al. wrote. “The self-management of CDT phase 2 includes continued meticulous skin and nail care, range of motion exercises, manual lymphatic drainage, and application of compression garments and/or bandages. Follow-up includes periodic monitoring of self-care practices. Findings of soft tissue changes requires alterations in the self-care plan.”
The ONS GuidelineTM contains evidence-based lymphedema risk-reduction and symptom management recommendations for clinicians to use in patients with cancer-related lymphedema.
Prospective Surveillance Interventions
Adults who have had cancer-related surgery and are at risk for developing lymphedema should be followed with active surveillance with an educational component, which the ONS Guidelines classified as a conditional recommendation with a very low level of evidence. It noted that patients may be more willing to accept the intervention if it is integrated throughout treatment during pre- and postsurgical visits and wellness visits during survivorship.
Risk Reduction Interventions
Exercise: Patients who are at risk for extremity or truncal lymphedema should delay exercise for at least seven days following surgery, which the ONS Guidelines panel classified as a conditional recommendation with a very low level of evidence. After seven days, patients may begin programmed or structured exercise interventions that include resistance or strengthening exercises, which is classified as a conditional recommendation with a low level of evidence.
Compression: Patients who are at risk for lower-extremity lymphedema may use compression garments to minimize or delay its development, which the ONS Guidelines classified as a conditional recommendation with a very low level of evidence. Patients at risk for truncal, upper-extremity, or head and neck lymphedema should only use compression in the context of a clinical trial to increase the evidence base, which the panel identified as a knowledge gap.
Massage: Patients at risk for extremity, truncal, or head and neck lymphedema may use massage for postsurgical scar tissue, which the panel classified as a conditional recommendation with a very low level of evidence. It noted that massage may be uncomfortable or painful for patients and should begin after the surgery site has healed, and a trained lymphedema therapist should perform it to teach patients proper technique.
Active interventions plus self-management: Patients with cancer treatment-related secondary lymphedema may be managed with an active treatment intervention (e.g., manual lymph drainage, compression pumps, resistance exercise, aerobic plus resistance exercise, water-based or yoga exercise, CDT plus resistance exercise, CDT plus compression pumps, CDT plus compression pumps plus aerobic and resistance exercise) in addition to self-management (phase 2 CDT). The ONS Guidelines panel classified the recommendation as conditional with a very low certainty of evidence. It noted that because of the patient-associated costs for compression pumps, they may wish to try the other active interventions first.
Resistance exercise, water activities, or yoga, plus self-management: Patients with cancer treatment-related secondary lymphedema may respond to resistance exercises, water-based activities, or yoga in addition to self-management, all of which the guidelines panel classified as conditional recommendations with a very low certainty of evidence.
Oncology nurses have an important role in implementing evidence-based interventions to minimize the development of cancer treatment-related lymphedema, educate patients and caregivers about signs of lymphedema to aid in early detection, and manage it once diagnosed.
For more information about the ONS Guidelines for Cancer Treatment-Related Lymphedema, including an overview of the methods used to develop the guidelines, refer to the full article by Armer et al. or listen to an interview with Marcia Beck, ACNS-BC, CLT-LANA, on the Oncology Nursing Podcast, then subscribe to the podcast on your favorite listening platform to get other episodes about the ONS Guidelines and more—all with free NCPD—delivered directly to your phone.