1. Maintaining Quality of Life for Individuals Diagnosed with Cancer Preventing Lymphedema : Maintaining Quality of Life for Individuals Diagnosed with Cancer Presented by Christine Flaherty

2. The Lymphatic System and Lymphedema   The lymphatic system includes: lymph fluid, lymphatic vessels and lymph nodes.   Two primary functions of the lymphatic system: protect the body from infection (immune response) and facilitate fluid movement from tissues to bloodstream   Lymphedema may occur when an individual’s lymphatic system is impaired.   When impairment occurs fluid may back up in an area, often in the arms and legs, and cause swelling.

3. The Lymphatic System and Lymphedema   The lymphatic system includes: lymph fluid, lymphatic vessels and lymph nodes.   Two primary functions of the lymphatic system: protect the body from infection (immune response) and facilitate fluid movement from tissues to bloodstream   Lymphedema may occur when an individual’s lymphatic system is impaired.   When impairment occurs fluid may back up in an area, often in the arms and legs, and cause swelling.

4.   Lymphedema is currently classified into two categories; primary and secondary   Primary lymphedema: lymph vessel or lymph node development has been impaired   Secondary lymphedema: the lymphatic system is damaged   Once the integrity of an individuals lymphatic system is compromised, he/she is always vulnerable to developing lymphedema   There is no cure for lymphedema, but treatment and therapy do exist. The Lymphatic System and Lymphedema

5. Possible Symptoms:

6.  Swelling  Pain/discomfort  Numbness, tingling, sensation of pressure or tightness  Heaviness of limb  Increased susceptibility to infection  Skin breakdown  Loss of mobility  Inhibited Range of Motion  Impaired wound healing

7. Why some cancer patients are vulnerable: Surgery Lymph nodes and vessels can be dissected or disrupted. Radiation Therapy Can result in fibrosis of involved tissue which can decrease circulation of lymph fluid. Radiation can also shrink lymph nodes. Secondary lymphedema can develop as a result of surgery or radiation because these procedures damage the lymphatic system. “Lymphedema should not be considered an inevitable side effect of cancer treatment.” - Some individuals’ bodies are able to compensate, for instance; some individuals have adequate, existing collateral circulation to manage the extra lymph load - Education regarding risk factors

8. Evidence

9. QOL following cancer treatment is greater among individuals who have not developed lymphedema when compared to individuals who have. Year of Publication QOL instrument Sample Size Authors 2003 European Organization for Research and Treatment of Cancer QOL questionnaire 990 Engel, J. et al. 2002 Functional Assessment of Cancer Therapy-Breast QOL instrument 151 Beaulac, S. et al. 2002 EORTC QLQ 744 Kwan, W. et al. 1999SF-36101 Velanovich, V. et al. 1995 Psychosocial Adjustment to Illness Scale 100 Woods, M. et al. 1993 Interviews, Psychological Symptom Index 205 Maunsell, E. et al.

10. Quality of Life Domains Explored:  Physical  Psychological  Social  Sexual  Functional

11. Evidence

12. The following risk factors were identified:  High Body Mass Index  Weight gain in post-treatment years  Infections or injury in the associated limb  Flying in airplanes

13. Application to Occupational Therapy:   Health, function and quality of life  Education regarding risk factors  OTs are involved in the treatment of lymphedema: Federal laws regulate who can perform complete decongestive therapy (CDT) for treatment of lymphedema. Occupational therapists are among the small group of healthcare professionals who are able to treat lymphedema after receiving training.

14. Research reporting a lack of knowledge regarding the condition of lymphedema and/or a lack of knowledge regarding preventative measures among individuals diagnosed with cancer: Bosompra, K., Takamaru, A., O’Brien, P., Nelson, L., Skelly, J., & Beatty, D. (2002). Knowledge about preventing and managing lymphedema: a survey of recently diagnosed and treated breast cancer patients. Patient Education and Counseling, 47, 155-163. Clark, R., Wasilewska, T., & Carter, J. (1997). Lymphedema: a study of Otago women treated for breast cancer. Nursing Praxis in New Zealand, 12, 4-14. Coward, D. (1999) Lymphedema prevention and management knowledge in women treated for breast cancer. ONF, 26, 1047-1053. Hawes, C., Neill, J., Borbasi, S., Groenkjaer, M., Piller, N., & Chapman, Y. (2004). Ignorance is not bliss: information provided to Australian women at risk of developing lymphoedema following treatment for breast cancer. Australian Journal of Cancer Nursing, 5, 3-15. Paskett, E., & Stark, N. (2000). Lymphedema: knowledge, treatment, and Impact among breast cancer survivors. The Breast Journal, 6, 373-378.

15. Conclusion and Recommendations :   That every individual considering surgery or radiation therapy, for treatment of cancer, be informed of the possibility of developing lymphedema as a result of these procedures before such measures are taken.   That every individual who receives a procedure affecting lymph node integrity in conjunction with cancer treatment be informed regarding risk factors associated with lymphedema incidence by a healthcare professional trained in this area.   That information regarding risk factors be presented in both verbal and written form to every individual.

16. References Beaulac, S., McNair, L., Scott, T., LaMorte, W., Kavanah, M. (2002). Lymphedema and quality of life in survivors of early-stage breast cancer. Arch Surg, 137, 1253-1257. Burt, Jeannie & White, Gwen. (1999). Lymphedema. Salt Lake City: Hunter House Publishers. Casley-Smith, J., & Casley-Smith, J. (1996) Lymphedema initiated by aircraft flights. Aviation, Space, and Environmental Medicine, 67, 52-56. Engel, J., Kerr, J., Schlesinger-Raab, A., Sauer, H., & Holzel, D. (2003). Axilla surgery severely affects quality of life: results of a 5-year prospective study in breast cancer patients. Breast Cancer Research and Treatment, 79, 47-57. Kelly, Deborah G. (2002). A Primer on Lymphedema. Upper Saddle River, New Jersey: Prentice Hall. Kwan, w., Jackson, J., Weir, L., Dingee, C., McGregor, G., & Olivotto, I. (2002). Chronic arm morbidity after curative breast cancer treatment: prevelance and impact on quality of life. Journal of Clinical Oncology, 20, 4242-4248. Johansson, K., Ohlsson, K., Ingvar, C., Albertsson, M., & Ekdahl, C. (2002). Factors associated with the development of arm lymphedema following breast cancer treatment: a match pair case-control study. Lymphology, 35, 59-71. Maunsell, E., Brisson, J., & Deschenes, L. (1993). Arm problems and psychological distress after surgery for breast cancer. Canadian Journal of Surgery, 36, 315-320. Petrek, J., Senie, R., Peters, M., & Rosen, P. (2001). Lymphedema in a cohort of breast carcinoma survivors 20 years after diagnosis. Cancer, 92, 1368-1377.

17. Velanovich, V., & Szymanski, W. (1999) Quality of life of breast cancer patients with lymphedema. American Journal of Surgery, 177, 184-188. Werner, R., McCormick, B., Petrek, J., Cox, L., Cirrincione, C., Gray, J., & Yahalom, J. (1991). Arm edema in conservatively managed breast cancer: obesity is a major predictive factor. Radiology, 180, 177-184. Woods, M., Tobin, M., & Mortimer, P. (1995) The psychosocial morbidity of breast cancer patients with lymphoedema. Cancer Nursing, 18, 467-471.