Treatment of cancer-related Secondary Lymphedema

Secondary lymphedema is a chronic disease caused by the accumulation of protein-rich lymph fluid in interstitial spaces and subcutaneous tissue, mainly adipose and connective tissue, which affects mostly the upper and lower limbs. The pathophysiological mechanism involved is the obstruction or disturbance of lymphatic flow due chiefly to surgical cancer treatment with lymph node dissection or sentinel node biopsy but also to radiation therapy or chemotherapy. Secondary lymphedema is a relatively frequent disease. Although its incidence is not accurately known owing to the variability in the definitions and disease detection techniques, it may range from 10% to 50%, depending on the type of cancer and treatment procedure. Breast cancer is the most common form of cancer involved (approximately 80% of cases), followed by genito-urinary and gynecological cancers and melanomas. Without appropriate management, this disease may progress and the edema may worsen, causing physical discomfort, pain, functional impairment, major physical and psychological complications, long-term morbidity, and a deterioration in quality of life. This disease most often requires extensive and intensive management that may be costly. Québec, however, does not have a specific lymphedema management program, and most treatments are not covered by the public health insurance plan.

Recommendations:

• All patients with or at risk for cancer-related secondary lymphedema should be properly informed.

• All health professionals involved in managing patients at risk for cancer-related secondary lymphedema should be given complete information on diagnosis, prevention and the various therapeutic options available, and they should be able to refer these patients to the appropriate resources when necessary.

• Providers of physiotherapy, massage therapy and any other applicable therapy should be duly trained in manual lymphatic drainage techniques specific to lymphedema treatment (Vodder or Leduc technique, etc.) and in techniques for applying multi-layered low-stretch compression bandages.

• A committee of expert clinicians should be formed to establish the best lymphedema management practices for Québec and to develop a program offering a continuum of integrated follow-up care.

• The ministère de la Santé et des Services sociaux, acting through the Direction québécoise du cancer (formerly Direction de la lutte contre le cancer), should examine modalities for the public health insurance plan to cover the costs associated with the different treatment phases of cancer-related secondary lymphedema.