- Email: [email protected]
Lymphedema care for the breast cancer patient: An integrative approach
The Breast 24 (2015) 82e85
Contents lists available at ScienceDirect
The Breast journal homepage: www.elsevier.com/brst
Short report
Lymphedema care for the breast cancer patient: An integrative approach Gail Elliott Patricolo a, Karen Armstrong a, Justin Riutta b, Thomas Lanni c, * a
Integrative Medicine, Beaumont Health System, 3577 W. Thirteen Mile Road, Royal Oak, MI 48073, USA Physical Medicine and Rehabilitation, Breast Cancer Rehabilitation, Lymphedema Clinic, Beaumont Health System, 3577 W. Thirteen Mile Road, Royal Oak, MI 48073, USA c Beaumont Cancer Institute, Beaumont Health System, 3577 W. Thirteen Mile Road, Royal Oak, MI 48073, USA b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 28 March 2014 Received in revised form 8 September 2014 Accepted 12 October 2014 Available online 11 November 2014
Lymphedema is a serious complication that involves the accumulation of protein-rich fluid in the interstitial space. Lymphedema is common after treatment for breast cancer, especially for those patients receiving axillary lymph node dissection. Severe lymphedema is associated with serious morbidities such as swelling, fibrosis, decreased function, reduced range of motion, infection, and pain. Here, we discuss a unique, multi-disciplinary approach to effectively manage patients during and after breast cancer therapy. In this approach, patient education and screening are implemented in various departments throughout the health care system, including Physical Therapy and Rehabilitation, Integrative Medicine, and the Breast Care Center, which houses the Lymphedema Clinic. Early patient education and regular screening are combined with aggressive treatment for overt disease to effectively manage lymphedema in the at-risk population. © 2014 Elsevier Ltd. All rights reserved.
Keywords: Lymphedema Breast cancer Integrative medicine Rehabilitation
Introduction1 Lymphedema is a serious medical complication commonly associated with breast cancer treatment [1e3]. Lymphedema involves the accumulation of protein-rich fluid in the interstitial space, and occurs when the lymphatic system is damaged and no longer properly drains the lymph fluid back to systemic circulation. Breast cancer-related lymphedema (BCRL) occurs when the damage is associated with breast cancer treatment such as surgery (sentinel or axillary lymph node dissection) and radiation treatment [2e5]. When the lymphatic system is damaged, fluid accumulates in the affected limb, leading to swelling, fibrosis, reduced range of motion (ROM), decreased function, and, in later stages, infection and pain [3,4]. The use of sentinel lymph node dissection in place of axillary has reduced the incidence and severity of lymphedema; however, even with treatment improvements, BCRL occurs in up to 10% of breast cancer patients [6]. When severe,
lymphedema can cause serious complications and reduce patient quality of life [7,8]. The Beaumont Health System (BHS) has implemented an integrative approach to screen breast cancer patients at risk for BCRL development, to prevent lymphedema onset, to treat patients if symptoms arise, and to maintain long-term lymphatic health. Here, we discuss how BHS uses a unique, multi-disciplinary approach to effectively manage patients during and after breast cancer therapy. The Medical Director of the Breast Cancer Rehabilitation Program and the Lymphedema Clinic is fellowship trained in Cancer Rehabilitation and Lymphedema Management and oversees this crossdepartmental effort. The Breast Cancer Rehabilitation program was initiated in 2004 and has had over 20,000 clinical visits for Breast Cancer Rehabilitation concerns over the last 10 years. This truly integrative program is unique to the region and has the goal of identifying and managing every individual at risk for BCRL. Education and prevention
* Corresponding author. Beaumont Cancer Institute, Oakland University-William Beaumont Hospital School of Medicine, 3601 West Thirteen Mile Road, Royal Oak, MI 48073, USA. Tel.: þ1 248 898 5964. E-mail addresses: [email protected] (G.E. Patricolo), karen. [email protected] (K. Armstrong), [email protected] (J. Riutta), [email protected] (T. Lanni). 1 BHS, Beaumont Health System. http://dx.doi.org/10.1016/j.breast.2014.10.004 0960-9776/© 2014 Elsevier Ltd. All rights reserved.
Prevention of BCRL is the primary goal. Effective prevention requires education, physician evaluation, and risk analysis; early screening is required to notice BCRL development in the early stages. Management of BCRL is most effective when initiated in the early stages: Stage I (reversible lymphedema) or Stage II (spontaneously irreversible lymphedema). Lymphedema that has
G.E. Patricolo et al. / The Breast 24 (2015) 82e85
progressed to Stage III (lymphostatic elephantiasis) requires intensive, long-term therapy and often results in severe complications and patient morbidity [9,10]. Patients who have been diagnosed with breast cancer are managed through the Breast Care Program with the oncology team, which may include members from various departments such as Surgery, Medical and Radiation Oncology, Physical Medicine and Rehabilitation (PMR), Physical Therapy (PT), and Integrative Medicine (IM). At every point along their treatment path, patients are provided education regarding the possible treatment-related effects. These side effects may include chemotherapy-induced peripheral neuropathy (CIPN), chest wall and muscle restrictions, spine disorders, and lymphedema [11,12], among many others, depending on the extent of surgery and radiation therapy and the type of chemotherapy administered. With regard to lymphedema, patients are counseled individually during clinic visits, and lecture series are presented quarterly to provide lymphedema information to the public. Patients are given information regarding BCRL in general and their individualized risk, based on their own situation, i.e., age, infections, body-mass index (BMI), fitness level, and treatments received [4,5]. Then, patients are taught to examine the at-risk limb for early signs of lymphedema such as swelling, aching, or a feeling of fullness or pressure. Patients are advised to examine the affected arm regularly and are informed on the importance of proper skin care, a healthy diet, and exercises appropriate for their situation. Care should be taken to avoid infection and to properly care for any skin breaks or wound. Restrictions such as avoiding punctures (blood draws), blood pressure measurements, and constrictive clothing in the at-risk limb are also discussed. The patients are provided with information regarding the specialized programs available at BHS through the PMR and IM departments and the Breast Care Center (discussed below).
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department is open to anyone; a physician referral is not required. Therefore, an oncology patient from outside the system may come to IM for an oncology or lymphatic wellness massage. Massage has been recognized as a technique that provides numerous benefits to the oncology patient [14e16]. However, at BHS, the massage therapists also play a key role in identifying patients at risk for lymphedema and providing information regarding the syndrome. The patients without overt lymphedema may benefit from lymphatic wellness massage. In this technique, massage therapists with postgraduate training in oncology massage work carefully with the lymphatic system to promote clearing the lymph while avoiding injury. Furthermore, a complete patient history is collected before any massage therapy session. Those who are considered at risk for developing lymphedema are screened for contraindications and early symptoms, and the affected limb is avoided if there is any suspicion of lymphedema. Patients are provided information regarding warning signs and taught the same self-care techniques discussed earlier. More specifically, the patients are given ‘homework’, which includes specific techniques to check limb symmetry and exercises to safely promote lymph drainage. In this way, MTs often ‘catch’ patients from outside the system who have come to BHS for an oncology or lymphatic massage or those who may not have received any PT sessions. Any patient suspected of presenting with signs of overt lymphedema (swelling, redness, heat, tight skin, or the patient describing a heavy sensation in the affected limb) is referred for medical evaluation by the lymphedema director, as are all patients with further questions regarding lymphedema management. In this way, the physical therapists and the massage therapists work together with common goals: to identify and educate patients at risk for lymphedema; to prevent lymphedema occurrence; and, to quickly and efficiently identify cases of overt lymphedema to initiate rapid treatment.
The role of physical and massage therapy In addition to the risk of lymphedema, mastectomies and lumpectomies are frequently associated with damage to the chest wall and subsequent muscle restriction [11e13]. Pre-operative education, home exercise programs, PT, and/or massage therapy are performed with the goal of stretching arm and shoulder muscles before surgery to increase arm ROM after surgery and radiation. This process often increases a patient's ability to properly position their arm for magnetic resonance imaging (MRI) scans and radiation treatments and decreases post-treatment morbidities and arm dysfunction. Post-operative medical evaluations, home exercise programs, PT, and massage therapy can also be administered with the goal of increasing arm ROM. Patients are then taught a selfdirected maintenance program that includes exercises, stretching, and massage techniques that can be performed at home. In addition, BHS has on staff multiple physical therapists with specialty training in lymphedema, many of which are certified by the Lymphology Association of North America (LANA), a certification indicating a level of knowledge regarding lymphedema and its care. LANA-certified physical therapists are trained to avoid additional damage to the lymphatic area and can recognize the signs of emerging lymphedema. Many patients require sessions of physical therapy, which can be impacted by insurance coverage and out-of-pocket expenses. During the patient education process, the patients are referred to the IM department, where they can receive oncology massage sessions (massage specifically tailored to the oncology patient), which include lymphatic wellness massage. These specialty programs are available to patients within the system, who may be referred to IM by the oncology team; however, they are also available to anyone who self-refers to the program. The IM
Lymphedema treatment Treatment for BCRL involves immediate, post-operative care as well as long-term follow up. Early intervention is key; therefore, screening for BCRL is performed at regular intervals and through the different departments that interact with breast cancer patients. Patients identified as showing signs of lymphedema are referred to the PMR department for a clinical assessment and initiation of complete decongestive therapy. In Phase I, LANA-certified PTs perform manual lymphatic drainage (MLD) and use compression bandages to reduce swelling. MLD is a specialized manual technique that directs the lymph fluid toward healthy lymph nodes and vessels. The compression bandages and garments (sleeves) are used to reduce swelling and soften tissue. The bandages are maintained for 23 h/day for the first week. Throughout Phase I, patients are taught how to self-administer MLD and how to use and care for the compression bandages and/or sleeves. Appropriate skin care and individualized exercise regimens along with any restrictions and precautions are discussed. In Phase II, the patients continue home care. Patients must continue to use the compression garments (bandages and/or sleeves) and practice MLD and proper skin care. The goals of these treatments are to reduce swelling, improve range of motion and limb utility, and prevent infection. Once the condition is considered stabilized, the patient is again eligible for lymphatic wellness massage through the IM department. This type of massage can help maintain wellness in the affected limb and in the whole body. Lymphedema is considered a chronic condition, and the patient must be aware of how the condition can impact patient lifestyle and life choices.
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G.E. Patricolo et al. / The Breast 24 (2015) 82e85
Survivorship and maintenance The focus on BCRL is part of the larger goal for patients, which is to have patients return to their pre-cancer life. The physical impairments after cancer treatment, mentioned above, can be debilitating and long lasting and can have a significant impact on patient quality of life [8,11,17]. These impairments are addressed to the greatest extent possible through education, home exercise programs, early clinical assessment, PT, and massage sessions. The physical therapists work with the patient to improve mobility and range of motion (ROM) and increase strength and stamina. Massage therapy can soften tissue and increase ROM and can positively affect fatigue and nausea [18,19]. Both massage and physical therapy improve self-image and reduce pain and insomnia. When the patient is physically able to return to work and daily activities, their quality of life improves. In addition to the physical issues, the patient is referred to Social Work Services, and social workers help patients adjust to illness and provide support with regard to maintaining a healthy diet or weight, coping with grief and loss, and providing access to resources. Furthermore, support groups or therapy sessions can help patients cope with a cancer diagnosis and their new reality. Patients frequently feel a sense of being out of control, a sense of loss for their previous, pre-diagnosis life, fear of the future, and fear for their families. Patients may also experience a grieving process during this time. By addressing all of these issues, the patient is treated in a holistic manner. Patients' primary concerns regarding treatment are the time and cost required to complete the process. The patient ultimately wants to return to their normal, pre-cancer life. To this end, it is imperative that the patient regain as much physical aptitude as possible, so they can participate in daily activities e work and home duties, hobbies, exercising, or simply enjoying their children and grandchildren e to the fullest extent possible. Binkley et al. have investigated how treatment side effects impact breast cancer patients who have completed therapy [8]. There are physical concerns (limb utility, reduced ROM, fatigue, weight gain or loss, CIPN) and emotional concerns (self-image, depression, anger, and frustration). Reducing the effects of lymphedema plays a substantial role in fulfilling this goal, as BCRL has been reported to have a negative psychosocial impact on patients [17,20].
node dissection. These patients are the most at risk for developing BCRL and are the target population for this unique program, which has been implemented at BHS for almost a decade. Fig. 1 indicates the number of lymphedema-related patient visits to the Breast Care Center from 2008 to 2013; in 2013, the Center logged almost 250 office visits for lymphedema-related concerns, of which, over a third were first-time patients. Notably, the percentage of patients presenting to the clinic with a primary complaint of lymphedema significantly decreased from 86.2% to 33.8% (p < 0.001) within the first five years of lymphedema clinic inception (2004e2009) [21]. The integrative approach at BHS is illustrated in Fig. 2. There are many benefits to using an integrative approach for the management of patients with lymphedema. The first is the increased focus on prevention through physical therapy and education. Indeed, the lymphedema clinic noted a significant increase in the fraction of patients seen for lymphedema preventative counseling in the first five years since clinic inception (2004 versus 2009, 18.9% versus 0%, respectively; p < 0.001) [21], thus indicating the increased awareness by patients and physicians regarding the need to take preventative measures against lymphedema. In addition, specially trained massage therapists can promote lymphatic wellness and help prevent lymphedema. It is important that the physical and massage therapists are specially trained to treat oncology patients in general and patients at risk for lymphedema in particular, as an incorrect technique can further damage a fragile lymphatics system and exacerbate the problem. Furthermore, having multiple departments trained in lymphedema recognition increases the chances of catching all at-risk patients and identifying issues early. In addition, the IM department sees patients from within and from outside of the BHS system, thus affording the opportunity to identify additional at-risk patients. In 2013, the IM department throughout BHS had over 1500 visits from oncology patients (including new and repeat visits). These visits include BHS inpatients and outpatients and also those who were treated for their cancer outside of BHS. As mentioned, these oncology patients are screened for signs of lymphedema, resulting in a significant fraction of patients that would not otherwise have been included into the lymphedema management program.
Conclusions e why an integrative approach? More than 1100 patients per year are diagnosed with breast cancer at BHS. Of these, 3e400 undergo a complete axillary lymph
Fig. 1. Lymphedema-related visits to the Beaumont Health System Breast Care Center, 2008e2013.
Fig. 2. A schematic indicating the integrated approach to breast cancer patient management at the Beaumont Health System.
G.E. Patricolo et al. / The Breast 24 (2015) 82e85
An integrative approach also reduces costs to the patient and the system. Once insurance will no longer cover PT session, patients may utilize massage therapy at a lower-cost alternative. Under appropriate conditions, massage can be a viable, useful option for patients who cannot afford multiple PT sessions. Currently, approximately 10% of the patients seen in the lymphedema clinic are also seen in the IM department for oncology massage. The average number of massage treatments received by these patients is ~2e3 per patient; however, the number varies greatly, with one individual patient receiving 60 massages from the IM department in a single year. In addition, the emphasis on preventing lymphedema avoids the increased costs associated with the overt condition. Finally, the integrative approach is appreciated by patients and increases satisfaction, as evidenced by numerous testimonials from patients, physicians, donors, and staff. The emphasis on prevention reduces lymphedema-associated morbidity. Moreover, the integrative approach encompasses all aspects of patient care, physical, psychological, and emotional, and treats the patient as a whole person. This situation, for a patient who may have been viewed as their disease, can increase their sense of well-being and help them on the road to recovery. Conflict of interest statement The authors have no conflicts of interest to disclose. Acknowledgments We would like to thank Christine Billecke, Ph.D. for her assistance in the preparation of this manuscript. References [1] McLaughlin SA. Lymphedema: separating fact from fiction. Oncol Willist Park Mar 2012;26(3):242e9. [2] Shah C, Arthur D, Riutta J, Whitworth P, Vicini FA. Breast-cancer related lymphedema: a review of procedure-specific incidence rates, clinical assessment AIDS, treatment paradigms, and risk reduction. Breast J JuleAug 2012;18(4):357e61. [3] Morrell RM, Halyard MY, Schild SE, Ali MS, Gunderson LL, Pockaj BA. Breast cancer-related lymphedema. Mayo Clin Proc Nov 2005;80(11):1480e4. [4] Ridner SH. Pathophysiology of lymphedema. Semin Oncol Nurs Feb 2013;29(1):4e11.
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[5] Hayes SC, Janda M, Cornish B, Battistutta D, Newman B. Lymphedema after breast cancer: incidence, risk factors, and effect on upper body function. J Clin Oncol Jul 20 2008;26(21):3536e42. [6] Shah C, Wilkinson JB, Baschnagel A, Ghilezan M, Riutta J, Dekhne N, et al. Factors associated with the development of breast cancer-related lymphedema after whole-breast irradiation. Int J Radiat Oncol Biol Phys Jul 15 2012;83(4):1095e100. [7] Kuwajerwala NK, Feczko C, Dekhne N, Pettings J, Lucia VC, Riutta J, et al. Comparison of lymphedema in patients with axillary lymph node dissections to those with sentinel lymph node biopsy followed by immediate and delayed ALND. Am J Clin Oncol Feb 2013;36(1):20e3. [8] Binkley JM, Harris SR, Levangie PK, Pearl M, Guglielmino J, Kraus V, et al. Patient perspectives on breast cancer treatment side effects and the prospective surveillance model for physical rehabilitation for women with breast cancer. Cancer Apr 15 2012;118(8 Suppl.):2207e16. [9] Stout Gergich NL, Pfalzer LA, McGarvey C, Springer B, Gerber LH, Soballe P. Preoperative assessment enables the early diagnosis and successful treatment of lymphedema. Cancer Jun 15 2008;112(12):2809e19. [10] Bar Ad V, Dutta PR, Solin LJ, Hwang TW, Tan KS, Both S, et al. Time-course of arm lymphedema and potential risk factors for progression of lymphedema after breast conservation treatment for early stage breast cancer. Breast J MayeJun 2012;18(3):219e25. [11] Gomide LB, Matheus JP, Candido dos Reis FJ. Morbidity after breast cancer treatment and physiotherapeutic performance. Int J Clin Pract Jun 2007;61(6): 972e82. [12] Smoot B, Wong J, Cooper B, Wanek L, Topp K, Byl N, et al. Upper extremity impairments in women with or without lymphedema following breast cancer treatment. J Cancer Surviv Jun 2010;4(2):167e78. [13] Hayes SC, Johansson K, Stout NL, Prosnitz R, Armer JM, Gabram S, et al. Upperbody morbidity after breast cancer: incidence and evidence for evaluation, prevention, and management within a prospective surveillance model of care. Cancer Apr 15 2012;118(8 Suppl.):2237e49. [14] Collinge W, MacDonald G, Walton T. Massage in supportive cancer care. Semin Oncol Nurs Feb 2012;28(1):45e54. [15] Corbin L. Safety and efficacy of massage therapy for patients with cancer. Cancer Control Jul 2005;12(3):158e64. [16] Myers CD, Walton T, Small BJ. The value of massage therapy in cancer care. Hematol Oncol Clin North Am Aug 2008;22(4):649e60 [viii]. [17] Fu MR, Kang Y. Psychosocial impact of living with cancer-related lymphedema. Semin Oncol Nurs Feb 2013;29(1):50e60. [18] Cassileth BR, Vickers AJ. Massage therapy for symptom control: outcome study at a major cancer center. J Pain Symptom Manage Sep 2004;28(3): 244e9. [19] Currin J, Meister EA. A hospital-based intervention using massage to reduce distress among oncology patients. Cancer Nurs MayeJun 2008;31(3):214e21. [20] Pusic AL, Cemal Y, Albornoz C, Klassen A, Cano S, Sulimanoff I, et al. Quality of life among breast cancer patients with lymphedema: a systematic review of patient-reported outcome instruments and outcomes. J Cancer Surviv Mar 2013;7(1):83e92. [21] Shah C, Ermis C, Vicini F. Developing a breast cancer-related lymphedema program: the William Beaumont Hospital experience. Breast J JaneFeb 2013;19(1):119e20.
Contents lists available at ScienceDirect
The Breast journal homepage: www.elsevier.com/brst
Short report
Lymphedema care for the breast cancer patient: An integrative approach Gail Elliott Patricolo a, Karen Armstrong a, Justin Riutta b, Thomas Lanni c, * a
Integrative Medicine, Beaumont Health System, 3577 W. Thirteen Mile Road, Royal Oak, MI 48073, USA Physical Medicine and Rehabilitation, Breast Cancer Rehabilitation, Lymphedema Clinic, Beaumont Health System, 3577 W. Thirteen Mile Road, Royal Oak, MI 48073, USA c Beaumont Cancer Institute, Beaumont Health System, 3577 W. Thirteen Mile Road, Royal Oak, MI 48073, USA b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 28 March 2014 Received in revised form 8 September 2014 Accepted 12 October 2014 Available online 11 November 2014
Lymphedema is a serious complication that involves the accumulation of protein-rich fluid in the interstitial space. Lymphedema is common after treatment for breast cancer, especially for those patients receiving axillary lymph node dissection. Severe lymphedema is associated with serious morbidities such as swelling, fibrosis, decreased function, reduced range of motion, infection, and pain. Here, we discuss a unique, multi-disciplinary approach to effectively manage patients during and after breast cancer therapy. In this approach, patient education and screening are implemented in various departments throughout the health care system, including Physical Therapy and Rehabilitation, Integrative Medicine, and the Breast Care Center, which houses the Lymphedema Clinic. Early patient education and regular screening are combined with aggressive treatment for overt disease to effectively manage lymphedema in the at-risk population. © 2014 Elsevier Ltd. All rights reserved.
Keywords: Lymphedema Breast cancer Integrative medicine Rehabilitation
Introduction1 Lymphedema is a serious medical complication commonly associated with breast cancer treatment [1e3]. Lymphedema involves the accumulation of protein-rich fluid in the interstitial space, and occurs when the lymphatic system is damaged and no longer properly drains the lymph fluid back to systemic circulation. Breast cancer-related lymphedema (BCRL) occurs when the damage is associated with breast cancer treatment such as surgery (sentinel or axillary lymph node dissection) and radiation treatment [2e5]. When the lymphatic system is damaged, fluid accumulates in the affected limb, leading to swelling, fibrosis, reduced range of motion (ROM), decreased function, and, in later stages, infection and pain [3,4]. The use of sentinel lymph node dissection in place of axillary has reduced the incidence and severity of lymphedema; however, even with treatment improvements, BCRL occurs in up to 10% of breast cancer patients [6]. When severe,
lymphedema can cause serious complications and reduce patient quality of life [7,8]. The Beaumont Health System (BHS) has implemented an integrative approach to screen breast cancer patients at risk for BCRL development, to prevent lymphedema onset, to treat patients if symptoms arise, and to maintain long-term lymphatic health. Here, we discuss how BHS uses a unique, multi-disciplinary approach to effectively manage patients during and after breast cancer therapy. The Medical Director of the Breast Cancer Rehabilitation Program and the Lymphedema Clinic is fellowship trained in Cancer Rehabilitation and Lymphedema Management and oversees this crossdepartmental effort. The Breast Cancer Rehabilitation program was initiated in 2004 and has had over 20,000 clinical visits for Breast Cancer Rehabilitation concerns over the last 10 years. This truly integrative program is unique to the region and has the goal of identifying and managing every individual at risk for BCRL. Education and prevention
* Corresponding author. Beaumont Cancer Institute, Oakland University-William Beaumont Hospital School of Medicine, 3601 West Thirteen Mile Road, Royal Oak, MI 48073, USA. Tel.: þ1 248 898 5964. E-mail addresses: [email protected] (G.E. Patricolo), karen. [email protected] (K. Armstrong), [email protected] (J. Riutta), [email protected] (T. Lanni). 1 BHS, Beaumont Health System. http://dx.doi.org/10.1016/j.breast.2014.10.004 0960-9776/© 2014 Elsevier Ltd. All rights reserved.
Prevention of BCRL is the primary goal. Effective prevention requires education, physician evaluation, and risk analysis; early screening is required to notice BCRL development in the early stages. Management of BCRL is most effective when initiated in the early stages: Stage I (reversible lymphedema) or Stage II (spontaneously irreversible lymphedema). Lymphedema that has
G.E. Patricolo et al. / The Breast 24 (2015) 82e85
progressed to Stage III (lymphostatic elephantiasis) requires intensive, long-term therapy and often results in severe complications and patient morbidity [9,10]. Patients who have been diagnosed with breast cancer are managed through the Breast Care Program with the oncology team, which may include members from various departments such as Surgery, Medical and Radiation Oncology, Physical Medicine and Rehabilitation (PMR), Physical Therapy (PT), and Integrative Medicine (IM). At every point along their treatment path, patients are provided education regarding the possible treatment-related effects. These side effects may include chemotherapy-induced peripheral neuropathy (CIPN), chest wall and muscle restrictions, spine disorders, and lymphedema [11,12], among many others, depending on the extent of surgery and radiation therapy and the type of chemotherapy administered. With regard to lymphedema, patients are counseled individually during clinic visits, and lecture series are presented quarterly to provide lymphedema information to the public. Patients are given information regarding BCRL in general and their individualized risk, based on their own situation, i.e., age, infections, body-mass index (BMI), fitness level, and treatments received [4,5]. Then, patients are taught to examine the at-risk limb for early signs of lymphedema such as swelling, aching, or a feeling of fullness or pressure. Patients are advised to examine the affected arm regularly and are informed on the importance of proper skin care, a healthy diet, and exercises appropriate for their situation. Care should be taken to avoid infection and to properly care for any skin breaks or wound. Restrictions such as avoiding punctures (blood draws), blood pressure measurements, and constrictive clothing in the at-risk limb are also discussed. The patients are provided with information regarding the specialized programs available at BHS through the PMR and IM departments and the Breast Care Center (discussed below).
83
department is open to anyone; a physician referral is not required. Therefore, an oncology patient from outside the system may come to IM for an oncology or lymphatic wellness massage. Massage has been recognized as a technique that provides numerous benefits to the oncology patient [14e16]. However, at BHS, the massage therapists also play a key role in identifying patients at risk for lymphedema and providing information regarding the syndrome. The patients without overt lymphedema may benefit from lymphatic wellness massage. In this technique, massage therapists with postgraduate training in oncology massage work carefully with the lymphatic system to promote clearing the lymph while avoiding injury. Furthermore, a complete patient history is collected before any massage therapy session. Those who are considered at risk for developing lymphedema are screened for contraindications and early symptoms, and the affected limb is avoided if there is any suspicion of lymphedema. Patients are provided information regarding warning signs and taught the same self-care techniques discussed earlier. More specifically, the patients are given ‘homework’, which includes specific techniques to check limb symmetry and exercises to safely promote lymph drainage. In this way, MTs often ‘catch’ patients from outside the system who have come to BHS for an oncology or lymphatic massage or those who may not have received any PT sessions. Any patient suspected of presenting with signs of overt lymphedema (swelling, redness, heat, tight skin, or the patient describing a heavy sensation in the affected limb) is referred for medical evaluation by the lymphedema director, as are all patients with further questions regarding lymphedema management. In this way, the physical therapists and the massage therapists work together with common goals: to identify and educate patients at risk for lymphedema; to prevent lymphedema occurrence; and, to quickly and efficiently identify cases of overt lymphedema to initiate rapid treatment.
The role of physical and massage therapy In addition to the risk of lymphedema, mastectomies and lumpectomies are frequently associated with damage to the chest wall and subsequent muscle restriction [11e13]. Pre-operative education, home exercise programs, PT, and/or massage therapy are performed with the goal of stretching arm and shoulder muscles before surgery to increase arm ROM after surgery and radiation. This process often increases a patient's ability to properly position their arm for magnetic resonance imaging (MRI) scans and radiation treatments and decreases post-treatment morbidities and arm dysfunction. Post-operative medical evaluations, home exercise programs, PT, and massage therapy can also be administered with the goal of increasing arm ROM. Patients are then taught a selfdirected maintenance program that includes exercises, stretching, and massage techniques that can be performed at home. In addition, BHS has on staff multiple physical therapists with specialty training in lymphedema, many of which are certified by the Lymphology Association of North America (LANA), a certification indicating a level of knowledge regarding lymphedema and its care. LANA-certified physical therapists are trained to avoid additional damage to the lymphatic area and can recognize the signs of emerging lymphedema. Many patients require sessions of physical therapy, which can be impacted by insurance coverage and out-of-pocket expenses. During the patient education process, the patients are referred to the IM department, where they can receive oncology massage sessions (massage specifically tailored to the oncology patient), which include lymphatic wellness massage. These specialty programs are available to patients within the system, who may be referred to IM by the oncology team; however, they are also available to anyone who self-refers to the program. The IM
Lymphedema treatment Treatment for BCRL involves immediate, post-operative care as well as long-term follow up. Early intervention is key; therefore, screening for BCRL is performed at regular intervals and through the different departments that interact with breast cancer patients. Patients identified as showing signs of lymphedema are referred to the PMR department for a clinical assessment and initiation of complete decongestive therapy. In Phase I, LANA-certified PTs perform manual lymphatic drainage (MLD) and use compression bandages to reduce swelling. MLD is a specialized manual technique that directs the lymph fluid toward healthy lymph nodes and vessels. The compression bandages and garments (sleeves) are used to reduce swelling and soften tissue. The bandages are maintained for 23 h/day for the first week. Throughout Phase I, patients are taught how to self-administer MLD and how to use and care for the compression bandages and/or sleeves. Appropriate skin care and individualized exercise regimens along with any restrictions and precautions are discussed. In Phase II, the patients continue home care. Patients must continue to use the compression garments (bandages and/or sleeves) and practice MLD and proper skin care. The goals of these treatments are to reduce swelling, improve range of motion and limb utility, and prevent infection. Once the condition is considered stabilized, the patient is again eligible for lymphatic wellness massage through the IM department. This type of massage can help maintain wellness in the affected limb and in the whole body. Lymphedema is considered a chronic condition, and the patient must be aware of how the condition can impact patient lifestyle and life choices.
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Survivorship and maintenance The focus on BCRL is part of the larger goal for patients, which is to have patients return to their pre-cancer life. The physical impairments after cancer treatment, mentioned above, can be debilitating and long lasting and can have a significant impact on patient quality of life [8,11,17]. These impairments are addressed to the greatest extent possible through education, home exercise programs, early clinical assessment, PT, and massage sessions. The physical therapists work with the patient to improve mobility and range of motion (ROM) and increase strength and stamina. Massage therapy can soften tissue and increase ROM and can positively affect fatigue and nausea [18,19]. Both massage and physical therapy improve self-image and reduce pain and insomnia. When the patient is physically able to return to work and daily activities, their quality of life improves. In addition to the physical issues, the patient is referred to Social Work Services, and social workers help patients adjust to illness and provide support with regard to maintaining a healthy diet or weight, coping with grief and loss, and providing access to resources. Furthermore, support groups or therapy sessions can help patients cope with a cancer diagnosis and their new reality. Patients frequently feel a sense of being out of control, a sense of loss for their previous, pre-diagnosis life, fear of the future, and fear for their families. Patients may also experience a grieving process during this time. By addressing all of these issues, the patient is treated in a holistic manner. Patients' primary concerns regarding treatment are the time and cost required to complete the process. The patient ultimately wants to return to their normal, pre-cancer life. To this end, it is imperative that the patient regain as much physical aptitude as possible, so they can participate in daily activities e work and home duties, hobbies, exercising, or simply enjoying their children and grandchildren e to the fullest extent possible. Binkley et al. have investigated how treatment side effects impact breast cancer patients who have completed therapy [8]. There are physical concerns (limb utility, reduced ROM, fatigue, weight gain or loss, CIPN) and emotional concerns (self-image, depression, anger, and frustration). Reducing the effects of lymphedema plays a substantial role in fulfilling this goal, as BCRL has been reported to have a negative psychosocial impact on patients [17,20].
node dissection. These patients are the most at risk for developing BCRL and are the target population for this unique program, which has been implemented at BHS for almost a decade. Fig. 1 indicates the number of lymphedema-related patient visits to the Breast Care Center from 2008 to 2013; in 2013, the Center logged almost 250 office visits for lymphedema-related concerns, of which, over a third were first-time patients. Notably, the percentage of patients presenting to the clinic with a primary complaint of lymphedema significantly decreased from 86.2% to 33.8% (p < 0.001) within the first five years of lymphedema clinic inception (2004e2009) [21]. The integrative approach at BHS is illustrated in Fig. 2. There are many benefits to using an integrative approach for the management of patients with lymphedema. The first is the increased focus on prevention through physical therapy and education. Indeed, the lymphedema clinic noted a significant increase in the fraction of patients seen for lymphedema preventative counseling in the first five years since clinic inception (2004 versus 2009, 18.9% versus 0%, respectively; p < 0.001) [21], thus indicating the increased awareness by patients and physicians regarding the need to take preventative measures against lymphedema. In addition, specially trained massage therapists can promote lymphatic wellness and help prevent lymphedema. It is important that the physical and massage therapists are specially trained to treat oncology patients in general and patients at risk for lymphedema in particular, as an incorrect technique can further damage a fragile lymphatics system and exacerbate the problem. Furthermore, having multiple departments trained in lymphedema recognition increases the chances of catching all at-risk patients and identifying issues early. In addition, the IM department sees patients from within and from outside of the BHS system, thus affording the opportunity to identify additional at-risk patients. In 2013, the IM department throughout BHS had over 1500 visits from oncology patients (including new and repeat visits). These visits include BHS inpatients and outpatients and also those who were treated for their cancer outside of BHS. As mentioned, these oncology patients are screened for signs of lymphedema, resulting in a significant fraction of patients that would not otherwise have been included into the lymphedema management program.
Conclusions e why an integrative approach? More than 1100 patients per year are diagnosed with breast cancer at BHS. Of these, 3e400 undergo a complete axillary lymph
Fig. 1. Lymphedema-related visits to the Beaumont Health System Breast Care Center, 2008e2013.
Fig. 2. A schematic indicating the integrated approach to breast cancer patient management at the Beaumont Health System.
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An integrative approach also reduces costs to the patient and the system. Once insurance will no longer cover PT session, patients may utilize massage therapy at a lower-cost alternative. Under appropriate conditions, massage can be a viable, useful option for patients who cannot afford multiple PT sessions. Currently, approximately 10% of the patients seen in the lymphedema clinic are also seen in the IM department for oncology massage. The average number of massage treatments received by these patients is ~2e3 per patient; however, the number varies greatly, with one individual patient receiving 60 massages from the IM department in a single year. In addition, the emphasis on preventing lymphedema avoids the increased costs associated with the overt condition. Finally, the integrative approach is appreciated by patients and increases satisfaction, as evidenced by numerous testimonials from patients, physicians, donors, and staff. The emphasis on prevention reduces lymphedema-associated morbidity. Moreover, the integrative approach encompasses all aspects of patient care, physical, psychological, and emotional, and treats the patient as a whole person. This situation, for a patient who may have been viewed as their disease, can increase their sense of well-being and help them on the road to recovery. Conflict of interest statement The authors have no conflicts of interest to disclose. Acknowledgments We would like to thank Christine Billecke, Ph.D. for her assistance in the preparation of this manuscript. References [1] McLaughlin SA. Lymphedema: separating fact from fiction. Oncol Willist Park Mar 2012;26(3):242e9. [2] Shah C, Arthur D, Riutta J, Whitworth P, Vicini FA. Breast-cancer related lymphedema: a review of procedure-specific incidence rates, clinical assessment AIDS, treatment paradigms, and risk reduction. Breast J JuleAug 2012;18(4):357e61. [3] Morrell RM, Halyard MY, Schild SE, Ali MS, Gunderson LL, Pockaj BA. Breast cancer-related lymphedema. Mayo Clin Proc Nov 2005;80(11):1480e4. [4] Ridner SH. Pathophysiology of lymphedema. Semin Oncol Nurs Feb 2013;29(1):4e11.
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