Living well with Cancer

Living well with CancerLiving well with

Lymphoedema

Norah Kyne, MISCP, CDT Therapist

University Hospital Galway

GUH Cancer Centre Annual Report 2012Breast Medical OncologyUrological Radiation OncologyUpper GI Cancer NursingColorectal Palliative MedicineSkin Cancer ResearchLung and cardiothoracic Education and

TrainingHead and Neck Cancer Charity

SupportEndocrine Stem Cell UnitHaematological Clinical TrialsRadiologyPathology

Cancer and/or Neoplastic Diagnosis recorded 2012

Gastrointestinal 363

Breast 860

Genitourinary 964

Dermatology 1859

Gynaecologic 96

Lung and mediastinum 155

Head and Neck

126Haematolymphoid

330Bone and soft tissue

67

Other 84

Physiotherapy managementSurgery - pre-operative as available, deep breathing exercises,

anti – dvt exs, posture, range of motion, scar management

Chemotherapy – management of fatigue, graduated

exercise programme

Radiation – range of motion, decreased skin mobility

Rehabilitation - depending on diagnosis

Lymphoedema management - based on

presentation of lymphoedema

Scar impact

Scar management

Location : potential barrier for lymphatic drainagedoes it limit joint mobility

Treatment(2-3 weeks post surgery as per Doctor’s protocol)MobilizationPrevent adherence and hypertrophyScar products eg mepiform(silicon)Foam (swell spot)

Kinesotape (post 4 weeks/no radiation)

Cording/Axillary Web

CausesInterruption to lymphatic vessels during

biopsy or lymph node dissection - fibrosiss

Incidence : around 19%

Treatment :Stretching and flexibility exercisesManual therapy

Definition of lymphoedema

Lymphoedema is the accumulation of protein rich fluid in tissues with inadequate lymphatic drainage.

National Lymphoedema Network (May 2012)

What can cause lymphoedema after cancer ?

Insult to the lymphatic system following

surgery and/or radiotherapy

Extent of surgery

Wound infection after surgery

BMI > 26

L

Incidence of breast cancer in Ireland from 2008 -2010

Females : 2,767 Males : 22

Arm lymphoedema 24-67% Breast lymphoedema 20-40% Trunk lymphoedema

Most common presentations with secondary lymphoedema

Upper Limb

Swelling in the arm is common, but the breast, chest and back areas can also develop lymphoedema

Lower limb lymphoedemacancers in the pelvic regionIncidence in Ireland 2008 – 2010Cervix : 308 incidence of lymphoedema 18%

Uterus : 389 incidence of lymphoedema 17%

Ovary : 345 incidence of lymphoedema 7%

Other gynaecological cancers : 99 (incidence of lymphoedema 47%)

Prostate : 3,014 incidence of lymphoedema 4%

Testes : 175 incidence of lymphoedema ?10%

Penile : 2% of all male tumors incidence of lymphoedema 21%

Bladder : female – 124, male – 310 incidence of lymphoedema 16%

Gynecological Cancer Secondary Lymphedema

Upper limb or lower limbMelanomaIncidence of Melanoma in Ireland 2008 –

2010

Females : 463 Males : 349

Sentinal node clearance : 1.7%

Axillary node clearance : 1 – 12%

melanoma

Head and NeckIncidence of mouth and pharynx cancer in

Ireland 2008-2010Females 119, Males 227

Treating LymphoedemaCDT:

Complete Decongestive Therapy

Treatment of lymphoedema4 cornerstones of care:

1. Skin care2. MLD/SLD3. Compression via multilayer bandage or garments4. Exercise

CDT

Benefits of CDTReduction of pain/discomfort

Reduced risk of infection/cellulitis

Maintain/improved skin texture

Improve motion and ability to perform daily

activities

Decrease fear and increase control over the

condition of lymphoedema – empower

Improve quality of life

Skin and nail careDecrease risk of infection

Keep skin supple and clean

Avoid injury (nicks, bites, burns etc)

Clean all injuries immediately

Lotions – non perfumed

Skin care : infectionSigns/symptomsRed, warm/hot, pain, not feeling well,

temperature, increased swellingGo to GP or emergency department

Manual Lymphatic DrainageMLD aims to redirect fluid from swollen areas to healthy lymphatic vessels, transporting it back to the normal circulatory system .

With gentle, light but precise hand movements applied to the skin.

This encourages the fluid away from congested areas by bypassing ineffective or injured lymph vessels. The treatment is very gentle and a typical session will involve drainage of the neck, trunk, and the affected extremity (in that order), lasting approximately 40 to 60 minutes.

The technique was pioneered by Doctor Emil Vodder in the 1930s for the treatment of chronic sinusitis and other immune disorders

Manual Lymphatic Drainage

Simple/self lymphatic drainage

Self Lymphatic drainage:

Deep breathing plus SLD

Multi layer compression bandageReduce swelling and prevent re-accumulation

of fluidProvides a firm support for muscles, whose

contractions against the lymph vessels enhance lymph flow

Compression garments

Exercise

ExercisePumping action moves lymph through the

lymphatic systemDeep breathing stimulates lymph flowMaintains strong muscles which give

protectionWear well fitting garmentsImprove sense of health and well-beingWalk, bicycle, swim, yoga, dance, housework !

OVERALL IMPROVE YOUR QUALITY OF LIFE

CDT

CDT should be carried out by a certified

lymphoedema therapist

Number and frequency of treatment depends on

severity of lymphoedema

Access to service will influence management

Compression garments as appropriate are fitted

On discharge self – management is key!

Self management

At discharge from treatment you should

know

Day time compression products

Night time compression

Skin care

Exercise programme

Self manual lymphatic drainage

Self managementCompression garments daytime :Freedom of movement

Provide pressure to control lymphoedema

Strong but not too strong that it is difficult to

get on or off

Well fitted

No constrictions

Compression garments

Compression at night

Depends on stage of management of conditionIn discussion with your therapist Made to measure garments available

Improved range of garments

Exercise (NLN)

Start gradually/conservativelyAdd exertion slowly and in small increments

only if there has been no increase in lymphoedema after exercise to date

Stay well hydratedTake periodic deep abdominal breaths –

facilitate lymph drainageAvoid temperature extremesModify moves to accommodate your own

needsWarm up, cool down, stretch

Self management

Lymphoedema cannot be cured but it can be managed

Self management is critical to reduce exacerbations of lymphoedema, infections and other symptoms associated with lymphoedema.

Self management

Can you prevent lymphoedema ?No-one can prevent lymphoedema once lymph

nodes have been removed or if radiation over lymph nodes

It can occur at any stage after surgery /irradiation

The goal is to

Reduce your risk

Risk reduction(National Lymphoedema Network NLN )

Protect skin – insect repellent, sunscreen, nail care

Avoid injections - in at risk limb

Exercise – gradually build up duration and intensity;

monitor reaction of limb

Avoid prolonged extreme heat or cold – (>15 mins) eg

hot tub/sauna

Weight control – manage your weight and well being

Know your body – pay attention to areas at risk

If you notice early symptoms seek medical attention

Early symptoms

Swelling – you may notice clothes

feeling tighter on affected side

A feeling of heaviness in the limb

Pain

Be informed/educationThe Irish Cancer Society – www.cancer.ie

Irish Health – www.irishhealth.com

Lymphoedema Ireland – www.lymphireland.com

Manual Lymphatic Drainage Ireland – www.mld.com

Gary Kelly Cancer Support centre – www.gkcancersupport.com

LARCC(Lakelands area Retreat & Cancer Centre – http://larcc.ie/

Arc Cancer Support – www.arccancersupport.ie

InformationNational Lymphoedema Network

(www.lymphnet.org)

Lymphatic Research foundation

(www.lymphaticresearch.org)

Current ServicesDCU/ICS research 2010, Living with Lymphoedema in Ireland :Patient and Service Provider Perspectives

Key Findings

Service settings

Public

Private

Cancer Support centre

Hospice

Community

Lymphoedema PractitionersMost work in large public hospitals 62.8%

Profile of practitioners : physiotherapists 48.6%, breast

care nurse 13.1%, PT manager 10.3%, MLD therapist 10.3%, OT

6.5%, Lymph nurse specialist 1.9%, other 15%

28 practitioners in a dedicated service

No report of Social worker, Psychologist or

Psychiatrist in any service

Referral SystemsHospital oncology clinicHospital surgical clinicsHospital Physiotherapy clinicsHospital dermatology clinicsCommunity Physiotherapy clinicsGeneral PractitionersPatients self referringFamily/Friends of patientsOther (eg palliative care teams, Cancer Care

Centres etc

Areas providing lymphoedema servicesArea % general service

N= 108% dedicated serviceN = 18

Dublin 33.3 50

Cork 14.8 11.1

Donegal 9.3

Galway 6.5

Laois 3.7 5.6

Cavan 3.7

Tipperary 3.7

Wexford 2.8 11.1

Westmeath 2.8

Meath 2.8

Louth 2.8

Lymphoedema Services contArea % general service

n= 108% dedicated serviceN= 18

Limerick 1.9 5.6

Mayo 1.9

Monaghan 1.9

Wicklow 1.9

Waterford 0.9 5.6

Sligo 0.9

Clare 0.9

Kerry 0.9

Kildare 0.9

Current ServicesDCU/ICS research 2010

Some Key Findings

Lymphoedema services are insufficient and patchyKey challenges exist with regard to sustainability

of servicesDelays with garments may compromise service

provisionPatients identified eg barriers to treatment,

impact of lymphoedema on daily life, fear of uninformed health professional inadvertently worsening their condition

Future Services – Good news !More information/education to public about

lymphoedema

Physiotherapy training : Education about and management of lymphoedema is included at undergraduate level

HSE National Director of Quality and Patient Safety Philip Crowley – supported carrying out a survey of

current lymphoedema Services , awaiting feedback .

NCCP are establishing a group to look at lymphoedema prevention – Physiotherapist sitting on this group

Thank you for your attentionAny Questions ?