LYMPHEDEMA IN PALLIATIVE CARE SARAH BUDDINGH SMITH, BSC, MPT BC CANCER PHYSIOTHERAPIST [email protected]
Jul 22, 2020
LYMPHEDEMAIN PALLIATIVE CARE
SARAH BUDDINGH SMITH, BSC, MPT
BC CANCER PHYSIOTHERAPIST
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• Lymphedema Education Benchmark Statements
• Interprofessional roles in best practice
• Research update on effective treatment
• Advanced cancer & edema at end of life
• Referrals & resources
OBJECTIVES
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• Lymphedema Education Benchmark Statements
• Interprofessional roles in best practice
• Research update on effective treatment
• Advanced cancer & edema at end of life
• Referrals & resources
OBJECTIVES
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BENCHMARK 1: LYMPH SYSTEM ANATOMY & PHYSIOLOGY
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BENCHMARK 2: PATHOPHYSIOLOGY OF LYMPHEDEMA
Planas-Paz and Lemmert 2013
RISK FACTORS FOR LYMPHEDEMA:
• Cancer• Surgical resection• Radiation• Tumor compression
• Venous insufficiency
• Obesity
• Immobility
• High exposure to mosquito bites
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BENCHMARK 3: OTHER CAUSES OF EDEMA
•Cellulitis
•Deep vein thrombosis
•Other vascular disorders
•Systemic disorders, e.g. cardiac, liver or renal
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BENCHMARK 3: EDEMA IN END OF LIFE
•Advanced Cancer
• Metastases
• Drugs
• Hypoalbuminaemia
• Ascites
•System Failure
• Chronic heart failure
• End stage renal disease
• End stage chronic respiratory disease
• Advanced liver disease
• Advanced neurological disease
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BENCHMARK 4: FEATURES OF LYMPHEDEMA
Principles and Practice of Lymphedema Surgery. July 2015.
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• Lymphedema Education Benchmark Statements
• Interprofessional roles in best practice
• Research update on effective treatment
• Advanced cancer & edema at end of life
• Referrals & resources
OBJECTIVES
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BENCHMARK 5: PATIENT EDUCATION
• Use BC Cancer handout
• With damaged lymph
nodes, always at risk
• No cure, only self-
management
• Early detection is key
• Treatment available
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BENCHMARK 6: LYMPHEDEMA MANAGEMENT
•Complex Decongestive
Therapy (CDT)
•Two phases:
• Intensive
•Maintenance
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MANUAL LYMPHATIC DRAINAGE
Lymphedema: Diagnosis and Therapy, 4th edition.
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COMPRESSION
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SKIN CARE
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EXERCISE
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SURGERY
MD Anderson
• Surgical Reduction
• Bypass lymphatic obstruction
• Liposuction
• VGH developing a surgical
program
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• Lymphedema Education Benchmark Statements
• Interprofessional roles in best practice
• Research update on effective treatment
• Advanced cancer & edema at end of life
• Referrals & resources
OBJECTIVES
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• Multifactorial edema
• Patient directs priorities
• Focus on quality of life
• Refer to Allied Health
ADVANCED CANCER & END OF LIFE
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• What region of the body?
• Head & Neck
• Genital
• Widespread
• Venous compression from a
tumor?
• Cellulitis?
• Fungating wound?
• Paralysis?
END OF LIFE ALGORITHM
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SUBCUTANEOUS LYMPHATIC DRAINAGE
Jacobsen & Blinderman (2011)
• Severe refractory lymphedema due to obstructive cancer
• Genitalia, lower abdomen, legs
• Pitting edema, no fibrosis
• #17 Gauge dialysis catheter(s)
• Urinary leg drainage bag
• Monitor for fever and
hypotension
• VGH PCU and BC Cancer
can perform
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• Lymphedema Education Benchmark Statements
• Interprofessional roles in best practice
• Research update on effective treatment
• Advanced cancer & edema at end of life
• Referrals & resources
OBJECTIVES
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• www.bccancer.bc.ca
Search “lymphedema”
• Patient handout
• Symptom Management
Guideline #9
ONLINE: PROVIDER
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• www.lympho.org
• Position documents
• Lymphedema in
Advanced Cancer &
Edema at End of Life
ONLINE: PROVIDER
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Canadalymph.ca
BClymph.org
Cancer.ca
CancerConnection.ca
ONLINE: PATIENT
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• Public
• Cancer Center
• Hospital Outpatient Department
• Home Care
• Private Practice
• Physical Therapy
• Massage Therapy
REFERRALS
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St. Paul’s Hospital
Royal Jubilee Hospital
Surrey Memorial Hospital
Abbotsford Regional Hospital
REFERRALS: HOSPITALS IN BC
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• Lymphedema significantly affects function
and quality of life
• Consider the lymph system when assessing edema
• Management algorithms are available online
• Educate patients on
• Monitoring for signs & symptoms
• Self management
• Refer to your Allied Health colleagues
CONCLUSION
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• Lymphoedema Education Benchmark Statements https://www.lympho.org/lebs/
• Lymphedema: Diagnosis and Therapy, 4th edition. Weissleder and Schuchhardt.
• Best Practices for the Management of Lymphedema https://www.lympho.org/wp-
content/uploads/2016/03/Best_practice.pdf
• The Management of Lymphoedema in Advanced Cancer and Oedema at the End of Life
https://www.lympho.org/wp-content/uploads/2016/03/Palliative-Document.pdf
• Introduction to the Lymphatic System, National Cancer Institute
https://training.seer.cancer.gov/anatomy/lymphatic/
• Moore JE Jr, Bertram CD. Lymphatic System Flows. Annu Rev Fluid Mech. 2018;50:459–482.
doi:10.1146/annurev-fluid-122316-045259 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5922450/
• https://www.lymphcareusa.com/professional/lymph-a-what/what-is-lymphedema/what-causes-
lymphedema.html
• Moore JE Jr, Bertram CD. Lymphatic System Flows. Annu Rev Fluid Mech. 2018;50:459–482.
doi:10.1146/annurev-fluid-122316-045259
• Planas-Paz and Lammert 2013. Mechanosensing in Developing Lymphatic Vessels. Available from:
https://www.researchgate.net/figure/Mechanotransduction-in-secondary-lymphedema-formation-a-
hypothetical-model-a_fig2_258923453 [accessed 25 Sep, 2019]
• Principles and Practice of Lymphedema Surgery. Cheng MH, Chang DW, Patel KM (Editors). Elsevier Inc, Oxford,
United Kingdom. ISBN 978-0-323-29897-1. July 2015.
• Self-Measured Arm Circumference in Women With Breast Cancer Is Reliable and Valid
https://www.ncbi.nlm.nih.gov/pubmed/30289500
• Jacobsen & Blinderman (2011). Subcutaneous Lymphatic Drainage (Lymphcentesis) for Palliation of Severe
Refractory Lymphedema in Cancer Patients. https://doi.org/10.1016/j.jpainsymman.2010.09.015
• Sellick. Subcutaneous Draining of Lower Extremity Edema in a Patient With Advanced Cancer Relieves Scrotal
Swelling and Improves Mobility DOI: 10.1200/JOP.2017.025429 Journal of Oncology Practice 14, no. 1 (January
01, 2018) 49-51.
REFERENCES