Comprehensive Guide to Lymphedema: Causes, Prevention, and Management Strategies

Lymphedema is a chronic condition caused by a blockage in the lymphatic system where the tissues swell due to the build-up of fluid that is normally drained from the body through the lymphatic system. This can cause swelling in the arms or legs and, in some cases, can occur in the neck, armpits, abdomen, and groin area.

Lymphedema may result from various factors including cancer treatments, trauma, heat or cold exposure, and obesity. Cancer therapies like surgery, chemotherapy, and radiation often damage lymph nodes, increasing the risk of lymphedema. Although not everyone undergoing treatment develops lymphedema, regular clinical exams and prompt medical attention for swelling or infections are crucial. Other triggers include air travel, carrying heavy loads, prolonged standing, and constriction of affected areas. Awareness of these risk factors can aid in prevention and early detection, emphasizing the importance of proactive healthcare management for individuals susceptible to lymphedema.

To learn about strategies for preventing and managing arm lymphedema, and what infection preventionists should know about associated infections, Infection Control Today^® (ICT^®) spoke with Steven Chen, MD, MBA, and chief medical officer, ImpediMed for his insights.

ICT: What are some of the most effective early intervention strategies for patients at risk of developing arm lymphedema after cancer treatment, and how do they differ from traditional approaches?

Steven Chen, MD, MBA: Traditionally, clinicians often waited until symptoms of lymphedema began to develop before attempting to intervene. Unfortunately, this means most patients are diagnosed with lymphedema at a later stage that cannot be reversed. A prospective surveillance model, however, can be the key to effective early intervention of breast cancer-related lymphedema. Utilization of tools such as a Lymphedema Prevention Program, based on the concept of getting a pretreatment baseline followed by regular surveillance to detect subclinical lymphedema, can aid in identifying those with lymphedema even before symptoms become apparent. If a patient has a trigger consistent with lymphedema, at-home treatment is initiated for 4 weeks. This model of care is supported by leading US and international clinical practice guidelines. Research has shown that 92% of patients with subclinical lymphedema detection using bioimpedance spectroscopy will not progress to chronic lymphedema if treated early, as identified using such a model.

ICT: We know that infections can complicate lymphedema. What proactive measures can patients take to prevent infections in the affected arm, particularly in the early stages of lymphedema development?

SC: Skin care is particularly important for patients at risk for lymphedema. This involves obvious things like good hand hygiene and less obvious measures such as proper pH of cleansers and moisturizers and avoiding sunburns and trauma to the skin. If patients incur a break in the skin, they should immediately wash the area and observe for signs and symptoms of infection, such as redness, warmth, and pain. They can also develop systemic symptoms such as rapid onset of fever or influenza-like symptoms. If they begin to develop any of these signs, they must seek immediate medical attention. Patients need to remember that their lymphatic system doesn’t just move fluid but also mediates their immune response in the limb and throughout the entire body. Additional measures that may be helpful include staying hydrated, exercising, and managing stress.

ICT: For infection preventionists and other health care workers, what pathogens are usually the cause of those infections?

SC:The most common pathogen associated with cellulitis is Group A Streptococcus (GAS), also known as Streptococcus pyogenes. This is a very common bacterium associated with skin infections in general. However, when a patient has lymphedema and the skin’s protective barrier is breached, the chances for infection increase due to compromised lymphatic circulation. Staphylococcus aureus and occasionally other types of streptococci are also implicated in many cases. Less common pathogens include Pasteurella multocida following bites or scratches from animals such as cats and dogs. Knowing the mechanism of injury can be important in understanding the possible pathogens involved.

ICT: In your experience, what are some common misconceptions patients have about lymphedema and its relationship to infection risk? How can health care providers effectively address and correct those?

SC: The most common misconception is that patients think lymphedema is an inert, benign swelling and don’t understand the impact of stagnant lymphatic flow that creates the impaired local immune response. It is a complicated situation that is not fully understood and is compounded by the lack of understanding among health care providers about the connection between lymphedema and cellulitis. Many patients have recurrent bouts of cellulitis and need a proactive approach to manage their lymphedema with the primary goal of preventing further infections that cause further damage to the lymphatic system. Health care providers need to learn about the growing body of evidence in the field of lymphatic microsurgery that can provide care for patients with repeated cellulitis infections.

ICT: Patient education plays a vital role in managing lymphedema risk. What key points should patients be aware of early on to prevent complications, and how can health care providers ensure effective communication in this regard?

SC: The best way to prevent infections due to lymphedema complications is to encourage patients to participate in prospective surveillance and treat any subclinical symptoms to decrease the likelihood of developing severe chronic lymphedema. This is done with shared decision-making, where a health care provider is knowledgeable about the risks and can work with the patient to make the best decisions for their unique, personal circumstances. Providers should be forthright about the possibility of lymphedema developing and ensure excellent 2-way communication between the care team and the patients to ensure that patients are able to describe their symptoms—which can be subtle. They should also reinforce that regular testing can be a useful adjunct to a clinical exam and improve compliance.

ICT: What are the most significant challenges health care systems face in ensuring early detection and timely intervention for lymphedema patients? How can these challenges be addressed on a broader scale?

SC: Identifying patients in the early stage of breast cancer-related lymphedema (BCRL) requires proactive screening by medical professionals. Currently, a diagnosis of chronic BCRL (C-BCRL) is typically made after visible or clinically apparent changes or symptoms occur. Before these changes, subclinical disease occurs, as indicated by an increase in extracellular fluid. Accurately identifying subclinical disease before it is visible facilitates early intervention and possibly C-BCRL prevention.

Many tools help quantify the development of subclinical (or early) BCRL. The only quantitative screening tool recommended by the National Comprehensive Care Network is bioimpedance spectroscopy. Additionally, it is crucial to educate patients about risk factors, early signs of lymphedema, and preventive measures.

Once early lymphedema is identified, customized exercise programs, delivered through digital platforms or inperson by trained therapists, can help maintain limb mobility and function, reducing the risk of lymphedema progression.

Digital platforms can offer educational resources, exercise programs, and tools for self-monitoring, promoting adherence to lymphedema prevention and management practices. Advanced imaging techniques can visualize lymphatic function and structure, aiding in early diagnosis and tailoring individual treatment plans.