Lymphedema and Vascular Access
Overcoming the Myths
Sheryl McDiarmid, RN, BSCN, MEd, MBA, AOCN®, ACNP, CVAA(c),CRNI(c)
CVAA Vancouver 2016 Financial Disclosures
1. Disclosure of Relevant Financial Relationships None
2. Disclosure of Off-Label and/or investigative Uses I will not discuss off label use and/or investigational use in my presentation.
CVAA Vancouver 2016 Learning Objectives:
This session will: Review anatomy and physiology of the lymphatic system Identify risk factors for secondary lymphedema Describe the implications for vascular access clinicians Discuss strategies for overcoming the myths to ensure patients and clinicians make well informed decisions related to vascular access and lymphedema
CVAA Vancouver 2016 Why is it so important?
25,000 women are diagnosed each year with cancer 5 year survival with stage III 72% 15% of women with metastatic breast cancer survive more than 5 years Median age at diagnosis is 61 years Breast cancer incidence continues to rise while mortality rates continue to fall Patients surviving breast cancer develop other health problems that require vascular access
CVAA Vancouver 2016 The Lymphatic System
A network of tissues and organs • Lymph vessels • One way and open ended • Thin walled, some valved • Superficial and deep • Lymph fluid • Protein rich fluid • 20-30 Litres/day produced • Forced through vessels by body movements • Lymph nodes • > 600 throughout the body • Filter harmful substances Anatomy of the Lymphatic and Immune Systems by OpenStax CVAA Vancouver 2016 The Lymphatic System
Functions • Preservation of fluid balance • Filters and collects lymph and large molecules in the interstitial space that come from the intravascular space • Intestinal lymphatic vessels absorb lipids from the intestinal tract • Host defense • Immune surveillance • Transports antigens
CVAA Vancouver 2016 Lymphatic Capillaries
Interstitial fluid enters the lymphatic system and becomes “lymph fluid” Lymph then travels through multiple lymphatic channels and nodes before returning to the venous system by the thoracic duct. The entry of fluid and other materials into the interstitial space is balanced by outflow of the lymphatic fluid
Anatomy of the Lymphatic and Immune Systems by OpenStax
CVAA Vancouver 2016 Lymphedema
Swelling in a body part due to excess accumulation of protein rich fluid in the interstitial spaces. Starling’s law "... there must be a balance between the hydrostatic pressure of the blood in the capillaries and the osmotic attraction of the blood for the surrounding fluids. “
Starling, E.H. On the adsorption of fluid from interstitial spaces. J Physiol. London 19:312-326, 1896.
CVAA Vancouver 2016 No universal definition of lymphedema
10% or greater change in limb volume Greater than 1 cm to 2 cm change from baseline Greater than 2 cm change from unaffected limb 2 cm increase in 2 consecutive anatomic sites Greater than 200 mL of volume increase ACOSOG : 2cm or greater increase over the baseline or greater than 10% increase in circumference of the ipsilateral arm at 10 cm proximal and distal to the lateral epicondyles. Subjective reports of heaviness, pain
CVAA Vancouver 2016 Differential Diagnosis
Edema Deep Vein Thrombosis Chronic Venous Insufficiency Infection Malignancy
CVAA Vancouver 2016 Pathophysiology of Lymphedema
A transport system breakdown with edema and protein A result of damage or malformation of the lymph system
CVAA Vancouver 2016 Forms of Lymphedema
Primary Impaired development of the lymph system Occurs most often in lower extremities May be present at birth or may develop later in life Secondary Often insidious A result of damage to the lymph system
CVAA Vancouver 2016 Secondary Lymphedema
CVAA Vancouver 2016 Lower-Limb Lymphedema
Gynecological cancers (20%) Vulvar cancer (36%) Ovarian cancer (5%) Melanoma (16%) Genitourinary cancer (10%)
CVAA Vancouver 2016 Stages of Lymphedema
Stage 1 (latency) Subclinical Stage 2 (Spontaneous reversible) Mild – soft pitting edema that elevation resolves Stage 3 (Spontaneous irreversible) Moderate – fibrosis that reduces the ability of the skin to indent with pressure Stage 4 (Elephantiasis) Severe – fibrosis with hypertrophic skin changes, massive limb size changes possible Stage 5 Progression to malignant lymphangio-sarcoma
CVAA Vancouver 2016 Epidemiology of Lymphedema in Patients with Breast Cancer
15-20% of breast cancer survivors are at a clinical risk of lymphedema 80-85% will remain free of lymphedema occurrence Can occur within days to up to 30 years after treatment for breast cancer Average time to onset is 14.4 months after treatment completion 70% experience onset within 2 years of surgery,90% within 3years 1% per year onwards
CVAA Vancouver 2016 Breast Cancer Stage at Diagnosis
61% of breast cancer cases are diagnosed while the cancer is still confined to the primary site- localized. (Stage I and II) 31% are diagnosed after the cancer has spread to regional lymph nodes or directly beyond the primary site - regional. (Stage III) 6% are diagnosed after the cancer has already metastasized - metastatic (Stage IV) Staging information is unknown for 2% remaining
CVAA Vancouver 2016 Risk Factors Associated with the Development of Breast Cancer Associated Lymphedema
Axillary lymph node dissection > 10 nodes removed Sentinel node excision between 5 & 17% Obesity – BMI greater than 30 at time of diagnosis – 3.6% more likely to develop lymphedema Radiotherapy Scarring of the left or right subclavian lymphatic ducts by either surgery or radiation Delayed wound healing (cellulitis) CVAA Vancouver 2016 Sentinel Lymph Node Dissection
When is it indicated? When is it not indicated?
Ductal Carcinoma in Situ (DCIS) When the cancer is > 5cm or with mastectomy locally advanced In women who have previously Inflammatory breast cancer had breast cancer surgery or DCIS treated with lumpectomy axillary node surgery The woman is pregnant In women who have been treated before with systemic treatment
CVAA Vancouver 2016 Lymph Node Dissection
• In both types lymph nodes are removed Axillary Lymph Node • Axillary dissection Dissection removes more • Extensive tissue damage can occur with axillary dissection • Since 1998 the use of SLB has increased from 27% to 66% • No lymph node dissection is indicated in de novo stage IV breast cancer CVAA Vancouver 2016 Staging Breast Cancer
Do patients: Know the extent of their lymph node dissections? Understand the long term risks related to axillary lymph node biopsy? Recognize that sentinel lymph node biopsy is evolving in selected clinical settings? Know that surgeon expertise is an important factor in staging outcomes?
CVAA Vancouver 2016 Impact of Lymphedema on Patients
Altered sensation in the limb Loss of body confidence, decreased physical activity, fatigue Psychological distress, frustration, depression, and anxiety are reported time and time again using well established and validated tools Overall reduction in quality of life
CVAA Vancouver 2016 Preventing Lymphedema
CVAA Vancouver 2016 Prevention of Lymphedema
What is the recommendation to not establish vascular access on the “affected side” based on? In 1992 a women noticed the onset of lymphedema 30 years after breast cancer surgery and 10 days after she commenced finger prick testing to monitor her diabetes…… Another case of a sewing machine needle puncture and subsequent lymphedema…. Single case of lymphedema post vaccination on surgical side
CVAA Vancouver 2016 Preventing Lymphedema by Avoiding Venipuncture
What is the Issue: If a foreign object (needle) is placed in the arm does it cause an immune response and put the lymphatic system under more stress? Infection? Sterile vascular access devices are inserted using aseptic technique and closely monitored for phlebitis. Maki 2006 reports the infection rate with peripheral intravenous catheters was 0.5 per 1000 catheter days Is it the tourniquet?
CVAA Vancouver 2016 National Lymphedema Network
People at risk for developing lymphedema should consider taking the following actions and precautions: If required to have venipuncture inform the phlebotomist of your lymphedema risk and use a not-at-risk limb if possible. If not possible, inform the phlebotomist of your lymphedema risk condition and ask for the most experienced phlebotomist. Do not allow multiple or traumatic searches for veins, which can increase tissue edema. Cites Cole, T. Risks and benefits of needle use in patients after axillary surgery. BrJNurs. 2006;15(18):969-979
CVAA Vancouver 2016 What Does T. Cole have to Say?
This article discusses the current evidence available on the subject of non-accidental skin puncture (NASP) relating to the patient at risk of lymphedema and provides guidelines for any professionals conducting such procedures for patients with a history of cancer. The results from a small audit of the guidelines are cited and they reveal that out of 14 patients who underwent NASP procedures in the at risk arm, no patients reported swelling to that limb within a month of these procedures.
CVAA Vancouver 2016 Cole continues
In light of little methodological sound evidence any research or case reports that have been published can be useful to guide practice. Clark et al (2005) in the only prospective study available concluded: Skin puncture (44% versus 18% for those who had none), mastectomy, and BMI > 26 significantly increased the risk of lymphedema. Other features previously postulated as risk factors (surgery on dominant side, age, axillary node status, number of axillary nodes removed, radiotherapy) were not associated with lymphedema in this study. 80% had developed lymphedema by 1 year post surgery
CVAA Vancouver 2016 Recent Literature
Ferguson et al., (2015) JCO 632 patients prospectively screened, 3041 arm measurements No significant association with blood draws, injections, number or duration of flights Significantly associated factors included BMI > 25, axillary lymph node dissection, regional lymph node irradiation, and cellulitis Concludes with statement “we cannot affirmatively state that risk-reduction practices have no effect on arm swelling we hope to generate evidence that brings about reasonable doubt”
CVAA Vancouver 2016 National Lymphedema Network
Controversies Regarding Lymphedema Risk Reduction Practices Air travel – little evidence that lymphedema is caused or worsened by air travel Blood pressure cuffs – studies have not determined the actual risk of having BP taken on the at-risk-arm
CVAA Vancouver 2016 Lifestyle Risk Factors Associated with Arm Swelling
Randomized controlled trial 295 breast cancer patients Exposure to 30 different potential risk factors 9% experienced arm swelling Sauna use only significant factor Non-white and non-black participants had a significantly increased risk for experiencing arm swelling.
CVAA Vancouver 2016 Contradictory Evidence
Several studies now suggest that neither blood pressure measurement nor venipuncture on the surgical side are risk factors Historical data on women with bilateral breast cancer and bilateral lymph node dissection do not show an increased prevalence of lymphedema when either arm is used Surgery for carpal tunnel syndrome on “affected” side shows no increase in lymphedema rates Patients requiring hemodialysis have fistulas placed in “affected” side without development of lymphedema CVAA Vancouver 2016 Exercise and Lymphedema
Old Rationale New Evidence
Historically, heavy Exercise increases resistance training was muscle mass and the discouraged in women muscular pump which with lymphedema facilitates movement of because it increased lymph fluid blood flow, adding to Exercise also helps to the workload of the combat obesity which is lymph system and a potent risk factor for overwhelming a lymphedema compromised system
CVAA Vancouver 2016
Challenging Teachings about Exercise
Began 1996 at the University of British Columbia Don McKenzie – sports medicine physician who was studying cardio-respiratory fitness of BC survivors Strove to dispel the myth that women with BC should refrain from repetitive upper body exercise for fear of lymphedema “Abreast-In-A-Boat” – 1st all BC survivors team Training: slow, progressive weight and aerobic training No new cases of lymphedema; no worsening of existing cases CVAA Vancouver 2016
Pre-Operative Assessment of Breast Cancer Patients by Physical Therapists Improves Lymphedema Diagnosis and Treatment
The authors demonstrated the effectiveness of a surveillance program to successfully detect and treat lymphedema Detection and management of lymphedema at early stages may prevent the condition from progressing Once lymphedema was diagnosed (3%) it was managed using a light-grade compression sleeve and gauntlet for daily wear for 4 to 6 weeks and then PRN
CVAA Vancouver 2016 Does marketing influence beliefs?
The serious condition of lymphedema slows down many people. But for those who’ve discovered N-Style ID medical jewellery, it’s merely a speed bump in the road. With practical information and posh style, our assortment of lymphedema bracelets provides extra peace of mind, so you get on with your life.
CVAA Vancouver 2016 Is this a better marketing strategy?
CVAA Vancouver 2016 Where does that leave the patient?
Psychological burden of having to protect the affected arm Life time risk – patients living longer with other health issues Contradictory information given to patients Reduces confidence in the health care system when conflicting information given
CVAA Vancouver 2016 Where does that leave the vascular access provider?
Venipuncture limited to one arm in women who already have smaller veins Restricts options in emergency situations Patients wear pink lymphedema bracelets Patients feet are being used for vascular access Increase use of central vascular access devices Insertion of central vascular access devices in less than optimal veins
CVAA Vancouver 2016 Managing Lymphedema
CVAA Vancouver 2016 Management
No current surgical or medical interventions exist Complete Decongestive Therapy (2 randomized trials) Manual lymph drainage Multi-layer, short stretch compression bandaging Lymphatic exercise Skin care Compression garments Weight loss
CVAA Vancouver 2016 Lymphedema and Cellulitis
Lymphedema conveys a 71-fold enhancement of risk for cellulitis The increased distance between the blood vessels and the tissues combined with lymph stasis causes: Impaired nutritional status Decreased oxygen to tissues Delayed immune response
CVAA Vancouver 2016 Cellulitis
Cellulitis is a common skin infection caused by bacteria. Staphylococcus and streptococcus bacteria are the most common causes of cellulitis.
CVAA Vancouver 2016 New Theories
New lymphatic genes and molecular proteins have been discovered The prospect of preventative intervention or pharmacological treatment is especially attractive given the estimated prevalence of up to 600,000 women who suffer from secondary lymphedema post breast cancer surgery Historically difficult to enroll breast cancer patients in lymphedema studies
CVAA Vancouver 2016 Our Approach at TOH
Met with Medical Oncologists They are in agreement about lack of evidence Most feel patients are obtaining information elsewhere They have agreed to start conversation with patients on why “protecting” the affected side from venipuncture is not necessary and the risks associated with that approach Vascular Access Team introduces concept of the best vein for access to reduce risk of complication Need to spread the word to other health professionals – RNs, Surgeons, Radiation Oncologists, Physiotherapists…….. APN co-investigator in study looking at the issue Rome was not built in a day
CVAA Vancouver 2016 What Can Vascular Access Experts Contribute?
Participate in studies as they become available Educate professionals Develop guidelines Advocate for vascular access experts in health care facilities Provide consistent information to patients Discuss risk/benefits Know the data
CVAA Vancouver 2016 Lymphedema: What you do not need to know
CVAA Vancouver 2016 References
Showalter, S. et al., Lifestyle Risk Factors Associated with Arm Swelling among Women with Breast Cancer. 2013. Ann Surg Oncol: 20(3):842-849 National Lymphedema Position Paper: The Diagnosis and Treatment of Lymphedema National Lymphedema Position Statement: Lymphedema Risk Reduction Practices 2012. Cole, T. Risks and benefits of needle use in patients with axillary node surgery. 2006. BrJN. Oct 12;15(18):969. Ferguson, C. et al., Impact of Ipsilateral Blood Draws, Injections, Blood Pressure Measurements, and Air Travel on the Risk of Lymphedema for Patients Treated for Breast Cancer. 2015. J Clin Oncol. Lyman, G. et al., Sentinel Lymph Node Biopsy for Patients with Early-Stage Breast Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update. 2014 Clark, B. Incidence and risk of arm oedema following treatment for breast cancer: a three-year follow-up study. QJM 2005. May;98(5):343-8. Winge, C. et al., After axillary surgery for breast cancer – is it safe to take blood samples or give intravenous infusions. J Clin Nurs 2010 May; 19(9-10):1270-4. Newman, B. et al. Possible Genetic Predisposition to Lymphedema after Breast Cancer. Lymphatic Research and Biology. 2012;10(1). Effect of Upper Extremity Exercise on Secondary Lymphedema in Breast Cancer Patients: A Pilot Study J Clin Onc. 2003 Stout Gergich, N.L., et al., (2008), Preoperative assessment enables the early diagnosis and successful treatment of lymphedema. Cancer, 112: 2809–2819.
CVAA Vancouver 2016 Thank you
CVAA Vancouver 2016