Lymphedema(BCRL) - A complication of breast cancer treatments.

In our earlier blog about commonly asked questions about breast cancer , we have discussed about signs and symptoms of breast cancer , risk factors , diagnosis and various treatment options for breast cancer treatments in India.In this blog we are going to discuss a chronic but serious complication of breast cancer treatment - Breast cancer related lymphedema(BCRL). Lymphedema usually occur in breast cancer treated patients after about 4 to 6 weeks of surgery or radiation and then go away over time. The most common type of lymphedema is painless. It tends to slowly develop, most often within 3 years of surgery. It does not get better without treatment.

Almost 1 in 5 breast cancer patients who have undergone breast cancer treatments develop lymphedema. Lymphedema is a chronic complication of breast cancer treatment. Usually it occurs within weeks of treatment and subsides on it's own.But it can occur at anytime in the lifetime of breast cancer treated patient and if not prevented or treated early , it can be permanent and hampers the quality of life of a successfully treated breast cancer patient.

What is breast cancer treatment-related lymphedema ( BCRL):

Lymph is clear watery fluid that drains out from the blood capillaries into body tissues. The major functions of lymph are as follows:

• Drains out the extra fluid consisting of toxins and other waste products, formed due to metabolism between the cells into blood stream.
• Lymph helps in absorbing the fats and proteins from small intestine by transporting it to blood stream.
• Lymph also contains white blood cells that form the immune system of the body to fight again infections.

Because of breast cancer or breast cancer treatments ( surgery and radiation therapy ) the fluid drainage channels of lymphatic system are hampered and the lymph fluid can not be drained out quickly and start getting accumulated causing the area to swell causing lymphedema. Lymphedema can develop in the arm or hand of the affected side. It can also develop in chest,breast,shoulder,trunk or on the back 

If Lymphedema is not treated in time it can get worse. It can be painful and moving the affected arm or hand will be difficult.

Signs and symptoms of Lymphedema:

Lymphedema may have a slow onset of swelling in the arm , hands or fingers of the affected side or it could be acute too.

An unusual sensation in the hand of the affected side , usually numbness or tingling even before the swelling is noticeable.

Symptoms of lymphedema post breast cancer treatment may include:

• A recent change in skin either in appearance or texture such as itching , tightness, redness , rash or tightening.
• Feeling of discomfort , achiness , tingling or increased warmth in affected area hand , chest, breast or underarm.
• Feeling fulness or heaviness in affected area arm , chest , breast , underarm, shoulder or back.
• Tightness or difficulty in moving shoulder , hands and wrists.
• tenderness in the elbow
• Burning or shooting pain sensations that may seem like pricking with pins and needles.
• Slight puffiness or swelling in arm, hand, breast, or chest with a temporary indentation of the skin when one presses on it with one's finger (this is called pitting edema).
• Veins or tendons in the hand that are harder to see, knuckles that look less pronounced, or once-wrinkled skin that looks smoother.
• Fever or flu like symptoms

If one observe a sudden swelling in the arm , hand , chest , breast or underarm , one must seek medical attention asap as it may indicate an infection, a blood clot (also known as deep vein thrombosis), or cancer recurrence that is affecting the lymphatic system.

What are risk factors associated with breast cancer treatment related lymphedema:

Any event that might damage the lymphatic vessels and interrupts the channels of lymph drainage systems can be the causative factor for development of lymphedema or it's flare up. All the breast cancer treatment modalities including breast cancer surgery , Radiation therapy for treating breast cancer or even chemotherapy increases the risk of one's developing lymphedema post breast cancer treatments.

Breast cancer surgery as causative factor for lymphedema:

Surgery is the mainstay for breast cancer treatments. Breast cancer surgery involves removal of either the whole breast ( Mastectomy ) or removal of the tumor or lump 

( Lumpectomy ) along with involved lymph nodes specially the axillary lymph nodes in the armpit area. But a breast cancer surgery may also cause lymphedema in breast cancer patients. Your breast cancer surgeon and healthcare professionals will advise you the preventive measures to avoid lymphedema post breast cancer surgery.

An extensive breast surgery for treating breast cancer can disturb the lymph drainage channels of lymphatic system and may become a causative factor for lymphedema. Total mastectomy as compared to lumpectomy increases the risk more.

Axillary lymph node dissection ( ALND) largely determine a breast cancer patient's risk of developing breast cancer treatment related lymphedema ( BCRL). 

Both extensive axillary lymph node dissection ( ANLD) as well as less extensive Sentinel lymph node biopsy ( SLNB) increases life long risk of developing breast cancer related lymphedema ( BCRL) in breast cancer patients. 

Sentinel lymph node biopsy ( SLNB) is an effective option for staging the axilla while minimizing the risk of lymphedema in patients with clinically node negative breast cancer patients.

A lack of breast reconstruction post breast cancer surgery also increases risk of developing BCRL.

Breast cancer radiation therapy as causative factor for BCRL:

Radiation treatments for breast cancer can affect the lymphatic system. Scar tissue from radiation therapy may press on or narrow the lymph vessels and nodes that remain after breast cancer surgery. This damage interferes with the flow of lymph out of the arm and upper body.

Regional lymph node radiation ( RLNR) is also a causative factor for breast cancer treatment related lymphedema ( BCRL).

Regional lymph node radiation ( RLNR ) either supraclavicular with or without posterior axillary boost significantly increased the risk of breast cancer treatment related lymphedema risk compared to breast or chest wall radiotherapy alone.

Lack of breast reconstruction post breast cancer surgery as a causative factor for BCRL:

Mastectomy ( total removal of cancer affected breast ) itself is a major risk factor for breast cancer treatment related lymphedema , recent studies suggest that patients who have not undergone a breast reconstruction surgery post breast cancer surgery stand a higher chance of developing breast cancer treatment related lymphedema.

Chemotherapy induced breast cancer treatment related lymphedema:

Chemotherapy for treatment of breast cancer can be given both prior to breast cancer surgery or post breast cancer surgery.  Certain breast cancer treatment chemotherapy protocols involving taxanes ( paclitaxel or docetaxel ) are also associated with increased risk of breast cancer treatment related lymphedema.

Intravenous chemotherapy may increase lymphedema risk if it’s placed in the arm on the same side of breast cancer surgery and lymph nodes removal.If chemotherapy is given IV through the pick line , it should be given from the opposite arm.Any picking with a syringe either to collect blood samples or administration of an Intravenous medication must also be done from the opposite arm of surgery side. It is advisable to give chemotherapy for treating breast cancer through a chemo port ( a small implantable device that is put in the upper chest area below the collar bone and under the skin ). It is used to draw blood and give treatments — including chemotherapy drugs — without a needle stick. A chemo. port can remain in place for weeks, months or even years.

Obesity and living a sedentary life style as a causative factor for BCRL:

People who live a sedentary life style and are obese ( overweight ) are more prone to develop breast cancer treatment related lymphedema post breast cancer treatment.

Sometimes the extra fat in obese women put pressure on lymph nodes and vessels and consequently disturbs the lymphatic system channels. Any disturbance in lymphatic system channels hampers lymph flow and drainage and thereby fluid build up takes place causing lymphedema.

Eating healthy and doing regular and suitable physical activities ( exercises ) not only keeps your weight in check but also reduces the risk of developing BCRL.

Any injury or infection can flare up BCRL:

A breast cancer patient may have fewer lymph nodes due to breast cancer surgery and any injury or infection can cause inflammation to body tissues. This inflammation may make the lymphatic system work harder because of increased blood flow and lymph fluid.

When one's lymphatic system can not cope up with this increased blood flow and lymph fluid due to infection or injury , a lymphedema can occur or gets flared up.

Air travel as causative factor for BCRL:

Air travel specially long distance flights or changing to connecting flights may increase the risk of flare up of Breast cancer related lymphedema.

Although it is not proven but theoretically there is a strong possibility that the 

hypobaric–hypoxic environment inside the aircraft, coupled with low cabin pressure, and the protracted reduced movement and dehydration experienced on flights, might be 

sufficient to incite or exacerbate breast cancer treatment related lymphoedema( BCRL).

How you can reduce risk of BCRL post breast cancer treatment:

• Taking good care of arm on the surgery side.Your breast cancer surgery team doctors will advise you to elevate the affected arm a few times a day for the first 24 to 48 hours after surgery. You will be advised when it is safe to prop up the affected arm on pillows.
• You will be advised to stretch your arm to workout the underarm. Most of lymph nodes are located in the armpit ( underarm) area. You may also be advised to lift the affected arm at shoulder height or above your head to restore the mobility and reduce chances of shoulder stiffness.
• Always inform the laboratory technician or nursing staff to prick the needle in the opposite arm for blood sample collection or medicine administering. Also blood pressure should be measured ( putting the blood pressure band) on the other arm.
• Protect against insect bites by using insect repellent (at least 50% DEET), and carry antiseptic cream for cuts and grazes. 
• Limit your alcohol intake.
• Keep you arm clean and moisturized.
• Avoid wearing too tight sleeved clothes.
• If you’re travelling to a country where quick access to good-quality medical care is difficult, ask your GP for a course of antibiotics to take with you in case of infection. If you develop signs of infection in your ‘at risk’ arm or hand, treat the infection as early as possible, even if there’s no swelling. 

Diagnosis of breast cancer treatment related lymphedema (BCRL):

Following diagnostic procedures are employed to diagnose a BCRL.

1. Sequential circumferential arm measurements.
2. Water displacement.
3. Infrared Perometry.
4. Bioelectrical impedance analysis.

Management of breast cancer treatment lymphedema (BCRL):

Once the BCRL is established in a breast cancer treated patient , there is nothing like a complete cure currently but providing symptomatic relief and avoiding complications of BCRL are the objectives of BCRL management. Management of lymphedema focuses on swelling reduction and symptom alleviation while minimizing exacerbations of swelling. Treatments include pharmacological therapy, surgery, complete decongestive physiotherapy (CDT), mechanical pneumatic pumps, and infection prevention and treatment.

Following procedures are employed for helping the BCRL patients.

• Pharmacological management of lymphedema uses benzopyrones, flavonoids, diuretics, hyaluronidase, pantothenic acid, and selenium.
• Surgical treatment for lymphedema includes microsurgical lympho-venous or lympho-lymphatic anastomoses, debulking, and liposuction.Surgery does not cure lymphedema, use of compression is necessary after surgery. Surgery for treatment of BCRL have it's owns cons like recurrence of swelling, poor wound healing, and infection.  Surgical treatment should only be considered when other treatments fail, and with careful consideration of the benefits to risks ratio.
• Chronic lymphedema leads to formation of excess subcutaneous adipose tissue secondary to slow or absent lymph flow.Liposuction can help to remove excess fat tissue.Liposuction increases skin capillary blood flow without further damaging already compromised lymph transport capacity in breast cancer survivors with lymphedema. Patients are able to maintain limb size reduction with the use of compression garments after liposuction. Liposuction does not correct inadequate lymph drainage and is contradictory when pitting edema is present.
• Complete decongestive therapy (CDT) is the standard care for lymphedema.This approach includes manual lymph drainage, multi-layer, short-stretch compression bandaging, gentle exercise, meticulous skin care, education in lymphedema self-management, and elastic compression garments.

( This information is copied from Breast cancer-related lymphedema: Symptoms, diagnosis, risk reduction, and management Mei R Fu)

Fu MR. Breast cancer-related lymphedema: Symptoms, diagnosis, risk reduction, and management. World J Clin Oncol 2014; 5(3): 241-247 [PMID: 25114841 DOI: 10.5306/wjco.v5.i3.241])

Feel free for any clarification or getting opinion from the best Indian breast cancer treatment specialists. You can send your queries to us on WhatsApp no: +91 9582056061.

 

Common questions about Breast cancers and treatments.

Medical Treatments in India with Best Doctors in Best Indian Hospitals.

Breast cancers are common cancers among women from all across the world. Early and prompt diagnosis and subsequent correct medical treatment can save many precious lives.In this blog we try to address common questions about breast cancers and their treatments.

Facts about breast cancer one must know for early diagnosis of breast cancer.

How do I know that I have breast cancer?

Although breast cancer is common in women it can rarely affect men too. If you are a woman and above 50 years of age and feel that you have developed some lump in breast tissues and have changes in the texture of your breast skin, if you have a relative in your family who was diagnosed with breast cancer, you must see a doctor for a diagnosis.

The most common breast cancer symptoms could be:

• A newly formed lump that could be soft and round or even hard and with irregular edges.
• If your nipple turns inward.
• If the skin on your breast or nipple area turns flaky, crusted, scaling, and appears to be peeling off.
• Change in size and shape of the breast.
• An unusual discharge from the breast other than the milk.
• Redness, swelling, warmth, or darkening of breast skin.

What are my chances of getting breast cancer ?

You have a higher chance of getting breast cancer if you have the following risk factors:

• Although men can also develop breast cancer but it is generally women who suffer more from best cancer.
• Women with increasing age are more prone to acquire breast cancers.
• Women who have an early onset ( Below 12 years of age ) are more prone to be affected with breast cancer later.
• Women in whom menopause sets in late ( above 50 years of age ) are having higher risk of getting breast cancer.
• Women with dense breast are at a higher risk
• Some noncancerous breast conditions like atypical hyperplasia of breast or lobular carcinoma in situ ( Not a breast cancer ) increases risk of breast cancer
• Women with a first degree relative like mother or daughter and sister have higher risk of developing breast cancer
• Women who live a sedentary life style and are obese
• Start drinking alcohol at early age like in teens also increases risk of developing breast cancer in future
• Smoking or tobacco consumption is associated with many cancers including breast cancer
• Exposure to radiation therapy increases one's risk of developing breast cancer in future
• Certain birth control pills and hormone replacement therapy in post menopausal women are also identified as risk factors
• Genetic mutations like BRC1 and BRC2 increases risk of breast cancer.

Combination of these factors increases risk of your being affected with breast cancer in future. It is important to note that Some of the women who were diagnosed with breast cancers never had any of the above mentioned risk factors and many other women who have many of these risk factors never had breast cancer.

Women who are at higher risk of developing breast cancer must undergo periodic breast cancer screening for early diagnosis of breast cancer.

What can i do to reduce my chances of getting breast cancer ?

Although being a woman , ageing normally , a family history of breast cancer and genetic factors responsible for breast cancers are not something that you can change but there are some changes that you can make to lower your chances of getting a breast cancer. 

You can make following changes to reduce your risk of getting breast cancer.

• Maintain a healthy body weight , being obese increases your chances of developing breast cancer
• Adopt a regular fitness regime , doing basic physical exercises reduces risk of getting breast cancer
• Avoid drinking alcoholic beverages and if you must , do it in moderation
• If you are postmenopausal and taking hormone replacement therapy ask your doctor about your risk factors and the best suited HRT for you
• If you are pre menopausal Oral contraceptive pills should be prescribed by a qualified doctor and after considering the pros and cons
• Breast feeding your children is considered to lower the risk of breast cancer
• If you have a family history of breast cancer or inherited changes in BRC1 and BRC2 genes , your doctor may suggest ways to reduce the risk of breast cancer

Living a healthy and balanced life will reduce your risk of breast cancer and God forbid , if you get breast cancer the chances of cure and survival are much better.

What is self breast examination, is it helpful in preventing breast cancer ?

Doing regular self examination of your breasts for any abnormal changes will not prevent breast cancer but paves way for early diagnosis and better treatment outcome. 

Although not all abnormalities or changes in breast observed during self breast examination turns out to be breast cancer. In majority of cases it turns out to be a benign cause. But any new changes or abnormality observed during self breast examination will make you see your doctor and your doctor will confirm if it is breast cancer by asking you to do some diagnostic tests.

Self breast examination involve standing in front of a mirror and closely observing your breasts for any changes in breast cancer skin or texture changes , feeling the breast tissues with your fingers to know if you have any mass or lump in breast or in the armpit area. If there is any discrepancy in either of the breast. 

Usually breast cancers are diagnosed when a person observe any new changes like a lump or hardness in breast tissues or change in the skin and texture of breast and discuss the observation with a doctor who does some diagnostic tests for confirming breast cancer diagnosis.

Early diagnosis of breast cancers offers a better prognosis.

When do i see a doctor if i suspect that i have breast cancer ?

If you observe any changes in breast during breast self examination , above 50 years of age , have a family history of breast cancer or observe any of the symptoms of breast cancers discussed earlier in this blog , Immediately see your doctor . 

What tests my doctor need to do to confirm breast cancer diagnosis ?

On suspicion of breast cancer , your treating doctor will do a physical examination , take your family history and recommend following tests for confirming the diagnosis:

• Diagnostic mammograms are performed when your doctors have a suspicion of breast cancer.
• If on diagnostic mammogram where the mammogram technician  take multiple images of your breast , some abnormalities are observed further tests will be done to confirm the diagnosis.
• Breast ultrasound is done to take images of breast to find for a lump or mass or a cystic lesion.
• An MRI will be conducted to take 3D images of breast . MRI is also done for women with dense breast. Dense breast means presence of more connective tissues than the normal fatty breast tissues.
• A more confirmatory tests called breast tissue biopsy.

What are different types of breast biopsies to confirm breast cancers ?

Biopsy is the confirmatory test for diagnosing breast cancers. Different types of breast cancer biopsies are done by the doctors to confirm the diagnosis.

• FNAC of Breast is fine needle aspiration of breast tissues. FNAC for breast is done under local anesthesia where a fine needle is inserted to collect fluid and some tissues from the lump or concerned area of breast to be tested in a lab.No cut is made or surgery is done in FNAC of breast. At times doctors may decide to do a ultrasound guided FNAC to collect the fluid and tissues from the concerned area of breast.
• Core Needle breast biopsy is using a thick needle inserted into the breast lump or the concerned tissues of breast and small cylinder of breast tissues are removed for pathological findings.
• Surgical breast biopsy or True cut breast biopsy is done by making a cut in the breast. The surgeon removes part or all of the lump or area of concern. In some cases the lump may be small, deep, and hard to find. Then a method called wire localization may also be used. For this, a thin needle with a very thin wire is put into the breast. X-ray images help guide it to the lump. The surgeon then follows this wire to find the lump.

Biopsy is the actual confirmatory test for diagnosis of breast cancer , it also confirms the type of breast cancer you may have and breast cancer treatment is decided on that.

How my doctor will decide about stage of my breast cancer ?

Staging of a breast cancer is done on grounds of size of tumor , extent of spread of tumor ( Localized or spread to lymph nodes , whether it has metastasized to any other surrounding or distant organs), types of cells of breast involved , expression of hormone receptors, and biomarkers.

There are two ways to determine the stage of breast cancer.

• Pre surgery assessment (Clinical stage)
• Post surgery (pathological stage)

The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments.

What treatment i will need for my breast cancer ?

Depending on stage of cancer , doctors will decide about treatment course. Following treatment modalities are used for treating breast cancers.

Surgery for treating breast cancer: 

Breast cancer surgery may involve lumpectomy , Mastectomy ,  Modified radical mastectomy , breast onco-plasty and breast reconstruction surgery.

  

Chemotherapy for breast cancer treatment:

Chemotherapy is administering chemotherapeutic medicines to treat breast cancers. It can be given prior to surgery as Neo adjuvant chemotherapy to reduces size of tumor , also given if lymph nodes are involved for a less extensive surgery.

Chemotherapy is also given post surgery to kill any remaining cancer cells and recurrence ( coming back ) of breast cancer. Chemotherapy when given post breast cancer surgery is called adjuvant chemotherapy.

Chemotherapy is the main treatment for metastatic breast cancer.

Chemotherapy is given in cycles like it may be given weekly , every 14 days , 21 days or every 28 days.

Radiation therapy for breast cancer:

Radiation therapy is also advised for breast cancer patients. Radiation therapy is usually given once your breast cancer surgery wounds are completely healed.

Radiation therapy for breast cancer is given either as external beam radiation therapy ( EBRT) or as internal radiation therapy ( Brachytherapy).

Your treating doctor will recommend the type depending on your breast cancer stage and kind of breast cancer surgery you have undergone.

External beam radiation therapy is given in sessions like 5 days a week and two days rest per week.

Targeted drug therapy for breast cancer:

Targeted drug therapy is used for those patients whose biopsy results shows affinity for certain hormones. Like for HER2 receptor positive breast cancers a targeted drug therapy is used either alone or along with the routine chemotherapy for breast cancer patients.

Immunotherapy for breast cancer:

Cancer immunotherapy is one of the most significant advancement in cancer treatments.

Cancer immunotherapy involves administration of immunotherapy agents that boosts one's own immunity to recognise and destroy breast cancer cells. Immunotherapy has demonstrated impressive anti tumor activity and durable clinical outcome in triple negative breast cancers. 

Hormone therapy for Breast cancer:

If your breast cancer biopsies expresses an affinity for certain hormones like estrogen , progesterone or HER2 , your doctor may add hormonal therapy for your breast cancer treatment protocol.

Sometimes more than 2 of these treatment modalities are used by your breast cancer treating doctors team to ensure a better success rate , minimizing the side effects of treatment and reducing the chances of breast cancer coming back.

Which country offers best and affordable breast cancer treatment ?

India has emerged as the top destination for breast cancer treatment among the global breast cancer patients. Patients not only from Nigeria, Tanzania , Kenya, Ghana . Rwanda, Uganda,Angola ,South Africa , Zambia , Zimbabwe , Cameroon, Iraq, Saudi Arab , Oman , Bahrain, Kuwait, Sudan, Uzbekistan , Kyrgyzstani, Turkmenistan, Tajikistan, Kazakhstan,Afghanistan , Bangladesh , Nepal, Bhutan , Burma ( Myanmar)  but United states, Australia, Philippine and many other European countries prefer to come to India for breast cancer treatments.

Why one should choose India for breast cancer treatment?

India is the favorite country for global medical travelers for complete and comprehensive yet affordable breast cancer treatment.The major reason for choosing India for breast cancer treatments are listed as below:

• Expertise and competency of Indian breast cancer specialists
• prompt start of treatment , no waiting period
• Truly global class hospitals and latest diagnostic infrastructure
• Ease of getting medical visa
• English being a commonly spoken language and availability of Language interpreters for overcoming language barrier
• Low cost of diagnostics and treatment
• All treatment options are available to offer complete and comprehensive breast cancer treatments
• Flexible and affordable accommodation rentals as per the need and budget of patient
• Safety and political stability

How do i decide a hospital for my breast cancer treatment ?

For any cancer treatment center availability of all major branches ( Nuclear medicine, diagnostics, Surgery , chemotherapy and radiation therapy ) at one center is most important.

Because at these hospitals a tumor board meeting is routine for deciding the best breast cancer treatment protocol for every individual breast cancer patient.

India is having many super speciality hospitals offering the services of top Indian breast cancer specialists under one roof. 

We can help you in having a video consultation with top Indian breast cancer specialists . Send all your medical reports and a brief medical history to us  even before flying to India.

You can chose among the top Indian breast cancer specialists and breast cancer hospitals  with our help for your breast cancer treatment.

How will i travel to India for breast cancer treatment ?

We offer you end to end support and services for complete and comprehensive breast cancer treatment in India without any hassles. 

The services we provide for global medical travelers seeking breast cancer treatment in India with best Indian breast cancer specialists:

•  Arranging a video consultation with your treating Indian doctor 
• Helping you in selecting you doctors and hospital for breast cancer treatment
•  Assistance in getting medical visas for coming to India 
•  Arrangement of guest houses for your India stay in safe and secure area and in the vicinity of your treating hospital
•  Airport pickup - meet and greet services
• Scheduling your medical treatment on arrival in India without any delay.
• 24X7 assistance in your breast cancer treatment as well as providing all logistics supports during your India stay
• Free interpreter ( Translator ) services for non English speaking patients
• Regular follow up with your treating Indian doctors once you reaches back your country after a successful breast cancer treatment.