Breast cancer is the most common cancer among women in industrialised countries and is now one of the most studied cancers. Research offers significant advances in the three basic pillars of therapy: surgery, radiotherapy and systemic treatment. Thanks to these advances there has been a clear reduction in mortality from this kind of cancer, despite its increased incidence, and its progression as a chronic disease.
However, breast cancer treatment can cause some significant side effects that affect the patient's quality of life. The sentinel lymph node method has lowered morbidity and improved quality of life, but in many cases the underarm lymph nodes must be removed, a procedure known as lymphadenectomy, which can cause lymphoedema and shoulder pain. Lymphoedema consists of oedema (swelling) of the affected upper limb, which can become chronic, and affects one in four women with breast cancer. In addition, this condition has the aggravating factor of being socially invisible.
Traditionally, lymphoedema treatment was begun when oedema manifested in the upper limb or when the shoulder ceased to function properly. Since 1997, in order to prevent lymphoedema and potential shoulder complications in breast cancer patients after axillary surgery, the Rehabilitation Department at the Hospital Clínic has carried out a prevention protocol that provides patients with suitable exercises to prevent these complications. This programme is run by Mrs Montserrat Gironès, a physiotherapist, and is built around informational sessions on healthcare education to prevent lymphoedema. The programme is intended not only to cure breast cancer but also to give patients a good quality of life.
About the protocol
The protocol is based on the early initiation of a series of specific exercises and the establishment of immediate treatment before the initial oedema. In the 12 years that the programme has been run, we have seen very encouraging results, with a reduction in complications in the short, medium and long term.
As such, we recommend practising these exercises every day, which can easily be done at home, and taking these recommendations into account.
Exercises to prevent lymphoedema
The lymphatic system has two basic functions: fluid removal and immune defence. Oedema can occur following the removal of axillary breast tissue, and the body is then less able to fight off infection in the upper limb. It is therefore necessary to maintain good lymphatic drainage with specific exercises in order to prevent the onset of oedema and to take all possible precautions to prevent serious infections.
Introduction to the physiotherapy protocol for the prevention of lymphoedema and shoulder complications following breast cancer surgery.
Exercises: Presentation of the recommended exercises
The exercises should be performed during admission, 48 hours after surgery. They should be practised twice a day, carefully, for 10 days.
Exercises: Exercises for lymphatic drainage
We recommend doing the exercises daily for life after the 10 days post-surgery.
Recommendations and advice for preventing lymphoedema in the limb operated on
- Do not take your blood pressure in the arm operated on. The limb may swell from the pressure of the device.
- Avoid having blood taken unless absolutely necessary. The rubber tourniquet may cause injury when pressed on the arm.
- Do not undergo a lymphogram or other vascular scans unless absolutely necessary.
- Avoid acupuncture in the affected arm. Avoid vaccines or shots.
- Be careful not to injure the arm during a manicure.
- Make sure small wounds heal, even if they do not seem significant, as all open wounds can lead to infection.
- Take care to avoid scratches from cats or other animals and dog bites. Should they occur, treat them immediately because they can cause serious infections.
- In the garden, take care around thorny plants (use padded gloves).
- Wear gloves while performing certain tasks (cleaning fish, washing dishes, etc.).
- Do not strain by making excessive overhead arm movements or carrying heavy objects.
- Avoid sudden movements, e.g. on the bus, walking the dog, and avoid repetitive work which is likely to place stress on the hand or arm.
- Clapping can cause swelling; simulate it instead.
- Use a thimble while sewing or wear leather gloves.
- Avoid insect bites or treat them immediately to avoid scratching them.
- Do not put your arm in very hot water. Avoid excessive temperatures (smoke, stove, electric blanket, infrared light, sunlight, UVA, sauna, paraffin, clay).
- Do not wear tight-fitting clothes or clothing that restricts the forearm or arm. Do not wear rings, bracelets or watches.
- Avoid rough or strong massages.
- Apply gentle moisturisers. It is very important to keep the skin hydrated, especially around the elbows.
- Do not shave armpits with a blade, or use hot or cold wax on them (use an electric razor and shave gently without irritating).
- Try to lead a life as normal as possible.
- Try to do the specific exercises shown to you by the physiotherapist every day to maintain good mobility and good drainage in the arm.
- It is important to do other types of exercise (long walks, some kind of dance, yoga). This will help you maintain a good physical and mental state.
- Swimming is an excellent exercise to improve quality of life, but it is not advisable to do so during chemotherapy or radiotherapy because it can cause skin problems.
- When travelling by air it is important to move the arm from time to time or support it with a cushion in a slightly elevated position.
- You can perform all types of work, without ever exerting strain. If signs of oedema (swelling) develop, seek medical attention.
Part of the programme consists of monthly sessions on healthcare education to prevent lymphoedema. These sessions will feature a presentation of the topic, followed by a seminar in which those attending can make comments or ask for advice. These sessions were originally meant only for hospital patients but, because they deal with healthcare and prevention, they are now open to all.
The sessions are usually held once a month, from 11:00 am to 12:30 pm, in the Miguel Servet lecture theatre at Hospital Clínic, calle Casanova 160. For more information, contact: schedule of sessions.
Study of lymphoedema
Lymphoedema: prevention and quality of life is a work that helps raise awareness of the reality surrounding this potential after-effect in hospitals and associations for those affected across the country. It is a document of great interest that complements the provision of resources for treatment of the disease within the public system.
The study was commissioned by the Spanish Federation of Breast Cancer (FECMA) and has benefited from cooperation of the company Pfizer. Mrs Montserrat Gironès Coromina, a physiotherapist at the Clínic, has led the coordination effort, and has worked together with the technical team formed by Mª Angeles Arenillas Pérez, also a physiotherapist at the Clínic, Mar González Sanz, a sociologist, and Laura Salom Seminario, a physiotherapist. The healthcare professionals, associations, and hospital and health centres throughout the country who have participated in the study include professionals from the Functional Unit for Breast Diseases of the Hospital Clínic and the Breast and Health Help Group (gAmis) association, created in 1997 by the first women suffering from breast cancer who attended the physiotherapy sessions at the Hospital Clínic.