Breast Cancer, Physical Therapy & Lymphedema

By, Robert A. Wascher, MD, FACS

Updated:  01/17/2010

Welcome to Weekly Health Update

“A critical weekly review of important new research findings for health-conscious readers”

BREAST CANCER, PHYSICAL THERAPY &

LYMPHEDEMA

Arm lymphedema, or chronic swelling of the arm, occurs in 10 to 30 percent of women following treatment for breast cancer.  When the lymphatic drainage network in the arm and hand has been disrupted by the surgical removal of axillary (armpit) lymph nodes, or by radiation therapy to the axilla (or, sometimes, following both types of treatment), the delicate network of lymphatic vessels that return excess tissue fluid back to the heart can become obstructed. This lymphatic obstruction can then result in chronic swelling of the hand and arm. Patients with significant lymphedema of the arm following breast cancer treatment may experience considerable swelling (edema), heaviness, stiffness and discomfort of the affected hand and arm.

Unfortunately, there are no known effective methods available to prevent lymphedema, and once significant lymphedema does develop, compression sleeves and soft tissue massage are the primary treatment modalities currently available. Unfortunately, currently available lymphedema treatments are often not highly effective for many patients, and there is no known cure for lymphedema once it develops.

Now, a newly published research study, in the British Medical Journal, suggests that physical therapy, when initiated early after breast cancer surgery, can significantly decrease the risk of arm and hand lymphedema. In this prospective randomized clinical research study, 120 women who underwent removal of their axillary lymph nodes for breast cancer were randomized to one of two groups. Women assigned to the experimental group underwent physical therapy 3 times per week, for a total of 3 weeks. Physical therapy techniques used in this group included manual lymph drainage and soft tissue massage techniques, as well as progressive shoulder exercises. Both groups of women also underwent the same lymphedema management educational course, but the control group of women did not receive any physical therapy interventions.

Among the 116 women who completed at least one year of follow-up, 18 women (16 percent) went on to develop lymphedema. Fourteen of the women who developed lymphedema were in the control group, while the remaining 4 women were in the experimental group. Thus, in this clinical study, early physical therapy following axillary lymph node dissection (ALND) was associated with a very significant 72 percent reduction in the risk of developing lymphedema, at least within the first year following breast cancer surgery.

Whether or not the use of early postoperative physical therapy can reduce the incidence of arm lymphedema over periods longer than one year is unknown at this time, and additional follow-up of the patients who participated in this clinical research study will be required to answer this very important question. However, this is one of the very few studies available that suggests a role for physical therapy in the actual prevention of arm and hand lymphedema following ALND for breast cancer. If additional, mature follow-up of these patients confirms a long-term benefit from early postoperative physical therapy in preventing arm lymphedema, then a strong case could be made for the routine use of early physical therapy in women who undergo ALND, and perhaps, as well, women who undergo sentinel lymph node biopsy with subsequent radiation therapy to the breast and armpit (axilla) area.

For additional information and resources related to cancer-associated lymphedema, please click on the links below:

http://www.cancersupportivecare.com/Abstracts/asbdpbtps.html

http://meeting.ascopubs.org/cgi/content/abstract/23/16_suppl/8185

http://www.annalssurgicaloncology.org/cgi/content/abstract/15/7/1996

http://www.cancerlynx.com/sln.html

http://doctorwascher.com/Archives/11-23-08.htm

http://doctorwascher.com/Archives/8-16-09.htm

Disclaimer:  As always, my advice to readers is to seek the advice of your physician before making any significant changes in medications, diet, or level of physical activity

---

Dr. Wascher is an oncologic surgeon, professor of surgery, cancer researcher, oncology consultant, and a widely published author

For a somewhat lighter perspective on Dr. Wascher, please click on the following YouTube link:

http://www.youtube.com/watch?v=7-Tdv7XW0qg

(Anticipated Publication Date:  May 2010)

(Click above image for TV36 interview of Dr. Wascher)

---

---

---

Send your feedback to Dr. Wascher at:

rwascher@doctorwascher.net

---

Dr. Wascher’s Biography

---

Links to Other Health & Wellness Sites

---

http://doctorwascher.com

---

Copyright 2007 – 2010

Robert A. Wascher, MD, FACS

All rights reserved

---

Dr. Wascher’s Archives:

1-10-2010: Prevention of Surgical Site Infections (SSIs) after Surgery

1-3-2010: Ginkgo Biloba, Memory & Cognitive Health

12-20-2009: CT Scans & Cancer Risk

12-13-2009: Soy Isoflavones Decrease Breast Cancer Recurrence Risk

12-6-2009: Salt (Sodium) Intake, Stroke & Cardiovascular Disease

11-29-2009: Exercise & Prostate Cancer Risk

11-22-2009: Genistein (Soy Isoflavone) & Prostate Cancer

11-15-2009: Breast Cancer Treatment & Chronic Pain

1-8-2009: Vitamin D & Breast Cancer Risk

11-1-2009: Exercise & Prostate Cancer Risk

10-25-2009: HPV Virus & Risk of Breast Cancer

10-18-2009: Post-Cholecystectomy Syndrome (Symptoms after Gallbladder Surgery)

10-11-2009: Vitamin D & Falls in the Elderly

10-4-2009: Surgery, NSQIP, Complications & Death

9-27-2009 Stress, Heart Disease, Exercise & Death

9-20-2009: Vitamin D & Colorectal Cancer Survival

9-13-2009: H1N1 Swine Flu Update

9-7-2009: Green Tea, Aging & Lifespan

8-30-2009: Irritable Bowel Syndrome (IBS), Diet & Fiber

8-23-2009: Update on Prostate Cancer and Cryotherapy

8-16-2009: Exercise Improves Lymphedema Symptoms in Breast Cancer Survivors

8-9-2009: Breast Cancer Recurrence, Death & Vitamin D

8-2-2009: Honesty, Dishonesty & Brain Function

7-26-2009: Coronary Artery CT Scans & Cancer Risk

7-19-2009: Hormone Replacement Therapy (HRT) & Ovarian Cancer

7-12-2009: Breast Cancer & Metformin (Glucophage)

7-5-2009: Prostate Cancer & Green Tea

6-28-2009: Air Pollution & the Risk of Deep Venous Thrombosis (DVT)

6-21-2009: Red Yeast Rice, Statins & Cholesterol

6-14-2009: Bone Marrow Stem Cell Transplant & Congestive Heart Failure (CHF)

6-7-2009: Diet, Soy & Breast Cancer Risk

5-31-2009: Diet and Prostate Cancer Risk

5-24-2009: Diabetes, Glucose Control & Death

5-17-2009: Drug Company Marketing & Physician Prescribing Bias

5-10-2009: Hemorrhoids & Surgery

5-3-2009: Statin Drugs & Blood Clots (Thromboembolism)

4-26-2009: Are We Really Losing the War on Cancer?

4-19-2009: Exercise in Middle Age & Risk of Death

4-12-2009: Can Chronic Stress Harm Your Heart?

4-5-2009: Does PSA Testing for Prostate Cancer Save Lives?

3-22-2009: CABG Surgery vs. PCI in Diabetics with Coronary Artery Disease; Sweetened Beverages and Coronary Artery Disease

3-15-2009: Depression, Stress, Anger & Heart Disease

3-8-2009: Coronary Artery Disease: CABG vs. Stents?; Swimming Lessons & Drowning Risk in Children

3-1-2009: Aspirin & Colorectal Cancer Prevention; Fish Oil & Respiratory Infections in Children

2-22-2009: Health Differences Between Americans & Europeans; Lycopene & Prostate Cancer

2-15-2009: Statin Drugs & Death Rates; Physical Activity, Breast Cancer & Sex Hormones

2-8-2009: Hormone Replacement Therapy (HRT) & Breast Cancer; Stool DNA Testing & Cancer of the Colon & Rectum

2-1-2009: Obesity and the Complications of Diverticulosis (Diverticulitis & Bleeding); Obesity, Weight Loss & Urinary Incontinence

1-25-2009: Prostate Cancer, Fatigue & Exercise; Does your Surgeon “Warm-up” Before Surgery?

1-18-2009: Cancer and Vitamins; Teenagers, MySpace and Risky Behaviors

1-11-2009: Exercise Reverses Some Effects of Fatty Meals; Vitamin C and Blood Pressure

1-4-2009: Secondhand Smoke & Heart Attack Risk; Poor Physical Fitness During Childhood & Heart Disease Risk During Adulthood

12-28-2008: Stress & Your Risk of Heart Attack; Vitamin D & the Prevention of Colon & Rectal Polyps

12-21-2008: Breast Cancer Incidence & Hormone Replacement Therapy; Circumcision & the Risk of HPV & HIV Infection

12-14-2008: Vitamin E, Vitamin C and Selenium Do Not Prevent Cancer; Postscript: A Possible Cure for Down’s Syndrome

12-7-2008: Generic vs. Brand-Name Drugs, Stress & Breast Cancer Survival

11-30-2008: A Possible Cure for Down’s Syndrome?; Smoking & Cognitive Decline; Calcium & Vitamin D & Breast Cancer Risk

11-23-2008:  Breast Cancer & Fish Oil; Lymphedema after Breast Cancer Treatment; Vasectomy & Prostate Cancer Risk

11-16-2008:  Vitamin E & Vitamin C: No Impact on Cardiovascular Disease Risk; Does Lack of Sleep Increase Stroke & Heart Attack Risk in Hypertensive Patients?

11-9-2008: Statins Cut Heart Attack Risk Even with Normal Cholesterol Levels; Statins & PSA Level

11-2-2008: Radiation Treatment of Prostate Cancer & Second Cancers; Sexual Content on TV & Teen Pregnancy Risk

10-26-2008:  Smoking & Quality of Life

10-19-2008:  Agent Orange & Prostate Cancer

10-12-2008:  Pomegranate Juice & Prostate Cancer

10-5-2008: Central Obesity & Dementia; Diet, Vitamin D, Calcium, & Colon Cancer

9-28-2008: Publication & Citation Bias in Favor of Industry-Funded Research?

9-21-2008: Does Tylenol® (Acetaminophen) Cause Asthma?

9-14-208:   Arthroscopic Knee Surgery- No Better than Placebo?; A Healthy Lifestyle Prevents Stroke

8-23-2008:  Alcohol Abuse Before & After Military Deployment; Running & Age; Running & Your Testicles

8-12-2008:  Green Tea & Diabetes; Breastfeeding & Adult Cholesterol Levels; Fish Oil & Senile Macular Degeneration

8-3-2008:   Exercise & Weight Loss; Green Tea, Folic Acid & Breast Cancer Risk; Foreign Language Interpreters & ICU Patients

7-26-2008:  Viagra & Sexual Function in Women; Patient-Reported Adverse Hospital Events; Curcumin & Pancreatic Cancer

7-13-2008:  Erectile Dysfunction & Frequency of Sex; Muscle Strength & Mortality in Men; Cryoablation for Prostate Cancer

7-6-2008:  Sleep, Melatonin & Breast Cancer Risk; Mediterranean Diet & Cancer Risk; New Treatment for Varicose Veins

6-29-2008:  Bone Marrow Stem Cells & Liver Failure; Vitamin D & Colorectal Cancer Survival; Green Tea & Colorectal Cancer

6-22-2008:  Obesity, Lifestyle & Heart Disease; Effects of Lifestyle & Nutrition on Prostate Cancer; Ginkgo Biloba, Ulcerative Colitis & Colorectal Cancer

6-15-2008:  Preventable Deaths after Coronary Artery Bypass Graft (CABG) Surgery; Green Tea & Colorectal Cancer; Attention-Deficit/Hyperactivity Disorder (ADHD) & St. John’s Wort

6-8-2008:  Vitamin D & Prostate Cancer Risk; Radiofrequency Ablation (RFA) of Kidney (Renal) Cancer; Antisense Telomerase & Cancer

6-2-2008:  Acute Coronary Syndrome- Do You Know the Symptoms?; Green Tea & Lung Cancer; Episiotomy & Subsequent Deliveries- An Unkind Cut

5-25-2008:  Early Childhood Screening Predicts Later Behavioral Problems; Psychiatric Disorders Among Parents of Autistic Children; Social & Psychiatric Profiles of Young Adults Born Prematurely

5-18-2008:  Can Statins Reverse Coronary Artery Disease?; Does Breast Ultrasound Improve Breast Cancer Detection?; Preventive Care Services at Veterans Administration (VA) Medical Centers

5-11-2008:  Smoking Cessation & Risk of Death; Childhood Traumas & Adult Suicide Risk; “White Coat Hypertension” & Risk of Cardiovascular Disease

5-4-2008:  Super-Size Me: Fast Food’s Effects on Your Liver; Exercise, Weight & Coronary Artery Disease; Contamination of Surgical Instruments in the Operating Room

4-27-2008:  Stents vs. Bypass Surgery for Coronary Artery Disease; The “DASH” Hypertension Diet & Cardiovascular Disease Prevention; Testosterone Therapy for Women with Decreased Sexual Desire & Function

4-20-2008:  BRCA Breast Cancer Mutations & MRI Scans; Bladder Cancer Prevention with Broccoli?; Diabetes: Risk of Death Due to Heart Attack & Stroke

4-13-2008:  Breast Cancer Recurrence & Hormone Replacement Therapy (HRT); Carotid Artery Disease: Surgery vs. Stents?; Statin Drugs & Cancer Prevention

4-6-2008:  Human Papilloma Virus (HPV), Pap Smear Results & Cervical Cancer; Human Papilloma Virus (HPV) Infection & Oral Cancer; Hormone Replacement Therapy (HRT) & the Risk of Gastroesophageal Reflux Disorder (GERD)

3-30-2008:  Abdominal Obesity & the Risk of Death in Women; Folic Acid Pretreatment & Heart Attacks; Pancreatic Cancer Regression after Injections of Bacteria

3-23-2008:  Age of Transfused Blood & Risk of Complications after Surgery; Obesity, Blood Pressure & Heart Size in Children

3-16-2008:  Benefits of a Full Drug Coverage Plan for Medicare Patients?; Parent-Teen Conversations about Sex; Soy (Genistein) & Prostate Cancer

3-9-2008:  Flat Colorectal Adenomas & Cancer; Health Risks after Stopping Hormone Replacement Therapy (HRT); Television, Children & Obesity

3-2-2008:  Medication & Risk of Death After Heart Attack; Hormone Replacement Therapy (HRT) & Mammogram Results; Selenium: Cancer, Heart Disease & Death

2-23-2008:  Universal Healthcare Insurance Study; Glucosamine & Arthritis

2-17-2008:  Exceptional Longevity in Men; Testosterone & Risk of Prostate Cancer; Smoking & Pre-malignant Colorectal Polyps

2-10-2008:  Thrombus Aspiration from Coronary Arteries; Intensive Management of Diabetes & Death; Possible Cure for  Down’s Syndrome?

2-3-2008:  Vitamin D & Cardiovascular Health; Vitamin D & Breast Cancer; Green Tea & Colorectal Cancer

1-27-2008:  Colorectal Cancer, Esophageal Cancer & Pancreatic Cancer: Update from the 2008 American Society of Clinical Oncology’s Gastrointestinal Cancers Symposium

1-20-2008:  Testosterone Levels & Risk of Fractures in Elderly Men; Air Pollution & DNA Damage in Sperm; Statins & Trauma Survival in the Elderly

1-12-2008:  Statins, Diabetes & Stroke and Obesity; GERD & Esophageal Cancer

1-7-2008:  Testosterone Supplements in Elderly Men; Colorectal Cancer– Reasons for Poor Compliance with Screening Recommendations

12-31-2007:  Minority Women, Hormone Replacement Therapy & Breast Cancer; Does Health Insurance Improve Health?

12-23-2007:  Is Coffee Safe After a Heart Attack?; Impact of Divorce on the Environment; Hypertension & the Risk of Dementia; Emotional Vitality & the Risk of Heart Disease

12-16-2007:   Honey vs. Dextromethorphan vs. No Treatment for Kids with Night-Time Cough, Acupuncture & Hot Flashes in Women with Breast Cancer, Physical Activity & the Risk of Death, Mediterranean Diet & Mortality

12-11-2007:  Bias in Medical Research; Carbon Nanotubes & Radiofrequency: A New Weapon Against Cancer?; Childhood Obesity & Risk of Adult Heart Disease

12-2-2007:  Obesity & Risk of Cancer; Testosterone Level & Risk of Death; Drug Company Funding of Research & Results; Smoking & the Risk of Colon & Rectal Cancer

---

Dr. Wascher’s Home Page

---

---

Share on digg

Health Report:

——————————————————————————–

“A critical weekly review of important new research findings for health-conscious readers…”

By, Robert A. Wascher, MD, FACS

Last Updated: 11/23/2008

——————————————————————————–

The information in this column is intended for informational purposes only, and does not constitute medical advice or recommendations by the author. Please consult with your physician before making any lifestyle or medication changes, or if you have any other concerns regarding your health.

——————————————————————————–

BREAST CANCER & FISH OIL

It is well known that the omega fatty acids present in cold water fish can reduce the risk of heart disease. Now, new research, performed at the University of Texas in San Antonio suggests that fish oil may be able to inhibit the growth of breast cancer tumors as well. This research study, just published in the journal Breast Cancer Research & Treatment, used a mouse model of breast cancer to assess the effects of dietary fish oil supplements on breast cancer tumors implanted into laboratory mice, and on human breast cancer cells grown in laboratory cultures.

Using sophisticated genetic tests, the researchers found that dietary fish oil inhibited genes associated with tumor growth while, simultaneously, increasing the activity of genes associated with tumor cell death. Regression of the implanted human breast tumors was also observed when mice were fed a diet containing omega fatty acids derived from fish oil.

In order to further evaluate the effects of fish oil on breast cancer cells, the researchers added DHA and EPA, the two active omega fatty acids found in most fish oil supplements, to human breast cancer cells growing in culture dishes. Once again, the scientists found that fish oil significantly inhibited genes associated with tumor growth, and simulated other genes associated with tumor cell death. In particular, fish oil appeared to increase the activity of a gene called PTEN, which belongs to a class of genes called tumor suppressor genes.

The PTEN gene plays a very important role in signaling normal cells to stop dividing when it is inappropriate for them to do so. PTEN, along with multiple other tumor suppressor genes, also helps to shunt damaged or abnormal cells into a cellular suicide pathway known as apoptosis. Together, these two protection mechanisms help to prevent uncontrolled cell growth that would, otherwise, result in the formation of tumors. In many cancers, the PTEN gene becomes inactivated by mutations, resulting in uncontrolled tumor growth, as well as tumor cell resistance to the apoptosis cell suicide pathway. Interestingly, an inherited mutation that inactivates the PTEN gene is known to cause Cowden’s Syndrome. People with Cowden’s Syndrome develop multiple benign tumors, or hamartomas, of the GI tract, bones, brain, eyes and urinary tract. At the same time, this hereditary cancer syndrome is associated with an increased risk of cancers of the breast, thyroid and uterus.

This study’s finding that fish oil increases the activity of the PTEN gene is a potentially important discovery, as are the other apparent anti-tumor effects of fish oil on other important cancer-associated genes. However, my enthusiasm for the findings of this study is tempered by the fact that, so far, these anti-tumor effects of fish oil have only been observed in cell cultures and in immune-compromised mice that have been implanted with human breast cancer cells. As has been, unfortunately, shown in thousands of prior research studies using cultured cancer cells or laboratory animals, there is no guarantee that these same findings will be reproducible in humans. These exciting findings with a relatively non-toxic dietary supplement should, therefore, now be studied in human patients with breast cancer as a potential complementary therapy, and as a potential cancer prevention agent in women who are at significantly increased risk of developing breast cancer.

LYMPHEDEMA AFTER BREAST CANCER TREATMENT

Arm lymphedema, or chronic swelling of the arm, occurs in 10 to 30 percent of women following treatment for breast cancer. When the lymphatic drainage network in the arm has been disrupted by the surgical removal of armpit lymph nodes by the surgeon, or by radiation therapy to the armpit area (or, sometimes, following both types of treatment), the delicate network of lymphatic vessels that return excess tissue fluid back to the heart can become obstructed. This lymphatic obstruction can result in chronic swelling of the hand and arm. Patients with significant lymphedema of the arm, following breast cancer treatment, may experience considerable swelling (edema), heaviness, stiffness and discomfort of the affected hand and arm.

A newly published study in the journal Breast Cancer Treatment & Research has taken a new look at factors associated with arm lymphedema following breast cancer treatment. This study was performed by researchers at the University of Southern California, the City of Hope in California, the National Cancer Institute in Bethesda, the Fred Hutchinson Cancer Center in Seattle, and the University of Louisville in Kentucky.

In this study, nearly 500 women who had been diagnosed with preinvasive or invasive breast cancer completed an initial interview with study researchers. A follow-up interview was then performed, on average, about 4 years later. The researchers then analyzed the resulting data from these two sets of interviews.

This study confirmed the findings of numerous prior studies that have linked the surgical removal of armpit lymph nodes, obesity, and high blood pressure with chronic arm lymphedema. In this study, women with high blood pressure were found to have almost two-and-a-half times the risk of developing lymphedema following breast cancer treatment when compared to women who did not have hypertension. Moreover, this hypertension-associated risk of lymphedema was essentially equivalent to the level of risk associated with the surgical removal of armpit lymph nodes and with obesity, which is a much higher level of risk than has been reported by most prior studies.

Taken together, the results of this study confirm several previously established risk factors for arm lymphedema following breast cancer therapy, but also suggest that high blood pressure may, by itself, be a more significant risk factor for lymphedema than has been previously appreciated.

The good news is that there are strategies available to most women that can address these lymphedema risk factors. Recently, a relatively new surgical technique has been developed, and allows surgeons to remove only one or a couple of lymph nodes (sentinel lymph node biopsy) in the 60 to 70 percent of breast cancer patients whose breast cancer has not yet spread to lymph nodes in the armpit area. Sentinel lymph node biopsy has been shown to reduce the risk of lymphedema to one-tenth the risk associated with the more radical complete axillary lymph node dissection that was formerly performed on all breast cancer patients. Likewise, losing excess weight may also reduce the incidence of obesity-associated lymphedema. The findings of this study also suggest that achieving good control of hypertension may reduce the volume of edema fluid generated in the arms of patients who have undergone breast cancer therapy, and may further reduce the risk of chronic lymphedema.

For additional information on the subject of chronic lymphedema following breast cancer therapy and sentinel lymph node biopsy for breast cancer, please see the following links:

http://www.cancersupportivecare.com/Abstracts/asbdpbtps.html

http://meeting.ascopubs.org/cgi/content/abstract/23/16_suppl/8185

http://www.annalssurgicaloncology.org/cgi/content/abstract/15/7/1996

http://www.cancerlynx.com/sln.html

VASECTOMY & PROSTATE CANCER RISK

Despite the fact that the majority of scientific evidence suggests no association between vasectomy and the risk of prostate cancer, several previously published studies have raised concerns that men with a family history of prostate cancer, and men who undergo vasectomy at a young age, may be at an increased lifetime risk of developing prostate cancer following vasectomy. A newly published study in the Journal of Urology adds further weight to prior studies showing that vasectomy is not associated with an increased risk of developing prostate cancer. This clinical study was performed by scientists at the Fred Hutchinson Cancer Center and the University of Washington.

More than 1,000 men recently diagnosed with prostate cancer were compared to 942 men without prostate cancer. All of these study volunteers were matched with each other in terms of age, race, and other important factors known to be related to prostate cancer risk.

Following detailed interviews with all of the men participating in this study, the researchers found absolutely no difference in the number of men in either group who had previously undergone vasectomy. In both groups of men, 36 percent had previously undergone vasectomy for the purpose of sterilization. Furthermore, the men who had undergone vasectomy at a young age did not appear to experience any increased subsequent risk of developing prostate cancer when compared to the men who had undergone vasectomy later in life, and when compared to the men who had never undergone vasectomy.

The findings of this clinical study should be reassuring to men who are considering sterilization by vasectomy (at least with respect to their lifetime risk of developing prostate cancer).

——————————————————————————–

Disclaimer: As always, my advice to readers is to seek the advice of your physician before making any significant changes in medications, diet, or level of physical activity.

——————————————————————————–

Dr. Wascher is an oncologic surgeon, professor of surgery, a widely published author, and the Director of the Division of Surgical Oncology at Newark Beth Israel Medical Center:

http://www.sbhcs.com/hospitals/newark_beth_israel/mservices/oncology/surgical.html

Send your feedback to Dr. Wascher at rwascher@doctorwascher.net

Dr. Wascher’s Biography

Share on digg