Understanding and Managing Breast Lymphedema After Breast Cancer Treatment

Breast edema (swelling) is a common side effect for those who have undergone breast-conserving surgery (such as a lumpectomy) and radiation therapy, for the treatment of breast cancer. This form of persistent swelling is called breast lymphedema, as it occurs when the fluid transport capacity is decreased in the breast, due to surgery and radiation treatment.  This can lead to significant changes in the breast tissue, and result in fluid accumulation, among other symptoms. While it can be a challenging part of recovery, understanding the signs of breast lymphedema and treatment options is the first step toward better management and improved symptoms.

What are the Signs and Symptoms of Breast Lymphedema?

Breast lymphedema is similar to upper extremity lymphedema, and both can result as a side effect from breast cancer treatment (for more on upper extremity lymphedema after breast cancer, see our blog post here.

Breast lymphedema is a type of swelling that typically progresses through three stages, starting with simple skin thickening that you may or may not even notice, to visible swelling and increased feelings of heaviness and pain. Key indicators of breast lymphedema include:

• Physical Changes: Visible swelling, skin thickening (often checked via a “pinch test”), a darkened skin hue.
• Texture: The breast may feel hard (either entirely or in specific spots) and exhibit “p’eau d’orange,” where skin pores appear enlarged or darker.
• Discomfort: Many patients report a heavy feeling in the breast, especially by the end of the day, as well as tenderness that may make it uncomfortable to sleep on that side or even receive a hug.
• Visible Marks: You may notice persistent creasing in the breast from bras, clothing, or foam inserts or “pitting edema” which is a visible depression in the skin when pressed with firmly with your finger.

Identifying Risk Factors

While any patient undergoing breast conserving surgery and radiation may develop some degree of swelling in the breast in the early post-treatment phase, and this may resolve on its own.  If swelling persists in the breast after the acute post-treatment phase, this would indicate some degree of lymphatic fluid accumulation (breast lymphedema).  Certain factors can increase the risk of breast lymphedema:

• Physical Attributes: A higher body weight (BMI) or a larger bra size (both band and cup size).
• Treatment specifics: Chemotherapy, axillary node surgery (more lymph nodes removed), or having an increased number of positive lymph nodes.
• Tumour Staging: Factors like tumour size and histologic grade (often captured in an NPI score) can play a role.

Timeline and Diagnosis

Research indicates that breast lymphedema typically peaks 4 to 6 months after radiation therapy. In some cases, breast lymphedema is transient and declines on its own by the 12-month mark; in many others, it is persistent and requires professional intervention.

Diagnosis is largely based on physical examination and patient reports of their symptoms. Lymphedema therapists may use an outcome measure such as the Breast Edema Questionnaire (BrEQ).

• The BrEQ: A validated tool that has sections related to signs and symptoms of swelling, and functional/activity components.
• Score:  A score of 8.5 or higher indicates the presence of breast edema

Breast Edema Questionnaire

Indicate to what extent you suffered from following complaints in the operated breast during the past week.

Other Causes of Swelling in the Breast after Cancer Treatment

The breast can be swollen after surgery, including lumpectomy, sentinel node biopsy, axillary node surgery, or plastic surgery approaches. Post-operative swelling can often resolve on its own, though signs and symptoms of lymphedema should be monitored for.

There are two related conditions that can affect a subset of breast cancer patients, and cause swelling in or near the breast.  Patients should alert their physician if they see signs of the conditions below, for early intervention/treatment.

1. Seroma. This can appear as a pocket of fluid, typically near the armpit after node surgery, where fluid is having difficulty draining. You may feel like there is an egg-like feeling in your armpit, or in the breast/chest itself. Your surgeon may wish to drain the seroma, or, may recommend observation alone, as these can often resolve on their own with gentle massage. A lymphedema therapist can often assist in helping it resolve more quickly, with manual therapy, modalities (as indicated), and lymphatic drainage massage techniques.  

2. Infection. This can be a complication that arises most typically in the early post-surgery phase (or it can occur later, particularly in those with chronic breast lymphedema). The area of infection typically appears red (or darker in skin tone), swollen, painful, and the body’s response to the infection can cause other symptoms such as fever, body aches, and fatigue. Infections require antibiotics to be treated, and your physician should be contacted immediately should you detect any of these signs or symptoms.

Treatment and Management Strategies for Breast Lymphedema

The goal of treatment for breast lymphedema is to restore the tissue quality, re-establishing optimal lymphatic fluid flow through the breast, and manage swelling through a multi-faceted approach.

1. Tissue Quality Optimization

• Softening Techniques: Lymphatic therapists typically use kneading type techniques to soften dense or fibrotic areas in the breast.
• Scar and Restriction Release: Techniques like rolling are used to release surgical scars, while myofascial release helps restore range of motion across the trunk, chest, armpit and shoulder.
• Advanced Options: Some therapists use silicone cupping (which patients can sometimes learn to do at home) or therapeutic ultrasound for particularly dense tissue areas.

2. Compression and Support

• Supportive Wear: Specialized compression bras (such as the Prairie Wear Prima or Vida) provide optimal coverage and compression. Some patients also find success with certain higher-compression sports bras.
• Inserts: Foam inserts, “swell spots,” or silicone pads can be used to provide localized pressure to help with volume reduction and/or dense tissue zones.
• Kinesiotape: Can be used for optimizing fluid drainage, focused areas of swelling, or to help resolve dense tissue areas.

3. Lifestyle and Self-Care

• Movement: Targeted exercise and self-massage (the techniques described above and including Manual Lymphatic Drainage) are essential to the resolution of breast lymphedema.
• Skin Health: Diligent skin care is important to prevent skin dryness, irritation, or infection, especially during and following radiation.
• Weight Management: Supporting weight loss goals can be a helpful component of the overall decongestive strategy.

References:

K Riches et al. Improving the Assessment and Diagnosis of Breast Lymphedema after Treatment for Breast Cancer. Cancers 2023, 15, 1758. https://doi.org/10.3390/cancers15061758

H Verbelen et al. Breast edema, from diagnosis to treatment: state of the art. Archives of Physiotherapy (2021) 11:8. https://www.archivesofphysiotherapy.com/index.php/aop/article/view/2819/3208

Verbelen H, et al. Development and clinimetric properties of the Dutch Breast Edema Questionnaire (BrEQ-Dutch version) to diagnose the presence of breast edema in breast cancer patients. Qual Life Res. 2020 Feb;29(2):569-578. https://springernature.figshare.com/articles/journal_contribution/Additional_file_1_of_Breast_edema_from_diagnosis_to_treatment_state_of_the_art/14331655?file=27337210