Breast Cancer Related Lymphedema: An Algorithm for Self-Care

In 2013, there were 2.8 million breast cancer survivors in America and Armer, et al, (2008) reveal that 20-40% will develop breast cancer-related lymphedema (BCRL). BCRL is an accumulation of lymph fluid in the interstitial spaces, of the arm or chest wall, where normal lymphatic flow has been disrupted by axillary node dissection, mastectomy, radiation or chemotherapy.  Once lymphedema (LE) develops it becomes a chronic condition requiring medical and therapeutic support. The purpose of this scholarly activity is to create then study an algorithm to assist the patient in self-care. Knowledgeable nurses, physicians and lymphedema therapists using the algorithm, will be able to plan, educate and support the patient’s self-care activities. The PICOT question is: For patients who have breast cancer surgery or treatment, would the patient increase BCRL self-care activities if provided a personalized self-care algorithm for BCRL versus being provided education materials without a personalized algorithm over a period of 6 months?  

The literature reviewed included seven primary research articles and one guideline. There is strong evidence for complete decongestive therapy (CDT) initial phase, which is performed by lymphedema therapists. Studies are few and sample sizes small for CDT maintenance phase or the care following the initial phase of CDT. During the CDT maintenance phase the patient manages their symptoms of lymphedema at home. Other findings in the literature search revealed, exercise and weight reduction provide a decrease in symptoms and a decreased arm volume. Patient educational information produces more risk-reduction activities, yet limitations of self-care are many. A gold standard for assessing lymphedema has not been established within the literature.

The Chronic Illness Trajectory Framework by Corbin and Strauss (1991) consists of concepts for understanding the management, perceptions, reciprocal impact and goals of the trajectory, or course, of a chronic illness.  The trajectory of BCRL is unpredictable thus making it unique to each patient.  Nurses are in a position to provide support during the patient’s journey along this trajectory.

Nurses educate patients regarding prevention and self-care for chronic disease processes. Communicating with the patient and a multidisciplinary team to identify patient goals, limiting factors, burden of treatment and self-care activities, are nursing roles. More specifically, assessment of the chronic illness trajectory phase and identifying appropriate healthcare referrals and self-care could possibly avert hospitalization or development of BCRL. The nurse is positioned to assist the patient in meeting self-care goals, management and challenges of the patient’s lifetime risk and unique trajectory of BCRL.

The BCRL Algorithm describes healthcare provider and patient activities in the management of BCRL throughout the trajectory. The research question could be answered by using the algorithm to identify the phase in which the patient presents. BCRL requires complex management and by assessing patient goals, planning interventions and evaluating patient limitations related to the phase of the trajectory, the nurse is able to support the patient through their life with BCRL. Future study of the algorithm is planned.