A few years ago at Stanford University, I had the opportunity to study with Jean-Paul Belgrado, PT, a leading researcher in the field of lymphedema from the Universite Libre de Bruxelles in Belgium. He presented at the Breast Cancer Conference the possible reasons why lymphedema occurs after surgery.

Lymphedema is the accumulation of protein-rich fluid, which normally can be transported out of the lymph system easily, but for some reason, the transport system is damaged. This causes a backlog of this fluid that fills up in the outer layer of the tissue.

For years, it was commonly believed that you would only be at risk if you had more than five lymph nodes removed and had gone through radiation, but now we know this is not the case. Patients who have had an axillary lymph node dissection have between a 15 to 25 percent risk of occurrence over their lifetime. Even if the patient only had the sentinel node removed (which is considered anything under four lymph nodes) and no radiation, there is still a 6 percent chance of occurrence.

A physical therapy evaluation by a trained breast cancer specialist is the key. It will provide you with education and teach you about precautions and prevention techniques that will allow you to return to your active lifestyle, with no worries about whether or not you are at risk.

Here are some of the possible reasons why lymphedema can happen after breast cancer:

• Surgical Intervention: What type of breast cancer surgery did they have? Was there an axillary re-section with lymph nodes removed? Or was it only a sentinel lymph node? If there was an axillary dissection performed, was the sheath of the axillary vein compromised when the nodes were removed? Where are the scar lines located? Are there multiple scars lines blocking the fluid flow patterns?

• Chemotherapy: There is evidence that certain drug interventions produce an inflammatory response, increasing the possibility of lymphedema. A physician in the EU has recently documented a list of meds that have been noted to increase this level of edema.

• Radiotherapy: It has been seen that with radiation of the breast tissue and the axillary region you can compromise the fluid movement patterns. All patients who have had radiation need to have an evaluation to determine skin integrity and scarring in the area of radiation and surrounding tissue to determine lymph flow health patterns.

• Scar tissue: The scar lines are significant in how the pattern of fluid can move. If they are restricted, thick, hard and immobile, then back flow of the fluid can occur around and behind the scar lines.

• Genetic: It has been evidenced that there is a genetic tendency towards edema in certain groups and populations.

• Physical Activity: What is your level of physical activity at work, home and in you community life? There must be a balance in your activity level, where you are activating the muscle pump, but not increasing the level so high (and with such repetitive activities) that you create an inflammation.

• Body Mass Index: The level of obesity present affects the amount of fluid that might occur. The higher the BMI the greater the likelihood of edema that can occur especially if their BMI is over 30 percent.

The above list needs to be considered and looked at to determine if you are at risk for lymphedema. Because of this, all breast cancer patients should have a baseline examination with a physical therapist specifically trained in breast cancer management — either as soon as their drains are removed or 12-14 days after surgery — to establish a plan of care for their musculoskeletal management, and to see if they are at risk for lymphedema and venous issues. These issues can be prevented and cared for early on if patients are at risk and their quality of life can be ensured.