Risk Factors for Lymphedema

Lymphedema is a chronic and progressive swelling condition. While some people are either born with it or develop it without a triggering event, many people develop lymphedema as a result of cancer treatment. Is there a way to reduce the risk factors for lymphedema after cancer treatment? Yes, there appears to be risk factors for lymphedema which you can modify. This blog post will review those risk factors, but does not constitute medical advice. I’ll be reviewing both modifiable and non-modifiable risk factors.

Surgical Risk Factors

One of the biggest risk factors for lymphedema risk is the number of lymph nodes that are removed during a cancer surgery (Gillespie, 2018). Of course, the goal of cancer surgery is to remove the cancer from your body – and this sometimes involves removing lymph nodes which have already been invaded by the cancer or could be.

Sentinel Node Biopsy vs Lymph Node Dissection

One method that surgeons have available is a sentinel node biopsy. With this procedure, blue dye is injected near cancer and the lymph node(s) that take up that dye are the one(s) removed.  A sentinel lymph node biopsy usually involve removing 1-5 lymph nodes. 

In comparison a lymph node dissection, involves the removal of lymph nodes, without the use of the dye. Which lymph nodes and how many to remove is decided on by the surgeon based on the staging tests, the visual appearance of the lymph nodes and their own judgement and experience. In general, the lymph node dissection usually results in more lymph nodes being removed (Ly, 2017).

Sometimes a person will have both. For example, in one study about 25% of the lymph nodes removed during a sentinel node biopsy were positive for cancer (Togaway, 2017). In these cases, a second surgery is usually done to remove and test more lymph nodes Doing the second surgery will add to the scar tissue, which can also impede lymph flow, so the decision of which procedure and how many lymph nodes to remove is not straightforward.

In addition to the number of lymph nodes removed, the location of the lymph nodes matters too. In a study of 249 woman with endometrial cancer treated with hysterectomy and lymphonodectomy 37% (92) developed lymphedema (Volpi, 2019).

When comparing those who developed lymphedema vs. those that did not. More women with lymph nodes removed from the para-aortic region – in front of the lumbar vertebrae developed lymphedema vs pelvic lymph nodes. 

I encourage anyone diagnosed with cancer to discuss the plan for lymph node removal with their cancer surgeon. In addition, after your surgery, there are some strategies to help reduce your risk of lymphedema, so keep reading.

Prophylactic Lympho-Venous Anastomosis

Prophylactic means to prevent disease and an anastomosis is a joining together. So, this surgery is done to prevent lymphedema by joining together a lymphatic vessel to a vein. It is a super microsurgery which means that it is done at 30 times magnification, so the surgeon basically does the entire surgery while looking through a microscope and using specially designed delicate instruments.

This is a relatively new and highly specialized procedure, which may not be available at every cancer centre. But where it is available this surgery is done during the cancer surgery when the lymph nodes are removed. It is done to reduce the risk of lymphedema developing.

A lympho-venous anastomosis can also be done once lymphedema develops, but what I am describing here is the prophylactic version which is done before there is lymphedema in an effort to prevent it.

Radiation

Whether to give radiation and how much to give for is another balancing act between cancer treatment and lymphedema prevention. Receiving radiation will increase the likelihood of successful cancer treatment in most cases, while at the same time, increase the risk for lymphedema after cancer.

It’s difficult to tell though how much risk is associated with the cancer surgery vs the risk contributed to by the radiation. A systematic review to assess the incidence or lymphedema based on radiation alone are (Shaitelmanm 2015): 

• 14.5% for breast/chest wall radiation
• 31.5% for breast/chest wall + supraclavicular radiation
• 41.4% for breast/chest wall + supraclavicular + posterior axillary boost radiation

Let me be clear…I’m NOT telling you to refuse radiation. I’m advising you to speak with your radiation oncologist about risk of lymphedema and anything they can do to mitigate risk. But, remember, just because you have lymph nodes removed and radiation, doesn’t mean you will automatically get lymphedema. Follow the modifiable risk reduction strategies below to help reduce your risks.

Race

Is your race a risk factor for lymphedema?

In 2021, researchers from Memorial Sloan Kettering Cancer Center in New York followed 276 breast cancer patients followed for two years post cancer surgery for axillary lymph node dissection (Pierso, 2023). Of these women 25% (69) people developed lymphedema. When they examined the incidence by race, this is what they found:

Results by Race after adjusting for number of lymph nodes removed;

• 39% of the African-American women in the study develop lymphedema
• 28% of Hispanic women developed lymphedema
• 23% of Asian women
• 21% of Caucasian women

Is Race a Risk Factor for Lymphedema?

With only examining the 69 women with lymphedema, it would be difficult to generalize these findings to the broader population, but this research highlights, that race could be a risk factor.

In other research of 190 women, race was not found to be a risk factor on its own. But African American women who had high blood pressure and received chemotherapy for their breast cancer did have a higher risk of lymphedema (Togawa, 2014).

Of course, race is not a modifiable risk factor, so having this information can mainly serve to help you sort if you may be at elevated risk. There are modifiable risk factors that you could implement to help lower your risk.

Modifiable Risk Factors for Lymphedema Risk

Let’s discuss some modifiable risk factors. I’ll list these in alphabetical order.

Inflammation

The anti-inflammatory diet is one of my favourite aspects of lymphedema risk reduction. While we don’t have all the pieces of the puzzle yet, this is what we know:

1. Inflammation is a risk factor for lymphedema (Ly, 2017)
2. Inflammation can be measured in the blood
3. Blood levels of inflammation can be reduced with diet and exercise

The definitive piece of the puzzle that we don’t have yet, is proof that, if you are at risk of developing lymphedema, and you implement an anti-inflammatory diet, that that will reduce your risk of lymphedema. But, I am hopeful that a study like this can be designed.

In the meantime, the anti-inflammatory diet is safe and healthy and is one of the strategies that I recommend for reducing the risk of cancer recurrence. For more details on this as well as other strategies, order the Cancer Risk Reduction Guide.

Blood Lipids

Are your cholesterol levels risk factors for lymphedema? In one study with 60 breast cancer survivors, researchers in Korea compared the blood lipid levels of the women that developed lymphedema after cancer and compared it to those that didn’t (Ryu , 2016). What they found was:

• No difference in:
  • Total cholesterol
  • High density lipoprotein (HDL)
  • Triglycerides (TG)
• Significant difference in:
  • Atherogenic index (ratio between TG:HDL ratio) which was higher in the lymphedema group
  • Total saturated fats (lower in lymphedema group)
  • Monounsaturated fats (lower in lymphedema group)

This study is only looking at associations (sometimes called correlations) and it can’t say that the higher TG:HDL ratio caused the lymphedema, but it is an interesting finding and one that I think should be looked at in future research.

Improving your TG:HDL ratio would include lowering the TG while increasing the HDL. To do this, you would reduce added sugars and keep your blood sugars within normal limits raising the HDL is not so straightforward, but being active helps. Ironically, having a high saturated fat in the healthy (non-lymphedema) group, seems counter to what you might have expected. Let’s hope further research will help to clarify this.

Blood Pressure

I’ve written an entire blog on blood pressure and lymphedema, so I’ll be brief here. It appears that high blood pressure (above 120/80) is a risk factor for developing lymphedema. Taking steps to lower your blood pressure with the DASH diet, regular exercise (even if you don’t lose weight), weight loss, quitting smoking, managing stress and medications, if needed will likely help to reduce your risk factors for lymphedema after cancer.

Body Weight

This is one of the most robust areas of study as far as nutrition and lymphedema goes. Multiple studies have shown that being overweight or gaining weight after cancer treatment will increase your risk of developing lymphedema. For this reason weight loss is recommended as a risk reduction strategy.

I know this is an issue that many people struggle with for their entire lives and there isn’t an easy solution, but if you can at least maintain your weight and prevent further weight gain, it’s a win.

It’s important to remember that many of the strategies that you would implement to help with weight loss such as: regular exercise, more fruits and vegetables, no night time eating, plenty of water drinking, limited processed and junk foods and portion control will likely reduce lymphedema risk even if it doesn’t lead to weight loss. So, stay on track and don’t let your healthy habits be dictated by the scale…just keep going!

Mobility

Being immobile is a risk factor for lymphedema. If you are not mobile after your cancer treatment, then you’ve got some work to do. Work with your physical therapist on exercises and strengthening that you can do to increase your mobility. If you are mobile – then keep moving, as the saying goes “use it or lose it”.

Prolonged Heat or Cold

You might have enjoyed a sauna, hot tub or heating pad before your cancer surgery, but current guidelines suggest that these are both high risk activities when it comes to developing lymphedema. Same goes for using ice packs for an injury and the polar bear dip. Speak with your lymphedema therapist about what duration of heat or cold exposure is safe for you.

Skin Care

If you are at risk of developing lymphedema, one of the most important things you can do is to take care of your skin in the at-risk area. This means, for example if you had lymph nodes removed from your left arm pit, you would want to be very careful with your left hand, arm and chest area. You should take care to protect against;

• Cuts
• Scratches
• Burns
• Bites
• Stings
• Chemicals

This means that if you go out to the garden to do some gardening, or working with chemicals that might splash you should wear gloves, if you are around mosquitos, you should wear long sleeves and put on bug repellant (you can spray it on your clothes).

If you have a cat or a dog, then use a toy to play with them and not your hand. If you are out in the sun, take precautions so you don’t get a burn. These are all important to avoiding lymphedema in your at risk arm.

The same goes for lymph nodes removed from the groin or pelvic area. Lymph node removal can occur for cancers of the prostate, colon, and any of the gynaecological cancers. In this case, you are at risk of lymphedema in your feet, legs and pelvic area. Some specific precautions for this would be: don’t want barefoot, don’t break in new shoes too quickly (and get a blister), wear long pants if you go hiking in the bush, don’t wear wet socks in the event you get a fungal infection. You get the idea – look after your feet and legs!

It’s important to know that if you get lymphedema because of any of these issues, the lymphedema remains with you, long after the scratch or the burn heals, so it’s not just a short term issue, you could be permanently left with lymphedema.

Tattoos

While some people like to get tattoos after surgery as a way to memorialize their cancer experience , you should think twice about this. Researchers in Germany examined the lymph nodes of people with tattoos who had passed away to see if tattoo ink could be detected in their lymph nodes (Schreiver,, 2017). Blue, green, orange and red pigments were detected in the lymph nodes. While the pigments were present in nano particles, it lead to chronic enlargement of the lymph nodes.

Some of the lymph nodes contained chromium and nickel which are both metals and both described as “toxic elements” which came from the tattoo needle shards themselves (Schreiver, 2019). The metals from the needle were more common when white tattoo ink which contains titanium dioxide was used.

These authors made the point that when foreign material is introduced into the body, fibrinogen and other proteins create an inflammatory environment. Unfortunately, we know from other research that inflammation is associated with a progression of lymphedema, and a thickening of the skin.

While the purpose of these studies was not to examine lymphedema risk (it was trying to explain allergic reactions to tattoos), it did demonstrate that some tattoo inks and needle metals do end up in the lymph nodes and I would suggest caution with tattoos after cancer treatment when your lymphatic system is already compromised and you are at risk of lymphedema.

Venous Insufficiency

Chronic venous insufficiency (veins that don’t work properly) puts an extra burden on the lymphatic system. If you have had lymph nodes removed from the groin, or abdominal areas and have venous insufficiency…well you are at extra risk of lymphedema.

Be sure to see a vascular specialist and a lymphedema therapist to get help to treat your vein issues and find out the best solutions for you – for example, compression socks or leggings will likely be recommended for you.

You can also learn how to do manual lymphatic drainage on yourself. There are nutrition strategies too – drinking lots of water and eating enough fibre so that you don’t strain when you go to the washroom are other strategies. Read more about venous insufficiency and lymphedema.

Bottom line on Risk Factors for Lymphedema

The risk factors for lymphedema include:

• Lymph node removal – the more nodes removed, the greater the risk
• Radiation to lymph nodes

Once you are at risk due to these treatments, then there are additional factors that will influence your risk and these include:

• Air travel
• Being overweight or gaining weight
• High blood pressure
• Inflammation
• Low mobility
• Prolonged heat or cold
• Venous insufficiency

In addition, there are some factors that may increase risk, but this is not yet clearly established including:

• Tattooing
• A high triglyceride:HDL ratio
• Being a non-caucasian race

Take care to reduce your modifiable risk factors. Work with a registered dietitian to help with an anti-inflammatory diet and see a certified lymphedema therapist to learn more risk reduction strategies.