WRITE ABOUT PSYCHIATRIC MANAGEMENT OF UPPER LIMB LYMPHEDEMA IN A CASE OF CARCINOMA OF BREAST TREATED WITH RADIOTHERAPY AND SURGERY ?
A 4 INTRODUCTION
1 Breast carcinoma continues to be the most frequently occurring carcinoma in women.
2 Presently, approximately one in every eight women will develop the disease.
3 Great strides have been made in the treatment of breast carcinoma that have reduced the risk of recurrence and improved survival rates. Thus, as with many other forms of cancer, breast carcinoma is a chronic illness requiring ongoing care and monitoring vv imp
4 With this transformation of the disease into a chronic one comes a greater emphasis on symptom management, quality of life, and the expectation on the part of patients, their families, and caregivers that the patient will attempt to maintain as normal a life style as possible.
5 So , One problematic condition for women recovering from breast carcinoma surgery or radiation, which, until recently, has received minimal attention, is lymphedema.
6 Although the minority of women develop this condition after treatment, nearly the entire population needs to be informed of the preventative measures necessary to minimize risk.
7 The functional and psychological adjustment needed to accept preventive life style alterations or adhere to treatment regimens requires time and, sometimes, additional supportive intervention.
DEFINITION
1 Lymphedema is an abnormal swelling and collection of excessive tissue protein in the body due to an interruption or obstruction of the lymphatic vessels by a tumor, fibrosis, or inflammation.
2 Women with breast carcinoma who undergo axillary lymph node dissection or radiation are at risk of scarring and infection, possibly causing blockages in the upper extremity.
3 Reports of the prevalence of upper extremity lymphedema vary widely, ranging from 6.7% to 62.5%
4 These findings are hard to reconcile, because the criteria for defining lymphedema are not standardized, and the various prevalence studies are not consistent in the length of follow-up.
5 There is general agreement that the risk for lymphedema is greatest among women who undergo axillary dissection followed by radiation VV IMP
6 The degree of swelling can be mild to severe and can occur immediately in the posttreatment period or several years later.
7 There may be a loss of normal sensation in the affected limb along with skin changes (pitting, abrasions, cellulitis).
8 Untreated, the affected limb can become very large and heavy, and the skin loses its elasticity.
9 In addition, upper extremity lymphedema predisposes women to the development of severe acute or chronic infection.
PSYCHOLOGICAL MORBIDITY / ASSOCIATED MORBIDITY
1 Problems encountered by women experiencing lymphedema include the disturbing weight of the affected limb and the physical disfigurement of the condition vv imp
2 The heaviness and size of the arm may put substantial limitations on functioning.
A ) Women experiencing this condition may have difficulties with performing the tasks needed for their job
B ) they may be unable to complete household responsibilities and
C ) in severe cases, may need assistance with daily care activities.
3 The enlarged size of the arm also may prevent women from wearing their usual clothing.
4 Thus, lymphedema, especially if it is untreated or undertreated, can cause serious disturbances in a patient’s quality of life, with additional consequences of psychological distress, depression, social inhibition, and sexuality concerns vv imp
5 patients with lymphedema had greater anxiety, depression, adjustment problems, and difficulty in the vocational, domestic, social, and sexual domains.
6 Many patients with lymphedema may see the development of this condition as a secondary blow to their physical and emotional well being.
A ) They have survived their breast carcinoma in dealing with the initial diagnosis and proceeded through the recommended treatment.
B ) The development of lymphedema, whether it is weeks or years after the cancer treatment, can bring back with full force the emotions associated with feeling ill, feeling different from peers, or feeling that “I will never be able to get on with my life.”
C ) Negative body image perceptions may arise with new concerns about social and sexual interactions
D ) The visible appearance of lymphedema or of the garments used in its treatment can make privacy issues more difficult, causing social anxieties and constant social reminders of the carcinoma experience.
E ) The compression garments themselves are considered unsightly by many women and can lead to decreased social activity.
F ) The disfigurement of lymphedema affecting the hand in particular is difficult to conceal, can be painful, and can cause decreased fine motor coordination.
F ) Problems in sexuality, common after the treatment for breast carcinoma, may worsen in women experiencing lymphedema
1 - For those feeling unattractive, self-consciousness can hinder intimate relations.
MANAGEMENT
1 Due to the morbidity associated with upper extremity lymphedema once it develops, prevention is an important and natural starting point in the effort to improve quality of life for women with breast carcinoma after surgery and radiation vv imp ( PREVENTION IS BETTER THAN CURE )
Such as -
A ) wearing loose jewelry, and carrying the handbag on the unaffected arm are other common recommendations
B ) Simpler suggestions are made to women not to lift heavy objects, or to get blood drawn, or to have blood pressure readings taken from the limb at risk
C ) Prevention efforts and the imparting of information about lymphedema should begin with presurgical discussion and is a key part of informed consent for surgery and axial node dissection
1 - In these early discussions, the clinician needs to be careful not to overburden the patient with too many fearful thoughts of the consequences of treatment given the high anxiety typical of tis time period
2 For women who do develop lymphedema, those at risk of experiencing the deleterious emotional effects of the condition should be identified early
3 The principle idea of lymphedema therapies is to increase pressure across the affected limb in order to decrease the amount of fluid that is produced and foster removal of excess fluid by any remaining functional lymphatics.
A ) This pressure may be applied by using pumps, massage, compression garments, and exercise.
4 Good skin care is essential.
5 The treatment may be time consuming and may require frequent follow-up visits to the clinic.
A ) Because the single most important factor in the management of lymphedema is patient compliance the time it takes to assess the patient’s adjustment to the condition and the treatment is crucial vv imp
6 For patients who need more extensive psychological intervention, individual and group therapy modalities that combine cognitive-behavioral, supportive, and insight-oriented techniques along with psychopharmacologic approaches all have a possible role in treating the problems encountered with lymphedema ( COMBINATION THERAPY )
A ) Sexuality concerns also should be addressed. Behavioral techniques are an important aspect of sexual therapy and would best be offered by a therapist with experience in working with carcinoma patients.
7 If depression develops, then psychopharmacologic interventions can be helpful. Medications need to be chosen with the lymphedema in mind.
Vv imp For example, antidepressants that cause weight gain should be avoided unless those that do not cause weight gain first prove to be ineffective.
8 CONCEPT OF PSYCHOEDUCATION vv imp
A ) Establishing a psychoeducational and support group within the clinic may help patients to deal with the lymphedema in a variety of ways.
B ) The acceptance of preventative strategies, the adaption of better coping methods, the decreased isolation that often accompanies the condition, and the identification of patients in need of formal consultation are all potential benefits of a support group
9 With a multidisciplinary approach to this neglected problem, the psychological morbidity associated with lymphedema can be diminished.
10 Decongestive physiotherapy vv imp - Complete decongestive physiotherapy is a 2-phase noninvasive therapeutic regimen.
A ) The first phase consists of manual lymphatic massage, multilayered inelastic compression bandaging, remedial exercises, and meticulous skin care.
B ) Phase 2 focuses on self-care by means of daytime elastic sleeve or stocking compression, nocturnal wrapping, and continued exercises.
11 Acupuncture - twice weekly for 4 weeks ( NEWER TREATMENT APPROACHES ) - with affected arm circumference ≥2 cm larger
12 Role of Low level Laser - facilitates edema drainage , reduces pain , increases the activity of defence cells
13 Role of Surgery - In the most severe cases, patients may be advised to have either a surgical debulking procedure a tissue autotransplant or more recently, a microsurgical operation to alleviate the symptoms of lymphedema and to improve the quality of life.