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Wysoka jakość protez piersi oraz udoskonalana w ciągu całego życia umiejętność robienia dobrej miny do złej gry sprawia, że właśnie to pytanie słyszą najczęściej kobiety po mastektomii. Obrzęk limfatyczny w wyniku raka sutka, który sprawia, że ręka wygląda jak nadmuchany balon, występuje średnio u 10-30% amazonek. Teoretycznie metoda leczenia obrzęku jest znana, oczywista i nieskomplikowana. W praktyce – mało kto w Polsce jest leczony prawidłowo.
Polish problem
Przy radykalnych operacjach nowotworu piersi usuwa się także węzły chłonne spod pachy, uniemożliwiając w ten sposób działanie zaprojektowanego przez naturę systemu rozprowadzania limfy. Nie znajduje ona ujścia i zbiera się w ręce po stronie amputowanej piersi, a kończyna nabrzmiewa, powodując raz, że nieestetyczny obrzęk — w skrajnych przypadkach w ręce kumuluje się kilka litrów płynu! – ale co gorsza ból, uczucie bardzo nieprzyjemnego napięcia skóry oraz zakłócenia motoryki i precyzji działania ręki.
Swelling can appear almost immediately after breast removal surgery, and only after several months or even thirty years! Its occurrence is a fact known to doctors. On websites aimed at amazons, the slogan of lymphedema is present, but its elaboration leaves much to be desired. The most common advice is: do not overstrain your arm, avoid carrying heavy things (and it is not a barbell, but a bag of sugar), sleep with your hand on the wedge, massage gently, and do not injure yourself. Yes, a slogan like “bandaging”, “compression underwear”, “sleeve” flies through the background, but without any details. The correct regimen of lymphedema therapy is presented in specialist articles intended for healthcare professionals, often on internet portals where you need to log in to access the content of the texts. Few people get there, so hardly anyone knows what questions to ask the doctor and physiotherapist and how he could be treated, if in Poland it was like, for example, in Germany.
Michał Dudkiewicz, president of the Polish Lymphological Foundation, started to act when he himself underwent lymphedema therapy in a specialist German clinic (edema occurs not only as a complication after mastectomy, it can also be congenital and affect various parts of the body) and he has experienced how easily it can be treated:
– Applied lymphology is not a particularly spectacular field of medicine, but the physical methods of treating edema are proven, simple and predictable, and most importantly effective. I myself saw a girl from Spain cut her leg circumference from 150 cm to 50 cm! – says.
Effective therapy
How to do it? Michał Dudkiewicz says that the correct therapy, known as Physical Edema Therapy or Comprehensive Anti-Stagnation Therapy, is divided into two stages. The first is the intensive swelling reduction phase, which takes place in the clinic and lasts from 3 weeks to 2 months. During this time, the patient has a manual lymphatic drainage treatment performed twice a day (every day – this is very important!), Followed by bandaging of the swollen limb. Lymphatic drainage is simply a gentle and pleasant, hand-performed massage of the whole body, not only of the arm or legs. In the case of upper limb massage, its purpose is to prepare a place for the lymph remaining in the swollen hand and manually push it to the working lymph nodes. This massage assumes the opposite direction to that of the classic massage: in the classic way, the movements are performed along the lymphatic vessels, towards the nearest lymph nodes, i.e. from the hand to the armpit; in the case of drainage, on the contrary, it starts from the parts of the torso farthest from the end of the limb, and hand finishes. After this massage, the limb is bandaged in a special way: the skin is protected with a cotton sheath, and then, with the help of special pads, the hands are given a similar shape to their normal shape and wrapped with special bandages so that the compression pressure in the limb grows gradually from the armpit towards the hand. Carrying out these treatments on a daily basis is crucial. In our hospitals, if they are already done, they take a weekend break, which destroys the work of the previous five days.
A week before the end of hospital therapy, the limb is carefully measured every four centimeters, and based on this measure, the so-called compression garments. It is these ephemeral “sleeves” that appear in therapy descriptions. At the moment of receiving a sleeve (stockings or tights), the second phase of therapy begins – maintaining the effect of reducing swelling. It will last for life, because lymphoedema cannot be cured, it is a chronic disease and the key to effective treatment is systematic therapy. Since compression garments need to be washed frequently (preferably daily as water restores its compressibility; unwashed it stretches and stops working), you need to have two sets per shift.
The sleeve has a thickness of up to 3 mm, so wearing it is not burdensome or unpleasant, some patients even like it, it can also be successfully hidden under looser clothing. Additionally, the physiotherapist performs lymphatic drainage about twice a week.
The therapy is based on the basic procedures described above, supported, of course, with care for hand hygiene, appropriate resting positions and avoiding any injuries, including even the smallest cuts, gives excellent results. So what is the problem?
Michał Dudkiewicz says:
– In Poland, compression products are not reimbursed by the National Health Fund. And the cost of one sleeve is about PLN 3, when you buy two, you have to spend six thousand zlotys every six months. It’s a lot. And if the patient decides to buy a sleeve, he has to wait for it, which means that the swollen limb is already too large in relation to the previously ordered size. The sleeve is uncomfortable, it does not work, the patient gets discouraged and does not take any more ‘risks’ of an expensive purchase. It also happens that he receives a circular sewn product, which is used in the treatment of varicose veins. It is unsuitable for the treatment of lymphedema, because a flat sleeve is required here, which better fits the very variable shape of the swollen limb. And again: discouragement and abandoning the only effective method of therapy.
In Germany, most health insurance funds reimburse 1-2 sets of compression garments every 6 months. The National Health Fund finances medical devices only up to the limit specified by the minister of health. If the price of the selected product is higher than the price specified in the limit, the patient pays the difference between the gross price and the amount of the refund.
Watch out for slot machines
The President of the Polish Lymphological Foundation also sensitizes to compressive devices, i.e. professionally: enabling pneumatic compression. Despite the relatively high price, they are sometimes bought by patients for home use. However, one must remember about contraindications – especially in the case of lymphoedema as a result of removal of lymph nodes and / or radiotherapy – and secondly about the fact that only 12-24-chamber devices are effective, not 4-6-chamber devices, as most of the available on the market (and much more than the effective cheaper ones), and thirdly and probably most importantly, doctors associated with the Foundation alert that when used without medical supervision, they can do more harm than good, because they should consist not only of a compression tube put on the hand, but from the entire compression jacket. The tube does, it makes room for the lymph from the swollen hand, but it “pushes” it only to the armpit, where there are no lymph nodes. The jacket would allow the lymph to circulate over the body, the sleeve interrupts the mission about halfway through.
From the published in the periodical Contemporary Oncology [(2007) vol. 11; 9 (444-448)] of the quality of life study of Polish women with lymphoedema after mastectomy shows that the vast majority of patients undergoing the study operated at the Lower Silesian Oncology Center in Wrocław, who used therapy at all to eliminate edema, benefited from classical massage (from many ineffective in the case of lymphedema) and diuretics. The authors of the study conclude that the situation of Polish amazons with lymphedema is more difficult than in the West.
So there is still a lot to do, but it is good to know that there is something to do! Our western neighbors have known clinically proven methods of treating lymphedema for a long time, we have someone to learn from, the more that the therapy is not complicated, burdensome or too demanding.
Oby szybko udało się wywalczyć dla polskich pacjentów z obrzękami limfatycznymi możliwość skutecznej terapii, a nie ruchów pozorowanych.
more information on the website of the Polish Lymphological Foundation: www.pfl.org.pl