Lymphedema after head and neck cancer is considerably more common than previously assumed and can persist long after cancer treatment has finished. Researchers at Lund University in Sweden have discovered that patients with a low level of physical activity face a higher risk of developing lymphedema. They have also noted that a lymph scanner objectively measures changes in the condition - a method that has now been introduced in Sweden's Southern Healthcare Region.
Head and neck cancer is a collective term for several types of cancer that arise in various parts of the head and neck region. Of the 1,800 individuals affected annually, around 550 are diagnosed with oropharyngeal cancer, which is cancer in the oropharynx, tonsils and base of the tongue. It is one of the most common types of head and neck cancer and has previously been strongly linked to smoking and alcohol. However, over the past 20-30 years the percentage of cases resulting from HPV infection has risen considerably and today over 80 per cent of the cases stem from HPV.
Many of those treated for this type of cancer live on with lymphedema in the head and neck region. Lymphedema arises when the body's drainage system - the lymphatic system - does not remove tissue water which means that fluid collects in tissue and causes swelling. This can occur when the lymph nodes have been surgically removed or if the lymphatic system has been damaged by radiation treatment or chemotherapy. The researchers therefore wanted to examine what affects the risk of lymphedema. The study covered 50 patients with an average age of 64, and two-thirds of the participants were men.
"It was shown that three months after treatment, 80 per cent of the patients had lymphedema and after nine months the figure was 69 per cent. We were actually surprised that so many had a persistent problem," says Agneta Hagren, doctoral student at Lund University and nurse practitioner at the Department of Otorhinolaryngology, Head & Neck Surgery, Skåne University Hospital.
Agneta Hagren has worked clinically with patients for many years and knows that more information is needed on the risk of lymphedema as a result of cancer treatment. She believes one of the reasons for the lack of information is that these patients face other more difficult side effects, which has meant lymphedema has not been prioritised.
"Patients with head and neck cancer are those who report the lowest health-related quality of life. Their cancer affects a sensitive area with a lot of pain and side effects such as speech impairment and problems associated with eating, which in turn impacts many social situations. But it's important to help them, as a changed appearance can easily lead to negative effects on self-esteem and affect mental health."
No homogenous study has previously been conducted to establish how many are affected by lymphedema after oropharyngeal cancer. In addition, there have been no clear criteria for what can be considered as healthy or sick, as previous assessments were mostly based on manual examinations of lymphedema, which entails a high degree of subjectivity.
"When examining lymphedema in the leg or arm, it's possible to use other measurement methods, such as volume measurement with water and compare the limb with oedema on the healthy side. This, for obvious reasons, is not possible with head and neck lymphedema."
The researchers therefore used a lymph scanner, which provides exact measurement of tissue water. Using this method, they could state limits for what is considered to be lymphedema.
"In Sweden there are no guidelines, only recommendations on how lymphedema is to be measured. One result of our study is that the Southern Healthcare Region has now started using lymph scanners and the measuring points we have identified. This is also a prerequisite for the long-term objective assessment of the range of outcomes from therapies."
In the study, the researchers saw that individuals who had higher self-estimated physical activity (4-6 on a six-grade scale) were affected to a lesser extent by lymphedema. Individuals with low levels of physical activity thus had a greater risk of developing lymphedema. The researchers hope to continue by studying which type of physical activity is most effective. Until those results are presented, Agneta Hagren wants to highlight the WHO guidelines:
"I think the recommendations for physical activity given by WHO are a good starting point. These state you should be physically active for 20-40 minutes per day at medium intensity, or 10-20 minutes per day at high intensity, and do weight training twice per week."
