Oncology Rehab is not CDT!

So why is the Lymphedema SIG in the Oncology Section of the APTA?

John Fuller Beckwith3/14/2024

When lymphedema therapy first came to the US, the cohort of patients driving the quest for good lymphedema care and therefore driving the spread of that care around the US was breast cancer patients. They weren’t the only patients with lymphedema who deserved the best lymphedema care, but they did help to usher in CDT from Europe. CDT changed lymphedema care in the US. It spread to other lymphedema patients from there, meaning to other oncology patients with lymphedema but also to primary lymphedema patients and the large cohort of phlebolymphedema patients. That is a good thing. However, since it was through oncology that CDT arrived, the oncology rehab specialists came to identify themselves with lymphedema care. Yet lymphedema is so much more than oncology. And not only that, oncology patients with lymphedema should receive full-throated lymphedema care, not partial care. Lymphedema in the context of oncology rehab still deserves a comprehensive approach. The problem is this often is not the case. Lymphedema patients receiving treatment in an oncology rehab setting don’t necessarily receive the gold standard of CDT. In short, Oncology Rehab is not synonymous with lymphedema. Oncology rehab specialists shouldn’t define what lymphedema therapy is.

Yes, many patients with lymphedema are oncology patients. But also, many patients with lymphedema are phlebolymphostatic patients with wounds or weeping. Lymphedema is lymphedema, no matter the cause. When a CLT sees a patient with wounds and weeping, certainly there are considerations and treatments in order to properly care for the wound in the moment, but that patient does not receive a lymphedema treatment that is truncated simply because there are concomitant concerns. In the case of the patient with wounds in addition to lymphedema, if we don’t treat the lymphedema comprehensively, meaning dosing of modalities to give best reduction in lymphedema, they may never heal the wound, or the wound is more likely to recur since the lymphedema was not reduced as much as possible. We apply full dosing of CDT and once the lymphedema is reduced and the patient is in the optimization phase of CDT, using their garments and now doing self-MLD and exercise as appropriate, we also address any concomitant causes of the wounds, such as diet, exercise, skin care.

To be sure, the oncology rehab world has been at the forefront of lymphedema surveillance, promoting pre-surgery volume measurements, post-surgical lymphedema referrals for education and awareness, use of bioimpedence to discover the earliest stages of lymphedema. These are all important advances, no question. They have helped to catch breast cancer related lymphedema very early and reduced morbidity due to lymphedema in this cohort. It allows those in oncology rehab to address lymphedema at the earliest stages when there may be very little swelling present. Granted, these patients with early stage lymphedema won’t need daily treatments and some don’t warrant short-stretch compression bandaging. Their ‘dose’ of lymphedema treatment is advisably small. The problem occurs when an oncology patient has more advanced lymphedema that only full dosing (meaning daily treatments, MLD in the clinic done by the CLT, skilled short-stretch compression in place 24 hours per day) will adequately reduce the lymphedema. Many times oncology rehab clinics still will not apply the full dose, opting instead for teaching self-MLD, use of velcro compression rather than skilled short-stretch, keeping treatment visits at 1-2 x week. These patients are not receiving the lymphedema therapy they deserve, nor are they achieving the results they could. This may be considered a disservice to these patients.

Oncology rehab is an important specialty having a unique body of knowledge that is applied meaningfully to the patients who need their services, but that is distinct from the needs of a lymphedema patient. A lymphedema patient with stage II or greater lymphedema needs the meaningful application of the unique body of knowledge of lymphedema therapy. In my practice I see a lot of wound patients. I have a lot of knowledge and experience in wound care. But the wound specialists who refer the patient control the wound care and I apply fully dosed lymphedema therapy. I am not an oncology specialist, when I see an oncology patient with lymphedema, I treat the lymphedema fully and if further therapy to address oncology needs is indicated, I refer the patient to an oncology specialist. As a licensed PT I could continue to see the patient, but they deserve the full scope of the oncology specialty. In the same respect, an oncology patient with lymphedema deserves the full scope of lymphedema treatment, not some truncated version.

The scope of the lymphedema specialty goes well beyond oncology rehab. Many patients with lifelong lymphedema long ago beat their cancer, but they continue to live with the challenges of life-changing secondary lymphedema. They need fully dosed lymphedema treatment. But there are also primary lymphedema patients, the millions of phlelolymphostatic patients and other lymphedema patients who never need oncology rehab. These patients should only go to lymphedema specialists who will provide fully dosed, appropriate therapy.

Oncology rehab specialists may do some lymphedema therapy, but they do not define the lymphedema specialty. I would argue the lymphedema cohort is larger than the oncology rehab cohort, meaning there are more referrals for lymphedema therapy than purely for oncology rehab. Yet oncology rehab has a full section in the APTA and lymphedema is merely a special interest group within that section. It is time to recognize that lymphedema deserves its own section and oncology rehab should not be defining the parameters of lymphedema treatment.