Interview with Lymphedema Expert Dr. Emily Iker
Dr. Emily Iker is director of the Lymphedema Center in Santa Monica. She is a well regarded Physical Medicine and Rehabilitation specialist focusing on the diagnosis, management and treatment of lymphatic disorders.
Iker teaches and lectures annually, nationally and internationally, and is an instructor for Lymphedema Management courses. She is a member of the Scientific Committee for the 26th World Congress of Lymphology taking place in Barcelona, September 25 to 29, 2017 [http://www.lymphologycongress2017.com/]. Here she will lead the Lymphedema Management course as well as present several lectures on Lymphedema and Lipedema.
We interviewed Dr. Emily Iker over the phone.
Q What is Lymphedema?
A According to the International Congress of Lymphology lymphedema is “an external or internal manifestation of lymphatic system insufficiency and deranged lymph transport.”
Q How does it manifest physically?
A Swelling, pain, fatigue and a diminishment of joint mobility.
Q I don’t think a lot of people understand how important the lymphatic system is …
A I don’t think a lot of physicians understand how important it is …
But it is very important, paralleling the circulatory system. In layman’s terms the lymphatic system has several functions. Its number one function is to filter impurities, the debris and toxins on the plasma level. And, it is also functions as an immune system.
When we have primarily secondary lymphedema (secondary meaning the condition is due to some intervention, such as breast cancer surgery, where the lymph pathways were interrupted), there is a stagnation of the lymph system and the lymph vessels become engorged. Their transport capacity is delayed. And then we have the increased permeability of protein cells into the tissue along with the fluid, which then becomes lymphedema or swelling. In early phases the swelling may not be so visible or the patient’s sensation may be lacking because they just had surgery. And especially after breast cancer, the area of the axila, or armpit, may be numb. So they may not feel it yet. But then when it becomes a little bit larger there is a sensation of pressure, tension, heaviness – and then it is true lymphedema.
Q Is it inevitable that everyone who has to undergo surgery for breast cancer or any surgery that interrupts the lymphatic system will get lymphedema?
A There is a variation in the statistics. Up to 50% of patients may end up with lymphedema.
Q Is there any way to prevent it from happening?
A Well today we have better technology in surgical approach than we had maybe 20 years ago. Now we have what we call sentinel node – where a blue dye is used on the first lymph node that’s involved so the surgeon is able to recognize it during surgery and remove a lesser number of lymph nodes. This is a good development for breast cancer patients, very good for melanoma patients (Dr. Morton in Santa Monica is the one who developed the sentinel node strategy). But just recently I had a patient who had prostate cancer, a fairly young man, and 80 lymph nodes had to be removed; 63 of those were positive. So we still don’t have sentinel nodes for all cancers.
In the old days there were many lymph nodes sacrificed and maybe 1 or 2 were positive. Now we can be a little more precise.
Let me also point out too that once a breast cancer patient has had surgery (lumpectomy or mastectomy) and then radiation, the incidence of lymphedema onset is far greater than if the treatment is just surgery and chemo.
Q Why is that?
A Scarring from the radiation treatment makes the patient more prone to developing lymphedema. The combination of those two things almost guarantees that you’ll get lymphedema.
Usually it develops very shortly after surgery and radiation treatment. But I’ve seen patients who came down with lymphedema 30 years later. Most likely they had a very good lymphatic system and it was able to be compromised but keep going.
Q Before we go on with these questions, would you talk a little bit about your own journey and career?
A I started in surgery – my aspiration was to be a surgeon and I went through pre-med while on chemotherapy – because I had lymphoma. Unfortunately, I had two episodes of lymphoma, the second 6 months after the first one and I had surgery and radiation and chemo – this was my undergraduate time. Then I went to medical school while I was in remission. During my surgical residency in my second year, I experienced excruciating pain and my right leg swelled up and that was the onset of my lymphedema.
The reality was I couldn’t continue my surgical training and I went into rehab medicine instead, which I completed in New York. After completion my lymphedema continued. At that time no one really understood the lymphatic system. I practiced a little bit on my own and, when I moved to California, I was fortunate to meet Professor Albert Leduc, an authority in lymphology. He is from Belgium and he was able to come to the US to give a lymphedema management course. I was a student and it was enlightening because finally I found someone who really understood the lymphatic system. It was wonderful that I could take the course and shortly after I started to practice lymphedema management. Now I work with a diagnostician, a clinician and we do lymphedema management for all kinds of lymphedema, even lipidema.
Q What is that?
A Lipidema is a fat disorder. Unlike those with lymphedema, these patients have symmetrical enlargements, especially in the lower extremities but the feet are spared, they’re tiny and not involved in early phases. The tissue consistency is very soft, buttery and is essentially a fat. There is a genetic component involved, mostly for women and there is hormonal influence. We see early onset in puberty and then it progresses if it’s not treated.
Q So how does one treat lymphedema?
A I’ll tell you my routine. I do still have lymphedema, but I am fortunate in that I can practice and be active – but I do wear a compression stocking on a daily basis. Without it my lymphedema would expand much more than it has.
I am blessed because I have almost 10-year old twins later in life (unfortunately my husband passed away when they were 2) – I am both mother and father. I get up early in the morning and I spend a few minutes massaging my leg – every day. And then I put my compression stocking on and go about my day. Even though I would say I am between stages 1 and 2 of lymphedema, at the end of the day my leg is swollen more than in the morning – even though I wear a compression stocking with 30 to 40 ml mercury pressure. I am active, I walk my little dog and I do like jogging, I love to swim, which is the best exercise for both lipidema and lymphedema. Because of the pressure of the water and moving every single muscle in the body plus moving the diaphragm – it helps to move the lymph from one segment to the other faster. So for all patients I highly recommend swimming as much as possible. And then at the end of the day I massage my leg and I do stretching exercises and once in a while I do a compression pump treatments at home and in my office as well. My staff treats me.
Q What is compression pump treatment?
A It involves a special sleeve attached to a pump. From distall to proximal it applies external pressure in segments. It presses on the involved site and there is a period of inflation and a period of deflation so it induces gentle pressure in sequences that stimulates and increases the flow of the lymph. This is very gentle pressure, more gentle than say a blood pressure cuff, which can be painful. With this treatment many patients simply fall asleep during the treatment. The key for lymphedema and for lipidema is compression and that can be via bandaging or compression pump treatment. In my practice I’ve found when we use the compression pump we can get 30% more reduction in volume in stage 1 or 2 lymphedema in about 2 weeks with daily treatment.
The other key is to have early diagnosis and early intervention. And in early phases after surgery (lumpectomy or mastectomy) it is important to start the treatment right away, before the patient is complaining about arm sleeves being too tight, or their clothes don’t fit and so on. With early intervention we have much better outcomes in the long run. And we don’t get disability or poor quality of life.
Q In your opinion, is there sufficient information circulating about lymphedema among surgeons and doctors treating women?
A It is much better than it was 20 years ago. I started to practice in 1992, back then they didn’t even know how to spell the word ‘lymphedema’. I remember way back when one insurance company refused to pay for the treatment and their explanation was that their policy was to not pay for prevention. We have much better awareness now, and I would attribute that to the women’s movement around breast cancer and the consequences of breast cancer. We now have much better awareness about what lymphedema and what lymphedema treatment is. Unfortunately though, even some of my colleagues still downplay the importance of the lymphatic system. They may look at the legs and say ‘oh well it’s a little bit swollen, no big deal’.
Q And it’s not something that can be cured or eradicated once a patient has it?
A Probably not. In my practice and in my decades of treating patients with lymphedema I’ve observed that upper body lymphedema is much easier to treat than lower body or facial or genital lymphedema. At the Center we see it all and we treat it all. It can be a lifelong condition.
Q How do undergarments and prosthetics figure into how you might treat a breast cancer patient who has developed lymphedema?
A It is absolutely essential for these patients to have the correct garments.
There are some studies where they are measuring the volume of the extremities even before surgery and then right after surgery so they can predict who will get lymphedema. But again it’s not only removal of the lymph nodes, it’s also the issue of disturbing the lymph pathways. After surgery it is essential that the patient wear an appropriate compression garment that has been properly fitted. For breast cancer patients, choosing the right undergarment and prosthetic is also important. I love the lightweight one that Bressanté makes. I don’t want to sound chauvinistic but it takes a woman to design one.
Q What about things like flying? Do you remove compression garments for travel?
A For long distance driving, yes. If compression stockings fit well they should not give any problem when flying. For long distance flights, patients are encouraged to walk during the flight, not just sit.
Q It can be difficult for patients to get the kind of information and advice that is really helpful. Can you recommend any reliable resources?
A You know they are so much better now than a decade ago and there are so many companies that make these products. The most important thing for the patient is to wear the compression sleeve and when there is too much swelling in the armpit area I recommend Danskin, something with a longer arm that covers the armpit area. I would also recommend the book on nutrition that I co-authored: The Lymphedema and Lipedema Nutrition Guide available from Amazon.
Lymphedema Center in Santa Monica
With lymphedema spokesperson, actress Kathy Bates discussing lymphedema on The Doctors:
Full list of clips: http://www.thedoctorstv.com/search?query=lymphedema
Lymphatic Education & Research Network (Le&Rn)
Facebook page: https://www.facebook.com/LymphaticResearch
Canadian Lymphedema Framework (CLF)
Lymphedema and Lipedema Nutrition Guide available on Amazon