Journal of Palliative Care 29:4 / 2013; 2 5 3 –257 © 2013 Institut universitaire de gériatrie de Montréal Secondary Lymphedema Pain among Cancer Patients 253 The many distressing symptoms associated with lymphedema include heaviness, tightness, pain, cramps, and a crawling sensation. The sever- ity of the pain, the most common of these symp- toms, depends upon the severity of the lym- phedema. Lymphedema pain can be caused by: the compression of nerves due to swelling; the increased pressure on nerves resulting from fibro- sis due to chronic inflammations (which occur fre- quently with lymphedema); cellulitis, lymphangi- tis, or other infections; overexertion of the affected limb as it struggles to cope with excess strain and weight; and the wounds and weeping sores that are usually present in the later stages of lym- phedema. Effects of lymphedema include limited range of motion and impaired function of the affected limb, and pain (which is present in more than 30 percent of lymphedema patients) (8). Pain can undermine rehabilitation efforts in this patient group and negatively affect quality of life. However, in spite of these related problems, lym- phedema remains a neglected aspect of breast cancer survivorship (9). Pain Associated with Secondary Lymphedema among Cancer Patients Theresa N. Elumelu-Kupoluyi, Adeniyi A. Adenipekun, and Atara I. Ntekim AI Ntekim (corresponding author): Department of Radiation Oncology, College of Medicine, University of Ibadan, Queen Elizabeth Road, Ibadan 200221, Nigeria; tarantekim@yahoo.com TN Elumelu-Kupoluyi, AA Adenipekun: Department of Radiation Oncology, College of Medicine, University of Ibadan, Ibadan, Nigeria GLOBAL EXCHANGE INTRODUCTION Cancer is a major problem worldwide, and pain is a major symptom among cancer patients, espe- cially as their disease progresses (1). It is estimated that every day at least three-to-five-million cancer patients worldwide suffer from pain (2). Lym- phedema is one of cancer’s most distressing and agonizing complications (3). It occurs most com- monly among breast cancer patients, but it is also associated with cervical cancer, prostate cancer, and malignant melanoma, among others (4). The condition can cause a range of discomforts, including pain — although the presence of such pain is not often recognized by the caregivers of those who suffer from lymphedema. Lymphedema is a form of high-protein edema that is characterized by chronic swelling of the affected body part. It occurs as a result of the body’s inability to drain lymph fluid from the tissues due to a malformation or malfunction of the lymphoid system. Among cancer patients, lymphedema is frequently triggered by the disease itself or by its treatments — notably, surgery and radiotherapy (5). The basic principle of the development of lym- phedema is that the rate of accumulation of lym- phatic fluid in the lymphatic drainage system of the affected site is faster than the rate of lymphatic fluid transport from the site. The condition has two main classifications: primary lymphedema, which is caused by congenital or hereditary factors; and secondary lymphedema, which is caused by a mechanical insufficiency that could be due to tumour, surgery, radiotherapy, trauma, infection, hemorrhage, prolonged immobilization, or tourniquet effect (6). Stage II lymphedema is a spontaneously irreversible (nonpitting) edema that is not relieved by elevation (Figure 1); it also has a positive Stemmer’s sign — that is, a thick- ened skin fold at the dorsum of the fingers or toes that cannot be lifted, or that can only be lifted with difficulty (7). Figure 1 / Stage II Spontaneously Irreversible Lymphedema (Right Upper Extremity)