A major impediment to quality of survival in patients with breast cancer, lymphedema, and its prevention has been hampered by a lack of research to guide practice. Case in point is that randomized controlled trials assessing risk of medical procedures on the at-risk arm have never advanced past the concept phase.1 Hence precautionary recommendations for breast cancer survivors to prevent lymphedema have primarily been based on physiologic rationale versus high-level scientific evidence.
A recent comprehensive review of mostly retrospective research on five lifestyle and health variables examined risks associated with 1) air travel and use of compression garments, 2) temperature extremes, 3) limb constriction (i.e., blood pressure measurement, tourniquets), 4) blood draws, infusions and skin puncture, and, 5) cellulitis.2 Thirty-one research articles were critiqued. An interdisciplinary team from Massachusetts General Hospital used a research grading system to evaluate the strength of the evidence reported and depicted how the findings supported the National Lymphedema Network’s recommendations.3 In summary, the major findings included the following:
Women with bilateral axillary lymph node dissection (ALND) do not have an increased risk of lymphedema compared with those who have undergone unilateral ALND;
While using the unaffected arm for blood draws and medical procedures is advised when possible, isolated use of the at-risk arm has frequently shown to not increase the risk for lymphedema even in patients with ALND;
In cases of bilateral ALND, consideration of which arm to take blood pressure measurements should depend on which arm had the fewer or no lymph nodes removed;
There is not an established link between air travel and lymphedema nor has there been any evidence of compression garments conferring benefit to at-risk women;
There is a paucity of data supporting the avoidance of sudden or prolonged limb exposure to extreme temperatures (i.e., saunas);
The one variable with the most evidence supporting risk reduction practices is the avoidance of infection and the maintenance of optimum skin integrity.
The authors proposed that not all patients be given the same precautionary advice. Rather they recommended that clinicians identify patients by risk stratification and advise accordingly. The following preliminary model using well-substantiated physiologic and treatment-related risk factors for lymphedema was compiled:
Low-risk group: Sentinel lymph node biopsy only or no nodes removed, BMI <25 kg/m2; lymphedema risk incidence 0% to 6%; these patients may have more flexibility in their adherence to conventional precautions;
Moderate-risk group: Sentinel lymph node biopsy and regional lymph node radiation; lymphedema risk 5% to 15%; these patients may have more flexibility in their adherence to conventional precautions;
High-risk group: ALND, ALND + regional lymph node radiation, BMI >30 kg/m2, previous episodes of lymphedema resolved either with or without treatment; precautionary guidelines should be reinforced continually.
The majority of the research reviewed in this article is more than 5 years old and may not be relevant to current clinical practice where sentinel lymph node biopsy now replaces ALND. Hence, the proportion of low-risk women is increasing and precautionary guidelines will require further scrutiny.
Findings shared represent why oncology nurses need to keep appraised of the literature in an effort to ensure their knowledge and patient teaching are based on the most recent evidence. We also can be the conduit of new evidence for our interdisciplinary team to discuss and introduce into practice.
Cheng CT, Deitch JM, Haines IE, et al. Do medical procedures in the arm increase the risk of lymphedema after axillary surgery? A review. ANZ J Surg. 2014 Jul-Aug;84(7-8):510-4.
Asdourian MS, Skolny MN, Brunelle C, et al. Precautions for breast cancer-related lymphedema: Risk from air travel, ipsilateral arm blood pressure measurements, skin puncture, extreme temperatures, and cellulitis. Lancet Oncol. 2016 Sep;17(9):e392-405.
National Lymphedema Network. Position Statement of the National Lymphedema Network. 2012 May.
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