Study Brings Lymphedema Prevention Guidelines Into Question

Many women with breast cancer are careful to avoid even slight trauma to their arms, in order to lower their risk of lymphedema. But new research suggests many of the precautions women are encouraged to take may not be necessary. The study was published in March in the Journal of Clinical Oncology.

Background and Goals

Lymphedema is a long-term potential side effect of breast cancer treatment. It happens when extra fluid builds up, causing swelling of the skin on the same side of the body as the breast cancer. It usually appears in the hands, arm, chest or torso.

It is estimated that about 20 percent of women who are treated for breast cancer develop lymphedema. Women who have a type of surgery called axillary lymph node dissection are at higher risk for lymphedema than women who have another type, called sentinel lymph node biopsy. Still, both groups of women can develop the condition. Lymphedema requires lifelong management and can impact a person’s quality of life. To help avoid lymphedema, women are told to wear special garments while flying and to avoid trauma to their at-risk arm, including blood draws, injections and blood pressure readings.

There is little scientific evidence supporting these safety measures, though. These researchers wanted more information about how different forms of trauma affect a person with breast cancer’s risk of lymphedema.

Design

The study included 632 women who were newly diagnosed with invasive breast cancer between 2009 and 2014 and who were screened for lymphedema. Because some of the women had both breasts removed and lymph nodes removed on both sides, 760 at-risk arms were part of the study.

Women were eligible for the study no matter what kind of lymph node surgery they had. Women were excluded from the study if the cancer came back or if they wore a compression sleeve during a flight, because doing so is a risk reduction technique, and these researchers were interested in the effects of activities that are considered risks.

Arm measurements were taken before surgery, after surgery, after any chemotherapy or radiation appointments, and then at follow-up intervals of usually between 3 to 7 months.

The women completed surveys at each follow-up appointment about any trauma to their arm on the side where they had breast cancer. They reported any blood draws, injections, or blood pressure readings they had on that arm. They also reported any flights they had taken and how long the flights were. The women also had their arms measured at each follow-up appointment.

Results

The women had a total of 3,041 post-surgery measurements taken. They were followed for a median of 24 months. In that time, fewer than 8 percent of women developed lymphedema.

Each question about arm trauma had between 2,950 and 3,000 responses. The women reported that they had the following on an at-risk arm:

• In 2.1 percent of responses, participants said they had one or more injection since their last measurement.
• In 8.5 percent of responses, participants said they had at least one blood draw done since their last measurement.
• In 16.3 percent of responses,  participants said they had one or more blood pressure readings since their last measurement
• In 1 percent of responses, participants reported some other type of trauma since their last measurement.

Thirty percent of participants reported they had flown, without using a compression sleeve, since their last measurement.

The researchers found that none of these were significantly linked to an increase in arm size.

Qualities that were associated with arm swelling were

• Being overweight at diagnosis
• Axillary lymph node dissection
• Radiation to lymph nodes near the breast
• Skin infection (cellulitis)

Limitations

The study would be stronger if more women were followed for a longer amount of time and if more than one way of measuring arm size was used. The study did not take into account whether women received physical therapy, and some women may have forgotten to report certain behaviors or traumas. This could have affected the results.

What This Means for You

If you’re worried about lymphedema, you may feel like you’re constantly trying to lower your risk. And accidentally having your blood pressure taken on the wrong arm or flying without a lymphedema sleeve may make you feel scared and disappointed in yourself.

These researchers can’t say for sure that these precautions meant to reduce lymphedema risk aren’t needed. They recommend more research be done. But their findings may help women feel better about forgetting to stick to these difficult-to-follow guidelines all the time.

You can continue to take part in risk reduction techniques if they are important to you, and you have the right to ask your healthcare providers to avoid causing trauma to your affected arm.

For more information about lymphedema, read our online overview of lymphedema and our Guide to Understanding Lymphedema and visit the National Lymphedema Network’s website. If you are interested in taking part in clinical trials involving lymphedema, talk to your doctor and visit ClinicalTrials.gov.

Ferguson, CM, Swaroop, MN, Horicket, N, et al. Impact of Ipsilateral Blood Draws, Injections, Blood Pressure Measurements, and Air Travel on the Risk of Lymphedema for Patients Treated for Breast Cancer. J Clin Oncol 34:691-698, March 1, 2016; doi: 10.1200/JCO.2015.61.5948