Ferguson, C.M., Swaroop, M.N., Horick, N., Skolny, M.N., Miller, C.L., Jammallo, L.S., . . . Taghian, A.G. (2016). Impact of ipsilateral blood draws, injections, blood pressure measurements, and air travel on the risk of lymphedema for patients treated for breast cancer. Journal of Clinical Oncology, 34, 691–698. 

To investigate the relative merits of the current guidelines advising patients to avoid ipsilateral blood draws, injections, blood pressure measurements, trauma, and wearing compression sleeve for air travel to reduce the risk of developing lymphedema

Patients with newly diagnosed breast cancer from 2009–2014 were prospectively screened for lymphedema in bilateral arms using an optoelectronic perimeter, an infrared light to measure arm circumference and volume. Participants were measured at preoperative baseline, postoperatively, and after chemotherapy and/or radiation therapy at regular follow-up oncology visits. (Regular means between three to seven months.) Patients were also measured at their request. At each measure, patients completed a questionnaire and reported on blood draws, injections, blood-pressure readings, trauma, and frequency and length of flights. A total of 3,040 measurements were made.

• N = 632   
• AGE = 52 years
• BMI: 26
• FEMALES: 100%
• CURRENT TREATMENT: Chemotherapy, radiation, immunotherapy
• KEY DISEASE CHARACTERISTICS: Patients newly diagnosed with breast cancer with six months of postsurgical follow-up; patients with axillary lymph node dissection or sentinel lymph node dissection; a history of cellulitis was okay; patients with bilateral lymphedema
• OTHER KEY SAMPLE CHARACTERISTICS: Exclusion criteria: Patients with metastases or who wore a compression sleeve when flying

• SITE: Outpatient clinic visit at Massachusetts General Hospital    
• SETTING TYPE: Outpatient
• LOCATION: Boston, MA

PHASE OF CARE: At start of breast cancer, up to six months of follow-up

A prospective screening study to assess for lymphedema in patients with newly diagnosed breast cancer from 2009 to 2014

The researchers used an optoelectronic perimeter to calculate bilateral arm volumes preoperatively, postoperatively, again after chemotherapy and/or radiation therapy, and at regular follow-up oncology visits (every three to seven months). The relative volume change (RVC) formula was used to quantify limb volume changes in unilateral limb involvement, and the weight-adjusted volume change (WAC) formula was used to quantify limb volume changes for bilateral limb involvement. Lymphedema was defined as RVC or WAC scores greater than or equal to 10%. Patients completed the questionnaire regarding limb risk behaviors, including blood draws, blood pressures, injections, and trauma.

No association of nonprecautionary limb behaviors and the development of lymphedema existed among patients with breast cancer in this prospective study. ALND, BMI greater than or equal to 25, RLND, and cellulitis were associated with increases in limb volume.

• Unintended interventions or applicable interventions not described that would influence results 
• What was said to the participants at the start of therapy is unclear.
• The discussion section clearly states that the authors provided “persistent recommendations to avoid blood draws, blood pressure reading and injections in the at-risk limb to reduce the risk of lymphedema,” which appears to be an unintended intervention.

Although most lymphedema precautionary behaviors are “expert opinion,” this study does not dismiss the need for such affected limb precautionary behaviors. Continue with all such precautionary behaviors. Just as all patients do not develop lymphedema, patients develop lymphedema from an array of activities.