April-June 2009: Risk-Reduction Practices

LymphLink Question Corner - Archived from April-June 2009
By Mei R. Fu, PhD, RN, ACNS-BC

Q: I am an ER physician and have a breast cancer-related question that has come up in our department. The conventional wisdom is that one should never take a blood pressure, phlebotomize, or start an IV on the arm on the same side as a previous mas tectomy (regardless of the time-frame), because of a concern that these procedures will result in “lymphedema.” No distinction is made between whether the patient has had a radical or modified radical mastectomy or previous symptoms of lymphedema.

I am well aware of the dogma that is written in many nursing protocols, but I haven’t seen any published articles documenting the risks. In particular, it would surprise me that taking an intermittent cuff blood pressure would be a significant factor. Are you aware of any published studies that document these risks or is this just one of those “old wives’ tales” in medicine?

ER physician
Melbourne, FL

A: Very few published studies have documented the exact risk of lymphedema from performing blood pressure, blood draws and injections in the affected limb. Factors that trigger or stimulate the development of lymphedema in an at-risk person have been identified, including infections and injuries.1,2 Performing blood pressure, blood draws and injections in the affected limb are among the risks leading to injuries. Lack of research and physiological variations in each person’s lymphatic system (such as numbers or sizes of lymph nodes) make it difficult to quantify personal risk and exact risk from each triggering factor. While further research is needed, healthcare professionals are encouraged to consider doing no harm to patients by minimizing the risk of lymphedema (such as performing blood pressure, blood draws and injections in the non-affected limb whenever is possible). If the only option is to use the affected limb, healthcare professionals should instruct patients about the signs and symptoms of lymphedema so that early detection and treatment can be achieved. Blood pressure, blood draws and injections should never be performed in a lymphedematous limb. The lifetime commitment to reduce the risk of lymphedema requires time and effort from both healthcare professionals and patients.

Q: What is the National Lymphedema Network’s stance on the risk of lymphedema in those breast cancer patients undergoing sentinel lymph node biopsy versus axillary dissection? Does the Network believe that these patients be treated with the same precautions as axillary dissection patients?

Breast Care Coordinator
Cedar Rapids, Iowa

A: The Advent of sentinel lymph nodes biopsy [SLNB] has decreased significantly the incidence of lymphedema and related symptoms in women who received SLNB alone, yet approximately 4% to 10% of women who received SLNB alone have developed lymphedema and 6% to 20% of women have experienced lymphedema-related symptoms.3-6 More patients who underwent SLNB plus removal of additional lymph nodes have developed lymphedema.7,8 SLNB continues to make patients susceptible to the risk of lymphedema. Recent research shows that provision of lymphedema risk reduction information does have a statistically significant affect on breast cancer survivors’ experiences of lymphedema-related symptoms.9 We encourage healthcare professionals to provide accurate lymphedema risk reduction information and do no harms to patients including those who received SLNB alone.

Q: We have been trying to find evidence to answer the question: when can a post mastectomy arm be used for IV therapy? We have searched the literature for answers to who is at risk and from studies that indicate if the risk subsides. Some nursing polices and practices say after 5 or 7 years, it is okay to use. Do you have any evidence supporting or negating this practice?

Nurse Clinician
Phildadelphia, PA

A: Unfortunately, the risk for lymphedema in patients who underwent mastectomy or lumpectomy exists throughout one’s lifetime. Patients could develop lymphedema as many as 15 to 30 years after surgery. 10 Since the risk is lifetime for patients, we encourage healthcare professionals to consider doing no harm to patients at all times by minimizing the risk of lymphedema (such as performing blood pressure, blood draws and injections in the affected limb).

References

  1. Mak, S.S., Yeo, W., Lee, Y.M., Mo, K.F., Tse, K.Y., Tse, S.M., Ho, F.P., Kwan., W.H. (2008). Predictors of lymphedema in patients with breast cancer undergoing axillary lymph node dissection in Hong Kong. Nursing Research, 57(6), 416-25.
  2. Soran, A., D’Angelo, G., Begovic, M., Ardic, F., Harlak, A., Samuel, Wieand, H., Vogel, V.G., Johnson, R.R. (2006). Breast cancerrelated lymphedema--what are the significant predictors and how they affect the severity of lymphedema? Breast Journal, 12(6), 536-543.
  3. McLaughlin, S. A., Wright, M. J., Morris, K. T., Giron, G. L., Sampson, M. R., Brockway, J.P., et al. (2008). Prevalence of lymphedema in women with breast cancer 5 years after sentinel lymph node biopsy or axillary dissection: objective measurements. Journal of Clinical Oncology, 26(32), 5213-5219.
  4. Paim, C.R., Lima, E., Fu, M.R., Lima, A., & Cassali, G.D. (2008). Post-lymphadenectomy complications and quality of life among breast cancer patients in Brazil. Cancer Nursing, 31(4), 302-309.
  5. Paskett, E.D., Naughton, M.J., McCoy, T.P., Case, L.D., Abbott, J.M. (2007). The epidemiology of arm and hand swelling in premenopausal breast cancer survivors. Cancer Epidemiology, Biomarkers & Prevention, 16(4), 775-82.
  6. Stout Gergich, N.L., Pfalzer, L.A., McGarvey, C., Springer, B., Gerber L.H., Soballe, P. (2008). Preoperative assessment enables the early diagnosis and successful treatment of lymphedema. Cancer, 112(12), 2809-19.
  7. Boneti, C., Korourian, S., Bland, K., Cox, K., Adkins, L.L., Henry-Tillman, R.S., & Klimberg, V.S. (2008). Axillary reverse mapping: mapping and preserving arm lymphatics may be important in preventing lymphedema during sentinel lymph node biopsy. Journal of the American College of Surgeons, 206(5):1038-42.
  8. Langer, I., Guller, U,. Berclaz, G., Koechli, O.R., Schaer, G., Fehr, M.K., Hess, T., Oertli, D., Bronz, L., Schnarwyler, B., Wight, E., Uehlinger, U., Infanger, E., Burger, D., Zuber, M. (2007). Morbidity of sentinel lymph node biopsy (SLN) alone versus SLN and completion axillary lymph node dissection after breast cancer surgery: a prospective Swiss multicenter study 452-61.on 659 patients. Annals of Surgery, 245(3)
  9. Fu, M.R., Axelrod, D. & Haber, J. (2008). Breast Cancer-Related Lymphedema: Information, Symptoms, and Risk Reduction Behaviors. Journal of Nursing Scholarship, 40(4), 341-348.
  10. Petrek, J.A., Senie, R.T., Peters, M., Rosen, P.P. (2001). Lymphedema in a cohort of breast carcinoma survivors 20 years after diagnosis. Cancer, 92(6):1368-77.

Mei Fu, PHD, RN, ACNS-BC
New York University College of Nursing
New York, NY
mf67 [at] nyu.edu


Please address questions to: Editor c/o NLN, 116 New Montgomery Street, Suite 235, San Francisco, CA 94105 or e-mail: nln [at] lymphnet.org. Deadlines for submissions (for the following issue) are: Feb 1, May 1, Aug 1, Nov 1.