CHERYL BRUNELLE, PT, M.S., CCS, CLT

BREAST CANCER-RELATED LYMPHEDEMA (BCRL) is a potential side effect of breast cancer treatment, affecting approximately 20 percent of survivors. This complication is characterized by the abnormal accumulation of lymphatic fluid, presenting as swelling of the arm, shoulder, hand, breast and/or trunk on the same side as breast cancer treatment. Further, BCRL can negatively impact a survivor’s quality of life and body image, contributing to higher rates of anxiety and depression. Treatment of advanced lymphedema can be difficult, but early detection and therapy may help prevent or slow down progression. Therefore, research focusing on early prevention and on identifying risk factors can be particularly helpful to patients and their providers.

In fact, BCRL research has revealed an extensive set of risk factors. Women more likely than others to develop BCRL include those who have undergone radiation or surgical dissection of the lymph nodes; have a high body mass index (BMI) at the time of diagnosis; experienced cellulitis (infection) in the at-risk arm after surgery; or experienced low-level arm volume changes after surgery.

The National Lymphedema Network (NLN) has outlined a number of precautionary behaviors for breast cancer survivors. They include avoiding venous puncture (ie, blood draws, intravenous lines) or constriction (ie, blood pressure cuffs, tourniquets and tight clothing) of the at-risk arm. Also, NLN suggests, survivors should wear a compression sleeve during airplane flights. However, these recommendations for at-risk patients, though based on clinical reasoning, have not yet been supported nor refuted by high-level scientific evidence. As such, further research needs to be done in large cohorts of patients to investigate the relationship between precautionary behaviors and risk of BCRL.

Ferguson and colleagues were among the first groups to prospectively investigate the relationship between precautionary behaviors and BCRL development. The group screened and measured the arm volumes of 632 women who had undergone breast surgery at Massachusetts General Hospital, in Boston. Upon each arm volume measurement, patients were asked to report the number of blood draws, blood pressure readings, injections and infections to the atrisk arm as well as the number of flights and flying hours since the last arm measurement was taken.

Upon analyzing 2,965 survey responses, the Ferguson team reported that high BMI, axillary lymph node dissection, regional lymph node radiation and cellulitis all increase the risk of BCRL development. However, the researchers did not find a significant association between BCRL and undergoing blood draws, blood pressure readings, injections to the at-risk arm or air travel. The Ferguson team’s study was limited by the low number of lymphedema events in the population; statistically, a higher number of events would have more reliably demonstrated which factors contributed to lymphedema flares. Therefore, guidelines deserve more research, but, in the meantime, NLN’s precautionary measures should be the standard.

Let us consider Jane Doe, a breast cancer survivor who noticed increased swelling in her at-risk arm after having her blood drawn and is now presenting with lymphedema. Should Jane or her doctor attribute her BCRL to the blood draw? It’s hard to say: Though some patients have blood drawn and go on to develop BCRL, many more do not, and current research has not proven that blood draws increase the risk of lymphedema. In the Ferguson team’s study, 251 patients reported undergoing one or more blood draws: 10 of these patients developed BCRL and 241 did not. In the 10 who developed BCRL, it is not known what caused the lymphedema: Was it actually the blood draws or another factor, such as infection, individual anatomy or genetic predisposition? In any case, Jane should discuss her individualized risk factors with her doctor in order to understand her new diagnosis. Individual triggers should be identified and avoided as much as possible. Lastly, if swelling does, indeed, arise, treatment by a certified lymphedema therapist is recommended to reduce arm volume and prevent increased swelling.

Overall, we recommend a large clinical study to definitively evaluate the merit of existing precautionary measures, particularly since efforts to avoid blood draws from one arm, or to wear compression sleeves while flying, may be inconvenient for patients.

It is of utmost importance that we clarify that these precautions have neither been supported nor refuted. Therefore, we recommend that the NLN’s precautionary guidelines be followed at this point by those who are at risk for, or who have, BCRL. To optimize the long-term quality of life of breast cancer survivors and minimize the anxieties involved with following a strict precautionary regimen, we hope that future research will lead to a more risk-adjusted set of precautionary guidelines to help survivors avoid BCRL.

 The Lymphedema Studies Program at Massachusetts General Hospital incorporates a multidisciplinary approach to research, with the goal of screening for and managing breast cancer-related lymphedema.

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CHERYL BRUNELLE, PT, M.S., CCS, CLT

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