What’s the Evidence? Can patients have procedures performed in the ipsalateral arm after breast cancer treatment?

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June 8, 2017 by Casey Carr

By: Casey Carr MD

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Bottom Line:

Patients with breast cancer carry an increased lifelong risk of developing lymphedema; the average time to onset being 14 months after treatment (90% of cases occuring within 3 years). While national guidelines endorse avoidance of procedures in the same arm after treatment, there remains no consistent evidence behind this, and multiple studies demonstrating the opposite. In the emergency setting, this should remain a shared decision making process, with risks, benefits, and evidence (or lack thereof) with patients.

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Background:

Clinicians and guidelines advise patients with breast cancer to avoid blood draws, injections, and blood pressure readings in the ipsilateral arm after treatment for breast cancer. These procedures are thought to increase the chance of developing breast cancer related lymphedema (BCRL). However, these recommendations are often based in anecdotal evidence and small, poorly powered studies.  These precautions become increasingly burdensome in the emergency department, where rapid, multi-point vascular access is often necessary.

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Evidence:

In a prospective cohort study, Ferguson etl al (2016) followed patients undergoing breast cancer treatment at their institution. Bilateral arm volume measurements were performed pre-operatively and post-operatively (at every regular follow up visit). At each measurement, patients were asked to complete a survey listing the number of procedures and trauma  to the treated arm. In over 3,000 measurements, there was no association between volume change in the treated arm and blood draws, injections, or blood pressure measurements.

A literature review by Cheng et al (2013) found small case series and one prospective study that demonstrated an association between venipuncture and BCRL – the authors note that the prospective study had “methodological issues”. In contrast, the authors found one cohort study and another prospective cohort study that found no such association. These studies were moderately sized. They also quote a case series in which patients with a history of treated breast cancer underwent hand surgery on the ipsilateral hand; there was no increase in the rate of development of lymphedema when compared to patients without a history of breast cancer.

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References:

1. Ferguson CM, Swaroop MN, Horick N. 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 : official journal of the American Society of Clinical Oncology. 34(7):691-8. 2016.
2. Cheng CT, Deitch JM, Haines IE, Porter DJ, Kilbreath SL. Do medical procedures in the arm increase the risk of lymphoedema after axillary surgery? A review. ANZ Journal of Surgery. 84(7-8):510-4. 2014.