Asdourian, M.S., Skolny, M.N., Brunelle, C., Seward, C.E., Salama, L., & Taghian, A.G. (2016). Precautions for breast cancer-related lymphoedema: Risk from air travel, ipsilateral arm blood pressure measurements, skin puncture, extreme temperatures, and cellulitis. Lancet Oncology, 17, E392–E405. 

STUDY PURPOSE: To examine the literature regarding precautionary and lifestyle behaviors to prevent adverse effects with arm lymphedema secondary to breast cancer surgery

TYPE OF STUDY: General review/\"semi\" systematic

• FINAL NUMBER STUDIES INCLUDED = 26 
• TOTAL PATIENTS INCLUDED IN REVIEW = 2,992
• SAMPLE RANGE ACROSS STUDIES: 12–632 patients
• KEY SAMPLE CHARACTERISTICS: All patient sample studies were of women with breast cancer; none had lymphedema or lymph node removals.

PHASE OF CARE: Late effects and survivorship

Nine studies looked at air travel and risk of lymphedema. No consensus among studies regarding the utility of compression garment use during air travel was found, and no evidence exists to show that its use is of benefit or a risk to patients. Five studies regarding temperature extremes were included. Two studies conducted in China reported benefit from local heat therapies, and one study showed that sauna use may be associated with increased risk. Findings were insufficient to draw firm conclusions. Four studies looked at risk and the use of the affected arm for blood pressure monitoring. Two studies showed some evidence that blood pressure measurement was associated with increased lymphedema. Ten studies looked at venipuncture and lymphedema risk or outcomes. Conflicting reports were seen, and most evidence was of low quality. Eight studies involving the relationship between infection and incident worsening of lymphedema were reviewed. Of these, six suggested a significant relationship between worse lymphedema outcomes and infection, injury, or cellulitis.

Insufficient evidence exists to draw firm conclusions about the necessity of precautionary guidelines for behavior to reduce the potential for incident worsening of lymphedema and related adverse effects, although guidelines are based on sound physiological principles. Studies have shown that skin infections and inflammation are significant risk factors.

• Limited number of studies included
• Mostly low quality/high risk of bias studies
• Included recommendations from hand surgeons and studies unrelated to breast cancer–related lymphedema.
• The strongest evidence was nonrandomized, prospective, observational, or cohort designs, but these were based on patient recollection and other survey data.

This study adds to a growing body of evidence encouraging the questioning of traditional patient teaching for risk reduction behaviors aimed at reducing the risk of incident worsening of arm lymphedema after surgery for breast cancer. Insufficient evidence shows that risk reduction behaviors are effective in reducing risk; however, insufficient evidence supports that elimination of these behaviors is safe for patients. Traditional patient teaching to avoid the use of tourniquets or limb constriction, wounds or punctures, exposure to extreme temperatures, the use of compression garments with air travel, and maintain cleanliness are founded in sound physiological rationale. Such risk reduction behaviors are not overly restrictive and are sensible aspects of patient teaching for self-care.