A 47-year-old woman with a history of right-sided breast cancer – status after lumpectomy, lymph node dissection, and radiation – comes in to clinic for evaluation. She asks the MA to take precautions on blood pressure measurement.
What precautions should be done?
A. Check BP in left arm only.
B. Do not inflate cuff greater than 180 mm in the right arm.
C. It’s okay to check BP in either arm.
About 10 years ago, a person asked me after a medical myth lecture I had given if I had any information on whether avoiding blood pressure readings in the ipsilateral arm in breast cancer patients was a myth. We both agreed that it sounded like a myth, and I promised to research it.
I found no studies at that time that refuted the advice that breast cancer patients were given to avoid blood pressure measurement, blood draws, and injections in the ipsilateral arm. I found no evidence at that time supporting this practice, just very authoritative statements in medical and nursing journals. Currently, the American Cancer society website recommends against blood pressure checks and blood draws from the ipsilateral arm in breast cancer patients.1
Dr. Douglas S. Paauw
Are there more data now to weigh in on whether this is a myth or not?
The rationale behind this longstanding advice is that women who have had breast surgery, lymph node dissections, or radiation were at higher risk for lymphedema in the ipsilateral arm.
The advice to avoid blood draws and injections was to decrease the risk of infection and subsequent cellulitis that could lead to longstanding lymphedema. The avoidance of blood pressure measurements was, I suppose, to decrease venous pressure that could stimulate edema.
Sarah A. McLaughlin, MD, and her colleagues reported on the precautionary behaviors that patients with breast cancer observed in an attempt to avoid lymphedema.2 They looked at two groups: women who had undergone axillary lymph node biopsy and those who had undergone sentinel node biopsy.
More than 90% of the women who had undergone axillary node dissection avoided blood draws, intravenous lines, and blood pressure measurements on the involved side – with more than 70% in the sentinel node biopsy group avoiding blood pressure measurements on the involved side, and almost 90% avoiding intravenous lines.
In the Physical Activity and Lymphedema trial, Shayna L. Showalter, MD, and her colleagues looked at a number of potential risk factors for arm swelling in patients with a history of breast cancer.3 There was no increased risk of arm swelling in patients who had blood draws or blood pressure checks in the ipsilateral arm. There also was no association with burns, bug bites, hangnails, or cuts in the ipsilateral arm – all risks that would suggest an increased risk of infection in the arm.
Chantal Ferguson and her colleagues reported on a 10-year prospective study looking at lymphedema and risk factors for lymphedema in breast cancer patients.4 Bilateral arm volume measurements were made preoperatively and postoperatively, and at each visit, patients reported on whether they had blood pressure measurements, injections, or blood draws in the ipsilateral arm.
In more than 3,000 measurements, there was no evidence of volume change associated with blood pressure measurements, blood draws, or injections. Risk factors that did increase arm volume were body mass index greater than 25 kg/m2, axillary lymph node dissection, cellulitis, and regional lymph node irradiation.
There just isn’t evidence that these classic behaviors to protect the ipsilateral arm are warranted. Hopefully, patients will have less worry and less stress if they do not have to be so vigilant trying to “protect” their arm.
References
1. American Cancer Society: “Lymphedema: What Every Woman With Breast Cancer Should Know.” Accessed online at www.cancer.org.
2. J Am Coll Surg. 2013 Mar;216(3):380-9.
3. Ann Surg Oncol. 2013 Mar;20(3):842-9.
4. J Clin Oncol. 2016 Mar 1;34(7):691-8.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at dpaauw@uw.edu.