– By Lisa Stember, RN, BSN
It’s hard to avoid the color pink during the month of October when even football stadiums are decorated to raise awareness of breast cancer. As a two-time survivor of the disease, I don’t need pink ribbons to raise my awareness, but the pink ribbons do help me to stay focused on prevention of one of the more devastating side effects of cancer treatment: lymphedema. This is especially important during flu season when I’m thinking about getting my annual flu vaccine.
Surgery to remove breast cancer frequently includes removal and examination of axillary lymph nodes for spread of disease. The removal of or damage to lymph nodes can result in lymphedema, the abnormal buildup of fluid in soft tissue due to a blockage in the lymphatic system. Lymphedema can develop immediately after surgery or radiation, but it may occur months or years after cancer treatment has ended. Swelling can cause pain, numbness and limit movement in the affected limb. In severe cases, the skin becomes tight and the scarring causes hyperkeratosis. Although treatment to reduce the swelling and relieve symptoms is available, once symptoms have occurred it’s usually a lifelong condition.
As a breast cancer survivor I have been instructed to avoid any blood draws, injections or blood pressure measurements on the affected side, as well as taking steps to avoid skin infections. This advice presents a dilemma when getting a vaccination because the Advisory Committee on Immunization Practices (ACIP) recommends the deltoid muscle area of the upper arm as the best route for adult vaccines. So what is the solution?
While ACIP discourages variations from the recommended route, site, volume, or number of doses of any vaccine1, when a patient has either lymph node removal or damage to the lymph system, using the thigh muscle as the vaccine injection site might become necessary. If the vaccine needed is for hepatitis B or rabies, use of any site other than the deltoid muscle is considered an invalid dose. For these vaccines, doses given in a nonstandard site can be verified by titer for efficacy.
After my first occurrence of breast cancer, I carefully protected my arm, avoided injuries, promptly treated cuts, and redirected health care personnel to my unaffected side for immunizations. When my breast cancer reoccurred on the opposite side resulting in the loss of more lymph nodes, I decided it was in my control to ask for help in preventing lymphedema and made a plan. Although it isn’t always convenient, I now ask for immunizations in an alternate site. Blood pressure can be done on a lower extremity. Although not many women and men are bilateral breast cancer survivors, any person with loss of lymph nodes needs consideration. If you are a breast cancer survivor or have loss of lymph nodes, check with your personal care provider for what adult vaccines you need, and where best to have them administered.
Lisa Stember is a registered nurse. She graduated with her nursing degree in 1986 from OHSU School of Nursing and also holds a Bachelor of Science degree in health education from Oregon State University. She is currently a public health nurse on the certification team for the Oregon School-Based Health Centers, Adolescent and School Health Program. Prior to that she worked for 17 years as a school nurse and spent 11 years in inpatient care in maternal and pediatrics at OHSU.