Air Travel and Postoperative Lymphedema—A Systematic Review
Michael Co, Judy Ng, Ava Kwong. Clinical Breast Cancer, 2017
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Air Travel and Postoperative Lymphedema—A Systematic Review
Michael Co, Judy Ng, Ava Kwong. Clinical Breast Cancer, 2017
Lymphedema is not uncommon after axillary dissection for breast cancer. Improved survival of patients with breast cancer from advances in adjuvant therapy has resulted in increased awareness of the quality of life for long-term survivors. Air travel has been postulated as 1 of the risk factors of lymphedema exacerbation. In the present systematic review, we sought to critically evaluate the current data on this topic. The present study was registered in the Research Registry. A systematic review of lymphedema and air travel was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol. The Medline, EMBASE, CINAHL, and Cochrane databases were searched for English-language studies up to June 2017 with a predefined strategy. The retrieved studies were independently screened and rated for relevance. Data were extracted by 2 of us. A total of 55 studies were identified using predefined keywords; 12 studies were included using the criteria stated in the study protocol. A pooled analysis of 2051 patients with a history of air travel revealed that 14.5% developed lymphedema after air flight. However, a subsequent analysis of 4 studies with a control arm showed that 107 of 1189 patients (9%) with a documented history of air travel developed lymphedema compared with 204 of 2356 patients (8.7%) who had not flown (c2 test; P ¼ .80). Two studies (1030 patients) evaluated the effect of lymphedema on patients’ air travel patterns. Of the 1030 patients, 141 (13.7%) had totally avoided air travel after the development of lymphedema. However, air travel was not adversely associated with the development of lymphedema.el Co, Judy Ng, Ava Kwong. Clinical Breast Cancer, 2017
Main findings
- Air pressure decreases with increases in altitude.
- Although a cabin altitude of 8000 ft will not pose major health hazards, the decreased cabin pressure can result in lymphedema secondary to the pressure difference. The possible mechanisms include increased fluid retention in the connective tissue, increased fluid production in the soft tissues, and reduced fluid return to the lymphatic system at the low cabin pressure at cruising level.
- Theoretically, the low cabin pressure during air travel can aggravate lymphedema. However, the evidence from the published data has been conflicting.
- 12 studies were included for analysis.
- A pooled analysis of 2051 patients from 7 studies found that only 14.5% of patients with postoperative lymphedema had a history of air travel. In addition, according to the 4 studies with a control arm in the analysis (patients without air travel history), 107 of 1189 patients (9%) with a documented history of air travel developed lymphedema. In contrast, 204 of 2356 patients (8.7%) who had not flown developed lymphedema.
- Of the 1030 studied subjects with lymphedema, 141 (13.7%) had totally avoided air travel.
- Patients with lymphedema had avoidant behaviour and some even restricted air travel to trips of < 1 hour.
- The evidence to support avoiding long-haul flights is not strong.
- The use of compression garments provides external pressure on the extremity to adequately support favourable resorption and decrease the potential for fluid accumulation in the tissue. Theoretically, the use of compression will prevent worsening of pre-existing lymphedema and has been recommended during air travel for those with lymphedema. Compression bandages will potentially increase the interstitial tissue pressure and enhance the muscle pump in the lymphedematous extremity.
- However, the use of compression garments has not been well studied.
- The early reports in the 1990s that suggested an association between air travel and lymphedema in breast cancer patients were confined to anecdotal evidence. However, these reports have already had a significant psychosocial effect on long-term breast cancer survivors.
- The review suggests although this topic has not been well studied by randomized controlled trials, our results suggest that only a very small proportion of lymphedema patients were adversely affected by air travel. Also, air travel was not associated with worsening lymphedema, regardless of the number or duration of the flights. With the introduction of new-generation aircrafts in the past decade, which are able to maintain an even greater cabin pressure than the older models, air travel should not be a concern for patients who have undergone axillary surgery and/or irradiation, regardless of whether they lymphedema. Breast cancer survivors should live a normal life that is as well-travelled as that of the normal population.
