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Byun HK, Kim JS, Chang JS, Cho Y, Ahn SJ, Yoon JH, Kim H, Kim N, Choi E, Park H, Kim K, Park SH, Rim CH, Choi HS, Oh YK, Lee IJ, Shin KH, Kim YB. Validation of a nomogram for predicting the risk of lymphedema following contemporary treatment for breast cancer: a large multi-institutional study (KROG 20-05). Breast Cancer Res Treat 2022; 192:553-561. [PMID: 35107713 DOI: 10.1007/s10549-021-06507-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 12/30/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE We previously constructed a nomogram for predicting the risk of arm lymphedema following contemporary breast cancer treatment. This nomogram should be validated in patients with different background characteristics before use. Therefore, we aimed to externally validate the nomogram in a large multi-institutional cohort. METHODS Overall, 8835 patients who underwent breast cancer surgery during 2007-2017 were identified. Data of variables in the nomogram and arm lymphedema were collected. The nomogram was validated externally using C-index and integrated area under the curve (iAUC) with 1000 bootstrap samples and by calibration plots. RESULTS Overall, 1377 patients (15.6%) developed lymphedema. The median time from surgery to lymphedema development was 11.4 months. Lymphedema rates at 2, 3, and 5 years were 11.2%, 13.1%, and 15.6%, respectively. Patients with lymphedema had significantly higher body mass index (median, 24.1 kg/m2 vs. 23.4 kg/m2) and a greater number of removed nodes (median, 17 vs. 6) and more frequently underwent taxane-based chemotherapy (85.7% vs. 41.9%), total mastectomy (73.1% vs. 52.1%), conventionally fractionated radiotherapy (71.9% vs. 54.2%), and regional nodal irradiation (70.7% vs 22.4%) than those who did not develop lymphedema (all P < 0.001). The C-index of the nomogram was 0.7887, and iAUC was 0.7628, indicating good predictive accuracy. Calibration plots confirmed that the predicted lymphedema risks were well correlated with the actual lymphedema rates. CONCLUSION This nomogram, which was developed using factors related to multimodal breast cancer treatment and was validated in a large multi-institutional cohort, can well predict the risk of breast cancer-related lymphedema.
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Affiliation(s)
- Hwa Kyung Byun
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea
| | - Jae Sik Kim
- Department of Radiation Oncology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, South Korea
| | - Jee Suk Chang
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Yeona Cho
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Sung-Ja Ahn
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, South Korea
| | - Jung Han Yoon
- Department of Surgery, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, South Korea
| | - Haeyoung Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Nalee Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Euncheol Choi
- Department of Radiation Oncology, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea
| | - Hyeli Park
- Department of Radiation Oncology, Presbyterian Medical Center, Jeonju, South Korea
| | - Kyubo Kim
- Department of Radiation Oncology, Ewha Womans University College of Medicine, Seoul, South Korea
| | - Shin-Hyung Park
- Department of Radiation Oncology, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Chai Hong Rim
- Department of Radiation Oncology, Korea University Medical College, Seoul, South Korea
| | - Hoon Sik Choi
- Department of Radiation Oncology, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Yoon Kyeong Oh
- Department of Radiation Oncology, Chosun University Medical School, Gwangju, South Korea
| | - Ik Jae Lee
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea
| | - Kyung Hwan Shin
- Department of Radiation Oncology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, South Korea.
| | - Yong Bae Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea.
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Disparities in the Use of Sentinel Lymph Node Dissection for Early Stage Breast Cancer. J Surg Res 2020; 254:31-40. [PMID: 32408028 DOI: 10.1016/j.jss.2020.03.063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 03/11/2020] [Accepted: 03/26/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Clinical trials have long established the long-term safety of omitting axillary lymph node dissection (ALND) after sentinel lymph node dissection (SLND) in patients with clinically node-negative early stage breast cancer. The variations in utilization of SLND and ALND in this patient population, however, are currently unknown. METHODS Adult female patients (40 years and older) within the National Cancer Database diagnosed with breast cancer between January 2013 and December 2015, who had clinical T1-T2 and N0 disease, and who underwent either SLND (with or without subsequent ALND) or ALND were included. Differences in utilization across race, ethnicity, insurance type, facility, and residential characteristics were assessed using multivariable logistic regression. RESULTS Overall, 271,689 patients were included, of which 26,527 (10%) received ALND and 245,162 (90%) underwent SLND. After adjusting for demographics and cancer characteristics, black (odds ratio [OR], 1.11; 95% confidence interval [95% CI], 1.06-1.17) and Hispanic women (OR, 1.16; 95% CI, 1.10-1.24) were more likely to receive ALND. Patients without health insurance (OR, 1.33; 95% CI, 1.19-1.47), compared with private health insurance, and those receiving treatment at community cancer centers (OR, 1.60; 95% CI, 1.53-1.67), compared with academic/research centers, were also more likely to receive ALND. CONCLUSIONS Although the vast majority of women undergo SLND, significant disparities exist in its utilization for early stage breast cancer, with traditionally underserved patients receiving unwarranted extensive axillary surgery. Increased patient and surgeon education is needed to decrease variations in care that can affect patient's quality of life.
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