Prevalence and aetiology of lymphoedema after breast cancer treatment in southern Tasmania

Age as a risk factor for breast cancer-related lymphedema: a systematic review

PURPOSE

Breast cancer-related lymphedema (BCRL) has been widely reported in the medical literature. Various patient characteristics, including age, have been investigated as possible risk factors for this disease entity, but the existence and direction of the cause-and-effect relationship are still unclear. In this review, we aimed to evaluate the effect of age on development of BRCL.

METHODS

PubMed, Scopus, and Ovid MEDLINE were searched for relevant articles, which were found to be published between 1974 and 2020.

RESULTS

Twenty-six studies involving 19,396 patients were selected. The average age of patients was 54.9. 26 studies were included in the final analysis, and 13 articles reported no association between age and BCRL development.

CONCLUSIONS

Though studies presented different findings, the majority did not identify age as a risk factor for development of lymphedema. However, the level of evidence of individual studies was low. In this article, we call attention to the need for uniform design of lymphedema studies and diagnosis.

IMPLICATIONS FOR CANCER SURVIVORS

All patients should be informed and screened regularly for lymphedema during and after the treatment independent of their age.

Patient-Reported Shoulder Morbidity and Fatigue among Breast Cancer Survivors: An Insight from a Tertiary Care Cancer Hospital

Context: Breast cancer is the most common cancer in Indian women with an annual mortality of around 87,000. Treatment for breast carcinoma may lead to swelling of the ipsilateral arm, shoulder stiffness, arm pain, and cancer-related fatigue. Very few centers in India have reported the arm and shoulder morbidity treated in their hospitals. Aims: The aim was to evaluate the predictive factors of arm and shoulder morbidity and fatigue among breast cancer survivors. Settings and Design: This was a retrospective analysis based on a prospectively maintained database. Materials and Methods: Early and locally advanced cases of breast cancer patients were screened for the study during 2015–2018. Eligible participants were invited to fill up the predetermined questionnaire, and their demographic and treatment-related information was accrued from a file archive. Follow-up period was estimated from the date of tissue diagnosis to last contact/time of interview. Results: Shoulder stiffness was the most common complaint followed by arm numbness. Obesity and diabetes played a crucial role in most of the morbidities and fatigue. The median fatigue score was 34, and the median time of appearance of lymphedema was 13 months. Modified radical mastectomy and radiotherapy to axilla were statistically significantly (P = 0.04 and 0.01, respectively) associated with greater shoulder stiffness and arm swelling. Conclusions: Obesity, diabetes, type of surgery, the extent of axillary dissection, and radiation plan are the major predictive factors of arm and shoulder morbidity. Further prospective validation is necessary for future breast cancer survivorship programs.

Body Fluid Trend and Prevalence of Lymphedema After Gynecological Cancer Surgery

Background: This study aimed at understanding the trend in extracellular fluid (ECF) change and estimating the efficacy of the early complex decongestive therapy (CDT) program in terms of prevalence of lower limb lymphedema, as well as at identifying the quality of life (QoL) associated with response to CDT after gynecological cancer therapy. Methods and Results: Thirty-one patients undergoing gynecological cancer treatment were enrolled and randomly assigned to the CDT and control groups. In the CDT group, CDT was started within 2 weeks after surgery for 30 minutes a day, for 2 weeks (5 days per week). The patients' QoL was assessed through the European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire; version 3. Inbody S10^® (Biospace, Seoul, South Korea) was used to calculate the ECF. The assessment was performed at pre- and post-surgery and at 3, 6, and 12 months after surgery. Statistically significant differences, in favor of the CDT group, were encountered at the 3-month follow-up visit, especially with respect to the QoL score. Regarding the prevalence of lymphedema, no significant difference was observed between groups. The mean value of the impedance ratio was low in the CDT group during the entire 12 month follow-up. Conclusions: The results of the present study show that early CDT had a positive effect on the prevalence of lymphedema and body composition. Long-term follow-up studies with a larger sample size are needed to warrant the time-group effect of early rehabilitation.

Risk Factors for Lymphedema in Breast Cancer Survivors Following Axillary Lymph Node Dissection

Objective

The aim of the current study was to assess the risk factors for developing lymphedema following breast cancer treatment.

Methods

The subjects of this study were 238 consecutive patients who underwent axillary lymph node dissection for breast cancer at Shikoku Cancer Center. The study variables were the occurrence of lymphedema, the body mass index, the follow-up period, the drain removal time, the level of lymph node dissection, the presence or absence of co-resident household members, radiation therapy, neoadjuvant chemotherapy, and adjuvant chemotherapy.

Results

We observed lymphedema in 23.9% of patients after axillary lymph node dissection for breast cancer. Neoadjuvant chemotherapy and adjuvant chemotherapy using docetaxel and cyclophosphamide increased the risk of developing lymphedema (P <0.05).

Conclusions

Those patients treated with neoadjuvant chemotherapy and adjuvant chemotherapy using docetaxel and cyclophosphamide should be observed closely after axillary lymph node dissection, and appropriate intervention should be considered from an early stage.

Evaluation of Stiffness in Postmastectomy Lymphedema Using Acoustic Radiation Force Impulse Imaging: A Prospective Randomized Controlled Study for Identifying the Optimal Pneumatic Compression Pressure to Reduce Stiffness

PURPOSE

We aimed to assess the improvement in stiffness in patients with postmastectomy lymphedema (PMLE) after intermittent pneumatic compression (IPC) using acoustic radiation force impulse (ARFI) imaging and evaluate the effects of different IPC pressures.

METHODS

We randomly assigned 45 patients with PMLE (stage II) to three groups based on the IPC pressure: 25, 35, and 45 mmHg. Patients received a single session of IPC for 30 minutes. We recorded the subcutaneous tissue thickness of the proximal upper limbs using ultrasonography and circumference of the upper limbs and stiffness using ARFI before and immediately after IPC.

RESULTS

Arm circumference and subcutaneous tissue thickness were significantly decreased after IPC in all groups. The shear wave velocity (SWV) decreased after IPC in all groups, but significantly decreased only in the 35 mmHg group. The subcutaneous tissue thickness and SWV in the 35 mmHg group were significantly decreased compared to the other groups.

CONCLUSION

IPC can reduce stiffness and subcutaneous tissue thickness of the proximal upper arm in patients with PMLE. A pressure of 35 mmHg yields the largest improvement of stiffness; higher compression pressure did not yield any additional improvement.

The need for preoperative baseline arm measurement to accurately quantify breast cancer-related lymphedema

Breast cancer-related lymphedema (BCRL) is a feared outcome of breast cancer treatment, yet the push for early screening is hampered by a lack of standardized quantification. We sought to determine the necessity of preoperative baseline in accounting for temporal changes of upper extremity volume. 1028 women with unilateral breast cancer were prospectively screened for lymphedema by perometry. Thresholds were defined: relative volume change (RVC) ≥10 % for clinically significant lymphedema and ≥5 % including subclinical lymphedema. The first postoperative measurement (pseudo-baseline) simulated the case of no baseline. McNemar's test and binomial logistic regression models were used to analyze BCRL misdiagnoses. Preoperatively, 28.3 and 2.9 % of patients had arm asymmetry of ≥5 and 10 %, respectively. Without baseline, 41.6 % of patients were underdiagnosed and 40.1 % overdiagnosed at RVC ≥ 5 %, increasing to 50.0 and 54.8 % at RVC ≥ 10 %. Increased pseudo-baseline asymmetry, increased weight change between baselines, hormonal therapy, dominant use of contralateral arm, and not receiving axillary lymph node dissection (ALND) were associated with increased risk of underdiagnosis at RVC ≥ 5 %; not receiving regional lymph node radiation was significant at RVC ≥ 10 %. Increased pseudo-baseline asymmetry, not receiving ALND, and dominant use of ipsilateral arm were associated with overdiagnosis at RVC ≥ 5 %; increased pseudo-baseline asymmetry and not receiving ALND were significant at RVC ≥ 10 %. The use of a postoperative proxy even early after treatment results in poor sensitivity for identifying BCRL. Providers with access to patients before surgery should consider the consequent need for proper baseline, with specific strategy tailored by institution.

Breast cancer-related lymphedema after axillary lymph node dissection: does early postoperative prediction model work?

PURPOSE

Early detection and timely intervention demonstrate the greatest promise of reducing the incidence of late-stage lymphedema in breast cancer patients undergoing axillary lymph node dissection (ALND). A nomogram was developed for predicting the risk of lymphedema (LE) in patients with ALND. This study's aim was to test the early postoperative prediction model for the diagnosis of clinical and subclinical LE after ALND.

METHODS

Patients requiring ALND were identified preoperatively through our LE program database. Measurements using metered tape with bioimpedance spectroscopy (L-Dex U400) were obtained preoperatively (n = 180) and at 3-6-month intervals postoperatively. The 5-year probability of LE after ALND was calculated using the Cleveland Clinic Risk Calculator. The discrimination of the nomogram was assessed by calculating the area under (AUC) the receiver operating characteristic curve.

RESULTS

LE was present in 36.1% (n = 65) of 180 patients with ALND. Of these 65 patients, 22 (12.2%) had clinical LE and 43 (23.9%) had subclinical LE. Statistical analyses showed significant differences in BMI and receipt of radiotherapy between patients with and without LE (p = 0.03 and p = 0.01, respectively). AUC was 0.601, 0.614, and 0.600 for the nomogram using any LE, clinical LE, and subclinical LE patients, respectively.

CONCLUSIONS

The recently created prediction model for the diagnosis of LE in ALND is not accurate in predicting who will develop clinical or subclinical LE. Periodic monitoring of women with ALND is the most effective method to aid in reducing clinical LE incidence through early detection and timely intervention of LE.

Prevalence, Classification, and Risk Factors for Postoperative Lower Extremity Lymphedema in Women With Gynecologic Malignancies: A Retrospective Study

Objective

Lower extremity lymphedema (LEL) is a major long-term complication of radical surgery. We aimed to estimate the incidence and grading of LEL in women who underwent lymphadenectomy and to evaluate risk factors associated with LEL.

Materials and Methods

We retrospectively reviewed 358 patients with cervical, endometrial, and ovarian cancer who underwent transabdominal complete systematic pelvic and para-aortic lymphadenectomy between 1997 and 2011. Lower extremity lymphedema was graded according to criteria of the International Society of Lymphology. Incidence of LEL and its correlation with various clinical characteristics were investigated using Kaplan-Meier survival and Cox proportional hazards methods.

Results

Overall incidence of LEL was 21.8% (stage 1, 60%; stage 2, 32%; and stage 3, 8%). Cumulative incidence increased with observation period: 12.9% at 1 year, 20.3% at 5 years, and 25.4% at 10 years. Age, cancer type, stage (International Federation of Gynecology and Obstetrics), body mass index, hysterectomy type, lymphocyst formation, lymph node metastasis, and chemotherapy were not associated with LEL. Multivariate analysis confirmed that removal of circumflex iliac lymph nodes (hazard ratio [HR], 4.28; 95% confidence interval [CI], 2.09–8.77; P < 0.0001), cellulitis (HR, 3.48; 95% CI, 2.03–5.98; P < 0.0001), and number of removed lymph nodes (HR, 0.99; 95% CI, 0.98–0.99; P = 0.038) were independent risk factors for LEL.

Conclusions

Postoperative LEL incidence increased over time. The results of the present study showed a significant correlation with removal of circumflex iliac lymph nodes and cellulitis with the incidence of LEL. Multicenter or prospective studies are required to clarify treatment efficacies.

Serum fibronectin 1 and ApoE levels increase with risk of lymphedema in Korean breast cancer survivors

PURPOSE

Lymphedema is an irreversible disorder often seen as a postoperative side effect in breast cancer survivors. We aimed to identify serum factors that are associated with lymphedema risk in breast cancer survivors.

METHODS

This study recruited 60 volunteer breast cancer survivors. Participants were classified into either a CTRL group who underwent sentinel lymph node biopsy (SLNB), a RISK group who underwent axillary lymph node dissection (ALND) with removal of fewer than five lymph nodes, or an LE group who underwent ALND with removal of more than five lymph nodes. Bioimpedance was measured to determine the ratio of extracellular water (ECW) to total cellular water (TCW) and single-frequency bioimpedance analysis (SFBIA) ratios. Serum lipid profiles were compared among the groups using label-free quantitative proteomics with the nano-liquid chromatography (LC)-tandem mass spectrometer (MS/MS) and emPAI method.

RESULTS

The CTRL, RISK, and LE groups had similar body weights and body mass indexes (BMIs) (<25 kg/m(2)). The LE group showed a higher grade of lymphedema severity compared to the RISK and CTRL groups. Lymphedema indices such as the ECW/TCW ratio and SFBIA ratio at 1 and 5 kHz were greatly increased in the LE group. Serum total cholesterol (total-C) level was higher in the LE group without affecting atherogenic index. Serum proteomics revealed that fibronectin 1 (FN1), apolipoprotein E (ApoE), antithrombin (ANT3), and complement C4 had different abundance values among the groups. ELISA confirmed that FN1 and ApoE were significantly elevated in both the RISK and LE groups compared to the CTRL group.

CONCLUSIONS

Changes in serum FN1 and ApoE levels were detected prior to changes in serum total-C level and lymphedema indices such as SFBIA ratio. Therefore, elevation in serum FN1 and ApoE concentrations could likely be used to monitor the risk of lymphedema in breast cancer survivors.

Risk factors for self-reported arm lymphedema among female breast cancer survivors: a prospective cohort study

INTRODUCTION

Lymphedema is a potentially debilitating condition that occurs among breast cancer survivors. This study examines the incidence of self-reported lymphedema, timing of lymphedema onset, and associations between sociodemographic, clinical and lifestyle factors and lymphedema risk across racial-ethnic groups using data from a multicenter, multiethnic prospective cohort study of breast cancer survivors, the Health, Eating, Activity and Lifestyle Study.

METHODS

A total of 666 women diagnosed with breast cancer staged as in situ, localized or regional disease at ages 35 to 64 years were recruited through the Surveillance, Epidemiology, and End Results registries in New Mexico (non-Hispanic white and Hispanic white), Los Angeles County (black), and Western Washington (non-Hispanic white) and followed for a median of 10.2 years. We evaluated sociodemographic factors, breast cancer- and treatment-related factors, comorbidities, body mass index (BMI), hormonal factors, and lifestyle factors in relation to self-reported lymphedema by fitting Cox proportional hazards models, estimating hazard ratios (HR) and 95% confidence intervals (CI).

RESULTS

Over the follow-up period, 190 women (29%) reported lymphedema. The median time from breast cancer diagnosis to onset of lymphedema was 10.5 months (range: 0.5 to 134.9 months). Factors independently associated with lymphedema were total/modified radical mastectomy (versus partial/less than total mastectomy; HR = 1.37, 95% CI: 1.01 to 1.85), chemotherapy (versus no chemotherapy; HR = 1.48, 95% CI: 1.09 to 2.02), no lymph nodes removed (versus ≥10 lymph nodes removed; HR = 0.17, 95% CI: 0.08 to 0.33), pre-diagnostic BMI ≥30 kg/m2 (versus BMI <25 kg/m2; HR = 1.59, 95% CI: 1.09 to 2.31), and hypertension (versus no hypertension; HR = 1.49, 95% CI: 1.06 to 2.10). After adjusting for demographics and breast cancer- and treatment-related factors, no significant difference in lymphedema risk was observed across racial/ethnic groups. Analyses stratified by race/ethnicity showed that hypertension and chemotherapy were lymphedema risk factors only for black women.

CONCLUSIONS

Breast cancer patients who have undergone extensive surgery or extensive lymph node dissection, or who have a higher BMI should be closely monitored for detection and treatment of lymphedema. Further studies are needed to understand the roles of chemotherapy and hypertension in the development of lymphedema.

Frequency of Early-Stage Lymphedema and Risk Factors in Postoperative Patients with Breast Cancer

OBJECTIVE

Lymphedema is a chronic major complication that is seen frequently post-operatively and has negative effects on quality of life. In our study, determining the early-stage postoperative lymphedema frequency and specifying the risk factors in its development has been aimed.

MATERIALS AND METHODS

One hundred one cases that were operated on for breast cancer were evaluated regarding the 12-month control of their clinical specifications, histopathological specifications, and specifications related with the surgical intervention retrospectively. The data related to the parameters envisioned as risk factors were evaluated.

RESULTS

Lymphedema development was found in 7 (6.9%) out of 101 cases constituting the study group. No significant difference (p>0.05) in terms of lymphedema development was determined among age, body mass index (BMI), chemotherapy (CT), postoperative seroma or infection, mastectomy with the dominant arm, and breast-conserving surgery (BCS), which were evaluated as risk factors. There was a significance (p<0.05) between the other risk factors, which were axillary dissection (AD), number of positive lymph nodes (LN), radiotherapy (RT), the tumor size (T), and lymphedema existence. In every case in which lymphedema was determined, it was seen that there was axillary LN involvement and 15≤LN were ablated in the dissection (p<0.05).

CONCLUSION

It is seen that AD, RT applied to the breast cancer patients, and T are important risk factors in early-stage lymphedema development. No early-stage lymphedema development was determined in any of the patients to whom sentinel lymph node dissection (SLND) was applied.

Defining a threshold for intervention in breast cancer-related lymphedema: what level of arm volume increase predicts progression?

The purpose of this study is to evaluate arm volume measurements and clinico-pathologic characteristics of breast cancer patients to define a threshold for intervention in breast cancer-related lymphedema. We prospectively performed arm volume measurements on breast cancer patients using a Perometer. Arm measurements were performed pre- and post-operatively, and change in arm volume was quantified using a relative volume change (RVC) equation. Patient and treatment risk factors were evaluated. Cox proportional hazards models with time-dependent covariates for RVC were used to evaluate whether RVC elevations of ≥3 to <5 % or ≥5 to <10 % occurring ≤3 months or >3 months after surgery were associated with progression to ≥10 % RVC. 1,173 patients met eligibility criteria with a median of 27 months post-operative follow-up. The cumulative incidence of ≥10 % RVC at 24 months was 5.26 % (95 % CI 4.01-6.88 %). By multivariable analysis, a measurement of ≥5 to <10 % RVC occurring >3 months after surgery was significantly associated with an increased risk of progression to ≥10 % RVC (HR 2.97, p < 0.0001), but a measurement of ≥3 to <5 % RVC during the same time period was not statistically significantly associated (HR 1.55, p = 0.10). Other significant risk factors included a measurement ≤3 months after surgery with RVC of ≥3 to <5 % (p = 0.007), ≥5 to <10 % (p < 0.0001), or ≥10 % (p = 0.023), axillary lymph node dissection (ALND) (p < 0.0001), and higher BMI at diagnosis (p = 0.0028). Type of breast surgery, age, number of positive or number of lymph nodes removed, nodal radiation, chemotherapy, and hormonal therapy were not significant (p > 0.05). Breast cancer patients who experience a relative arm volume increase of ≥3 to <5 % occurring >3 months after surgery do not have a statistically significant increase in risk of progression to ≥10 %, a common lymphedema criterion. Our data support utilization of a ≥5 to <10 % threshold for close monitoring or intervention, warranting further assessment. Additional risk factors for progression to ≥10 % include ALND, higher BMI, and post-operative arm volume elevation.

Risk factors of lymph edema in breast cancer patients

Background. Lymphedema secondary to breast cancer treatment is a common and serious problem for disease survivors. The objective of the current study was to identify the risk factors of secondary lymphedema after breast carcinoma treatment. Materials & Methods. The breast cancer patients who were followed up in three centers in Tehran and Mashhad in 2010 were recruited in the study. The circumference measurement was used for defining lymphedema. Results. Among 410 breast cancer patients, 123 cases (30%) developed lymphedema. Variables such as low educational level, body mass index (BMI), higher stage of disease, number of involved lymph nodes, comorbid diseases, trauma, infection, and the time after surgery showed significant correlation with the development of lymphedema. In logistic regression analysis, increase of 1 kg/m² in BMI (OR = 1.09; 95%  CI 1.05–1.15), each number increase in lymph node involvement (OR = 1.15; 95%  CI 1.08–1.21) and the increase of every 1 month after surgery (OR = 1.01; 95%  CI 1.01–1.02) significantly increased the risk of lymphedema. Conclusion. The results of this study demonstrated that preserving a fitted BMI, emphasis on self-care, and educating preventive activities may have important roles in decreasing the lymphedema incidence and improving the patients' quality of life.

Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis

BACKGROUND

The body of evidence related to breast-cancer-related lymphoedema incidence and risk factors has substantially grown and improved in quality over the past decade. We assessed the incidence of unilateral arm lymphoedema after breast cancer and explored the evidence available for lymphoedema risk factors.

METHODS

We searched Academic Search Elite, Cumulative Index to Nursing and Allied Health, Cochrane Central Register of Controlled Trials (clinical trials), and Medline for research articles that assessed the incidence or prevalence of, or risk factors for, arm lymphoedema after breast cancer, published between Jan 1, 2000, and June 30, 2012. We extracted incidence data and calculated corresponding exact binomial 95% CIs. We used random effects models to calculate a pooled overall estimate of lymphoedema incidence, with subgroup analyses to assess the effect of different study designs, countries of study origin, diagnostic methods, time since diagnosis, and extent of axillary surgery. We assessed risk factors and collated them into four levels of evidence, depending on consistency of findings and quality and quantity of studies contributing to findings.

FINDINGS

72 studies met the inclusion criteria for the assessment of lymphoedema incidence, giving a pooled estimate of 16.6% (95% CI 13.6-20.2). Our estimate was 21.4% (14.9-29.8) when restricted to data from prospective cohort studies (30 studies). The incidence of arm lymphoedema seemed to increase up to 2 years after diagnosis or surgery of breast cancer (24 studies with time since diagnosis or surgery of 12 to <24 months; 18.9%, 14.2-24.7), was highest when assessed by more than one diagnostic method (nine studies; 28.2%, 11.8-53.5), and was about four times higher in women who had an axillary-lymph-node dissection (18 studies; 19.9%, 13.5-28.2) than it was in those who had sentinel-node biopsy (18 studies; 5.6%, 6.1-7.9). 29 studies met the inclusion criteria for the assessment of risk factors. Risk factors that had a strong level of evidence were extensive surgery (ie, axillary-lymph-node dissection, greater number of lymph nodes dissected, mastectomy) and being overweight or obese.

INTERPRETATION

Our findings suggest that more than one in five women who survive breast cancer will develop arm lymphoedema. A clear need exists for improved understanding of contributing risk factors, as well as of prevention and management strategies to reduce the individual and public health burden of this disabling and distressing disorder.

FUNDING

The National Breast Cancer Foundation, Australia.

Comparison of relative versus absolute arm size change as criteria for quantifying breast cancer-related lymphedema: the flaws in current studies and need for universal methodology

The purpose of this article is to evaluate arm measurements of breast cancer patients to critically assess absolute change in arm size compared to relative arm volume change as criteria for quantifying breast cancer-related lymphedema (BCRL). We used pre-operative measurements of 677 patients screened for BCRL before and following treatment of unilateral breast cancer at Massachusetts General Hospital between 2005 and 2008 to model the effect of an absolute change in arm size of 200 mL or 2 cm compared to relative arm volume change. We also used sequential measurements to analyze temporal variation in unaffected arm volume. Pre-operative arm volumes ranged from 1,270 to 6,873 mL and correlated strongly (Kendall's τ = 0.55) with body mass index (BMI). An absolute arm volume change of 200 mL corresponded to relative arm volume changes ranging from 2.9 to 15.7 %. In a subset of 45 patients, modeling of a 2-cm change in arm circumference predicted relative arm volume changes ranging from 6.0 to 9.8 %. Sequential measurements of 124 patients with >6 measurements demonstrated remarkable temporal variation in unaffected arm volume (median within-patient change 10.5 %). The magnitude of such fluctuations correlated (τ = 0.36, P < 0.0001) with pre-operative arm volume, patient weight, and BMI when quantified as absolute volume change, but was independent of these variables when quantified as relative arm volume change (P > .05). Absolute changes in arm size used as criteria for BCRL are correlated with pre-operative and temporal changes in body size. Therefore, utilization of absolute volume or circumference change in clinical trials is flawed because specificity depends strongly on patient body size. Relative arm volume change is independent of body size and should thus be used as the standard criterion for diagnosis of BCRL.

Possible genetic predisposition to lymphedema after breast cancer

BACKGROUND

Known risk factors for secondary lymphedema only partially explain who develops lymphedema following cancer, suggesting that inherited genetic susceptibility may influence risk. Moreover, identification of molecular signatures could facilitate lymphedema risk prediction prior to surgery or lead to effective drug therapies for prevention or treatment. Recent advances in the molecular biology underlying development of the lymphatic system and related congenital disorders implicate a number of potential candidate genes to explore in relation to secondary lymphedema.

METHODS AND RESULTS

We undertook a nested case-control study, with participants who had developed lymphedema after surgical intervention within the first 18 months of their breast cancer diagnosis serving as cases (n=22) and those without lymphedema serving as controls (n=98), identified from a prospective, population-based, cohort study in Queensland, Australia. TagSNPs that covered all known genetic variation in the genes SOX18, VEGFC, VEGFD, VEGFR2, VEGFR3, RORC, FOXC2, LYVE1, ADM, and PROX1 were selected for genotyping. Multiple SNPs within three receptor genes, VEGFR2, VEGFR3, and RORC, were associated with lymphedema defined by statistical significance (p<0.05) or extreme risk estimates (OR <0.5 or >2.0).

CONCLUSIONS

These provocative, albeit preliminary, findings regarding possible genetic predisposition to secondary lymphedema following breast cancer treatment warrant further attention for potential replication using larger datasets.

Study of incidence of lymphedema in Indian patients undergoing axillary dissection for breast cancer

Lymphedema of the upper extremity, in addition to being unsightly, can be painful, can limit the arm movements, increases the risk of infection and is psychologically distressing, serving as a constant reminder of cancer. 1. To ascertain the incidence of lymphedema in a hospital based population (in patients undergoing axillary dissection for breast cancer. 2. To determine the clinico-epidemilogical factors associated with the occurrence of lymphedema in these patients. For all patients undergoing axillary dissection, arm measurements were taken in the pre-& post-operative period from at least 3 sites; one in the arm, forearm and wrist (points fixed in reference to fixed bony landmarks). Patients included in this study were followed up for at least 12 months. Circumference difference of more than 5% was taken as mild lymphedema; more than 10% as moderate lymphedema and more than 15% as severe lymphedema. Data was analyzed using SPSS 11.0 statistical software. Of the 231 patients in this study mean age was 51.2 years, majority were housewives (71.9%) and postmenopausal (58.5%). Modified radical mastectomy (MRM), was performed on 203 (87.9%) patients. 57.2% patients had positive lymph nodes. The mean number of positive nodes was 6.52. Majority of the patients received chemo and radio therapy. Overall incidence of lymphedema was 41.1%. The definition of 5-10% increase as mild lymphedema may be a bit severe as in most patients with this increase, lymphedema is not clinically apparent. The incidence of moderate and severe lymphedema in our series is only 7.4%. The incidence of clinically significant lymphedema (moderate to severe lymphedema & symptomatic mild lymphedema) was 16.8%. Only axillary irradiation and pathological nodal status (pN3) emerged as significant risk factors for lymphedema development on multivariate analysis. Lymphedema once established is difficult to treat. Combination of axillary dissection with radiation and more nodal positivity seems to predispose to lymphedema. Prevention by means of sentinel node biopsy in early cases, good surgical technique, arm care post surgery, exercises and massage therapy may help reducing the incidence and/or severity.

Incidence, Treatment Costs, and Complications of Lymphedema After Breast Cancer Among Women of Working Age: A 2-Year Follow-Up Study

Purpose

This study estimated the economic burden of breast cancer–related lymphedema (BCRL) among working-age women, the incidence of lymphedema, and associated risk factors.

Methods

We used claims data to study an incident cohort of breast cancer patients for the 2 years after the initiation of cancer treatment. A logistic regression model was used to ascertain factors associated with lymphedema. We compared the medical costs and rate of infections likely associated with lymphedema between a woman with BCRL and a matched control. We performed nonparametric bootstrapping to compare the unadjusted cost differences and estimated the adjusted cost differences in regression analysis.

Results

Approximately 10% of the 1,877 patients had claims indicating treatment of lymphedema. Predictors included treatment with full axillary node dissection (odds ratio [OR] = 6.3, P < .001) and chemotherapy (OR = 1.6, P = .01). A geographic variation was observed; women who resided in the West were more likely to have lymphedema claims than those in the Northeast (OR = 2.05, P = .01). The matched cohort analysis demonstrated that the BCRL group had significantly higher medical costs ($14,877 to $23,167) and was twice as likely to have lymphangitis or cellulitis (OR = 2.02, P = .009). Outpatient care, especially mental health services, diagnostic imaging, and visits with moderate or high complexity, accounted for the majority of the difference.

Conclusion

Although the use of claims data may underestimate the true incidence of lymphedema, women with BCRL had a greater risk of infections and incurred higher medical costs. The substantial costs documented here suggest that further efforts should be made to elucidate reduction and prevention strategies for BCRL.

Lymphedema After Breast Cancer: Incidence, Risk Factors, and Effect on Upper Body Function

Purpose

Secondary lymphedema is associated with adverse physical and psychosocial consequences among women with breast cancer (BC). This article describes the prevalence and incidence of lymphedema between 6 and 18 months after BC treatment; personal, treatment, and behavioral correlates of lymphedema status; and the presence of other upper-body symptoms (UBS) and function (UBF).

Patients and Methods

A population-based sample of Australian women (n = 287) with recently diagnosed, invasive BC were evaluated on five occasions using bioimpedance spectroscopy. Lymphedema was diagnosed when the ratio of impedance values, comparing treated and untreated sides, was three standard deviations more than normative data. UBF was assessed using the validated Disability of the Arm, Shoulder, and Hand questionnaire.

Results

From 6 to 18 months after surgery, 33% (n = 62) of the sample were classified as having lymphedema; of these, 40% had long-term lymphedema. Although older age, more extensive surgery or axillary node dissection, and experiencing one or more treatment-related complication(s) or symptom(s) at baseline were associated with increased odds, lower socioeconomic status, having a partner, greater child care responsibilities, being treated on the dominant side, participation in regular activity, and having good UBF were associated with decreased odds of lymphedema. Not surprisingly, lymphedema leads to reduced UBF; however, BC survivors report high prevalences of other UBS (34% to 62%), irrespective of their lymphedema status.

Conclusion

Lymphedema is a public health issue deserving greater attention. More systematic surveillance for earlier detection and the potential benefits of physical activity to prevent lymphedema and mitigate symptoms warrant further clinical integration and research.

Fatores de risco para linfedema após câncer de mama: uma revisão da literatura

O linfedema representa uma das principais seqüelas do câncer de mama. Esta revisão da literatura visou discutir os principais fatores associados ao linfedema após o tratamento do câncer de mama. Foram selecionados 26 artigos publicados entre janeiro de 2000 e março de 2008 nas bases Medline e Lilacs, utilizando os descritores breast neoplasms, lymphedema, upper extremity, arm e risk factors. Sua revisão permitiu discutir os fatores relacionados ao linfedema, quanto a: clínica e paciente (tabagismo, escolaridade, etnia, comorbidades, hipertensão arterial, diabetes melito, menopausa, idade, peso corporal, índice de massa corporal, atividade física, membro dominante, restrição articular, infecção, seroma e trauma no membro superior); tratamento do câncer de mama (cirurgia, reconstrução mamária, número de linfonodos retirados, nível da linfadenectomia axilar, radioterapia, quimioterapia, hormonioterapia e tempo transcorrido após o tratamento); tumor (tamanho, grau, localização, comprometimento dos linfonodos axilares e estadiamento). A revisão feita indica que a linfadenectomia axilar, a radioterapia em cadeias de drenagem e a obesidade são fatores preponderantes do risco para desenvolvimento do linfedema.

Lymphedema following axillary lymph node dissection for breast cancer

Lymphedema is a relatively common, potentially serious and unpleased complication after axillary lymph node dissection (ALND) for breast cancer. It may be associated with functional, esthetic, and psychological problems, thereby affecting the quality-of-life (QOL) of breast cancer survivors. Objective measurements (preferentially by measuring arm volumes or arm circumferences at predetermined sites) are required to identify lymphedema, but also subjective assessment can help to determine the clinical significance of any volume/circumference differences. Lymphedema per se predisposes to the development of other secondary complications, such as infections of the upper limb, psychological sequelae, development of malignant tumors, alterations of the QOL, etc. The risk of lymphedema is associated with the extent of ALND and the addition of axillary radiation therapy. Treatment involves the application of therapeutic measures of the so-called decongestive lymphatic therapy. Prevention is of key importance to avoid lymphedema formation. The application of the sentinel lymph node biopsy in the management of breast cancer has been associated with a reduced incidence of lymphedema formation.

The impact of axillary lymph nodes removed in staging of node-positive breast carcinoma

PURPOSE

Number of positive lymph nodes in the axilla and pathologic lymph node status (pN) have a great impact on staging according to the current American Joint Committee on Cancer staging system of breast carcinoma. Our aim was to define whether the total number of removed axillary lymph nodes influences the pN and thus the staging.

METHODS AND MATERIALS

The records of 798 consecutive invasive breast cancer patients with T1-3 tumors and positive axillary lymph nodes who underwent modified radical mastectomy between 1999 and 2005 in our hospital were reviewed. The total number of removed nodes were grouped, and compared with the patient and tumor characteristics and the influence of the number of nodes removed on the staging was analyzed.

RESULTS

The proportion of patients with > or =4 positive nodes (59%), and pN3 status (51%) were the highest in the group with 21-25 nodes removed. Compared with patients with 1-20 nodes removed, the proportion of patients with > or =4 positive nodes (52%), and pN3 status (46%) were significantly higher in those with more than 20 nodes removed. Although the proportion of Stage IIA and IIB decreased, the proportion of Stage IIIA and IIIC increased in patients with >20 nodes removed compared with those with 1-20 nodes removed.

CONCLUSIONS

In patients with axillary node-positive breast carcinoma, staging is highly influenced by total number of removed nodes. Levels I-III axillary dissection with more than 20 axillary lymph nodes removed could lead to more effective adjuvant chemotherapy and increases substantially the proportion of patients to receive radiotherapy.

Post-operative arm morbidity and quality of life. Results of the ALMANAC randomised trial comparing sentinel node biopsy with standard axillary treatment in the management of patients with early breast cancer

This study is the first large prospective RCT of sentinel node biopsy (SNB) compared with standard axillary treatment (level I-III axillary lymph node dissection or four node sampling), which includes comprehensive and repeated quality of life (QOL) assessments over 18 months. Patients (n = 829) completed the Functional Assessment of Cancer Therapy - Breast (FACT-B+4) and the Spielberger State/Trait Anxiety Inventory (STAI) at baseline (pre-surgery) and at 1, 3, 6, 12, and 18 months post-surgery. There were significant differences between treatment groups favouring the SNB group throughout the 18 months assessment. Patients in the standard treatment group showed a greater decline in Trial Outcome Index (TOI) scores (physical well-being, functional well-being and breast cancer concerns subscales in FACT-B+4) and recovered more slowly than patients in the SNB group (p < 0.01). The change in total FACT-B+4 scores (measuring global QOL) closely resembled the TOI results. 18 months post-surgery approximately twice as many patients in the standard group compared with the SNB group reported substantial arm swelling (14% versus 7%) (p = 0.002) or numbness (19% versus 8.7%) (p < 0.001). Despite the uncertainty about undergoing a relatively new procedure and the possible need for further surgery, there was no evidence of increased anxiety amongst patients randomised to SNB (p > 0.05). For 6 months post-surgery younger patients reported less favourable QOL scores (p < 0.001) and greater levels of anxiety (p < 0.01). In view of the benefits regarding arm functioning and quality of life, the data from this randomised study support the use of SNB in patients with clinically node negative breast cancer.

Lymphoedema: estimating the size of the problem

Lymphoedema is a problem frequently encountered by professionals working in palliative care. This article reviews the evidence on the magnitude of the problem of lymphoedema in the general population and provides evidence on specific high risk groups within it. Prevalence is a good indicator of the burden of disease for chronic problems such as lymphoedema, as it indicates the numbers of patients who require care. Incidence is indicative of changes in the causes of lymphoedema and the success of any prevention programmes. Both are important means of assessing the current level of need and the potential for the changing needs in managing this condition. Problems exist in all studies in relation to precise definitions of lymphoedema, inconsistent measures to assess differential diagnosis and poorly defined populations. While there is some evidence of high rates in relation to breast cancer therapy, the total burden of lymphoedema in the general population is largely unknown.

Lymphedema after treatment of breast cancer

BACKGROUND

Lymphedema is one of the major long-term complications of axillary dissection. This study was designed to investigate the risk factors that are predicted to effect the development of lymphedema after complete axillary dissection.

METHODS

Two hundred forty patients who had undergone modified radical mastectomy with complete axillary dissection were examined at least 18 months after the surgery. The effects of age, diabetes, smoking, hypertension, chemotherapy, radiotherapy, tamoxifen use, stage, body mass index, number of the removed and metastatic lymph nodes, and total volume of the wound drainage on the development of lymphedema were analyzed.

RESULTS

Lymphedema developed in 68 (28%) of the 240 cases. Axillary radiotherapy and body mass index were found to increase the incidence of the lymphedema.

CONCLUSIONS

Women who had the combination of full axillary dissection and axillary radiotherapy carry a significant risk of lymphedema.

Factors Associated with Arm Swelling after Breast Cancer Surgery

PURPOSE

As life expectancy improves for women with breast cancer, more women will be living with symptoms of lymphedema. This study reports the incidence of arm or hand swelling and associated risk factors in women with invasive breast cancer following surgery.

METHODS

Data were obtained from baseline and follow-up interviews of women with invasive breast cancer (n = 145), and mammography and pathology records. The Kaplan-Meier method was used to estimate the probability of developing arm or hand swelling over time. Univariate and multivariate logistic regression analyses were conducted to identify risk factors for arm or hand swelling.

RESULTS

Of women in this study, 38% self-reported arm or hand swelling. There was a significantly increased risk of arm swelling if women were under 50 years of age, had axillary node dissection, received chemotherapy, worked outside the home, and had a high household income. There was no association of body weight with swelling. A significantly decreased risk of arm swelling was found in women who were on treatment for high blood pressure. After adjustment for nodal dissection, only age had a significant independent effect.

CONCLUSIONS

Our study highlights two important areas of future research that could reduce the incidence of lymphedema. There is a need to better understand the role that treatment for high blood pressure may play in protecting women from arm edema. Second, the potential effect of weight as a modifiable lymphedema risk factor needs to be studied in more detail in light of the conflicting results of different studies.

Perceptions of upper-body problems during recovery from breast cancer treatment

Despite improved recognition recently, restrictions in upper-body movement continue to cause impairment and distress for many women long after breast cancer treatment. The purpose of this research is to investigate this issue through the perceptions of breast cancer survivors in the context of their everyday lives. Twenty-four women recruited from a private breast clinic in south-eastern Queensland, Australia, participated in a qualitative study. Discussion groups comprised women treated for breast cancer within the previous 18 months. Discussions centred on experiences of physical difficulties, follow-up support, arm lymphoedema and exercise therapy during the women's recoveries. Returning to normal activities for women after breast surgery was felt to take longer than either the women's or their physicians' expectations. Many women reported difficulties in upper-body tasks, which worsened simple everyday responsibilities. The physical impact leads to psychological strain, as the women are constantly reminded of their illness and the possibility they may never return to their full capacity. These upper-body difficulties may include discomfort while driving and sleeping, posture disturbances, reduced employability in physical work, and decreased ability to do housework and gardening. Having lymphoedema or the threat of developing it was very distressing for most women. The potential preventive role of physiotherapy-led exercises to prevent further decline and improve function was strongly emphasised during these discussions. Clinicians need to recognise that it is very common for women with breast cancer to experience upper-body morbidity long after their treatment, and consequently every effort to enhance recovery and avoid further deterioration in function is required.

Axilla surgery severely affects quality of life: results of a 5-year prospective study in breast cancer patients

No long-term prospective study has investigated arm morbidity and patient quality of life. It is unclear to what extent breast cancer patients suffer from arm problems, how long such problems affect their lives, and whether quality of life improves as arm problems abate. This prospective cohort study aims to provide data on the clinical factors associated with arm dysfunction, to estimate its prevalence and to relate arm morbidity to quality of life. The Munich Cancer Registry records clinical details of all cancer patients in and around Munich. Quality of life information was provided directly by breast cancer patients (n = 990) over 5 years. Arm morbidity, including movement limitations, swelling and lymph drainage, and quality of life (EORTC QLQ-C30) were assessed. Up to 5 years after diagnosis, 38% of patients were still experiencing arm problems (swelling and limited movement). Consistently over the 5 years, quality of life was significantly (p < 0.001) lower for patients with arm difficulties. For those whose arm problems dissipated, quality of life significantly improved (p < 0.01). A logistic regression analysis showed that extent of axilla surgery (p < 0.003), comorbidity (CVD and diabetes) (p < 0.003), employment (p < 0.01), younger age (p < 0.02), and operating clinic (p < 0.05) significantly contributed to arm problems. Axilla surgery should be re-evaluated since arm morbidity has such a profound effect on patient quality of life.

Risk of lymphedema after regional nodal irradiation with breast conservation therapy

PURPOSE

To evaluate the risk factors for lymphedema in patients receiving breast conservation therapy for early-stage breast cancer.

METHODS AND MATERIALS

Between 1982 and 1995, 727 Stage I-II breast cancer patients were treated with breast conservation therapy at Massachusetts General Hospital. A retrospective analysis of the development of persistent arm edema was performed. Lymphedema was defined as a >2-cm difference in forearm circumference compared with the untreated side. The median follow-up was 72 months. Breast and regional nodal irradiation (BRNI) was administered in 32% of the cases and breast irradiation alone in 68%.

RESULTS

Persistent arm lymphedema was documented in 21 patients. The 10-year actuarial incidence was 4.1%. The median time to edema was 39 months. The only significant risk factor for lymphedema was BRNI. The 10-year risk was 1.8% for breast irradiation alone vs. 8.9% for BRNI (p = 0.001). The extent of axillary dissection did not predict for lymphedema even within the subgroups of patients defined by the extent of irradiation. Most patients underwent Level I or II dissection. In this subgroup, the lymphedema risk at 10 years was 10.7% for BRNI vs. 1.0% for breast irradiation alone (p = 0.0003).

CONCLUSION

Nodal irradiation was the only significant risk factor for arm lymphedema in patients receiving breast conservation therapy for early-stage breast cancer. Our data suggest that this risk is low with Level I/II dissection and breast irradiation. However, even after the addition of radiotherapy to the axilla and supraclavicular fossa, the development of lymphedema was only 1 in 10, lower than generally recognized.

Comparison of side effects between sentinel lymph node and axillary lymph node dissection for breast cancer

BACKGROUND

Axillary lymph node dissection (ALND) is often associated with permanent arm side effects. Side effects after sentinel lymph node dissection (SLND) should be less common, because the surgery is less extensive.

METHODS

The study compared side effects and interference with daily life between 169 women who underwent an SLND and 78 who underwent an ALND for breast cancer. Patients rated symptom severity and interference with daily life caused by pain, numbness, limitation of arm range of motion (ROM), and arm swelling at 1, 6, and 12 months after surgery by using the Measure of Arm Symptom Survey. Repeated-measures and regression analyses for each time period were used to determine associations between symptoms and dissection type.

RESULTS

At 1 month, SLND patients reported less pain, numbness, limitation in ROM, and seromas than ALND patients. At 6 months, SLND patients had less pain, numbness, and arm swelling, and at 12 months, SLND patients had less numbness, arm swelling, and limitation in ROM than ALND patients. At 1 month, pain, numbness, and limitation in ROM interfered significantly more with daily life for ALND patients. At 6 and 12 months, only numbness interfered more with daily life for ALND patients.

CONCLUSIONS

SLND was associated with fewer side effects than ALND at all time points.

Physiotherapy after breast cancer surgery: results of a randomised controlled study to minimise lymphoedema

The development of secondary arm lymphoedema after the removal of axillary lymph nodes remains a potential problem for women with breast cancer. This study investigated the incidence of arm lymphoedema following axillary dissection to determine the effect of prospective monitoring and early physiotherapy intervention. Sixty-five women were randomly assigned to either the treatment (TG) or control group (CG) and assessments were made preoperatively, at day 5 and at 1, 3, 6, 12 and 24 months postoperatively. Three measurements were used for the detection of arm lymphoedema: arm circumferences (CIRC), arm volume (VOL) and multi-frequency bioimpedance (MFBIA). Clinically significant lymphoedema was confirmed by an increase of at least 200 ml from the preoperative difference between the two arms. Using this definition, the incidence of lymphoedema at 24 mo. was 21%, with a rate of 11% in the TG compared to 30% in the CG. The CIRC or MFBIA methods failed to detect lymphoedema in up to 50% of women who demonstrated an increase of at least 200 ml in the VOL of the operated arm compared to the unoperated arm. The physiotherapy intervention programme for the TG women included principles for lymphoedema risk minimisation and early management of this condition when it was identified. These strategies appear to reduce the development of secondary lymphoedema and alter its progression in comparison to the CG women. Monitoring of these women is continuing and will determine if these benefits are maintained over a longer period for women with early lymphoedema after breast cancer surgery.

Prevalence of self-reported arm morbidity following treatment for breast cancer in the Australian Breast Cancer Family Study

Population-based women (n=1049) with breast cancer diagnosed mainly between 1996 and 1998, when aged 20-59 years, were mailed a questionnaire seeking information about self-reported shoulder stiffness and swelling, numbness and pain/ache in the arm following treatment (excluding 6 months from diagnosis). Of the 809 who completed the survey, approximately seven in eight experienced at least one symptom, one in six reported all four symptoms, and one in three considered that their arm morbidity interfered substantially with activities of daily living. Arm swelling occurred at some time in 39% of women, was present in 20% 1 year, and in 29% 4 years, after diagnosis. The prevalence of arm swelling was higher in women with axillary node dissection (OR=2.4; 95% Cl 1.0-5.6), and was increased in a women with a higher body mass index (P=0.02) and less education (P=0.01), but was not related to age, number of nodes excised or self-reports of radiation or type of surgery.