Reduced Incidence of Breast Cancer–Related Lymphedema following Mastectomy and Breast Reconstruction versus Mastectomy Alone

Abstract

Sir: Breast reconstructive surgery and microsurgical treatment of lymphedema has been one of our major activities for more than a decade. Therefore, we were pleased to read an article demonstrating a beneficiary effect of breast reconstruction on the incidence of lymphedema.1 The authors compared the incidence of lymphedema between two groups of patients: mastectomy alone and mastectomy with reconstruction. In their Conclusion, the authors state that patients who underwent breast reconstruction had a lower incidence and later onset of breast cancer–related lymphedema compared with patients who underwent mastectomy alone after cross-matching both groups for age, axillary radiotherapy, and surgical axillary interventions. First, in their article, the overall incidence of lymphedema is 6.8 percent, which is relatively low, compared with studies based on the breast cancer survivor population, which show rates ranging from 13 to 65 percent.2–4 This suggests a possible underdiagnosis in the current study.1 Furthermore, lymphedema continues to be underdiagnosed and is not defined or measured in a standardized manner. This makes obtaining reliable estimates of the incidence of lymphedema from a retrospective analysis difficult. In the article, the advent of lymphedema is based on a retrospective search in a database of postoperative clinical contacts going back to 2000.1 It is not clear which criteria were used to diagnose lymphedema. In this article, it is said that lymphedema was diagnosed on clinical suspicion, which was confirmed on the basis of objective data (e.g., arm circumference measurements) in a referral clinic. Nevertheless, no data about the measurements are available in the article. The second important point is the distribution of risk factors in the two compared groups. It is well known that risk factors for developing upper limb lymphedema after breast cancer are high body mass index, axillary surgery, radiotherapy, and the number of positive lymph nodes.3–5 Another risk factor that has been reported recently is chemotherapy, mainly after use of Taxol (Bristol-Myers Squibb Company, Princeton, N.J.).6 The authors matched the two groups (borderline, 0.07) for neoadjuvant chemotherapy but did not provide any data about postoperative chemotherapy. When we looked carefully at the patient characteristics within the two groups, we observed that three of five of these risk factors were not matched between the two groups. Indeed, patients who underwent mastectomy alone were significantly more obese and had significantly more positive lymph nodes. It is obvious that the study lacks proper matching of the lymphedema risk factors between the two groups. Although breast reconstruction came out as an independent risk factor in a multivariate analysis including the risk factors, it remains an essential methodologic weakness in the design of the study. Finally, the authors failed to find any difference in the reconstruction subgroup analysis, meaning that breast reconstruction by means of a breast expander equally reduces the incidence of lymphedema, as is done by free autologous abdominal tissue reconstruction. However, it is not clear in the article whether the above-mentioned risk factors were equally matched between the reconstruction subgroups. Nevertheless, we should congratulate the authors for their great efforts. However, we need better and well-controlled data in lymphedema with objective measurements and/or quality-of-life–based questionnaires. We encourage centers, including ours, with similar large databases containing consecutive lymphedema information to publish their findings on this highly demanding issue. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Geert Peeters M.D. Moustapha Hamdi M.D., Ph.D. Brussels University Hospital Brussels, Belgium