Incidence Of Breast Cancer-related Lymphedema Research Articles

The effectiveness of axillary reverse mapping in preventing breast cancer-related lymphedema: a meta-analysis based on randomized controlled trials.

Here, we carried out an extensive meta-analysis to investigate the effectiveness of the use of axillary reverse mapping (ARM) during axillary lymph node dissection (ALND) in preventing breast cancer-related lymphedema (BCRL). Database searches to identify relevant randomized controlled trials (RCTs) were performed of MEDLINE (PubMed), Web of Science, Embase, and the Cochrane Library. Eligible articles with a publication date from database establishment to December 2020 were retrieved by combining keywords including: "breast cancer", "breast carcinoma", "breast neoplasm", "axillary reverse mapping", "axillary lymph node dissection", "lymphatic arm drainage", and "lymphedema". Independent data extraction was conducted, and Review Manager (version 5.3) was used for statistical analyses. Five eligible RCTs were included in the meta-analysis. A total of 37 patients suffered arm lymphedema (37/786, 4.71%) in the experimental group (ARM during ALND), compared with 164 arm lymphedemas (164/873, 18.79%) in the control group (ALND alone). The results showed that ARM during ALND was superior to ALND alone in reducing the incidence of BCRL [OR =0.20, 95% confidence intervals (CI): 0.13-0.29, P<0.00001]; however, the 2 procedures did not differ significantly in terms of oncological safety or shoulder movement (OR =0.30, 95% CI: 0.03-2.96, P=0.30; OR =0.44, 95% CI: 0.14-1.40, P=0.17). ARM during ALND can prevent and reduce the occurrence of BCRL in patients with early-stage BC during long-term follow-up. Due to the limited number of RCTs available, more in-depth, high-quality RCTs are urgently needed to provide a reliable and convincing basis for the application of ARM during ALND.

The Lived Experience of African American Women with Lymphedema

African American women have a greater number of aggressive cancer treatments and higher incidence of Breast Cancer-Related Lymphedema (BCRLE) than Caucasians. BCRLE cannot be cured and the treatment requires patients to make considerable lifestyle changes and maintain daily and lifelong care to decrease the swelling and prevent exacerbations.

Abstract P3-14-02: Upper extremity edema in the at-risk arm among patients receiving PI3K/mTOR/CDK4/6 inhibitors for metastatic breast cancer

Abstract Background: Targeted therapies, including mTOR and CDK 4/6 inhibitors, have changed the landscape of management of hormone receptor-positive (HR+) metastatic breast cancer (MBC). These therapies have shown significant improvement in progression-free survival and are generally well-tolerated. In pre-clinical models, modulation of the PI3K/mTOR pathway can impede lymphoangiogenesis resulting in capillary leakage. In this study, we examined the impact of PI3K, mTOR, and CDK 4/6 inhibitors in the development of upper extremity edema (UEE) in the at-risk arm for breast cancer-related lymphedema (BCRL) in patients with MBC. Methods: We conducted a retrospective chart review of patients treated with PI3K/mTOR/CDK4/6 inhibitors for MBC. Clinicopathologic data including age, body-mass index (BMI), specific pathway targeted, treatment duration, and presence of edema were recorded. Characteristics of treatment including surgery type and laterality, nodal surgery, radiation regimen, and tumor subtype were also collected. Results: Among patients with MBC treated with PI3K, mTOR, and/or CDK 4/6 inhibitors (N = 160), the incidence of edema that developed after initiation of the targeted therapy was 11.3% (18/160) for UEE and 31.9% (51/160) for edema in any anatomical location. 50.0% (11/22) of patients treated with a PI3K-a inhibitor, 32.6% (14/43) of patients treated with an mTOR inhibitor, and 33.3% (8/24) of patients treated with a CDK4/6 inhibitor alone developed peripheral edema following initiation of the respective targeted therapy. Further, swelling developed in the at-risk upper extremity after C1D1 in 13.6% (3/22) patients treated with a PI3K-α inhibitor exclusively, 7.0% (3/43) treated with an mTOR inhibitor exclusively, and in 12.5% (3/24) treated with a CDK4/6 inhibitor exclusively. Of the 42 patients treated with a CDK4/6 inhibitor in combination with either an mTOR inhibitor, aromatase inhibitor, or an ER-binding promoter, the incidence of UEE in the at-risk upper extremity after C1D1 was 18.8% (6/32), 0.0% (0/7), and 0.0% (0/3) respectively. In multivariate logistic regression analysis, both therapy with PI3K-a inhibitors (OR: 3.22; p = 0.049) and a relative decrease in serum albumin after 3 months of treatment (OR: 3.35, p = 0.024) increased the risk of developing peripheral edema; however, duration of therapy, and nodal surgery were not significant risk factors. Upon stratification of this cohort by number of BCRL-related risk factors, the incidence of BCRL was 18.3%, 39.5%, and 83.3% in women with one, two, or three BCRL-related risk factors, respectively. Conclusions: PI3K, mTOR, and CDK 4/6 inhibitors may influence the development of UEE, which may cause or exacerbate progression of BCRL in at-risk arm among patients with MBC. Further research is needed to prospectively evaluate these novel findings as well as elucidate physiologic and clinical impacts of these therapies on peripheral edema and BRCL. Moreover, it is crucial to understand the role of close monitoring for the development or progression of peripheral edema or BCRL to ensure early detection and treatment, thus potentially minimizing the negative impacts on the quality of life of patients with MBC. Citation Format: Daniell KM, Bardia A, Sun F, Brunelle CL, Gillespie TC, Sayegh HE, Naoum GE, Isakoff SJ, Juric D, Taghian AG. Upper extremity edema in the at-risk arm among patients receiving PI3K/mTOR/CDK4/6 inhibitors for metastatic breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-14-02.

A comparison of developing breast cancer-related lymphedema between mastectomy with reconstruction and mastectomy alone among breast cancer patients in Saudi Arabia

Context: The study was undertaken to compare developing breast cancer-related lymphedema between those who underwent mastectomy with reconstruction and mastectomy alone. Aims: One of the most feared consequences after a mastectomy is breast cancer-related lymphedema (BCRL). However, few papers have questioned whether breast reconstruction impacts the development of lymphedema. This study aims to determine if breast reconstruction has an effect on the incidence of BCRL. Furthermore, the effect of the time (immediate vs. delayed) and type (implant based vs. autologous) of breast reconstruction on the development of BCRL will be evaluated. Settings and Design: We conducted a retrospective cohort study on 320 patients who underwent mastectomy with reconstruction and mastectomy alone between January 1, 2007, and December 31, 2017, at King Abdulaziz Medical City – Jeddah. Subjects and Methods: We conducted a retrospective cohort study on 320 patients who underwent mastectomy with or without breast reconstruction between January 2007 and December 2017. We reviewed patient medical records progressively to extract patients' characteristics, operative details, and lymphedema information. We divided our sample into two main groups: patients who underwent mastectomy with reconstruction and mastectomy alone. Mastectomy with reconstruction group was subdivided into immediate or delayed reconstruction and autologous or implant-based reconstruction. Statistical Analysis Used: Statistical analysis was performed using the Statistical Package for the Social Sciences version 20. Results: Of the total sample size 320, only 78 (24.4% (underwent mastectomy with breast reconstruction (Group 1), while the rest 242 (75.6%) underwent mastectomy alone (Group 2). From both the groups, 24 (7.5%) patients developed lymphedema; there was no significant difference between the breast reconstruction and development of lymphedema (P = 0.67). We subdivided Group 1 (patients who underwent mastectomy with breast reconstruction) into immediate breast reconstruction (40 patients, [51%]) and delayed breast reconstruction (38 patients, [49%]). In comparison between immediate versus delayed breast reconstruction, there was no significant difference between immediate and delayed breast reconstruction (P = 0.67). In terms of the type of reconstruction, we further subdivided Group 1 (patients who underwent mastectomy with breast reconstruction) into implant-based breast reconstruction (42 patients, [54%]), and autologous breast reconstruction (36 patients, [46%]). In comparison between implant-based versus autologous breast reconstruction, there was no significant difference between implant-based and autologous breast reconstruction (P = 0.66). Conclusions: Although our result is insignificant, it suggests that patients who underwent mastectomy with reconstruction have a lower incidence of BCRL in comparison with those who underwent mastectomy alone. Moreover, our result suggests that immediate breast reconstruction and implant-based breast reconstruction have a lower incidence than delayed and autologous breast reconstruction. Further studies are needed to determine if the breast reconstruction has an effect on the development of lymphedema.

Breast Cancer-Related Lymphedema—a Case of the Left Upper Arm Lymphedema After Modified Radical Mastectomy Presenting with Nonfunctional Limb

Breast cancer-related lymphedema (BCRL) is a common and feared complication of breast cancer treatment. Incidence of BCRL ranges from 0 to 60% and it depends upon stage of disease, type of surgery, and adjuvant treatment like chemotherapy and radiation. This is a case report of a patient presenting with nonfunctional limb (grade III as per CTC staging of lymphedema) who required amputation for the symptomatic relief.

The incidence and risk factors of related lymphedema for breast cancer survivors post-operation: a 2-year follow-up prospective cohort study.

To investigate the incidence rate, severity and risk factors of related lymphedema in breast cancer survivors. A 2-year follow-up prospective study of 387 women who had operation from four hospitals from January 1, to December 31, 2014 was conducted. Limb volume was measured by circumference and symptoms were measured using questionnaires pre-treatment and 1, 3, 6, 12, 18, 24months after surgery separately. The incidence rates and the severity of lymphedema were evaluated, respectively. Risk factors for the development of breast cancer-related lymphedema (BCRL) were analyzed using log-rank test and Cox regression. The incidences of BCRL were 4.4, 10.1, 15.2, 28.6, 31.2 and 32.5% at 1, 3, 6, 12, 18, 24months after surgery, respectively, measured by Norman questionnaire. The rates measured by arm circumference were 2.5, 6.7, 13.4, 21.4, 26.3 and 29.4%, respectively. About 114 (29.4% of 387) women were diagnosed with BCRL, and 78 of them got mild lymphedema. Axillary lymph node dissection (ALND) (HR=5.2, 95% CI 1.6-17.3), radiotherapy (HR=3.9, 95% CI 2.0-7.5), modified radical mastectomy (MRM) (HR=2.1, 95% CI 1.3-3.4), the number of positive lymph nodes (HR=1.1, 95% CI 1.0-1.2) and body mass index (BMI) (HR=1.1, 95% CI 1.0-1.1) were independent risk factors for BCRL. BCRL is a common complication for breast cancer patients after surgery. It can be fairly diagnosed only 1month post-operation and the cumulative incidence of BCRL seems to be increasing over time, especially in the first year after surgery. ALND, radiotherapy, MRM, the number of positive axillary lymph nodes and BMI were found to be independent risk factors in the development of BCRL in this study.

Breast cancer-related lymphedema in postmastectomy patients receiving adjuvant irradiation: A prospective study.

In India, most breast cancer patients present with advanced stage requiring postmastectomy radiotherapy. Lymphedema is a long-term side effect that causes both physical and psychological distresses. The present prospective study was carried out to study various factors affecting breast cancer-related lymphedema (BCRL). From January 2015 to March 2016, 100 postmastectomy patients who received adjuvant irradiation to chest wall were selected prospectively. Circumference of both arms was measured before surgery, at start, and at end of radiotherapy followed by 3 monthly intervals till last follow-up. Lymphedema was defined as a difference of ≥2 cm from the baseline in the arm circumference on the side of surgery. At a median follow-up of 24 months, the cumulative incidence of BCRL was 13%. On multivariate analysis, risk of BCRL was significantly associated with higher body mass index (BMI) (P = 0.004), greater number of lymph nodes (LNs) dissected (P = 0.005), higher nodal ratio (P = 0.006), and regional LN radiation (RLNR) (P = 0.048) but not with the type of fractionation (P = 0.094). Adjuvant RLNR, higher BMI, greater number of LNs dissected, and higher nodal ratio significantly increases the risk of development of BCRL. There was no significant difference in the lymphedema with the type of fractionation. Females receiving RLNR should be prospectively monitored for lymphedema to ensure early detection and possible intervention.

Breast Cancer-Related Lymphedema Risk is Related to Multidisciplinary Treatment and Not Surgery Alone: Results from a Large Cohort Study.

Breastcancer-related lymphedema (BCRL) is a significant complication for women undergoing treatment. We assessed BCRL incidence and risk factors in a large population-based cohort. We utilized the Olmsted County Rochester Epidemiology Project Breast Cancer Cohort from 1990-2010 and ascertained BCRL and risk factors. The cumulative incidence estimator was used to estimate the rate of BCRL; competing risks regression was used for multivariable analysis. A total of 1794 patients with stage 0-3 breast cancer with a median of 10years follow-up were included. The cumulative incidence of BCRL diagnosis within 5years was 9.1% [95% confidence interval (CI) 7.8-10.5%]. No BCRL events occurred among patients without axillary surgery. In the axillary surgery subset (n = 1512), the 5-year incidence of BCRL was 5.3% in sentinel lymph node (SLN) surgery and 15.9% in axillary dissection (ALND) patients (p < 0.001). In patients treated with surgery only, BCRL rates were not different between ALND versus SLN (3.5 and 4.1% at 5years, p = 0.36). Addition of breast or chest wall radiation more than doubled the BCRL rate in ALND patients (3.5 vs. 9.5% at 5years, p = 0.01). The groups with highest risk (>25% at 5years) all involved ALND with nodal RT and/or anthracycline/cytoxan + taxane chemotherapy. In multivariable analysis of patients with any axillary surgery factors significantly associated with BCRL were ALND, chemotherapy, radiation, and obesity. BCRL is a sequelae of multimodal breast cancer treatment and risk is multifactorial. BCRL rates are higher in patients receiving chemotherapy, radiation, ALND, more advanced disease stage, and higher body mass index.

Abstract PD4-03: Chemotherapy-related risk factors associated with lymphedema in breast cancer patients: Should repeated ipsilateral arm infusions be avoided?

Abstract Background: Breast Cancer-Related Lymphedema (BCRL) is a chronic, iatrogenic condition that can occur after damage to the lymphatic system during surgery (sx) or radiation, precipitating edema of the arm, breast, or trunk. BCRL risk-reduction education is an essential component of clinical care, and practitioners often advise patients (pts) to avoid needle punctures on the treated arm when possible. There is, however, a lack of substantial scientific evidence to lessen patient distress. Considering the common use of chemotherapy (CT) agents in this population, we assessed whether repeated skin punctures on the ipsilateral arm for CT infusions increased the risk of BCRL compared to CT via central lines in a large, prospective cohort of breast cancer (BC) pts. Methods: We prospectively screened 630 pts with unilateral (487) or bilateral (143) BC sx receiving neoadjuvant (NAC) and/or adjuvant CT (AdjCT) for arm lymphedema (defined as volume change ≥10%) at our hospital from 2005–16. Pts were measured with a perometer pre-operatively and at 3–7 month follow-up intervals. Clinicopathologic and treatment (tx)-related characteristics, including details on CT regimen and the method of intravenous (IV) CT administration [peripheral IV catheters (PIVCs), central venous access devices (CVADs), peripherally inserted central catheters (PICCs)] were obtained by chart review. Cox proportional hazard analyses were applied to ascertain the risk of BCRL associated with these factors. Results: The median post-op follow-up was 44 months. Of the 630 pts, 40% underwent axillary lymph node dissection (ALND), 60% underwent sentinel lymph node biopsy (SLNB) or no nodal sx, 16% and 89% received NAC or AdjCT, respectively. CT was administered via PIVCs inserted in the hand/arm for 59%, via CVADs or PICCs for 26%, and via both PIVCs at least once and CVADs/PICCs for 15%. The 2-yr cumulative incidence of BCRL was 12% (95% CI 9.9-15.2%). Multivariable regression results indicated that pts with both peripheral IV infusions on the arm and implanted CVADs did not have a higher risk of BCRL (HR(95% CI)=1.4(0.6-3.6)) than pts who received CT via CVADs only (1.7(0.7-3.8)). The overall number of NAC (p=0.24;0.9(95% CI 0.8-1.1)) or AdjCT cycles (p=0.78;1.0(0.9-1.1)) was not associated with BCRL, nor was the number of peripheral IV infusions (p=0.17;1.0(1.0-1.1)). BMI &amp;gt;30 (p&amp;lt;0.0001;3.4(1.9-6.0)) and number of positive lymph nodes (p=0.02;3.2(1.3-8.1)) were significantly associated with BCRL. Among those with PIVCs, pts with bilateral SLNB/ALND were more likely to develop BCRL than pts with unilateral sx (p&amp;lt;0.01;5.0(1.9-13.4)). Only 38% of the 32 bilateral pts with BCRL received at least one peripheral IV infusion on their ipsilateral arm. Conclusion: Results suggest that repeated skin punctures on the ipsilateral arm for CT infusions do not significantly increase the risk for BCRL compared to implanted CVADs, nor does the overall number of CT cycles. As survivors may be concerned about the risk of developing BCRL following sx and tx, healthcare practitioners should strive to mitigate pt worry during and well beyond the course of tx, educating pts about the lifestyle risk exposures for BCRL and precautionary guidelines not being definitive. Citation Format: Asdourian MS, Rao SR, Skolny MN, Salama L, Brunelle C, Seward C, Taghian AG. Chemotherapy-related risk factors associated with lymphedema in breast cancer patients: Should repeated ipsilateral arm infusions be avoided? [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr PD4-03.

Incidence and risk factors for breast cancer-related lymphedema: a retrospective cohort study

Objective To determine the incidence of breast cancer-related lymphedema (BCRL) in China and to analyze the associated risk factors. Methods A retrospective analysis was performed on the clinical data and the incidence of BCRL in 281 patients who were newly diagnosed with breast cancer and received surgery. The incidence of BCRL was evaluated using arm circumference measurement and Norman questionnaire. The risk factors for lymphedema were analyzed using chi-square test and logistic regression model. Results In all patients, the incidence rates of BCRL determined by arm circumference measurement and Norman questionnaire were 31.7% and 27.0%, respectively. The multivariate analysis showed that postoperative radiotherapy, a preoperative body mass index no less than 24 kg/m2, a large axillary lymph node dissection area, and a large number of positive axillary lymph nodes significantly increased the risk of BCRL (HR=2.87, P=0.042; HR=2.54, P=0.011; HR=1.97, P=0.037; HR=1.06, P=0.023). Moreover, patients with breast cancer and hypertension had 1.74-fold higher risk of BCRL than those with normal blood pressure. Conclusions The incidence of BCRL is still very high. However, most of patients only have mild edema. Postoperative radiotherapy, a large axillary lymph node dissection area, a large number of positive axillary lymph nodes, a high preoperative body mass index, and hypertension are risk factors for BCRL. Key words: Lymphedema; Incidence rates; Risk factors; Breast neoplasms/surgery; Breast neoplasms/radiotherapy

Abstract P1-09-13: Risk of breast cancer related lymphedema after treatment with taxane-based chemotherapy: A prospective cohort study

Abstract Background: Taxane-based chemotherapy is routinely used in the treatment of breast cancer and has been shown to improve both disease-free survival (DFS) and overall survival (OS). A common side effect of taxane-based chemotherapy is fluid retention in the extremities, which may increase the risk of breast cancer related lymphedema (BCRL). BCRL is a chronic swelling of the arms, breast, or trunk due to accumulation of lymphatic fluid in the interstitial tissues, which has a profoundly negative impact on quality of life. Little data exists regarding the impact of taxane-based chemotherapy and fluid retention on risk of developing BCRL. We sought to determine whether receipt of taxane-based chemotherapy for the treatment of breast cancer increases the risk of BCRL development in a large, prospective cohort of breast cancer patients. Methods: We identified 569 patients diagnosed with unilateral breast cancer between 2005-2012 who underwent surgery and prospective screening for BCRL at our institution. All patients included in this analysis had ≥ 18 months of post-operative follow-up. Bilateral arm volume measurements were performed using a perometer preoperatively and every 3-7 months postoperatively. BCRL was defined as a relative volume change (RVC) of ≥10%. Clinicopathologic characteristics and treatment details were obtained by medical record review. Cox proportional hazard analyses were performed to analyze risk of BCRL. Arm measurements obtained after contralateral prophylactic surgery or diagnosis of metastasis were excluded to avoid potential confounding. Results: Arm volume measurements from 569 patients were included with a median post-operative follow-up of 28 months (range 18-75.1). 33% (187/569) of patients received taxane-based chemotherapy in the neoadjuvant and/or adjuvant setting, and 92% (172/187) of these patients received pre-medication with dexamethasone to prevent hypersensitivity and reduce edema. 3% (18/569) received non-taxane based chemotherapy and 64% (364/569) received no chemotherapy. 23% (131/569) had axillary lymph node dissection (ALND), 61% (346/569) had sentinel lymph node biopsy (SLNB), and 16% (92/569) had no nodal surgery. At 24 months, the cumulative incidence of BCRL was 5.0% (95% CI: 3.15-7.81%) among patients who did not receive taxane-based chemotherapy, compared to 13.4% (95% CI: 9.17-19.4%) in the taxane-based chemotherapy group. On univariate analysis, taxane-based chemotherapy was associated with increased risk of BCRL (HR=2.2, p=0.0037), in addition to ALND, higher body mass index, greater number of lymph nodes (LNs) dissected and greater number of positive LNs (p&amp;lt;0.05 for all). However, taxane-based chemotherapy was not associated with increased BCRL risk on multivariate analysis (HR= 0.78, p=0.43), in which only ALND (HR=4.9, p&amp;lt;0.0001) and number of positive LNs (HR=1.1, p=0.02) remained significant. Conclusion: Our results suggest that patients who receive taxane-based chemotherapy are not at an increased risk of BCRL compared with patients who received non-taxane or no chemotherapy. This data can be used to improve patient education and counsel those who experience temporary fluid retention while on taxane-based chemotherapy. Citation Format: Meyha N Swaroop, Cynthia L Miller, Nora Horick, Chantal M Ferguson, Melissa N Skolny, Jean O'Toole, Lauren S Jammallo, Michelle C Specht, Alphonse G Taghian. Risk of breast cancer related lymphedema after treatment with taxane-based chemotherapy: A prospective cohort study [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-09-13.

Reply

Sir: We would like to thank Dr. Peeters and Hamdi for their comments regarding our article entitled “Reduced Incidence of Breast Cancer-Related Lymphedema following Mastectomy and Breast Reconstruction versus Mastectomy Alone.”1 The authors present a relevant discussion concerning the underdiagnosis of lymphedema that may be reflected in our study. As described in our Discussion section, one major criticism of lymphedema incidence studies is the criteria used for diagnosis and description of lymphedema. In addition, objective measurements are not standardized and most importantly vary widely.2 As with any retrospective study, there are limitations to how data are documented, as confirmed by the authors. Thus, with further follow-up and better awareness, including improved diagnosis with techniques such as bioimpedance and perometry, more patients may be found to have lymphedema with improved recording of consistent objective measurements. We agree with the authors that information concerning postoperative chemotherapy and lymphedema would contribute to the findings in our article. We did find that neoadjuvant chemotherapy approached significance and, as pointed out by the authors, more recent studies are finding an association with adjuvant chemotherapy and an increased incidence of lymphedema.2,3 To the issue of matching the two study groups, as we know, there are multiple risk factors associated with developing lymphedema. To reduce the confounders in our study, we cross-matched the two groups on three known risk factors: patient age (±5 years), sentinal/axillary lymph node dissection status, and postoperative radiotherapy status. Cross-matching for additional risk factors would reduce the size of the study sample. The more matching variables that are used, the harder it is to find matched pairs, and therefore the more samples we would have excluded from the study, reducing the power of the study. To maintain an adequate sample size for the analysis, we decided to perform cross-matching on only three variables. To consider other risk factors, we applied multivariate analysis. After adjusting for body mass index, the number of positive lymph nodes, and radiotherapy, the conclusion reached by the study was still supported. We described the design and the cross-matching process in the last paragraph of the Discussion. With regard to subgroup analysis, the objective of this study was to compare the incidence of upper limb lymphedema in patients who undergo mastectomy with reconstruction versus mastectomy alone. We discussed the incidence of lymphedema for patients undergoing reconstruction in another article, “Immediate Breast Reconstruction and Lymphedema Incidence,” in which the differences in the lymphedema rates of various reconstruction subgroups were presented and discussed.4 We appreciate the comments by the authors regarding our recent study and look forward to future contributions in the field of lymphedema by Dr. Peeters and Hamdi. We agree that there is a need for improved controlled and prospective trials evaluating both psychosocial and medical outcomes associated with breast cancer–related lymphedema and breast reconstruction. DISCLOSURE None of the authors has a financial interest to declare in relation to the content of this communication. Melissa A. Crosby M.D. Jun Lui M.D., M.S. David W. Chang M.D. Department of Plastic Surgery University of Texas M. D. Anderson Cancer Center Houston, Texas

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

As breast cancer survivorship has increased, so has an awareness of the morbidities associated with its treatment. The incidence of breast cancer-related lymphedema has been reported to be 8 to 30 percent in all breast cancer survivors. To determine whether breast cancer reconstruction has an impact on the incidence of breast cancer-related lymphedema, the authors compared its incidence in patients who underwent mastectomy with reconstruction versus mastectomy alone. All patients who underwent mastectomy, with or without immediate breast reconstruction, between 2001 and 2006, were identified through a search of prospective institutional databases. To reduce variation caused by known predictive factors, the individuals were cross-matched for age, axillary intervention, and postoperative axillary irradiation. The incidence of lymphedema was based on the presence of arm edema that lasted more than 6 months and was documented clinically. Of the 574 cross-matched patients included in the study, 78 (6.8 percent) developed lymphedema (21 with reconstructed breasts and 57 with unreconstructed breasts). Patients who did not undergo reconstruction were significantly more likely to develop breast cancer-related lymphedema (9.9 percent versus 3.7 percent; p < 0.001). Postoperative axillary radiation therapy (p < 0.001), one or more positive lymph nodes (p = 0.010), and body mass index of 25 or greater (p = 0.021) were also associated with an increased incidence of lymphedema. Reconstruction patients developed lymphedema significantly later than nonreconstruction patients (p < 0.001). Patients who undergo breast reconstruction have a lower incidence and a delay in onset of breast cancer-related lymphedema compared with patients who undergo mastectomy alone. Therapeutic, III.

Breast Cancer–Related Lymphedema in Elderly Patients

Treatment of breast cancer has improved dramatically over the last 2 decades. Although these treatment options have significantly increased the 5-year survival rates, they are not without lasting adverse effects. As survival continues to improve for older women, the development of most feared long-term complication, breast cancer–related lymphedema (BCRL), will increase and can be more severe with increased age-related comorbidities. Since currently no definitive cure for BCRL exists, prevention by limiting and/or eliminating risk factors is of prime importance. Preventive exercise and education are recommended to reduce the incidence of BCRL and to enhance quality of life. There are new studies that mention mapping the axillary lymphatics before/during surgery to reduce the incidence of BCRL, as a mean to avoid extensive lymph node dissection; however its not definitely clarified. New surgical approaches such as microsurgical lymphaticovenous anastomosis are promising. In this article, we review the literature and discuss BCRL incidence, diagnosis, and treatment considering elderly patients.

Lymphedema after breast cancer in a prospective cohort study

20736 Background: Breast cancer-related lymphedema (BCRL) is a chronic, debilitating condition that may occur among breast cancer survivors after surgery and/or radiation therapy to the axilla. BCRL patients can experience overall decreased quality of life. Reports of the true incidence of lymphedema vary widely, and no large, population-based studies have been conducted with standardized diagnosis, measurement, and follow-up. Methods: In an ongoing, prospective study of recently-diagnosed breast cancer survivors at Kaiser Permanente Northern California (KPNC), we ascertained the incidence of BCRL based on electronic medical records. Cases were identified by ICD-9 code 4571.0, outpatient procedures for manual lymph drainage, or durable medical equipment orders after breast cancer diagnosis. We compared demographic, medical care utilization, and cancer characteristics among BCRL and non-BCRL women using Pearson’s chi- square test and Satterthwaite t-test. A brief questionnaire about BCRL education was administered at cohort entry among a sample of women. Results: As of 16 October 2007, 111 out of 1,176 breast cancer patients were diagnosed with BCRL (9.4% incidence with up to 22 months of follow-up). The mean time to diagnosis after cancer diagnosis was 6.2 months with the majority (37.9%) diagnosed in the first three months. BCRL patients were younger, had significantly more physical therapy and surgery visits, and had more advanced cancer stage than non-BCRL patients (p<0.05). No differences were observed by BMI at cancer diagnosis. Among 332 respondents, 67.8% reported having received BCRL educational materials from KPNC. Awareness of risk reduction strategies was poor, with only 60.5% and 57.8% reporting avoidance of trauma/injury and arm constriction, respectively. Suggestions for improving BCRL education included a discussion with the surgeon pre- and post-surgery and a mandatory physical therapy meeting post-surgery. Conclusions: Within a large HMO setting, BCRL remains an important health issue despite recent changes in surgical technique to remove positive lymph nodes. More improvements are needed for disseminating BCRL information to breast cancer patients due to mounting evidence that progression can be prevented through early treatment. No significant financial relationships to disclose.