Risk Of Breast Cancer-related Lymphedema Research Articles

ASO Author Reflections: Infection and Skin Trauma Incrementally Increase the Risk of Breast Cancer-Related Lymphedema.

ASO Author Reflections: Infection and Skin Trauma Incrementally Increase the Risk of Breast Cancer-Related Lymphedema.

Body Mass Index and Breast Cancer-Related Lymphedema: A Retrospective Cohort Study.

This study aims to evaluate the association between body mass index (BMI) and the incidence of breast cancer-related lymphedema (BCRL). This retrospective cohort study analyzed data from 1464 breast cancer patients treated at The Third Hospital of Nanchang between 2018 and 2021. Patients were categorized based on BMI (<25, 25 to < 30, ≥ 30 kg/m²). Variables such as axillary lymph node dissection, infections, radiotherapy, and comorbidities were taken into account. The incidence of BCRL was 23.4%. Higher BMI was associated with increased risk of BCRL, with significant incidence rates observed at 1, 2, and 3 years in the higher BMI groups. Multivariate analysis confirmed BMI as an independent risk factor for BCRL. Elevated BMI is associated with increased BCRL risk and decreased BCRL-free survival, underscoring the significance of weight management in breast cancer care.

The Effects of a Web Application for Reducing the Risk of Breast Cancer-Related Lymphedema on Health Literacy and Self-Efficacy in Managing Symptoms Among Patients With Breast Cancer.

This study aimed to examine the effectiveness of a web application on health literacy and self-efficacy in managing arm oedema symptoms among patients with breast cancer. The research was carried out in four phases as follows: Phase 1, using a qualitative approach to explore problems and information needs in educating breast cancer patients through in-depth interviews with 10 professional nurses who had experiences in caring for breast cancer patients and 20 breast cancer patients. Data were analysed by content analysis; Phase 2, designing and developing a web application and confirming its quality by five experts with experience caring for breast cancer patients; Phase 3, testing the web application with five breast cancer patients; and Phase 4, examining the effectiveness of a web application in breast cancer patients using a quasiexperimental research method. Patients were divided into 15 persons in control and 15 in intervention groups, a total of 30 persons. The tools used in the study consisted of (1) a web application on practices for reducing risk for arm oedema after breast cancer treatment, (2) a health literacy assessment tool, (3) a self-efficacy for managing symptoms questionnaire and (4) a web application satisfaction questionnaire. Data were analysed using descriptive statistics, chi-square and t test. Qualitative findings: The web application should cover patients' and nurses' views on arm oedema causes, assessment, prevention and self-care for managing swelling after breast cancer treatment. Characteristics of a web application required: large text, bright colours, clear visibility, accompanying pictures or videos, using simple language without official terminology, easy to access, convenient to use, concise, interesting content and shareable to others. Quantitative findings: The intervention group had significantly higher health literacy and self-efficacy in managing symptom scores than before the trial (p < 0.001). Sample groups were satisfied with the developed web application at a high level. When considering each item, it was found that all items were rated at high levels. Two items with the same highest score were ease of use and the attractiveness of the presentation style. This web application, aimed at reducing the risk of arm oedema after breast cancer treatment, is an effective tool for educating all hospitalized patients. In addition, further research should be conducted to monitor the sustainability of long-term and clinical outcomes.

Is axillary web syndrome a risk factor for breast cancer-related lymphedema of the upper extremity? A systematic review and meta-analysis.

To systematically review the available literature to determine if axillary web syndrome (AWS) is a risk factor for breast cancer-related lymphedema (BCRL) of the upper extremity. The study is Prospero-registered (ID CRD42024508169) and follows PRISMA guidelines. Ovid MEDLINE, PubMED, CINAHL, Embase, clinicaltrials.gov and the WHO International Clinical Trials Registry Platform were searched February 24, 2024. Original studies including a cohort of females > 18 years of age diagnosed with AWS after breast cancer surgery and assessing BCRL outcome were included. Scoping, mapping, systematic or qualitative reviews, dissertations without peer-review and conference abstracts were excluded. Methodological quality was assessed using the Modified Downs and Black Checklist and overall certainty in the body of evidence was assessed using Cochrane's GRADE criteria (Grading of Recommendations Assessment, Development and Evaluation). Nine cohort studies representing 3218 participants were included. The median incidence of AWS and BCRL was 31.79% (IQR 8.90%) and 14.29% (IQR 19.01%), respectively, across all studies. Pooled analysis indicated an odds ratio of 1.19 (95% confidence interval 0.60,2.37), with substantial heterogeneity across studies (Chi2 p < 0.0001, I2 = 82%). Methodological quality of the included studies was poor to fair, and there was very low certainty evidence indicating no difference in AWS for BCRL risk. The strongest study included, found that AWS more than doubles BCRL risk in the upper extremity. The available evidence base cannot definitively determine whether AWS imparts risk of BCRL. AWS should be considered a potential risk factor for BCRL, until definitive conclusions from future research are available.

Effects of dietary habits and catheterization type on breast cancer-related lymphedema: a retrospective cohort study

BackgroundUnderstanding the factors that contribute to variability in breast cancer-related lymphedema (BCRL) is an important first step in developing targeted interventions to improve quality of life in breast cancer patients. Although previous research studies have has identified many risk factors for BCRL, dietary habits and catheterization type have rarely been studied until the present.AimThis study aims to explore the effects of nursing factors such as dietary habits and catheterization type on breast cancer-related lymphedema (BCRL).MethodsThis retrospective cohort study included 1,476 breast cancer patients who underwent surgery between January 1, 2012, and September 1, 2020. Lymphedema was assessed with a validated self-report questionnaire. All research data were obtained from medical records and a follow-up database. Multivariate Cox regression was conducted to explore the effects of dietary habits and catheterization type on BCRL.ResultsThe results showed an increased risk for BCRL among breast cancer patients who followed a high-fat diet prehospitalization (HR = 2.47; 95% CI = 1.55–3.94; P < 0.001), indwelling totally implantable venous access ports (TIVAPs) compared with indwelling needles (HR = 0.56; 95% CI = 0.35–0.90;P = 0.017) or indwelling peripherally inserted central catheters (PICCs) (HR = 0.69; 95% CI = 0.45–1.05; P = 0.086).ConclusionHigh-fat diet pre-hospitalization was an independent risk factor for lymphedema. The TIVAPs did not exert a protective effect on lymphedema compared with the PICC and indwelling needle. This study finding offers new insights to develop targeted interventions to decrease the incidence of lymphedema.

Distally Based Lymphatic Microsurgical Preventive Healing Approach-A Modification of the Classic Approach.

The treatment of breast cancer has seen great success in the recent decade. With longer survivorship, more attention is paid to function and aesthetics as integral treatment components. However, breast cancer-related lymphedema (BCRL) remains a significant complication. Immediate lymphatic reconstruction is an emerging technique to reduce the risk of BCRL, the Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) being the most widely used approach. Despite promising results, it is often difficult to find suitably sized recipient venules and perform the microanastomoses between mismatched vessels deep in the axilla. Moreover, high axillary venous pressure gradients and potential damage from radiotherapy may affect the long-term patency of the anastomoses. From an ergonomic point of view, performing lymphaticovenular anastomosis in the deep axilla may be challenging for the microsurgeon. In response to these limitations, we modified the technique by moving the lymphatic reconstruction distally-terming it distally based LYMPHA (dLYMPHA). A total of 113 patients underwent mastectomy with axillary clearance in our institution from 2018 to 2021. Of these, 26 underwent subsequent dLYMPHA (Group 2), whereas 87 did not (Group 1). In total, 17.2% (15 patients) and 3.84% (1 patient) developed BCRL in Groups 1 and 2, respectively ( p = 0.018). Lymphatics and recipient venules suitable for anastomoses can be reliably found in the distal upper limb with better size match. A distal modification achieves a more favorable lymphaticovenular pressure gradient, vessel match, and ergonomics while ensuring a comparably low BCRL rate.

The Effects of Daily-Living Risks on Breast Cancer-Related Lymphedema.

Conventional advice to reduce the risk of breast cancer-related lymphedema (BCLE) suggests avoidance of daily-living risks, and limited research has investigated these risks. This study aimed to examine the occurrence, patterns, and effects of daily-living risks on BCLE. A cross-sectional design was used to collect data from 567 patients at a metropolitan cancer center in the United States. The Lymphedema Risk-Reduction Behavior Checklist was used to assess the occurrence of 11 daily-living risks. Descriptive, regression, and factor analyses were performed. Significant odds of BCLE were associated with infection (odds ratio [OR] 2.58, 95% confidence interval [CI] 1.95-3.42), cuts/scratches (OR 2.65, 95% CI 1.97-3.56), sunburn (OR 1.89, 95% CI 1.39-3.56), oil splash or steam burns (OR 2.08, 95% CI 1.53-3.83), and insect bites (OR 1.59, 95% CI 1.18-2.13). The daily-living risks were clustered into factors related to skin trauma and carrying objects. Skin trauma risk was significantly associated with BCLE (B=0.539, z=3.926, OR 1.714, 95% CI 1.312-2.250; p<0.001). Having three, four, or five skin trauma risks significantly increased the odds of BCLE to 4.31, 5.14, and 6.94 times, respectively. The risk of carrying objects had no significant or incremental effects on BCLE. Complete avoidance of daily-living risks is challenging given 52.73% of patients incurred more than five daily-living risks. Our study findings underscore the importance of 'what to do' strategies to minimize infection and skin trauma.

The effect of exercise and educational programs for breast cancer patients on the development of breast cancer-related lymphoedema: secondary endpoint from a randomized controlled trial in the Setouchi Breast Project-10.

Although the association between higher physical activity and preventive effect on breast-cancer-related lymphoedema (BCRL) has been reported, it is unclear what intervention is optimal. We aimed to investigate the effect of exercise and educational programs on BCRL development. This study was a secondary endpoint analysis from a prospective randomized controlled trial. We enrolled patients with stage 0-III breast cancer from March 2016 to March 2020 and randomly assigned them to the control (n = 111), education (n = 115), or exercise (n = 104) group. As secondary endpoint, we assessed the incidence of and preventive effect on BCRL at 12months post-intervention. There were no significant differences in the incidence of BCRL at 12months post-intervention between the exercise and control groups (9.8% and 10.8%, P = 0.83) and the education and control groups (11.6% and 10.8%, P = 1.00). There were no significant differences in time to BCRL onset from the day of surgery between the exercise and control groups (event rate at 12months: 20.7% and 17.2%, log-rank, P = 0.54) and the education and control groups (18.8% and 17.2%, log-rank, P = 0.57). The multivariable analyses indicated that axillary dissection and obesity significantly increased the risk of BCRL [hazard ratio (HR): 2.36, 95% confidence interval (CI) 1.52-3.67 and HR: 1.68, 95% CI 1.07-2.63, respectively]. The intervention did not decrease the risk of BCRL, and axillary dissection and obesity were the risk factors of BCRL. UMIN000020595 at UMIN Clinical Trial Registry.

Development and validation of a nomogram for breast cancer-related lymphedema

To establish and validate a predictive model for breast cancer-related lymphedema (BCRL) among Chinese patients to facilitate individualized risk assessment. We retrospectively analyzed data from breast cancer patients treated at a major single-center breast hospital in China. From 2020 to 2022, we identified risk factors for BCRL through logistic regression and developed and validated a nomogram using R software (version 4.1.2). Model validation was achieved through the application of receiver operating characteristic curve (ROC), a calibration plot, and decision curve analysis (DCA), with further evaluated by internal validation. Among 1485 patients analyzed, 360 developed lymphedema (24.2%). The nomogram incorporated body mass index, operative time, lymph node count, axillary dissection level, surgical site infection, and radiotherapy as predictors. The AUCs for training (N = 1038) and validation (N = 447) cohorts were 0.779 and 0.724, respectively, indicating good discriminative ability. Calibration and decision curve analysis confirmed the model’s clinical utility. Our nomogram provides an accurate tool for predicting BCRL risk, with potential to enhance personalized management in breast cancer survivors. Further prospective validation across multiple centers is warranted.

Assessing breast cancer-related lymphedema screening and treatment gaps in a safety-net hospital.

We evaluated the unmet breast cancer-related lymphedema(BCRL) treatment and education needs at New England's largest safety-net hospital serving a diverse population by assessing prevalence, risk factors, and treatment. This was a retrospective cohort study examining breast cancer surgery patients from September 2016 to September 2021. The primary outcome was BCRL diagnosis. Secondary outcomes included BCRL risk factors, and physical and occupational therapy (PT/OT)referral frequency and completion. Of 639 patients, 17% of patients had documented BCRL, which was significantly associated with axillary lymph node dissection (ALND).There were no racial, insurance, breast radiation, or BMI category differences between patients with and without a BCRL diagnosis. Of those with BCRL, 58% received a PT/OTreferral, and 56% completed their referral. There were no racial, insurance, or BMI category differences between those who received a PT/OTreferral and those who did not. In our high-risk population, rates of documented BCRL were higher than expected, approaching rates of ALND, despite the majority undergoing sentinel lymph node biopsy (SLNB).PT/OTreferral and completion rates were low, concerning for an unmet BCRL treatment and education need. No disparities in care delivery were seen, but a program that addresses treatment gaps and ensures accessible and patient-centered BCRL care is urgently needed.

Relationship between receipt of combined axillary dissection and nodal irradiation and age.

11043 Background: Combined axillary lymph node dissection and regional nodal irradiation (ALND+RNI) is the greatest risk factor for breast cancer-related lymphedema (BCRL), a lifelong ailment that negatively impacts quality of life. As disability from BCRL may be particularly profound for adults &lt;45 yo with longer life expectancy, we examined the association of age and other sociodemographics with receipt of ALND+RNI to further our understanding of patients at greatest risk for BCRL. Methods: The National Cancer Database (NCDB) was used to examine age-based differences in receipt of ALND+RNI in patients with stage I-III breast cancer treated from 2018-2020. Cohort characteristics were compared by age (&lt;45 yo, 45-64 yo, and 65 yo). Multivariable regression examined the association between age and ALND+RNI adjusting for relevant factors. Sensitivity analyses explored associations between covariates and combined ALND+RNI by age group. Results: Of 155,010 patients, 5.4% were &lt;45 yo, 47.2% were 45-64 yo, and 47.4% were 65 yo. Clinical and pathological node (cN, pN) positive disease, and receipt of ALND, RNI, and ALND+RNI were more common in patients &lt;45 yo (Table). Age &lt;45 yo was independently associated with ALND+RNI (&lt;45 yo OR 1.40; 45-64 yo OR 1.26 vs 65, p&lt;0.001). Residing in areas with a high proportion of high-school graduates (%HSG), Hispanic ethnicity but not race, and lower income were also associated with ALND+RNI in adjusted analyses (all p&lt;0.05). Medicare (p=0.02 vs private insurance) was inversely associated with ALND+RNI. Among clinical factors, pN+ was the greatest risk factor for receipt of ALND+RNI (all p&lt;0.001 vs pN0). Higher cT, cN1 and cN2 categories, lobular tumors, mastectomy, not receiving endocrine therapy, and having chemotherapy were also associated with ALND+ RNI (all p&lt;0.05). Sensitivity analyses showed that while sociodemographics influenced receipt of ALND+RNI for women 45 yos, only clinical factors were significant for ALND+RNI for &lt;45 yo. Among 45-64 yo, high %HSG (p&lt;0.001) and low household incomes (p&lt;0.01) were associated with ALND+RNI. In the 65 yo cohort, high %HSG (p=0.028), and Asian race (p=0.011) were more likely to receive ALND+RNI while Medicare patients were less likely to have ALND+RNI (p=0.012). Conclusions: Our findings suggests that clinical factors predominate in axillary treatment decisions for younger patients; while sociodemographic factors are more prominent for those 45 yo. Given their higher odds of receiving ALND+RNI, BCRL screening may be especially important in patients &lt;45 yo. Further studies are needed to understand the interplay between age and sociodemographics on receipt of ALND+RNI. [Table: see text]

Geographic Disparities and Payment Variation for Immediate Lymphatic Reconstruction in Massachusetts.

Little is known about practice patterns and payments for immediate lymphatic reconstruction (ILR). This study aims to evaluate trends in ILR delivery and billing practices. We queried the Massachusetts All-Payer Claims Database between 2016 and 2020 for patients who underwent lumpectomy or mastectomy with axillary lymph node dissection for oncologic indications. We further identified patients who underwent lymphovenous bypass on the same date as tumor resection. We used ZIP code data to analyze the geographic distribution of ILR procedures and calculated physician payments for these procedures, adjusting for inflation. We used multivariable logistic regression to identify variables, which predicted receipt of ILR. In total, 2862 patients underwent axillary lymph node dissection over the study period. Of these, 53 patients underwent ILR. Patients who underwent ILR were younger (55.1 vs 59.3 years, P = 0.023). There were no significant differences in obesity, diabetes, or smoking history between the two groups. A greater percentage of patients who underwent ILR had radiation (83% vs 67%, P = 0.027). In multivariable regression, patients residing in a county neighboring Boston had 3.32-fold higher odds of undergoing ILR (95% confidence interval: 1.76-6.25; P < 0.001), while obesity, radiation therapy, and taxane-based chemotherapy were not significant predictors. Payments for ILR varied widely. In Massachusetts, patients were more likely to undergo ILR if they resided near Boston. Thus, many patients with the highest known risk for breast cancer-related lymphedema may face barriers accessing ILR. Greater awareness about referring high-risk patients to plastic surgeons is needed.

Abstract PO4-12-03: PATIENT REPORTED OUTCOMES IN TERMS OF ARM AND SHOULDER FUNCTIONS AND QUALITY OF LIFE AND LYMPHEDEMA ARE AFFECTED BY THE STAGE, AND EXTENT OF AXILLARY SURGERY IN THE EARLY POSTOPERATIVE PERIOD OF PATIENTS WITH BREAST CANCER

Abstract This study evaluated whether lymphedema, patient-reported arm and shoulder morbidity and quality of life one year after axillary surgery are affected by stage or axillary surgery type between early stage patients and patients with locally advanced breast cancer who underwent surgery following neoadjuvant therapy. By determining the risk factors associated with severe lymphedema and deterioration of patient-reported outcomes, lymphedema could be prevented by early intervention to improve the prognosis of lymphedema and quality of life. Material and Methods: Between January 2021 and May 2022, a total of 253 breast cancer patients, 128 early stage and 125 locally advanced stage who underwent surgery including sentinel lymph node biopsy (SLNB) with/without axillary lymph node dissection (ALND) following neoadjuvant therapy were included in this study. The patients who underwent upfront surgery were defined as early-stage, and those who underwent surgery following neoadjuvant chemotherapy were considered as having locally advanced breast cancer (LABC) who have also participated in the prospective MF18-03 registry trial. Patients were prospectively evaluated by the SF-12 quality of life and QUICK-DASH hand, arm, and shoulder range of motion questionnaires and circumferential tape measurements of the arm width to evaluate the lymphedema before surgery, and 6 month- and 12-month assessments. The volume difference of 10% or more in the operated arm compared to the healthy arm was considered as lymphedema. Results: In the assessment of SF-12 quality of life questionnaire, there was a decrease in physical function scores at the 6th month despite recovery at the 12th month in both groups compared to the initial preoperative scores (p&amp;lt; 0,001). Moreover, patients with locally advanced breast cancer were found to have decreased SF-12 general health (p=0.024), vitality (p=0.034), and mental health scores in one year after surgery (p=0.004). Patients with mastectomy and locally advanced breast cancer were more likely to have a diminished arm and shoulder function as assessed with the QUICK-DASH questionnaire at the 6th and 12th months compared to those with breast conservation (6. month, p=0,009, 12. month, p=0.004), and early breast cancer, respectively (6. month, p=0.014, 12. month, p&amp;lt; 0.001) In the present cohort, lymphedema was detected in 19 (7.5%) patients including 16 cases with mild (11-20%), 2 cases with moderate (21-40%), and one case with severe (41-80%) lymphedema one year after surgery. Axillary dissection was found to be associated with an increased risk of lymphedema (SLNB, 5.0% vs ALND, 17.6%; p=0.005). Similarly, removal of &amp;gt;6 lymph nodes was also associated with an increased risk of lymphedema that was not statistically significant (&amp;lt;6 LNs, 6.4% vs &amp;gt;6LNs, 10.8%; p=0.277). Among those with LABC, however, patients with removal &amp;gt;6 LNs were more likely to have lymphedema (&amp;gt;6 LNs, 15.4% vs &amp;lt;6 LNs, 5.8%; p=0.096). Conclusion: These findings suggest that only an extensive axillary surgery was associated with an increased risk of breast cancer-related lymphedema. Patients with a mastectomy were more likely to have diminished arm and shoulder function compared to those with breast conservation. Furthermore, patients with locally advanced breast cancer were more likely to have a dispaired quality of life score and a limited arm and shoulder function regardless of the presence of lymphedema. Early prompt diagnosis and therapy of lymphedema can therefore potentially improve quality of life. Citation Format: Halime Gul Kilic, Selman Emiroglu, Ekin Ozgorgu, Mustafa Tukenmez, Atilla Bozdogan, Mahmut Muslumanoglu, Vahit Ozmen, Dilsad Sindel, Abdullah Igci, Aydan Oral, Neslihan Cabıoğlu. PATIENT REPORTED OUTCOMES IN TERMS OF ARM AND SHOULDER FUNCTIONS AND QUALITY OF LIFE AND LYMPHEDEMA ARE AFFECTED BY THE STAGE, AND EXTENT OF AXILLARY SURGERY IN THE EARLY POSTOPERATIVE PERIOD OF PATIENTS WITH BREAST CANCER [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-12-03.

Acupuncture Needles and the Risk of Lymphedema After Breast Cancer Surgery: A Retrospective National Cohort Study

Background: Controversies remain over the impact of using needles on breast cancer patients after surgery due to risk of breast cancer-related lymphedema (BCRL). While recent literature suggests that vascular access during the postsurgical stage does not affect the risk of BCRL, the impact of acupuncture on the risk of BCRL during the postsurgical stage has not been studied.Methods: This study included 35,153 patients from 2011 to 2013 who were newly diagnosed with breast cancer in a population-based cohort from the Korean National Health Insurance Service database. All patients received breast surgery, and the treatment group received acupuncture for more than 3 sessions in the 3-6 months post-surgery. The control group did not receive acupuncture. The incidence rate ratio, Kaplan-Meier curve, and Cox proportional hazards models were used to compare the risk of BCRL, and death between groups.Results: About 5.8% of the study population received acupuncture during the 3-6 months post-surgery treatment window. After propensity score matching, the acupuncture treatment group did not show an increased risk of BCRL (IRR 1.017, 95% CI 0.868-1.193; unadjusted HR 1.018, 95% CI 0.868-1.193). This risk was robust in all multivariate Cox proportional hazards models.Conclusion: An association of BCRL with acupuncture was not observed. Patients who received acupuncture to manage symptoms such as pain during the 3-6 months postsurgical stage did not have a higher risk of developing BCRL. Breast cancer patients who seek acupuncture to alleviate post-surgery symptoms such as pain, can receive acupuncture without concerns for potential risk of BCRL.

Comparison of machine learning models to predict the risk of breast cancer-related lymphedema among breast cancer survivors: a cross-sectional study in China.

The aim of this study was to develop and validate a series of breast cancer-related lymphoedema risk prediction models using machine learning algorithms for early identification of high-risk individuals to reduce the incidence of postoperative breast cancer lymphoedema. This was a retrospective study conducted from January 2012 to July 2022 in a tertiary oncology hospital. Subsequent to the collection of clinical data, variables with predictive capacity for breast cancer-related lymphoedema (BCRL) were subjected to scrutiny utilizing the Least Absolute Shrinkage and Selection Operator (LASSO) technique. The entire dataset underwent a randomized partition into training and test subsets, adhering to a 7:3 distribution. Nine classification models were developed, and the model performance was evaluated based on accuracy, sensitivity, specificity, recall, precision, F-score, and area under curve (AUC) of the ROC curve. Ultimately, the selection of the optimal model hinged upon the AUC value. Grid search and 10-fold cross-validation was used to determine the best parameter setting for each algorithm. A total of 670 patients were investigated, of which 469 were in the modeling group and 201 in the validation group. A total of 174 had BCRL (25.97%). The LASSO regression model screened for the 13 features most valuable in predicting BCRL. The range of each metric in the test set for the nine models was, in order: accuracy (0.75-0.84), sensitivity (0.50-0.79), specificity (0.79-0.93), recall (0.50-0.79), precision (0.51-0.70), F score (0.56-0.69), and AUC value (0.71-0.87). Overall, LR achieved the best performance in terms of accuracy (0.81), precision (0.60), sensitivity (0.79), specificity (0.82), recall (0.79), F-score (0.68), and AUC value (0.87) for predicting BCRL. The study established that the constructed logistic regression (LR) model exhibits a more favorable amalgamation of accuracy, sensitivity, specificity, recall, and AUC value. This configuration adeptly discerns patients who are at an elevated risk of BCRL. Consequently, this precise identification equips nurses with the means to undertake timely and tailored interventions, thus averting the onset of BCRL.

Predictive models for breast cancer-related lymphedema after mastectomy.

To establish a nomogram incorporating clinical characteristics to predict the risk of breast cancer-related lymphedema (BCRL). In this retrospective study, we included 200 consecutive patients with breast cancer undergoing radical mastectomy from January 2022 to December 2023. Of these, 98 patients diagnosed with BCRL were designated as the experimental group, while 102 patients served as the control group. Logistic regression analyses were conducted to explore factors associated with clinical prognosis and to construct and validate a nomogram for predicting the risk of BCRL using R language version 4.1.2. Univariate and multivariate logistic regression analyses identified six independent risk factors: the number of lymph node dissections (95% CI: 1.425-8.956, P < 0.01), radiotherapy (95% CI: 1.134-2.341, P < 0.01), lack of functional exercise (95% CI: 4.908-19.064, P = 0.001), adjuvant and neoadjuvant chemotherapy (95% CI: 1.763-4.287, P = 0.001), BMI (95% CI: 1.075-2.897, P < 0.05), and hypertension (95% CI: 1.077-2.999, P < 0.05). Using these variables, we developed a nomogram to predict the incidence of BCRL. The AUC value for the model was 0.74 (95% CI: 0.675-0.887), indicating acceptable agreement between predicted and observed outcomes. Decision curve analysis demonstrated good positive net benefits for the model. The number of lymph node dissections, radiotherapy, lack of functional exercise, adjuvant and neoadjuvant chemotherapy, BMI, and hypertension are independent risk factors for BCRL. Moreover, the nomogram prediction model showed good predictive performance, high accuracy, and clinical applicability.

Impact of neoadjuvant chemotherapy on breast cancer-related lymphedema after axillary lymph node dissection: a retrospective cohort study.

We aimed to evaluate whether neoadjuvant chemotherapy (NAC) could be a risk factor for breast cancer-related lymphedema (BCRL) associated with axillary lymph node dissection (ALND). A total of 596 patients with cT0-4N0-3M0 breast cancer who underwent ALND and chemotherapy were retrospectively analyzed between March 2012 and March 2022. NAC was administered in 188 patients (31.5%), while up-front surgery in 408 (68.5%). Univariate and multivariable Cox regression analyses were performed to determine whether NAC was an independent risk factor for BCRL. With propensity score matching (PSM), the NAC group and up-front surgery group were matched 1:1 by age, body mass index (BMI), molecular subtypes, type of breast surgery, and the number of positive lymph nodes. Kaplan-Meier survival analyses were performed for BCRL between groups before and after PSM. Subgroup analyses were conducted to explore whether NAC differed for BCRL occurrence in people with different characteristics. At a median follow-up of 36.3months, 130 patients (21.8%) experienced BCRL [NAC, 50/188 (26.60%) vs. up-front surgery, 80/408 (19.61%); P = 0.030]. Multivariable analysis identified that NAC [hazard ratio, 1.503; 95% CI (1.03, 2.19); P = 0.033] was an independent risk factor for BCRL. In addition, the hormone receptor-negative/human epidermal growth factor receptor 2-negative (HR-/HER2-) subtype, breast-conserving surgery (BCS), and increased positive lymph nodes significantly increased BCRL risk. After PSM, NAC remained a risk factor for BCRL [hazard ratio, 1.896; 95% CI (1.18, 3.04); P = 0.007]. Subgroup analyses showed that NAC had a consistent BCRL risk in most clinical subgroups. NAC receipt has a statistically significant increase in BCRL risk in patients with ALND. These patients should be closely monitored and may benefit from early BCRL intervention.

Effectiveness of a dedicated therapist on improving prospective identification and pre-operative rehabilitation (PREHAB) to reduce post-operative treatment encounters for breast cancer-related lymphedema (BCRL) in a rural and underserved population.

399 Background: The rural and underserved have unique challenges and barriers to receiving evaluation and treatment for BCRL. Prospective identification and PREHAB for those at high risk including mastectomy over age 60, axillary node dissection, and radiation reduces the risk of BCRL and post-operative treatment encounters. In a rural Virginia breast program in 2021, 71% (40/56) of breast cancer (BC) patients were identified as high-risk for BCRL. Only fifteen percent (6/40) of high-risk patients received PREHAB with fifty-two percent (29/56) of total BC patients required post-operative encounters for treatment of BCRL. A quality improvement project to improve these numbers was implemented. Methods: We sought to increase the number of PREHAB encounters for patients at high-risk for developing BCRL and to decrease the total number of BC patients requiring post-operative BCRL treatment encounters. A Certified Lymphedema Therapist (CLT) prospectively identified patients at high-risk for development of BRCL during multidisciplinary breast cancer conference (MBCC). High-risk patients were offered PREHAB appointments, and the rates of PREHAB and post-operative intervention encounters were recorded. Results: In 2022, 76% (51/67) of BC patients were identified as high-risk for developing BCRL. Thirty-seven percent (19/51) received PREHAB, a 22% increase from 2021. The average number of visits was 7.7 visits for patients who received PREHAB and 19.2 visits for patients who did not. Forty-two percent (28/67) of total BC patients required post-operative encounters for treatment of BCRL, a 10% decrease from 2021. Barriers/Challenges: Both providers and patients showed limited engagement in the PREHAB model at the start of the program. Patient barriers to treatment included transportation and time limitations. Conclusions: A dedicated focus including high-risk screening, PREHAB, and a CLT at MBCC, can improve outcomes for BCRL in a rural and underserved population. Future investigation will include measuring BCRL rates over time.

Is it the Type of Axillary Surgery or the Number of Removed Lymph Nodes That Increases the Risk of Breast Cancer Related Lymphedema (BCRL)? Results from a Prospective Screening Trial

Axillary surgery has been identified as the main risk factor for BCRL regardless the delivery of regional nodal radiation (RLNR). Yet it remains unknown if it is the type of axillary surgery or the number of removed lymph nodes (LN) that increases BCRL risks. Between 2008 and 2021, 3,350 patients (pts) who received surgery for breast cancer were enrolled in a lymphedema screening trial. Patients with bilateral breast cancer or without axillary surgery were excluded. Perometry was used to assess limb volume preoperatively in all patients. BCRL was defined as a ≥10% relative arm-volume increase arising >3 months postoperatively. The cohort was divided by axillary surgery type: axillary lymph node dissection (ALND) and sentinel lymph node biopsy (SLNB). Radiation was delivered using 3D conformal technique and RLNR was defined as the usage of anterior supraclavicular field. No hypofractionation was used and doses ranged between 50 and 50.4 Gy in 25-28 fractions. Multivariable Cox proportional hazard models compared the cumulative incidence of BCRL and local failure between different patient groups. After applying inclusion criteria, 2,623 pts were available with overall median follow-up s of 6.1 years. Of the entire cohort, 709 (27%) had ALND with a median of 16 LN removed, while 1,914 (73%) received SLNB only with a median of 2 LN removed. The median number of malignant LN and patients receiving RLNR was higher in ALND group compared to SLNB only group. Frequency distribution analysis showed that the main overlap between ALND and SLNB only groups happen in the range of 3-11 LN removed. Therefore, the primary analysis focused only on pts with 3-11 LN across both groups (n = 690: ALND n = 140, SLNB n = 550). The multivariable model adjusted for BMI, RLNR, age and breast surgery showed that in this group with 3-11 LN removed in both cohorts, ALND remained significantly associated with BCRL (HR: 4.2, p<0.0001). Separate analyses for the entire SLNB only group and ALND groups were conducted to evaluate if the BCRL risk increases per each removed LN within the same axillary surgery group. The multivariable analysis for SLNB only pts(N = 1,914) showed that for each LN removed the risk of BCRL did not increase significantly (HR:1.06, p = 0.3), similarly for ALND group (N = 709) for each LN removed (HR:1.02, p = 0.08). For pts with pathologic N2-N3 disease and clinical node negative without neoadjuvant chemotherapy receiving ALND, the number of LN removed did not significantly improve neither Local control (HR:1.02, p = 0.8) nor distant disease survival (HR:1.01, p = 0.6). ALND procedure per se is the main risk factor for BCRL not the number of LNs removed. For high-risk pts with >N2 disease, aggressive ALND did not improve tumor outcome. De-escalation with targeted axillary sampling followed by RLNR should be evaluated. Future lymphedema research should account for type of axillary surgery instead of number of LNs removed as a factor. (NCT01521741).

Analysis of the Risk Factors of Breast Cancer-Related Lymphedema and Construction and Evaluation of a Prediction Model.

Objective: The occurrence of breast cancer-related lymphedema (BCRL) in postoperative breast cancer survivors is described and the independent risk factors of BCRL are analyzed. A BCRL nomogram prediction model is constructed, and its effectiveness is evaluated to screen out high-risk patients with BCRL. Methods: A univariate analysis was carried out to determine the risk factors possibly related to BCRL, and a logistic regression analysis was utilized to determine the independent risk factors related to BCRL. A BCRL nomogram prediction model was built, and a nomogram was drawn by R software v4.1.0. The area under the curve (AUC) of the receiver operating characteristic (ROC) and the Hosmer-Lemeshow test were used to evaluate the efficacy of the constructed model to assess its clinical application value. Results: The risk factors independently associated with BCRL were body mass index (BMI), handedness on the operation side, no BCRL-related rehabilitation plan, axillary lymph node dissection (ALND), taxane-based chemotherapy, and radiotherapy (all p < 0.05). The BCRL nomogram prediction model was built on this basis, and the results of the efficacy evaluation showed a good fit: AUC = 0.952 (95% confidence interval: 0.930-0.973) for the ROC and χ2 = 6.963, p = 0.540 for the Hosmer-Lemeshow test. Conclusions: The risk factors for BCRL included higher BMI, handedness on the operation side, no BCRL-related rehabilitation plan, ALND, taxane-based chemotherapy, and radiotherapy. In addition, the BCRL nomogram prediction model accurately calculated the risk of possible BCRL among breast cancer survivors and effectively screened for high-risk patients with BCRL. Therefore, this prediction model can provide a basis for rehabilitation physicians and therapists to formulate early and individualized prevention and treatment programs.