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Guliyeva G, Huayllani MT, Boczar D, Avila FR, Lu X, Forte AJ. Age as a risk factor for breast cancer-related lymphedema: a systematic review. J Cancer Surviv 2023; 17:246-253. [PMID: 33486706 DOI: 10.1007/s11764-021-00994-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 01/15/2021] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Gunel Guliyeva
- Division of Plastic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Maria T Huayllani
- Division of Plastic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Daniel Boczar
- Division of Plastic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Francisco R Avila
- Division of Plastic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Xiaona Lu
- Section of Plastic Surgery, Yale University, 333 Cedar Street, New Haven, CT, 06510, USA
| | - Antonio Jorge Forte
- Division of Plastic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA.
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Risk factors of unilateral breast cancer-related lymphedema: an updated systematic review and meta-analysis of 84 cohort studies. Support Care Cancer 2022; 31:18. [PMID: 36513801 DOI: 10.1007/s00520-022-07508-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 12/02/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE To review and update the incidence and risk factors for breast cancer-related lymphedema based on cohort studies. METHODS The study was guided by the Joanna Briggs Institute methodology and the Cochrane handbook for systematic reviews. PubMed, EMBASE, CINAHL, Scopus, Web of Science, The Cochrane Library, CNKI, SinoMed, and Wan Fang Database were searched from inception to November 15, 2021. Cohort studies reported adjusted risk factors were selected. PRISMA guideline was followed. Study quality were evaluated using the Newcastle-Ottawa scale. Random-effects models were adopted. The robustness of pooled estimates was validated by meta-regression and subgroup analysis. Lymphedema incidence and adjusted risk factors in the multivariable analyses with hazard / odds ratios and 95% CIs were recorded. RESULTS Eighty-four cohort studies involving 58,358 breast cancer patients were included. The pooled incidence of lymphedema was 21.9% (95% CI, 19.8-24.0%). Fourteen factors were identified including ethnicity (black vs. white), higher body mass index, higher weight increase, hypertension, higher cancer stage (III vs. I-II), larger tumor size, mastectomy (vs. breast conservation surgery), axillary lymph nodes dissection, more lymph nodes dissected, higher level of lymph nodes dissection, chemotherapy, radiotherapy, surgery complications, and higher relative volume increase postoperatively. Additionally, breast reconstruction surgery, and adequate finance were found to play a protective role. However, other variables such as age, number of positive lymph nodes, and exercise were not correlated with risk of lymphedema. CONCLUSION Treatment-related factors still leading the development of breast cancer-related lymphedema. Other factors such as postoperative weight increase and finance status also play a part. Our findings suggest the need to shift the focus from treatment-related factors to modifiable psycho-social-behavioral factors.
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Erdinç Gündüz N, Şahin E, Dilek B, Ellidokuz H, Akalın E. Adherence to Compression Garment Wear and Associated Factors Among Patients with Breast Cancer-Related Lymphedema: A Pilot Study from a Turkish Tertiary Center. Lymphat Res Biol 2022; 20:665-670. [PMID: 35245100 DOI: 10.1089/lrb.2021.0091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Background: Compression garments are the basis of the maintenance phase of the breast cancer-related lymphedema (BCRL) treatment. The aim of this study is to investigate the adherence to compression garment wear and the associated factors among patients with BCRL. Methods and Results: Patients who received standard therapy and training on compression garment wear from a single center were asked to fill out a 28-item questionnaire on compression garment wear. Adherence to compression garment wear and the associated factors were examined. These factors were compared between patients who were wearing and who were not wearing compression garments as recommended. The study was completed with 60 patients. Twenty-five percent of the patients used custom-made compression garment. The rate of patients wearing compression garments as per recommendation was 51.7% (n = 31). The most common reasons for not wearing/discontinuation included functional difficulties in daily life (33%) and discomfort (28.8%). Compared according to the factors with potential impact on wearing, the rate of garment wear as per recommendation was statistically significantly higher in patients who had modified radical mastectomy than in those who had breast-conserving surgery (p = 0.038). Conclusion: Although standard information was provided to the patients, the adherence to compression garments was nonoptimal. The economic status of the patients is one of the main factors affecting the choice of compression garments and thus their adherence. To improve the adherence to this method, which is the basis of maintenance treatment of lymphedema, training programs to reduce patient beliefs and anxiety that are tailored to individual needs can be useful. Clinical trial registration number: NCT04832386.
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Affiliation(s)
- Nihan Erdinç Gündüz
- Department of Physical Medicine and Rehabilitation, Izmir Tepecik Training and Research Hospital, Health Science University, Izmir, Turkey
| | - Ebru Şahin
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Banu Dilek
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Hülya Ellidokuz
- Department of Biostatistics and Medical Informatics, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Elif Akalın
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
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Tatar KK, Turhan B. The effects of complex decongestive therapy on pain and functionality in individuals with breast cancer who developed adhesive capsulitis due to lymphedema: an evaluation by an isokinetic computerized system. Korean J Pain 2022; 35:280-290. [PMID: 35768983 PMCID: PMC9251399 DOI: 10.3344/kjp.2022.35.3.280] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/19/2022] [Accepted: 04/25/2022] [Indexed: 11/21/2022] Open
Abstract
Background This study aimed to determine the impact of complex decongestive therapy applications on upper extremity function in breast cancer patients who developed adhesive capsulitis after lymphedema. Methods Thirty patients who developed adhesive capsulitis due to lymphedema were divided into two groups as study (n = 15) and control (n = 15) groups. Both groups received 20 minutes of exercise five days a week for three weeks using a Biodex isokinetic dynamometer, as well as a hot pack and TENS (Transcutaneous Electrical Nerve Stimulation) treatment to the shoulder joint. The study group received 45 minutes of intensive decongestive therapy along with the adhesive capsulitis treatment. The visual analogue scale was used to assess pain, circumference, and volumetric measurements were used to assess edema, and the Arm, Shoulder, and Hand Problems Questionnaire (DASH: Disabilities of the Arm, Shoulder, and Hand) was used to assess upper extremity functionality. The shoulder range of motion was evaluated. Results Both groups had improvements in pain (P < 0.001), shoulder joint range of motion (P < 0.001), and upper extremity functionality (P < 0.001) after the treatment. There was a significant decrease in circumference and volumetric measurements in the study group (P < 0.001). However, no differences were seen in measurements in the control group. Conclusions The results showed that complex decongestive therapy was beneficial in reducing lymphedema in breast cancer patients who acquired adhesive capsulitis due to lymphedema. Consequently, the authors believe that supplementing conventional physiotherapy with complex decongestive therapy will benefit patients.
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Affiliation(s)
- Konca Kaya Tatar
- Department of Therapy and Rehabilitation, Vocational School of Health Services, Baskent University, Adana, Turkey
| | - Begumhan Turhan
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Hasan Kalyoncu University, Gaziantep, Turkey
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5
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Effects of diet-induced obesity in the development of lymphedema in the animal model: A literature review. Obes Res Clin Pract 2022; 16:197-205. [PMID: 35659463 DOI: 10.1016/j.orcp.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 11/17/2021] [Accepted: 05/12/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Obesity poses deleterious consequences on every organ system, especially the lymphatic network. However, the underlying cellular mechanisms through which obesity causes lymphatic dysfunction remains unclear. We aimed to summarize experimental studies that evaluated the effect of obesity on the lymphatic system on animal models. METHODS We used the following terms to search the Ovid EMBASE, Ovid MEDLINE(R), Cochrane, and Scopus databases: "lymphedema", "lymphatic diseases", "lymphatic system/complications* ", "lymphatic system/injuries* ", "lymphatic system/abnormalities* ", AND "obesity/complications* ", "diet/high-fat", "adipogenesis" and "lipid metabolism disorder". From a total of 166 articles identified in the initial search, 13 met our eligibility criteria. RESULTS Long-term exposure to high-fat diet in mice demonstrated significant amount of adipose tissue deposition which sets off an inflammatory cascade resulting in disruption of the chemokine gradient, inhibition of lymphangiogenesis, and changes in gene expression of lymphatic endothelial cells, that alter vessel permeability and induce cell death. Reduced contractile properties of lymphatic collectors, dilated capillaries, increased tissue pressure, and reduced hydraulic conductivity collectively contribute to reduced impaired lymphatic drainage. Aerobic exercise has shown reversal of lymphatic dysfunction in the obese and pharmacological interventions targeting T-cells, iNOS and VEGFR-3 signaling have the potential to combat acquired lymphedema. CONCLUSION Scientists should focus their future experiments on developing therapies that regulate expression of T-cell derived cytokines and VEGFR-3 expression whereas clinicians are urged to counsel their patients to reduce weight through aerobic exercise.
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Mülkoğlu C, Ayhan F, Erel S. Sexual Functions and Quality of Life in Patients Developing Lymphedema After Total Mastectomy: A Pilot Study. Lymphat Res Biol 2021; 20:220-227. [PMID: 33646047 DOI: 10.1089/lrb.2020.0053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Sexual functions in women with lymphedema secondary to breast cancer surgery have not been investigated sufficiently. This study aimed to compare patients with and without lymphedema after total mastectomy in terms of emotional state, sexual functions, and quality of life. We also investigated the factors affecting sexual functions in these patients. Methods: Married women 20-55 years of age, who presented to lymphedema polyclinic of Health Sciences University Ankara Training and Research Hospital after having undergone total mastectomy at least 1 year earlier owing to breast cancer were included. Twenty-five patients with lymphedema were assigned to the lymphedema group, and 20 without lymphedema to the control group. Hospital Anxiety and Depression Scale (HADS) was used to assess emotional state. We evaluated sexual functions of the participants by Female Sexual Function Index (FSFI) and quality of life with European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QOL-C30). Results: There was no statistically significant difference in age and body mass index between the groups (p > 0.05). The mean HADS score was 13.4 ± 6.5 in lymphedema group and 13.4 ± 6.0 in control group. The groups were also similar in aspect of the HADS score (p > 0.05). FSFI and global health and physical function scores of EORTC QOL-C30 were statistically significantly lower in the lymphedema group (p < 0.05). A statistically significant correlation was found between FSFI and age and time elapsed postmenopause (p < 0.05, for both). Conclusion: We evaluated sexual functions of the patients who underwent mastectomy in this study. Although the HADS score is similar in patients with and without lymphedema, both sexual functions and quality of life are adversely affected in patients who undergo mastectomy and develop lymphedema. This study is important for investigating whether lymphedema developing after total mastectomy affects sexual functions of the patients.
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Affiliation(s)
- Cevriye Mülkoğlu
- Department of Physical Medicine and Rehabilitation, Health Sciences University Ankara Training and Research Hospital, Ankara, Turkey
| | - Figen Ayhan
- Physical Medicine and Rehabilitation, Medicana International Hospital, Ankara, Turkey
| | - Serap Erel
- Department of General Surgery, Health Sciences University Ankara Training and Research Hospital, Ankara, Turkey
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Erdinç Gündüz N, Dilek B, Şahin E, Ellidokuz H, Akalın E. Diagnostic Contribution of Ultrasonography in Breast Cancer-Related Lymphedema. Lymphat Res Biol 2021; 19:517-523. [PMID: 33601960 DOI: 10.1089/lrb.2020.0068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Background: Many assessments have been reported and used in evaluating lymphedema. The aim of this study was to investigate the diagnostic contribution of ultrasonography in unilateral breast cancer-related lymphedema. Methods and Results: Upper extremity circumferences were measured with a measuring tape from ulnar styloid at the wrist to the axilla at 4 cm intervals. The point with the highest difference between the upper extremities and the control point with no difference between the lower extremities were marked. Skin and subcutaneous thicknesses were measured from four quadrants (volar medial-lateral and dorsal medial-lateral) at the marked points and also subcutaneous tissue changes were graded according to the subcutaneous echogenicity grade (SEG) scale ultrasonographically. The correlations between circumferential and ultrasonographic measurements were investigated. Receiver operating characteristic curve analysis was made to estimate the diagnostic accuracy of the difference in ultrasonographic subcutaneous thickness measurements between the two arms. The study was completed with 34 female patients. Circumferential and subcutaneous tissue thickness measurements were moderately positively correlated in the volar quadrants and strongly positively correlated in the dorsal quadrants of the affected extremity. In the unaffected extremity, a strong positive correlation was identified in all quadrants. The clinical stages of lymphedema and SEG were weakly positively correlated in the volar medial quadrant. The difference between the two upper extremities was found to have a high (0.83%) sensitivity, and an acceptable (0.75%) specificity in the differentiation of Grade II and Grade III lymphedema. Conclusion: A correlation was established between circumferential measurements and ultrasonographic measurements. Ultrasonography can be used complementary to circumferential measurements in diagnosing lymphedema. Clinical trial registration number: NCT04213001.
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Affiliation(s)
- Nihan Erdinç Gündüz
- Department of Physical Medicine and Rehabilitation, Izmir Tepecik Training and Research Hospital, Health Science University, Izmir, Turkey
| | - Banu Dilek
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Ebru Şahin
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Hülya Ellidokuz
- Department of Biostatistics and Medical Informatics, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Elif Akalın
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
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Akezaki Y, Tominaga R, Kikuuchi M, Kurokawa H, Hamada M, Aogi K, Ohsumi S, Tsuji T, Kawamura S, Sugihara S. Risk Factors for Lymphedema in Breast Cancer Survivors Following Axillary Lymph Node Dissection. Prog Rehabil Med 2020; 4:20190021. [PMID: 32789268 DOI: 10.2490/prm.20190021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 11/14/2019] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Yoshiteru Akezaki
- Division of Physical Therapy, Kochi Professional University of Rehabilitation, Kochi, Japan
| | - Ritsuko Tominaga
- Department of Rehabilitation Medicine, National Hospital Organization Shikoku Cancer Center, Ehime, Japan
| | - Masato Kikuuchi
- Department of Rehabilitation Medicine, National Hospital Organization Shikoku Cancer Center, Ehime, Japan
| | - Hideaki Kurokawa
- Department of Rehabilitation Medicine, National Hospital Organization Shikoku Cancer Center, Ehime, Japan
| | - Makiko Hamada
- Department of Rehabilitation Medicine, National Hospital Organization Shikoku Cancer Center, Ehime, Japan
| | - Kenjiro Aogi
- Department of Breast Surgery, National Hospital Organization Shikoku Cancer Center, Ehime, Japan
| | - Shozo Ohsumi
- Department of Breast Surgery, National Hospital Organization Shikoku Cancer Center, Ehime, Japan
| | - Tetsuya Tsuji
- Department of Rehabilitation Medicine, Keio University Hospital, Tokyo, Japan
| | - Susumu Kawamura
- Department of Plastic and Reconstructive Surgery, National Hospital Organization Shikoku Cancer Center, Ehime, Japan
| | - Shinsuke Sugihara
- Department of Rehabilitation Medicine, National Hospital Organization Shikoku Cancer Center, Ehime, Japan.,Department of Orthopaedic Oncology, National Hospital Organization Shikoku Cancer Center, Ehime, Japan
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He L, Qu H, Wu Q, Song Y. Lymphedema in survivors of breast cancer. Oncol Lett 2020; 19:2085-2096. [PMID: 32194706 PMCID: PMC7039097 DOI: 10.3892/ol.2020.11307] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 11/07/2019] [Indexed: 12/16/2022] Open
Abstract
The tremendous improvement of survival in patients with breast cancer can be attributed to several treatment strategies, but these strategies also lead to the occurrence of breast cancer-related lymphedema (BCRL). BRCL is regularly associated with factors such as axillary lymph node dissection and local lymph node radiotherapy and manifests as an increase of >10% in the volume of affected limbs. Being overweight or having obesity (body mass index ≥25 kg/m2), an excessive number of positive lymph nodes (>8) and capsular invasion by a tumor are additional risk factors for lymphedema. It is worth assessing the risk before surgery as this can prevent the occurrence of BCRL at the initial stage of breast cancer management. The clinical utility of many diagnostic tools and lymphedema surveillance allows early stage and even subclinical BCRL to be diagnosed, and allows real-time monitoring of the disease. The early diagnosis of BRCL allows treatment at an early stage, which is beneficial to the reduction of excess limb volume and the improvement of quality of life. At present, the major therapeutic methods of BCRL include complex decongestive therapy, pneumatic compression devices, participating in exercise, microsurgery and liposuction, each of which alleviates lymphedema effectively. No medications for treatment of BRCL have yet been developed. However, the recent findings on the success of molecular therapy in animal models may remedy this deficiency. Furthermore, the volume reduction of swollen limbs without swelling rebound by transplanting autologous stem cells has been successfully reported in some pilot studies, which may provide a new technique for treating BCRL. This review aimed to discuss the pathogenesis, clinical manifestation, risk factors, advantages and disadvantages of diagnostic tools, lymphedema surveillance and the characteristics of traditional and newly emerging BCRL treatments.
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Affiliation(s)
- Lin He
- Breast Center B Ward, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266000, P.R. China
| | - Huili Qu
- Breast Center B Ward, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266000, P.R. China
| | - Qian Wu
- Breast Center B Ward, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266000, P.R. China
| | - Yuhua Song
- Breast Center B Ward, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266000, P.R. China
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Wu R, Huang X, Dong X, Zhang H, Zhuang L. Obese patients have higher risk of breast cancer-related lymphedema than overweight patients after breast cancer: a meta-analysis. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:172. [PMID: 31168453 DOI: 10.21037/atm.2019.03.44] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Increasing scientific evidences suggest that body weight is a risk factor for breast cancer-related lymphedema (LE) in breast cancer patients, but many existing studies have yielded inconclusive results. This meta-analysis aims to provide a more precise estimation of the effects of body mass index (BMI) on LE in breast cancer patients. Methods Two authors searched independently in the main English-language databases, including PubMed, Embase, and Cochrane Central Register of Controlled Trials, and the main Chinese databases, including China National Knowledge Infrastructure and WanFang Data from inception through June 1, 2018 in human. Odds ratios with 95% confidence interval were calculated to evaluate the effect of BMI on LE. Results Twelve studies were identified with a total of 8,039 breast cancer patients, including 2102 patients who were suffered from LE; therefore, the total incidence of LE was 26.15%.The meta-analysis results reveal that the odds ratios were 1.42 [95% confidence interval (CI), 1.20 to 1.68] for BMI 25-30 kg/m2 versus BMI <25 kg/m2 group, 1.39 (95% CI, 1.21 to 1.60) for BMI ≥30 kg/m2 versus BMI 25-30 kg/m2 group, and 1.84 (95% CI, 1.47 to 2.32) for BMI ≥30 kg/m2 versus BMI <25 kg/m2 group. Conclusions Our results will generate awareness of LE, especially obese patients should pay more attention to LE after breast cancer than overweight patients. Thus, it is necessary and meaningful to distinguish obese from overweight patients.
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Affiliation(s)
- Ruxing Wu
- Reproductive Medicine Center, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Xiaoyuan Huang
- Cancer Biology Research Centre, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Xiyuan Dong
- Reproductive Medicine Center, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Hanwang Zhang
- Reproductive Medicine Center, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Liang Zhuang
- Cancer Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
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Findings of lymphoscintigraphy and the severity of lymphedema according to the extent of axillary lymph node dissection. Asian J Surg 2019; 43:95-101. [PMID: 30857863 DOI: 10.1016/j.asjsur.2019.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 01/25/2019] [Accepted: 02/14/2019] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Lymphedema of the upper extremity is a common disease in breast cancer patients following breast cancer operation accompanied by lymphadenectomy. However, clinically, there is a discrepancy between the extent of axillary lymph node dissection (ALND) and the severity of lymphedema. Therefore, we investigated the relationship between the severity of lymphedema following breast cancer operation, including ALND, and axillary lymph node findings on lymphoscintigraphy. METHODS Eighty-two patients with lymphedema following breast cancer operation with ALND (82 women; mean age 55.57 ± 9.39, range 36-65) were retrospectively recruited. Lymphoscintigraphy was conducted after an average of 5.44 ± 2.01 months following operation. Percentage differences in the circumference of the upper extremities between affected and unaffected sides were used as a severity index. RESULTS Percentage differences in the circumference of the upper extremities in a positive and negative group in lymphoscintigraphy were 3.42 ± 2.47% and 12.87 ± 10.23% in the mid-arm respectively (p < 0.05), and 3.36 ± 3.80% and 12.83 ± 10.00% in the mid-forearm respectively (p < 0.05). However, the extent of lymph node dissection and the difference in the circumference of mid-arm and mid-forearm volume did not have a statistically significant relationship. CONCLUSION Lymph node activity in the proximal upper extremity is not related to the extent of ALND. The existence of a bypass connection and remainder function of a lymph node is crucial for the severity of lymphedema.
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Manirakiza A, Irakoze L, Shui L, Manirakiza S, Ngendahayo L. Lymphoedema After Breast Cancer Treatment is Associated With Higher Body Mass Index: A Systematic Review and Meta-Analysis. East Afr Health Res J 2019; 3:178-192. [PMID: 34308212 PMCID: PMC8279288 DOI: 10.24248/eahrj-d-19-00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 10/07/2019] [Indexed: 11/25/2022] Open
Abstract
Background: Excess body weight has been identified as an important risk factor for lymphoedema following breast cancer treatment, however it remains unclear how much risk increases as weight increases. We conducted a meta-analysis to assess the relationship between body mass index (BMI) and risk of lymphoedema in breast cancer patients, and to estimate the level of risk by BMI category. Methods: We conducted a systematic search of all articles published through May 2018 in PubMed and the Cochrane library. Studies that included data on BMI and lymphoedema in breast cancer patients were included in the meta-analysis. We compared risk of lymphoedema in BMI groups as: BMI<25 versus BMI≥25, BMI<25 versus BMI≥30, BMI≥25 to <30 versus BMI≥30, BMI<30 versus BMI≥30, BMI<25 versus BMI≥25 to BMI<30. Results: After exclusion of ineligible studies, 57 studies were included in the meta-analysis. The mean difference in BMI between patients with lymphoedema compared to those without lymphoedema was 1.7 (95% CI, 1.3–2.2). Compared to patients with a BMI<25, risk of lymphoedema was higher in those with a BMI >25 to <30 (odds ratio [OR] 1.3; 95% CI, 1.2 to 1.5), a BMI≥25 (OR 1.7; 95% CI, 1.5 to 1.9), or a BMI≥30 (OR 1.9; 95% CI, 1.6 to 2.4). Compared to patients with a BMI of >25 to <30, risk of lymphoedema was higher in patients with a BMI>30 (OR 1.5; 95% CI,1.4 to 1.8). Conclusion: Excess body weight is a risk factor for lymphoedema following treatment of breast cancer, with the magnitude of risk increasing across higher categories of BMI.
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Affiliation(s)
- Astère Manirakiza
- Department of Oncology, Karuzi Fiftieth Hospital, Karuzi, Burundi.,Department of Oncology, University Hospital Centre of Kamenge, Bujumbura, Burundi
| | - Laurent Irakoze
- Department of Endocrinology, First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Lin Shui
- Department of Oncology, West China Medical Center, Sichuan University, Chengdu, China
| | - Sébastien Manirakiza
- Faculty of Medicine, University of Burundi, Bujumbura, Burundi.,Department of Radiology, University Hospital Centre of Kamenge, Bujumbura, Burundi
| | - Louis Ngendahayo
- Faculty of Medicine, University of Burundi, Bujumbura, Burundi.,Department of Pathology, University Hospital Centre of Kamenge, Bujumbura, Burundi
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Tsai RJ, Dennis LK, Lynch CF, Snetselaar LG, Zamba GKD, Scott-Conner C. Lymphedema following breast cancer: The importance of surgical methods and obesity. ACTA ACUST UNITED AC 2018; 3. [PMID: 30555923 DOI: 10.15761/fwh.1000144] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background Breast cancer-related arm lymphedema is a serious complication that can adversely affect quality of life. Identifying risk factors that contribute to the development of lymphedema is vital for identifying avenues for prevention. The aim of this study was to examine the association between the development of arm lymphedema and both treatment and personal (e.g., obesity) risk factors. Methods Women diagnosed with breast cancer in Iowa during 2004 and followed through 2010, who met eligibility criteria, were asked to complete a short computer assisted telephone interview about chronic conditions, arm activities, demographics, and lymphedema status. Lymphedema was characterized by a reported physician-diagnosis, a difference between arms in the circumference (> 2cm), or the presence of multiple self-reported arm symptoms (at least two of five major arm symptoms, and at least four total arm symptoms). Relative risks (RR) were estimated using logistic regression. Results Arm lymphedema was identified in 102 of 522 participants (19.5%). Participants treated by both axillary dissection and radiation therapy were more likely to have arm lymphedema than treated by either alone. Women with advanced cancer stage, positive nodes, and larger tumors along with a body mass index > 40 were also more likely to develop lymphedema. Arm activity level was not associated with lymphedema. Conclusions Surgical methods, cancer characteristics and obesity were found to contribute to the development of arm lymphedema. Vigorous arm activity post-surgery was not found to increase the risk of arm lymphedema.
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Affiliation(s)
- Rebecca J Tsai
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Leslie K Dennis
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA.,Division of Epidemiology and Biostatistics, College of Public Health, University of Arizona, Tucson, AZ, USA
| | - Charles F Lynch
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Linda G Snetselaar
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Gideon K D Zamba
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Carol Scott-Conner
- Department of Surgery, College of Medicine, University of Iowa, Iowa City, IA, USA
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The incidence and risk factors of related lymphedema for breast cancer survivors post-operation: a 2-year follow-up prospective cohort study. Breast Cancer 2018; 25:309-314. [DOI: 10.1007/s12282-018-0830-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 01/03/2018] [Indexed: 02/01/2023]
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Roman MM, Barbieux R, Leduc O, Bourgeois P. Lymphatic Drainage to the Paravertebral Lymph Nodes in Breast Cancer Patients. Lymphat Res Biol 2017; 15:99-106. [PMID: 28323571 DOI: 10.1089/lrb.2016.0037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Aberrant, altered, or blocked lymphatic drainage may contribute to the high recurrence rate of breast cancer. Thus, an efficient evaluation of lymphatic drainage from the breasts and/or upper limbs is essential in the management of lymphedema and in ipsilateral primary or contralateral recurrent breast cancer patients. There are very few reports of lymphatic drainage to the paravertebral lymph nodes in patients with a lymphedema after breast cancer surgery with or without reconstruction. METHODS We used lymphoscintigraphy to examine lymphatic drainage in a case series. RESULTS We observed five patients with upper limb and/or mammary lymphedema (after breast cancer surgery with or without reconstruction) who had lymphatic drainage from the upper limb or breast to the posterior intercostal and/or paravertebral lymph nodes. One patient also presented with nodal relapse at the time of our investigation. CONCLUSIONS The cases from this study demonstrate the unusual, and mostly unrecognized, lymphatic drainage pathways toward lymph nodes, which may be at risk for further evolution of breast cancer.
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Affiliation(s)
- Mirela Mariana Roman
- 1 Department of Mammo-Pelvic Surgery, Jules Bordet Institute , Brussels, Belgium .,2 Multi-disciplinary Clinic of Lymphology, Jules Bordet Institute , Brussels, Belgium
| | - Romain Barbieux
- 2 Multi-disciplinary Clinic of Lymphology, Jules Bordet Institute , Brussels, Belgium .,3 Service of Kinesitherapy, Jules Bordet Institute , Brussels, Belgium .,4 Service of Nuclear Medicine, Jules Bordet Institute , Brussels, Belgium
| | - Olivier Leduc
- 2 Multi-disciplinary Clinic of Lymphology, Jules Bordet Institute , Brussels, Belgium .,5 HE PHSpaak , Brussels, Belgium
| | - Pierre Bourgeois
- 2 Multi-disciplinary Clinic of Lymphology, Jules Bordet Institute , Brussels, Belgium .,4 Service of Nuclear Medicine, Jules Bordet Institute , Brussels, Belgium
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Three-dimensional stereophotogrammetry as an accurate tool for analyzing lymphedema of the hand. JPRAS Open 2016. [DOI: 10.1016/j.jpra.2016.07.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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Dieli-Conwright CM, Orozco BZ. Exercise after breast cancer treatment: current perspectives. BREAST CANCER-TARGETS AND THERAPY 2015; 7:353-62. [PMID: 26543382 PMCID: PMC4622557 DOI: 10.2147/bctt.s82039] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Over the past 2 decades, great strides have been made in the field of exercise-oncology research, particularly with breast cancer. This area of research is particularly important since there are >2.8 million breast cancer survivors who are in need of an intervention that can offset treatment-related side effects. Noticeable reductions in physical fitness (ie, cardiopulmonary fitness and muscular strength), negative changes in body composition (ie, increase in body mass, decrease in lean body mass, and increase in fat mass), increased fatigue, depression, or anxiety are some of the common side effects of cancer treatments that negatively impact overall quality of life and increase the risk for the development of comorbidities. Exercise plays a vital role in improving cardiopulmonary function, psychological events, muscular strength, and endurance in breast cancer survivors, and thus should be considered as a key factor of lifestyle intervention to reverse negative treatment-related side effects. The purpose of this review is to address current perspectives on the benefits of aerobic and resistance exercise after breast cancer treatments. This review is focused on the well-established benefits of exercise on physical and emotional well-being, bone health, lymphedema management, and the postulated benefits of exercise on risk reduction for recurrence of breast cancer.
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Affiliation(s)
- Christina M Dieli-Conwright
- Division of Biokinesiology and Physical Therapy, Women's Health and Exercise Laboratory, University of Southern California, Los Angeles, CA, USA
| | - Breanna Z Orozco
- Division of Biokinesiology and Physical Therapy, Women's Health and Exercise Laboratory, University of Southern California, Los Angeles, CA, USA
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Zhu YQ, Xie YH, Liu FH, Guo Q, Shen PP, Tian Y. Systemic analysis on risk factors for breast cancer related lymphedema. Asian Pac J Cancer Prev 2015; 15:6535-41. [PMID: 25169483 DOI: 10.7314/apjcp.2014.15.16.6535] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To evaluate risk factors for upper extremity lymphedema due to breast cancer surgery. MATERIALS AND METHODS Clinical studies published on PubMed, Ovid, EMbase, and Cochrane Library from January 1996 to December 2012 were selected. RESULTS Twenty-five studies were identified, including 12,104 patients. Six risk factors related to the incidence of lymphedema after breast cancer treatment were detected: axillary lymph node dissection (OR=3.73, 95%CI 1.16 to 11.96), postoperative complications (OR=2.64, 95%CI 1.10 to 6.30), hypertension (OR=1.83, 95%CI 1.38 to 2.42), high body mass index (OR=1.80, 95%CI 1.30 to 2.49), chemotherapy (OR=1.38, 95%CI 1.07 to 1.79) and radiotherapy (OR=1.35, 95%CI 1.10 to 1.66). We found significant protective factors for lymphedema: pathologic T classification (OR=0.57, 95%CI 0.36 to 0.91) and stage (OR=0.60, 95%CI 0.39 to 0.93), while some factors, like age, number of positive lymph nodes, number of lymph node dissection, demonstrated no obvious correlation. CONCLUSIONS Axillary lymph node dissection, postoperative complications, hypertension, body mass index, chemotherapy, radiotherapy are risk factors for lymphedema after breast cancer treatment. Attention should be paid to patients with risk factors to prevent the occurrence of lymphedema.
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Affiliation(s)
- Ya-Qun Zhu
- Department of Radiotherapy and Oncology, The Second Affiliated Hospital of Soochow University, Suzhou, China * E-mail :
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Ezzo J, Manheimer E, McNeely ML, Howell DM, Weiss R, Johansson KI, Bao T, Bily L, Tuppo CM, Williams AF, Karadibak D. Manual lymphatic drainage for lymphedema following breast cancer treatment. Cochrane Database Syst Rev 2015; 2015:CD003475. [PMID: 25994425 PMCID: PMC4966288 DOI: 10.1002/14651858.cd003475.pub2] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND More than one in five patients who undergo treatment for breast cancer will develop breast cancer-related lymphedema (BCRL). BCRL can occur as a result of breast cancer surgery and/or radiation therapy. BCRL can negatively impact comfort, function, and quality of life (QoL). Manual lymphatic drainage (MLD), a type of hands-on therapy, is frequently used for BCRL and often as part of complex decongestive therapy (CDT). CDT is a fourfold conservative treatment which includes MLD, compression therapy (consisting of compression bandages, compression sleeves, or other types of compression garments), skin care, and lymph-reducing exercises (LREs). Phase 1 of CDT is to reduce swelling; Phase 2 is to maintain the reduced swelling. OBJECTIVES To assess the efficacy and safety of MLD in treating BCRL. SEARCH METHODS We searched Medline, EMBASE, CENTRAL, WHO ICTRP (World Health Organization's International Clinical Trial Registry Platform), and Cochrane Breast Cancer Group's Specialised Register from root to 24 May 2013. No language restrictions were applied. SELECTION CRITERIA We included randomized controlled trials (RCTs) or quasi-RCTs of women with BCRL. The intervention was MLD. The primary outcomes were (1) volumetric changes, (2) adverse events. Secondary outcomes were (1) function, (2) subjective sensations, (3) QoL, (4) cost of care. DATA COLLECTION AND ANALYSIS We collected data on three volumetric outcomes. (1) LE (lymphedema) volume was defined as the amount of excess fluid left in the arm after treatment, calculated as volume in mL of affected arm post-treatment minus unaffected arm post-treatment. (2) Volume reduction was defined as the amount of fluid reduction in mL from before to after treatment calculated as the pretreatment LE volume of the affected arm minus the post-treatment LE volume of the affected arm. (3) Per cent reduction was defined as the proportion of fluid reduced relative to the baseline excess volume, calculated as volume reduction divided by baseline LE volume multiplied by 100. We entered trial data into Review Manger 5.2 (RevMan), pooled data using a fixed-effect model, and analyzed continuous data as mean differences (MDs) with 95% confidence intervals (CIs). We also explored subgroups to determine whether mild BCRL compared to moderate or severe BCRL, and BCRL less than a year compared to more than a year was associated with a better response to MLD. MAIN RESULTS Six trials were included. Based on similar designs, trials clustered in three categories.(1) MLD + standard physiotherapy versus standard physiotherapy (one trial) showed significant improvements in both groups from baseline but no significant between-groups differences for per cent reduction.(2) MLD + compression bandaging versus compression bandaging (two trials) showed significant per cent reductions of 30% to 38.6% for compression bandaging alone, and an additional 7.11% reduction for MLD (MD 7.11%, 95% CI 1.75% to 12.47%; two RCTs; 83 participants). Volume reduction was borderline significant (P = 0.06). LE volume was not significant. Subgroup analyses was significant showing that participants with mild-to-moderate BCRL were better responders to MLD than were moderate-to-severe participants.(3) MLD + compression therapy versus nonMLD treatment + compression therapy (three trials) were too varied to pool. One of the trials compared compression sleeve plus MLD to compression sleeve plus pneumatic pump. Volume reduction was statistically significant favoring MLD (MD 47.00 mL, 95% CI 15.25 mL to 78.75 mL; 1 RCT; 24 participants), per cent reduction was borderline significant (P=0.07), and LE volume was not significant. A second trial compared compression sleeve plus MLD to compression sleeve plus self-administered simple lymphatic drainage (SLD), and was significant for MLD for LE volume (MD -230.00 mL, 95% CI -450.84 mL to -9.16 mL; 1 RCT; 31 participants) but not for volume reduction or per cent reduction. A third trial of MLD + compression bandaging versus SLD + compression bandaging was not significant (P = 0.10) for per cent reduction, the only outcome measured (MD 11.80%, 95% CI -2.47% to 26.07%, 28 participants).MLD was well tolerated and safe in all trials.Two trials measured function as range of motion with conflicting results. One trial reported significant within-groups gains for both groups, but no between-groups differences. The other trial reported there were no significant within-groups gains and did not report between-groups results. One trial measured strength and reported no significant changes in either group.Two trials measured QoL, but results were not usable because one trial did not report any results, and the other trial did not report between-groups results.Four trials measured sensations such as pain and heaviness. Overall, the sensations were significantly reduced in both groups over baseline, but with no between-groups differences. No trials reported cost of care.Trials were small ranging from 24 to 45 participants. Most trials appeared to randomize participants adequately. However, in four trials the person measuring the swelling knew what treatment the participants were receiving, and this could have biased results. AUTHORS' CONCLUSIONS MLD is safe and may offer additional benefit to compression bandaging for swelling reduction. Compared to individuals with moderate-to-severe BCRL, those with mild-to-moderate BCRL may be the ones who benefit from adding MLD to an intensive course of treatment with compression bandaging. This finding, however, needs to be confirmed by randomized data.In trials where MLD and sleeve were compared with a nonMLD treatment and sleeve, volumetric outcomes were inconsistent within the same trial. Research is needed to identify the most clinically meaningful volumetric measurement, to incorporate newer technologies in LE assessment, and to assess other clinically relevant outcomes such as fibrotic tissue formation.Findings were contradictory for function (range of motion), and inconclusive for quality of life.For symptoms such as pain and heaviness, 60% to 80% of participants reported feeling better regardless of which treatment they received.One-year follow-up suggests that once swelling had been reduced, participants were likely to keep their swelling down if they continued to use a custom-made sleeve.
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Affiliation(s)
- Jeanette Ezzo
- JME EnterprisesResearch Director1905 West Rogers AveBaltimoreMarylandUSA21209
| | - Eric Manheimer
- University of Maryland School of MedicineCenter for Integrative Medicine520 W. Lombard StRoom 101DBaltimoreMarylandUSA21201
| | - Margaret L McNeely
- University of AlbertaDepartment of Physical Therapy/ Department of Oncology2‐50, Corbett HallEdmontonABCanadaT6G 2G4
| | - Doris M Howell
- University Health Network (PMH site)Nursing610 University AveRoom 15‐617TorontoONCanadaM5G 2M9
| | - Robert Weiss
- 10671 Baton Rouge AvenuePorter RanchCaliforniaUSA91326
| | - Karin I Johansson
- Skane University HospitalLymphoedema Unit, Department of OncologyLundSweden22185
| | - Ting Bao
- Memorial Sloan Kettering Cancer CentreIntegrative Medicine and Breast Cancer Services1429 First AvenueNew YorkNew YorkUSA10021
| | - Linda Bily
- Stony Brook Medicine133 Boyle Rd.SeldenNew YorkNew YorkUSA11784
| | - Catherine M Tuppo
- Stony Brook MedicineBariatric and Metabolic Weight Loss Center101 Nicolls RoadStony BrookNew YorkUSA11794
| | | | - Didem Karadibak
- Dokuz Eylul UniversitySchool of Physical Therapy and RehabilitationIzmirTurkey9035340
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Treatment-related risk factors for arm lymphedema among long-term breast cancer survivors. J Cancer Surviv 2015; 9:422-30. [PMID: 25913877 DOI: 10.1007/s11764-014-0416-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Accepted: 11/19/2014] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Treatment-related factors may increase the risk for arm lymphedema, which may occur after surgery or even many years after initial treatment for breast cancer. The association between treatment-related risk factors and development of arm lymphedema was examined for women who participated in the long-term quality of life (LTQOL) study, a 12-15-year follow-up of a breast cancer case-control study of Hispanic and non-Hispanic white women. METHODS Among 199 cases, 43 women (15 Hispanic, 28 non-Hispanic white) reported physician-diagnosed lymphedema during follow-up. Multivariable logistic regression analysis was used to calculate the odds ratios (OR) and 95% confidence intervals (CI) for the association of risk factors with lymphedema, adjusting for relevant covariates. RESULTS Tamoxifen had a non-significant, positive association with lymphedema (OR = 2.07, 95% CI 0.94-4.55, p =0.07). There were no significant associations with type of surgery, radiation, or chemotherapy. Risk was increased specifically in overweight and obese women (body mass index (BMI) > =25 kg/m(2)) treated with tamoxifen (OR = 2.62, 95% CI 0.99-6.93, p = 0.05). CONCLUSIONS This study suggests that breast cancer survivors with a BMI >25 who report the use of tamoxifen therapy may be at increased risk for arm lymphedema. IMPLICATIONS FOR CANCER SURVIVORS Larger case-control studies and clinical trials should investigate the long-term association of tamoxifen treatment with arm lymphedema especially in overweight and obese women. Lymphedema risk may be another indication to consider a weight reduction program in breast cancer survivors.
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Atalay OT, Özkir A, Çalik BB, Baskan E, Taşkin H. Effects of phase I complex decongestive physiotherapy on physical functions and depression levels in breast cancer related lymph edema. J Phys Ther Sci 2015; 27:865-70. [PMID: 25931748 PMCID: PMC4395732 DOI: 10.1589/jpts.27.865] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 11/07/2014] [Indexed: 11/24/2022] Open
Abstract
[Purpose] Breast cancer-related upper extremity lymph edema is known to cause physical, functional and psychological impairments in women after modified radical mastectomy. The aim of this study was to investigate the effects of phase I Complex Decongestive Physiotherapy (CDP) on physical functions and depression levels in women with breast cancer-related upper extremity lymph edema. [Subjects and Methods] Fifty-eight subjects with breast cancer-related upper extremity lymph edema were the subjects of this study. The arm circumference, shoulder range of motion (ROM), muscle strength and depression levels of the subjects were assessed before and after phase I CDP treatment. [Results] After phase I CDP, there was a statistically significant reduction in circumference measurements at all levels of the affected arm. There was not any statistically significant difference in muscle strength after CDP. The shoulder ROM improved after treatment. There was a significant reduction in the Beck Depression Inventory score. A significant positive correlation was found between depression levels and circumference measurement. [Conclusion] Based on the results we suggest that by reducing limb volume, beside improving physical functions, phase I CDP can affect psychological status, especially depression which is very common in women with breast cancer-related upper extremity lymph edema.
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Affiliation(s)
- Orçin Telli Atalay
- Department of Physiotherapy and Rehabilitation, School of
Physical Therapy and Rehabilitation, Pamukkale University, Turkey
| | - Anıl Özkir
- Department of Physiotherapy and Rehabilitation, Institute
of Health Sciences, Pamukkale University, Turkey
| | - Bilge Başakçi Çalik
- Department of Orthopedical Rehabilitation, School of
Physical Therapy and Rehabilitation, Pamukkale University, Turkey
| | - Emre Baskan
- Department of Neurological Rehabilitation, School of
Physical Therapy and Rehabilitation, Pamukkale University, Turkey
| | - Harun Taşkin
- Department of Physiotherapy and Rehabilitation, School of
Physical Therapy and Rehabilitation, Pamukkale University, Turkey
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Togawa K, Ma H, Sullivan-Halley J, Neuhouser ML, Imayama I, Baumgartner KB, Smith AW, Alfano CM, McTiernan A, Ballard-Barbash R, Bernstein L. Risk factors for self-reported arm lymphedema among female breast cancer survivors: a prospective cohort study. Breast Cancer Res 2014; 16:414. [PMID: 25145603 PMCID: PMC4189147 DOI: 10.1186/s13058-014-0414-x] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2014] [Accepted: 07/17/2014] [Indexed: 01/29/2023] Open
Abstract
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.
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Liu JB, Merton DA, Berger AC, Forsberg F, Witkiewicz A, Zhao H, Eisenbrey JR, Fox TB, Goldberg BB. Contrast-enhanced sonography for detection of secondary lymph nodes in a melanoma tumor animal model. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2014; 33:939-47. [PMID: 24866601 PMCID: PMC4404634 DOI: 10.7863/ultra.33.6.939] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
OBJECTIVES To investigate the use of contrast-enhanced ultrasound imaging (US) for detection of secondary lymph nodes (LNs) in a naturally occurring melanoma swine model compared to surgery and pathologic assessment. METHODS Twenty-seven Sinclair swine were studied. The perfluorobutane microbubble contrast agent Sonazoid (GE Healthcare, Oslo, Norway) was administered (1.0 mL total dose) around the melanoma, and contrast-enhanced US was used to localize contrast-enhanced sentinel lymph nodes (SLNs). Then Sonazoid (dose, 0.25-1.0 mL) was injected into the SLNs to detect contrast-enhanced efferent lymphatic channels and secondary LNs. After peritumoral injection of blue dye, a surgeon (blinded to the contrast-enhanced US results) performed a radical LN dissection. Contrast-enhanced US was used to guide removal of any enhanced secondary LNs left after radical LN dissection. Clustered conditional logistic regression analyzed the benefit of contrast-enhanced US-directed secondary LN dissection over radical LN dissection using pathologic findings as the reference standard. RESULTS A total of 268 secondary LNs were resected, with 59 (22%) containing metastases. Contrast-enhanced US detected 92 secondary LNs; 248 were identified by radical LN dissection; and 68 were identified by both methods. Metastases were detected in 20% (51 of 248) and 40% (37 of 92) of the secondary LNs identified by radical LN dissection and contrast-enhanced US, respectively. Thus, secondary LNs detected by contrast-enhanced US were nearly 5 times more likely to contain metastases than secondary LNs removed by radical LN dissection (odds ratio, 4.8; P < .0001). Twenty-two of the 180 secondary LNs (12%) identified only by radical LN dissection contained metastases, whereas contrast-enhanced US identified 20 secondary LNs after the surgeon completed the radical LN dissection, of which 8 (40%) contained metastases. CONCLUSIONS Secondary LNs can be detected by using contrast-enhanced US after injection of Sonazoid into SLNs. Secondary LNs detected with contrast-enhanced US are significantly more likely to contain metastases than those removed by radical LN dissection.
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Affiliation(s)
- Ji-Bin Liu
- Departments of Radiology (J.B.L., D.A.M., F.F., H.Z., J.R.E., T.B.F., B.B.G.), Surgery (A.C.B.), and Pathology (A.W.), Thomas Jefferson University, Philadelphia, Pennsylvania USA. Dr Witkiewicz is currently with the Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas USA; Dr Zhao is currently with the Department of Ultrasound, Second People's Hospital of Fujian, Fuzhou, Fujian, China.
| | - Daniel A Merton
- Departments of Radiology (J.B.L., D.A.M., F.F., H.Z., J.R.E., T.B.F., B.B.G.), Surgery (A.C.B.), and Pathology (A.W.), Thomas Jefferson University, Philadelphia, Pennsylvania USA. Dr Witkiewicz is currently with the Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas USA; Dr Zhao is currently with the Department of Ultrasound, Second People's Hospital of Fujian, Fuzhou, Fujian, China
| | - Adam C Berger
- Departments of Radiology (J.B.L., D.A.M., F.F., H.Z., J.R.E., T.B.F., B.B.G.), Surgery (A.C.B.), and Pathology (A.W.), Thomas Jefferson University, Philadelphia, Pennsylvania USA. Dr Witkiewicz is currently with the Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas USA; Dr Zhao is currently with the Department of Ultrasound, Second People's Hospital of Fujian, Fuzhou, Fujian, China
| | - Flemming Forsberg
- Departments of Radiology (J.B.L., D.A.M., F.F., H.Z., J.R.E., T.B.F., B.B.G.), Surgery (A.C.B.), and Pathology (A.W.), Thomas Jefferson University, Philadelphia, Pennsylvania USA. Dr Witkiewicz is currently with the Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas USA; Dr Zhao is currently with the Department of Ultrasound, Second People's Hospital of Fujian, Fuzhou, Fujian, China
| | - Agnieszka Witkiewicz
- Departments of Radiology (J.B.L., D.A.M., F.F., H.Z., J.R.E., T.B.F., B.B.G.), Surgery (A.C.B.), and Pathology (A.W.), Thomas Jefferson University, Philadelphia, Pennsylvania USA. Dr Witkiewicz is currently with the Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas USA; Dr Zhao is currently with the Department of Ultrasound, Second People's Hospital of Fujian, Fuzhou, Fujian, China
| | - Hongjia Zhao
- Departments of Radiology (J.B.L., D.A.M., F.F., H.Z., J.R.E., T.B.F., B.B.G.), Surgery (A.C.B.), and Pathology (A.W.), Thomas Jefferson University, Philadelphia, Pennsylvania USA. Dr Witkiewicz is currently with the Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas USA; Dr Zhao is currently with the Department of Ultrasound, Second People's Hospital of Fujian, Fuzhou, Fujian, China
| | - John R Eisenbrey
- Departments of Radiology (J.B.L., D.A.M., F.F., H.Z., J.R.E., T.B.F., B.B.G.), Surgery (A.C.B.), and Pathology (A.W.), Thomas Jefferson University, Philadelphia, Pennsylvania USA. Dr Witkiewicz is currently with the Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas USA; Dr Zhao is currently with the Department of Ultrasound, Second People's Hospital of Fujian, Fuzhou, Fujian, China
| | - Traci B Fox
- Departments of Radiology (J.B.L., D.A.M., F.F., H.Z., J.R.E., T.B.F., B.B.G.), Surgery (A.C.B.), and Pathology (A.W.), Thomas Jefferson University, Philadelphia, Pennsylvania USA. Dr Witkiewicz is currently with the Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas USA; Dr Zhao is currently with the Department of Ultrasound, Second People's Hospital of Fujian, Fuzhou, Fujian, China
| | - Barry B Goldberg
- Departments of Radiology (J.B.L., D.A.M., F.F., H.Z., J.R.E., T.B.F., B.B.G.), Surgery (A.C.B.), and Pathology (A.W.), Thomas Jefferson University, Philadelphia, Pennsylvania USA. Dr Witkiewicz is currently with the Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas USA; Dr Zhao is currently with the Department of Ultrasound, Second People's Hospital of Fujian, Fuzhou, Fujian, China
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Soyder A, Taştaban E, Özbaş S, Boylu Ş, Özgün H. Frequency of Early-Stage Lymphedema and Risk Factors in Postoperative Patients with Breast Cancer. THE JOURNAL OF BREAST HEALTH 2014; 10:92-97. [PMID: 28331651 DOI: 10.5152/tjbh.2014.1973] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 01/27/2014] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Aykut Soyder
- Department of General Surgery, Adnan Menderes University Faculty of Medicine, Aydın, Turkey
| | - Engin Taştaban
- Department of Physical Therapy and Rehabilitation, Adnan Menderes University Faculty of Medicine, Aydın, Turkey
| | - Serdar Özbaş
- Department of General Surgery, Güven Hospital, Ankara, Turkey
| | - Şükrü Boylu
- Department of General Surgery, Adnan Menderes University Faculty of Medicine, Aydın, Turkey
| | - Hedef Özgün
- Department of General Surgery, Adnan Menderes University Faculty of Medicine, Aydın, Turkey
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Sayko O, Pezzin LE, Yen TWF, Nattinger AB. Diagnosis and treatment of lymphedema after breast cancer: a population-based study. PM R 2013; 5:915-23. [PMID: 23684778 DOI: 10.1016/j.pmrj.2013.05.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 04/30/2013] [Accepted: 05/03/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine factors associated with variations in diagnosis and rehabilitation treatments received by women with self-reported lymphedema resulting from breast cancer care. DESIGN A large, population-based, prospective longitudinal telephone survey. SETTING California, Florida, Illinois, and New York. PARTICIPANTS Elderly (65+ years) women identified from Medicare claims as having had an incident breast cancer surgery in 2003. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Self-reported incidence of lymphedema symptoms, formal diagnosis of lymphedema, treatments for lymphedema. RESULTS Of the 450 breast cancer survivors with lymphedema who participated in the study, 290 (64.4%) were formally diagnosed with the condition by a physician. An additional 160 (35.6%) reported symptoms consistent with lymphedema (ie, arm swelling on the side of surgery that is absent on the contralateral arm) but were not formally diagnosed. Of those who reported being diagnosed by a physician, 39 (13.4%) received complete decongestive therapy that included multiple components of treatment (ie, manual lymphatic drainage, bandaging with short stretch bandages, the use of compression sleeves, skin care, and remedial exercises); 24 (8.3%) were treated with manual lymphatic drainage only; 162 (55.9%) used bandages, compression garments, or a pneumatic pump only; 8 (2.8%) relied solely on skin care or exercise to relieve symptoms; and 65 (22.4%) received no treatment at all. Multivariate regressions revealed that race (African American), lower income, and lower levels of social support increased a woman's probability of having undiagnosed lymphedema. Even when they were formally diagnosed, African American women were more likely to receive no treatment or to be treated with bandages/compression only rather than to receive the multimodality, complete decongestive therapy. CONCLUSIONS Lymphedema is a disabling chronic condition related to breast cancer treatment. Our results suggest that a substantial proportion of persons reporting symptoms were not formally diagnosed with the condition, thereby reducing their opportunity for treatment. The variation in rehabilitation treatments received by women who were formally diagnosed with the condition by a physician suggests that lymphedema might not have been optimally addressed in many cases despite the availability of effective interventions.
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Affiliation(s)
- Oksana Sayko
- Department of Physical Medicine and Rehabilitation, Medical College of Wisconsin, Milwaukee, WI(∗)
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DiSipio T, Rye S, Newman B, Hayes S. Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis. Lancet Oncol 2013; 14:500-15. [PMID: 23540561 DOI: 10.1016/s1470-2045(13)70076-7] [Citation(s) in RCA: 1039] [Impact Index Per Article: 94.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Tracey DiSipio
- School of Public Health and Social Work, Institute of Health and Biomedical Innovation, Queensland University of Technology, Queensland, Australia.
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Paskett ED, Dean JA, Oliveri JM, Harrop JP. Cancer-Related Lymphedema Risk Factors, Diagnosis, Treatment, and Impact: A Review. J Clin Oncol 2012; 30:3726-33. [PMID: 23008299 DOI: 10.1200/jco.2012.41.8574] [Citation(s) in RCA: 160] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
PurposeCancer-related lymphedema (LE) is an incurable condition associated with lymph-involved cancer treatments and is an increasing health, quality of life (QOL), and cost burden on a growing cancer survivor population. This review examines the evidence for causes, risk, prevention, diagnosis, treatment, and impact of this largely unexamined survivorship concern.MethodsPubMed and Medline were searched for cancer-related LE literature published since 1990 in English. The resulting references (N = 726) were evaluated for strength of design, methods, sample size, and recent publication and sorted into categories (ie, causes/prevention, diagnosis, treatment, and QOL). Sixty studies were included.ResultsExercise and physical activity and sentinel lymph node biopsy reduce risk, and overweight and obesity increase risk. Evidence that physiotherapy reduces risk and that lymph node status and number of malignant nodes increase risk is less strong. Perometry and bioimpedence emerged as attractive diagnostic technologies, replacing the use of water displacement in clinical practice. Swelling can also be assessed by measuring arm circumference and relying on self-report. Symptoms can be managed, not cured, with complex physical therapy, low-level laser therapy, pharmacotherapy, and surgery. Sequelae of LE negatively affect physical and mental QOL and range in severity. However, the majority of reviewed studies involved patients with breast cancer; therefore, results may not be applicable to all cancers.ConclusionResearch into causes, prevention, and effect on QOL of LE and information on LE in cancers other than breast is needed. Consensus on definitions and measurement, increased patient and provider awareness of signs and symptoms, and proper and prompt treatment/access, including psychosocial support, are needed to better understand, prevent, and treat LE.
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Affiliation(s)
| | - Julie A. Dean
- All authors: The Ohio State University, Columbus, OH
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Effects of Lymphedema on Shoulder Kinematics and Function in Survivors of Breast Cancer: An Observational Study. REHABILITATION ONCOLOGY 2012. [DOI: 10.1097/01893697-201230030-00002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ahmed RL, Schmitz KH, Prizment AE, Folsom AR. Risk factors for lymphedema in breast cancer survivors, the Iowa Women's Health Study. Breast Cancer Res Treat 2011; 130:981-91. [PMID: 21761159 PMCID: PMC4091732 DOI: 10.1007/s10549-011-1667-z] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Accepted: 06/29/2011] [Indexed: 02/08/2023]
Abstract
Risk factors for lymphedema and related arm symptoms in breast cancer (BC) survivors have not been examined using a large prospective population-based cohort. The Iowa Women's Health Study (IWHS) collected self-reported data for diagnosed lymphedema in 2004, and data for cancer diagnosis, treatment, behavioral and health characteristics between 1986 and 2003. We studied 1,287 women, aged 55-69 at baseline, who developed unilateral BC: n = 104 (8%) with diagnosed lymphedema, n = 475 (37%) with arm symptoms but without diagnosed lymphedema, and n = 708 without lymphedema. Age- and multivariate-adjusted logistic regression models examined risk factors for lymphedema and related arm symptoms (OR [95% confidence interval]). The mean time between BC and the 2004 survey was 8.1 ± 5.0 (mean ± SD) years. After multivariate adjustment, the following cancer characteristics were positively associated with lymphedema: tumor stage (regional vs. in situ: 3.92 [1.61-9.54]), number of excised nodes (highest vs. lowest quintile: 3.52 [1.32-9.34], P (trend) = 0.003), tumor-positive nodes (yes vs. no 2.12 [1.19, 3.79]), and adjuvant chemotherapy (yes vs. no: 3.05 [1.75-5.30]). Several health characteristics were positively associated with lymphedema: baseline body mass index (highest vs. lowest tertile: 3.24 [1.70-6.21]), waist and hip circumference, and general health (fair/poor vs. excellent: 3.44 [1.30-9.06]). Positive associations with arm symptoms were number of excised nodes (highest vs. lowest quintile: 2.38 [1.41-4.03], P (trend) = 0.007), axillary radiation (yes vs. no: 1.72 [1.15-2.57]), and baseline general health (fair/poor vs. excellent: 4.27 [2.60-7.00]). In the IWHS, obesity, poorer general health, and markers of more advanced cancer were risk factors for lymphedema and related arm symptoms in BC survivors.
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Affiliation(s)
- Rehana L Ahmed
- Department of Dermatology, University of Minnesota, Mayo Mail Code 98, 420 Delaware Street SE, Minneapolis, MN 55455-0392, USA.
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Abstract
OBJECTIVES Lymphedema is a common complication of breast cancer surgery, leading to a decreased quality of life. The risk and severity of lymphedema were associated with surgery side upper extremity infection, ≥25 kg/m(2) body mass index (BMI), and the level of hand use (LHU). Our aim was to estimate the probability of lymphedema after breast cancer surgery by using previously published incidence rates and these 3 risk factors. METHODS The design was a n:m matched case control study; data were analyzed on 51 patients with lymphedema and 126 available controls matched on age, radiation therapy, and operation type. In conjunction with published estimates of lymphedema, incidence rates, and estimates of the proportions of risk factor combinations in cases and controls, the Bayes' theorem was used to estimate the probability of developing lymphedema. RESULTS Lymphedema probabilities of 7 combinations for 6 different published calculations were used. With the assumption of 16% LE incidence rate of lymphedema, a BMI<25, no infection, and a low LHU, the estimated probability of lymphedema was 6.8%. With the assumption of 46.3% LE incidence a BMI ≥25, infection, and a high LHU led to an estimated lymphedema probability of 93.7%. CONCLUSIONS This study shows that control of predisposing factors in both high and low incidence rates has a marked effect on the probability of LE development. In other words, patients with low incidence for LE are more prone to develop LE if the predisposing factors are controlled poorly compared to the high incidence patients whom the predisposing factors are avoided.
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Felmerer G, Sattler T, Lohrmann C, Tobbia D. Treatment of various secondary lymphedemas by microsurgical lymph vessel transplantation. Microsurgery 2011; 32:171-7. [PMID: 22113994 DOI: 10.1002/micr.20968] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Revised: 08/30/2011] [Accepted: 09/01/2011] [Indexed: 01/29/2023]
Abstract
Chronic lymphedema is a debilitating complication of cancer diagnosis and therapy and poses many challenges for health care professionals. It remains a poorly understood condition that has the potential to occur after any intervention affecting lymph node drainage mechanism. Microsurgical lymph vessel transplantation is increasingly recognized as a promising method for bypassing the obstructed lymph pathways and promoting long-term reduction of edema in the affected limb. A detailed review of 14 patients with postoperative lymphedema treated with autologous lymph vessel transplantation between October 2005 and November 2009 was performed. In this report, the authors gave an account of their experience in utilizing this operative method to alleviate secondary lymphedema including upper limb, lower limb, genital, and facial edemas. Lymph vessel transplantation enhanced lymphatic drainage in patients with secondary lymphedema. In the upper and lower extremities, three patients had completed symptomatic recovery and another nine patients achieved reasonable reduction of lymphedema, four of these needed no further lymph drainage or compression garments and the remaining maintained their improvement with further decongestive therapy with or without compression garments. The patients with facial and genital edemas also experienced significant symptomatic improvement. The authors were able to establish long-term patency of the lymph vessel anastomosis by magnetic resonance lymphangiography.
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Affiliation(s)
- Gunther Felmerer
- Division of Plastic Surgery, Department of Trauma Surgery, Plastic and Reconstructive Surgery, University of Medicine, Göttingen, Germany.
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Armer JM, Brooks CW, Stewart BR. Limitations of self-care in reducing the risk of lymphedema: supportive-educative systems. Nurs Sci Q 2011; 24:57-63. [PMID: 21220577 DOI: 10.1177/0894318410389058] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The purpose of this study was to examine patient perceptions of limitations related to self-care measures to reduce lymphedema risk following breast cancer surgery. Secondary analysis of survey data from a companion study to a study piloting a behavioral-educational intervention was conducted to examine the specific limitations in performing lymphedema risk-reduction self-care measures. Findings suggest a more comprehensive approach is needed if patients are to engage in self-care actions to reduce lymphedema risk. Understanding the concepts of self-care and personal support interventions that include motivational interviewing can help nurses design supportive-educative care systems that assist patients in overcoming limitations in the estimative, transitional, and productive phases of self-care necessary to reduce lymphedema risk.
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Quirion E. Recognizing and treating upper extremity lymphedema in postmastectomy/lumpectomy patients: a guide for primary care providers. ACTA ACUST UNITED AC 2011; 22:450-9. [PMID: 20854636 DOI: 10.1111/j.1745-7599.2010.00542.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE To provide an overview of the lymphatics, physiology of lymphedema (LE), incidence, risks, and costs as well as a guide for the primary care provider on how to recognize the symptoms of LE, a review of current published treatment recommendations, and advice about making a referral to appropriate LE specialists. DATA SOURCES Selected studies on diagnosing and treating LE in breast cancer patients following mastectomy/lumpectomy and evidence-based treatment guidelines. CONCLUSIONS LE is the most common complication related to breast cancer treatment with an occurrence estimated between 10% and 60% depending on the parameters used for measurement. Most commonly, LE occurs within the first 3 years after breast cancer treatment, but the remaining cases happen beyond this period of time and can occur after many years. This means that significant numbers of patients with LE can present to primary care clinicians. IMPLICATIONS FOR PRACTICE A patient who is treated for breast cancer will be followed for a time by the oncology team, but eventually, that patient will be discharged from the oncology practice and will be seen in primary care. Risk factors for developing LE include treatment-related (number of nodes removed and radiation to axilla), disease-related (stage and location of tumor), and patient-related (younger age, obesity, and comorbid conditions) factors. A systematic evaluation of any patient presenting with LE will assure accurate diagnosis and prompt treatment.
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Norman SA, Localio AR, Kallan MJ, Weber AL, Torpey HAS, Potashnik SL, Miller LT, Fox KR, DeMichele A, Solin LJ. Risk factors for lymphedema after breast cancer treatment. Cancer Epidemiol Biomarkers Prev 2010; 19:2734-46. [PMID: 20978176 PMCID: PMC2976830 DOI: 10.1158/1055-9965.epi-09-1245] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND As cancer treatments evolve, it is important to reevaluate their effect on lymphedema risk in breast cancer survivors. METHODS A population-based random sample of 631 women from metropolitan Philadelphia, Pennsylvania, diagnosed with incident breast cancer in 1999 to 2001, was followed for 5 years. Risk factor information was obtained by questionnaire and medical record review. Lymphedema was assessed with a validated questionnaire. Using Cox proportional hazards models, we estimated the relative incidence rates [hazard ratios (HR)] of lymphedema with standard adjusted multivariable analyses ignoring interactions, followed by models including clinically plausible treatment interactions. RESULTS Compared with no lymph node surgery, adjusted HRs for lymphedema were increased following axillary lymph node dissection [ALND; HR, 2.61; 95% confidence interval (95% CI), 1.77-3.84] but not sentinel lymph node biopsy (SLNB; HR, 1.04; 95% CI, 0.58-1.88). Risk was not increased following irradiation [breast/chest wall only: HR, 1.18 (95% CI, 0.80-1.73); breast/chest wall plus supraclavicular field (+/- full axilla): HR, 0.86 (95% CI, 0.48-1.54)]. Eighty-one percent of chemotherapy was anthracycline based. The HR for anthracycline chemotherapy versus no chemotherapy was 1.46 (95% CI, 1.04-2.04), persisting after stratifying on stage at diagnosis or number of positive nodes. Treatment combinations involving ALND or chemotherapy resulted in approximately 4- to 5-fold increases in HRs for lymphedema [e.g., HR of 4.16 (95% CI, 1.32-12.45) for SLNB/chemotherapy/no radiation] compared with no treatment. CONCLUSION With standard multivariable analyses, ALND and chemotherapy increased lymphedema risk whereas radiation therapy and SLNB did not. However, risk varied by combinations of exposures. IMPACT Treatment patterns should be considered when counseling and monitoring patients for lymphedema.
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Affiliation(s)
- Sandra A Norman
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA 19104-6021, USA.
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Cormier JN, Xing Y, Zaniletti I, Askew RL, Stewart BR, Armer JM. Minimal limb volume change has a significant impact on breast cancer survivors. Lymphology 2010. [PMID: 20218084 DOI: 10.1089/lrb.2005.2.208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
We sought to define the incidence, risk factors, symptoms, and quality of life (QOL) outcomes associated with various degrees of postoperative limb volume change (LVC). A prospective cohort study was performed obtaining serial limb volume measurements using a perometer on 269 women undergoing surgery for breast cancer. Four groups were created based on maximum LVC: none < 5.0%, mild 5.0-9.9%, moderate 10.0-14.9%, and severe 15.0%. Symptoms and QOL were assessed. 81 (30.1%), 70 (26.0%), and 14 (5.2%) women developed mild, moderate, and severe LVC, respectively. Increases in body mass index (p < 0.001) and post-operative complications (p = 0.002) were associated with increasing LVC. Lower QOL scores were associated with a moderate LVC (OR = 3.72, 95% CI, 1.29-10.73, p = 0.015) and postoperative infections (OR = 5.04, 95% CI, 1.73-14.70, p = 0.003). LVC at 5.0% occurs in up to 61.3% of breast cancer survivors and is associated with a significant increase in symptoms and a change in reported quality of life.
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Affiliation(s)
- J N Cormier
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77230-1402, USA.
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Armer JM. The Problem of Post-Breast Cancer Lymphedema: Impact and Measurement Issues. Cancer Invest 2009. [DOI: 10.1081/cnv-48707] [Citation(s) in RCA: 158] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Shih YCT, Xu Y, Cormier JN, Giordano S, Ridner SH, Buchholz TA, Perkins GH, Elting LS. Incidence, Treatment Costs, and Complications of Lymphedema After Breast Cancer Among Women of Working Age: A 2-Year Follow-Up Study. J Clin Oncol 2009; 27:2007-14. [DOI: 10.1200/jco.2008.18.3517] [Citation(s) in RCA: 318] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Ya-Chen Tina Shih
- From the Section of Health Services Research, Department of Biostatistics, Division of Quantitative Sciences; Department of Surgical Oncology; Department of Breast Medical Oncology, Division of Cancer Medicine; and Department of Radiation Oncology, Division of Radiation Oncology, Breast Service, The University of Texas M. D. Anderson Cancer Center, Houston, TX; and Vanderbilt University School of Nursing, Nashville, TN
| | - Ying Xu
- From the Section of Health Services Research, Department of Biostatistics, Division of Quantitative Sciences; Department of Surgical Oncology; Department of Breast Medical Oncology, Division of Cancer Medicine; and Department of Radiation Oncology, Division of Radiation Oncology, Breast Service, The University of Texas M. D. Anderson Cancer Center, Houston, TX; and Vanderbilt University School of Nursing, Nashville, TN
| | - Janice N. Cormier
- From the Section of Health Services Research, Department of Biostatistics, Division of Quantitative Sciences; Department of Surgical Oncology; Department of Breast Medical Oncology, Division of Cancer Medicine; and Department of Radiation Oncology, Division of Radiation Oncology, Breast Service, The University of Texas M. D. Anderson Cancer Center, Houston, TX; and Vanderbilt University School of Nursing, Nashville, TN
| | - Sharon Giordano
- From the Section of Health Services Research, Department of Biostatistics, Division of Quantitative Sciences; Department of Surgical Oncology; Department of Breast Medical Oncology, Division of Cancer Medicine; and Department of Radiation Oncology, Division of Radiation Oncology, Breast Service, The University of Texas M. D. Anderson Cancer Center, Houston, TX; and Vanderbilt University School of Nursing, Nashville, TN
| | - Sheila H. Ridner
- From the Section of Health Services Research, Department of Biostatistics, Division of Quantitative Sciences; Department of Surgical Oncology; Department of Breast Medical Oncology, Division of Cancer Medicine; and Department of Radiation Oncology, Division of Radiation Oncology, Breast Service, The University of Texas M. D. Anderson Cancer Center, Houston, TX; and Vanderbilt University School of Nursing, Nashville, TN
| | - Thomas A. Buchholz
- From the Section of Health Services Research, Department of Biostatistics, Division of Quantitative Sciences; Department of Surgical Oncology; Department of Breast Medical Oncology, Division of Cancer Medicine; and Department of Radiation Oncology, Division of Radiation Oncology, Breast Service, The University of Texas M. D. Anderson Cancer Center, Houston, TX; and Vanderbilt University School of Nursing, Nashville, TN
| | - George H. Perkins
- From the Section of Health Services Research, Department of Biostatistics, Division of Quantitative Sciences; Department of Surgical Oncology; Department of Breast Medical Oncology, Division of Cancer Medicine; and Department of Radiation Oncology, Division of Radiation Oncology, Breast Service, The University of Texas M. D. Anderson Cancer Center, Houston, TX; and Vanderbilt University School of Nursing, Nashville, TN
| | - Linda S. Elting
- From the Section of Health Services Research, Department of Biostatistics, Division of Quantitative Sciences; Department of Surgical Oncology; Department of Breast Medical Oncology, Division of Cancer Medicine; and Department of Radiation Oncology, Division of Radiation Oncology, Breast Service, The University of Texas M. D. Anderson Cancer Center, Houston, TX; and Vanderbilt University School of Nursing, Nashville, TN
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Tsai RJ, Dennis LK, Lynch CF, Snetselaar LG, Zamba GKD, Scott-Conner C. The Risk of Developing Arm Lymphedema Among Breast Cancer Survivors: A Meta-Analysis of Treatment Factors. Ann Surg Oncol 2009; 16:1959-72. [PMID: 19365624 DOI: 10.1245/s10434-009-0452-2] [Citation(s) in RCA: 233] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2008] [Revised: 03/13/2009] [Accepted: 03/14/2009] [Indexed: 11/18/2022]
Affiliation(s)
- Rebecca J Tsai
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA.
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Norman SA, Localio AR, Potashnik SL, Simoes Torpey HA, Kallan MJ, Weber AL, Miller LT, Demichele A, Solin LJ. Lymphedema in breast cancer survivors: incidence, degree, time course, treatment, and symptoms. J Clin Oncol 2009; 27:390-7. [PMID: 19064976 PMCID: PMC2645852 DOI: 10.1200/jco.2008.17.9291] [Citation(s) in RCA: 252] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2008] [Accepted: 09/16/2008] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To examine the incidence, degree, time course, treatment, and symptoms of lymphedema in breast cancer survivors. METHODS We conducted a 5-year, population-based prospective study of 631 randomly selected Philadelphia and Delaware County, Pennsylvania female residents with incident breast cancer who were diagnosed from 1999 to 2001. Using a questionnaire previously validated against physical therapists' measurement-based clinical criteria, we assigned a score indicating the degree of lymphedema (none, mild, or moderate/severe) to each month of follow-up based on the respondent's perceived differences in hand/arm size. Standard survival analysis methods permitted maximum use of follow-up. RESULTS Five-year cumulative incidence of lymphedema was 42 (42%) per 100 women. Among the 238 affected women, lymphedema first occurred within 2 years of diagnosis in 80% and within 3 years in 89%. Among 433 women observed for 3 years, 23% reported no more than mild lymphedema, 12% reported moderate/severe lymphedema, and 2% reported chronically moderate/severe lymphedema. Women with mild lymphedema were more than three times more likely to develop moderate/severe lymphedema than women with no lymphedema. Thirty-seven percent of women with mild lymphedema and 68% with moderate/severe lymphedema received treatment. Increasing proportions of women with increasing degree of lymphedema reported symptoms (eg, jewelry too tight, tired/thick/heavy arm). Symptoms present before the first occurrence of lymphedema were associated with a higher probability of later lymphedema (eg, hazard ratio for jewelry too tight = 7.37; 95% CI, 4.26 to 12.76). CONCLUSION Lymphedema after breast cancer is common but mostly mild. Subtle differences in self-reported hand/arm size and symptoms can be early signs of progressing lymphedema.
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Affiliation(s)
- Sandra A Norman
- Department of Medicine, Division of Hematology/Oncology, Center for Clinical Epidemiologyand Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA 19104-6021, USA.
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Nielsen I, Gordon S, Selby A. Breast cancer-related lymphoedema risk reduction advice: A challenge for health professionals. Cancer Treat Rev 2008; 34:621-8. [DOI: 10.1016/j.ctrv.2007.11.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2007] [Revised: 11/19/2007] [Accepted: 11/20/2007] [Indexed: 11/29/2022]
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Risk factors for arm lymphedema following breast cancer diagnosis in Black women and White women. Breast Cancer Res Treat 2008; 113:383-91. [DOI: 10.1007/s10549-008-9940-5] [Citation(s) in RCA: 120] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2008] [Accepted: 02/08/2008] [Indexed: 11/25/2022]
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Deutsch M, Land S, Begovic M, Sharif S. The incidence of arm edema in women with breast cancer randomized on the National Surgical Adjuvant Breast and Bowel Project study B-04 to radical mastectomy versus total mastectomy and radiotherapy versus total mastectomy alone. Int J Radiat Oncol Biol Phys 2007; 70:1020-4. [PMID: 18029105 DOI: 10.1016/j.ijrobp.2007.07.2376] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2007] [Revised: 07/16/2007] [Accepted: 07/17/2007] [Indexed: 02/06/2023]
Abstract
PURPOSE To determine the incidence and factors associated with the development of arm edema in women who participated in the National Surgical Adjuvant Breast and Bowel Project (NSABP) study B-04. METHODS AND MATERIALS Between 1971 and 1974, the NSABP protocol B-04 randomized 1,665 eligible patients with resectable breast cancer to either (1) the Halstead-type radical mastectomy; (2) total mastectomy and radiotherapy to the chest wall, axilla, supraclavicular region, and internal mammary nodes if by clinical examination axillary nodes were involved by tumor; and (3) for patients with a clinically uninvolved axilla, a third arm, total mastectomy alone. Measurements of the ipsilateral and contralateral arm circumferences were to be performed every 3 months. RESULTS There was at least one recorded measurement of arm circumferences for 1,457 patients (87.5% of eligible patients). There were 674 women (46.3%) who experienced arm edema at some point during the period of follow-up until February 1976. For radical mastectomy patients, total mastectomy and radiotherapy patients, and total mastectomy patients alone, arm edema was recorded at least once in 58.1%, 38.2%, and 39.1% of patients, respectively (p<.001) and at last recorded measurement in 30.7%, 14.8%, and 15.5%, respectively (p=or<.001). Increasing body mass index (BMI) also showed a statistically significant correlation with arm edema at any time (p=.001) and at last assessment (p=.005). CONCLUSIONS Patients who undergo mastectomy, including those whose treatment plans do not include axillary dissection or postoperative radiotherapy, suffer an appreciable incidence of arm edema.
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Affiliation(s)
- Melvin Deutsch
- National Surgical Adjuvant Breast and Bowel Project (NSABP) Operations and Biostatistical Centers, University of Pittsburgh Medical Center, Department of Radiation Oncology, Pittsburgh, PA, USA.
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Samoilova E, Davis JT, Hinson J, Brill YM, Cibull ML, McGrath P, Romond E, Moore A, Samayoa LM. Size of Sentinel Node Tumor Deposits and Extent of Axillary Lymph Node Involvement: Which Breast Cancer Patients May Benefit From Less Aggressive Axillary Dissections? Ann Surg Oncol 2007; 14:2221-7. [PMID: 17549569 DOI: 10.1245/s10434-007-9458-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2007] [Accepted: 04/26/2007] [Indexed: 11/18/2022]
Abstract
BACKGROUND In most breast cancer series, nearly 30% to 40% of all patients are sentinel node positive; however, in a large proportion of these, the disease is limited to three or fewer positive nodes. On the basis of these observations, the object of this study is to identify a subset of patients who might benefit from a less aggressive axillary dissection, without compromising staging or local disease control. We reviewed known clinicopathologic variables associated with a higher risk for axillary metastasis in 467 patients who underwent sentinel node mapping at our institution. We then compared the incidence of these variables in patients with N1a versus N2-3 stage disease. RESULTS Although the presence of lymphvascular invasion in the primary tumor and extracapsular extension of tumor in the sentinel node were statistically significantly different between N1a and N2-3 patients (P < .025 and P < .01, respectively), the variable that most reliably separated N1a from N2-3 patients was the size of the tumor deposits in the sentinel node (P < .001). All patients with sentinel node tumor deposits <or=5 mm had three or fewer positive nodes; 95% were sentinel node-positive only, and 91% had single-node involvement. CONCLUSIONS Patients at low risk for extensive axillary nonsentinel node involvement may benefit from a more conservative surgical approach to their axillae, perhaps limited to sentinel node biopsy only or to axillary procedures restricted to the group of axillary nodes in close proximity to those designated as sentinel nodes.
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Affiliation(s)
- Elena Samoilova
- Department of Pathology, University of Kentucky Breast Cancer Center, 800 Rose Street, Lexington, Kentucky 40536, USA
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Paskett ED, Naughton MJ, McCoy TP, Case LD, Abbott JM. The epidemiology of arm and hand swelling in premenopausal breast cancer survivors. Cancer Epidemiol Biomarkers Prev 2007; 16:775-82. [PMID: 17416770 PMCID: PMC4771019 DOI: 10.1158/1055-9965.epi-06-0168] [Citation(s) in RCA: 188] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Breast cancer survivors suffer from lymphedema of the arm and/or hand. Accurate estimates of the incidence and prevalence of lymphedema are lacking, as are the effects of this condition on overall quality of life. METHODS Six hundred twenty-two breast cancer survivors (age, <or=45 years at diagnosis) were followed with semiannual questionnaires for 36 months after surgery to determine the incidence of lymphedema, prevalence of persistent swelling, factors associated with each, and quality of life. RESULTS Of those contacted and eligible for the study, 93% agreed to participate. Fifty-four percent reported arm or hand swelling by 36 months after surgery, with 32% reporting persistent swelling. Swelling was reported to occur in the upper arm (43%), the hand only (34%), and both arm and hand (22%). Factors associated with an increased risk of developing swelling included having a greater number of lymph nodes removed [hazards ratio (HR), 1.02; P < 0.01], receiving chemotherapy (HR, 1.76; P = 0.02), being obese (HR, 1.51 versus normal weight; P = 0.01), and being married (HR, 1.36; P = 0.05). Factors associated with persistent swelling were having more lymph nodes removed (odds ratio, 1.03; P = 0.01) and being obese (odds ratio, 2.24 versus normal weight; P < 0.01). Women reporting swelling had significantly lower quality of life as measured by the functional assessment of cancer therapy-breast total score and the SF-12 physical and mental health subscales (P < 0.01 for each). CONCLUSIONS Lymphedema occurs among a substantial proportion of young breast cancer survivors. Weight management may be a potential intervention for those at greatest risk of lymphedema to maintain optimal health-related quality of life among survivors.
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Affiliation(s)
- Electra D Paskett
- Ohio State University Comprehensive Cancer Center, A356 Starling-Loving Hall, 320 West 10th Avenue, Columbus, OH 43210, USA.
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Rao AV, Demark-Wahnefried W. The older cancer survivor. Crit Rev Oncol Hematol 2006; 60:131-43. [PMID: 16965920 DOI: 10.1016/j.critrevonc.2006.06.003] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2005] [Revised: 06/06/2006] [Accepted: 06/06/2006] [Indexed: 12/31/2022] Open
Abstract
Cancer is an age-related disease, and has increased in prevalence as the population has grown older. Improvements in screening and the availability of better therapeutic options contribute to burgeoning numbers of cancer survivors, who number more than 24 million worldwide. Sixty-one percent of these survivors are at least 65 years old. This review is an attempt to consolidate some of the data available in the area of cancer survivorship, with emphasis on the elderly. Our aim is to provide a better description of the population, elucidate specific physical and psychosocial sequelae secondary to cancer and it's treatment, and better understand how comorbid conditions, functional status, body-weight, and other issues contribute to quality of life, and overall health. This paper also suggests some surveillance guidelines for following elderly cancer survivors and identifies areas that require further research.
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Affiliation(s)
- Arati V Rao
- Division of Geriatrics, Division of Medical Oncology, Duke University Medical Center and Durham VA Medical Center DUMC, Box 3003, Durham 27710, North Carolina, USA.
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Influence of mammographic density on the diagnostic accuracy of tumor size assessment and association with breast cancer tumor characteristics. Eur J Radiol 2006; 60:398-404. [PMID: 17030108 DOI: 10.1016/j.ejrad.2006.08.002] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2005] [Revised: 07/18/2006] [Accepted: 08/03/2006] [Indexed: 10/24/2022]
Abstract
PURPOSE The accuracy of breast cancer staging involves the estimation of the tumor size for the initial decision-making in the treatment. We investigated the accuracy of tumor size estimation and the association between tumor characteristics and breast density (BD). MATERIALS AND METHODS A total of 434 women with a primary diagnosis of breast cancer were included in this prospective study at a specialist breast unit. Estimated tumor characteristics included tumor size, nodal status, estrogen/progesterone receptor status, Ki-67, HER2/neu, vascular invasion. Radiomorphological data included tumor size as assessed by mammography, breast ultrasonography, and clinical examination, and American College of Radiology (ACR) categories for BD. RESULTS BD did not have a significant impact on the assessment of tumor size using breast ultrasound (deviation from ACR categories 1-4: 0.55-0.68 cm; P=0.331). The deviation in mammography was significantly different dependent on BD (0.42-0.9 cm; P<0.001). The clinical examination was not affected by BD. Age and tumor size were the only parameters associated with a denser breast in the multivariate analysis. Older women were less likely to have dense breasts (odds ratio 0.157 for women aged >or=70 years), and patients with larger tumors were less likely to have dense breasts (adjusted OR 0.36 for tumors>2 cm). CONCLUSION Breast ultrasonography is more accurate than mammography for assessing tumor size in breasts with a higher BD. The difference in tumor size assessment needs to be taken into consideration in the design of clinical trials and treatment decisions.
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Armer JM, Stewart BR. A comparison of four diagnostic criteria for lymphedema in a post-breast cancer population. Lymphat Res Biol 2006; 3:208-17. [PMID: 16379589 DOI: 10.1089/lrb.2005.3.208] [Citation(s) in RCA: 199] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Breast cancer survivors are at life-time risk of developing lymphedema (LE). The goal of this research was to describe LE incidence over time among women treated for breast cancer. METHODS AND RESULTS Limb volume changes (LVC) were evaluated by two measurement methods, circumferences and perometry, among 118 participants followed preoperative to 12 months postdiagnosis. Four diagnostic criteria were used: 200 mL perometry LVC; 10% perometry LVC; 2 cm circumferential increase; and report of heaviness or swelling, either "now" or "in the past year." Using 200 mL, the estimated LE rate was 24% (95% CI = 17%-32%) at 6 months, and 42% (31%-53%) at 1 year. Using 10% LVC, the estimated LE rate was 8% (2%-13%) at 6 months, and 21% (12%-30%) at 1 year. Using 2 cm, the estimated LE rate was 46% (36%-56%) at 6 months, and 70% (60%-79%) at 1 year. Based on reported symptoms of heaviness or swelling, the estimated LE rate was 19% (11%-26%) at 6 months, and 40% (30-59%) at 1 year. CONCLUSIONS In the absence of a gold standard, we can only say that the different LE definitions are not equivalent, but cannot say which is "best". From this data, it appears that 10% LVC corresponds to a more conservative definition, whereas the 2 cm difference corresponds to a more liberal definition. These preliminary findings also document the importance of baseline (preoperative) anthropometric and symptom data and monitoring of changes over time. Further investigation of LE occurrence over an extended time period is warranted.
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Affiliation(s)
- Jane M Armer
- Sinclair School of Nursing, University of Missouri-Columbia, DC 116.05, EFCC 408, Columbia, MO 65211, USA.
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Abstract
Every year in the United States, breast cancer is diagnosed in more than 200,000 women. Because of the prevalence of breast cancer, treatment-related sequelae are of Importance to many survivors of the disease. One such sequela is upper extremity lymphedema, which occurs when fluid accumulates in the Interstitial space and causes enlargement and usually a feeling of heaviness in the limb. Axillary surgery contributes considerably to the incidence of lymphedema, with the incidence and severity of swelling related to the number of lymph nodes removed. Lymphedema after standard axillary lymph node dissection can occur in up to approximately 50% of patients. However, the risk of lymphedema is decreased substantially with newer sentinel lymph node sampling procedures. Adjuvant radiotherapy to the breast or lymph nodes increases the risk of lymphedema, which has been reported in 9% to 40% of these patients. Management of lymphedema requires a multidisciplinary approach to minimize the effect on the patient's quality of life. This review presents an overview of the pathophysiology, diagnosis, prevention, and treatment of breast cancer-related lymphedema.
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Affiliation(s)
- Rosalyn M Morrell
- Department of Radiation Oncology, Mayo Clinic College of Medicine, Scottsdale, Arizona 85259, USA
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Abstract
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.
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Affiliation(s)
- Anne F Williams
- Centre for Research and Implementation of Clinical Practice, Thames Valley University, London, UK
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