Breast cancer-related lymphoedema: Risk factors and prediction model

Optimizing Lymphedema Management After Breast Cancer: Predictive Risk Models in Clinical Practice

BACKGROUND AND OBJECTIVES

Lymphedema secondary to multimodal breast cancer treatment is a relatively common complication that significantly impacts patients' quality of life. Despite identifying several associated risk factors, accurately assessing individual risk remains challenging. This study aims to develop predictive tools integrating patient characteristics, tumor attributes, and treatment modalities to optimize clinical surveillance, enhance prevention, and enable earlier diagnosis.

METHODS

Data were analyzed from 309 patients referred to the Lymphedema Unit of Rehabilitation Service who underwent lymphadenectomy for breast cancer between January 2016 and December 2021. Collected variables included patient demographics, tumor clinicopathological features, and treatment details. A lymphedema incidence study was conducted, complemented by univariate and multivariate regression analyses to identify risk factors. A nomogram was developed to predict high-risk patients, facilitating personalized prevention and management strategies.

RESULTS

The cumulative incidence of lymphedema was 18.4%. Independent risk factors included high body mass index, sedentary lifestyle, number of positive nodes (N stage), and radiotherapy, particularly targeting the breast, axilla, and supra-infraclavicular regions. The logistic regression model demonstrated an area under the ROC curve (AUC) of 0.75, with acceptable calibration, validating the predictive model.

CONCLUSIONS

The predictive tools developed provide healthcare professionals with a means to identify patients at elevated risk of lymphedema, supporting individualized prevention and management.

Developing the Short-Form of Lymphedema Needs Questionnaire for Iranian Breast Cancer Patients

PURPOSE

The informational needs of patients with Breast Cancer-Related Lymphedema (BCRL) have not been sufficiently addressed in the scientific literature. Moreover, the only existing questionnaire in this field contains many items. Therefore, the purpose of this study is to develop a short-form version of this questionnaire.

METHODS

The questionnaire items were extracted from the Lymphoedema Needs Questionnaire-Breast Cancer (LNQ-BC). Demographic variables and clinical characteristics were considered separately. Out of 62 items, 24 were selected, and 2 additional questions were included based on feedback from 10 experts. 100 participants with BCRL completed the short-form questionnaire. Exploratory Factor Analysis (EFA) was performed using principal components extraction and varimax rotation, and Cronbach's alpha was calculated for each dimension.

RESULTS

After evaluating the content validity, the instrument's construct validity with 26 items was conducted using EFA. The KMO (Kaiser-Meyer-Olkin) value was equal to 0.879 and Bartlett's sphericity test was significant (p-value < 0.001), indicating the data's adequacy and appropriateness to perform EFA. Five extracted dimensions were named: "Lymphedema information needs" (5 items), "Informational support, peers" (5 items), "Access to a lymphedema care specialist" (5 items), "Physical and daily activities" (7 items) and "Financial issues and compression garments" (4 items). The level of needs in this study in all dimensions was high (more than 77%).

CONCLUSIONS

The high factor loadings and the total explained variance of 78.152% support the construct validity of the short questionnaire. Although some items exhibited cross-loadings, the majority loaded strongly on a single factor, indicating good discriminant validity. Providing services according to the needs of patients can be prioritized. Healthcare providers, insurers, and individuals should be better informed about lymphedema, its associated costs, and the importance of implementing appropriate management programs.

Commonly Prescribed Chronic Pharmacological Medications as Risk Factors for Breast Cancer-Related Lymphedema: An Observational Retrospective Cohort Study

Background/Objectives: Breast cancer-related lymphedema (BCRL) is a significant complication of breast cancer (BC) treatment, characterized by swelling and fluid accumulation. Many risk factors have already been proven to be related to BCRL; meanwhile, many others are still debated and poorly investigated in the literature. This study investigated the potential involvement of commonly prescribed chronic medications in BCRL development. Methods: This observational retrospective cohort study included 162 post-surgical breast cancer survivors attending an oncological rehabilitation outpatient service between January 2021 and April 2023. BCRL was diagnosed by physicians through clinical evaluation and objective measures (≥2 cm increase in circumferential girth measurements). Descriptive statistics summarized patient characteristics, and Cox regression models (univariable and multivariable) were employed to analyze risk factors for BCRL. Results: BCRL was observed in 53% of participants. The univariable model identified BMI (hazard ratio 1.07, 95% CI 1.02-1.11), overweight (BMI ≥ 25) (HR 1.46, 95% CI 0.95-2.25), and breast prosthesis implantation (HR 1.75, 95% CI 1.09-2.80) as potential risk factors for lymphedema. In the multivariable model, overweight (HR 2.90, 95% CI 1.18-7.14), hypertension (HR 5.09, 95% CI 1.88-13.79), radiotherapy (HR 3.67, 95% CI 1.43-9.38), and breast prosthesis implantation (HR 8.93, 95% CI 2.77-28.81) were identified as independent risk factors for BCRL. Conclusions: The findings emphasize the need for further research to understand the role of chronic medications in BCRL risk comprehensively.

The LyBra score: A risk assessment tool to address targeted prevention against breast cancer - Related lymphedema

INTRODUCTION

Nowadays, physicians have tools to prevent breast cancer-related lymphedema (BCRL) but there is no consensus on when to apply them. The authors analysed patient- and treatment-related risk factors to create the LyBra score, to identify patients that may benefit the most from BCRL preventive interventions.

MATERIALS AND METHODS

Patients were selected from cases of breast cancer treated from January 2019 to July 2022. Inclusion criteria were age above 18, breast cancer diagnosis and surgical treatment with lymph-node biopsy or axillary dissection. Recurrent cancers, inflammatory cancer, previous axillary surgery, bilateral cases and patients with primary lymphedema were excluded. Selected cases were assessed with the LyBra Score. Numerosity and distribution of expected BCRL were compared to the BCRL registered during the minimum follow-up of 2 years.

RESULTS

During an average 41 months follow-up (range, 24-62), 131 cases (14 %) of BCRL were registered in the total 933 patients included in the study. According to LyBra score, expected BCRL cases were 149 (16 %), slightly higher but with no statistical significance. The major incidence of BCRL (40 cases in 47 patients) was registered in the high-risk group that included 5 % of the study population. A ROC curve was used to determine the diagnostic performance of the LyBra score and the AUC was 0.78 corresponding to a good discriminating ability.

CONCLUSION

By sorting patients into risk groups, the LyBra score offers a solution to the actual dilemma of timing and indication of the modern preventive-BCRL microsurgeries.

Preventing Breast Cancer-Related Lymphedema: A Comprehensive Analysis of a 9-Year Single-Center Experience of Prophylactic Lymphovenous Bypass

BACKGROUND

Prophylactic lymphovenous bypass (pLVB) is a microsurgical technique aimed to prevent breast cancer-related lymphedema (BCRL) after axillary lymph node dissection (ALND) by redirecting lymphatic flow from the ligated lymphatics into neighboring veins. This report describes the authors' 9-year institutional experience of pLVB in patients undergoing ALND to prevent BCRL.

METHODS

Patients who underwent ALND were reviewed. Demographic and oncologic data were analyzed. The primary outcomes included limb circumference and perometry. The secondary outcomes included patient-reported outcomes, incidence of cellulitis, and need for therapeutic lymphovenous bypass (LVB). Furthermore, the study identified risk factors for the development of BCRL within the ALND plus pLVB population.

RESULTS

Of the 370 patients, 25% underwent ALND plus pLVB. Demographic and oncologic features were similar between the two cohorts, and the average follow-up time was 23 months. The rate of BCRL was 8.7% in the ALND plus pLVB group and 20.1% in the no-pLVB group (p < 0.05), whereas the postoperative circumferential measurements were significantly improved among the ALND plus pLVB patients. In addition, the patients treated with ALND plus pLVB had a lower incidence of positive symptoms of lymphedema (pain, tightness, heaviness) and were less likely to require therapeutic LVB. The medical history of cardiac arrythmia was identified as a risk factor for the development of lymphedema in the ALND plus pLVB cohort.

CONCLUSIONS

Prophylactic lymphovenous bypass contributes to a decreased incidence of lymphedema as well as improved patient symptoms and limb functionality. Furthermore, pLVB modulates disease severity for patients who experience BCRL. The authors advocate that pLVBs should be routinely offered to breast cancer patients undergoing ALND.

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

OBJECTIVE

This study aims to evaluate the association between body mass index (BMI) and the incidence of breast cancer-related lymphedema (BCRL).

METHODS

This retrospective cohort study analyzed data from 1464 breast cancer patients treated at The Third Hospital of Nanchang between 2018 and 2021. Patients were categorized based on BMI (<25, 25 to < 30, ≥ 30 kg/m²). Variables such as axillary lymph node dissection, infections, radiotherapy, and comorbidities were taken into account.

RESULTS

The incidence of BCRL was 23.4%. Higher BMI was associated with increased risk of BCRL, with significant incidence rates observed at 1, 2, and 3 years in the higher BMI groups. Multivariate analysis confirmed BMI as an independent risk factor for BCRL.

CONCLUSION

Elevated BMI is associated with increased BCRL risk and decreased BCRL-free survival, underscoring the significance of weight management in breast cancer care.

Immediate lymphatic reconstruction with targeted lymphatic axillary repair

Current surgical treatment for established lymphedema can be challenging and not always successful. To reduce the incidence of post-operative lymphedema, we began trialing targeted lymphatic axillary repair (TLAR) as a technique for immediate lymphatic reconstruction with the aim of reducing post-operative lymphedema incidence. In this observational prospective study, conducted between March 2017 and May 2022, we assessed the effectiveness of TLAR in reducing lymphedema occurrence in consecutive breast cancer patients who underwent surgery involving axillary lymph node dissection (ALND). Patients meeting the inclusion criteria were considered for simultaneous lymphedema risk-reducing surgery using TLAR. They were monitored for a minimum of 18 months by medical physiotherapists, and post-operative testing was conducted using indocyanine green lymphography. Among the 50 women who underwent TLAR, 34 (68%) received neoadjuvant chemotherapy. On an average, 2.18 lymphatics were identified per patient, with a mean of 1.84 lymphatico-venous anastomoses performed. Adjuvant axillary radiotherapy was administered to 41 patients (82%), with axillary levels I-II spared from direct radiotherapy in 24 patients (48%). Only 2 patients (4%) developed lymphedema during the minimum 18.2-month follow-up period. In conclusion, TLAR is shown to be a safe, effective, and physiologic technique for reducing lymphedema risk in patients with breast cancer.

The Intermittent Pneumatic Compression Influences Edema Fluid Movement and Promotes the Compensatory Drainage Pathways in Patients with Breast Cancer Related Lymphedema

Introduction: Upper limb lymphedema is the most common complication after breast cancer therapy. Suddenly disturbed lymphatic transport in the affected arm causes tissue fluid accumulation in tissue spaces, limb enlargement, and secondary changes in tissue. Early compression therapy is necessary. We aim to evaluate the effectiveness of intermittent pneumatic compression (IPC) in fluid movement along the limb and the possibility of creating compensatory drainage pathways. Methods and Results: We investigated 25 patients with Breast Cancer Related Lymphedema (BCRL) stages II and III. Indocyanine green observation and measurement of skin water concentration and skin and subcutaneous tissue stiffness were done before and after a single 45-minute session of IPC. After IPC, we observed the movement of edema fluid upper in the arm (92%) and in three main directions not seen before IPC: to the ipsilateral supraclavicular lymph node (30%), to the ipsilateral axilla (22%), and to the axilla, chest, and scapula (26%). We noticed two changes in fluorescent intensity along the entire limb: a decrease in the hand and forearm, an increase in the arm (64%), and a decrease along some parts or the entire limb (36%). Skin and subcutaneous tissue stiffness decreased at all limb levels. The highest, statistically significant reduction of subcutaneous tissue stiffness was noticed in the middle forearm and elbow (36.4% and 33.4%, respectively). Conclusions: IPC can effectively move edema fluid from the distal to the proximal part of the limb, promote compensatory drainage pathways, and decrease tissue stiffness. This compression type should be applied even in the early stages to prevent limb enlargement and secondary tissue changes.

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

BACKGROUND

Understanding the factors that contribute to variability in breast cancer-related lymphedema (BCRL) is an important first step in developing targeted interventions to improve quality of life in breast cancer patients. Although previous research studies have has identified many risk factors for BCRL, dietary habits and catheterization type have rarely been studied until the present.

AIM

This study aims to explore the effects of nursing factors such as dietary habits and catheterization type on breast cancer-related lymphedema (BCRL).

METHODS

This retrospective cohort study included 1,476 breast cancer patients who underwent surgery between January 1, 2012, and September 1, 2020. Lymphedema was assessed with a validated self-report questionnaire. All research data were obtained from medical records and a follow-up database. Multivariate Cox regression was conducted to explore the effects of dietary habits and catheterization type on BCRL.

RESULTS

The results showed an increased risk for BCRL among breast cancer patients who followed a high-fat diet prehospitalization (HR = 2.47; 95% CI = 1.55-3.94; P < 0.001), indwelling totally implantable venous access ports (TIVAPs) compared with indwelling needles (HR = 0.56; 95% CI = 0.35-0.90;P = 0.017) or indwelling peripherally inserted central catheters (PICCs) (HR = 0.69; 95% CI = 0.45-1.05; P = 0.086).

CONCLUSION

High-fat diet pre-hospitalization was an independent risk factor for lymphedema. The TIVAPs did not exert a protective effect on lymphedema compared with the PICC and indwelling needle. This study finding offers new insights to develop targeted interventions to decrease the incidence of lymphedema.

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

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

Primary surgical prevention of lymphedema

Lymphedema in the upper and lower extremities can lead to significant morbidity in patients, resulting in restricted joint movements, pain, discomfort, and reduced quality of life. While physiological lymphatic reconstructions such as lymphovenous anastomosis (LVA), lymphovenous implantation (LVI), and vascularized lymph node transfer (VLNT) have shown promise in improving patients' conditions, they only provide limited disease progression control or modest reversal. As lymphedema remains an incurable condition, the focus has shifted toward preventive measures in developed countries where most cases are iatrogenic due to cancer treatments. Breast cancer-related lymphedema (BCRL) has been a particular concern, prompting the implementation of preventive measures like axillary reverse mapping. Similarly, techniques with lymph node-preserving concepts have been used to treat lower extremity lymphedema caused by gynecological cancers. Preventive lymphedema measures can be classified into primary, secondary, and tertiary prevention. In this comprehensive review, we will explore the principles and methodologies encompassing lymphatic microsurgical preventive healing approach (LYMPHA), LVA, lymphaticolymphatic anastomosis (LLA), VLNT, and lymph-interpositional-flap transfer (LIFT). By evaluating the advantages and limitations of these techniques, we aim to equip surgeons with the necessary knowledge to effectively address patients at high risk of developing lymphedema.

Supermicrosurgical lymphovenous anastomosis

Lymphedema impairs patients' function and quality of life. Currently, supermicrosurgical lymphovenous anastomosis (LVA) is regarded as a significant and effective treatment for lymphedema. This article aims to review recent literature on this procedure, serving as a reference for future research and surgical advancements. Evolving since the last century, LVA has emerged as a pivotal domain within modern microsurgery. It plays a crucial role in treating lymphatic disorders. Recent literature discusses clinical imaging, surgical techniques, postoperative care, and efficacy. Combining advanced tools, precise imaging, and surgical skills, LVA provides a safer and more effective treatment option for lymphedema patients, significantly enhancing their quality of life. This procedure also presents new challenges and opportunities in the realm of microsurgery.

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

PURPOSE

We aimed to evaluate whether neoadjuvant chemotherapy (NAC) could be a risk factor for breast cancer-related lymphedema (BCRL) associated with axillary lymph node dissection (ALND).

PATIENTS AND METHODS

A total of 596 patients with cT0-4N0-3M0 breast cancer who underwent ALND and chemotherapy were retrospectively analyzed between March 2012 and March 2022. NAC was administered in 188 patients (31.5%), while up-front surgery in 408 (68.5%). Univariate and multivariable Cox regression analyses were performed to determine whether NAC was an independent risk factor for BCRL. With propensity score matching (PSM), the NAC group and up-front surgery group were matched 1:1 by age, body mass index (BMI), molecular subtypes, type of breast surgery, and the number of positive lymph nodes. Kaplan-Meier survival analyses were performed for BCRL between groups before and after PSM. Subgroup analyses were conducted to explore whether NAC differed for BCRL occurrence in people with different characteristics.

RESULTS

At a median follow-up of 36.3 months, 130 patients (21.8%) experienced BCRL [NAC, 50/188 (26.60%) vs. up-front surgery, 80/408 (19.61%); P = 0.030]. Multivariable analysis identified that NAC [hazard ratio, 1.503; 95% CI (1.03, 2.19); P = 0.033] was an independent risk factor for BCRL. In addition, the hormone receptor-negative/human epidermal growth factor receptor 2-negative (HR-/HER2-) subtype, breast-conserving surgery (BCS), and increased positive lymph nodes significantly increased BCRL risk. After PSM, NAC remained a risk factor for BCRL [hazard ratio, 1.896; 95% CI (1.18, 3.04); P = 0.007]. Subgroup analyses showed that NAC had a consistent BCRL risk in most clinical subgroups.

CONCLUSION

NAC receipt has a statistically significant increase in BCRL risk in patients with ALND. These patients should be closely monitored and may benefit from early BCRL intervention.

Temporal validation of a risk prediction model for breast cancer-related lymphoedema in European population: A retrospective study

AIMS

To perform temporal validation of a risk prediction model for breast cancer-related lymphoedema in the European population.

DESIGN

Temporal validation of a previously developed prediction model using a new retrospective cohort of women who had undergone axillary lymph node dissection between June 2018 and June 2020.

METHODS

We reviewed clinical records to identify women who did and did not develop lymphoedema within 2 years of surgery and to gather data regarding the variables included in the prediction model. The model was calibrated by calculating Spearman's correlation between observed and expected cases. Its accuracy in discriminating between patients who did versus did not develop lymphoedema was assessed by calculating the area under the receiver operating characteristic curve (AUC).

RESULTS

The validation cohort comprised 154 women, 41 of whom developed lymphoedema within 2 years of surgery. The value of Spearman's coefficient indicated a strong correlation between observed and expected cases. Sensitivity of the model was higher than in the derivation cohort, as was the value of the AUC.

CONCLUSION

The model shows a good capacity to discriminate women at risk of lymphoedema and may therefore help in developing improved care pathways for individual patients.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Identifying risk factors for lymphoedema secondary to breast cancer treatment is vital given its impact on women's physical and emotional well-being.

IMPACT

What problem did the study address? Risk of BCRL. What were the main findings? The prediction model has a good capacity to discriminate women at risk of lymphoedema. Where and on whom will the research have an impact? In clinical practice with women at risk of BCRL.

REPORTING METHOD

STROBE checklist. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: It presents a validated risk prediction model for BCRL.

NO PATIENT OR PUBLIC CONTRIBUTION

There was no patient or public contribution in the conduct of this study.

Development of predictive models for lymphedema by using blood tests and therapy data

Lymphedema is a disease that refers to tissue swelling caused by an accumulation of protein-rich fluid that is usually drained through the lymphatic system. Detection of lymphedema is often based on expensive diagnoses such as bioimpedance spectroscopy, shear wave elastography, computed tomography, etc. In current machine learning models for lymphedema prediction, reliance on observable symptoms reported by patients introduces the possibility of errors in patient-input data. Moreover, these symptoms are often absent during the initial stages of lymphedema, creating challenges in its early detection. Identifying lymphedema before these observable symptoms manifest would greatly benefit patients by potentially minimizing the discomfort caused by these symptoms. In this study, we propose to use new data, such as complete blood count, serum, and therapy data, to develop predictive models for lymphedema. This approach aims to compensate for the limitations of using only observable symptoms data. We collected data from 2137 patients, including 356 patients with lymphedema and 1781 patients without lymphedema, with the lymphedema status of each patient confirmed by clinicians. The data for each patient included: (1) a complete blood count (CBC) test, (2) a serum test, and (3) therapy information. We used various machine learning algorithms (i.e. random forest, gradient boosting, decision tree, logistic regression, and artificial neural network) to develop predictive models on the training dataset (i.e. 80% of the data) and evaluated the models on the external validation dataset (i.e. 20% of the data). After selecting the best predictive models, we created a web application to aid medical doctors and clinicians in the rapid screening of lymphedema patients. A dataset of 2137 patients was assembled from Seoul National University Bundang Hospital. Predictive models based on the random forest algorithm exhibited satisfactory performance (balanced accuracy = 87.0 ± 0.7%, sensitivity = 84.3 ± 0.6%, specificity = 89.1 ± 1.5%, precision = 97.4 ± 0.7%, F1 score = 90.4 ± 0.4%, and AUC = 0.931 ± 0.007). We developed a web application to facilitate the swift screening of lymphedema among medical practitioners: https://snubhtxt.shinyapps.io/SNUBH_Lymphedema . Our study introduces a novel tool for the early detection of lymphedema and establishes the foundation for future investigations into predicting different stages of the condition.

Managing the Morbidity: Individualizing Risk Assessment, Diagnosis, and Treatment Options for Upper Extremity Lymphedema

In the setting where breast cancer-related lymphedema (BCRL) remains a feared and common complication of breast cancer, here we review important factors for the development, diagnosis, prevention, and treatment of BCRL. We find that race/ethnicity affect BCRL development risk, that future studies should focus on understanding the biological reasons behind the increased susceptibility of certain racial minorities to BCRL, that surveillance, early detection, exercise programs, and arm compression can reduce the risk of BCRL, and that surgical techniques to preserve and restore lymphatic drainage being evaluated in randomized trials may become transformative in reducing BCRL risk for high-risk patients.

Risk prediction models for breast cancer-related lymphedema: A systematic review and meta-analysis

PURPOSE

To review and critically evaluate currently available risk prediction models for breast cancer-related lymphedema (BCRL).

METHODS

PubMed, Embase, CINAHL, Scopus, Web of Science, the Cochrane Library, CNKI, SinoMed, WangFang Data, VIP Database were searched from inception to April 1, 2022, and updated on November 8, 2022. Study selection, data extraction and quality assessment were conducted by two independent reviewers. The Prediction Model Risk of Bias Assessment Tool was used to assess the risk of bias and applicability. Meta-analysis of AUC values of model external validations was performed using Stata 17.0.

RESULTS

Twenty-one studies were included, reporting twenty-two prediction models, with the AUC or C-index ranging from 0.601 to 0.965. Only two models were externally validated, with the pooled AUC of 0.70 (n = 3, 95%CI: 0.67 to 0.74), and 0.80 (n = 3, 95%CI: 0.75 to 0.86), respectively. Most models were developed using classical regression methods, with two studies using machine learning. Predictors most frequently used in included models were radiotherapy, body mass index before surgery, number of lymph nodes dissected, and chemotherapy. All studies were judged as high overall risk of bias and poorly reported.

CONCLUSIONS

Current models for predicting BCRL showed moderate to good predictive performance. However, all models were at high risk of bias and poorly reported, and their performance is probably optimistic. None of these models is suitable for recommendation in clinical practice. Future research should focus on validating, optimizing, or developing new models in well-designed and reported studies, following the methodology guidance and reporting guidelines.

Risk factors of unilateral breast cancer-related lymphedema: an updated systematic review and meta-analysis of 84 cohort studies

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.

Prediction models for breast cancer-related lymphedema: a systematic review and critical appraisal

PURPOSE

The development of risk prediction models for breast cancer lymphedema is increasing, but few studies focus on the quality of the model and its application. Therefore, this study aimed to systematically review and critically evaluate prediction models developed to predict breast cancer-related lymphedema.

METHODS

PubMed, Web of Science, Embase, MEDLINE, CNKI, Wang Fang DATA, Vip Database, and SinoMed were searched for studies published from 1 January 2000 to 1 June 2021. And it will be re-run before the final analysis. Two independent investigators will undertake the literature search and screening, and discrepancies will be resolved by another investigator. The Prediction model Risk Of Bias Assessment Tool will be used to assess the prediction models' risk of bias and applicability.

RESULTS

Seventeen studies were included in the systematic review, including 7 counties, of which 6 were prospective studies, only 7 models were validation studies, and 4 models were externally validated. The area under the curve of 17 models was 0.680~0.908. All studies had a high risk of bias, primarily due to the participants, outcome, and analysis. The most common predictors included body mass index, radiotherapy, chemotherapy, and axillary lymph node dissection.

CONCLUSIONS

The predictive factors' strength, external validation, and clinical application of the breast cancer lymphedema risk prediction model still need further research. Healthcare workers should choose prediction models in clinical practice judiciously.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021258832.

Evaluation of Circulating MicroRNAs and Adipokines in Breast Cancer Survivors with Arm Lymphedema

Breast cancer-related lymphedema (BCRL) is a form of secondary lymphedema that is characterized by abnormal swelling of one or both arms due to the accumulation of lymph fluid in the interstitial tissue spaces, resulting from obstruction of the lymphatic vessels due to surgery insults, radiotherapy, or chemotherapy. Due to the multifactorial nature of this condition, the pathogenesis of secondary lymphedema remains unclear and the search for molecular factors associated with the condition is ongoing. This study aimed to identify serum microRNAs and adipokines associated with BCRL. Blood was collected from 113 breast cancer survivors and processed to obtain serum for small RNA-sequencing (BCRL vs. non-BCRL, n = 7 per group). MicroRNAs that were differentially expressed (fold change >1.5, p < 0.05) between lymphedema cases and those without lymphedema were further quantified in a validation cohort through quantitative reverse transcription PCR (BCRL n = 16, non-BCRL, n = 83). Leptin and adiponectin levels were measured in a combined cohort (BCRL n = 23, non-BCRL n = 90) using enzyme-linked immunosorbent assays. Two of the most significantly upregulated microRNAs, miR-199a-3p and miR-151a-3p, were strongly correlated with the onset of lymphedema and diabetes mellitus in the BCRL group. Leptin levels were higher in the BCRL cohort compared to the non-BCRL cohort (p < 0.05). A metabolic syndrome biomarker, the adiponectin/leptin ratio, was found to be lower in the BCRL group than in the non-BCRL group (median: 0.28 vs. 0.41, p < 0.05). Extensive studies on the mechanisms of the identified microRNAs and association of leptin with arm lymphedema may provide new insights on the potential biomarkers for lymphedema that should be followed up in a prospective cohort study.

Long-Term Patient Satisfaction and Quality of Life Following Breast Reconstruction Using the BREAST-Q: A Prospective Cohort Study

Background

Breast reconstruction is a promising surgical technique to improve health-related quality of life (HRQoL) in patients with breast cancer. However, the long-term risk factors associated with HRQoL after breast surgery are still unclear. Our aim was to evaluate breast satisfaction and HRQoL following breast reconstruction to identify clinical factors associated with each domain of BREAST-Q in the long-term.

Methods

Patient-reported BREAST-Q outcomes were analyzed 1 and 5 years after breast reconstruction in a single-blinded, prospective study. Multiple regression analysis was performed to identify the risk and protective factors associated with BREAST-Q scores. These scores at 1 and 5 years were also compared across three types of operation: mastectomy only, tissue expander/implant (TE/Imp), and a deep inferior epigastric perforator (DIEP) flap.

Results

Surveys were completed by 141 subjects after 1 year and 131 subjects after 5 years. Compared to mastectomy only, breast reconstruction was significantly associated with greater “Satisfaction with breasts” (TE/Imp, p &lt; 0.001; DIEP, p &lt; 0.001) and “Psychosocial well-being” (TE/Imp, p &lt; 0.001; DIEP, p &lt; 0.001), higher body mass index (BMI) resulted in lower “Satisfaction with breasts” (p = 0.004), and a history of psychiatric or neurological medication was significantly associated with “Physical well-being” at 1-year postoperatively (p = 0.02). At 5 years, reconstructive procedures were significantly positively associated with greater “Satisfaction with breasts” (TE/Imp, p &lt; 0.001; DIEP, p &lt; 0.001) and “Psychosocial well-being” (TE/Imp, p = 0.03; DIEP, p &lt; 0.001), and a bilateral procedure was a significant risk factor for lower “Psychosocial well-being” (p = 0.02).

Conclusions

The results of this study show that breast reconstruction improves “Satisfaction with Breasts” and “Psychosocial well-being” compared to mastectomy. Among all three types of operation, DIEP gave the best scores at 5 years postoperatively. Thus, autologous reconstruction is recommended for promotion of long-term HRQoL after breast surgery.