Chemotherapy, radiation, and higher body mass index are strongly associated with increased risk of lymphedema in breast cancer patients who have undergone sentinel node biopsy or axillary lymph node dissection, according to analysis of data from the Rochester Epidemiology Project.
Judy C. Boughey, MD, professor of surgery and vice chair of research at the Mayo Clinic, Rochester, Minn., and her associates performed a chart review of 1,794 patients diagnosed with a first breast cancer in Olmsted County, Minn., between 1990 and 2010. Patients’ median age at diagnosis was 60 years. About half (48%) were diagnosed at stage I, while 17% were diagnosed at Stage 0, 29% at Stage II, and 6% at Stage III.
At a median of 10 years of follow-up, 209 patients had been diagnosed with breast cancer–related lymphedema, with most diagnoses occurring within 5 years of surgery. No cases of lymphedema were found in patients who did not have axillary surgery.
There was no significant difference in the rate of lymphedema based on type of breast cancer surgery (mastectomy vs. lumpectomy with breast-conserving surgery); however, lymphedema occurred significantly more frequently in patients who received ALND as compared to those who received SLN (15.9% vs. 5.3%). Lymphedema rates did not differ based on type of axillary surgery (3.5% for ALND and 4.1% for SLN) in a subset of 453 patients who did not receive radiation or chemotherapy.
Almost a third (31.3%) of patients who had nodal radiation, with or without breast or chest wall radiation, developed lymphedema by 5 years, as compared with 5.9% of patients who did not receive radiation (P less than .001). Similarly, patients who received chemotherapy were significantly more likely to develop lymphedema. At 5 years, lymphedema was present in 27.2% of patients who received anthracylcline/cyclophosphamide (AC) with a taxane agent, 29.7% of those who received a taxane agent without AC , and 6.0% of those who did not get chemotherapy (P less than .001).
Five-year incidence of lymphedema also increased significantly with body mass index, occurring in 17.1% of patients with a BMI greater than 35 kg/m2, 13% of those with a BMI between 30-34.99, and 14.4% of those with a BMI between 25-29.99, as compared with 8% of those with a BMI below 25.
On univariate analysis, increased stage was associated with risk of lymphedema, Dr. Boughey said. However, on multivariate analysis, stage was no longer associated with risk of lymphedema and “the dominate factors were BMI, type of axillary surgery, use of radiation therapy and particularly nodal radiation, and the use of chemotherapy.”
The highest rate of lymphedema was seen in a patients with the most advanced disease who had ALND with nodal radiation and AC with a taxane agent, she said.
“We think this is primarily due to the modalities of treatment rather that the pure phenomenon of stage,” Dr. Boughey added. “This study can help identify patients at a higher risk of lymphedema so that we can individualize the surveillance of these patients to allow them to have earlier identification and earlier treatment of lymphedema.”
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