From: The American Society of Breast Surgeons
Axillary Surgery Only One Factor
Breast cancer-related lymphedema, chronic swelling of the arm and chest area, is strongly associated with multi-modality therapies and not axillary node surgery alone as widely believed, according to a new study presented this week at the Annual Meeting of the American Society of Breast Surgeons.
The study found that chemotherapy, more advanced disease and greater than normal body weight significantly increased the risk of lymphedema for patients who had surgery of lymph nodes under their arms to assess the spread of cancer. Radiation therapy also strongly correlated with lymphedema for patients undergoing axillary node dissection (ALND), the more invasive form of axillary surgery.
“Lymphedema rate was significantly lower among patients undergoing axillary surgery without these additional risk factors,” says study co-author Judy Boughey, M.D., FACS, professor of surgery and research chair, department of surgery at Mayo Clinic. “We must recognize that today, breast cancer is no longer a disease treated primarily through surgery, and many therapies impact the risk of this chronic condition. Risk factors appeared to be cumulative, affecting women in a step-like fashion.”
According to Dr. Boughey, most breast cancer patients are extremely concerned about developing lymphedema, and this study provides important new information furthering an understanding of the condition. “It has long been widely assumed that axillary surgery is the dominant factor affecting lymphedema development,” she says.
Dr. Boughey notes that axillary surgery for lymph node staging can involve sentinel lymph node biopsy (SLNB), which involves removal of an average of two or three lymph nodes, or ALND, usually involving removal of between 10 and 30 nodes. ALND was not associated with a higher lymphedema rate than SLNB unless chemotherapy or radiation therapy was involved.
The new study included 1794 women with stage 0 to 3 breast cancer between 1990 and 2010 drawn from a large regional database. Of these patients, 59% underwent breast-conserving lumpectomy, 28% unilateral mastectomy and 13% bilateral mastectomy. The type of breast surgery was not associated with lymphedema development.
Forty-four percent of patients were treated with ALND with an average of 16 nodes removed, while 40% had SLNB with an average of 3 nodes removed. Within five years, 5.3% of SLNB and 15.9% of ALND patients developed lymphedema. In the study, all patients who developed lymphedema within five years had undergone some form of axillary surgery.
The study found that lymphedema was associated with stage 2 and 3 disease because patients typically were treated with radiation and/or chemotherapy. Lymphedema risk also increased with higher body mass index (BMI) considered overweight and additionally for women considered obese.
“Clearly, for a realistic perspective on lymphedema risk, women should talk not only to their surgeons but also to their oncologists and radiation oncologists and take into account the full multidisciplinary treatment that they are undertaking,” comments Dr. Boughey.
She also notes that treatment options for lymphedema have improved during the past decade. “Patients with a high lymphedema risk profile should be carefully followed so that any necessary interventions can begin early,” she advises.
“This study stresses the importance of preoperative patient counseling regarding lymphedema,” notes Deanna Attai, M.D., assistant clinical professor of surgery at the David Geffen School of Medicine at UCLA and ASBrS immediate past-president. “Lymphedema can have a significant impact on long term quality of life, and patients will benefit from a multidisciplinary approach to education on this topic.”