Reliable prediction of postmastectomy lymphedema: The Risk Assessment Tool Evaluating Lymphedema

Presented as an Oral Presentation at the American Society of Plastic Surgeon's Annual Meeting, October 2015, Boston, Massachusetts.
https://doi.org/10.1016/j.amjsurg.2016.08.016Get rights and content

Abstract

Background

Breast cancer-related lymphedema remains a significant complication post mastectomy. Identifying patients at highest risk may better inform targeted healthcare resource allocation and improve outcomes. This study aims to identify lymphedema predictors after mastectomy to develop a simple, accurate risk assessment tool.

Methods

An institutional retrospective review identified all women with breast cancer undergoing mastectomy between January 2000 and July 2013 with postmastectomy lymphedema as the primary outcome. Stepwise multivariate Cox regression identified independent predictors of lymphedema. A simplified risk assessment tool was derived and composite risk estimated for each patient.

Results

Of 3,136 patients included, 325 (10.4%) developed lymphedema after a follow-up of 4.2 years. Significant predictors included invasive cancer diagnosis (hazard ratio [HR] = 2.25), postmastectomy radiation (HR = 2.05), age over 65 years (HR = 1.90), and axillary dissection (HR = 1.79). Stratified lymphedema risk by group was defined as follows: low 6.2%, moderate 10.0%, high 16.4%, and extreme 36.4%. The model demonstrated excellent risk discrimination (C = .78).

Conclusions

Postmastectomy lymphedema incidence was 10.4%. Invasive cancer diagnosis, chemoradiation, and axillary dissection imparted significant risk. The Risk Assessment Tool Evaluating Lymphedema offers accurate risk discrimination ranging from 6.2% to 36.4%. Selective treatment approaches may improve outcomes and delivery of cost-effective healthcare.

Section snippets

Study design

An Institutional Review Board approved (#818797) retrospective chart review was performed to identify all women diagnosed with breast cancer who underwent mastectomy at our institution from January 1, 2000 to July 1, 2013. Patients were initially identified by querying electronic medical records for the inclusion criteria of breast cancer diagnosis and mastectomy (Appendix A). Specific operations for oncologic resection and any subsequent reconstructions were classified according to the

Patient and operative characteristics

Of the 4,647 eligible patients identified (Appendix B), a total of 3,136 patients met inclusion criteria and were included with an average age of 52.8 ± 11.6 years (Table 1). Patients were excluded from analysis based on the following: no mastectomy within study time frame (n = 557), incomplete dataset (n = 719), pre-existing upper extremity lymphedema diagnosis (n = 22), and follow-up less than 12 months or mortality within 12 months of mastectomy (n = 213). Thirty percent of patients were

Comments

This study reviews the clinical course of 3,136 women undergoing mastectomy for breast cancer to develop an effective and simple predictive tool for postmastectomy lymphedema. Factors most influential in determining risk included invasive cancer diagnosis, chemoradiation treatment, axillary dissection, and obesity. Approximately 10% of patients suffered BCRL overall—application of the RATE-L resulted in a risk discrimination ranging from a low of 6.2% to a high of 36.4%. Several findings merit

Conclusions

This study demonstrated a 10.4% cumulative incidence of postmastectomy lymphedema in a cohort of 3,136 women treated within one health system. The most significant modulators of risk included invasive cancer diagnosis, chemoradiation, and extent of axillary intervention. We propose a simple risk assessment tool for lymphedema (the RATE-L) that offers significant discrimination of lymphedema risk ranging from 6.2% to 36.4%. Patient outcomes and delivery of cost-effective healthcare are likely to

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    Financial Support: Funded by the Center for Human Appearance, the Department of Surgery at the Hospital of the University of Pennsylvania and the Perelman School of Medicine at the University of Pennsylvania.

    This study was reviewed and approved by the Institutional Review Board at the Hospital of the University of Pennsylvania.

    The authors declare no conflicts of interest.

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