International Journal of Radiation Oncology*Biology*Physics
Clinical InvestigationA Model to Estimate the Risk of Breast Cancer-Related Lymphedema: Combinations of Treatment-Related Factors of the Number of Dissected Axillary Nodes, Adjuvant Chemotherapy, and Radiation Therapy
Introduction
Breast cancer-related lymphedema (LE) is one of the unpleasant complications of breast cancer surgery with axillary lymph node dissection (ALND). As the survival rate among breast cancer patients has increased, LE has emerged as an important long-term morbidity that can cause functional, cosmetic, and psychological problems and which can impair survivors' quality of life.
The reported incidence of LE after breast cancer treatment varies widely, from less than 5% with lumpectomy alone to more than 60% when treatment includes mastectomy with ALND and radiation therapy (RT) (1). In addition to these therapeutic modalities, nonstandard diagnostic methods of LE and variation in the follow-up period also contribute to the large variation in LE incidence.
The origins of and risk factors associated with LE are multifactorial and are still not fully understood. Three categories of treatment-related, disease-related, and patient-related risk factors have been reported to increase the incidence of LE in several series 2, 3, 4. Although sentinel lymph node biopsy (SLNB) has replaced ALND for staging of patients in whom axillary nodes are clinically negative, and it is well known that LE after SLNB is less common or severe than after ALND, ALND remains the standard of care in the management of invasive breast carcinoma when patients have clinically positive lymph nodes or metastatic spread to the sentinel nodes 5, 6. Approximately one-third of patients undergo ALND, and treatment-related factors for ALND, chemotherapy, and RT are assumed to be closely related to LE development 7, 8. For this subset of patients, a tool for predicting the risk of LE should be created to help physicians and breast cancer patients control such patient-related factors as obesity, infection, injury, and arm overuse.
In the present study, we analyzed the probability of LE by using grading scales that combined objective and subjective methods with a relatively long follow-up period. The main purpose was to create a model for use in estimating the risk of LE based on combinations of treatment- or disease-related risk factors, which can be used easily and effectively in a busy clinical setting.
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Patients
The study population consisted of 1254 consecutive patients with breast cancer who underwent modified radical mastectomy (MRM) or breast-conserving surgery (BCS) with ALND at the National Cancer Center, Korea between May 2004 and April 2009. Among these, 375 women who were treated with neoadjuvant chemotherapy followed by surgery were excluded from the study. Patients with synchronous or metachronous contralateral breast cancer (n=4) and male patients (n=2) were excluded. Patients whose
Results
Patient and treatment characteristics are summarized in Table 1. The median age at the time of surgery was 47 years old (range, 26-83 years old). BCS was performed in 606 (79%) and MRM in 166 (21%) patients. Median N-ALN was 11 (range, 5-41). ACT was administered to 677 patients (88%). In total, RT was administered to 674 patients (87%), among whom 400 (52%) received breast or chest wall irradiation alone. SCRT was delivered to 274 patients (35%). Among 98 patients (13%) who did not receive RT,
Discussion
The incidence of LE is difficult to compare among studies because of a lack of standardization of follow-up periods and definitions. Several reports with long-term follow-up have shown that the risk of lymphedema increases persistently until 20 years after surgery, although most cases occurred within 3 years 6, 7. Therefore, studies reporting the incidence of LE with less than 5 years of follow-up would underestimate the true incidence. We followed our patients for at least 3 years (median, 5.1
Conclusions
In conclusion, the results of the current analysis show that N-ALN, ACT, and SCRT are independent risk factors for the development of LE. The number of risk factors was well correlated with the LE risk. A simple model to estimate the 5-year LE probability using combinations of risk factors was proposed, which might be useful for identifying patients at risk for LE and in creating a management plan for these patients.
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Cited by (0)
M. Kim and S.W. Kim contributed equally to this work.
This research was supported by National Cancer Center Grant NCC-1210181-1.
Conflict of interest: none.