Since your breast cancer surgery, have you had hand or ar

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Lymphedema after breast cancer surgery Have we
made any progress?

• Tina Yen, M.D., MS
• Department of Surgery
• Medical College of Wisconsin
• Milwaukee, WI
• October 25, 2008

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Outline

• Symptoms and sequelae
• Measurements
• Incidence
• Risk factors
• Prevention
• Treatment

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Lymphedema

• Accumulation of protein-rich fluid in the
  surrounding tissues
• Etiology
• Surgery
• Radiation
• Infection
• Trauma
• Lymph transport is interrupted
• Physical disruption of channels due to surgery
• Compression of lymphatic channels from radiation
  or surgical changes
• Obstruction of lymphatics by tumor
• Lifetime risk

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Lymphedema

• Tissue swelling/edema
• Repeated episodes of infection
• Chronic inflammation
• Stasis of protein-rich fluid
• Impaired immune clearance
• Fibrosis (hardening)
• Variable time of onset
• Temporary or permanent
• Variable severity
• Not curable

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Symptoms

• Tightness
• Fullness
• Heaviness

• Pain
• Other sensory changes
• Weakness
• Decreased range of motion

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Sequelae of lymphedema

• Physical discomfort and upper extremity
  disability
• Alter activities of daily living
• Cosmetic deformity
• Recurrent arm infections
• Psychosocial morbidity
• Anxiety, depression, and emotional distress
• Psychological distress
• Sexual, physical, and social dysfunction
• Diminished quality of life

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Objective measures

• Circumferential arm measurements
• Measurements of both arms at various points
• Volumetric measurements
• Limb submersion in water
• More accurate but difficult to perform
• Skin/soft tissue tonometry
• Soft-tissue compression is quantified
• Not standardized procedure

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Measurement issues

• All three methods employed
• No standard definition of lymphedema
• Most common definition is gt 2 cm difference
  between circumference measurements from both arms
• No reliable or standard measure exists
• Measure lymphedema
• Assess the functional impact of lymphedema

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Wide variation in lymphedema incidence rates

• Two recent comprehensive reviews (1985-1999)
• 6 to 30
• 0 to 56 (mean 26)
• Reasons for variability
• Retrospective, single-institutional, small
  numbers
• Extent of breast and axillary surgery
• Use and extent of radiation therapy
• Completeness and duration of follow-up
• No standardized methods used to define lymphedema
• No standard time interval to assess for
  lymphedema
• Selection bias

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Established risk factors for lymphedema

• Axillary radiation therapy plus ALND
• 41 incidence of lymphedema (21 - 51)
• Extent of axillary surgery
• 17 incidence of lymphedema (6 - 39)
• Risk of lymphedema increases with the number of
  lymph nodes removed
• Issues
• Older data
• More extensive operations
• More frequent use of axillary radiation

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Sentinel lymph node biopsy in breast cancer
Sentinel lymph node biopsy
Selective approach to ALND
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Lymphatic Mapping Technique
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Lymphatic Mapping Technique with blue dye and
colloid
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Lymphedema and arm morbidity after SLNB

• Compared with ALND patients, SLNB patients have
• Less lymphedema (0-7)
• Less pain
• Less numbness
• Better arm mobility
• Less psychological morbidity
• Better quality of life
• Limitations of current studies
• Small numbers
• Single institution
• Retrospective
• Short follow-up (12-24 months)

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Other potential risk factors

• Patient age
• Patient weight/BMI
• History of arm infections
• Extent of disease
• Tumor size
• Nodal involvement
• Type of breast surgery (lumpectomy vs.
  mastectomy)
• Type of axillary surgery (SLNB vs. ALND)
• Treatment modalities
• Radiation therapy
• Chemotherapy
• Hormonal therapy
• Surgeon technique

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Population-based study of older breast cancer
patients

• Population-based cohort of 2,154 women
• Aged 65-89 years at time of breast cancer surgery
  in 2003
• Reside in California, Florida or Illinois
• Three telephone surveys
• Completed at median of 48 months after surgery
• Variables demographic and adjuvant treatment
• Medicare claims
• Type of breast and axillary surgery
• Surgeon volume
• State tumor registries

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Self-reported lymphedema

• Since your breast cancer surgery, has a doctor
  ever told you that you have lymphedema or arm
  edema?
• Since your breast cancer surgery, have you had
  hand or arm swelling on the side of your breast
  cancer surgery that you have not had on the other
  side?

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Results

• 2,154 women were operated on by 966 different
  surgeons
• Majority had early stage disease
• 17 DCIS
• 64 Node-negative
• 18 Node-positive
• 0.7 Distant disease
• 64 breast-conserving surgery
• Type of axillary surgery
• 19 none
• 23 SLNB alone
• 58 ALND
• 15.5 (n 333) had self-reported lymphedema at a
  median of 48 months postoperatively

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Univariate analysis

• Younger age (72.1 vs. 72.9 years)
• Higher BMI
• Time of surgery (27.7 vs. 26.8)
• At 48 months postoperatively (27.9 vs. 26.5)
• More extensive disease
• Larger tumor size
• Presence of lymph node metastases
• Higher tumor stage
• More extensive surgery
• Mastectomy vs. lumpectomy
• ALND vs. SLNB
• More lymph nodes removed
• Chemotherapy
• No association change in BMI since surgery,
  race, tumor grade, receipt of radiation or
  hormonal therapy, and surgeon volume

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Association between axillary surgery type and
development of lymphedema
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Number of lymph nodes removed is the only
independent predictor of the development of
lymphedema
Model also adjusts for patient age, BMI at time
of surgery, tumor size, lymph node status, type
of breast and axillary surgery, receipt of
radiation therapy, chemotherapy, hormonal
therapy, and surgeon volume
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Study summary

• 15.5 self-reported lymphedema at 4 years
• Only independent predictor of lymphedema was the
  removal of gt 5 lymph nodes
• Regardless of whether SLNB or ALND performed
• Risk of lymphedema
• No axillary surgery 6.0
• SLNB alone 7.4
• No association with lymphedema
• Radiation therapy
• Surgeon volume
• Age, BMI, lymph node status, extent of breast
  surgery, and receipt of chemotherapy or hormonal
  therapy

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Study limitations/conclusions

• Limitations
• Cohort of older women
• Medicare claims
• Self-report of lymphedema
• Conclusions
• Consider the removal 5 or fewer lymph nodes with
  SLNB
• Counsel women undergoing SLNB on their risk of
  lymphedema

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Prevention of lymphedema

• Principles
• Production of lymph flow should not be increased
• Blockage to lymph transport should not be
  increased
• Avoid any procedures on the affected arm
• Avoid punctures or injuries to the skin
• Keep meticulous skin and nail care
• Avoid constricting sleeves or jewelry
• Avoid heat
• Avoid excessive exercise to the affected arm

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Lymphedema treatment

• Begin once lymphedema is recognized
• Options
• Elevation
• Compression garments
• Centripetal massage and exercises
• Pneumatic compression devices
• Program of complete decongestive physiotherapy
  (CDP)/decongestive lymphatic therapy (DLT)

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Complete decongestive physiotherapy

• Phase I Treatment phase (1-4 weeks)
• 1 or 2 75- to 90-minute treatments daily
• Meticulous skin and nail care
• Manual lymphatic drainage (MLD)
• Low-stretch multilayer bandaging
• Physical therapy in bandages
• Phase II Maintenance phase (for life)
• Meticulous skin and nail care
• Elastic compression sleeve during the day
• Low-stretch multilayer bandages overnight
• Exercises in bandages

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Efficacy of treatments

• Therapies are often used in combination
• Most common modalities elevation, massage, and
  exercise
• Therapies show a 15 - 75 reduction in arm
  volume or circumference
• Need for large randomized studies
• Relative efficacy of interventions
• Optimal timing of interventions
• Effect of treatment on disease progression

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Summary

• Lymphedema causes physical and psychosocial
  morbidity.
• Women with breast cancer have a life-long risk of
  developing lymphedema.
• In our population-based cohort of older breast
  cancer women, 15.5 developed self-reported
  lymphedema at 4 years.
• In our study, the only risk factor for the
  development of lymphedema is the removal of more
  than 5 lymph nodes.
• Prevention measures are not evidence-based.
• Treatment can be successful, especially if
  instituted early.

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Acknowledgements

• Patient Care and Outcomes Research (PCOR)
• Ann B. Nattinger, MD, MPH
• Rodney Sparapani, MS
• Purushuttom Laud, PhD
• Xiaolin Fan, PhD
• Changbin Guo, BS
• Alonzo P. Walker, MD
• Funding support
• NIH/NCI K07CA125586
• NIH/NCI R01CA81379

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Resources

• National Lymphedema Network
• www.lymphnet.org
• National Cancer Institute
• http//www.cancer.gov/cancertopics/pdq/supportivec
  are/lymphedema/Patient
• American Cancer Society
• http//www.cancer.org/docroot/MIT/content/MIT_7_2x
  _Lymphedema_and_Breast_Cancer.asp