Lauren S. Jammallo

The Impact of Radiation Therapy on the Risk of Lymphedema After Treatment for Breast Cancer: A Prospective Cohort Study

PURPOSE/OBJECTIVE Lymphedema after breast cancer treatment can be an irreversible condition with a negative impact on quality of life. The goal of this study was to identify radiation therapy-related risk factors for lymphedema. METHODS AND MATERIALS From 2005 to 2012, we prospectively performed arm volume measurements on 1476 breast cancer patients at our institution using a Perometer. Treating each breast individually, 1099 of 1501 patients (73%) received radiation therapy. Arm measurements were performed preoperatively and postoperatively. Lymphedema was defined as ≥10% arm volume increase occurring >3 months postoperatively. Univariate and multivariate Cox proportional hazard models were used to evaluate risk factors for lymphedema. RESULTS At a median follow-up time of 25.4 months (range, 3.4-82.6 months), the 2-year cumulative incidence of lymphedema was 6.8%. Cumulative incidence by radiation therapy type was as follows: 3.0% no radiation therapy, 3.1% breast or chest wall alone, 21.9% supraclavicular (SC), and 21.1% SC and posterior axillary boost (PAB). On multivariate analysis, the hazard ratio for regional lymph node radiation (RLNR) (SC ± PAB) was 1.7 (P=.025) compared with breast/chest wall radiation alone. There was no difference in lymphedema risk between SC and SC + PAB (P=.96). Other independent risk factors included early postoperative swelling (P<.0001), higher body mass index (P<.0001), greater number of lymph nodes dissected (P=.018), and axillary lymph node dissection (P=.0001). CONCLUSIONS In a large cohort of breast cancer patients prospectively screened for lymphedema, RLNR significantly increased the risk of lymphedema compared with breast/chest wall radiation alone. When considering use of RLNR, clinicians should weigh the potential benefit of RLNR for control of disease against the increased risk of lymphedema.

Lymphedema following breast cancer treatment and impact on quality of life: A review

Lymphedema resulting from breast cancer treatment is a chronic condition which can significantly compromise quality of life. We sought to review various aspects of breast-cancer related lymphedema including measurement techniques, definitions, risk factors, and specifically, impact on physical, psychological, and emotional well-being of women treated for breast cancer. For the purpose of this review, we performed a literature search using PubMed for articles on lymphedema secondary to breast cancer treatment published since 1997. While improvements in breast cancer therapy have contributed to a decrease in the incidence of lymphedema, the overall negative impact the condition has on patients and survivors has remained unchanged. The development of lymphedema results in physical impairments including compromised function, diminished strength, fatigue, and pain in the affected arm. Affected women may have decreased self-confidence resulting from a distorted body image. Negative emotions reported by women with lymphedema include anxiety, frustration, sadness, anger, fear, and increased self-consciousness. Lymphedema secondary to breast cancer treatment remains a significant quality of life issue, with known consequences related to a womans physical, psychological, and emotional well-being.

Impact of Ipsilateral Blood Draws, Injections, Blood Pressure Measurements, and Air Travel on the Risk of Lymphedema for Patients Treated for Breast Cancer

PURPOSE The goal of this study was to investigate the association between blood draws, injections, blood pressure readings, trauma, cellulitis in the at-risk arm, and air travel and increases in arm volume in a cohort of patients treated for breast cancer and screened for lymphedema. PATIENTS AND METHODS Between 2005 and 2014, patients undergoing treatment of breast cancer at our institution were screened prospectively for lymphedema. Bilateral arm volume measurements were performed preoperatively and postoperatively using a Perometer. At each measurement, patients reported the number of blood draws, injections, blood pressure measurements, trauma to the at-risk arm(s), and number of flights taken since their last measurement. Arm volume was quantified using the relative volume change and weight-adjusted change formulas. Linear random effects models were used to assess the association between relative arm volume (as a continuous variable) and nontreatment risk factors, as well as clinical characteristics. RESULTS In 3,041 measurements, there was no significant association between relative volume change or weight-adjusted change increase and undergoing one or more blood draws (P = .62), injections (P = .77), number of flights (one or two [P = .77] and three or more [P = .91] v none), or duration of flights (1 to 12 hours [P = .43] and 12 hours or more [P = .54] v none). By multivariate analysis, factors significantly associated with increases in arm volume included body mass index ≥ 25 (P = .0236), axillary lymph node dissection (P < .001), regional lymph node irradiation (P = .0364), and cellulitis (P < .001). CONCLUSION This study suggests that although cellulitis increases risk of lymphedema, ipsilateral blood draws, injections, blood pressure readings, and air travel may not be associated with arm volume increases. The results may help to educate clinicians and patients on posttreatment risk, prevention, and management of lymphedema.

Lymphedema following treatment for breast cancer: A new approach to an old problem

Lymphedema following treatment for breast cancer can be an irreversible condition with a profound negative impact on quality of life. The lack of consensus regarding standard definitions of clinically significant lymphedema and optimal methods of measurement and quantification are unresolved problems. Inconsistencies persist regarding the appropriate timing of intervention and what forms of treatment should be the standard of care. There are reports that early detection and intervention can prevent progression, however,the Level 1 evidence to support this hypothesis has yet to be generated. To assess these controversies, we propose the implementation of a screening program to detect early lymphedema in conjunction with a randomized, prospective trial designed to generate Level 1 evidence regarding the efficacy of early intervention and appropriate treatment strategies. Collaboration among institutions that manage breast cancer patients is essential to establish a standardized approach to lymphedema and to establish guidelines for best practice.

Immediate Implant Reconstruction Is Associated With a Reduced Risk of Lymphedema Compared to Mastectomy Alone: A Prospective Cohort Study.

Objective:We sought to determine the risk of lymphedema associated with immediate breast reconstruction compared to mastectomy alone. Background:Immediate breast reconstruction is increasingly performed at the time of mastectomy. Few studies have examined whether breast reconstruction impacts development of lymphedema. Methods:A total of 616 patients with breast cancer who underwent 891 mastectomies between 2005 and 2013 were prospectively screened for lymphedema at our institution, with 22.2 months’ median follow-up. Mastectomies were categorized as immediate implant, immediate autologous, or no reconstruction. Arm measurements were performed preoperatively and during postoperative follow-up using a Perometer. Lymphedema was defined as 10% or more arm volume increase compared to preoperative. Kaplan-Meier and Cox regression analyses were performed to determine lymphedema rates and risk factors. Results:Of 891 mastectomies, 65% (580/891) had immediate implant, 11% (101/891) immediate autologous, and 24% (210/891) no reconstruction. The two-year cumulative incidence of lymphedema was as follows: 4.08% [95% confidence interval (CI): 2.59–6.41%] implant, 9.89% (95% CI: 4.98–19.1%) autologous, and 26.7% (95% CI: 20.4–34.4%) no reconstruction. By multivariate analysis, immediate implant [hazards ratio (HR): 0.352, P < 0.0001] but not autologous (HR: 0.706, P = 0.2151) reconstruction was associated with a significantly reduced risk of lymphedema compared to no reconstruction. Axillary lymph node dissection (P < 0.0001), higher body mass index (P < 0.0001), and greater number of nodes dissected (P = 0.0324) were associated with increased lymphedema risk. Conclusions:This prospective study suggests that in patients for whom implant-based reconstruction is available, immediate implant reconstruction does not increase the risk of lymphedema compared to mastectomy alone.

Factors Associated With Fear of Lymphedema After Treatment for Breast Cancer

PURPOSE/OBJECTIVES To identify demographic and treatment characteristics associated with postoperative fear of lymphedema. DESIGN Prospective cohort study. SETTING Outpatient breast clinic at a comprehensive cancer center in the northeastern United States. SAMPLE 324 patients undergoing treatment for unilateral breast cancer. METHODS Women with breast cancer were prospectively screened for lymphedema (relative volume change of 10% or greater) preoperatively and every three to eight months postoperatively via Perometer arm volume measurements. Fear was simultaneously evaluated via questionnaire. Multivariate linear mixed-effects regression models were used to identify factors associated with mean postoperative fear score and to plot the average fear score over time within axillary surgery type subgroups. MAIN RESEARCH VARIABLES Postoperative fear of lymphedema. FINDINGS Higher preoperative fear score (p < 0.0001), younger age at diagnosis (p = 0.0038), and axillary lymph node dissection (ALND) (p < 0.0001) were significantly associated with higher mean postoperative fear score. The average fear score changed nonlinearly over time (p < 0.0001), decreasing from preoperative to 24 months postoperative and leveling thereafter. CONCLUSIONS Preoperative fear, younger age at diagnosis, and ALND may contribute to postoperative fear of lymphedema. IMPLICATIONS FOR NURSING Individualized education that begins preoperatively, continues throughout treatment, and is re-emphasized 24 months postoperatively may help minimize fear of lymphedema.

Screening for Breast Cancer-Related Lymphedema: The Need for Standardization

This commentary explores the challenges surrounding the development of a standard definition of lymphedema and method of quantification, proposes solutions, and calls for a collaborative effort among providers who care for patients with breast cancer.

The Role of Sonographic Imaging to Assess the Pathophysiology of Cording in Patients Treated for Breast Cancer A Pilot Study

The pathophysiology of cording (visible bands of tissue that can form in the ipsilateral axilla and arm following breast cancer surgery) remains equivocal. Cording can be a painful and functionally limiting condition. Our aim was to assess the role of duplex ultrasonographic imaging as a diagnostic tool for assessment of this condition. We evaluated five women who had undergone surgery for unilateral breast cancer. Cording was identified by self-report and confirmed by physical examination. Duplex ultrasonography was performed within one week of the clinical diagnosis of cording. Duplex ultrasonography failed to identify the cording structures and does not appear to be a useful diagnostic tool for determining the pathophysiology of cording following treatment for breast cancer. Research focusing on intervention strategies to facilitate the clinical resolution of cording following breast cancer surgery is needed.

Abstract PD4-5: Blood draws, injections, blood pressure readings in the at-risk arm, and flying might not be associated with increases in arm volume: A prospective study

Introduction: Breast cancer related lymphedema (BCRL) is a swelling caused by compromise of the lymphatic system after breast cancer treatment. Commonly-cited risk factors include treatment related variables such as axillary lymph node dissection (ALND) and regional lymph node radiation (RLNR), and patient characteristics including BMI. Patients are often advised to avoid blood draws, injections, and blood pressure cuffs on their at-risk arm, airplane travel, and extensive exercise to reduce the risk of developing BCRL; however, data demonstrating the efficacy of such avoidance strategies do not exist. We sought to determine the impact of blood draws, injections, and blood pressure readings in the at-risk arm, and flying on increases in arm volume in a large, prospective cohort of patients. Methods: 522 patients who underwent treatment for unilateral breast cancer between were included. Patients were prospectively screened for BCRL with Perometer arm measurements pre-operatively, post-operatively, and at 3-8 month intervals thereafter. At each measurement patients were asked to report number of blood draws, injections, and blood pressure readings in the at-risk arm, and number of flights since the last measurement, and their responses were assessed for association with relative volume change (RVC). RVC was analyzed as a continuous variable for association with risk factors. Results: 522 patients with 2033 post operative measurements were included. Patients were followed for a median of 23 months and 4 post-operative measurements, with a minimum of 1 post-operative measurement and a maximum of 14. 5.56%. 76.8% (401/522) underwent lumpectomy, 23.2% (121/522) underwent mastectomy. 70% (366/522) underwent sentinel lymph node biopsy, and 19% (98/522) underwent ALND. 62.4% (352/521) received radiation to the breast/ chest wall only, and 21.5% (112/521) also received regional lymph node radiation. By univariate analysis, there was no significant association between RVC increase and undergoing one or more blood draws (p=0.36), blood pressure (p=0.88), injections (p=0.79), or number of flights (p=0.89). ALND was significantly associated with increases in arm volume (p=0.0017) by univariate analysis and older age at diagnosis was associated with increased RVC with borderline significance (p=0.059). Conclusions: In our patient population, non-treatment related risk factors including blood draws, blood pressures, and injections in the at-risk arm, and flying were not significantly associated with increases in arm volume. This data can be used to help improve and refine patient education regarding the importance of risk-reducing practices after breast cancer treatment. Citation Format: Chantal M Ferguson, Cynthia L Miller, Nora Horick, Melissa N Skolny, Meyha N Swaroop, Lauren S Jammallo, Jean A O9Toole, Michelle C Specht, Alphonse G Taghian. Blood draws, injections, blood pressure readings in the at-risk arm, and flying might not be associated with increases in arm volume: A prospective study [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr PD4-5.

Abstract P1-09-13: Risk of breast cancer related lymphedema after treatment with taxane-based chemotherapy: A prospective cohort study

Background: Taxane-based chemotherapy is routinely used in the treatment of breast cancer and has been shown to improve both disease-free survival (DFS) and overall survival (OS). A common side effect of taxane-based chemotherapy is fluid retention in the extremities, which may increase the risk of breast cancer related lymphedema (BCRL). BCRL is a chronic swelling of the arms, breast, or trunk due to accumulation of lymphatic fluid in the interstitial tissues, which has a profoundly negative impact on quality of life. Little data exists regarding the impact of taxane-based chemotherapy and fluid retention on risk of developing BCRL. We sought to determine whether receipt of taxane-based chemotherapy for the treatment of breast cancer increases the risk of BCRL development in a large, prospective cohort of breast cancer patients. Methods: We identified 569 patients diagnosed with unilateral breast cancer between 2005-2012 who underwent surgery and prospective screening for BCRL at our institution. All patients included in this analysis had ≥ 18 months of post-operative follow-up. Bilateral arm volume measurements were performed using a perometer preoperatively and every 3-7 months postoperatively. BCRL was defined as a relative volume change (RVC) of ≥10%. Clinicopathologic characteristics and treatment details were obtained by medical record review. Cox proportional hazard analyses were performed to analyze risk of BCRL. Arm measurements obtained after contralateral prophylactic surgery or diagnosis of metastasis were excluded to avoid potential confounding. Results: Arm volume measurements from 569 patients were included with a median post-operative follow-up of 28 months (range 18-75.1). 33% (187/569) of patients received taxane-based chemotherapy in the neoadjuvant and/or adjuvant setting, and 92% (172/187) of these patients received pre-medication with dexamethasone to prevent hypersensitivity and reduce edema. 3% (18/569) received non-taxane based chemotherapy and 64% (364/569) received no chemotherapy. 23% (131/569) had axillary lymph node dissection (ALND), 61% (346/569) had sentinel lymph node biopsy (SLNB), and 16% (92/569) had no nodal surgery. At 24 months, the cumulative incidence of BCRL was 5.0% (95% CI: 3.15-7.81%) among patients who did not receive taxane-based chemotherapy, compared to 13.4% (95% CI: 9.17-19.4%) in the taxane-based chemotherapy group. On univariate analysis, taxane-based chemotherapy was associated with increased risk of BCRL (HR=2.2, p=0.0037), in addition to ALND, higher body mass index, greater number of lymph nodes (LNs) dissected and greater number of positive LNs (p Conclusion: Our results suggest that patients who receive taxane-based chemotherapy are not at an increased risk of BCRL compared with patients who received non-taxane or no chemotherapy. This data can be used to improve patient education and counsel those who experience temporary fluid retention while on taxane-based chemotherapy. Citation Format: Meyha N Swaroop, Cynthia L Miller, Nora Horick, Chantal M Ferguson, Melissa N Skolny, Jean O9Toole, Lauren S Jammallo, Michelle C Specht, Alphonse G Taghian. Risk of breast cancer related lymphedema after treatment with taxane-based chemotherapy: A prospective cohort study [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-09-13.