Meyha N. Swaroop

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.

Establishing and Sustaining a Prospective Screening Program for Breast Cancer-Related Lymphedema at the Massachusetts General Hospital: Lessons Learned

There has been an increasing call to prospectively screen patients with breast cancer for the development of breast cancer-related lymphedema (BCRL) following their breast cancer treatment. While the components of a prospective screening program have been published, some centers struggle with how to initiate, establish, and sustain a screening program of their own. The intent of this manuscript is to share our experience and struggles in establishing a prospective surveillance program within the infrastructure of our institution. It is our hope that by sharing our history other centers can learn from our mistakes and successes to better design their own prospective screening program to best serve their patient population.

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.

Diagnostic Methods, Risk Factors, Prevention, and Management of Breast Cancer-Related Lymphedema: Past, Present, and Future Directions

Purpose of ReviewBreast cancer-related lymphedema (BCRL) is a chronic, adverse, and much feared complication of breast cancer treatment, which affects approximately 20% of patients following breast cancer treatment. BCRL has a tremendous impact on breast cancer survivors, including physical impairments and significant psychological consequences. The intent of this review is to discuss recent studies and analyses regarding the risk factors, diagnosis, prevention through early screening and intervention, and management of BCRL.Recent FindingsHighly-evidenced risk factors for BCRL include axillary lymph node dissection, lack of reconstruction, radiation to the lymph nodes, high BMI at diagnosis, weight fluctuations during and after treatment, subclinical edema within and beyond 3 months after surgery, and cellulitis in the at-risk arm. Avoidance of potential risk factors can serve as a method of prevention. Through establishing a screening program by which breast cancer patients are measured pre-operatively and at follow-ups, are objectively assessed through a weight-adjusted analysis, and are clinically assessed for signs and symptoms, BCRL can be tracked accurately and treated effectively. Management of BCRL is done by a trained professional, with research mounting towards the use of compression bandaging as a first line intervention against BCRL. Finally, exercise is safe for breast cancer patients with and without BCRL and does not incite or exacerbate symptoms of BCRL.SummaryRecent research has shed light on BCRL risk factors, diagnosis, prevention, and management. We hope that education on these aspects of BCRL will promote an informed, consistent approach and encourage additional research in this field to improve patient outcomes and quality of life in breast cancer survivors.

Hand Edema in Patients at Risk of Breast Cancer–Related Lymphedema: Health Professionals Should Take Notice

Background. There is little research on hand edema in the population at risk for breast cancer‐related lymphedema (BCRL). Objectives. Study aims included reporting potential importance of hand edema (HE) as a risk factor for progression of edema in patients treated for breast cancer at risk for BCRL, reporting risk factors for BCRL, and reporting treatment of HE. Design/Methods. This was a retrospective analysis of 9 patients treated for breast cancer in Massachusetts General Hospitals lymphedema screening program who presented with isolated HE. Limb volumes via perometry, BCRL risk factors, and HE treatment are reported. Results. Edema was mostly isolated to the hand. Three patients had arm edema >5% on perometry; and 2 of these had edema outside the hand on clinical examination. Patients were at high risk of BCRL with an average of 2.9/5 known risk factors. Arm edema progressed to >10% in 2 high‐risk patients. Treatment resulted in an average hand volume reduction of 10.2% via perometry and improvement upon clinical examination. Limitations. The small sample size and lack of validated measures of subjective data were limitations. Conclusions. In this cohort, patients with HE carried significant risk factors for BCRL. Two out of 9 (22%), both carrying ≥4/5 risk factors, progressed to edema >10%. Isolated HE may be a prognostic factor for edema progression in patients treated for breast cancer at risk for BCRL. Further research is warranted.

Association Between Precautionary Behaviors and Breast Cancer–Related Lymphedema in Patients Undergoing Bilateral Surgery

Purpose This study examined the lifestyle and clinical risk factors for lymphedema in a cohort of patients who underwent bilateral breast cancer surgery. Patients and Methods Between 2013 and 2016, 327 patients who underwent bilateral breast cancer surgery were prospectively screened for arm lymphedema as quantified by the weight-adjusted volume change (WAC) formula. Arm perometry and subjective data were collected preoperatively and at regular intervals postoperatively. At the time of each measurement, patients completed a risk assessment survey that reported the number of blood draws, injections, blood pressure readings, trauma to the at-risk arm, and number of flights since the previous measurement. Generalized estimating equations were applied to ascertain the association among arm volume changes, clinical factors, and risk exposures. Results The cohort comprised 327 patients and 654 at-risk arms, with a median postoperative follow-up that ranged from 6.1 to 68.2 months. Of the 654 arms, 83 developed lymphedema, defined as a WAC ≥ 10% relative to baseline. On multivariable analysis, none of the lifestyle risk factors examined through the risk assessment survey were significantly associated with increased WAC. Multivariable analysis demonstrated that having a body mass index ≥ 25 kg/m2 at the time of breast cancer diagnosis ( P = .0404), having undergone axillary lymph node dissection ( P = .0464), and receipt of adjuvant chemotherapy ( P = .0161) were significantly associated with increased arm volume. Conclusion Blood pressure readings, blood draws, injections, and number or duration of flights were not significantly associated with increases in arm volume in this cohort. These findings may help to guide patient education about lymphedema risk reduction strategies for those who undergo bilateral breast cancer surgery.

In response to: Letter to the Editor by Kilbreath et al

MEYHA N. SWAROOP, MS, CHERYL L. BRUNELLE, PT, CLT, MARIA S. ASDOURIAN, BS, HODA E. SAYEGH, BA, MELISSA N. SKOLNY, NP, LAURA SALAMA, MD, AND ALPHONSE G. TAGHIAN, MD, PhD* Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts Department of Physical and Occupational Therapy, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts

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.