The Risk of Developing Arm Lymphedema Among Breast Cancer Survivors: A Meta-Analysis of Treatment Factors

Background  As more women survive breast cancer, long-term complications that affect quality of life, such as lymphedema of the arm, gain greater importance. Numerous studies have attempted to identify treatment and prognostic factors for arm lymphedema, yet the magnitude of these associations remains inconsistent. Methods  A PubMed search was conducted through January 2008 to locate articles on lymphedema and treatment factors after breast cancer diagnosis. Random-effect models were used to estimate the pooled risk ratio. Results  The authors identified 98 independent studies that reported at least one risk factor of interest. The risk ratio (RR) of arm lymphedema was increased after mastectomy when compared with lumpectomy [RR = 1.42; 95% confidence interval (CI) 1.15–1.76], axillary dissection compared with no axillary dissection (RR = 3.47; 95% CI 2.34–5.15), axillary dissection compared with sentinel node biopsy (RR = 3.07; 95% CI 2.20–4.29), radiation therapy (RR = 1.92; 95% CI 1.61–2.28), and positive axillary nodes (RR = 1.54; 95% CI 1.32–1.80). These associations held when studies using self-reported lymphedema were excluded. Conclusions  Mastectomy, extent of axillary dissection, radiation therapy, and presence of positive nodes increased risk of developing arm lymphedema after breast cancer. These factors likely reflected lymph node removal, which most surgeons consider to be the largest risk factor for lymphedema. Future studies should consider examining sentinel node biopsy versus no dissection with a long follow-up time post surgery to see if there is a benefit of decreased lymphedema compared with no dissection.     

Risk Factors Associated with Breast Lymphedema

Background

The development of breast lymphedema (BLE) after breast/axillary surgery is poorly characterized. We prospectively evaluated clinical and surgical factors associated with development of BLE.

Methods

Patients undergoing unilateral breast-conserving surgery were prospectively enrolled preoperatively and followed for development of BLE. To augment the number of patients with BLE for evaluation of risk factors, postoperative patients identified in the clinic with signs and symptoms of BLE were also enrolled. Logistic regression with Firth’s penalized likelihood bias-reduction method was used for univariate and multivariate analysis.

Results

Of 144 women, 124 were enrolled preoperatively (38 of whom developed BLE), and 20 women with BLE were enrolled postoperatively. Any type of axillary surgery was the strongest factor associated with BLE (odds ratio, 134; 95 % confidence interval, 18 to >1,000). All 58 BLE events occurred in women with axillary surgery as compared with no events in the 46 patients without axillary surgery (p < 0.0001). Among 98 women who underwent axillary surgery, BLE did not occur more often after axillary lymph node dissection versus sentinel lymph node biopsy (p = 0.38) and was not associated with total number of nodes removed (p = 0.52). In multivariate analysis, factors associated with the development of BLE in the axillary surgery subgroup included baseline BMI (p = 0.004), incision location (p = 0.009), and prior surgical biopsy (p = 0.01).

Conclusions

Risk of BLE is primarily related to performance of any axillary surgery but not the extent of axillary surgery or number of lymph nodes removed. Other factors associated with BLE were increased body mass index, incision location, and prior surgical excisional biopsy.     

Sexuality and Spousal Support Among Women with Advanced Breast Cancer

Abstract: This study examines the relationships of mood, age, living with a spouse, and time elapsed since diagnosis of first recurrence to sexual interest. Seventy-two women with metastatic breast cancer and 26 of their spouses were recruited through their oncologists. Women and their spouses were administered a battery of measures designed to assess psychosocial and medical variables. Eighty-three percent of the women and 100% of the spouses indicated that sexual pleasure was something they wanted to experience; however, only 25% of the women indicating this interest and only 19% of the spouses reported that it had been easy for them to experience sexual pleasure. For patients, living with a spouse was significantly associated with being interested in experiencing sexual pleasure [p <.05]. Patients with lower mood disturbance were significantly more able to experience sexual pleasure than those with high mood disturbance scores [p <.05]. Ability to experience sexual pleasure was significantly and positively correlated between patients and their spouses ( r =.56, p <.01). Sexuality is an important aspect of quality of life for metastatic breast cancer patients and their spouses. Further research is needed to examine psychosocial factors that affect sexuality for this population.     

A Contemporary, Population-Based Study of Lymphedema Risk Factors in Older Women with Breast Cancer

Background  We studied potential risk factors for lymphedema in a contemporary population of older breast cancer patients. Methods  Telephone surveys were conducted among women (65–89 years) identified from Medicare claims as having initial breast cancer surgery in 2003. Lymphedema was classified by self-report. Surgery and pathology information was obtained from Medicare claims and the state cancer registries. Results  Of 1,338 patients treated by 707 surgeons, 24% underwent sentinel lymph node biopsy (SLNB) and 57% axillary lymph node dissection (ALND). At a median of 48 months postoperatively, 193 (14.4%) had lymphedema. Lymphedema developed in 7% of the 319 patients who underwent SLNB and in 21% of the 759 patients who underwent ALND. When controlling for patient age, tumor size, type of breast cancer, type of breast and axillary surgery, receipt of radiation, chemotherapy, and hormonal therapy, and surgeon case volume, the independent predictors of lymphedema were removal of more than five lymph nodes [odds ratio (OR) 4.68–5.61, 95% confidence interval (CI) 1.36–19.74 for 6–15 nodes; OR 10.50, 95% CI 2.88–38.32 for >15 nodes] and presence of lymph node metastases (OR 1.98, 95% CI 1.21–3.24). Conclusions  Four years postoperatively, 14% of a contemporary, population-based cohort of elderly breast cancer survivors had self-reported lymphedema. In this group of predominately community-based surgeons, the number of lymph nodes removed is more predictive of lymphedema rather than whether SLNB or ALND was performed. As more women with breast cancer undergo only SLNB, it is essential that they still be counseled on their risk for lymphedema. Presented at the 61st Annual Society of Surgical Oncology Cancer Symposium, Chicago, IL, March 2008.     

Incidence,Risk Factors,and Obstetrical Outcomes of Women with Breast Cancer in Pregnancy

Abstract: Breast cancer in pregnancy is a rare condition. The objective of our study was to describe the incidence, risk factors, and obstetrical outcomes of breast cancer in pregnancy. We conducted a population‐based cohort study on 8.8 million births using data from the Healthcare Cost and Utilization Project – Nationwide Inpatient Sample from 1999–2008. The incidence of breast cancer was calculated and logistic regression analysis was used to evaluate the independent effects of demographic determinants on the diagnosis of breast cancer and to estimate the adjusted effect of breast cancer on obstetrical outcomes. There were 8,826,137 births in our cohort of which 573 cases of breast cancer were identified for an overall 10‐year incidence of 6.5 cases per 100,000 births with the incidence slightly increasing over the 10‐year period. Breast cancer appeared to be more common among women >35 years of age, odds ratio (OR) = 3.36 (2.84–3.97); women with private insurance plans, OR = 1.39 (1.10–1.76); and women who delivered in an urban teaching hospital, OR = 2.10 (1.44–3.06). After adjusting for baseline characteristics, women with pregnancy‐associated breast cancer were more likely to have an induction of labor, OR = 2.25 (1.88, 2.70), but similar rates of gestational diabetes, preeclampsia, instrumental deliveries, and placental abruption. The incidence of breast cancer in pregnancy appears higher than previously reported with women over 35 being at greatest risk. Aside from an increased risk for induction of labor, women with breast cancer in pregnancy have similar obstetrical outcomes.     

Women with Locally Advanced Breast Cancer are Not at Higher Risk for Contralateral Synchronous Breast Cancer

Abstract: Breast magnetic resonance imaging (MRI) may provide a more accurate assessment of synchronous contralateral breast cancer in select cohorts of patients. The utility of this imaging technique for detecting synchronous contralateral breast cancers in patients with locally advanced breast cancer (LABC) has not previously been described. We report our experience in assessing contralateral disease in a cohort of women with LABC who had clinical assessment, mammography, ultrasound, and MRI prior to neo‐adjuvant therapy. Patients, who presented with LABC, stage IIB (T3N0), stage III A/B, were identified from a prospectively kept data base at a single tertiary care centre between November 2001 and August 2005. Charts were retrospectively reviewed and demographic, imaging and pathologic variables were abstracted. One hundred and one female patients with LABC were identified (median age 49). One hundred of 101 patients presented with a clinically obvious LABC. Three patients had LABC that was not visualized mammographically but was detected on ultrasound and MRI. Seventeen of 101 patients (17%) had contralateral imaging findings that required biopsy for diagnosis. Of the contralateral biopsies, 41% (7/17) were malignant. These malignant lesions were identified clinically in 4/7 patients, on 7/7 ultrasounds, 7/7 mammograms, and 5/5 MRI. Overall, 7% (7/101) patients had malignant synchronous contralateral disease. In our LABC patient cohort, 7% of patients presented with malignant contralateral disease. The incidence of contralateral disease in women with LABC is comparable with patients who present with early stage breast cancer. No single screening technique, ultrasound, mammogram or MRI, appeared to be superior for identifying contralateral synchronous malignancy.     

Tamoxifen and the Risk of Endometrial Cancer in Japanese Women with Breast Cancer

Purpose There is ongoing debate about whether tamoxifen for breast cancer is associated with a risk of endometrial cancer in Japanese women. We conducted a study to investigate this further. Methods We conducted a retrospective hospital-based cohort study. A total of 674 consecutive patients underwent surgery for primary breast cancer between January 1989 and December 1998. By December 2003, endometrial cancers had been diagnosed in six of these patients. Based on medical records, we evaluated the potential risk factors for endometrial cancer, including age, menopausal status, obesity, parity, diabetes mellitus, hypertension, and tamoxifen. The 674 patients were divided into three groups based on the cumulative duration of tamoxifen use (A, <2 years vs B, 2–5 years vs C, >5 years). To examine the relationships between endometrial cancer and tamoxifen (and other factors), the hazards ratio (HR), 95% confidence interval (CI), and two-sided P value for endometrial cancer associated with each variable were calculated by the Cox regression method. Results Endometrial cancer was found in 1/318 (0.31%) patients in group A, 3/247 in group B, and 2/109 in group C. In a multivariate analysis no variable was significant, but tamoxifen use for longer than 5 years (group C) was closely correlated with endometrial cancer (HR = 7.92, CI = 0.69–90.89, P = 0.096). Conclusion Although our data did not reach significance, they support a link between long-term tamoxifen and the development of endometrial cancer in Japanese women with breast cancer.     

乳腺癌正规治疗后对侧乳腺癌发生的危险因素分析

目的 探讨女性初发乳腺癌治疗后再发对侧乳腺癌(contralateral breast cancer, CBC)的危险因素.方法 回顾性分析我院1997年1月至2002年12月期间收治的340例女性初发乳腺癌患者的临床资料,包括患者的年龄、病理结果、手术方式、化疗、放疗、激素治疗具体方案和执行情况等.采用Kaplan-Meier法评估CBC的发生率,Cox部分相关回归评估CBC的相关危险因素.结果 14例诊断为CBC,总发病率为4.1%.10年CBC发生率(2.7%)高于5年CBC发生率(1.4%),随着随访时间的延长发生率逐年升高.单因素分析提示,患者年龄≤45岁、乳腺癌家族史、病理学分型为髓样癌及未采取内分泌治疗为5年和10年CBC发生的危险因素(P＜0.05),而化疗和放疗与否为CBC发生的非危险相关因素(P＞0.05).多因素分析表明,其中年龄≤45岁及乳腺内放疗为5年和10年CBC发生的独立危险因素(P＜0.05).结论 对于≤45岁、髓样癌、有乳腺癌家族史的初发乳腺癌患者应警惕CBC的发生; 初发乳腺癌患者应采取内分泌治疗,避免乳腺内放疗以降低CBC的发生率.     

Preoperative Risk Assessment Among Women Undergoing Bilateral Prophylactic Mastectomy for Cancer Risk Reduction

Background  

Cancer risk assessment is an important decision-making tool for women considering irreversible risk-reducing surgery. Our objective was to determine the prevalence of BRCA testing among women undergoing bilateral prophylactic mastectomy (BPM) and to review the characteristics of women who choose BPM within a metropolitan setting.     

Outcomes of Multimodality Breast Screening for Women at Increased Risk of Familial Breast Cancer

Background

While population-based breast screening for women over the age of 50 years is a generally accepted and proven health strategy, the role of breast screening specifically among women at high risk of familial breast cancer has remained controversial. Indeed, there are very few services specifically offering a breast-screening program for women at high risk of familial breast cancer.

Methods

In 1999 a Familial Breast Cancer Screening Clinic (FBCSC) was established at the North Brisbane BreastScreen Queensland Service to provide a regular multimodality screening program utilizing clinical breast examination, breast ultrasound, and mammography for women at higher risk of hereditary breast cancer and with entry into the program commencing from the age of 30 years.

Results

Since its inception, a total of 2440 women have participated in the FBCSC. A total 7051 breast-screening examinations have been performed on these participants, with 53 breast cancers being diagnosed, including 8 in situ ductal carcinomas, 38 invasive ductal carcinomas, and 7 invasive lobular carcinomas. The mean size of the cancers was 16 mm (range = 1–45 mm), and of the 45 invasive cancers, 60% were less than or equal to 15 mm in size. The overall axillary node positive rate was 24.5% (13/53). The invasive cancer detection rate for first-round screening was 8.3 cancers per 1000 women screened, with 5.2 cancers per 1000 women detected on subsequent round screening.

Conclusions

The results from this service demonstrate that multimodality screening for women at high risk of familial breast cancer and including women of younger age is effective and appropriate, with very acceptable cancer detection rates and pathological cancer characteristics being observed consistent with early-stage detection. The colocated siting of this service within a BreastScreen Queensland facility has proven to be efficient and cost effective.     

Surgical Site Infection Among Women Discharged with a Drain In Situ After Breast Cancer Surgery

Background There are scarce data on the factors associated with surgical site infection (SSI) among women who are discharged with a drain in situ after breast cancer surgery. The aim of this study was to determine the incidence and the factors associated with SSI in a center where women are routinely discharged with a drain in place. Methods A prospective cohort study included 354 women who underwent surgical treatment for breast cancer at a referral center in Rio de Janeiro, Brazil. Results SSI was diagnosed in 60 patients (17%) after a median follow-up of 17 days. Most infections were caused by Staphylococcus aureus. The probability of bacterial colonization of the drain was 33% on postoperative day (POD) 7 and rose to 80.8% up to the POD 14. In 83% of the cases of microbiologically documented infection, SSI was caused by the same bacterial species that had been previously isolated from the drainage fluid. In multivariate regression analyses, age 50 years (p < 0.001), skin flap necrosis (p < 0.001), and bacterial colonization of the drain (p = 0.03) were independently associated with a higher incidence of SSI. Conclusion The incidence of SSI among women who were routinely discharged with a drain in place was high. Older age, skin flap necrosis, and bacterial colonization of the drain were independent predictors of SSI. Modifications of the surgical technique aimed at reducing the risk of wound necrosis and early removal of the drain may contribute to lowering the risk of SSI among these patients. This study was partially supported by CAPES.     

Breast Reconstruction after Bilateral Prophylactic Mastectomy in Women at High Risk for Breast Cancer

Abstract:  Several studies have shown the effectiveness of bilateral prophylactic mastectomies (BPM) at reducing the risk of developing breast cancer in women by more than 90%. A growing number of women at high risk for breast cancer are electing to undergo prophylactic mastectomy as part of a risk reduction strategy. This unique group of women frequently chooses to undergo reconstructive surgery as a part of their immediate treatment plan. Breast reconstruction after BPM has profound physiological and emotional impact on body image, sexuality, and quality of life. These factors should be taken into consideration and addressed when consulting the patient prior to BPM and reconstructive surgery. The timing of reconstructive surgery, the type of mastectomy performed, the reconstructive modalities available, and the possibility to preserve the nipple–areola complex, should all be discussed with the patient prior to surgery. In this article, we review our experience and the current existing literature on breast reconstruction for high-risk women after BPM.