Lymph node surgery increases arm morbidity in younger women with breast cancer

Issue: January 25, 2018

Anne Kuijer

SAN ANTONIO — Younger women who underwent axillary surgery for breast cancer appeared more likely to experience arm swelling and a decreased range of motion, according to results from a multicenter prospective cohort study presented at the San Antonio Breast Cancer Symposium.

Perspective from Eli Avisar, MD

Arm morbidity is the most common late effect following axillary surgery, presenting as lymphedema in approximately 21% of patients with breast cancer, and shoulder impairment in 4% to 28%, Anne Kuijer, PhD, who was a postdoctoral research fellow at Dana-Farber Cancer Institute/Brigham and Women’s Hospital at the time of the study, said during her presentation.

“Breast cancer is the most common form of cancer in women under the age of 40 years, but younger breast cancer patients are frequently underrepresented in clinical trials,” Kuijer, surgical resident at Diakonessen Hospital Utrecht in the Netherlands, said in a press release. “As a result, little is known about optimal treatment strategies and comorbidities — such as arm swelling and decreased range of motion — in younger patients. These issues are of particular importance in these patients given their long survivorship period, frequently active lifestyle, and the importance of body image.”

Kuijer and colleagues used the Young Women’s Breast Cancer Study — established to explore biological, medical and psychosocial issues among younger patients — which included 1,302 women aged 40 years or younger with stage 0 to 4 breast cancer.

For the current analysis, researchers excluded stage 4 patients (n = 60), those without arm morbidity data (n = 198) and those with bilateral cancer with different therapies used on each side (n = 7).

The analysis included 1,037 patients (median age, 37 years; 86% white).

Patients completed surveys at baseline, 4 months after diagnosis and every 6 months for 3 years. Two questions on the Breast Cancer Prevention Trial symptom checklist asked about arm morbidity.

More than half of patients (52%; n = 539) underwent sentinel lymph node biopsy, and 39% (n = 407) underwent axillary lymph node dissection. Kuijer noted that the use of sentinel lymph node biopsy increased from 2006-2007 to 2014-2015, from 50% to 56%, whereas use of axillary lymph node dissection decreased from 24% to 11%.

Thirty percent of patients underwent breast-conserving therapy, 25% underwent mastectomy and 45% underwent bilateral mastectomy. Most patients also underwent radiotherapy (60%) and chemotherapy (74%).

At 1 year, 13% of patients experienced arm swelling — including 11% of patients who underwent breast-conserving surgery, and 14% of patients who underwent mastectomy — and 33% experienced decreased range of motion in the ipsilateral arm, including 32% of patients who underwent breast-conserving surgery, and 34% who underwent mastectomy.

PAGE BREAK

Among those who underwent breast-conserving surgery, a greater percentage of women who underwent axillary lymph node dissection vs. sentinel lymph node biopsy experienced arm swelling (25% vs. 6%; P < .01), with an insignificant increase in decreased range of motion (37% vs. 31%).

This trend also occurred among women who underwent mastectomy without radiation in terms of arm swelling (19% vs. 4%; P < .01) and decreased range of motion (34% vs. 20%). The difference in incidence of arm morbidity only trended toward significance among women who underwent mastectomy with radiation (arm swelling, 25% vs. 11%; decreased range of motion, 46% vs. 41%).

Researchers found arm swelling appeared more common among patients who were overweight (OR = 1.7; 95% CI, 1.1-2.7), had T4 tumors (OR = 4.1; 95% CI, 1.1-15.8) and who underwent axillary lymph node dissection (OR = 3.4; 95% CI, 1.8-6.4), whereas it was less common among those with financially comfortable status (OR = 0.6; 95% CI, 0.4-0.9).

Overweight (OR = 1.4; 95% CI, 1-2.1) and use of mastectomy with radiation (OR = 2.1; 95% CI, 1.3-3.3) independently predicted increased risk for decreased range of motion.

“[Being overweight] is not something patients can influence right away at the time of

diagnosis, but it highlights the overall importance of an active and healthy lifestyle,” Kuijer said.

Also, the impact of financial status on arm swelling “highlights the importance of ensuring adequate social support and resources for young patients undergoing breast cancer treatment,” Kuijer added. – by Alexandra Todak

Reference:

Kuijer A, et al. Abstract GS5-03. Presented at: San Antonio Breast Cancer Symposium; Dec. 5-9, 2017; San Antonio.

Disclosures: Kuijer and all study authors report no relevant financial disclosures.

Perspective

Eli Avisar, MD

This is a very nice study that pointed out the morbidity of surgery and radiation. We understand axillary dissection, the standard way, is harmful and causes lymphedema. Radiation therapy also is harmful, and combining them is worse. It seems that we have been trying to avoid axillary dissection and adding more radiation to the axilla in many patients.

Perhaps an alternative approach is to do an axillary dissection without the morbidity of lymphedema, and there are a few techniques. One of them, described in a poster presented here, was called the SLYMPHA procedure — in which lymphatic channels identified by reverse arm mapping are inserted using a sleeve technique into the cut end of a neighboring vein — where you can actually do an axillary dissection with minimal amount of lymphedema, thereby not having to do radiation therapy and still having very low morbidity.

Reference:

Ozmen T, et al. Abstract PS-22-05. Presented at: San Antonio Breast Cancer Symposium; Dec. 5-9, 2017; San Antonio.

Eli Avisar, MD

University of Miami Health System

Disclosures: Avisar served as an author on the study of SLYMPHA.