Black women at greatest risk for breast cancer-related lymphedema
Click Here to Manage Email Alerts
Black and Hispanic women appeared more likely than white women to develop breast cancer-related lymphedema, according to study results presented at San Antonio Breast Cancer Symposium.
Black race appeared to be the strongest predictor of lymphedema development and severity.
“The more we learn about lymphedema, the more we understand how complex the pathogenesis of the disease really is,” Andrea V. Barrio, MD, FACS, associate attending physician in with the breast service in the department of surgery at Memorial Sloan Kettering Cancer Center, told Healio. “While we understand that about a quarter of women will develop lymphedema, there are several factors that influence risk — including race, which has not previously been assessed in a prospective longitudinal study. An important message is to understand that the morbidity of our breast cancer treatments varies across racial and ethnic groups, and preventive strategies to mitigate risk and minimize the complications of our treatments are needed.”
Previously published self-reported and epidemiological data suggested Black women may be at elevated risk for breast cancer-related lymphedema after axillary lymph node dissection. However, prospective trial data are limited.
“Risk factors for lymphedema [among] women undergoing axillary lymph node dissection are poorly understood,” Barrio said. “This study was done to determine the patient, clinical and treatment factors associated with lymphedema development.”
Barrio and colleagues quantitatively assessed breast cancer-related lymphedema incidence and severity in a prospective cohort of 304 patients who underwent axillary lymph node dissection between November 2016 and March 2020.
Study participants underwent arm volume measurements and BMI assessment at baseline, after axillary lymph node dissection and then at 6-month intervals.
Researchers defined breast cancer-related lymphedema as relative volume change of 10% or greater from baseline. They used univariate and multivariable analysis to calculate the OR for incidence and compare severity.
The analysis included 276 patients (60% white, 20% Black, 11% Asian, 6% Hispanic, 3% not reported) who had at least one longitudinal measurement after baseline. Black women were older (P = .007), had higher baseline BMI (P < .001) and were more likely to have node-positive disease (P = .016) than white, Asian or Hispanic women.
Black and Hispanic women more often underwent breast-conserving surgery (P = .037) and received nodal radiotherapy (P = .02).
After median 24 months follow-up, 24.7% of women developed breast cancer-related lymphedema.
Black women had a 3.5 times higher risk for lymphedema than white women. Hispanic women had a threefold higher risk than white women, but researchers emphasized the number of Hispanic women in the study was low and additional research would be needed to confirm this result.
Multivariable analysis revealed Black race as the strongest predictor of breast cancer-related lymphedema (vs. white, OR = 4.41; 95% CI, 2.42-8.1). Results showed no association between Asian race or Hispanic ethnicity with breast cancer-related lymphedema incidence.
“While I was not surprised to learn that lymphedema rates varied across racial and ethnic groups, I was surprised to see the striking difference in lymphedema rates between Black and white women at 2 years of follow-up,” Barrio said.
“Both inflammation and fibrosis are important in the pathogenesis of lymphedema,” Barrio added. “We believe that Black women may have an increased propensity toward inflammation and/or increased fibrosis — particularly in response to radiation therapy, which most breast cancer patients receive. However, these hypotheses require further study.”
Other factors independently associated with breast cancer-related lymphedema development included receipt of neoadjuvant chemotherapy (vs. upfront surgery, OR = 1.89; 95% CI, 1.02-3.63), older age (per 1-year increase, OR = 1.04; 95% CI, 1.01-1.06), number of lymph nodes removed (per each additional node, OR = 1.05; 95% CI, 1.01-1.09) and longer follow-up (per every 6-month increase, OR = 1.6; 95% CI, 1.31-1.96).
Results showed no difference in lymphedema severity between racial or ethnic groups.
Barrio and colleagues intend to assess the biologic mechanisms that contribute to racial disparities in lymphedema development.
“We plan to compare inflammatory biomarkers, markers of fibrosis and response to radiotherapy between racial and ethnic groups in women with and without lymphedema after axillary surgery,” Barrio said. “This will allow us to better understand the reason for the differences in lymphedema rates observed in our study.”
Researchers acknowledged short median follow-up as the primary study limitation. Follow-up is ongoing.
“As we learn more about lymphedema, we can begin to individualize the risk for lymphedema development for each patient,” Barrio said. “[Although] studies looking at preventive strategies — such as immediate lymphatic reconstruction — are ongoing, those at highest risk for lymphedema development may be good candidates for these preventive treatments in the future. There is also an ongoing need to continue to find strategies to de-escalate surgery in the axilla and minimize the need for axillary lymph node dissection, which will also significantly reduce risk for lymphedema development.”
Perspective
Back to Top
Virginia Kaklamani, MD
This is a very important study looking at how ethnicity plays a role in potential adverse effects from our treatments. We already know African American women have a higher rate of triple-negative breast cancer which is one of the most aggressive subtypes to treat. Now we see in a very well-conducted trial that AA women have higher risk of lymphedema. It is important for us to be able to recognize this recognize the symptoms early and treat our patients preemptively so we can potentially prevent lymphedema in these patients.
Collapse
Barrio AV, et al. Abstract GS4-01. Presented at: San Antonio Breast Cancer Symposium; Dec. 7-10, 2021; San Antonio.
Read more about
Click Here to Manage Email Alerts