Physical quality of life after axillary lymph node dissection impacted by race, insurance
Click Here to Manage Email Alerts
Key takeaways:
- Hispanic, Black and Asian women experience more subjective arm swelling compared with white women after axillary lymph node dissection.
- Women covered by Medicare or Medicaid had worse physical quality of life.
Black, Hispanic and Asian women reported more arm swelling after axillary lymph node dissection for breast cancer compared with white women, according to findings published in JAMA Surgery.
Women covered by Medicare or Medicaid also experienced worse physical quality of life (QOL) compared with women with private insurance after axillary lymph node dissection (ALND).
“It is important to understand the long-term survivorship issues in women after breast cancer treatment and to understand that treatments may affect women across racial and ethnic groups differently,” Andrea V. Barrio, MD, breast surgeon at Memorial Sloan Kettering Cancer Center, told Healio. “Early identification of arm symptoms and arm swelling allow for early referral to physical therapy or lymphedema therapy, which can help mitigate symptoms and improve long-term quality of life.”
Background and methodology
Individuals who receive ALND can have reduced strength and mobility, and have a 20% to 30% chance of long-term lymphedema, according to background information provided by researchers.
Black and Hispanic women had a three times greater risk for developing lymphedema following ALND compared with white women, based on results from another Memorial Sloan Kettering study, researchers wrote.
Additionally, patients can experience perceived arm swelling that is not measured as lymphedema.
Researchers wanted to determine if racial differences existed in terms of subjective arm symptoms as well.
“There have been very few studies prospectively evaluating lymphedema risk and quality of life after ALND, and limited data regarding the association between self-reported race and quality of life after ALND,” Barrio said. Barrio and colleagues conducted a prospective cohort study including women aged at least 18 years, who had invasive breast cancer and underwent breast surgery and unilateral ALND at Memorial Sloan Kettering between November 2016 and March 2020, Study participants had 6 months of follow-up.
Researchers defined lymphedema as at least a 10% relative volume change from baseline, and used the Upper Limb Lymphedema 27 scale, which included questions about patients’ physical, psychological and social wellbeing to obtain QOL data.
The study cohort consisted of 281 women (median age, 48 years; 58% white; 20% Black; 11% Asian; 8% Hispanic; 3% unidentified). Sixty-six percent of patients had private insurance
The cohort had a median follow-up of 2.97 years.
Results and next steps
The study results backed-up previous research, as Black and Hispanic women had a 20% higher rate of lymphedema at 2 years compared with white and Asian women.
Hispanic women experienced the most subjective arm swelling (87%), followed by Black (70%), Asian (57%) and white women (44%; P < .001). Subjective arm swelling occurred substantially more than lymphedema (55% vs. 26%).
Hispanic, Black and Asian women reported worse physical QOL scores at almost every follow-up point after ALND.
Researchers determined an independent association with worse physical QOL for Asian and Hispanic women, but not for Black women.
“Many women without lymphedema have significant arm symptoms after ALND that can affect long-term quality of life,” Barrio said. “It was surprising to see that Asian women, who have the lowest risk for lymphedema among all racial and ethnic groups, have significantly worse physical symptoms after ALND compared with white women.”
Researchers noted BMI could have played a role in Hispanic and Black women having worse subjective arm swelling than white women, and hypothesized Asian women, who had the lowest BMI, could have experienced more due to higher rates of mastectomy.
Individuals who had Medicaid or Medicare experienced worse QOL than those with private insurance (P < .001) as well.
Psychological and social QOL did not differ between race and ethnicity.
“Close monitoring, early identification of symptoms and patient education are important, so women are aware of these disparities,” Barrio said. “If available, consideration of prophylactic immediate lymphatic reconstruction at the time of ALND and/or use of compression garments after surgery may reduce lymphedema rates although the effects of these interventions on QOL remain under investigation.”
Researchers identified attrition as a study limitation. They anticipated 25%, but the COVID-19 pandemic closed the study and more than 80% of measurements for 30- and 36-month time intervals did not get included.
Barrio said more research needs to be done to determine why these disparities exist.
“My colleague Babak J. Mehrara, MD, and I are studying possible cellular mechanisms responsible for the observed racial disparities in lymphedema development by assessing the effect of baseline inflammatory differences between Black and white women on subsequent inflammatory response to lymphatic injury,” she said. “Improving quality of life for our breast cancer survivors is of paramount importance, as ‘living well’ is just as important as living longer.”
References:
- Heller DR, et al. JAMA Surg. 2024;doi:10.1001/jamasurg.2024.0118.
- Montagna G, et al. JAMA Oncol. 2022;doi:10.1001/jamaoncol.2022.1628.
For more information:
Andrea V. Barrio, MD, can be reached at barrioa@mskcc.org.
Collapse
Click Here to Manage Email Alerts