Risk Factors and Racial and Ethnic Disparities in Patients With Breast Cancer–Related Lymphedema

Montagna, Giacomo; Zhang, Jennifer; Sevilimedu, Varadan; Charyn, Jillian; Abbate, Kelly; Gomez, Ethan A.; Mehrara, Babak J.; Morrow, Monica; Barrio, Andrea V.

doi:10.1001/jamaoncol.2022.1628

Cited by 35 publications

(36 citation statements)

References 16 publications

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“…Using diagnosis codes to identify cases of lymphedema, Black et al demonstrated that Black patients have higher rates of ALND vs SLNB and higher rates of BCRL following ALND compared with White patients. Our group has similarly shown that Black race and Hispanic ethnicity are independent risk factors for BCRL on multivariable analysis . In this study, we found that the average Black woman treated for breast cancer had a 10.2% risk of lymphedema compared with a 6.9% risk for the average White woman based on our preoperative model, with a similarly significant increase in risk based on our postoperative model.…”

Section: Discussionsupporting

confidence: 71%

“…Our model includes any (neoadjuvant or adjuvant) chemotherapy in addition to any radiation therapy, since both have been associated with BCRL risk in prospective cohort studies . Despite strong evidence that neoadjuvant therapy alone is associated with BCRL risk, this variable did not improve the accuracy of our model, potentially due to exclusion bias as neoadjuvant chemotherapy was rarely used during the study period of the 1999 to 2003 MSKCC cohort (data set 1). ALND was the strongest predictor in our preoperative model with a predicted probability of 20.0%, consistent with Level I evidence showing a nearly 4-fold greater risk of lymphedema following ALND vs SLNB .…”

Section: Discussionmentioning

confidence: 99%

“…Female breast cancer is the most frequently diagnosed cancer worldwide, with 2.3 million new cases annually, including 300 000 in the US alone . Pooled estimates suggest that approximately 16.6% of women develop lymphedema following breast cancer treatment, with women of Black race disproportionately affected . Similar to hypertension, cardiovascular disease, and other diseases with substantial global burden and the potential to develop into chronic conditions, BCRL prediction is critical to identifying at-risk patients and instituting preventive strategies.…”

Section: Introductionmentioning

confidence: 99%

“…Multiple predictive models for BCRL have appeared in the literature over the past 2 decades, although to our knowledge, none have gained widespread acceptance. Importantly, despite recent studies demonstrating the effects of racial disparities in lymphedema, no previously published model includes race as a predictive factor. Some models have favorable predictive ability, as measured by the area under the receiver operating characteristic curve (AUC), but include variables that are not readily available in a preoperative and/or postoperative setting; these variables include radiation field and fractionation type, number of cycles of chemotherapy in the ipsilateral arm, chemotherapeutic agent, proportion of lymph flow above the level of the axillary vein, mammographic breast density, and number of lymph nodes removed or positive nodes .…”

Section: Introductionmentioning

confidence: 99%

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Feasibility and Clinical Utility of Prediction Models for Breast Cancer–Related Lymphedema Incorporating Racial Differences in Disease Incidence

et al. 2023

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ImportanceBreast cancer–related lymphedema (BCRL) is a common complication of axillary lymph node dissection (ALND) but can also develop after sentinel lymph node biopsy (SLNB). Several models have been developed to predict the risk of disease development before and after surgery; however, these models have shortcomings that include the omission of race, inclusion of variables that are not readily available to patients, low sensitivity or specificity, and lack of risk assessment for patients treated with SLNB.ObjectiveTo create simple and accurate prediction models for BCRL that can be used to estimate preoperative or postoperative risk.Design, Setting, and ParticipantsIn this prognostic study, women with breast cancer who underwent ALND or SLNB from 1999 to 2020 at Memorial Sloan Kettering Cancer Center and the Mayo Clinic were included. Data were analyzed from September to December 2022.Main Outcomes and MeasuresDiagnosis of lymphedema based on measurements. Two predictive models were formulated via logistic regression: a preoperative model (model 1) and a postoperative model (model 2). Model 1 was externally validated using a cohort of 34 438 patients with an International Classification of Diseases diagnosis of breast cancer.ResultsOf 1882 included patients, all were female, and the mean (SD) age was 55.6 (12.2) years; 80 patients (4.3%) were Asian, 190 (10.1%) were Black, 1558 (82.8%) were White, and 54 (2.9%) were another race (including American Indian and Alaska Native, other race, patient refused to disclose, or unknown). A total of 218 patients (11.6%) were diagnosed with BCRL at a mean (SD) follow-up of 3.9 (1.8) years. The BCRL rate was significantly higher among Black women (42 of 190 [22.1%]) compared with all other races (Asian, 10 of 80 [12.5%]; White, 158 of 1558 [10.1%]; other race, 8 of 54 [14.8%]; P &lt; .001). Model 1 included age, weight, height, race, ALND/SLNB status, any radiation therapy, and any chemotherapy. Model 2 included age, weight, race, ALND/SLNB status, any chemotherapy, and patient-reported arm swelling. Accuracy was 73.0% for model 1 (sensitivity, 76.6%; specificity, 72.5%; area under the receiver operating characteristic curve [AUC], 0.78; 95% CI, 0.75-0.81) at a cutoff of 0.18, and accuracy was 81.1% for model 2 (sensitivity, 78.0%; specificity, 81.5%; AUC, 0.86; 95% CI, 0.83-0.88) at a cutoff of 0.10. Both models demonstrated high AUCs on external (model 1: 0.75; 95% CI, 0.74-0.76) or internal (model 2: 0.82; 95% CI, 0.79-0.85) validation.Conclusions and RelevanceIn this study, preoperative and postoperative prediction models for BCRL were highly accurate and clinically relevant tools comprised of accessible inputs and underscored the effects of racial differences on BCRL risk. The preoperative model identified high-risk patients who require close monitoring or preventative measures. The postoperative model can be used for screening of high-risk patients, thus decreasing the need for frequent clinic visits and arm volume measurements.

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Section: Discussionsupporting

confidence: 71%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Feasibility and Clinical Utility of Prediction Models for Breast Cancer–Related Lymphedema Incorporating Racial Differences in Disease Incidence

et al. 2023

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“…Lymphedema, which can cause limb swelling, discomfort, and impaired arm function, is a major morbidity among breast cancer survivors. The estimated risk of developing lymphedema after treatment is approximately 20% [1][2][3], with the main risk factor being axillary dissection [4,5].…”

Section: Introductionmentioning

confidence: 99%

Lymphedema therapy referral is associated with improved understanding of lymphedema prevention among breast cancer survivors

Klugman

Tringale

Patil

et al. 2022

Preprint

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Purpose: Lymphedema is common among breast cancer survivors (BCS) and negatively affects quality of life. There are modifiable factors to reduce lymphedema risk and exacerbation; it is unknown how aware survivors are of these factors. We hypothesized referral to lymphedema therapy (LT) to be associated with greater lymphedema knowledge.Methods: BCS at an NCI-designated cancer center between 2014-2015 were asked to complete an anonymous questionnaire. Eligibility criteria were the following: age ≥18, female sex, English-speaking, > 6 months post definitive breast cancer surgery, no cancer recurrence, and no prior or subsequent second cancer. The questionnaire included sociodemographics, clinical factors including LT referral, and 10 true/false questions assessing lymphedema knowledge. Multivariable logistic regressions assessed the relationship between prior LT referral and correctly answering questions about lymphedema misconceptions.Results: Of 209 participants, 53 (25%) had been referred to LT. Those who had sentinel lymph node dissection were less frequently referred to LT [15 (14%)] than those who had axillary lymph node dissection [38 (39%)]. Five of the true/false questions had a correct response rate of <80%. In multivariable regression adjusted for age, race/ethnicity, education, axillary surgery, and radiation therapy, LT referral was associated with answering the questions about weight gain and exercising the arm on an airplane correctly [weight gain: odds ratio, 95% confidence interval (OR, 95%CI): 3.63 (1.66-7.96), airplane: 2.65 (1.15-6.13)].Conclusion: Misconceptions surrounding lymphedema prevention and management are common among BCS. LT referral is a potential opportunity to debunk common misunderstandings regarding lymphedema risk reduction.

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Quality of Life After Axillary Lymph Node Dissection Among Racial and Ethnic Minority Women

Heller,

Axelrod,

Sevilimedu

et al. 2024

JAMA Surg

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ImportanceHigher lymphedema rates after axillary lymph node dissection (ALND) have been found in Black and Hispanic women; however, there is poor correlation between subjective symptoms, quality of life (QOL), and measured lymphedema. Additionally, racial and ethnic differences in QOL have been understudied.ObjectiveTo evaluate the association of race and ethnicity with long-term QOL in patients with breast cancer treated with ALND.Design, Setting, and ParticipantsThis cohort study enrolled women aged 18 years and older with breast cancer who underwent unilateral ALND at a tertiary cancer center between November 2016 and March 2020. Preoperatively and at 6-month intervals, arm volume was measured by perometer and QOL was assessed using the Upper Limb Lymphedema-27 (ULL-27) questionnaire, a validated tool for assessing lymphedema that evaluates how arm symptoms affect physical, psychological, and social functioning. Data were analyzed from November 2016 to October 2023.ExposuresBreast surgery and unilateral ALND in the primary setting or after sentinel lymph node biopsy.Main Outcomes and MeasuresScores in each domain of the ULL-27 were compared by race and ethnicity. Factors impacting QOL were identified using multivariable regression analyses.ResultsThe study included 281 women (median [IQR] age, 48 [41-58] years) with breast cancer who underwent unilateral ALND and had at least 6 months of follow-up. Of these, 30 patients (11%) self-identified as Asian individuals, 57 (20%) as Black individuals, 23 (8%) as Hispanic individuals, and 162 (58%) as White individuals; 9 individuals (3%) who did not identify as part of a particular group or who were missing race and ethnicity data were categorized as having unknown race and ethnicity. Median (IQR) follow-up was 2.97 (1.96-3.67) years. The overall 2-year lymphedema rate was 20% and was higher among Black (31%) and Hispanic (27%) women compared with Asian (15%) and White (17%) women (P = .04). Subjective arm swelling was more common among Asian (57%), Black (70%), and Hispanic (87%) women than White (44%) women (P &lt; .001), and lower physical QOL scores were reported by racial and ethnic minority women at nearly every follow-up. For example, at 24 months, median QOL scores were 87, 79, and 80 for Asian, Black, and Hispanic women compared with 92 for White women (P = .003). On multivariable analysis, Asian race (β = –5.7; 95% CI, −9.5 to −1.8), Hispanic ethnicity (β = –10.0; 95% CI, −15.0 to −5.2), and having Medicaid (β = −5.4; 95% CI, −9.2 to −1.7) or Medicare insurance (β = −6.9; 95% CI, −10.0 to −3.4) were independently associated with worse physical QOL (all P &lt; .001).Conclusions and RelevanceFindings of this cohort study suggest that Asian, Black, and Hispanic women experience more subjective arm swelling after unilateral ALND for breast cancer compared with White women. Black and Hispanic women had higher rates of objective lymphedema than their White counterparts. Both minority status and public medical insurance were associated with worse physical QOL. Understanding disparities in QOL after ALND is an unmet need and may enable targeted interventions to improve QOL for these patients.

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Risk Factors and Racial and Ethnic Disparities in Patients With Breast Cancer–Related Lymphedema

Cited by 35 publications

References 16 publications

Feasibility and Clinical Utility of Prediction Models for Breast Cancer–Related Lymphedema Incorporating Racial Differences in Disease Incidence

Feasibility and Clinical Utility of Prediction Models for Breast Cancer–Related Lymphedema Incorporating Racial Differences in Disease Incidence

Lymphedema therapy referral is associated with improved understanding of lymphedema prevention among breast cancer survivors

Quality of Life After Axillary Lymph Node Dissection Among Racial and Ethnic Minority Women

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