Risk factors for self-reported arm lymphedema among female breast cancer survivors: a prospective cohort study

Abstract

IntroductionLymphedema is a potentially debilitating condition that occurs among breast cancer survivors. This study examines the incidence of self-reported lymphedema, timing of lymphedema onset, and associations between sociodemographic, clinical and lifestyle factors and lymphedema risk across racial-ethnic groups using data from a multicenter, multiethnic prospective cohort study of breast cancer survivors, the Health, Eating, Activity and Lifestyle Study.MethodsA total of 666 women diagnosed with breast cancer staged as in situ, localized or regional disease at ages 35 to 64 years were recruited through the Surveillance, Epidemiology, and End Results registries in New Mexico (non-Hispanic white and Hispanic white), Los Angeles County (black), and Western Washington (non-Hispanic white) and followed for a median of 10.2 years. We evaluated sociodemographic factors, breast cancer- and treatment-related factors, comorbidities, body mass index (BMI), hormonal factors, and lifestyle factors in relation to self-reported lymphedema by fitting Cox proportional hazards models, estimating hazard ratios (HR) and 95% confidence intervals (CI).ResultsOver the follow-up period, 190 women (29%) reported lymphedema. The median time from breast cancer diagnosis to onset of lymphedema was 10.5 months (range: 0.5 to 134.9 months). Factors independently associated with lymphedema were total/modified radical mastectomy (versus partial/less than total mastectomy; HR = 1.37, 95% CI: 1.01 to 1.85), chemotherapy (versus no chemotherapy; HR = 1.48, 95% CI: 1.09 to 2.02), no lymph nodes removed (versus ≥10 lymph nodes removed; HR = 0.17, 95% CI: 0.08 to 0.33), pre-diagnostic BMI ≥30 kg/m2 (versus BMI <25 kg/m2; HR = 1.59, 95% CI: 1.09 to 2.31), and hypertension (versus no hypertension; HR = 1.49, 95% CI: 1.06 to 2.10). After adjusting for demographics and breast cancer- and treatment-related factors, no significant difference in lymphedema risk was observed across racial/ethnic groups. Analyses stratified by race/ethnicity showed that hypertension and chemotherapy were lymphedema risk factors only for black women.ConclusionsBreast cancer patients who have undergone extensive surgery or extensive lymph node dissection, or who have a higher BMI should be closely monitored for detection and treatment of lymphedema. Further studies are needed to understand the roles of chemotherapy and hypertension in the development of lymphedema.Electronic supplementary materialThe online version of this article (doi:10.1186/s13058-014-0414-x) contains supplementary material, which is available to authorized users.

Race/ethnicity, genetic ancestry, and breast cancer-related lymphedema in the Pathways Study

“…In a recent study, Togawa et al showed that a 1.6-fold increased risk of BCRL in AA women was almost entirely eliminated after adjusting for BMI, hypertension, and treatment-related factors [8]. However, in our analyses, controlling for these and other risk factors attenuated but did not completely explain the elevated risk in AA women or with African ancestry.…”

“…Misclassification of BCRL status is certainly possible; however, our analyses excluded any reported BCRL event within the first 6 months of breast cancer diagnosis to minimize misclassification due to postsurgical swelling. Although we assessed self-reported BCRL only up to 48 months after cancer diagnosis, it was recently reported that BCRL incidence primarily occurs within the first five years [8]. While we fully acknowledge that self-report should ideally be validated against physical measures such as perometry, bioimpedance, or arm circumference measures, our proportion of women reporting BCRL was in the range of what has been reported in the literature.…”

“…Only a few prospective studies have examined racial/ethnic differences in BCRL risk [6–8], including our group which found a nearly twofold elevated risk among African Americans (AA) [6]. However, the other studies found no association after 40 [7] and 123 months of follow-up [8] with multivariable adjustment accounting for BMI, chemotherapy, and hypertension.…”

“…However, the other studies found no association after 40 [7] and 123 months of follow-up [8] with multivariable adjustment accounting for BMI, chemotherapy, and hypertension. To our knowledge, studies of patients' genetic background with BCRL risk have not been conducted.…”

Diagnostic Methods, Risk Factors, Prevention, and Management of Breast Cancer-Related Lymphedema: Past, Present, and Future Directions

“…Patients are screened for signs and symptoms of BCRL and a clinical exam ensues to confirm a diagnosis. Additionally, those at higher risk of BCRL are more frequently monitored [67]. In order to maximize consistency, the group implemented a well-defined measurement protocol [7].…”