There are nearly 3,000,000 breast cancer survivors in the United States and lymphedema is one of the most concerning complications of breast cancer therapy. Lymphedema impacts many aspects of a woman's daily life, including family social activities. In addition, lymphedema can affect a woman's sense of well-being and body image.
Because of the fundamental impact that lymphedema can have, it is important to have good information concerning the incidence and severity of the lymphedema. It is well known that damage to lymphatic vessels by surgical intervention, radiation or the combination can result in lymphedema. The metabolic products of the tissues are drained by lymphatics, and when the volume of lymphatic fluid produced exceeds the capacity of the lymphatic system to drain the fluid, a build up of protein rich fluid results. Th is build up of protein rich fluid results in swelling and a sensation of heaviness in extremity. Over time, this process can lead to increased swelling, hardening of the tissues and changes in color of the skin.
Despite the fact that lymphedema is a common complication of breast cancer therapy, the true incidence of lymphedema following surgery and/or radiation varies considerably between reports in medical literature. Part of the complication arises from variations in definitions of what is considered lymphedema. Another challenge is that many studies are retrospective and thus rely on a person's memory, which is not precise. Another compounding factor is the duration of the study. While most cases of lymphedema appear within 1-3 years after the time of surgery, cases of lymphedema can occur many more years after treatment for breast cancer. Studies that only assess lymphedema in the months following breast cancer therapy often miss cases of lymphedema. Another confounding factor is that in some cases the swelling associated with breast cancer therapy can improve over time. Studies suggests that while up to 50-60% of patients may report arm swelling in the months immediately following surgery and radiation for b reast cancer, in about half of the cases this can improve over time. Consequently, the prevalence of persistent lymphedema may be in the range of 15-25%.
To help better understand the incidence of lymphedema, a group of over 2000 Danish woman responded to a survey about lymphedema. In this survey, patients who were treated for early stage breast cancer in 2005 and 2006, received follow-up surveys in 2008 and again in 2012. In these surveys, 37% reported to have lymphedema in the 2008 survey and 31% reported lymphedema on the follow-up 2012 survey. In addition, the severity of symptoms had decreased from the 2008 survey to the 2012 survey. To note, 50% of th e women who underwent a sentinel lymph node biopsy and reported lymphedema in the 2008 survey did not report symptoms in the 2012 survey. In contrast, 30% of women (that reported lymphedema in 2008) treated with axillary lymph node dissection did not report symptoms in the 2012 survey.
This survey, which is one of the largest of this kind, can provide very useful insights into the causes of lymphedema and the changes that occur with lymphedema over time. This study provides useful comparisons between sentinel lymph node biopsy and axillary dissection and also compares patients who received chemotherapy and radiation. For example, 48% of the women who underwent axillary lymph node dissection reported lymphedema while only 12% for those with sentinel lymph node biopsy reported lymphedema. In contrast, treatment with chemotherapy had less impact on lymphedema. In this study, there was no significant difference in the rate of lymphedema among those who received chemotherapy compared to those who did not receive chemotherapy. There is more interesting information in this study which I will report in a subsequent Lymphedema eNews.
Reference: Gärtner R, et al., Development in self-reported arm-lymphedema in Danish women treated for early-stage breast cancer in 2005 and 2006 e A nationwide follow-up study, The Breast (2014), http://dx.doi.org/10.1016/j.breast.2014.03.001
Tony Reid MD Ph.D