Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York.
JAMA Oncol. 2022 Aug 1;8(8):1195-1200. doi: 10.1001/jamaoncol.2022.1628.
Risk factors for breast cancer-related lymphedema (BCRL) after axillary lymph node dissection (ALND) are poorly understood.
To evaluate rates of and risk factors associated with BCRL in a prospective cohort of women treated with ALND.
DESIGN, SETTING, AND PARTICIPANTS: This prospective BCRL screening study performed at a tertiary cancer center enrolled women with breast cancer 18 years and older undergoing breast surgery and unilateral ALND in the primary setting or after sentinel lymph node biopsy.
Risk of BCRL during the first 2 years after ALND and radiotherapy.
Patients were prospectively evaluated with arm volume (perometer) measurements, and BCRL was defined as a relative volume change of 10% or greater from baseline. Cumulative incidence of BCRL was assessed using competing risk analysis. Risk factors for BCRL were assessed on univariate and multivariable analyses.
From November 2016 to March 2020, 304 patients were enrolled; 276 had at least 1 longitudinal measurement. Median (IQR) age was 48 (40-57) years; median (IQR) body mass index, calculated as weight in kilograms divided by height in meters squared, was 26.4 (22.5-31.2). Of the 276 patients included in the analysis, 29 (11%) self-identified as Asian, 55 (20%) as Black, 16 (6%) as Hispanic, 166 (60%) as White, and 10 (3%) as unknown race and ethnicity; 70% received neoadjuvant chemotherapy (NAC); 93% received nodal irradiation. The 24-month BCRL rate was 23.8% (95% CI, 17.9%-29.8%), with significant variation by race and ethnicity (24-month rate: 37.2% [Black], 27.7% [Hispanic], 22.5% [Asian], and 19.8% [White]; P = .004). The BCRL rates were also higher among patients receiving NAC vs up-front surgery (24-month rate: 29.3% vs 11.1%; P = .01). On multivariable analysis, Black race and Hispanic ethnicity (compared with White race) (odds ratio [OR], 3.88; 95% CI, 2.14-7.08 and OR, 3.01; 95% CI, 1.10-7.62, respectively; P < .001 for each), receipt of NAC (compared with up-front surgery) (OR, 2.10; 95% CI, 1.16-3.95; P = .01), older age (OR, 1.04; 95% CI, 1.02-1.07 per 1-year increase; P = .001), and a longer follow-up interval (OR, 1.57; 95% CI, 1.30-1.90 per 6-month increase; P < .001) were independently associated with an increased risk of BCRL, while ERBB2-positive subtype was associated with a decreased risk of BCRL (compared with hormone receptor positive/ERBB2 negative): OR, 0.50; 95% CI, 0.23-0.99; P = .04).
In this cohort study, Black race, Hispanic ethnicity, NAC receipt, older age, and longer follow-up were independently associated with risk of BCRL. Studies are warranted to evaluate the biologic mechanisms behind racial and ethnic disparities in BCRL development and alternatives to NAC to avoid ALND in tumor subtypes unlikely to achieve nodal pathologic complete response.
腋窝淋巴结清扫术（ALND）后乳腺癌相关淋巴水肿（BCRL）的风险因素了解甚少。
评估前瞻性队列中接受 ALND 治疗的女性的 BCRL 发生率和相关风险因素。
设计、地点和参与者：这项在三级癌症中心进行的前瞻性 BCRL 筛查研究纳入了 18 岁及以上接受乳房手术和单侧 ALND 的乳腺癌患者，包括原发治疗或前哨淋巴结活检后。
ALND 和放疗后 2 年内的 BCRL 风险。
前瞻性评估患者手臂容积（测径器），BCRL 定义为基线相对体积变化 10%或以上。采用竞争风险分析评估 BCRL 的累积发生率。使用单变量和多变量分析评估 BCRL 的风险因素。
2016 年 11 月至 2020 年 3 月，共纳入 304 例患者；276 例至少有 1 次纵向测量。中位（IQR）年龄为 48（40-57）岁；中位（IQR）体重指数（体重以千克为单位除以身高以米为单位的平方）为 26.4（22.5-31.2）。在分析中包括的 276 例患者中，29 例（11%）自我认定为亚洲人，55 例（20%）为黑人，16 例（6%）为西班牙裔，166 例（60%）为白人，10 例（3%）为未知种族和民族；70%接受新辅助化疗（NAC）；93%接受淋巴结照射。24 个月 BCRL 发生率为 23.8%（95%CI，17.9%-29.8%），种族和民族差异显著（24 个月发生率：黑人 37.2%，西班牙裔 27.7%，亚洲人 22.5%，白人 19.8%；P=0.004）。接受 NAC 与术前手术相比，BCRL 发生率更高（24 个月率：29.3%比 11.1%；P=0.01）。多变量分析显示，黑人种族和西班牙裔（与白人种族相比）（比值比[OR]，3.88；95%CI，2.14-7.08 和 OR，3.01；95%CI，1.10-7.62；P<0.001），接受 NAC（与术前手术相比）（OR，2.10；95%CI，1.16-3.95；P=0.01），年龄较大（OR，1.04；95%CI，每增加 1 岁增加 1.02-1.07；P=0.001）和随访时间较长（OR，1.57；95%CI，每增加 6 个月增加 1.30-1.90；P<0.001）与 BCRL 风险增加独立相关，而 ERBB2 阳性亚型与 BCRL 风险降低相关（与激素受体阳性/ERBB2 阴性相比）：OR，0.50；95%CI，0.23-0.99；P=0.04）。
在这项队列研究中，黑人种族、西班牙裔、接受 NAC、年龄较大和随访时间较长与 BCRL 风险独立相关。有必要研究种族和民族之间在 BCRL 发展方面的差异背后的生物学机制，以及避免淋巴结病理完全缓解可能性较低的肿瘤亚型接受 NAC 的替代方法。
