Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York.
JAMA Surg. 2024 Jun 1;159(6):668-676. doi: 10.1001/jamasurg.2024.0118.
Higher 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.
To evaluate the association of race and ethnicity with long-term QOL in patients with breast cancer treated with ALND.
DESIGN, SETTING, AND PARTICIPANTS: This 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.
Breast surgery and unilateral ALND in the primary setting or after sentinel lymph node biopsy.
Scores in each domain of the ULL-27 were compared by race and ethnicity. Factors impacting QOL were identified using multivariable regression analyses.
The 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 < .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 < .001).
Findings 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.
已经发现，在接受腋窝淋巴结清扫术（ALND）后，黑人和西班牙裔女性的淋巴水肿发生率更高；然而，主观症状、生活质量（QOL）和测量的淋巴水肿之间的相关性很差。此外，种族和民族之间的 QOL 差异研究不足。
评估种族和民族与接受 ALND 治疗的乳腺癌患者长期 QOL 的关系。
设计、地点和参与者：这项队列研究纳入了 2016 年 11 月至 2020 年 3 月在一家三级癌症中心接受单侧 ALND 的年龄在 18 岁及以上的女性乳腺癌患者。在术前和 6 个月的间隔期，使用周长仪测量手臂体积，并使用上肢淋巴水肿 27 项问卷（ULL-27）评估 QOL，这是一种评估手臂症状如何影响身体、心理和社会功能的淋巴水肿评估工具。数据分析于 2016 年 11 月至 2023 年 10 月进行。
原发性或前哨淋巴结活检后的乳房手术和单侧 ALND。
使用 ULL-27 的每个域的分数按种族和民族进行比较。使用多变量回归分析确定影响 QOL 的因素。
该研究纳入了 281 名接受单侧 ALND 且至少有 6 个月随访的乳腺癌患者（中位数[IQR]年龄，48 [41-58] 岁）。其中，30 名患者（11%）自我认定为亚裔，57 名（20%）为非裔，23 名（8%）为西班牙裔，162 名（58%）为白人；9 名（3%）未确定为特定群体或种族和民族数据缺失的患者被归类为种族和民族未知。中位（IQR）随访时间为 2.97（1.96-3.67）年。总的 2 年淋巴水肿发生率为 20%，黑人（31%）和西班牙裔（27%）女性高于亚裔（15%）和白人（17%）女性（P = .04）。亚裔（57%）、非裔（70%）和西班牙裔（87%）女性的手臂主观肿胀比白人女性（44%）更为常见（P < .001），在几乎每个随访时，少数族裔女性的身体 QOL 评分较低。例如，在 24 个月时，亚裔、非裔和西班牙裔女性的 QOL 中位数分别为 87、79 和 80，而白人女性为 92（P = .003）。多变量分析显示，亚裔种族（β = -5.7；95%CI，-9.5 至-1.8）、西班牙裔民族（β = -10.0；95%CI，-15.0 至-5.2）和拥有医疗补助（β = -5.4；95%CI，-9.2 至-1.7）或医疗保险（β = -6.9；95%CI，-10.0 至-3.4）与较差的身体 QOL 独立相关（均 P < .001）。
这项队列研究的结果表明，与白人女性相比，接受单侧 ALND 治疗乳腺癌的亚裔、非裔和西班牙裔女性术后手臂肿胀的主观症状更为明显。黑人和西班牙裔女性的客观淋巴水肿发生率高于其白人对应者。少数族裔身份和公共医疗保险均与较差的身体 QOL 相关。了解 ALND 后 QOL 的差异是一个未满足的需求，可能会促使为这些患者改善 QOL 的针对性干预措施。
