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Complicated breast cancer–related lymphedema: evaluating health care resource utilization and associated costs of management
ECONOMIC, LEGAL & SOCIAL ISSUES Complicated breast cancererelated lymphedema: evaluating health care resource utilization and associated costs of management
Am J Surg 211:133-141, 2016
with complicated lymphedema, breast reconstruction appeared unrelated. Conclusions.dComplicated lymphedema develops in a quantifiable number of patients. The health care burden of lymphedema underscored here mandates further investigation into targeted, anticipatory management strategies for breast cancererelated lymphedema.
Background.dLymphedema can become a disabling condition necessitating inpatient care. This study aimed to estimate complicated lymphedema incidence after breast cancer surgery and calculate associated hospital resource utilization. Methods.dWe identified adult women undergoing lumpectomy and/ or mastectomy with axillary lymph node surgery between 2006 and 2012 using 5-state inpatient databases. Patients were grouped according to the development of complicated lymphedema. The primary outcomes were all-cause hospitalizations and health care charges within 2 years of surgery. Multivariate regression models were used to compare outcomes. Results.dOf 56,075 women included, 2.3% had at least 1 hospital admission for complicated lymphedema within 2 years of surgery. Despite confounder adjustment, women with complicated lymphedema experienced 5 fold more all-cause (incidence rate ratio ¼ 5.02, 95% confidence interval: 4.76 to 5.29) admissions compared with women without lymphedema. This resulted in substantially higher health care charges ($58,088 vs $31,819 per patient, P < .001). Although axillary dissection and certain comorbidities were associated
Increased focus on early detection of breast cancer, improved breast imaging techniques, and advances in the treatment of breast cancer have resulted in increasing numbers of breast cancer survivors. The National Comprehensive Cancer Network guidelines focusing on the care of cancer survivors include the effect of cancer and its treatments on physical health and financial standing.1 Lymphedema is one of the most dreaded consequences of breast cancer treatment which affects patients’ quality of life and results in significant financial burdens.2 As reported in this article, Basta and colleagues used a 5-state database to identify patients undergoing breast cancer treatment with 2 years of follow-up to show increased healthcare resource use and costs resulting from lymphedema. Not surprisingly, patients with lymphedema required more hospitalizations that resulted in greater costs than did those without lymphedema. The only surgical factor significantly associated with lymphedema was axillary lymph node dissection. Interestingly, patients with concurrent procedure coding for lumpectomy and mastectomy were excluded from analysis. However, these patients should have been
Basta MN, Fox JP, Kanchwala SK, et al (Univ of Pennsylvania, Philadelphia)
226
Breast Diseases: A Year BookÒ Quarterly Vol 27 No 3 2016
included, as it is known that marginnegative lumpectomy is required in all cases. Some patients with marginpositive lumpectomies will opt for mastectomy to achieve this goal, and, for some, mastectomy will be required to achieve negative margins. In addition, patients undergoing lumpectomy with reconstruction were excluded from this analysis. Given the rising prevalence of lumpectomy with reconstruction, inclusion of these patients in future studies is important. The early identification and treatment of lymphedema has shown the greatest likelihood of reversing symptoms, improving patients’ quality of life, and reducing healthcare costs.3 However, we must consider that perhaps patients should undergo intervention prior to developing clinical lymphedema. Soran and colleagues4 showed that patients with subclinical lymphedema benefitted from early intervention, including physical therapy, compression garments, and education. Of course, surgeons are responsible for best practice by ensuring that appropriate axillary treatment is rendered such that patients with node-positive disease who meet American College of Surgeons Oncology Group Z0011 trial criteria are not subjected to unnecessary completion axillary dissections and its negative sequelae.5,6 Overall, these data highlight the need to educate patients about their risk for lymphedema and potential symptoms as well as implement prospective screening to improve early detection, including detection of subclinical lymphedema, and thus provide timely
and effective treatment for this condition, ultimately resulting in decreased downstream complications and costs. S. M. DeSnyder, MD M. V. Schaverien, MD
References 1. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Survivorship. Version 1.2016. https:// www.nccn.org/professionals/ physician_gls/pdf/survivorship.pdf. Accessed June 2, 2016.
2. Shih YT, Xu Y, Cormier JN, et al. Incidence, treatment costs, and complications of lymphedema after breast cancer among women of working age: a 2-year follow-up study. J Clin Oncol. 2009;27:2007-2014. 3. Ahmed RL, Prizment A, Lazovich D, et al. Lymphedema and quality of life in breast cancer survivors: the Iowa Women’s Health Study. J Clin Oncol. 2008;26:5689-5696. 4. Soran A, Ozmen T, McGuire KP, et al. The importance of detection of subclinical lymphedema for the prevention of breast cancer-related clinical lymphedema after axillary lymph node dissection; a prospective observational study. Lymphat Res Biol. 2014;12:289-294.
5. Giuliano AE, Hunt KK, Ballman KV, et al. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA. 2011;305: 569-575. 6. Lucci A, McCall LM, Beitsch PD, et al. American College of Surgeons Oncology Group. Surgical complications associated with sentinel lymph node dissection (SLND) plus axillary lymph node dissection compared with SLND alone in the American College of Surgeons Oncology Group Trial Z0011. J Clin Oncol. 2007;25: 3657-3663.
SURVIVORSHIP Inherited Mutations in Cancer Susceptibility Genes Are Common Among Survivors of Breast Cancer Who Develop Therapy-Related Leukemia Churpek JE, Marquez R, Neistadt B, et al (The Univ of Chicago, IL; et al) Cancer 122:304-311, 2016
Background.dRisk factors for the development of therapy-related leukemia (TRL), an often lethal late complication of cytotoxic therapy, remain poorly understood and may differ for survivors of different malignancies. Survivors of breast cancer (BC) now account for the majority of TRL cases, making the study of TRL risk factors in this population a priority. Methods.dSubjects with TRL after cytotoxic therapy for a primary
BC were identified from the TRL registry at The University of Chicago. Those with an available germline DNA sample were screened with a comprehensive gene panel covering known inherited BC susceptibility genes. Clinical and TRL characteristics of all subjects and those with identified germline mutations were described. Results.dNineteen of 88 survivors of BC with TRL (22%) had an additional primary cancer and 40 of the 70 survivors with an available family history (57%) had a close relative with breast, ovarian, or pancreatic cancer. Of the 47 subjects with available DNA, 10 (21%) were found to carry a deleterious inherited mutation in BRCA1 (3 subjects; 6%), BRCA2 (2 subjects; 4%), TP53 (tumor protein p53) (3 subjects; 6%), CHEK2 (checkpoint kinase 2) (1 subject; 2%), and PALB2 (partner and localizer of BRCA2) (1 subject; 2%).
Conclusions.dSurvivors of BC with TRL have personal and family histories suggestive of inherited cancer susceptibility and frequently carry germline mutations in BC susceptibility genes. The data from the current study support the role of these genes in TRL risk and suggest that longterm follow-up studies of women with germline mutations who are treated for BC and functional studies of the effects of heterozygous mutations in these genes on bone marrow function after cytotoxic exposures are warranted. According to the National Cancer Institute’s Surveillance, Epidemiology, and End Results database, the 5year survival rate after a cancer diagnosis increased from 49% in 1975 to 68% in 2008.1 As the number of cancer survivors increases, the
Breast Diseases: A Year BookÒ Quarterly Vol 27 No 3 2016
227
Am J Surg 211:133-141, 2016
with complicated lymphedema, breast reconstruction appeared unrelated. Conclusions.dComplicated lymphedema develops in a quantifiable number of patients. The health care burden of lymphedema underscored here mandates further investigation into targeted, anticipatory management strategies for breast cancererelated lymphedema.
Background.dLymphedema can become a disabling condition necessitating inpatient care. This study aimed to estimate complicated lymphedema incidence after breast cancer surgery and calculate associated hospital resource utilization. Methods.dWe identified adult women undergoing lumpectomy and/ or mastectomy with axillary lymph node surgery between 2006 and 2012 using 5-state inpatient databases. Patients were grouped according to the development of complicated lymphedema. The primary outcomes were all-cause hospitalizations and health care charges within 2 years of surgery. Multivariate regression models were used to compare outcomes. Results.dOf 56,075 women included, 2.3% had at least 1 hospital admission for complicated lymphedema within 2 years of surgery. Despite confounder adjustment, women with complicated lymphedema experienced 5 fold more all-cause (incidence rate ratio ¼ 5.02, 95% confidence interval: 4.76 to 5.29) admissions compared with women without lymphedema. This resulted in substantially higher health care charges ($58,088 vs $31,819 per patient, P < .001). Although axillary dissection and certain comorbidities were associated
Increased focus on early detection of breast cancer, improved breast imaging techniques, and advances in the treatment of breast cancer have resulted in increasing numbers of breast cancer survivors. The National Comprehensive Cancer Network guidelines focusing on the care of cancer survivors include the effect of cancer and its treatments on physical health and financial standing.1 Lymphedema is one of the most dreaded consequences of breast cancer treatment which affects patients’ quality of life and results in significant financial burdens.2 As reported in this article, Basta and colleagues used a 5-state database to identify patients undergoing breast cancer treatment with 2 years of follow-up to show increased healthcare resource use and costs resulting from lymphedema. Not surprisingly, patients with lymphedema required more hospitalizations that resulted in greater costs than did those without lymphedema. The only surgical factor significantly associated with lymphedema was axillary lymph node dissection. Interestingly, patients with concurrent procedure coding for lumpectomy and mastectomy were excluded from analysis. However, these patients should have been
Basta MN, Fox JP, Kanchwala SK, et al (Univ of Pennsylvania, Philadelphia)
226
Breast Diseases: A Year BookÒ Quarterly Vol 27 No 3 2016
included, as it is known that marginnegative lumpectomy is required in all cases. Some patients with marginpositive lumpectomies will opt for mastectomy to achieve this goal, and, for some, mastectomy will be required to achieve negative margins. In addition, patients undergoing lumpectomy with reconstruction were excluded from this analysis. Given the rising prevalence of lumpectomy with reconstruction, inclusion of these patients in future studies is important. The early identification and treatment of lymphedema has shown the greatest likelihood of reversing symptoms, improving patients’ quality of life, and reducing healthcare costs.3 However, we must consider that perhaps patients should undergo intervention prior to developing clinical lymphedema. Soran and colleagues4 showed that patients with subclinical lymphedema benefitted from early intervention, including physical therapy, compression garments, and education. Of course, surgeons are responsible for best practice by ensuring that appropriate axillary treatment is rendered such that patients with node-positive disease who meet American College of Surgeons Oncology Group Z0011 trial criteria are not subjected to unnecessary completion axillary dissections and its negative sequelae.5,6 Overall, these data highlight the need to educate patients about their risk for lymphedema and potential symptoms as well as implement prospective screening to improve early detection, including detection of subclinical lymphedema, and thus provide timely
and effective treatment for this condition, ultimately resulting in decreased downstream complications and costs. S. M. DeSnyder, MD M. V. Schaverien, MD
References 1. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Survivorship. Version 1.2016. https:// www.nccn.org/professionals/ physician_gls/pdf/survivorship.pdf. Accessed June 2, 2016.
2. Shih YT, Xu Y, Cormier JN, et al. Incidence, treatment costs, and complications of lymphedema after breast cancer among women of working age: a 2-year follow-up study. J Clin Oncol. 2009;27:2007-2014. 3. Ahmed RL, Prizment A, Lazovich D, et al. Lymphedema and quality of life in breast cancer survivors: the Iowa Women’s Health Study. J Clin Oncol. 2008;26:5689-5696. 4. Soran A, Ozmen T, McGuire KP, et al. The importance of detection of subclinical lymphedema for the prevention of breast cancer-related clinical lymphedema after axillary lymph node dissection; a prospective observational study. Lymphat Res Biol. 2014;12:289-294.
5. Giuliano AE, Hunt KK, Ballman KV, et al. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA. 2011;305: 569-575. 6. Lucci A, McCall LM, Beitsch PD, et al. American College of Surgeons Oncology Group. Surgical complications associated with sentinel lymph node dissection (SLND) plus axillary lymph node dissection compared with SLND alone in the American College of Surgeons Oncology Group Trial Z0011. J Clin Oncol. 2007;25: 3657-3663.
SURVIVORSHIP Inherited Mutations in Cancer Susceptibility Genes Are Common Among Survivors of Breast Cancer Who Develop Therapy-Related Leukemia Churpek JE, Marquez R, Neistadt B, et al (The Univ of Chicago, IL; et al) Cancer 122:304-311, 2016
Background.dRisk factors for the development of therapy-related leukemia (TRL), an often lethal late complication of cytotoxic therapy, remain poorly understood and may differ for survivors of different malignancies. Survivors of breast cancer (BC) now account for the majority of TRL cases, making the study of TRL risk factors in this population a priority. Methods.dSubjects with TRL after cytotoxic therapy for a primary
BC were identified from the TRL registry at The University of Chicago. Those with an available germline DNA sample were screened with a comprehensive gene panel covering known inherited BC susceptibility genes. Clinical and TRL characteristics of all subjects and those with identified germline mutations were described. Results.dNineteen of 88 survivors of BC with TRL (22%) had an additional primary cancer and 40 of the 70 survivors with an available family history (57%) had a close relative with breast, ovarian, or pancreatic cancer. Of the 47 subjects with available DNA, 10 (21%) were found to carry a deleterious inherited mutation in BRCA1 (3 subjects; 6%), BRCA2 (2 subjects; 4%), TP53 (tumor protein p53) (3 subjects; 6%), CHEK2 (checkpoint kinase 2) (1 subject; 2%), and PALB2 (partner and localizer of BRCA2) (1 subject; 2%).
Conclusions.dSurvivors of BC with TRL have personal and family histories suggestive of inherited cancer susceptibility and frequently carry germline mutations in BC susceptibility genes. The data from the current study support the role of these genes in TRL risk and suggest that longterm follow-up studies of women with germline mutations who are treated for BC and functional studies of the effects of heterozygous mutations in these genes on bone marrow function after cytotoxic exposures are warranted. According to the National Cancer Institute’s Surveillance, Epidemiology, and End Results database, the 5year survival rate after a cancer diagnosis increased from 49% in 1975 to 68% in 2008.1 As the number of cancer survivors increases, the
Breast Diseases: A Year BookÒ Quarterly Vol 27 No 3 2016
227