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Time-Course of Arm Lymphedema and Potential Risk Factors for Progression of Lymphedema After Breast Conservation Treatment for Early Stage Breast Cancer
result on the reconstructed breast is easily identified could reasonably direct plastic surgeons toward a 2-stage approach. In conclusion, we believe there is definitely a role for single-stage, implant-based reconstruction when it is performed after careful patient selection and based on intraoperative findings. Committing to single-stage reconstruction without considering the status of the mastectomy skin flaps, the
potential for adjuvant radiotherapy, or the type of symmetry procedures that will need to be performed in cases of unilateral reconstruction can lead to complications and patient dissatisfaction. Prospective, randomized studies could be very beneficial at this point and lead to more definite conclusions.
Reference 1. Pusic AL, Lemaine V, Klassen AF, Scott AM, Cano SJ. Patient-reported outcome measures in plastic surgery: use and interpretation in evidencebased medicine. Plast Reconstr Surg. 2011;127:1361-1367.
V. J. Hassid, MD S. J. Kronowitz, MD
FOLLOW-UP MANAGEMENT Time-Course of Arm Lymphedema and Potential Risk Factors for Progression of Lymphedema After Breast Conservation Treatment for Early Stage Breast Cancer Bar Ad V, Dutta PR, Solin LJ, et al (Univ of Pennsylvania, Philadelphia) Breast J 18:219-225, 2012
The objective of this study was to describe the progression of arm lymphedema (ALE) after the initial presentation among patients receiving breast conservation therapy for early stage breast cancer and to identify potential risk factors contributing to ALE progression. The study sample was the 266 stage I or II breast cancer patients with documented ALE who underwent breast conservation therapy that included lumpectomy, axillary staging followed by radiation therapy. ALE were graded according to a difference of 0.5e2 cm (mild), 2.1e3 cm (moderate), and > 3 cm (severe) in the circumference between the upper extremities for the
92
treated and untreated sides. ALE at presentation was scored as mild, moderate, and severe in 109 (41%), 125 (47%), and 32 (12%) patients, respectively. One third of patients with ALE progressed to a more severe grade of lymphedema at 5 years of follow-up. Age older than 65 years at the time of breast cancer treatment was associated with higher risk of ALE progression when compared 65 year age or younger (p ¼ 0.04). The patients who had regional lymph node irradiation including posterior axillary boost were at higher risk of lymphedema progression than the patients treated with whole breast irradiation only (p ¼ 0.001). Progression of ALE is a common occurrence. The current study provides support for the utility of routine arm measurements after breast cancer treatment to facilitate timely diagnosis and treatment of ALE. This article by Bar Ad and colleagues presents a series of patients with stage I and II breast cancer who underwent breastconserving therapy at the University
Breast Diseases: A Year BookÒ Quarterly Vol 24 No 1 2013
of Pennsylvania and had ALE. The investigators sought to assess the factors associated with the progression of ALE. Patients were diagnosed with mild, moderate, or severe ALE based on circumferential arm measurements. One-third of the patients with ALE were found to have progression of ALE. Multivariate analysis showed that the risk factors for the progression of ALE included age older than 65 years and radiation treatment that included a posterior axillary boost (PAB). The mean time from breast cancer treatment to ALE was 19 months. In contrast to previously reported data, body mass index, the number of lymph nodes removed, and the number of lymph nodes involved with tumor were not predictive of the progression of ALE. It is uncertain if this finding is related to the natural history of ALE or, more likely, to the inherent biases in a retrospective chart review. Of note, the posterior axillary boost is typically delivered either in the setting of an insufficient axillary lymph node dissection or when gross residual
lymphadenopathy is seen in the axilla; thus, it is surprising that neither tumor biology nor surgical treatment influenced the progression of ALE. Although this article indicates that radiation therapy can contribute to ALE progression, the lack of a correlation between the extent of lymph node metastasis and the progression of ALE merits further investigation. The patients in this study were assessed for ALE using a traditional technique of circumferential arm measurements at nonspecific time points and in the setting of grossly visualized upper extremity edema or patient complaints. Measurements were not taken prospectively before any oncologic treatment was delivered. The authors were also not able to comment on the ALE treatment interventions delivered; approximately one-third of patients with mildto-moderate ALE were referred for physical therapy. This makes it difficult to discern whether the pattern of
ALE described truly reflects the natural history of the ailment versus outcomes resulting from variable treatment of the disease. The National Lymphedema Network recommends that health care providers take a proactive position in the prevention and early treatment of breast cancer patients at risk for ALE.1 A surveillance program that includes pretreatment baseline measurements and routine follow-up measurements is considered a best practice. Ideally, perometer or bioimpedance measurements should be included in the screening program to reduce the interobserver error that can be seen with circumference measurements alone. Despite the known effect of ALE on quality of life and its contribution to health care expenditures, reimbursement for screening is limited. Significant challenges to augmenting our understanding of the natural history of, prevention strategies for, and best
Neuropsychological Performance in Survivors of Breast Cancer More Than 20 Years After Adjuvant Chemotherapy
unknown, yet it becomes increasingly relevant because of the widespread use of chemotherapy for early-stage breast cancer and the improved survival. We investigated whether cyclophosphamide, methotrexate, and fluorouracil (CMF) chemotherapy for breast cancer is associated with worse cognitive performance more than 20 years after treatment. Patients and Methods.dThis casecohort study compared the cognitive performance of patients with breast cancer who had a history of adjuvant CMF chemotherapy treatment (six cycles; average time since treatment, 21 years; n ¼ 196) to that of a population-based sample of women never diagnosed with cancer (n ¼ 1,509). Participants were
Koppelmans V, Breteler MMB, Boogerd W, et al (Erasmus MC Univ Med Ctr, Rotterdam, the Netherlands; Netherlands Cancer Inst/Antoni van Leeuwenhoek Hosp, Amsterdam; et al) J Clin Oncol 30:1080-1086, 2012
Purpose.dAdjuvant chemotherapy for breast cancer can have adverse effects on cognition shortly after administration. Whether chemotherapy has any longterm effects on cognition is largely
treatment of ALE remain. This article highlights the need for long-term follow-up of breast cancer survivors for ALE. Until major cancer centers are systematically screening breast cancer patients for ALE, retrospective chart reviews such as this one by Bar Ad and colleagues are important for improving our understanding of factors associated with ALE progression in breast cancer patients. S. F. Shaitelman, MD, EdM J. L. Wagner, DO
Reference 1. National Lymphedema Network. Position statement of the national lymphedema network. Topic: screening and measurement for early detection of breast cancer related lymphedema. 2011. http://www. lymphnet.org/pdfDocs/nlnBCLE.pdf. Accessed January 4, 2013.
between 50 and 80 years of age. Exclusion criteria were ever use of adjuvant endocrine therapy, secondary malignancy, recurrence, and/or metastasis. Results.dThe women exposed to chemotherapy performed significantly worse than the reference group on cognitive tests of immediate (P ¼.015) and delayed verbal memory (P ¼.002), processing speed (P < .001), executive functioning (P ¼ .013), and psychomotor speed (P ¼ .001). They experienced fewer symptoms of depression (P < .001), yet had significantly more memory complaints on two of three measures that could not be explained by cognitive test performance. Conclusion.dSurvivors of breast cancer treated with adjuvant CMF
Breast Diseases: A Year BookÒ Quarterly Vol 24 No 1 2013
93
potential for adjuvant radiotherapy, or the type of symmetry procedures that will need to be performed in cases of unilateral reconstruction can lead to complications and patient dissatisfaction. Prospective, randomized studies could be very beneficial at this point and lead to more definite conclusions.
Reference 1. Pusic AL, Lemaine V, Klassen AF, Scott AM, Cano SJ. Patient-reported outcome measures in plastic surgery: use and interpretation in evidencebased medicine. Plast Reconstr Surg. 2011;127:1361-1367.
V. J. Hassid, MD S. J. Kronowitz, MD
FOLLOW-UP MANAGEMENT Time-Course of Arm Lymphedema and Potential Risk Factors for Progression of Lymphedema After Breast Conservation Treatment for Early Stage Breast Cancer Bar Ad V, Dutta PR, Solin LJ, et al (Univ of Pennsylvania, Philadelphia) Breast J 18:219-225, 2012
The objective of this study was to describe the progression of arm lymphedema (ALE) after the initial presentation among patients receiving breast conservation therapy for early stage breast cancer and to identify potential risk factors contributing to ALE progression. The study sample was the 266 stage I or II breast cancer patients with documented ALE who underwent breast conservation therapy that included lumpectomy, axillary staging followed by radiation therapy. ALE were graded according to a difference of 0.5e2 cm (mild), 2.1e3 cm (moderate), and > 3 cm (severe) in the circumference between the upper extremities for the
92
treated and untreated sides. ALE at presentation was scored as mild, moderate, and severe in 109 (41%), 125 (47%), and 32 (12%) patients, respectively. One third of patients with ALE progressed to a more severe grade of lymphedema at 5 years of follow-up. Age older than 65 years at the time of breast cancer treatment was associated with higher risk of ALE progression when compared 65 year age or younger (p ¼ 0.04). The patients who had regional lymph node irradiation including posterior axillary boost were at higher risk of lymphedema progression than the patients treated with whole breast irradiation only (p ¼ 0.001). Progression of ALE is a common occurrence. The current study provides support for the utility of routine arm measurements after breast cancer treatment to facilitate timely diagnosis and treatment of ALE. This article by Bar Ad and colleagues presents a series of patients with stage I and II breast cancer who underwent breastconserving therapy at the University
Breast Diseases: A Year BookÒ Quarterly Vol 24 No 1 2013
of Pennsylvania and had ALE. The investigators sought to assess the factors associated with the progression of ALE. Patients were diagnosed with mild, moderate, or severe ALE based on circumferential arm measurements. One-third of the patients with ALE were found to have progression of ALE. Multivariate analysis showed that the risk factors for the progression of ALE included age older than 65 years and radiation treatment that included a posterior axillary boost (PAB). The mean time from breast cancer treatment to ALE was 19 months. In contrast to previously reported data, body mass index, the number of lymph nodes removed, and the number of lymph nodes involved with tumor were not predictive of the progression of ALE. It is uncertain if this finding is related to the natural history of ALE or, more likely, to the inherent biases in a retrospective chart review. Of note, the posterior axillary boost is typically delivered either in the setting of an insufficient axillary lymph node dissection or when gross residual
lymphadenopathy is seen in the axilla; thus, it is surprising that neither tumor biology nor surgical treatment influenced the progression of ALE. Although this article indicates that radiation therapy can contribute to ALE progression, the lack of a correlation between the extent of lymph node metastasis and the progression of ALE merits further investigation. The patients in this study were assessed for ALE using a traditional technique of circumferential arm measurements at nonspecific time points and in the setting of grossly visualized upper extremity edema or patient complaints. Measurements were not taken prospectively before any oncologic treatment was delivered. The authors were also not able to comment on the ALE treatment interventions delivered; approximately one-third of patients with mildto-moderate ALE were referred for physical therapy. This makes it difficult to discern whether the pattern of
ALE described truly reflects the natural history of the ailment versus outcomes resulting from variable treatment of the disease. The National Lymphedema Network recommends that health care providers take a proactive position in the prevention and early treatment of breast cancer patients at risk for ALE.1 A surveillance program that includes pretreatment baseline measurements and routine follow-up measurements is considered a best practice. Ideally, perometer or bioimpedance measurements should be included in the screening program to reduce the interobserver error that can be seen with circumference measurements alone. Despite the known effect of ALE on quality of life and its contribution to health care expenditures, reimbursement for screening is limited. Significant challenges to augmenting our understanding of the natural history of, prevention strategies for, and best
Neuropsychological Performance in Survivors of Breast Cancer More Than 20 Years After Adjuvant Chemotherapy
unknown, yet it becomes increasingly relevant because of the widespread use of chemotherapy for early-stage breast cancer and the improved survival. We investigated whether cyclophosphamide, methotrexate, and fluorouracil (CMF) chemotherapy for breast cancer is associated with worse cognitive performance more than 20 years after treatment. Patients and Methods.dThis casecohort study compared the cognitive performance of patients with breast cancer who had a history of adjuvant CMF chemotherapy treatment (six cycles; average time since treatment, 21 years; n ¼ 196) to that of a population-based sample of women never diagnosed with cancer (n ¼ 1,509). Participants were
Koppelmans V, Breteler MMB, Boogerd W, et al (Erasmus MC Univ Med Ctr, Rotterdam, the Netherlands; Netherlands Cancer Inst/Antoni van Leeuwenhoek Hosp, Amsterdam; et al) J Clin Oncol 30:1080-1086, 2012
Purpose.dAdjuvant chemotherapy for breast cancer can have adverse effects on cognition shortly after administration. Whether chemotherapy has any longterm effects on cognition is largely
treatment of ALE remain. This article highlights the need for long-term follow-up of breast cancer survivors for ALE. Until major cancer centers are systematically screening breast cancer patients for ALE, retrospective chart reviews such as this one by Bar Ad and colleagues are important for improving our understanding of factors associated with ALE progression in breast cancer patients. S. F. Shaitelman, MD, EdM J. L. Wagner, DO
Reference 1. National Lymphedema Network. Position statement of the national lymphedema network. Topic: screening and measurement for early detection of breast cancer related lymphedema. 2011. http://www. lymphnet.org/pdfDocs/nlnBCLE.pdf. Accessed January 4, 2013.
between 50 and 80 years of age. Exclusion criteria were ever use of adjuvant endocrine therapy, secondary malignancy, recurrence, and/or metastasis. Results.dThe women exposed to chemotherapy performed significantly worse than the reference group on cognitive tests of immediate (P ¼.015) and delayed verbal memory (P ¼.002), processing speed (P < .001), executive functioning (P ¼ .013), and psychomotor speed (P ¼ .001). They experienced fewer symptoms of depression (P < .001), yet had significantly more memory complaints on two of three measures that could not be explained by cognitive test performance. Conclusion.dSurvivors of breast cancer treated with adjuvant CMF
Breast Diseases: A Year BookÒ Quarterly Vol 24 No 1 2013
93