Lymphedema and Breast Cancer: When Is Risk Greatest?

The time course for developing lymphedema depends on the type of breast cancer treatment, but the risk peaks between 24 and 36 months post therapy, regardless of treatment type, according to new research. Receipt of radiation therapy (RT) is also a key to the timing. "Lymphedema develops earlier in patients who receive radiation, especially those receiving regional lymph node radiation," said the study's lead author, Susan McDuff, MD, PhD, a resident in radiation oncology at the Massachusetts General Hospital (MGH) Cancer Center in Boston.

Lymphedema can be "an incredibly morbid" complication following treatment for breast cancer and is an ongoing source of anxiety for survivors, she said here at the American Society for Radiation Oncology (ASTRO) 2016 Annual Meeting. To help patients know when they may be "out of the woods," Dr McDuff and colleagues undertook a cohort study to determine whether there is a period when patients are at greatest risk. First, they looked at cumulative incidence.

The team analyzed the records of 1495 patients seen between 2005 and 2016 in a prospective lymphedema screening program at MGH. The time it took to reach 5% cumulative incidence by treatment group was 32 months for surgery alone and 15 months for RT (P = .02) However, a further look at the data revealed that patients who received regional lymph node radiation (RLNR) reached the 5% cumulative incidence in only 6 months vs 37 months for those who received local RT (P < .0001). There was a median follow-up of 3.9 years and a cumulative lymphedema incidence of 11.4% in the study population. Nearly three quarters (73%) of the patients received RT as a component of their treatment. To pinpoint risk over time, the researchers looked at the percentage of patients in various treatment groups who were diagnosed with lymphedema in each year during the first 5 years post therapy. This was done by plotting the annual hazard rate for the treatment groups. All patients received some mix of axillary surgery and RT.

The groups were as follows: no axillary surgery (n = 180); sentinel lymph node biopsy (SLNB) plus or minus local RT (n = 899); SLNB plus regional lymph node radiation (RLNR) (n = 46); and axillary lymph node dissection (ALND) plus or minus local RT (n = 132); and ALND plus RLNR (n = 264). "The timing of the risk appears to be the most significant within the first 2 to 3 years after treatment," summarized Dr McDuff.


The new study addresses an important clinical question, said Abram Recht, MD, professor of radiation oncology at Harvard Medical School in Boston, who acted as an adviser to the study authors. "If you are going to do surveillance, how long do you have to do it?" he commented to Medscape Medical News. "You can expect that most patients who undergo sentinel lymph node biopsy with or without local RT, which is the largest treatment group, may not need active monitoring past 2 years," he concluded. "The period of the greatest risk is the first 3 years," said Dr Recht, echoing Dr McDuff. "If lymphedema hasn't developed by 5 years, then it probably won't happen," he added. The new results are an argument for "personalizing" a lymphedema monitoring program, said Dr McDuff, adding that more follow-up is needed for high-risk groups.

The goal is early identification and intervention. Shannon MacDonald, MD, associate professor of radiation oncology at Harvard, who acted as discussant of the study, said that the hope with monitoring is "that an earlier intervention for lymphedema would improve outcome." Dr MacDonald told Medscape Medical News that the new study results will also "allow patients to have some alleviation of anxiety as to when to expect lymphedema if it occurs," she said. The findings could also influence "when clinicians have patients come in for monitoring," Dr MacDonald added. This "very large" study makes a "meaningful contribution" to clinical knowledge, in part because there are "limited" data on timing, she said. Lymphedema is less common than in the past, owing to improvements in surgical management, but inaccuracy of measurements has plagued estimates of the incidence of lymphedema, Dr MacDonald said.

The new MGH study used a perometer, a tool that employs infrared technology to objectively measure the limb, which is "more likely to be accurate than a tape measure or other modalities," she said. The perometer was used to perform prospective arm volume measurements of the study patients preoperatively and then postoperatively and in follow-ups at regular intervals. Lymphedema was defined as a >10% relative volume increase occurring >3 months postoperatively. The treatments for lymphedema in the cohort included compression sleeves (88%), manual decompression (52%), and physical therapy–directed exercise (89%). "Patients worry a lot about lymphedema" concluded Dr Recht. "It's a really hard thing in survivorship," agreed Dr McDuff.

Mastectomy vs. Lumpectomy for Early Breast Cancer: How to Choose

Weighing the pros and cons of two different surgical options.
By Deborah Kotz

Each year more than 200,000 women diagnosed with early-stage breast cancer, the most common kind, must make myriad treatment decisions. Among them: whether to have a mastectomy or breast-conserving surgery known as a lumpectomy.

If you’ve been diagnosed with a stage 1 or 2 breast tumor that’s not highly aggressive, you may have been offered both surgical options and left to decide which is best for you.

“Once we determine that we can remove the tumor with clear cancer-free margins, we generally leave the choice up to the woman whether to have a lumpectomy or mastectomy without recommending one over the other,” says Bonnie Sun, a breast surgeon at Sibley Memorial Hospital in the District of Columbia. “It becomes a personal decision, and the patient will have to decide, ‘what do I really want?’”

A large body of evidence indicates that breast cancer patients who have mastectomies face the same survival odds as those who have lumpectomies along with breast radiation, and for the past few decades oncologists have been encouraging women with early-stage breast cancer to opt for the less radical surgery.

In fact, an expert panel convened by the National Cancer Institute declared in 1990 that lumpectomy with radiation was “preferable” to mastectomy for women with stage 1 or 2 breast cancer – which helped drive down mastectomy rates for these patients from 100 percent in the 1980s to less than 40 percent today.

But the pendulum is starting to swing back a bit toward mastectomies. A 2014 study published in the journal JAMA Surgery – which examined anonymous records from 70 to 80 percent of American women who had breast cancer surgery – found that the percentage of those with early-stage breast cancer increased from 34 percent in 1998 to 38 percent in 2011.

While the study authors could not explain the reasons for the increase, several developments over the past decade may have contributed.

Improvements in breast reconstruction following mastectomy provide patients with more natural looking results than in decades past, says Mehra Golshan, director of breast surgical services at Dana-Farber Cancer Institute in Boston. More breast cancer patients are also getting insurance coverage for the procedure, thanks to a 1998 federal law mandating coverage.

In recent years, oncologists have moved away from strongly recommending lumpectomies toward involving women in a shared decision-making process, which entails a more in-depth discussion of the pros and cons of both surgeries.

Ask yourself the following questions to help determine which surgical option is best for you.

1. How much do you fear annual breast screenings and a potential new breast tumor? Many breast cancer patients opt to have a mastectomy – and even a prophylactic mastectomy on the other healthy breast – because they know they’ll feel extreme anxiety during future annual mammograms and over any abnormal finding, follow-up biopsy and possible diagnosis of another breast tumor down the road. About 5 percent of patients who opt for a lumpectomy will have a recurrence in the affected breast or opposite breast, Golshan says, but it’s rarely life threatening.

2. How much do you want to avoid a painful recuperation? Mastectomy with breast reconstruction typically involves multiple surgical procedures and a painful healing process that can last for weeks or even months. Lumpectomy, on the other hand, is usually a shorter procedure with a shorter recovery time but sometimes also requires a second surgery if a pathologist later finds cancer cells in the tissue surrounding the removed tumor.

 “I give patients the option of speaking with women who have had lumpectomies and mastectomies, so they can get first-hand experiences of what others went through,” Golshan says.

3. Do you have concerns about radiation treatments? After lumpectomy surgery, patients typically need five to seven weeks of radiation therapy, five days per week, to destroy any stray cancer cells. Side effects from the treatments can include breast swelling, fatigue and skin redness and blistering (like a sunburn). Scatter from the radiation can, in rare cases, damage the heart, lungs or surrounding bones.

Some women are now being offered a new option called intraoperative radiation therapy, IORT for short, in which a single dose of radiation is delivered directly into the tumor site during lumpectomy surgery. Those who have IORT do not need subsequent radiation treatments, but only certain patients are candidates. “These are women over age 45 with early-stage invasive tumors less than 2.5 centimeters in size,” says Andrea McKee, chairman of the radiation oncology department at Lahey Hospital and Medical Center in Burlington, Massachusetts. Candidates also must have only ductal breast cancer, which occurs in the milk-producing ducts, with no signs of tumor cells in healthy tissue surrounding the excised lump and no spread to local lymph nodes.

Some caveats: Since the procedure is fairly new, many cancer treatment centers do not yet offer it, and some insurance companies do not cover it. What’s more, about 15 percent of patients who have IORT wind up needing traditional radiation treatments because their final pathology report shows that they weren’t appropriate candidates, McKee says.

4. How much importance do you place on breast appearance? On sexual pleasure? Reconstructed breasts may look great, but they don’t respond to cold, heat, touch or stimulation, which can reduce sexual pleasure, Golshan says. Lumpectomy will retain the sensation of the breast, but may result in a lopsided appearance if a large amount of tissue is removed or if a woman has a small breast. For this reason, breast reconstruction may be offered along with lumpectomy to even out breast size.

5. What’s your life expectancy? Women diagnosed with breast cancer at a younger age may be more likely to opt for mastectomy because their longer expected lifespan means they have a higher lifetime risk of recurrence. “We typically tell patients that their risk of developing another primary breast cancer is about ½ percent per year,” Sun says. A 30-year-old breast cancer patient who expects to live another 50 years will face a 25 percent risk of developing another breast cancer compared to a 5 percent risk for a woman diagnosed at age 70.

Young breast cancer patients are also more likely to carry gene mutations that put them at even greater risk of recurrence, Sun said, which could tip the balance toward having a single or double mastectomy.

Lymphedema Challenge

Actress and Academy Award winner, Kathy Bates recently kicked off theLymphatic Education & Research Network's Face of Lymphedema Challege. She proclaimed, "I'm Kathy Bates. I had a double mastectomy 2 years ago and as a result I have lymphedema in both arms. I didn't have a clue what would be involved after surgery and it was hard to find a doctor who would help me deal with, not only the physical effects, but the psychological effects as well. Struggling alone with lymphedema can feel like a punishment for having cancer. That's why I hope to bring awareness."

It's great to have such a high profile spokesperson help to bring awareness and hopefully a cure to lymphedema. Take the Face of Lymphedema Challege: http://lymphaticnetwork.org/get-involved/face-of-lymphedema-challenge/

I Am Scheduled To Undergo Mastectomy Surgery. What Are Some Recovery Tips?

Going through mastectomy surgery can be extremely taxing on both your body and your emotions.  Here are some tips to help you when you get home.

Follow Your Doctors Instructions
Follow all your Doctor’s instructions in regards to wound care, rest, lifting restrictions, driving, surgical bras and garments etc.  Most importantly if your Doctor says don’t do something – listen and don’t do it!

When discharged from hospital ask all your questions (to Doctors and Nurses) no matter how insignificant you may think they are and have contact numbers for when you get home and have another question or concern.

Rest, Rest and then Rest Some More
Take it totally easy the first full week.  Take multiple naps, watch movies, read books and relax.  Have people do almost everything for you to avoid overdoing it.  Be warned it is super easy to overdo it when you first get home.  Even opening the fridge, opening drawers, picking up stuff and carrying laundry is too much!  Also washing your hair is too much in the first week as you can’t lift your arms so book into the hairdressers.  If you do too much you will pay for it that night and the next day with muscle pain and a very sore body.

Fatigue is normal.  Gradually increase your activity and ease back into your ‘normal’ routine.  Remember most women require four to six weeks off work to recover.  A mastectomy is a major invasive surgery and body tissues need rest to recover and repair from the procedure.  By over doing it you are slowing down your recovery and healing.

Remember no strenuous activity or lifting for approximately six weeks following your surgery (your Doctor will tell you when you are ready).

Medication and Pain Control
Get all your scripts filled immediately (with non child proof caps – you will find the push down and turn type difficult to open with limited arm strength) and in a notebook write down what you take and when.  It is easy to lose track of whether you have taken your medication or not and writing it down ensures you have and have taken it at the right time (and haven’t taken a double dose).  Writing down your pain medication is also useful as it allows you to slowly reduce the amount and strength over a few weeks.   

When it comes to pain management take your pain medication regularly.  The job of the medicine is to avoid pain.  If you get in too much pain you will feel miserable waiting for the pain medication to kick in.  Also studies have shown that a patient who has less pain recovers better.

Medical Supplies
It is useful to have the following at home:

• Laxatives as the pain medications/general aesthetic can make you constipated
• Ibuprofen
• Acetaminophen
• Post scar treatment (although you won’t need this until your tape/bandages have been removed)
• Spare dressings (although in some cases you won’t need these as your Surgeon will remove your tape/dressings at your first follow up appointment)

Sleeping
You will most likely need to sleep on your back for at least three or four weeks (definitely the case if you have had a double mastectomy).  This is actually harder than it sounds if you are used to sleeping on your stomach or side and getting sleep is really important for your recovery (and feeling rested and able to cope in general).

Exercise
Follow your Surgeon’s instructions regarding exercise.  Usually you will be encouraged to walk and have been doing laps of the hospital.  When you get home walk a bit further each day.  Listen to your body and stop if you get tired or dizzy.  Resume more physically active exercise, running, swimming etc. once your Doctor gives approval and gradually build back up to your pre surgery levels.

It can be frustrating, for example if you were a runner and feel great but still have bruising and swelling and your Surgeon says no running (raising your heart rate/pulse slows down healing) – listen, grit your teeth and DON’T RUN.

Get Comfortable
New clothes may be necessary to accommodate your surgery.  Specialty camisoles are a great option because they provide a light layer that can hold drains.  Many styles have pockets to hold forms and can be worn under your clothing.  You may also opt for a robe that is made with pockets for breast forms or ice packs and also can support the weight of fluid from drains.

You will want to get a prosthesis or breast form around six weeks after surgery.  Typically at this time the swelling will have reduced.  Make sure that you see a BOC or ABC certified fitter.  These certifications ensure that you are fitted properly.  A certified fitter can also help you find a well-fitting bra to act as a good foundation for style and comfort.

Drink Water
It is very important that you drink plenty of water during your mastectomy recovery.  While having surgery, a lot of blood and other fluids are removed from the body and you will have to reinstate these in the days following surgery for getting the best recovery results.

Eat Well
To assist your recovery each a diet rich in nutrients – in other words eat healthy.  For your cells and tissues nutrients are the building blocks and will assist your recovery.  So eat a well balanced diet of to help your body.

Support and Talking to Others
Regardless of your level of support from family and friends, you may find it helpful to talk to others who have gone through a mastectomy.  Talking to others who have gone through the same decision making process and procedure will give first hand understanding and support.  It is a major deal both physically and emotionally to undergo a mastectomy and it helps to connect with other women who have gone through what you are feeling.

You have just come home from major surgery and most likely haven’t finished your reconstruction so be aware that your chest/breasts/body will not look perfect/normal and you still have recovery and further surgery to go – however you have just achieved something amazing so try to be proud of your body.

Our team at Ricky Knowles Hair and Wellness is here to support you through your journey.  We can connect you with a support group that fits with your schedule, fit you for a mastectomy prosthesis, help you with with lymphedema preventative care, and serve as your patient advocate by untangling the insurance benefit web.  We have a BOC, ABC mastectomy prosthesis fitter and an insurance specialist on staff.   In addition to mastectomy forms, we also carry post mastectomy products such as camisoles, bras and robes.  If you are ready for us to partner with you, please call us at 713-623-4247.