Plastic Surgery in Los Angeles and Beverly Hills
Lymphedema and Quality of Life in Survivors
of Early-Stage Breast Cancer
Sarah M. Beaulac, MPH; Lindsay A. McNair, MD, MPH; Thayer E. Scott, MPH;
Wayne W. LaMorte, MD, PhD, MPH; Maureen T. Kavanah, MD
Background: The standard of care for early-stage breast
cancer includes surgical removal of the tumor and axillary
lymph node dissection (ALND). Despite increased
use of breast-conserving surgery, lymphedema rates are
similar to those with more radical surgery.
Hypothesis: Women who experience breast cancer–
related lymphedema have a measurable reduction in
quality of life compared with women without lymphedema.
Design: In a retrospective cohort study, we explored the
association between lymphedema and quality of life, controlling
for patient demographics, surgical factors, and
treatment types.
Settings: An urban academic medical center and a community
hospital.
Participants: A total of 151 women surgically treated
for early-stage breast cancer (stages 0-II) were assessed
at least 1 year after their ALND. The women had been
treated with either conservative surgery and radiation or
mastectomy without radiation.
Main Outcome Measures: Arm volume was measured
by water displacement. Grip strength and rangeof-
motion measurements assessed arm function. The
Functional Assessment of Cancer Therapy–Breast
(FACT-B) quality-of-life instrument assessed breast, emotional,
functional, physical, and social well-being.
Results: Lymphedema (an arm volume difference200
cm3) was measured in 42 women (27.8%). Mastectomy
or conservative surgery patients had similar lymphedema
rates. Women with lymphedema in both surgical
groups scored significantly lower on 4 of the 5 subsections
than women without lymphedema, even after adjusting
for other factors influencing quality of life.
Conclusions: Lymphedema occurs at appreciable rates,
and its impact on long-term quality of life in survivors of
early-stage breast cancer should not be underestimated.
Arch Surg. 2002;137:1253-1257
THEPREVALENCEofearly-stage
(stages 0-II) breast cancer is
increasing with enhanced
early detection techniques.
Improvedtreatment options
are pushing survival rates up to 77% for
regional and 96% for localized breast cancer.
1Asmorewomenbecomelong-termsurvivors,
their health-related quality of life
becomes an increasingly important issue.
Despite surgical advances and less radical
procedures, axillary dissection is still associated
with lymphedema. The physical and
psychological problems associated with
lymphedema have the potential to significantly
affect quality of life. This study investigated
the effects of lymphedema on quality
of life in survivors of early-stage breast
cancer.
METHODS
PATIENT POPULATION
Women who had been surgically treated for
stages 0 (ductal carcinoma in situ), I, and II
breast cancer between 1986 and 2000 were enrolled
into a retrospective cohort study. The
women were treated at either Boston University
Medical Center, an urban academic medical
center, or Jordan Hospital, a community
hospital in Plymouth, Massachusetts. Approval
was obtained from the institutional review
boards of each hospital. Potentially eligible
patients were identified from tumor
registry records at both hospitals with consent
of the treating physicians. In the initial
phase of this study, identified patients were approached
by their treating physician at the time
of their surgical follow-up appointment and invited
to participate in the study. Ninety-five
women were approached in this manner, and
all of these women consented to be enrolled
in this study. A later phase of this study was
added to include patients from the community
hospital who were initially contacted by
mail and then by a telephone call inviting
them to participate. In this approach, 29 of
the 143 eligible women were contacted but
refused, 56 were enrolled, and 58 were unable
to be contacted by telephone. The reasons
given for refusal included transportation
problems, scheduling conflicts, and disinterest
in the study.
ORIGINAL ARTICLE
From the Departments of
Epidemiology and Biostatistics
(Ms Beaulac and Drs McNair
and LaMorte) and Surgery
(Ms Scott and Drs LaMorte and
Kavanah), Boston University
Medical Center, Boston, Mass.
(REPRINTED) ARCH SURG/VOL 137, NOV 2002 WWW.ARCHSURG.COM
1253
©2002 American Medical Association. All rights reserved.
Downloaded from www.archsurg.com at UCLA Digital Collections Services, on March 9, 2009
Eligible women had been treated with either mastectomy
or breast-conserving surgery. Breast-conserving surgery was defined
as a lumpectomy or segmentectomy followed by whole
breast radiation therapy. Woman who had breast-conserving
surgery without radiation therapy were excluded, as were women
who had a mastectomy and radiation therapy. All patients had
also had a standard (level I and II) axillary lymph node dissection.
Patients became eligible for the study at least 1 year after
their node dissection. Women were excluded from the study
if they had bilateral node dissection or axillary, supraclavicular,
or mediastinal node recurrence. Women who underwent
neoadjuvant chemotherapy were excluded. Patients with a
known neurologic or rheumatologic condition that led to selfreported
significant upper extremity weakness or impairment
of either arm, diagnosed before surgery or known to be unrelated
to surgical therapy, were also excluded from the study.
DATA COLLECTION
During the patient’s scheduled appointment, the purpose of the
study was explained and informed consent was obtained. The
patient completed a quality-of-life questionnaire and then underwent
measurements for arm volumes, upper extremity range
of motion, and handgrip strength.
The Functional Assessment of Cancer Therapy–Breast
(FACT-B) scale was used to assess quality of life. This validated,
36-item, cancer site–specific instrument includes questions
regarding breast, emotional, functional, physical, and social
well-being.2 The FACT-B uses the 5-point Likert scale (each
item has a possible score of 0-4, corresponding to the phrases
not at all, 0; a little bit, 1; somewhat, 2; quite a bit, 3; and very
much, 4). Patients choose the number corresponding to how
true each statement has been for them during the last 7 days.
The scores from the 36 items are given equal weight and then
summed to create a total FACT-B score. The total FACT-B score
has a range of 0 to 144, with a higher number correlating to a
more favorable quality of life. The breast well-being subsection
addresses questions associated with adverse effects of breast
cancer and therapy, such as hair loss, changes in weight, and
body image. This section has 9 items, with a range of points
from 0 to 36. The emotional well-being subsection asks questions
regarding sadness, health outlook, and mental health (6
items; point range, 0-24). The functional well-being subsection
assesses a woman’s ability to perform work and her fulfillment
with work and normal hobbies (7 items; point range,
0-28). The physical well-being subsection focuses on energy,
nausea, pain, and other physical adverse effects of treatment
and recovery (7 items; point range, 0-28). The social wellbeing
subsection assesses relationships with friends and family
and includes questions regarding the woman’s satisfaction
with her support system and her sex life (7 items; point range,
0-28). Quality-of-life measurements as assessed by the FACT-B
survey were scored and interpreted in accordance with the standardized
scoring protocol.3
Plastic surgeon Dr. Granzow is located in Los Angeles and serves Southern California areas including Los Angeles, and Beverly Hills.
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