More Aggressive Surgery Linked to Arm Problems in Young Women With Breast Cancer
Younger women newly diagnosed with breast cancer face a medical dilemma: If their physicians order aggressive surgical treatment, they may have a higher risk of problems with the arm on that side of the body. Such problems include swelling and difficulty extending the arm. And, because many women now survive breast cancer, these problems may have a longer-term impact.
More aggressive surgery is associated with a greater risk of arm swelling known as edema, in which fluid collects in the arm, according to results of a study presented at the annual San Antonio Breast Cancer Symposium in December 2017. The study focused on women with breast cancer who were under the age of 40.
Such forms of aggressive surgery include mastectomies (as compared with breast-conserving treatment) and a procedure called the axillary lymph node dissection (ALND).
When a woman is diagnosed with breast cancer, her caregivers will often examine the lymph nodes in her armpit to determine whether the cancer has spread to them, according to Anne Kuijer, Ph.D., a surgical resident at Diakonessen Hospital in the Netherlands who gave the presentation in San Antonio on Dec. 8.
In an ALND procedure, surgeons remove and examine all of the lymph nodes in the armpit on the side of the body in which the breast cancer was discovered. An ALND is more aggressive than a more limited form of surgery called a sentinel lymph node biopsy (SLNB), in which only one lymph node is removed and tested for cancer.
The purpose of surgery on the lymph nodes in the armpit is to learn whether the cancer has spread, and if it has spread, to remove the cancerous lymph nodes to try to prevent the disease from spreading farther throughout the body.
But more aggressive surgery may be unnecessary for young patients, according to some researchers.
“There is no data that bigger surgery, mastectomy, or bilateral mastectomy improves survival in young women with breast cancer,” Kuijer told HealthCentral in an email interview.
Doctors now try to reduce chronic problems in survivors
Women with breast cancer who had an ALND were 3.4 times more likely to report arm swelling a year after diagnosis than those who received SLNBs, according to the presentation, in which researchers analyzed data from the Helping Ourselves Helping Others Young Women’s Breast Cancer Study (YWS).
But part of the difficulty lies in determining which patients truly need aggressive surgical treatment of their breast cancer.
According to Seema Khan, M.D., professor of surgery at Northwestern University in Chicago, SLNB without axillary surgery is only appropriate if the burden of disease in the lymph nodes is low. Khan moderated the session in San Antonio in December.
“However, the data presented by Dr. Kuijer shows that there has been a trend away from (ALND), which is prompted by concerns about morbidity for the arm. Additionally, newer data over the last few years has shown that it may be possible to treat the axilla with radiotherapy,” Khan told HealthCentral in a phone interview from Beijing, where she gave a presentation at the 2018 SABCS update.
The more aggressive ALND procedure was not by itself associated with more problems with range of motion in the arm, but other procedures were. Patients who had a mastectomy as well as radiation therapy were 2.1 times as likely to report decreased range of motion in the arm a year after diagnosis as patients who receive breast-conserving surgery, according to the study.
“These issues are of particular importance in these patients given their long survivorship period, frequently active lifestyle, and the importance of body image,” said Kuijer.
In addition, being overweight and having uncomfortable financial status were also associated with an increased risk for arm swelling. Patients with a body mass index between 25 and 29.9 were 50 percent more likely to report decreased range of motion a year after diagnosis. Those who described themselves as having a comfortable financial status were only 60 percent as likely to have arm swelling one year after diagnosis.
“Arm swelling could sometimes be resolved by use of lymph-edema therapists. It could be that patients who perceived themselves as less financially comfortable had less access to resources which prevent arm-swelling such as physiotherapy,” said Kuijer in a press release. “These findings highlight the importance of an active and healthy lifestyle.”
A study designed to explore issues unique to younger women with breast cancer
In the YWS, researchers at 12 institutions enrolled 1,302 breast cancer patients under the age of 40 from October 2006 until June 2016. Of the participants, between 50 percent and 57 percent received only a SLNB. Additionally, the ratio of patients receiving upfront ALND decreased over time from 24 percent to 11 percent.
Of the patients, 335, or 33 percent, experienced reduced range of motion in their arm one year from diagnosis. Of those who received an ALND with radiation, 44 percent reported reduced range of motion, compared with 33 percent of those who received ALND without radiotherapy. On the other hand, 33 percent of those who received a SLNB with radiation reported reduced range of motion, compared with 21 percent of those who had a SLNB without radiation. In contrast, only 13 percent (or 136 patients) reported arm swelling at one-year follow-up.
“As to range of motion, it really doesn’t matter that much in terms of whether the procedure used was SLNB or ALND, but lymphedema was seen more frequently in women with larger tumors, in whom the incidence of arm swelling was up to four-fold higher,” noted Kahn.
Ten-year follow-up for the participants is incorporated into the trial design, and researchers are currently re-analyzing the data to see whether arm-swelling persists at three years from the date of diagnosis, Kuijer said.
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John Otrompke is an experienced medical journalist, specializing in clinical news, conference coverage, and regulatory reporting.