Context Persistent pain and sensory disturbances following surgical treatment for breast cancer is a significant clinical problem. The pathogenic mechanisms are complex and may be related to patient characteristics, surgical technique, and adjuvant therapy. Objective To examine prevalence of and factors associated with persistent pain after surgical treatment for breast cancer. Design, Setting, and Patients A nationwide cross-sectional questionnaire study of 3754 women aged 18 to 70 years who received surgery and adjuvant therapy (if indicated) for primary breast cancer in Denmark between January 1, 2005, and December 31, 2006. A study questionnaire was sent to the women between January and April 2008. Main Outcome Measures Prevalence, location, and severity of persistent pain and sensory disturbances in 12 well-defined treatment groups assessed an average of 26 months after surgery, and adjusted odds ratio (OR) of reported pain and sensory disturbances with respect to age, surgical technique, chemotherapy, and radiotherapy. Results By June 2008, 3253 of 3754 eligible women (87%) returned the questionnaire. A total of 1543 patients (47%) reported pain, of whom 201 (13%) had severe pain, 595 (39%) had moderate pain, and 733 (48%) had light pain. Factors associated with chronic pain included young age (18-39 years: OR, 3.62; 95% confidence interval [CI], 2.25-5.82;P  Conclusion Two to 3 years after breast cancer treatment, persistent pain and sensory disturbances remain clinically significant problems among Danish women who received surgery in 2005 and 2006.

https://jamanetwork.com/journals/jama/articlepdf/184861/joc90122_1985_1992.pdf

Prevalence of and factors associated with persistent pain following breast cancer surgery.

Purpose The American College of Surgeons Oncology Group trial Z0011 was a prospective, randomized, multicenter trial comparing overall survival between patients with positive sentinel lymph nodes (SLNs) who did and did not undergo axillary lymph node dissection (ALND). The current study compares complications associated with SLN dissection (SLND) plus ALND, versus SLND alone. Patients and Methods From May 1999 to December 2004, 891 patients were randomly assigned to SLND + ALND (n = 445) or SLND alone (n = 446). Information on wound infection, axillary seroma, paresthesia, brachial plexus injury (BPI), and lymphedema was available for 821 patients. Results Adverse surgical effects were reported in 70% (278 of 399) of patients after SLND + ALND and 25% (103 of 411) after SLND alone (P ≤ .001). Patients in the SLND + ALND group had more wound infections (P ≤ .0016), seromas (P ≤ .0001), and paresthesias (P ≤ .0001) than those in the SLND-alone group. At 1 year, lymphedema was reported subjectively by 13% (3...

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

This study is the first large prospective RCT of sentinel node biopsy (SNB) compared with standard axillary treatment (level I-III axillary lymph node dissection or four node sampling), which includes comprehensive and repeated quality of life (QOL) assessments over 18 months. Patients (n = 829) completed the Functional Assessment of Cancer Therapy - Breast (FACT-B+4) and the Spielberger State/Trait Anxiety Inventory (STAI) at baseline (pre-surgery) and at 1, 3, 6, 12, and 18 months post-surgery. There were significant differences between treatment groups favouring the SNB group throughout the 18 months assessment. Patients in the standard treatment group showed a greater decline in Trial Outcome Index (TOI) scores (physical well-being, functional well-being and breast cancer concerns subscales in FACT-B+4) and recovered more slowly than patients in the SNB group (p 0.05). For 6 months post-surgery younger patients reported less favourable QOL scores (p < 0.001) and greater levels of anxiety (p < 0.01). In view of the benefits regarding arm functioning and quality of life, the data from this randomised study support the use of SNB in patients with clinically node negative breast cancer.

Post-operative arm morbidity and quality of life. Results of the ALMANAC randomised trial comparing sentinel node biopsy with standard axillary treatment in the management of patients with early breast cancer

BACKGROUND. The incidence of breast cancer (BC)-related lymphedema (LE) ranges from 7% to 47%. Successful management of LE relies on early diagnosis using sensitive measurement techniques. In the current study, the authors demonstrated the effectiveness of a surveillance program that included preoperative limb volume measurement and interval postoperative follow-up to detect and treat subclinical LE. METHODS. LE was identified in 43 of 196 women who participated in a prospective BC morbidity trial. Limb volume was measured preoperatively and at 3month intervals after surgery. If an increase >3% in upper limb (UL) volume developed compared with the preoperative volume, then a diagnosis of LE was made, and a compression garment intervention was prescribed for 4 weeks. Upon reduction of LE, garment wear was continued only during strenuous activity, with symptoms of heaviness, or with visible swelling. Women returned to the 3-month interval surveillance pathway. Statistical analysis was a repeated-measures analysis of variance by time and limb (P � .001) comparing the LE cohort with an age-matched control group. RESULTS. The time to onset of LE averaged 6.9 months postoperatively. The mean (� standard deviation) affected limb volume increase was 83 mL (� 119 mL;

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Preoperative assessment enables the early diagnosis and successful treatment of lymphedema

Purpose This study estimated the economic burden of breast cancer–related lymphedema (BCRL) among working-age women, the incidence of lymphedema, and associated risk factors. Methods We used claims data to study an incident cohort of breast cancer patients for the 2 years after the initiation of cancer treatment. A logistic regression model was used to ascertain factors associated with lymphedema. We compared the medical costs and rate of infections likely associated with lymphedema between a woman with BCRL and a matched control. We performed nonparametric bootstrapping to compare the unadjusted cost differences and estimated the adjusted cost differences in regression analysis. Results Approximately 10% of the 1,877 patients had claims indicating treatment of lymphedema. Predictors included treatment with full axillary node dissection (odds ratio [OR] = 6.3, P < .001) and chemotherapy (OR = 1.6, P = .01). A geographic variation was observed; women who resided in the West were more likely to have lymphed...

Incidence, Treatment Costs, and Complications of Lymphedema After Breast Cancer Among Women of Working Age: A 2-Year Follow-Up Study

Risk, severity and predictors of physical and psychological morbidity after axillary lymph node dissection for breast cancer.

Background: The aim was to explore measurements of arm circumference and shoulder abduction as indicators of quality of life after axillary lymph node dissection for invasive breast cancer. Methods: Differences in arm circumference and shoulder abduction were measured in 465 consecutive women who underwent axillary lymph node dissection. These women received a treatment-specific questionnaire on the severity of physical disability and the effects on their daily life and well-being. Results: The questionnaire was returned by 400 women (86 per cent). Of these 400, only the 332 women who did not receive axillary radiotherapy were included in the analysis. Their mean time since axillary lymph node dissection was 4.2 (range 0.3-28) years. For 86 patients (26 per cent) there was a difference in arm circumference of 2 cm or more, or a difference in abduction of 20° or more. These patients found it more difficult to do household chores, were more likely to have given up hobbies, felt more disabled and were more likely to be treated by a physiotherapist. However, complaints also occurred among the women with smaller differences in arm circumference and shoulder abduction, although the frequency and severity of their complaints were similar to those in women without swelling of the arm or without restricted shoulder abduction. Conclusion: Measuring arm circumference and shoulder abduction during control visits identifies only some of the women whose daily life and well-being is affected by the side-effects of axillary lymph node dissection.

/pdf/lymphoedema-and-reduced-shoulder-function-as-indicators-of-3ydh7bcbx6.pdf

J M M A Ververs

Papers

Risk, severity and predictors of physical and psychological morbidity after axillary lymph node dissection for breast cancer.

Lymphoedema and reduced shoulder function as indicators of quality of life after axillary lymph node dissection for invasive breast cancer.