Download PDF
J Reconstr Microsurg 2020; 36(08): 606-615
DOI: 10.1055/s-0040-1713667
Original Article

Surgical versus Nonsurgical Management of Postmastectomy Lymphedema: A Prospective Quality of Life Investigation

Halley Darrach‡   *
1   Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
,
Pooja S. Yesantharao  ‡   *
1   Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
,
Sarah Persing
1   Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
,
George Kokosis
1   Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
,
Hannah M. Carl
1   Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
,
Kelly Bridgham
1   Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
,
Michelle Seu
1   Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
,
Samantha Stifler
1   Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
,
Justin M. Sacks
2   Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
› Author Affiliations Funding J.M.S. was a former consultant/speaker for Allergan, receives unrestricted research support from ViOptix, Inc., and is a cofounder of LifeSprout. None of the other authors have a financial interest in any of the products, devices, or drugs mentioned in this manuscript.
› Further Information
    Permissions and Reprints

Abstract

Background Postmastectomy secondary lymphedema can cause substantial morbidity. However, few studies have investigated longitudinal quality of life (QoL) outcomes in patients with postmastectomy lymphedema, especially with regard to surgical versus nonoperative management. This study prospectively investigated QoL in surgically versus nonsurgically managed patients with postmastectomy upper extremity lymphedema.

Methods This was a longitudinal cohort study of breast cancer-related lymphedema patients at a single institution, between February 2017 and January 2020. Lymphedema Quality of Life Instrument (LyQLI) and RAND-36 QoL instrument were used. Mann–Whitney U and Fisher's exact tests were used for descriptive statistics. Wilcoxon's signed-rank testing and linear modeling were used to analyze longitudinal changes in QoL.

Results Thirty-two lymphedema patients were recruited to the study (20 surgical and 12 nonsurgical). Surgical and nonsurgical cohorts did not significantly differ in clinical/demographic characteristics or baseline QoL scores, but at the 12-month time point surgical patients had significantly greater LyQLI overall health scores than nonsurgical patients (79.3 vs. 58.3, p = 0.02), as well as higher composite RAND-36 physical (68.5 vs. 38.3, p = 0.04), and mental (77.0 vs. 52.7, p = 0.02) scores. Furthermore, LyQLI overall health scores significantly improved over time in surgical patients (60.0 at baseline vs. 79.3 at 12 months, p = 0.04). Besides surgical treatment, race, and age were also found to significantly impact QoL on multivariable analysis.

Conclusion Our results suggest that when compared with nonoperative management, surgery improved QoL for chronic, secondary upper extremity lymphedema patients within 12-month postoperatively. Our results also suggested that insurance status may have influenced decisions to undergo lymphedema surgery. Further study is needed to investigate the various sociodemographic factors that were also found to impact QoL outcomes in these lymphedema patients.

Keywords

lymphedema - surgery - quality of life - RAND-36 - LyQLI

Note

Podium presentation at American Association of Plastic Surgeons 99th Annual Meeting; Podium presentation at 65th Annual Meeting of the Plastic Surgery Research Council, May 28 to 31, 2020, Toronto, Ontario, Canada.


Data Availability

The data that support the findings of this study are available from the corresponding author upon request.


* These authors contributed equally to this work.




Publication History

Received: 27 March 2020

Accepted: 17 May 2020

Article published online:
05 July 2020

Thieme Medical Publishers
333 Seventh Avenue, New York, NY 10001, USA.

 

  • References

  • 1 Rockson SG, Rivera KK. Estimating the population burden of lymphedema. Ann N Y Acad Sci 2008; 1131 (01) 147-154
    CrossrefPubMedGoogle Scholar
  • 2 Kerchner K, Fleischer A, Yosipovitch G. Lower extremity lymphedema update: pathophysiology, diagnosis, and treatment guidelines. J Am Acad Dermatol 2008; 59 (02) 324-331
    CrossrefPubMedGoogle Scholar
  • 3 Cormier JN, Askew RL, Mungovan KS, Xing Y, Ross MI, Armer JM. Lymphedema beyond breast cancer: a systematic review and meta-analysis of cancer-related secondary lymphedema. Cancer 2010; 116 (22) 5138-5149
    CrossrefPubMedGoogle Scholar
  • 4 Lawenda BD, Mondry TE, Johnstone PAS. Lymphedema: a primer on the identification and management of a chronic condition in oncologic treatment. CA Cancer J Clin 2009; 59 (01) 8-24
    CrossrefPubMedGoogle Scholar
  • 5 Executive Committee. The diagnosis and treatment of peripheral lymphedema: 2016 consensus document of the international society of lymphology. Lymphology 2016; 49 (04) 170-184
    PubMedGoogle Scholar
  • 6 Carl HM, Walia G, Bello R. , et al. Systematic review of the surgical treatment of extremity lymphedema. J Reconstr Microsurg 2017; 33 (06) 412-425
    Article in Thieme ConnectPubMedGoogle Scholar
  • 7 Chang DW, Masia J, Garza III R, Skoracki R, Neligan PC. Lymphedema. Plast Reconstr Surg 2016; 138 (03) 209S-218S
    CrossrefPubMedGoogle Scholar
  • 8 Morgan PA, Franks PJ, Moffatt CJ. Health-related quality of life with lymphoedema: a review of the literature. Int Wound J 2005; 2 (01) 47-62
    CrossrefPubMedGoogle Scholar
  • 9 Shih Y-CT, Xu Y, Cormier JN. , et al. Incidence, treatment costs, and complications of lymphedema after breast cancer among women of working age: a 2-year follow-up study. J Clin Oncol 2009; 27 (12) 2007-2014
    CrossrefPubMedGoogle Scholar
  • 10 Ridner SH. The psycho-social impact of lymphedema. Lymphat Res Biol 2009; 7 (02) 109-112
    CrossrefPubMedGoogle Scholar
  • 11 Sleigh BC, Manna B. Lymphedema. StatPearls Publishing; 2019. . Available at: http://www.ncbi.nlm.nih.gov/pubmed/30725924 (PMID: . Accessed August 12, 2019)
    Google Scholar
  • 12 Landau MJ, Kim JS, Gould DJ, Patel KM. Vectra 3D Imaging for quantitative volumetric analysis of the upper limb: a feasibility study for tracking outcomes of lymphedema treatment. Plast Reconstr Surg 2018; 141 (01) 80e-84e
    CrossrefPubMedGoogle Scholar
  • 13 Maruccia M, Elia R, Ciudad P. , et al. Postmastectomy upper limb lymphedema: Combined vascularized lymph node transfer and scar release with fat graft expedites surgical and patients' related outcomes. A retrospective comparative study. J Plast Reconstr Aesthet Surg 2019; 72 (06) 892-901
    CrossrefPubMedGoogle Scholar
  • 14 Hays RD, Morales LS. The RAND-36 measure of health-related quality of life. Ann Med 2001; 33 (05) 350-357
    CrossrefPubMedGoogle Scholar
  • 15 Klernäs P, Johnsson A, Horstmann V, Kristjanson LJ, Johansson K. Lymphedema Quality of Life Inventory (LyQLI)-development and investigation of validity and reliability. Qual Life Res 2015; 24 (02) 427-439
    CrossrefPubMedGoogle Scholar
  • 16 Klernäs P, Johnsson A, Boyages J, Brorson H, Munnoch A, Johansson K. Test of responsiveness and sensitivity of the questionnaire “lymphedema quality of life inventory”. Lymphat Res Biol 2018; 16 (03) 300-308
    CrossrefPubMedGoogle Scholar
  • 17 Basta MN, Wu LC, Kanchwala SK. , et al. Reliable prediction of postmastectomy lymphedema: the risk assessment tool evaluating lymphedema. Am J Surg 2017; 213 (06) 1125-1133.e1
    CrossrefPubMedGoogle Scholar
  • 18 Megari K. Quality of life in chronic disease patients. Health Psychol Res 2013; 1 (03) e27
    CrossrefPubMedGoogle Scholar
  • 19 Lin C-Y, Liu H-E, Cheng M-H. Factors associated with professional healthcare advice seeking in breast cancer-related lymphedema. J Surg Oncol 2020; 121 (01) 67-74
    CrossrefPubMedGoogle Scholar
  • 20 Chen T-H, Li L, Kochen MM. A systematic review: how to choose appropriate health-related quality of life (HRQOL) measures in routine general practice?. J Zhejiang Univ Sci B 2005; 6 (09) 936-940
    CrossrefPubMedGoogle Scholar
  • 21 Haaverstad R, Nilsen G, Rinck PA, Myhre HO. The use of MRI in the diagnosis of chronic lymphedema of the lower extremity. Int Angiol 1994; 13 (02) 115-118 . Accessed August 12 2019
    PubMedGoogle Scholar
  • 22 Aström KG, Abdsaleh S, Brenning GC, Ahlström KH. MR imaging of primary, secondary, and mixed forms of lymphedema. Acta Radiol 2001; 42 (04) 409-416
    CrossrefPubMedGoogle Scholar
  • 23 Lu Q, Xu J, Liu N. Chronic lower extremity lymphedema: a comparative study of high-resolution interstitial MR lymphangiography and heavily T2-weighted MRI. Eur J Radiol 2010; 73 (02) 365-373
    CrossrefPubMedGoogle Scholar
  • 24 Duyur Cakıt B, Pervane Vural S, Ayhan FF. Complex decongestive therapy in breast cancer-related lymphedema: does obesity affect the outcome negatively?. Lymphat Res Biol 2019; 17 (01) 45-50
    CrossrefPubMedGoogle Scholar
  • 25 Center for Medicaid and Medicare Services. Title IX–Women's Health and Cancer Rights. Available at: https://www.cms.gov/Regulations-and-Guidance/Health-Insurance-Reform/HealthInsReformforConsume/Downloads/WHCRA_Statute.pdf . Accessed August 12, 2019
    PubMedGoogle Scholar
  • 26 Odom EB, Schmidt AC, Myckatyn TM, Buck II DW. A cross-sectional study of variations in reimbursement for breast reconstruction: is a healthcare disparity on the horizon?. Ann Plast Surg 2018; 80 (03) 282-286
    CrossrefPubMedGoogle Scholar
  • 27 Livermore G, Stapleton D, Claypool H. Health insurance and health care access before and after SSDI entry. Available at: https://www.commonwealthfund.org/publications/fund-reports/2009/may/health-insurance-and-health-care-access-and-after-ssdi-entry . Accessed June 1, 2020
    PubMedGoogle Scholar
  • 28 Granzow JW. Lymphedema surgery: the current state of the art. Clin Exp Metastasis 2018; 35 (5-6): 553-558
    CrossrefPubMedGoogle Scholar
  • 29 Kwan ML, Yao S, Lee VS. , et al. Race/ethnicity, genetic ancestry, and breast cancer-related lymphedema in the Pathways Study. Breast Cancer Res Treat 2016; 159 (01) 119-129
    CrossrefPubMedGoogle Scholar
  • 30 Black DM, Jiang J, Kuerer HM, Buchholz TA, Smith BD. Racial disparities in adoption of axillary sentinel lymph node biopsy and lymphedema risk in women with breast cancer. JAMA Surg 2014; 149 (08) 788-796
    CrossrefPubMedGoogle Scholar
  • 31 Quiñones AR, Botoseneanu A, Markwardt S. , et al. Racial/ethnic differences in multimorbidity development and chronic disease accumulation for middle-aged adults. PLoS One 2019; 14 (06) e0218462
    CrossrefPubMedGoogle Scholar
  • 32 Adams ML. Differences between younger and older US adults with multiple chronic conditions. Prev Chronic Dis 2017; 14: E76
    CrossrefPubMedGoogle Scholar
  • 33 Scaglioni MF, Arvanitakis M, Chen Y-C, Giovanoli P, Chia-Shen Yang J, Chang EI. Comprehensive review of vascularized lymph node transfers for lymphedema: outcomes and complications. Microsurgery 2018; 38 (02) 222-229
    CrossrefPubMedGoogle Scholar
  • 34 Scaglioni MF, Fontein DBY, Arvanitakis M, Giovanoli P. Systematic review of lymphovenous anastomosis (LVA) for the treatment of lymphedema. Microsurgery 2017; 37 (08) 947-953
    CrossrefPubMedGoogle Scholar
  • 35 Patel KM, Lin C-Y, Cheng M-H. A prospective evaluation of lymphedema-specific quality-of-life outcomes following vascularized lymph node transfer. Ann Surg Oncol 2015; 22 (07) 2424-2430
    CrossrefPubMedGoogle Scholar