Black women are about 3.5 times more likely to develop lymphedema after having axillary lymph node surgery than white women, according to a small study.
The research was presented on Dec. 10, 2021, at the San Antonio Breast Cancer Symposium. Read the abstract of “Impact of race and ethnicity on incidence and severity of breast cancer related lymphedema after axillary lymph node dissection: Results of a prospective screening study.”
About axillary lymph node surgery
Axillary lymph node surgery — also called axillary lymph node dissection by doctors — is done at the same time as mastectomy or lumpectomy to remove early-stage breast cancer. The surgeon removes five or more lymph nodes in the armpit area on the same side as the breast cancer. A pathologist then examines the lymph nodes to figure out if there are any cancer cells in them.
If cancer cells are present in the removed lymph nodes, there is a higher risk of the breast cancer coming back, called recurrence by doctors.
When a pathology report shows cancer cells in the lymph nodes, doctors recommend more treatment after surgery, such as radiation therapy, chemotherapy, and possibly targeted therapy.
Lymphedema is abnormal swelling that can develop in the arm, hand, breast, or torso as a side effect of breast cancer surgery, radiation therapy, or both. Lymphedema can appear in some people months or even years after treatment ends.
Lymphedema happens when surgery and radiation therapy cut off or damage some of the lymph nodes and lymph channels, so lymph fluid can’t move through the body as easily. Over time, the flow of lymph fluid can overwhelm the remaining channels, resulting in a backup of fluid in the body’s tissues.
Axillary lymph node dissection is the main risk factor for lymphedema.
About the study
Although there is some evidence that Black women are more likely to develop lymphedema after breast cancer surgery than white women, most studies have not reported the race or ethnicity of the participants.
Also, most studies on lymphedema have relied on people self-reporting symptoms or have used diagnosis codes from medical records.
For this study, the researchers wanted to measure any arm size changes in the study’s participants to see if any factors, including race, were linked to lymphedema risk.
The study included 276 women diagnosed with early-stage breast cancer who had axillary lymph node dissection between November 2016 and March 2020:
- 60% were white women
- 20% were Black women
- 11% were Asian women
- 6% were Hispanic women
- 3% lacked information on race or ethnicity
Compared with white women, Black women were:
- more likely to have cancer in the lymph nodes; 84% of Black women had cancer in one or more lymph nodes compared with 71% of white women
- more likely to have a higher body mass index (BMI); the average BMI for Black women was 30.3 compared with an average BMI of 25.2 for white women
A BMI of 25 to 29.9 is considered overweight, and a BMI of 30 or greater is considered obese. While BMI can be a helpful tool, it does have limits. It may overestimate the amount of fat in athletes and other people who are very muscular. It also can underestimate the amount of fat in older people and people who may have lost muscle mass.
Several studies have shown a link between excess weight and lymphedema.
Almost all of the women received other treatments besides surgery:
- about 70% received chemotherapy before surgery (neoadjuvant chemotherapy), and the rest received chemotherapy after surgery (adjuvant chemotherapy)
- 95% received radiation therapy to the area of the breast where the cancer tumor was
- 93% received radiation therapy to the lymph nodes
The researchers used a perometer to measure the women’s arms:
- before surgery
- right after surgery
- every six months after surgery, for up to two years
A perometer uses infrared light to scan a limb and is considered to offer a highly accurate measurement of limb size and volume.
The researchers said women had lymphedema if their arm volume increased 10% or more than their before-surgery measurement.
After 24 months of follow-up, 24.7% of the women had developed lymphedema.
Black and Hispanic women had higher rates of lymphedema than white and Asian women. The percentages of women who developed lymphedema by race and ethnicity were:
- 39.4% of Black women
- 27.7% of Hispanic women
- 23.4% of Asian women
- 20.5% of white women
Women who received neoadjuvant chemotherapy followed by axillary lymph node dissection were twice as likely to develop lymphedema than women who had surgery first and then chemotherapy.
The researchers’ analysis showed that being Black was the strongest predictor of developing lymphedema. Other risk factors for lymphedema were:
- being older
- receiving chemotherapy before surgery
- longer time periods after surgery
The analysis found that Black women were about 3.5 times more likely to develop lymphedema than white women.
Hispanic women were about three times more likely to develop lymphedema than white women, but the number of Hispanic women in the study was very small — 16 women — so more research is needed to confirm these findings.
The severity of the lymphedema among affected women wasn’t different based on race or ethnicity.
“Inflammation is a key driver of lymphedema development, and so maybe Black women are predisposed to a different inflammatory reaction to treatment or perhaps have higher levels of inflammation at baseline,” said lead author Andrea Barrio, MD, associate attending physician at Memorial Sloan Kettering Cancer Center, at a media briefing on the study. “I think it’s also important to stratify a woman’s risk for lymphedema, and once we can tailor that risk, we can start to identify which patients might benefit from preventative strategies.”
What this means for you
If you’re a Black woman who’s been diagnosed with early-stage breast cancer, the results of this study are troubling.
This study suggests that Black women have a much higher risk of lymphedema than white women, but the reason is not clear.
You can’t control the characteristics of the cancer you’ve been diagnosed with, and you also can’t control the cancer treatments your doctor recommends to keep your risk of recurrence as low as it can be. But there are steps you can take to reduce your risk of lymphedema and increase the chances of noticing its early symptoms.
Before breast cancer surgery, it’s a good idea to meet with a lymphedema therapist, physical therapist, or other medical professional who specializes in breast cancer-related lymphedema management to record baseline measurements of your arm and hand, as well as asses your arm and upper body strength.
With baseline measurements as a comparison, you can better judge any changes in the size of your arm and hand over time.
Knowing your pre-surgery upper body strength can help your therapist develop a post-surgery exercise and rehabilitation program tailored to your unique needs.
A therapist also can tell you about the signs and symptoms of lymphedema and what to do if you experience them.
Learn more about Reducing Risk of Lymphedema and Lymphedema Flare-Ups.
Written by: Jamie DePolo, senior editor
Reviewed by: Brian Wojciechowski, MD, medical adviser
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