Study Looks at Lymphedema Risk Factors

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Lymphedema is swelling of the arm, hand, chest wall, trunk, back, or other body part caused by lymph fluid collecting in tissue after surgery, especially breast cancer surgery that removes underarm (axillary) lymph nodes. Edema is the medical term for swelling, so swelling caused by lymph fluid is "lymphedema."

Lymphedema can reduce your ability to use your arm or the affected area, as well as increase your risk for infection in the area. Lymphedema also can be painful, can change the quality of the skin in the affected area, and decrease quality of life.

Individual studies have reported that as little as 10% up to as many as 90% of women develop lymphedema after breast cancer surgery and radiation therapy. Such a wide range of results may be due to:

  • researchers have used different ways of defining and then measuring lymphedema
  • many of these studies have involved small numbers of patients
  • many studies were done with women who had a large number of underarm lymph nodes removed, which used to be standard practice

Today, many experts estimate that the range is probably close to 20-30%.

While having a large number of lymph nodes removed and having radiation therapy are known risk factors for lymphedema, research looking at other factors, such as airplane travel and having blood pressure readings on the affected arm, have produced mixed results. In groups of women with the same demographic, surgical, and treatment characteristics, some developed lymphedema and some didn’t, making it unclear which factors affected lymphedema risk the most.

A study looked at a number of potential lifestyle and clinical risk factors for lymphedema and assessed the relationship between the risk factors and developing lymphedema.

The research was published online on Oct. 4, 2017 by the Journal of Clinical Oncology. Read the abstract of “Association Between Precautionary Behaviors and Breast Cancer-Related Lymphedema in Patients Undergoing Bilateral Surgery.”

The study included 327 women who had surgery on both breasts between 2013 and 2016. The researchers evaluated the women's 654 arms, which were at risk for lymphedema:

  • 95.1% (622 arms) had mastectomy
  • 4.9% (32 arms) had lumpectomy
  • 68% (445 arms) had sentinel lymph node surgery (the one or two nodes in the underarm area closest to the cancer were removed)
  • 16.7% (109 arms) had axillary lymph node surgery (a cluster of lymph nodes in the underarm area were removed)
  • 15.3% (100 arms) had no lymph node surgery
  • 54% of the surgeries were to treat breast cancer
  • 46% of the surgeries were done prophylactically (preventively to reduce breast cancer risk)

All the women had their arms measured before surgery using a perometer, a device that illuminates and scans arm volume. The arms were measured every 3 to 8 months after surgery at the women’s follow-up appointments or more often if the women requested it.

At each follow-up appointment, the women also filled out a lymphedema questionnaire and a lymphedema risk assessment survey. The lymphedema questionnaire asked about:

  • quality of life
  • changes in arm mobility and use
  • any changes in behavior because of lymphedema or fear of lymphedema

The lymphedema risk survey asked about:

  • number of blood pressure readings
  • number of blood draws
  • number of injections
  • any trauma to the arm; a fracture, for example
  • number and length of airplane flights since the last appointment

Follow-up time for the study ranged from 6 months to more than 5 1/2 years.

The women’s age at diagnosis ranged from 25 to 72 years and their body mass index (BMI) ranged from 18 to 56. Most BMI calculators classify a BMI of 18.5 to 24.9 as a healthy weight, a BMI of 25 to 29.9 as overweight, and a BMI of 30 or higher as obese.

There were 36 cases of cellulitis, a potentially serious bacterial skin infection, of the 654 treated breasts and/or arms that required antibiotics.

After 2 years, the rate of lymphedema was 11.8%. A woman was considered to have lymphedema if the weight-adjusted volume change in the arm was 10% or higher.

The results of the lymphedema risk surveys were:

  • 5.1% of the women had one or more blood draws in their affected arm since their last arm measurement
  • 15.6% had blood pressure readings on the affected arm
  • 2.9% had injections in the affected arm
  • 1.3% had trauma (bruising, fractures) to the affected arm
  • 19% had taken one or more airplane flights

The researchers’ analysis found that there was no statistically significant association between increased arm volume and:

  • one or more blood draws compared to no blood draws
  • one or more injections compared to no injections
  • one or more incidents of trauma compared to no trauma
  • number or length of flights compared to no flights

This means that any link between these risk factors and lymphedema could have been due to chance and not because of the risk factors.

Also, there was no statistically significant link between cellulitis and increased arm volume.

There was a statistically significant link between increased arm volume and:

  • axillary lymph node surgery compared to sentinel lymph node surgery
  • breast, chest wall, and regional lymph node radiation compared to no radiation
  • BMI of 25 or greater at diagnosis compared to a BMI lower than 25
  • chemotherapy after surgery compared to no chemotherapy after surgery

While this study suggests that there is not a link between several lifestyle risk factors and lymphedema, the researchers were quick to point out that they do not think that current recommendations to reduce the risk of lymphedema should be eliminated.

“We strongly emphasize that we do not consider these findings as sufficient data to do away with current precautions provided to patients, and we do not support changing clinical practice with regard to risk reduction patient education,” they wrote. “Our goal is to add to the research base and bring reasonable doubt to current guidelines to ensure that any recommendations we give to patients are well-substantiated and individualized to prevent unnecessary distress in light of historical research and improved treatment modalities. Patients at different risk for breast cancer-related lymphedema should be provided different precautionary guidelines, and we hope to see a move toward a risk-adjusted approach in the application of these guidelines pending high-level research.”

If you’ve been diagnosed with breast cancer and know that you’ll be having surgery, radiation, or chemotherapy, there are things you can do before treatment starts to reduce your risk of lymphedema, including scheduling an appointment with a medical professional who specializes in lymphedema management. This trained lymphedema therapist can take baseline measurements of your arm and hand, as well as assess the strength of your arm and upper body and then create a tailored post-surgery exercise and rehabilitation plan for you.

For more information, visit the Breastcancer.org pages on Reducing Risk of Lymphedema and Lymphedema Flare-Ups.


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