How common is lymphedema among breast cancer patients in Singapore?

The rates of breast cancer-related lymphedema (BCRL) in Singapore are similar to those across the globe, reports a Singapore study. In addition, the findings also stress the comparable profiles of patients who are vulnerable to the disease.

“Although the severity of BCRL were largely subclinical or mild, having a comprehensive lymphedema surveillance strategy is paramount to address and further reduce the impact of this debilitating condition,” said the researchers.

This cross-sectional study conducted at Changi General Hospital Breast Centre, Singapore, assessed the prevalence of BCRL and its associated risk factors in a total of 511 breast cancer patients. BCRL prevalence rates were defined based on the patients’ self-reporting, objective arm circumference measurement, and clinical diagnosis based on International Society of Lymphology staging.

The cumulative prevalence rate of BCRL in this population over a median follow-up of 88.8 months was 30.9 percent. [Ann Acad Med Singap 2024;53:80-89]

Patients with BCRL were older (58.4 vs 54.9 years), had higher mean body mass index (BMI; 27.7 vs 25.2 kg/m²), higher proportion of mastectomy (77 percent vs 64.3 percent), axillary clearance, were less likely to have breast reconstruction, had more lymph nodes excised, more advanced nodal disease, higher-grade tumour, and undergone adjuvant chemotherapy.

However, only 33 of 511 patients (6.5 percent) had clinically apparent BCRL. The proportion of clinically significant BCRL in patients who had undergone sentinel lymph node biopsy or axillary sampling was lower than those who had undergone axillary clearance (1.7 percent vs 9.9 percent). Notably, the severity of most BCRLs diagnosed were either mild or subclinical.

At-risk patients

“The clinical risk factors associated with BCRL identified in our current study corroborated with those in literature review,” the researchers said. “These risk factors included elevated BMI, higher tumour, and nodal pathological stage, presence of axillary clearance, and chemotherapy.” [World J Clin Oncol 2014;5:241-247]

Patients with these risk factors may choose to undergo a more intensive lymphedema surveillance strategy and recommendation, according to the researchers.

“Risk factors directly related to disease and treatment factors may be unavoidable, but certain modifiable targets such as obesity or weight gain after treatment and minimizing infections or injury to the at-risk limb can be emphasized during patient education,” they added. [Curr Breast Cancer Rep 2013;5:134-134; Ann Surg Oncol 2017;24:2827]

Implications

Researchers are also trying to safely reduce BCRL morbidity by providing the best breast cancer treatment available without compromising on oncological outcomes. Such approach involves a review of patient selection criteria for different axilla therapies, including axillary lymph node dissection or radiotherapy, as well as to avoid practices that are of low value. [NPJ Breast Cancer 2022;8:25]

In addition, “there is an emerging role for lymphatic preserving or restoring procedures that have shown promising results at reducing the severity of BCRL for those whose disease and treatment factors cannot be modified otherwise,” the researchers said. [Ann Surg 2022;276:e255-e263]

“However, it would require validation of other assessment tools to diagnose, assess the severity of lymphedema, and progress following conservative or surgical treatment,” they added. [Lymphology 2013;46:1-11]