Prevalence and Factors Associated With Upper Extremity Lymphedema in Patients Post Breast Cancer Surgery at Kenyatta National Hospital

Abstract

Background Worldwide, Upper extremity lymphedema is among the prevalent debilitating complications post breast surgery. Its impacts are challenging to healthcare systems, healthcare providers, and patients. The incidence of lymphedema varies globally, ranging from 5%-60%. The risk factors to developing lymphedema post breast surgery have also been studied. There has been no study to get the real prevalence and hence the burden of lymphedema after breast surgery in our set up. Objective To find out the prevalence of upper extremity lymphedema post breast surgery; and characterize the risk factors associated with it. Methods and Materials This was be a 5-year retrospective cross sectional study at KNH records department. Data was extracted from complete medical records of a sample of all breast cancer patients who had undergone an operation for the disease at KNH between January 2014 and December 2019. A structured closed-ended questionnaire was employed to collect data from the patients’ files. The initial data collected was to check the presence or absence of post breast surgery upper extremity lymphedema. This was used to calculate the prevalence. The data collected at this stage included, the demographics; the diagnosis; radiotherapy post mastectomy; axillary lymph node dissection, sentinel lymph node dissection, adjuvant chemotherapy, neoadjuvant chemotherapy, number of lymph nodes dissected, axillary recurrence, tumor location in terms of quadrants. This was then entered into SPSS version 24 for analysis. General descriptive statistics were applied to derive frequencies, means, and standard deviations. Data was analyzed continuously and presentation done using means and standard deviations. Categorical data analysis and presentation was done using frequencies and proportions. Statistical significance was then taken at p-value of <0.05 and data displayed in tables, graphs and charts. Results A total of 364 participants were included in the study. Mean age of respondents was 50.5±13.8 years and ranged from 12years to 96years. The majority of the participants were between 41- 50 years. The incidence of lymphedema in patients who had undergone surgery for breast cancer in our set up was 7.1%. Among the non-treatment related factors that we studied were; Age, pathology of breast ca (invasive/DCIS), axillary recurrence, BMI, tumor location in quadrants. Page 13 of 52 There was no significant difference in mean age of participants who developed lymphedema (51.7yrs±16.2) compared to those who didn’t (50.4±13.7yrs) (p=0.431). The relationship between diagnosis and lymphedema development was also not statistically significant (with a likelihood ratio of 0.08 and a p=0.928). The same applied to the tumor location/diseased part (p=0.795). The BMI of patients studied ranged from 17kg/m2 to 35 kg/m2. With a likelihood ratio of 18.6, and a chi square of 25.3. This was found to be statistically significant (p=0.021). On the other hand axillary recurrence was also found as an independent risk factor (p=0.02). The treatment related risk factors that we studied included, type of surgery to the breast and to the axilla, adjuvant and neoadjuvant radiotherapy and chemotherapy. All the patients who developed lymphedema (26 patients) had undergone ALND while none developed after WLE, though this was not statistically significant (p=1). In our study the use of chemotherapy, whether in the adjuvant or neoadjuvant set up was not statistically significant (p=0.06). This was similar to the relationship between adjuvant radiotherapy and lymphedema which was also not statistically significant (p=0.06) Conclusions Our results suggest that the most important treatment and patient-related risk factors for breast cancer-related lymphedema were BMI and axillary recurrence. Clinically it was also noted that all patients who had developed lymphedema had undergone ALND, as opposed to none who had SLNB. Elimination or prevention of these risk factors may reduce the incidence of lymphedema.