Quality of Life for Women with Breast Cancer-Related Lymphedema: The Importance of Collaboration between Physical Medicine and Rehabilitation and General Surgery Clinics

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Türkan Turgay
Pınar Günel Karadeniz
Göktürk Maralcan


Breast cancer-related lymphedema, quality of life


Background: The aim of this study was to examine the clinical characteristics and quality of life (QOL) of patients with BCRL (breast cancer-related lymphedema).
Methods: In this cross-sectional descriptive study, patients' characteristics such as age, body mass index (BMI: kg/m²), history of chemotherapy (CT), radiotherapy (RT), hormone replacement therapy (HRT), neoadjuvant therapy (NT), cancer stages, and types of surgery were recorded. Patients were evaluated using the ‘Disabilities of the Arm, Shoulder and Hand questionnaire’ (DASH), the ‘Lymphedema Quality of Life Questionnaire’ (LYMQOL-ARM), and a visual analogue scale (VAS).
Results: A total of 68 women with the mean age of 52.50±9.33 and BMI 29.240 ± 5.05 kg/m² were recruited after breast cancer surgery in this study: thirty-three patients (48.5%) in Stage 0; 24 (35.3%) in Stage 1; 10 (14.7%) in Stage 2; and 1 (1.5%) in Stage 3. No statistically significant difference was found in the QOL according to treatments received after the diagnosis of breast cancer surgery, RT (except the appearance domain of QOL), CT, HRT, or NT. In patients who had received axillary dissection in combination with RT, a statistically significant association was observed between QOL related to body image and symptoms (p=0.009 and p=0.017, respectively). A statistically significant difference was found only in body image and clinical symptom domains according to the lymphedema stage (p=0.027 and p=0.002, respectively). It was observed that as shoulder pain (VAS) and disability (DASH) scores increased, scores of all domains of QOL increased except the overall domain in QOL (p<0.05).
Conclusion: It was observed that clinical symptoms and body image parameters in QOL were associated with the lymphedema stage and the number of lymph nodes dissected. It was concluded that axillary dissection with axillary RT and RT alone after breast cancer surgery is associated with body image. Our study revealed that body image perception is related to the quality of life in patients with BCRL. Optimal management of the negative effects of self-reported lymphedema evaluated in the latency phase on quality of life requires coordination between Physical Medicine and Rehabilitation and General Surgery Clinics.


1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, et al. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68(6):394-424.
2. Ozmen V, Ozmen T & Dogru V. Breast Cancer in Turkey; An Analysis of 20.000 Patients with Breast Cancer. Eur J Breast Health. 2019;15(3): 141-146.
3. Lawenda BD, Mondry TE & Johnstone PA. Lymphedema: a primer on the identification and management of a chronic condition in oncologic treatment. CA Cancer J Clin. 2009;59(1):8-24.
4. Hopkins JO, Allred J, Hurria A, Jatoi A, Lafky JM, et al. Lymphedema, musculoskeletal events and arm function in older patients receiving adjuvant chemotherapy for breast cancer (Alliance A171302). Breast Cancer Res Treat. 2017;166(3):793-808.
5. DiSipio T, Rye S, Newman B & Hayes S. Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis. Lancet Oncol. 2013;14(6):500-515.
6. Bundred N, Foden P, Todd C, Morris J, Watterson D, et al. Increases in arm volume predict lymphoedema and quality of life deficits after axillary surgery: a prospective cohort study. Br J Cancer. 2020;123(1):17-25.
7. Basta MN, Wu LC, Kanchwala SK, Serletti JM, Tchou JC, et al. Reliable prediction of postmastectomy lymphedema: The Risk Assessment Tool Evaluating Lymphedema. Am J Surg. 2017;213(6):1125-1133 e1121.
8. Hormes JM, Bryan C, Lytle LA, Gross CR, Ahmed RL, et al. Impact of lymphedema and arm symptoms on quality of life in breast cancer survivors. Lymphology. 2010;43(1):1-13.
9. Lee TS, Morris CM, Czerniec SA & Mangion AJ. Does Lymphedema Severity Affect Quality of Life? Simple Question. Challenging Answers. Lymphat Res Biol. 2018;16(1):85-91.
10. Düger T, Yakut E, Öksüz Ç, Yörükan S, Bilgutay BS, et al. Reliability and validity of the Turkish version of the Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire. Turkish Journal of Physiotherapy Rehabilitation. 2006;17:99-107.
11. Czerniec SA, Ward LC, Refshauge KM, Beith J, Lee MJ, et al. Assessment of breast cancer-related arm lymphedema--comparison of physical measurement methods and self-report. Cancer Invest. 2010;28(1):54-62.
12. Gencay Can A, Eksioglu E & Cakci FA. Early Detection and Treatment of Subclinical Lymphedema in Patients with Breast Cancer. Lymphat Res Biol. 2019;17(3):368-373.
13. Soran A, Ozmen T, McGuire KP, Diego EJ, McAuliffe PF, et al. The importance of detection of subclinical lymphedema for the prevention of breast cancer-related clinical lymphedema after axillary lymph node dissection; a prospective observational study. Lymphat Res Biol. 2014;12(4):289-294.
14. International Society of L. The diagnosis and treatment of peripheral lymphedema: 2013 Consensus Document of the International Society of Lymphology. Lymphology. 2013;46(1):1-11.
15. Borman P, Yaman A, Denizli M, Karahan S & Ozdemir O. The reliability and validity of Lymphedema Quality of Life Questionnaire-Arm in Turkish patients with upper limb lymphedema related with breast cancer. Turk J Phys Med Rehabil. 2018;64(3):205-212.
16. Arikawa AY, Kaufman BC, Raatz SK & Kurzer MS. Effects of a parallel-arm randomized controlled weight loss pilot study on biological and psychosocial parameters of overweight and obese breast cancer survivors. Pilot Feasibility Stud. 2018;4(17.
17. Vafa S, Zarrati M, Malakootinejad M, Totmaj AS, Zayeri F, et al. Calorie restriction and synbiotics effect on quality of life and edema reduction in breast cancer-related lymphedema, a clinical trial. Breast. 2020;54(37-45.
18. Champion VL, Wagner LI, Monahan PO, Daggy J, Smith L, et al. Comparison of younger and older breast cancer survivors and age-matched controls on specific and overall quality of life domains. Cancer. 2014;120(15):2237-2246.
19. Morrow PK, Broxson AC, Munsell MF, Basen-Enquist K, Rosenblum CK, et al. Effect of age and race on quality of life in young breast cancer survivors. Clin Breast Cancer. 2014;14(2):e21-31.
20. Harris SR, Hugi MR, Olivotto IA, Levine M, Steering Committee for Clinical Practice Guidelines for the C, et al. Clinical practice guidelines for the care and treatment of breast cancer: 11. Lymphedema. CMAJ. 2001;164(2): 191-199.
21. Boccardo FM, Ansaldi F, Bellini C, Accogli S, Taddei G, et al. Prospective evaluation of a prevention protocol for lymphedema following surgery for breast cancer. Lymphology. 2009;42(1):1-9.
22. Petrek JA & Heelan MC. Incidence of breast carcinoma-related lymphedema. Cancer. 1998;83(12 Suppl American):2776-2781.
23. He L, Qu H, Wu Q & Song Y. Lymphedema in survivors of breast cancer. Oncol Lett. 2020;19(3):2085-2096.
24. Fu MR, Axelrod D, Cleland CM, Qiu Z, Guth AA, et al. Symptom report in detecting breast cancer-related lymphedema. Breast Cancer (Dove Med Press). 2015;7(345-352.
25. Denlinger CS, Sanft T, Baker KS, Broderick G, Demark-Wahnefried W, et al. Survivorship, Version 2.2018, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2018;16(10):1216-1247.
26. International Society of L. The diagnosis and treatment of peripheral lymphedema. 2009 Concensus Document of the International Society of Lymphology. Lymphology. 2009; 42(2):51-60.
27.Nguyen TT, Hoskin TL, Habermann EB, Cheville AL & Boughey JC. Breast Cancer-Related Lymphedema Risk is Related to Multidisciplinary Treatment and Not Surgery Alone: Results from a Large Cohort Study. Ann Surg Oncol. 2017;24(10):2972-2980.
28. Tsai RJ, Dennis LK, Lynch CF, Snetselaar LG, Zamba GK, et al. The risk of developing arm lymphedema among breast cancer survivors: a meta-analysis of treatment factors. Ann Surg Oncol. 2009;16(7):1959-1972.
29. Belmonte R, Garin O, Segura M, Pont A, Escalada F, et al. Quality-of-life impact of sentinel lymph node biopsy versus axillary lymph node dissection in breast cancer patients. Value Health. 2012;15(6):907-915.
30. Velanovich V & Szymanski W. Quality of life of breast cancer patients with lymphedema. Am J Surg. 1999;177(3):184-187; discussion 188.
31. Bromham N, Schmidt-Hansen M, Astin M, Hasler E & Reed MW. Axillary treatment for operable primary breast cancer. Cochrane Database Syst Rev. 2017;1(CD004561.
32. Cariati M, Bains SK, Grootendorst MR, Suyoi A, Peters AM, et al. Adjuvant taxanes and the development of breast cancer-related arm lymphoedema. Br J Surg. 2015;102(9):1071-1078.
33. Zhu W, Li D, Li X, Ren J, Chen W, et al. Association between adjuvant docetaxel-based chemotherapy and breast cancer-related lymphedema. Anticancer Drugs. 2017;28(3):350-355.
34. Gillespie TC, Sayegh HE, Brunelle CL, Daniell KM & Taghian AG. Breast cancer-related lymphedema: risk factors, precautionary measures, and treatments. Gland Surg. 2018;7(4):379-403.
35. Kadakia KC, Snyder CF, Kidwell KM, Seewald NJ, Flockhart DA, et al. Patient-Reported Outcomes and Early Discontinuation in Aromatase Inhibitor-Treated Postmenopausal Women With Early Stage Breast Cancer. Oncologist. 2016;21(5):539-546.
36. Laroche F, Coste J, Medkour T, Cottu PH, Pierga JY, et al. Classification of and risk factors for estrogen deprivation pain syndromes related to aromatase inhibitor treatments in women with breast cancer: a prospective multicenter cohort study. J Pain. 2014;15(3):293-303.
37. Rossi AM, Hibler BP, Navarrete-Dechent C & Lacouture ME. Restorative Oncodermatology: Diagnosis and Management of Dermatologic Sequelae from Cancer Therapies. J Am Acad Dermatol. 2020; Online ahead of print.
38. Kwan W, Jackson J, Weir LM, Dingee C, McGregor G, et al. Chronic arm morbidity after curative breast cancer treatment: prevalence and impact on quality of life. J Clin Oncol. 2002;20(20):4242-4248.
39. Jeong HJ, Sim YJ, Hwang KH & Kim GC. Causes of shoulder pain in women with breast cancer-related lymphedema: a pilot study. Yonsei Med J. 2011;52(4):661-667.