Lymphedema, musculoskeletal events and arm function in older patients receiving adjuvant chemotherapy for breast cancer

Judith O. Hopkins, Jake Allred, Arti Hurria, Aminah Jatoi, Jacqueline M. Lafky, Harvey Cohen, Clifford Hudis, Eric Winer, Jeanne Mandelblatt, Ann Partridge, Lisa Carey, Hyman B. Muss. Breast Cancer Res Treat (2017) 166:793–808

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Lymphedema, musculoskeletal events and arm function in older patients receiving adjuvant chemotherapy for breast cancer

Judith O. Hopkins, Jake Allred, Arti Hurria,  Aminah Jatoi, Jacqueline M. Lafky, Harvey Cohen, Clifford Hudis, Eric Winer, Jeanne Mandelblatt, Ann Partridge, Lisa Carey, Hyman B. Muss. Breast Cancer Res Treat (2017) 166:793–808

Purpose

Musculoskeletal events (MEs) resulting from breast cancer treatment can significantly interfere with the quality of life (QOL) of older adults. We evaluated the incidence of MEs in women 65 years and older who had surgery and adjuvant chemotherapy for breast cancer, and the impact of treatment on MEs and arm function.

Patients and methods

Patient-reported data in Alliance/ CALGB 49907 were collected using the EORTC QLQBR23 and physician-reported adverse events to characterize self-reported MEs and incidence of lymphedema. EORTC QLQ-BR23 items related to musculoskeletal events were analyzed in this study and data collected at study entry (post-operative) and 12 and 24 months post entry.

Results

Lymphedema, arm function, and ME data were available for 321 patients. One or more MEs were reported by 87% (median number = 3) and 64% (median number = 1) of patients post-operatively and at 24 months. At 24 months 2% had persistence of six MEs. Seventy-four percent experienced at least C3/6 types of MEs over the 24-month period. Detection of lymphedema at any time during the study was noted in 7.5% of the patients and appeared to be associated with the type of chemotherapy given: CMF 16.4%, capecitabine 5.8%, and AC 4%. Mastectomy and axillary node dissection were associated with the most MEs. LROM correlated with poorer arm function at all time periods.

Conclusion

Potentially debilitating MEs occur in three fourths of elderly women undergoing standard therapy for breast cancer. Emphasis should be placed on prevention, identification, and treatment of these MEs to improve QOL.

Main findings

  • The following areas were measured (1) pain in the arm/ shoulder, (2) arm/hand swelling, (3) difficulty in raising arm or moving it sideways (limited range of motion, LROM), (4) breast pain in the affected breast, (5) breast swelling in the affected breast, and 6) oversensitivity in the affected breast. Patients also reported on the severity.
  • Patients completed the assessments at three time points: study baseline (within 84 days following surgery), 12 months from baseline, and 24 months from baseline.
  • 321 participants.
  • Twenty percent had only a sentinel lymph node (SLN) biopsy and 80% had an axillary lymph node dissection (ALND). Fifty-four percent received radiation therapy (RT) and per protocol all received chemotherapy (48% capecitabine, 31% AC, and 21% CMF).
  • Eighty-seven percent had at least one self-reported musculoskeletal event (ME) at study baseline (within 84 days post-operative) and the median number of MEs at baseline was 3. By 12 months, 72% had persistence of at least one ME symptom and 64% had at least one lingering ME symptom at 24 months.
  • Over the 24-month period, 7.5% of these 321 women developed grade 1 or grade 2 LE (Table 3). LE incidence was associated with the type of chemotherapy received: CMF (13.4% grade 1 and 3.0% grade 2), capecitabine (4.5% grade 1 and 1.3% grade 2), and AC (4.0% grade 1 and 0% grade 2) (p = 0.007).
  • This study found 60% of our patients had LROM and poor arm function (as defined by ability to lift a suitcase or shopping bag).
  • Breast/chest wall swelling was commonly reported postoperatively but almost completely resolved by 24 months.
  • This data is reassuring and suggest that the frequency of major musculoskeletal symptoms in an older patient population participating in a clinical trial is substantial but dramatically decreases with time. However, for many patients these symptoms are quite bothersome and affect quality of life.