The risk of developing arm lymphedema among breast cancer survivors: A meta-analysis of treatment factors

Background: As more women survive breast cancer, long-term complications that affect quality of life, such as lymphedema of the arm, gain greater importance. Numerous studies have attempted to identify treatment and prognostic factors for arm lymphedema, yet the magnitude of these associations remains inconsistent. Methods: A PubMed search was conducted through January 2008 to locate articles on lymphedema and treatment factors after breast cancer diagnosis. Random-effect models were used to estimate the pooled risk ratio. Results: The authors identified 98 independent studies that reported at least one risk factor of interest. The risk ratio (RR) of arm lymphedema was increased after mastectomy when compared with lumpectomy [RR = 1.42; 95% confidence interval (CI) 1.15-1.76], axillary dissection compared with no axillary dissection (RR = 3.47; 95% CI 2.34-5.15), axillary dissection compared with sentinel node biopsy (RR = 3.07; 95% CI 2.20-4.29), radiation therapy (RR = 1.92; 95% CI 1.61-2.28), and positive axillary nodes (RR = 1.54; 95% CI 1.32-1.80). These associations held when studies using self-reported lymphedema were excluded. Conclusions: Mastectomy, extent of axillary dissection, radiation therapy, and presence of positive nodes increased risk of developing arm lymphedema after breast cancer. These factors likely reflected lymph node removal, which most surgeons consider to be the largest risk factor for lymphedema. Future studies should consider examining sentinel node biopsy versus no dissection with a long follow-up time post surgery to see if there is a benefit of decreased lymphedema compared with no dissection.