Abstract PD4-03: Chemotherapy-related risk factors associated with lymphedema in breast cancer patients: Should repeated ipsilateral arm infusions be avoided?
Authors: Asdourian MS , Rao SR , Skolny MN , Salama L , Brunelle C , Seward C , Taghian AG 
Published: March 2017

Abstract
Background: Breast Cancer-Related Lymphedema (BCRL) is a chronic, iatrogenic condition that can occur after damage to the lymphatic system during surgery (sx) or radiation, precipitating edema of the arm, breast, or trunk. BCRL risk-reduction education is an essential component of clinical care, and practitioners often advise patients (pts) to avoid needle punctures on the treated arm when possible. There is, however, a lack of substantial scientific evidence to lessen patient distress. Considering the common use of chemotherapy (CT) agents in this population, we assessed whether repeated skin punctures on the ipsilateral arm for CT infusions increased the risk of BCRL compared to CT via central lines in a large, prospective cohort of breast cancer (BC) pts.
Methods: We prospectively screened 630 pts with unilateral (487) or bilateral (143) BC sx receiving neoadjuvant (NAC) and/or adjuvant CT (AdjCT) for arm lymphedema (defined as volume change ≥10%) at our hospital from 2005–16. Pts were measured with a perometer pre-operatively and at 3–7 month follow-up intervals. Clinicopathologic and treatment (tx)-related characteristics, including details on CT regimen and the method of intravenous (IV) CT administration [peripheral IV catheters (PIVCs), central venous access devices (CVADs), peripherally inserted central catheters (PICCs)] were obtained by chart review. Cox proportional hazard analyses were applied to ascertain the risk of BCRL associated with these factors.
Results: The median post-op follow-up was 44 months. Of the 630 pts, 40% underwent axillary lymph node dissection (ALND), 60% underwent sentinel lymph node biopsy (SLNB) or no nodal sx, 16% and 89% received NAC or AdjCT, respectively. CT was administered via PIVCs inserted in the hand/arm for 59%, via CVADs or PICCs for 26%, and via both PIVCs at least once and CVADs/PICCs for 15%. The 2-yr cumulative incidence of BCRL was 12% (95% CI 9.9-15.2%). Multivariable regression results indicated that pts with both peripheral IV infusions on the arm and implanted CVADs did not have a higher risk of BCRL (HR(95% CI)=1.4(0.6-3.6)) than pts who received CT via CVADs only (1.7(0.7-3.8)). The overall number of NAC (p=0.24;0.9(95% CI 0.8-1.1)) or AdjCT cycles (p=0.78;1.0(0.9-1.1)) was not associated with BCRL, nor was the number of peripheral IV infusions (p=0.17;1.0(1.0-1.1)). BMI &gt;30 (p&lt;0.0001;3.4(1.9-6.0)) and number of positive lymph nodes (p=0.02;3.2(1.3-8.1)) were significantly associated with BCRL. Among those with PIVCs, pts with bilateral SLNB/ALND were more likely to develop BCRL than pts with unilateral sx (p&lt;0.01;5.0(1.9-13.4)). Only 38% of the 32 bilateral pts with BCRL received at least one peripheral IV infusion on their ipsilateral arm.
Conclusion: Results suggest that repeated skin punctures on the ipsilateral arm for CT infusions do not significantly increase the risk for BCRL compared to implanted CVADs, nor does the overall number of CT cycles. As survivors may be concerned about the risk of developing BCRL following sx and tx, healthcare practitioners should strive to mitigate pt worry during and well beyond the course of tx, educating pts about the lifestyle risk exposures for BCRL and precautionary guidelines not being definitive.
Citation Format: Asdourian MS, Rao SR, Skolny MN, Salama L, Brunelle C, Seward C, Taghian AG. Chemotherapy-related risk factors associated with lymphedema in breast cancer patients: Should repeated ipsilateral arm infusions be avoided? [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr PD4-03.