Originally published as JCO Early Release 10.1200/JCO.2008.17.9291 on December 8 2008

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Lymphedema in Breast Cancer Survivors: Incidence, Degree, Time Course, Treatment, and Symptoms

Sandra A. Norman, A. Russell Localio, Sheryl L. Potashnik, Heather A. Simoes Torpey, Michael J. Kallan, Anita L. Weber, Linda T. Miller, Angela DeMichele, Lawrence J. Solin

From the Center for Clinical Epidemiology and Biostatistics; Department of Medicine, Division of Hematology/Oncology; Department of Radiation Oncology; Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, PA; and Breast Cancer Physical Therapy Center, Cherry Hill, NJ

Corresponding author: Sandra A. Norman, PhD, 801 Blockley Hall, 423 Guardian Dr, University of Pennsylvania, Philadelphia, PA 19104-6021; e-mail: snorman{at}mail.med.upenn.edu

Purpose To examine the incidence, degree, time course, treatment, and symptoms of lymphedema in breast cancer survivors.

Methods We conducted a 5-year, population-based prospective study of 631 randomly selected Philadelphia and Delaware County, Pennsylvania female residents with incident breast cancer who were diagnosed from 1999 to 2001. Using a questionnaire previously validated against physical therapists’ measurement-based clinical criteria, we assigned a score indicating the degree of lymphedema (none, mild, or moderate/severe) to each month of follow-up based on the respondent's perceived differences in hand/arm size. Standard survival analysis methods permitted maximum use of follow-up.

Results Five-year cumulative incidence of lymphedema was 42 (42%) per 100 women. Among the 238 affected women, lymphedema first occurred within 2 years of diagnosis in 80% and within 3 years in 89%. Among 433 women observed for 3 years, 23% reported no more than mild lymphedema, 12% reported moderate/severe lymphedema, and 2% reported chronically moderate/severe lymphedema. Women with mild lymphedema were more than three times more likely to develop moderate/severe lymphedema than women with no lymphedema. Thirty-seven percent of women with mild lymphedema and 68% with moderate/severe lymphedema received treatment. Increasing proportions of women with increasing degree of lymphedema reported symptoms (eg, jewelry too tight, tired/thick/heavy arm). Symptoms present before the first occurrence of lymphedema were associated with a higher probability of later lymphedema (eg, hazard ratio for jewelry too tight = 7.37; 95% CI, 4.26 to 12.76).

Conclusion Lymphedema after breast cancer is common but mostly mild. Subtle differences in self-reported hand/arm size and symptoms can be early signs of progressing lymphedema.

published online ahead of print at www.jco.org on December 8, 2008

Supported by Grant No. R01 CA65422 from the National Cancer Institute and Grant No. ROG-02-259 from the American Cancer Society (S.A.N.).

Presented in part as abstracts and posters at the following three meetings: Cancer Survivorship: Pathways to Health after Treatment, National Cancer Institute and American Cancer Society, June 16-18, 2004, Washington, DC; Cancer Survivorship: Embracing the Future, National Cancer Institute, American Cancer Society, and Lance Armstrong Foundation, October 4-6, 2006, Bethesda, MD; and Cancer Survivorship Research: Mapping the New Challenges, American Cancer Society, National Cancer Institute, and Lance Armstrong Foundation, June 18-20, 2008, Atlanta, GA.

Authors’ disclosures of potential conflicts of interest and author contributions are found at the end of this article.

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