Hindawi Publishing Corporation

International Journal of Breast Cancer

Volume 2013, Article ID 641818, 7 pages
http://dx.doi.org/10.1155/2013/641818

Research Article
Risk Factors of Lymph Edema in Breast Cancer Patients

Haghighat Shahpar,1 Akbari Atieh,2 Ansari Maryam,1 Homaei Shandiz Fatemeh,3

Najafi Massoome,4 Ebrahimi Mandana,1 Yunesian Masud,5
Mirzaei Hamid Reza,2 and Akbari Mohammad Esmaeil2,6
1
Breast Cancer Research Group, Breast Cancer Research Center (BCRC), ACECR, Tehran 1315685981, Iran
2
Cancer Research Center (CRC), Shahid Beheshti University of Medical Sciences, Tehran 1989934148, Iran
3
Solid Tumor Treatment Research Center, Mashhad University of Medical University, Mashhad 91397, Iran
4
Cancer Institute, Tehran University of Medical Sciences, Tehran 1419733141, Iran
5
Tehran University of Medical Sciences, Tehran 1411717415, Iran
6
Cancer Research Center, Shohada Hospital, Tajrish Square, Tehran, Iran

Correspondence should be addressed to Akbari Mohammad Esmaeil; [email protected]

Received 22 March 2013; Revised 19 May 2013; Accepted 19 May 2013

Academic Editor: Claudio Luparello

Copyright © 2013 Haghighat Shahpar et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.

Background. Lymphedema secondary to breast cancer treatment is a common and serious problem for disease survivors. The
objective of the current study was to identify the risk factors of secondary lymphedema after breast carcinoma treatment. Materials
& Methods. The breast cancer patients who were followed up in three centers in Tehran and Mashhad in 2010 were recruited in the
study. The circumference measurement was used for defining lymphedema. Results. Among 410 breast cancer patients, 123 cases
(30%) developed lymphedema. Variables such as low educational level, body mass index (BMI), higher stage of disease, number
of involved lymph nodes, comorbid diseases, trauma, infection, and the time after surgery showed significant correlation with the
development of lymphedema. In logistic regression analysis, increase of 1 kg/m2 in BMI (OR = 1.09; 95% CI 1.05–1.15), each number
increase in lymph node involvement (OR = 1.15; 95% CI 1.08–1.21) and the increase of every 1 month after surgery (OR = 1.01; 95% CI
1.01–1.02) significantly increased the risk of lymphedema. Conclusion. The results of this study demonstrated that preserving a fitted
BMI, emphasis on self-care, and educating preventive activities may have important roles in decreasing the lymphedema incidence
and improving the patients’ quality of life.

1. Introduction blockage, chronic venous insufficiency, immobility, or tourni-

quet effects [2].
Lymphedema (LE) is an external (or internal) manifestation Upper extremity LE is one of the most common compli-
of lymphatic system insufficiency and impaired lymph trans- cations after breast cancer surgery with a reported incidence
port [1]. It is characterized by accumulation of lymphatic fluid of 6% to 30% [3]. It is estimated that 120,000–600,000 patients
in the interstitial tissue that causes swelling, most often in suffer from postmastectomy lymphedema in the United
extremities. States [4]. In a meta-analysis of 72 studies achieved by Disipio
The development of LE occurs when the lymphatic load et al. in 2013, pooled estimate of lymphedema incidence was
exceeds the transport capacity. There are two general classifi- 16.6% (95% CI 13.6–20.2). It was 21.4% (14.9–29.8) when data
cations of LE: primary and secondary. Primary LE develops were restricted to prospective cohort studies (30 studies) [5].
as a consequence of a pathologic congenital and/or hereditary The occurrence time of lymphedema has been studied in
etiology. Secondary LE, which is more common, is caused many researches. The incidence of arm lymphedema seems
by mechanical insufficiency of the lymphatic system due to to increase up to 2 years after diagnosis or surgery of breast
surgery, radiation, chemotherapy, trauma, infection, tumoral cancer [5]. Its overall incidence ranges from 8% to 56% at 2
2 International Journal of Breast Cancer

years of followup, depending on the extent of axillary surgery The breast cancer patients who were being followed
and the use of radiotherapy [6]. up less than 3 years after initial treatment in Breast Can-
In recent decades, breast cancer mortality rates have de- cer Research Center (Tehran), Azar Sample from Cancer
clined, reflecting advances in early detection as well as more Research Center (Tehran) and Ghaem Hospital (Mashhad)
widespread application of effective adjuvant therapies, and in 2010 were included in the study. Patients who had bilateral
many women diagnosed with breast cancer may expect breast cancer and male cases were excluded from the study.
survival probability similar to age-matched women without This project was approved by ethical committee of BCRC.
breast cancer. The National Cancer Institute estimates that 1
in 7 women in the USA have a lifetime risk of being diagnosed 2.2. Data Collection. Demographic and clinical character-
with BC and 1 in 33 will die from it [7]. As life expectancy istics of patients referred to 3 centers for followup were
improves for women with breast cancer, more women will recorded by a questionnaire. Data consisted of the following.
be living with possible side effects of the treatment. Conse-
quently, effective prevention and management of treatment (1) Demographic variables (age, marital status, educa-
sequels such as lymphedema that can impair function and tional status, and dominant hand) and past medical
quality of life in breast cancer survivors have taken on history (history of comorbid conditions such as dia-
increasing importance [8]. betes, hypertension, chronic heart failure, renal fail-
Lymphedema may present with different signs and symp- ure, hypothyroidism, and history of infection or trau-
toms including a feeling of heaviness or tightness in the limb, ma in affected limb) were collected by interview with
pain or discomfort, restricted range of motion, and swelling participants.
in a part or entire limb.
(2) Treatment modalities consisting of the type of sur-
Several variables have been identified as potential risk
gery, chemotherapy regimen, radiotherapy, and hor-
factors for development of breast cancer related lymphedema.
mone therapy were identified by patient interview and
In a study on breast cancer patients living in Florence, radio-
physicians’ notes. Data pertaining to the tumor size,
therapy, the number of lymph nodes removed, and the size
number of excised and involved lymph nodes were
of the tumor were identified as significant prognostic factors
recorded according to pathology report.
that increase the risk of lymphedema in patients who undergo
dissection of the axillary lymph nodes [9]. (3) BMI: height and weight were measured by a trained
According to a review conducted by American Cancer observer in interview, and BMI was defined as the
Society, the most important risk factors for the development weight in kilograms divided by the square of the
of lymphedema are tumor location in the upper outer quad- height in meters.
rant, postoperative axillary trauma, infection, hematoma, and
seroma, axillary radiation after axillary lymph node dissec- Arm circumferences were measured at 5 points in two arms.
tion (ALND), extent of ALND (inclusion of level 3), axillary These points were hand (at the first and fifth metacarpal),
recurrence, and large number of positive axillary lymph wrist (the distal edge of the styloid process), 10 cm below
nodes [3]. Meta-analysis of 29 studies showed that risk factors elbow, and 5 and 15 cm above elbow. If the circumference
with strong level of evidence were extensive surgery (i.e., axil- difference was 2 cm or higher in any point, she was considered
lary lymph node dissection, greater number of lymph nodes as a lymphedema case. Their characteristics were compared to
dissected, and mastectomy) and being overweight or obese other patients without edema, with the difference of less than
[5]. 2 cm in any point.
The aim of this study was to examine the main lym- Some subjective symptoms were also recorded. Women
phedema risk factors in breast cancer patients referred to were asked to answer “yes” or “no” to the questions about
3 cancer centers in Iran. Defining the most important risk having arm symptoms (pain, heaviness, and paresthesia) and
factors of lymphedema can help physicians and health care their experience of edema. Their answer to the question “since
providers to explain precautions to the patients and encour- the diagnosis of breast cancer have you experienced arm
age them to seek care promptly if they experience symptoms swelling?” indicated the presence of subjective edema.
of lymphedema and promote the surgeons to choose more
safe and conservative treatments. 2.3. Data Analysis. By univariate analysis, the independent
Importantly, with the early identification and manage- effect of each variable on edema occurrence was studied. Lo-
ment of lymphedema, we can help patients to maintain their gistic regression was used to examine the intercorrelation
quality of life by minimizing cosmetic, functional, psychoe- effect of demographic and clinical characteristics on outcome
motional, and potentially life-threatening complications. of interest. Two-tailed test and 𝑃 value <0.05 were considered
as statistical significance values. Considering the important
2. Materials and Methods role of age, physical activity, and number of excised lymph
nodes, as were mentioned in many previous studies, variables
2.1. Study Population. Sample size of this study was estimated with significance level of 𝑃 ≥ 0.1 were included in regression
by Epi info software to be about 400 patients. This calculation analysis.
was based on 80% power and 5% of two sided significance The frequencies of subjective symptoms in two groups
level (alpha error) and reported OR of most important were compared by kappa coefficient. In general, values of
lymphedema risk factors in previous studies. kappa greater than 0.80 denote very good agreement beyond
International Journal of Breast Cancer 3

chance, values below 0.2 indicate poor agreement, and values incidence of 30% for lymphedema among breast cancer sur-
between 0.2 and 0.4, 0.4 and 0.6, and 0.6 and 0.8 represent fair, vivors who were studied with a mean followup of 34 months
moderate, and good agreement beyond chance, respectively in lymphedema group.
[10]. Lymphedema following treatment for breast cancer has
Statistical procedures were performed using the statistical received attention in multiple studies. According to some
package SPSS 17 for windows. reports, overall incidence of arm lymphedema can range from
8% to 56% in 2 years following surgery, depending on the
extent of axillary surgery and the use of radiotherapy. It devel-
3. Results ops most commonly in the first 12 to 14 months following
treatment [6]. In this study, half of the lymphedema had been
Totally, 410 breast cancer patients were studied. According to
detected in the first 17 months after surgery which was similar
lymphedema definition, 123 patients (30%) had lymphedema
to other studies. So, more frequent surveillance throughout
and were defined as cases. All the other 298 patients were
this time (e.g., once every 3–6 months) seems reasonable [5].
considered as noncase group. The mean age of the patients
In Petrek et al. study, the onset of lymphedema was noted by
was 49 years (±10.9). Half of them were educated high school
approximately three-quarters (77%) of the patients within the
and higher, and about 88% of them were married.
first 3 years after breast cancer treatment [11]. The large range
Demographic and clinical characteristics of patients
in the prevalence can be due to various methods of edema
(Table 1) showed that the educational level of cases was
measurement [12, 13], and this highlights the importance of
significantly lower than the other group (𝑃 = 0.02). In 58.5%
determining an accurate measurement method by future
of patients with lymphedema, the dominant arm and affected
studies.
one were the same while in noncase group this proportion
Similar to some other studies [14], we did not find any
was 62%. Breast cancer in advanced stages was more common
significant statistical correlation between marital status and
in cases (24.4%) compared to the second group (14.6%), and
lymphedema, while Paskett and colleagues have shown that
the frequency of trauma and comorbid diseases in lymphe-
the risk of swelling among married women was 1.36 times
dematous patients compared to noncases were 9.8% versus
higher than the risk for unmarried women [6].
3.8% and 35% versus 24%, respectively. Univariate analysis of demographic characteristics
Table 2 shows the mean difference of age, BMI, number of showed that lymphedema was significantly more prevalent in
excised and involved lymph nodes, and the follow-up dura- higher age, lower levels of education, and higher BMI. It was
tion between two groups. The effect of each unit change of shown that the odds of edema in illiterates and low levels of
these variables on increasing the odds of lymphedema occur- education was 1.66 times more than higher levels of educa-
rence has been measured by odds ratio. It is noticeable that tion. Definitely higher awareness and better self-care practice
half of the lymphedema had been occurred in the first 17 in educated patients have an important role in this difference.
months after surgery. In spite of some studies that neither age at the time of
Categorical and continuous variables on lymphedema assessment nor age at the diagnosis of breast cancer was
incidence were analyzed by logistic regression. Predictor fac- predictor of lymphedema [15], Meeske et al. have shown that
tors of this analysis and their effect have been displayed in arm lymphedema was associated with younger age at diag-
Table 3. nosis (OR per year of age = 0.96, CI = 0.93–0.99), history of
As a secondary outcome, comparison of subjective edema hypertension (OR = 2.31, CI = 1.38–3.88), obesity (OR = 2.48,
and symptoms between two groups was achieved (Table 4). CI = 1.05–5.84) and 10 or more lymph node excised (OR =
The agreement level of subjective symptoms with objective 2.16, CI = 1.12–4.17) [16]. In a study in Hong Kong, adjusted
ones was assessed by kappa coefficient. odds ratios for the development of lymphedema were 1.11
In 410 patients surveyed, 130 (31.7%) reported having
(95% CI = 1.01–1.22) for an increase of 1 kg/m2 in body mass
developed arm swelling after their treatment and about 39%
index (BMI) at recruitment and 1.05 (95% CI = 1.01–1.10) for
of them complained of symptoms such as pain, heaviness, and
an increase of 1 year of age at recruitment time [17]. Hayes
paresthesia. The frequency of these symptoms in cases com-
showed that age more than 50 may increase the risk of
pared to noncases was 47.2 versus 35.5 percent (𝑃 = 0.018).
lymphedema incidence to 3.3 times [18].
It seems that in older people, lower physical activity,
4. Discussion weakness of muscle pump, and higher BMI may increase ede-
ma.
Lymphedema is a common complication of cancer therapy. It The association between BMI and lymphedema has been
can occur anywhere that lymph nodes have been surgically approved in many studies [3, 13, 15]. Soran et al., believe
removed or lymph flow has been disturbed. that it is not clear whether obesity is a direct risk factor for
The results of this study showed that each unit increase arm edema; it is certainly a risk factor for infection and poor
of BMI, every additional lymph node involvement, and each wound healing [4]. Foeldi believes that lymphedema com-
month after surgery could increase the odds of swelling by bined with obesity is more than the sum of the two diseases.
9%, 15%, and 1%, respectively. Obesity causes the diaphragm to be above its normal position,
Swelling may occur at any point following axillary node impairing its movement. As a result, a mechanism that
dissection or radiation therapy, beginning immediately after supports lymph flow is impaired [19]. Segerstrom et al. (1992)
or even delayed by several years. Our findings revealed the surmised that increased weight may lead to an increase in
4 International Journal of Breast Cancer

Table 1: Demographic and clinical characteristic of patients.

Variable Case Noncase OR (95% CI) P value

no. (%) no. (%)
Education
Illiterate/primary school 72 (58.5) 132 (46) 1.66 (1.08–2.54) 0.02
High school/university 51 (41.5) 155 (54) 1
Marital status
Single/widow/divorce 14 (11.4) 34 (11.8) 0.96 (0.49–1.85) 0.893
Married 109 (88.6) 253 (88.2) 1
Dominant limb = involve limb
Yes 72 (58.5) 178 (62) 0.87 (0.56–1.33) 0.508
No 51 (41.5) 109 (38) 1
Physical activity
Low 34 (27.6) 54 (18.8) 1.89 (0.95–3.75) 0.069
Moderate 71 (57.7) 179 (62.4) 1.19 (0.65–2.17) 0.57
High 18 (14.6) 54 (18.8) 1
Stage of disease
I 10 (8.1) 37 (12.9) 1
II 83 (67.5) 208 (72.5) 1.48 (0.7–3.1) 0.304
III/IV 30 (24.4) 42 (14.6) 2.64 (1.14–6.13) 0.024
Breast surgery
Modified radical mastectomy 83 (67.5) 197 (68.6) 0.95 (0.6–1.49) 0.817
Breast preservation 40 (32.5) 90 (31.4) 1
Radiation therapy
No 31 (25.2) 88 (30.7) 1
Yes 92 (74.8) 199 (69.3) 1.32 (0.81–2.12) 0.265
Chemotherapy
No 7 (5.7) 13 (4.5) 1
Regimen with Adriamycin 95 (77.2) 214 (74.6) 0.82 (0.31–2.13) 0.69
Regimen without Adriamycin 21 (17.1) 60 (20.9) 0.65 (0.23–1.85) 0.42
Hormone therapy
No 50 (40.7) 119 (41.5) 1
Yes 73 (59.3) 168 (58.5) 1.03 (0.67–1.59) 0.878
Co-morbid disease
No 80 (65) 216 (75.3) 1
Yes 43 (35) 71 (24.7) 1.64 (1.04–2.58) 0.035
History of Trauma/infection in affected limb
No 111 (90.2) 276 (96.2) 1
Yes 12 (9.8) 11 (3.8) 2.71 (1.16–6.33) 0.02
History of seroma
No 113 (91.9) 260 (90.6) 1
Yes 10 (8.1) 27 (9.4) 0.85 (0.4–1.81) 0.679

radiation dose, which may be associated with lymphedema. in weight control strategies to minimize their risk for swelling
So they suggest that controlling BMI can be helpful in and development of other chronic diseases.
reducing lymphedema, even though it may not be a direct Treatment modalities have been introduced as predictor
risk factor for it [8]. According to mentioned evidences it factors of lymphedema in different studies. Even though type
seems that all physicians and health care providers should of surgery [8, 15, 20] chemotherapy [6, 13] and radiotherapy
strongly encourage breast cancer patients to engage routinely [2, 8, 9, 13] has shown significant relation with the incidence
International Journal of Breast Cancer 5

Table 2: Demographic and clinical characteristics of patients (numeric variables).

Variable Case Non-case OR (95% CI) P value

mean (±SD) mean (±SD)
Age (years) 50.6 (±11.4) 48.4 (±10.6) 1.02 (0.99–1.04) 0.059
BMI 30.7 (±5.2) 28.8 (±4.6) 1.08 (1.03–1.13) <0.001
Tumor size (cm) 3.1 (±1.5) 2.9 (±1.5) 1.21 (0.98–1.28) 0.98
No. of excised LN 11.1 (±5.3) 10.1 (±4.9) 1.04 (1–1.28) 0.062
No. of involved LN 4.2 (±5.2) 2 (±3.5) 1.132 (1.07–1.97) <0.001
Duration after surgery (months) 34.2 (±38.8) 27.6 (±25.8) 1.007 (1–1.01) 0.04

Table 3: Predictor factors of lymphedema. tion are important factors for decreasing the risk of lym-
phedema.
Variable 𝛽 SE P-value OR (65% CI) Risk reduction related to surgeons’ experience can be
Constant −4.17 0.75 <0.001 reflected specifically in axillary dissection. It is expected that
BMI 0.09 0.24 <0.001 1.09 (1.05–1.15) the use of sentinel lymph node biopsy (SLNB) as a minimally
No. of involved LN 0.14 0.03 <0.001 1.15 (1.08–1.21) invasive technique instead of classical axillary lymph node
Months after surgery 0.008 0.004 0.025 1.01 (1.01–1.02) dissection can reduce the incidence of lymphedema.
In spite of many studies which have introduced the high-
Table 4: Subjective comparison of feeling edema and lymphedema er number of excised lymph nodes as a predictor of lym-
symptoms. phedema [3, 6, 9, 16, 21], in some valid studies only a higher
number of involved lymph nodes or a higher stage of disease
Frequency of were noticed to be related to lymphedema [2, 13]. In our study,
Kappa P value
Variable subjective edema (%) the number of the involved lymph nodes was represented as
co-efficient
No Yes edema risk factor (OR = 1.15, CI = 1.08–1.21), revealing that for
Presence of every node involved, the odds of swelling increased by 15%.
0.33 <0.001
lymphedema It is expected that by early diagnosis of breast cancer in lower
Noncase 225 (78.4) 62 (21.6) stage, the incidence of lymphedema would decline.
As we mentioned before, a subjective comparison of feel-
Case 55 (44.7) 68 (55.3)
ing edema and lymphedema symptoms between two groups
Symptoms (pain, was made. About 31.7% of patients reported developing arm
heaviness, 0.15 0.002
swelling after their treatment, and 39% of them complained of
paresthesia)
symptoms such as pain, heaviness, and paresthesia. In a study
No 185 (74) 65 (26) of Otago women, the frequency of subjective edema and
Yes 95 (59.4) 65 (40.6) pain has been reported 38% and 37.5% in patients with and
without lymphedema [22]. Pain is a common symptom in
lymphedema patients. For example, in Paskett and Stark
of edema, but such an association have not been insisted in study 72% of the lymphedema patients reported pain in addi-
some studies [8, 11]. According to recent meta-analysis, strong tion to edema, and 57% of them had intermittent pain [23],
evidence supports the association of extensive surgery (chest and Moffatt showed that 50% of patients had experienced
wall and axilla) with increased risk of lymphedema and mod- pain or discomfort from their edema [24]. In our study, 47.2%
erate evidence supports its association with adjuvant therapy of lymphedema patients complained of arm symptoms.
(radiation and chemotherapy) [5]. In this research, none of In the present study, the agreement between subjective
those treatment modalities showed significant relation with edema with measured lymphedema and arm symptoms was
lymphedema but the limitations of data collection in this considered as indexes of patients’ knowledge of lymphedema.
study should not be overlooked. For example, data related to The result of analysis showed fair and poor level of agreement
direct radiation to the axilla had not been recorded, and the coefficient between the current variables (0.33 versus 0.15). It
possibility of radiation scattered to the axilla during breast or is noticeable that about 60% of patients with arm symptoms
chest wall therapy could not be estimated. and 44.7% of cases had no complaint of edema. The results
Patients underwent surgery by several surgeons with of a study found that the symptoms of “heaviness in the past
different techniques of surgery, and this could confound the year” and “swelling now” were predictive of a maximal limb
comparison of role of modified radical mastectomy with circumference difference of 2 cm, so they introduce these
breast preservation in inducing edema. According to a re- symptoms as precursors to the clinical diagnosis of lym-
search referred by Foeldi, lymphedema develops more fre- phedema [2]. The low level of agreement in our study can
quently after breast cancer surgeries performed by residents emphasize that many patients are not familiar with the early
compared to surgeries performed by experienced surgeons signs and symptoms of lymphedema. So, educational pro-
[19]. Thus, the experience of the surgeon and less manipula- grams may be helpful and necessary for increasing knowledge
6 International Journal of Breast Cancer

of patients and healthcare practitioners for providing better paper. Haghighat Shahpar and Yunesian Masud have ana-
self-care and preventive strategies. lyzed the data. Ansari Maryam, Homaei Shandiz Fatemeh,
One of the advantages of this study is recruitment of study and Akbari Atieh have contributed to design project and
sample in follow-up clinics. Mostly the main protocol of these gathered and managed the data set. Najafi Massoome,
clinics does not focus on lymphedema, besides recording Ebrahimi Mandana, and Mirzaei Hamid Reza contributed as
patients’ data before measurement of arm circumference the experts to discuss the results and provide the final draft
could decrease recall bias. These three clinics are referral cen- of paper. All authors have read and approved the contents of
ters for breast cancer in two cities of Iran. So, considering that paper.
they are not representative of all breast cancer patients in Iran,
but this design provided an opportunity for estimating the Acknowledgments
frequency of lymphedema in referred patients.
In this study, about 62% of patients whose dominant hand The authors thank the Academic Center for Education,
and involved limb were the same had no defined lymphede- Culture and Research (ACECR) and Shahid Beheshti Medical
ma. Even though in some studies the disease in dominant side University (SBMU) for their generous funding support of this
has been introduced as a predictor factor for lymphedema project.
[17], there are other researches that have not shown such an
association [8]. The authors of this paper believe that after References
surgery, most of the patients automatically limit the move-
ment of the affected side which can induce edema. If this side [1] International Society of Lymphology, “The diagnosis and treat-
is the dominant hand, the patient automatically uses it in daily ment of peripheral lymphedema. 2009 Concensus Document of
activities, and by increasing the lymph flow, the incidence of the International Society of Lymphology,” Lymphology, vol. 42,
lymphedema may decrease. no. 2, pp. 51–60, 2009.
As many other studies, we had the limitation in measure- [2] B. D. Lawenda, T. E. Mondry, and P. A. S. Johnstone, “Lym-
ment method validity which was unavoidable in spite of the phedema: a primer on the identification and management of a
chronic condition in oncologic treatment,” CA Cancer Journal
training of the observers.
for Clinicians, vol. 59, no. 1, pp. 8–24, 2009.
Another limitation was natural asymmetry of healthy
limbs. As we know, there can be a slight natural difference bet- [3] B. Clark, J. Sitzia, and W. Harlow, “Incidence and risk of arm
oedema following treatment for breast cancer: a three-year
ween a subject’s arms because of hypertrophied muscle in the
follow-up study,” QJM, vol. 98, no. 5, pp. 343–348, 2005.
overused arm. For studying the effect of this variable, the
comparison between the preoperative and postoperative [4] A. Soran, G. D’Angelo, M. Begovic et al., “Breast cancer-related
lymphedema—what are the significant predictors and how they
measurement of the same arm could be a more precise
affect the severity of lymphedema?” Breast Journal, vol. 12, no.
method. So it is recommended that lymphedema assessment 6, pp. 536–543, 2006.
should begin preoperatively with assessment of both arm, and
[5] T. Disipio, S. Rye, B. Newman, and S. Hayes, “Incidence of
it ought to be continued at regular intervals.
unilateral arm lymphoedema after breast cancer: a systematic
review and meta-analysis,” The Lancet Oncology, vol. 14, no. 6,
5. Conclusion pp. 500–515, 2013.
[6] E. D. Paskett, M. J. Naughton, T. P. McCoy, L. D. Case, and J. M.
According to the finding of this study, it seems that preserving Abbott, “The epidemiology of arm and hand swelling in pre-
a fitted BMI, increasing patients’ knowledge about lym- menopausal breast cancer survivors,” Cancer Epidemiology
phedema, emphasis on self-care, and educating preventive Biomarkers and Prevention, vol. 16, no. 4, pp. 775–782, 2007.
strategies after surgery and during follow-up visits may have [7] A. F. Williams, P. J. Franks, and C. J. Moffatt, “Lymphoedema:
important roles in decreasing the lymphedema incidence. estimating the size of the problem,” Palliative Medicine, vol. 19,
To achieve this goal and improving quality of life of pa- no. 4, pp. 300–313, 2005.
tients, educating health professionals regarding basic patho- [8] J. H. Park, W. H. Lee, and H. S. Chung, “Incidence and risk fac-
physiology of lymphedema and promoting early diagnosis tors of breast cancer lymphoedema,” Journal of Clinical Nursing,
and treatment modalities may be beneficial practices. vol. 17, no. 11, pp. 1450–1459, 2008.
[9] A. Herd-Smith, A. Russo, M. G. Muraca, M. R. Del Turco, and
Conflict of Interests G. Cardona, “Prognostic factors for lymphedema after primary
treatment of breast carcinoma,” Cancer, vol. 92, no. 7, pp. 1783–
This research was sponsored by the Academic Center for Edu- 1787, 2001.
cation, Culture and Research (ACECR) and Shahid Beheshti [10] D. Altman, Practical Statistics For Medical Research, Chapman
Medical University (SBMU). But the authors have full control & Hall, London, UK, 1991.
of all primary data, and they agree to allow the journal to [11] J. A. Petrek, R. T. Senie, M. Peters, and P. P. Rosen, “Lym-
review their data if requested. phedema in a cohort of breast carcinoma survivors 20 years after
diagnosis,” Cancer, vol. 92, no. 6, pp. 1368–1377, 2001.
Authors’ Contribution [12] S. Hayes, B. Cornish, and B. Newman, “Comparison of methods
to diagnose lymphoedema among breast cancer survivors: 6-
Akbari Mohammad Esmaeil and Haghighat Shahpar coor- month follow-up,” Breast Cancer Research and Treatment, vol.
dinated and supervised the project and wrote the first draft 89, no. 3, pp. 221–226, 2005.
International Journal of Breast Cancer 7

[13] S. V. S. Deo, S. Ray, G. K. Rath et al., “Prevalence and risk factors

for development of lymphedema following breast cancer treat-
ment,” Indian Journal of Cancer, vol. 41, no. 1, pp. 8–12, 2004.
[14] J. Engel, J. Kerr, A. Schlesinger-Raab, H. Sauer, and D. Hölzel,
“Axilla surgery severely affects quality of life: results of a 5-
year prospective study in breast cancer patients,” Breast Cancer
Research and Treatment, vol. 79, no. 1, pp. 47–57, 2003.
[15] T. L. Edwards, “Prevalence and aetiology of lymphoedema after
breast cancer treatment in southern Tasmania,” Australian and
New Zealand Journal of Surgery, vol. 70, no. 6, pp. 412–418, 2000.
[16] K. A. Meeske, J. Sullivan-Halley, A. W. Smith et al., “Risk factors
for arm lymphedema following breast cancer diagnosis in Black
women and White women,” Breast Cancer Research and Treat-
ment, vol. 113, no. 2, pp. 383–391, 2009.
[17] S. S. Mak, W. Yeo, Y. M. Lee et al., “Predictors of lymphedema in
patients with breast cancer undergoing axillary lymph node dis-
section in hong kong,” Nursing Research, vol. 57, no. 6, pp. 416–
425, 2008.
[18] S. C. Hayes, M. Janda, B. Cornish, D. Battistutta, and B. New-
man, “Lymphedema after breast cancer: incidence, risk factors,
and effect on upper body function,” Journal of Clinical Oncology,
vol. 26, no. 21, pp. 3536–3542, 2008.
[19] M. Foldi, E. Foldi, and S. F. E. Kubik, Text Book of Lymphology
for Physicians and Lymphedema Therapists, Urban & Fischer,
Munchen, Bavaria, 1st edition, 2003.
[20] H. Schunemann and N. Willich, “Lymphedema after breast
carcinoma. A study of 5868 cases,” Dtsch Med Wochenschr, vol.
122, no. 17, pp. 536–541, 1997.
[21] J. I. Goldberg, E. R. Riedel, M. Morrow, and K. J. Van Zee, “Mor-
bidity of sentinel node biopsy: relationship between number of
excised lymph nodes and patient perceptions of lymphedema,”
Annals of Surgical Oncology, vol. 18, no. 10, pp. 2866–2872, 2011.
[22] R. Clark, T. Wasilewska, and J. Carter, “Lymphoedema: a study
of Otago women treated for breast cancer,” Nursing Praxis in
New Zealand Inc, vol. 12, no. 2, pp. 4–15, 1997.
[23] E. D. Paskett and N. Stark, “Lymphedema: knowledge, treat-
ment, and impact among breast cancer survivors,” Breast
Journal, vol. 6, no. 6, pp. 373–378, 2000.
[24] C. J. Moffatt, P. J. Franks, D. C. Doherty et al., “Lymphedema:
an underestimated health problem,” QJM, vol. 96, pp. 731–738,
2003.
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