Treatment related morbidity in breast cancer patients

Background: Sentinel lymph node biopsy (SLNB) was introduced for staging of the axilla to reduce the number of unnecessary axillary lymph node dissections (ALND’s) and proved to be an accurate and safe procedure to predict metastatic disease in clinically negative axillary lymph nodes. SLNB was expected to have less treatment related morbidity in comparison to ALND. In a multicenter prospective cohort study, long term upper-limb morbidity, perceived disabilities in activities of daily life (ADL) and quality of life (QOL) were assessed before and six weeks, 12 month and 24 month after SLNB or ALND for breast cancer. - \ud Methods: 204 patients with stage I/II breast cancer, mean age 55.6 years (sd: 11.6) entered the study and 181 patients (89%) could be evaluated after two years. Sixty-six patients (32%) underwent SLNB only, and 138 (68%) underwent a level I-II ALND. Reliable and valid assessment instruments were used for assessment of upper limb morbidity, ADL and QOL. Assessment included evaluation of shoulder range of motion, muscle strength, grip strength, pain, upper/forearm circumference, shoulder disability and activities of daily life (ADL) and Quality of Live. - \ud Results: Considerable treatment related upper-limb morbidity was observed. Significant (p<0.05) changes between before and up till two years after surgery were found in almost all assessments of shoulder function, ADL and several QOL subscales. Patients in the ALND group showed significant more changes in range of motion (ROM), grip strength, arm volume, ADL and QOL physical- and role functioning, pain and sleeplessness and arm symptoms compared to the SLNB group. Upper limb morbidity and associated disabilities in ADL are at worse in the early stage (first months) after surgical treatment. Concerning arm edema; in the ALND group arm volume increased significantly at 1 and 2 years follow up. Concerning QOL, significantly differences in mean change over the two years comparing SLNB with ALND were found for physical and role functioning and also for symptom items such as pain, insomnia (sleeplessness) and arm symptoms in favor of the SLNB group. QOL in the SLNB group was just improving in the 2 years after treatment whereas in de ALND group only emotional functioning and future perspective improved. Multivariate linear regression analysis showed that radiation therapy on the axilla is besides ALND an important factor in the prediction of impaired shoulder ROM and arm edema. Radiation therapy on the breast had no influence on shoulder ROM. - \ud Conclusion: 1. Significant treatment related short-term, middle-term and long-term upper limb morbidity and perceived disabilities in ADL and long-term reduction of QOL exist in breast cancer patients. 2. In the assessment of changes in upper limb function, ADL and QOL, ALND is the most frequent found predictor of deterioration. Additional radiation therapy on the axilla predicts a further decrease in shoulder ROM and arm edema. 3. Long-term upper limb morbidity is significantly correlated with disabilities in ADL and worsening of QOL