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Development and validation of a nomogram to predict the risk of breast cancer-related lymphedema among Chinese breast cancer survivors

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Abstract

Purpose

Breast cancer-related lymphedema (BCRL) is a major long-term complication for post-surgery breast cancer survivors. Although several risk factors have been identified, lifestyle characteristics have been neglected in previous studies. The aim of this study was to develop and validate a nomogram for estimating this population’s risk of developing lymphedema, taking into consideration their demographic, clinical, and personal lifestyle behaviors.

Methods

In a cross-sectional study, we collected data from 775 post-operative breast cancer survivors who had attended a follow-up session in the recent 10 years (primary cohort). Lymphedema was assessed using the Norman telephone questionnaire, self-reported by patients. Multiple logistic regression was used to identify risk factors for lymphedema, including demographic, clinical, and lifestyle-related factors. A nomogram was constructed based on those factors and was validated using a separate group of 314 breast cancer patients (validation cohort).

Results

The factors independently associated with lymphedema were higher body mass index (BMI), modified radical mastectomy (MRM), postsurgical infection, chemotherapy, radiotherapy, exercise of the affected arm, and the active participation in physical activity (P<0.05). The area under the curve (AUC) values of the primary and the validation cohorts were 0.721 (95% confidence interval: 0.685–0.756) and 0.702 (95% confidence interval: 0.646–0.759), respectively.

Conclusions

BCRL risk factors include MRM, radiotherapy, chemotherapy, and higher BMI, while the active physical activity behavior of patients appears to be a factor against lymphedema. The nomogram incorporating the patients’ clinical and lifestyle factors might be useful for predicting lymphedema in breast cancer survivors.

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Data Availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Code availability

The statistical analyses were conducted using STATA 15.0 for Mac (StataCorp Texas, USA) and R software version 3.4.1 (rms package; R Project, Vienna, Austria; http://www.Rproject.org).

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Acknowledgements

The authors thank all of the women who participated in the study and the following institutions for their assistance in collecting the data: Beijing Tiantan Hospital affiliated to Capital Medical University, Beijing Shijitan Hospital affiliated to Capital Medical University, Beijing Friendship Hospital affiliated to Capital Medical University, Cancer Rehabilitation Society of China Anti-Cancer Association, and the Fourth Affiliated Hospital of China Medical University.

Funding

This study was funded by the Beijing Natural Science Foundation (No: 7182015).

Author information

Authors and Affiliations

  1. School of Nursing, Capital Medical University, No. 10, Xitoutiao, You An Men Wai, Feng-Tai District, Beijing, China

    Yan-fei Liu, Jun-E Liu, Hui Qiu, Shen-shen Yang & Shao-hua Chen

  2. Hospice Palliative Care Alliance of China Foundation, 3200 Ridge Pike, P. O. Box 436, Eagleville, PA, 19403, USA

    Yi Zhu

  3. School of Nursing, Hong Kong Polytechnic University, Yuk Choi Road, Hung Hom, Kowloon, Hong Kong, China

    Yim Wah Mak

  4. Beijing Shijitan Hospital affiliated to Capital Medical University, Beijing, China

    Li-hui Liu

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  1. Yan-fei Liu
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Contributions

Conceptualization: Yi Zhu, Jun-E Liu, Hui Qiu, and Yan-fei Liu. Methodology: Yan-fei Liu, Jun-E Liu, Yim Wah Mak, and Yi Zhu. Data collection: Yan-fei Liu, Hui Qiu, Li-hui Liu, Shen-shen Yang, and Shao-hua Chen. Formal analysis and investigation: Yan-fei Liu, Hui Qiu, Shen-shen Yang, and Shao-hua Chen. Writing-original draft preparation: Yan-fei Liu and Jun-E Liu. Writing-review and editing: Yan-fei Liu, Jun-E Liu, and Yim Wah Mak. All authors read and approved the final manuscript.

Corresponding authors

Correspondence to Jun-E Liu or Yim Wah Mak.

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Ethics approval

Approval was obtained from the Medical Ethics Committee of Capital Medical University (Z2019SY022). The procedures used in this study adhere to the tenets of the Declaration of Helsinki.

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Informed consent was obtained from all of the participants in this study.

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Not applicable.

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The authors declare no competing interests.

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Liu, Yf., Liu, JE., Zhu, Y. et al. Development and validation of a nomogram to predict the risk of breast cancer-related lymphedema among Chinese breast cancer survivors. Support Care Cancer 29, 5435–5445 (2021). https://doi.org/10.1007/s00520-021-06122-y

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