Physical and Psychological Morbidity After Axillary Lymph Node Dissection for Breast Cancer By Thomas F. Hack, Lorenzo Cohen, Joel Katz, Lynda S. Robson, and Paul Goss Purpose: Alternativesto axillary lymph node dissec- tion (ALND) are being developed amid controversy sur- rounding the therapeutic benefit and overall utility of thisroutine surgical procedure. Although potential nega- tive side effects associated with ALND are known, we set out to examine w hether these side effects contribute significantly to patient reports of quality of life and mental health. Patients and Methods: We surveyed 222 women who had received an ALND as part of breast cancer surgery. All women underwent a physical therapy as- sessment of range of arm/ shoulder motion and com- pleted the Modified Post-operative Pain Questionnaire, the Pain Disability Index, the McGill Pain Questionnaire (short form), the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, and the Mental Health Inventory. Results: Seventy-two percent of the women experi- enced arm/ shoulder pain, weakness, or numbness in the week before the interview, and range of motion of the affected arm/ shoulder w as impaired in 73% of the women. Severity of pain was reported to be low to moderate, and younger patients experienced greater pain than older patients. Pain severity correlated posi- tively with the number of lymph nodes removed and receipt of chemotherapy and was not significantly re- lated to length of time since surgery or receipt of radiation therapy. Generally high levels of cancer- specificquality of life and mental health w ere reported. Quality of life was significantly predicted by the McGill Pain Questionnaire, and mental health w as signifi- cantly predicted by the Pain Disability Index and the physical therapy assessment. Conclusion: Surgery-related symptoms after ALND persist for a majority of w omen w ith breast cancer and are not significantly related to time since surgery or receipt of radiation therapy. These symptoms and asso- ciated disability are significantly predictive of cancer- specificquality of life and mental health. JClin Oncol 17:143-149.  1999 by American Society of Clinical Oncology. L IKE THE SIZE OF THE primary tumor, axillary lymph node dissection (ALND) is a valued staging and prognostic aid in the treatment of breast cancer. 1 The presence of cancer cells in the axilla indicates that cancer has spread beyond the breast, thereby worsening prognosis. Some clinicians view negative nodes in premenopausal women with small primary tumors as an indication that adjuvant chemotherapy is unnecessary and therefore spare patients the associated negative side effects of chemother- apy. Until recently, there has been no clear alternative to ALND. The impetus to establish a surgical alternative arose out of the ongoing debate over the therapeutic value of ALND and the perceived usefulness of ALND in guiding the selection of adjuvant treatment. Advocates of ALND have maintained that the procedure may have therapeutic value and that total axillary lymphadenectomy provides more complete staging information and protection from locore- gional recurrence than partial axillary lymph node dissec- tion. 2 It is unclear, however, whether ALND provides any benefit beyond that of delaying locoregional recurrence 3 and whether the better survival rates that have been observed are attributable to the axillary clearance itself or to the adjuvant treatment that follows the dissection. 4 Given that a positive correlation has been observed between the size of the primary tumor and the presence of positive nodes in the axilla, it has been suggested that ALND be performed routinely only when the primary tumor is larger than 5 mm. 5 Those who believe there is no survival benefit associated with ALND have suggested that some premenopausal women with large primary tumors be spared any potentially damag- ing effects of ALND if adjuvant chemotherapy is to be given regardless of the outcome of the dissection. However, for reasons that include imperfect a priori knowledge of nodal status, the desire to avoid potentially severe side effects associated with chemotherapy, and the uncertainty surround- ing the therapeutic benefit of ALND, the dissection contin- ues to be performed routinely. Despite the staging and prognostic advantages of ALND, the potential negative long-term effects associated with this procedure include pain, 6-13 numbness, 6,8-10,12,13 swelling 8-10, From the University of Manitoba, Winnipeg, Manitoba; The Toronto Hospital and University of Toronto, Ontario; Institute for Work & Health, Toronto, Ontario; Princess Margaret Hospital, Toronto, On- tario, Canada; and M.D. Anderson Cancer Center, University of Texas, Houston, TX. Submitted April 24, 1998; accepted September 4, 1998. Supported by the Canadian Breast Cancer Foundation. Partial funding for L.C. was provided by the National Cancer Institute of Canada with funds from the Terry Fox Run. Address reprint requests to Thomas Hack, PhD, WCA, 12th Floor, 447 Portage Ave, Winnipeg, Manitoba, Canada R3B 3H5; Email thack@wca.mb.ca.  1999 by American Society of Clinical Oncology. 0732-183X/99/1701-0143$3.00/0 Journal of Clinical Oncology, Vol 17, No 1 (January), 1999: pp 143-149 143 Downloaded from jco.ascopubs.org on February 14, 2016. For personal use only. No other uses without permission. Copyright © 1999 American Society of Clinical Oncology. All rights reserved.