The impact of arm lymphedema on healthcare utilization during long-term breast cancer survivorship: a population-based cohort study

Abstract

Purpose: Cancer treatment-related late effects degrade survivors' quality of life, independence, and societal integration, yet may be ameliorated, or even reversed, with effective care. Unfortunately, survivors inconsistently receive this care and the impact on their healthcare utilization is unknown. We sought to estimate differences in utilization between breast cancer (BC) survivors with and without upper extremity lymphedema; a common, remediable late effect.

Methods: We conducted a population-based, retrospective longitudinal cohort study of survivors with incident BC diagnosed from January 1, 1990, through December 31, 2010. HC utilization was characterized using the Berenson-Eggers Type of Service (BETOS) categories. Outcomes included overall healthcare utilization as well as its compartmentalization into the BETOS categories of (1) Evaluation and management, (2) Procedures, (3) Imaging, (4) Tests, (5) Durable medical equipment, (6) Physical/occupational therapy, (7) Other, and (8) Exceptions/Unclassified.

Results: The cohort included 1906 subjects of which 94% (1800) had records meeting the inclusion criteria. Mean follow-up per survivor was 12.8 years (mean, 11, range 1-25 years). Analysis revealed that (1) survivors with BC-associated lymphedema used > 30% more services annually; (2) their increased utilization lessened but persisted for at least 10 years after diagnosis; and (3) this finding of increased utilization extends across all BETOS categories, is further amplified as BMI increases, and cannot be explained solely by lymphedema-directed care.

Conclusions: BC-related lymphedema appears to be an important driver of survivors' healthcare utilization and guideline-concordant activities to reduce its incidence and severity may be cost neutral or saving.

Implications for cancer survivors: Early detection and effective management of cancer-related late effects like lymphedema may reduce survivors' healthcare needs in the decades that follow their cancer treatment.

Keywords: Breast cancer; Cost; Healthcare utilization; Late effect; Lymphedema.

Fig. 1

Forest plot of the magnitude of the BCRL coefficient and related increased utilization in different BETOS categories

Fig. 2

The line graph plots BMI against total BETOS counts per year of survivorship. The parallel slopes of the BCRL(+) and BCRL(−) lines to the right and left of BMI = 22 indicate the absences of an interaction between BMI and BCRL status. The dotted lines represent the confidence interval for the BCRL(−) line