Objective: To evaluate the impact of ALND and SLNB on upper limb (UL) morbidity in breast
cancer patients.
Summary Background: Axillary de-escalation is motivated by a desire to reduce harm of
ALND. Understanding the impact of axillary surgery and disparities in operative procedures
on post-operative arm morbidity would better direct resources to the point of need and cement
the need for de-escalation strategies.
Methods: Embase, Medline, CINAHL and PsychINFO were searched from 1990 until March
2020. Included studies were randomized-controlled and observational studies focusing on UL
morbidities, in breast surgery patients. The study followed the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The prevalence of upper limb
morbidity comparing SLNB and ALND at less than 12 months, 12-24 months and beyond 24
months were analyzed.
Results: Sixty-seven studies were included. All studies reported a higher rate of lymphedema
and pain after ALND compared to SLNB. The difference in lymphedema and pain prevalence
between SLNB and ALND was 13.7% (95% CI 10.5-16.8, p<0.005) and 24.2% (95% CI 12.1-
36.3, p<0.005) respectively. Pooled estimates for prevalence of reduced strength and range
of motion after SLNB and ALND were 15.2% vs 30.9% and 17.1% vs 29.8% respectively.
Type of axillary surgery, greater BMI, and radiotherapy were some of the predictors for UL
morbidities.
Conclusions: Prevalence of lymphedema after ALND was higher than previously estimated.
ALND patients experienced greater rates of lymphedema, pain, reduced strength, and ROM
compared to SLNB. The findings support the continued drive to de-escalate axillary surgery.