Conservative and dietary interventions for cancer‐related lymphedema

Abstract

The findings support the use of compression garments and compression bandaging for reducing lymphedema volume in upper and lower extremity cancer-related lymphedema. Specific to breast cancer, a statistically significant, clinically small beneficial effect was found from the addition of manual lymph drainage massage to compression therapy for upper extremity lymphedema volume. Cancer 2011;117:1136-48. V C 2010 American Cancer Society.KEYWORDS: cancer-related lymphedema, dietary interventions, conservative interventions, manual lymph drainage.Lymphedema remains a prevalent and potentially debilitating side effect of cancer treatment. Although data on the prevalence of lymphedema are limited, it is estimated that over 3 million people in the United States suffer from lymphedema, with a significant proportion developing the disease secondary to cancer and/or cancer treatment. 1 When treated conservatively in the earliest stages, complications of lymphedema may be diminished or reversed. 2 Unfortunately, lymphedema may progress to irreversible swelling and fibrosis requiring lifelong attention and management. 1,3,4 Thus, the impact of chronic lymphedema for the cancer survivor is often profound, resulting in significant psychosocial morbidity and poorer quality of life. 5,6 The effectiveness of conservative interventions for lymphedema has been assessed in several systematic reviews; however, these reviews have been limited in scope. 7,8 Kligman et al performed a systematic review of randomized controlled trials (RCTs) examining conservative and medical therapies for breast cancer related lymphedema. 7 This review included 10 studies examining both conservative (6 studies) and medical therapies (4 studies) for lymphedema. The authors reported positive findings from use of a compression garment, early evidence in support of pneumatic compression pumps, and conflicting/no evidence for medical therapies. Moseley et al performed a systematic review examining the effect of conservative therapies for breast cancer related lymphedema. 8 The review included 43 trials examining conservative and pharmacological interventions that included randomized and controlled clinical trials, as well as case control and cohort studies. In contrast to the Kligman review, the authors concluded that all conservative therapies produced improvements in upper extremity lymphedema volume, with more intensive therapies resulting in greater volume reductions. 8 It is known, however, that the inclusion of nonrandomized and uncontrolled trials may result in an overestimate of treatment effect 9 ; therefore, it is recommended that systematic reviews be limited to RCTs whenever possible. The aim of this systematic review was to update the evidence from RCTs concerning the benefits of conservative and dietary interventions for all cancer-related lymphedema.

The management of secondary lower limb lymphoedema in cancer patients: A systematic review

“…Moreover, previous systematic reviews only included conservative management of lymphoedema. [17][18][19] We also included a study on surgical management of LLL in this systematic review. 29 However, the included studies showed clinical heterogeneity and often included participants with LLL secondary to different aetiologies (Table 1 and Figure 2).…”

“…Finally, long-term outcomes of lymphoedema treatment have rarely been investigated. [17][18][19] In 2010, the Core Outcome Measures in Effectiveness Trials (COMET) initiative was launched to develop agreed standardised sets of outcomes to represent the minimum set that should be measured and reported in all randomised trials of a specific condition. 31 We believe core outcomes set should be developed for future trials of LLL.…”

“…1,3 Moreover, previous reports suggested that clinicians had often shown inadequate knowledge and lack of interest in the evidence-based management of lymphoedema, 15 particularly lymphoedema secondary to non-breast malignancies. [16][17][18][19] Standardised assessments of LLL exist (e.g. the International Society of Lymphology lymphoedema staging system 10 ) and are routinely used by specialist management units of lymphoedema.…”

“…10 However, the majority of interventional studies were performed on patients with upper limb lymphoedema secondary to breast cancer. [17][18][19] None of the previous systematic reviews have specifically evaluated the evidence available for the treatment of patients with non-infective secondary LLL. [16][17][18][19] This study systematically reviewed the current evidence for the treatment of patients with LLL secondary to malignancies and their treatment.…”

Clinical practice guidelines for breast cancer rehabilitation

“…Another recent RCT has shown that early physical therapy (manual lymph drainage, scar tissue massage, active and active-assisted shoulder range of motion exercises) was effective in preventing lymphedema during the first year after surgery, 70 and a 2011 meta-analysis reported a significant benefit of manual lymph drainage when added to compression therapy in treatment of breast cancer-related lymphedema. 71 A 2010 Cochrane review reported that structured exercise during the postoperative period had significant short-term benefits in improving shoulder flexion range of motion, with physical therapy resulting in additional benefits for shoulder function. 72 Certainly, the breadth and quality of research available since the upper extremity rehabilitation and lymphedema guidelines were published underscore the need for them to be updated and revised to incorporate this evidence.…”