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Common conservative treatments for lymphoedema post breast cancer: A focus article

Abstract

Breast cancer is the most common type of cancer in women worldwide (J. Ferley et al., 2015). Breast cancer-related lymphoedema (BCRL) is a disabling complication with a long term impact on quality on life after breast cancer treatment, with an incidence of 2–5% in patients post sentinel node procedures (M. King et al., 2012) up to 40% following axillary lymph node dissection (A.C. Pereira et al., 2017). BCRL results in swelling of the arm, hand, and trunk which can lead to limb pain, heaviness, and altered sensation (Y.J. Sim et al., 2010). These symptoms can result in functional limitations, psychosocial distress and an overall reduction in quality of life (S.J. Merchant et al., 2015). The aim of this review is to evaluate the effects of some of the more common conservative rehabilitation interventions in BCRL. Conservative interventions reviewed include early physiotherapy and exercise, complex decongestive therapy, manual lymphatic drainage, compression, electrotherapy & acupuncture, self-treatment & weight management. The review may inform policies for treatment within the health service.

1Breast cancer related lymphoedema

Breast cancer related lymphoedema (BCRL) is one of the most commonly reported complications of treatment for the estimated 2 million breast cancer cases worldwide annually [6–8] with an incidence of 17% [9].

BCRL occurs due to partial or total destruction of the lymphatic system. Risk factors include post-surgery radiotherapy, infection/cellulitis [9] and a high body-mass index > 25 [10]. Conservative sentinel lymph node procedures reduce the risk of BCRL to 2–5% [2, 11, 12] compared to more invasive procedures [13].

BCRL results in swelling of the arm, hand, and trunk which can lead to limb pain, heaviness, and altered sensation [4] resulting in functional limitations and psychological distress [5]. It increases the risk of cellulitis and hospitalisation [14]. It is therefore important to have safe, effective and evidence based treatment options [15].

2Common treatment strategies

With diagnosis of BCRL based on either a 10% greater affected limb volume/2cm greater circumferential measurements [10, 14, 16, 17], a range of conservative treatments are commonly prescribed by health professionals to treat BCRL. The aim of the BCRL treatment is to alleviate symptoms, prevent progression and reduce risk of skin infection [18].

3Early physiotherapy and exercise

Patients should complete physiotherapy programmes+/resistance training as it reduces the rates of incidence [19, 20] and exacerbation [20] of lymphoedema and also reduces volume [21–23], while also resulting in increased Quality of life [21, 22].

4Complex decongestive therapy

Complex decongestive therapy (CDT) consists of manual lymphatic drainage, bandaging, compression, skin care, remedial exercises and patient education [24]. It is considered the standard treatment technique to control and even reduce the lymphoedema volume and symptoms, preserve skin integrity and improve limb function [25]. Phase 1 is intensive treatment to reduce swelling; Phase 2 (maintenance phase) maintains the reduced swelling, with compression usually in the form of hosiery (compression sleeve) [10, 24–27].

A systematic review found strong evidence that CDT is an effective way to treat various degrees of lymphoedema from mild to severe; early or late onset; recent or chronic; in patients with active cancer; and in palliative care situations, also improving overall quality of life (QOL) [28].

A Cochrane review [25] found that MLD is safe and may offer additional benefit to compression bandaging for swelling reduction.

Compression sleeves should be worn by patients to prevent sub-clinical lymphoedema (determined using bio-impedance spectroscopy) developing into chronic lymphoedema [29, 30]. Patients who adhere to wearing the compression sleeve in the maintenance phase have the lowest risk for regaining oedema volume [27]. Compression bandaging resulted in greater median volume reductions than compression garments in the intensive phase of treatment [2, 31]. A recent review [32] described how bandaging pressures in the range of 20–30 mg Hg seem to be effective in the treatment of arm lymphoedema.

Adjustable compression systems (ACS) were found to be effective for the reduction of excess lymphoedema volume [33, 34] and can be used in the intensive and maintenance phase of treatment [32]. Patients reported that the device was more practical and more comfortable compared to compression bandaging [34]. Unlike standard compression which lose pressure over time, patients can adjust the ACS to maintain optimal pressure [32].

Pneumatic compression lacks the ability to be a standalone therapy [27, 35] as it only stimulates the lymphatic drainage in working/intact lymphatic collectors. When combined with CDT it reduced oedema, and pain [35].

5Acupuncture & electrotherapy

A systematic review and meta-analysis [36] found low level evidence that acupuncture alleviated upper limb swelling and pain post BCRL.

Low-level laser therapy was found to be effective for the management of BCRL in terms of volume reduction [37–39]. Extracorporeal shockwave therapy (ESWT) was also found to be effective for lymphoedema volume reduction both post treatment [40, 41] and at 6 month follow-up [41].

6Self-treatment including weight loss

Life-long self-management is necessary to control lymphoedema and is essential for achieving and maintaining successful treatment, as the damage to the lymphatic system is permanent [10, 42]. This includes compression arm sleeves worn daily, practicing good skin care, self- lymphatic massage and exercise, avoiding injury/ trauma to the affected area; elevating the affected area to reduce swelling; monitoring the affected area for changes in size, colour, and/or temperature [10, 14, 43]. Establishing routines, taking ownership of [44], and greater knowledge of lymphoedema [43] help improve control of lymphoedema and adherence to self-management.

Patients with “at-risk” arms post breast cancer treatment should be advised to avoid weight gain and to avoid infection as these are the only two proven risk factors for BCRL in this patient group [45]. There is a significant correlation between weight loss and reduction in excess arm volume in women with BCRL [46], and may have additional health benefits [47].

7Kinesiotape (KT)

A systematic review [48] found kinesiotape effective for improving range of motion, strength, and QOL, as well as reducing pain, disability and oedema, improved treatment retention effect at 3 months [49] and is more cost-effective [50] although volume reduction is not as effective as MLD and compression [48, 51, 52]. However, it can be used in alternation to, or provide an alternative treatment strategy for women who have contra-indications to, or are non-compliant with traditional lymphoedema treatment, [15, 48, 53] or in hot and humid conditions when bandages may be uncomfortable [54]. It should still be used with great caution as it results in skin complications in 10–21% of patients [15].

8Conclusion

All BCRL patients should receive MLD in addition to compression bandaging. Adjustable compression wraps provide an interesting alternative to multilayer bandaging and may allow for increased self- management in BCRL.

Progressive resistance training intervention should be included in each patient’s initial treatment, education and self-management programme as it almost halves the odds of BCRL incidence/exacerbation. Acupuncture, LLLT, and ESWT all show promising results in the treatment of BCRL and give alternative treatment options. Kinesiotaping is another option for use in clinical practice, yet should be used with caution. Self-treatment remains a key treatment strategy and patients should be advised to avoid weight gain and infection. With the advent of Covid-19, and restrictions in outpatient appointments, self-management and treatment adjuncts that allow self-treatment become even more important.

It would be hoped that going forward, patients are exposed to the best possible treatment from the earliest possible stage. This would include patients being screened for sub-clinical lymphoedema, who can then receive compression-garments [30]. Patients receiving early physiotherapy and progressive resistance exercise also have seen a reduction in the incidence of lymphoedema [19, 21]. With accurate early diagnosis and effective therapy now available this should be able to shift the focus of lymphoedema treatment to a more proactive rather than reactive approach [10].

References

[1] 

Ferlay J , Soerjomataram I , Dikshit R , Eser S , Mathers C , Rebelo M , Parkin DM , Forman D , Bray F . Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN2012. International Journal of Cancer. 2015;136(5):E359–86.

[2] 

King M , Deveaux A , White H , Rayson D . Compression garments versus compression bandaging in decongestive lymphatic therapy for breast cancer-related lymphedema: a randomized controlled trial. Supportive Care in Cancer. 2012;20(5):1031–6.

[3] 

Pereira AC , Koifman RJ , Bergmann A . Incidence and risk factors of lymphedema after breast cancer treatment: 10 years of follow-up. The Breast. 2017;36:67–73.

[4] 

Sim YJ , Jeong HJ , Kim GC . Effect of active resistive exercise on breast cancer–related lymphedema: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation. 2010;91(12):1844–8.

[5] 

Merchant SJ , Chen SL . Prevention and management of lymphedema after breast cancer treatment. The Breast Journal. 2015;21(3):276–84.

[6] 

Soran A , D’Angelo G , Begovic M , Ardic F , Harlak A , Samuel Wieand H , Vogel VG , Johnson RR . Breast cancer-related lymphedema–what are the significant predictors and how they affect the severity of lymphedema? The Breast Journal. 2006;12(6):536–43.

[7] 

Bray F , Ferlay J , Soerjomataram I , Siegel RL , Torre LA , Jemal A . Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: A Cancer Journal for Clinicians. 2018;68(6):394–424.

[8] 

De Vrieze T , Nevelsteen I , Thomis S , De Groef A , Tjalma WA , Gebruers N , Devoogdt N . What are the economic burden and costs associated with the treatment of breast cancer-related lymphoedema? A systematic review. Supportive Care in Cancer. 2020:1-1.

[9] 

DiSipio T , Rye S , Newman B , Hayes S . Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis. The Lancet Oncology. 2013;14(6):500–15.

[10] 

Executive Committee. The diagnosis and treatment of peripheral lymphedema: 2016 consensus document of the International Society of Lymphology. Lymphology. 2016;49(4):170–84.

[11] 

Mansel RE , Fallowfield L , Kissin M , Goyal A , Newcombe RG , Dixon JM , Yiangou C , Horgan K , Bundred N , Monypenny I , England D . Randomized multicenter trial of sentinel node biopsy versus standard axillary treatment in operable breast cancer: the ALMANAC Trial. Journal of the National Cancer Institute. 2006;98(9):599–609.

[12] 

Lucci A , McCall LM , Beitsch PD , Whitworth PW , Reintgen DS , Blumencranz PW , Leitch AM , Saha S , Hunt KK , Giuliano AE . Surgical complications associated with sentinel lymph node dissection (SLND) plus axillary lymph node dissection compared with SLND alone in the American College of Surgeons Oncology Group Trial Z0011. Journal of Clinical Oncology. 2007;25(24):3657–63.

[13] 

Deutsch M , Land S , Begovic M , Sharif S . The incidence of arm edema in women with breast cancer randomized on the National Surgical Adjuvant Breast and Bowel Project study B-04 to radical mastectomy versus total mastectomy and radiotherapy versus total mastectomy alone. International Journal of Radiation Oncology* Biology* Physics. 2008;70(4):1020–4.

[14] 

Framework L . Best practice for the management of lymphoedema. International consensus. London: MEP Ltd. 2006:3-52.

[15] 

Gatt M , Willis S , Leuschner S . A meta-analysis of the effectiveness and safety of kinesiology taping in the management of cancer-related lymphoedema. European Journal of Cancer Care. 2017;26(5):e12510.

[16] 

Hidding JT , Viehoff PB , Beurskens CH , van Laarhoven HW , Nijhuis-van der Sanden MW , van der Wees PJ . Measurement properties of instruments for measuring of lymphedema: systematic review. Physical Therapy. 2016;96(12):1965–81.

[17] 

Shah C , Vicini FA , Arthur D . Bioimpedance spectroscopy for breast cancer related lymphedema assessment: clinical practice guidelines. The Breast Journal. 2016;22(6):645–50.

[18] 

Finnane A , Janda M , Hayes SC . Review of the evidence of lymphedema treatment effect. American Journal of Physical Medicine & Rehabilitation. 2015;94(6):483–98.

[19] 

Lacomba MT , Sánchez MJ , Goñi ÁZ , Merino DP , del Moral OM , Téllez EC , Mogollón EM . Effectiveness of early physiotherapy to prevent lymphoedema after surgery for breast cancer: randomised, single blinded, clinical trial. Bmj. 2010;340:b5396.

[20] 

Cheema BS , Kilbreath SL , Fahey PP , Delaney GP , Atlantis E . Safety and efficacy of progressive resistance training in breast cancer: a systematic review and meta-analysis. Breast Cancer Research and Treatment. 2014;148(2):249–68.

[21] 

Cho Y , Do J , Jung S , Kwon O , Jeon JY . Effects of a physical therapy program combined with manual lymphatic drainage on shoulder function, quality of life, lymphedema incidence, and pain in breast cancer patients with axillary web syndrome following axillary dissection. Supportive Care in Cancer. 2016;24(5):2047–57.

[22] 

Romesberg M , Tucker A , Kuzminski K , Tremback-Ball A . The Effects of Resistance Exercises on Secondary Lymphedema Due to Treatment of Breast Cancer: A Review of Current Literature. Journal of Women’s Health Physical Therapy. 2017;41(2):91–99.

[23] 

Möller UO , Beck I , Ryden L , Malmström M . A comprehensive approach to rehabilitation interventions following breast cancer treatment-a systematic review of systematic reviews. BMC Cancer. 2019;19(1):472.

[24] 

Sezgin Ozcan D , Dalyan M , Unsal Delialioglu S , Duzlu U , Polat CS , Koseoglu BF . Complex decongestive therapy enhances upper limb functions in patients with breast cancer-related lymphedema. Lymphatic Research and Biology. 2018;16(5):446–52.

[25] 

Ezzo J , Manheimer E , McNeely ML , Howell DM , Weiss R , Johansson KI , Bao T , Bily L , Tuppo CM , Williams AF , Karadibak D . Manual lymphatic drainage for lymphedema following breast cancer treatment. Cochrane Database of Systematic Reviews. 2015(5).

[26] 

Douglass J , Graves P , Gordon S . Self-care for management of secondary lymphedema: a systematic review. PLoS Neglected Tropical Diseases. 2016;10(6):e0004740.

[27] 

Rogan S , Taeymans J , Luginbuehl H , Aebi M , Mahnig S , Gebruers N . Therapy modalities to reduce lymphoedema in female breast cancer patients: a systematic review and meta-analysis. Breast Cancer Research and Treatment. 2016;159(1):1–4.

[28] 

Lasinski BB , Thrift KM , Squire D , Austin MK , Smith KM , Wanchai A , Green JM , Stewart BR , Cormier JN , Armer JM . A systematic review of the evidence for complete decongestive therapy in the treatment of lymphedema from 2004 to 2011. PM&R. 2012;4(8):580–601.

[29] 

Soran A , Ozmen T , McGuire KP , Diego EJ , McAuliffe PF , Bonaventura M , Ahrendt GM , DeGore L , Johnson R . The importance of detection of subclinical lymphedema for the prevention of breast cancer-related clinical lymphedema after axillary lymph node dissection; a prospective observational study. Lymphatic Research and Biology. 2014;12(4):289–94.

[30] 

Kaufman DI , Shah C , Vicini FA , Rizzi M . Utilization of bioimpedance spectroscopy in the prevention of chronic breast cancer-related lymphedema. Breast Cancer Research and Treatment. 2017;166(3):809–15.

[31] 

Karafa M , Karafova A , Szuba A . The effect of different compression pressure in therapy of secondary upper extremity lymphedema in women after breast cancer surgery. Lymphology. 2018;51(1):28–37.

[32] 

Badger CM , Peacock JL , Mortimer PS . A randomized, controlled, parallel-group clinical trial comparing multilayer bandaging followed by hosiery versus hosiery alone in the treatment of patients with lymphedema of the limb. Cancer. 2000;88(12):2832–7.

[33] 

Mosti G , Cavezzi A . Compression therapy in lymphedema: Between past and recent scientific data. Phlebology. 2019;34(8):515–22.

[34] 

Pujol-Blaya V , Salinas-Huertas S , Catasús ML , Pascual T , Belmonte R . Effectiveness of a precast adjustable compression system compared to multilayered compression bandages in the treatment of breast cancer–related lymphoedema: a randomized, single-blind clinical trial. Clinical Rehabilitation. 2019;33(4):631–41.

[35] 

Campanholi LL , Lopes GC , Mansani FP , Bergmann A , Baiocch JM . The validity of an adjustable compression Velcro wrap for the treatment of patients with upper limb lymphedema secondary to breast cancer: a pilot study. Mastology. 2017;27:206–12.

[36] 

Keswani S , Kalra S , Kanupriya HK . Utilizing Complete Decongestive Therapy and Pneumatic Compression on Patients with Breast Carcinoma for Treatment of Postoperative Arm Lymphedema–A Review. Executive Editor. Journal of Physiotherapy & Occupational Therapy. 2019;13(1):66.

[37] 

Hou W , Pei L , Song Y , Wu J , Geng H , Chen L , Wang Y , Hu Y , Zhou J , Sun J . Acupuncture therapy for breast cancer-related lymphedema: A systematic review and meta-analysis. Journal of Obstetrics and Gynaecology Research. 2019;45(12):2307–17.

[38] 

Omar MT , Shaheen AA , Zafar H . A systematic review of the effect of low-level laser therapy in the management of breast cancer-related lymphedema. Supportive Care in Cancer. 2012;20(11):2977–84.

[39] 

Moseley AL , Carati CJ , Piller NB . A systematic review of common conservative therapies for arm lymphoedema secondary to breast cancer treatment. Annals of Oncology. 2007;18(4):639–46.

[40] 

Baxter GD , Liu L , Petrich S , Gisselman AS , Chapple C , Anders JJ , Tumilty S . Low level laser therapy (Photobiomodulation therapy) for breast cancer-related lymphedema: a systematic review. BMC Cancer. 2017;17(1):833.

[41] 

El-Shazly M , Borhan WH , Thabet WN , Hassan A . Response of post-mastectomy lymphedema to Extracrorporeal Shockwave Therapy. J Surg. 2016;4(3-1):14–20.

[42] 

Cebicci MA , Sutbeyaz ST , Goksu SS , Hocaoglu S , Oguz A , Atilabey A . Extracorporeal shock wave therapy for breast cancer–related lymphedema: a pilot study. Archives of Physical Medicine and Rehabilitation. 2016;97(9):1520–5.

[43] 

Temur K , Kapucu S . The effectiveness of lymphedema self-management in the prevention of breast cancer-related lymphedema and quality of life: A randomized controlled trial. European Journal of Oncology Nursing. 2019;40:22–35.

[44] 

Alcorso J , Sherman KA , Koelmeyer L , Mackie H , Boyages J . Psychosocial factors associated with adherence for self-management behaviors in women with breast cancer-related lymphedema. Supportive Care in Cancer. 2016;24(1):139–46.

[45] 

Jeffs E , Ream E , Shewbridge A , Cowan-Dickie S , Crawshaw D , Huit M , Wiseman T . Exploring patient perception of success and benefit in self-management of breast cancer-related arm lymphoedema. European Journal of Oncology Nursing. 2016;20:173–83.

[46] 

Ferguson CM , Swaroop MN , Horick N , Skolny MN , Miller CL , Jammallo LS , Brunelle C , O’Toole JA , Salama L , Specht MC , Taghian AG . Impact of ipsilateral blood draws, injections, blood pressure measurements, and air travel on the risk of lymphedema for patients treated for breast cancer. Journal of Clinical Oncology. 2016;34(7):691.

[47] 

Shaw C , Mortimer P , Judd PA . A randomized controlled trial of weight reduction as a treatment for breast cancer-related lymphedema. Cancer. 2007;110(8):1868–74.

[48] 

McNeely ML , Peddle CJ , Yurick JL , Dayes IS , Mackey JR . Conservative and dietary interventions for cancer-related lymphedema: a systematic review and meta-analysis. Cancer. 2011;117(6):1136–48.

[49] 

Tremback-Ball A , Harding R , Heffner K , Zimmerman A . The Efficacy of Kinesiology Taping in the Treatment of Women With Post–Mastectomy Lymphedema: A Systematic Review. Journal of Women’s Health Physical Therapy. 2018;42(2):94–103.

[50] 

Pekyavaş NÖ , Tunay VB , Akbayrak T , Kaya S , Karataş M . Complex decongestive therapy and taping for patients with postmastectomy lymphedema: a randomized controlled study. European Journal of Oncology Nursing. 2014;18(6):585–90.

[51] 

Melgaard D . What is the effect of treating secondary lymphedema after breast cancer with complete decongestive physiotherapy when the bandage is replaced with Kinesio Textape?–A pilot study. Physiotherapy Theory and Practice. 2016;32(6):446–51.

[52] 

Kasawara KT , Mapa JM , Ferreira V , Added MA , Shiwa SR , Carvas N Jr , Batista PA . Effects of Kinesio Taping on breast cancer-related lymphedema: A meta-analysis in clinical trials. Physiotherapy Theory and Practice. 2018;34(5):337–45.

[53] 

Tsai HJ , Hung HC , Yang JL , Huang CS , Tsauo JY . Could Kinesio tape replace the bandage in decongestive lymphatic therapy for breast-cancer-related lymphedema? A pilot study. Supportive Care in Cancer. 2009;17(11):1353.

[54] 

Pyszora A , Krajnik M . Is Kinesio Taping useful for advanced cancer lymphoedema treatment? A case report. Advances in Palliative Medicine. 2010;9(4):141–4.

[55] 

Bosman J . Lymphtaping for lymphoedema: an overview of the treatment and its uses. British Journal of Community Nursing. 2014;19(Sup4):S12–8.