No Preventive Manual — Lymphedema Related to Breast Cancer

Abstract & Commentary

By Russell H. Greenfield, MD, Editor

Synopsis: In a prospective study of women with breast cancer who had undergone axillary node dissection, use of manual lymphatic drainage techniques over 5 months provided no additional preventive benefit with respect to development of arm lymphedema over general preventive lifestyle measures and individualized exercise therapy.

Source: Devoogdt N, et al. Effect of manual lymph drainage in addition to guidelines and exercise therapy on arm lymphoedema related to breast cancer: Randomized controlled trial. BMJ 2011;343:d5326.

The belgian authors of this randomized, controlled, single-blind study point out at the onset that early detection and treatment of breast cancer have advanced to such a degree that increased emphasis is now being placed on the prevention and management of long-term side effects and complications of therapy, including lymphedema, for survivors. Toward this end, the researchers set their sights on determining whether a program of manual lymph drainage (MLD) combined with exercise therapy and general preventive guidelines might be more effective against the development of lymphedema related to breast cancer than the exercises + guidance alone.

Over approximately 2 years, 160 consecutive women who had undergone unilateral axillary node dissection in association with treatment for breast cancer were randomized to either active (MLD + exercise + guidance, n = 79) or control (exercise + guidance, n = 81) groups (337 women were asked to participate, 52% declined). Subjects were stratified based on BMI and whether post-surgical axillary radiation therapy was performed (two of the factors most commonly cited as increasing the risk for development of lymphedema, along with the number and levels of axillary nodes dissected). Treatment allocation was concealed, and the groups were comparable at baseline.

All subjects received a brochure and, if desired, tutorials regarding the prevention of lymphedema (guidelines included but were not limited to avoidance of lifting heavy objects and performing repetitive movements, wearing a therapeutic sleeve during air travel, and avoiding weight gain), and individualized exercise training beginning shortly after surgery. The frequency of exercise training sessions was dependent on improvements in limb range of motion, with less frequent sessions the farther a subject was out from surgery.

Starting approximately 5 weeks post-surgical intervention, subjects in the active group also received standardized MLD over 20 weeks, the goal being that each participant would receive a total of 40 MLD treatments, "...with an increase in frequency from once a week to three times a week, and then a decrease to once a week, to create a gradual adaptation of the lymph system and not to end too abruptly." The 1-hour treatments were described thus: "Firstly, lymph nodes of neck and axilla were emptied. Secondly, axilloaxillary anastomoses at the breast and back and lymphatics at the lateral side of the shoulder (Mascagni pathway) were stimulated. Thirdly, the arm and hand were drained from proximal to distal."

All interventions (MLD, exercise, and preventive guidelines) were provided by a group of four therapists, two of whom had more than 10 years' experience with MLD and who performed more than 70% of all the MLD treatments. Arm volume was determined using a volumeter by blinded assessors at 1, 3, 6, and 12 months post-surgery. Lymphedema was defined as an increase of 200 mL or more in the difference in arm volume between the affected and healthy side compared with the difference from presurgical measurements, and an increase of 2 cm or more in the difference in arm circumference between the affected and healthy side at two or more adjacent measurement points compared with the preoperative difference. Health-related quality of life (SF-36) was assessed at 3, 6, and 12 months after surgery. 

Four patients in the active group and two in the control group developed arm lymphedema before the start of the 20-week treatment period and were excluded from the final analysis. By the trial's end, 4% of participants had dropped out of the study (4 in the intervention group, 2 controls); 11 members of the active group (15%) had received 23-29 manual lymph drainage sessions, 26 had (36%) received 30-35 sessions, and 36 (49%) underwent > 35 sessions of MLD (reasons for absence were primarily illness related to chemotherapy and radiotherapy).

At 1 year post-op, participants in the active group had a cumulative incidence rate for arm lymphedema of 24% vs 19% in the control group (OR = 1.3, 95% CI 0.6 to 2.9; P = 0.45). Time to development of arm lymphedema was also comparable between the two groups (HR = 1.3, 0.6 to 2.5; P = 0.49), with similar cumulative incidences at 3 and 6 months post-surgery. Results remained consistent when controlled for risk factors such as BMI and axillary radiation therapy. Quality-of-life measures were similar between the two groups.

The researchers concluded that MLD in addition to lifestyle guidelines and individualized exercise therapy after axillary lymph node dissection for breast cancer is unlikely to have a significant beneficial effect in reducing the incidence of arm lymphedema in the short term.

Commentary

MLD remains an integral part of the treatment of established limb edema after cancer treatment, but the results of the current study suggest that it does not offer a preventive benefit for women having undergone axillary node dissection as part of the treatment for breast cancer. This is more than unfortunate, as arm lymphedema is recognized as a presently incurable problem that negatively impacts quality of life in many ways. In addition, those who have escaped arm edema for the year following axillary dissection are still at risk for developing the disorder (more than 20% of cases develop > 1 year following surgery).

MLD is purported to enhance resorption and transport of lymph through existing collaterals. Studies suggest it to be an effective treatment strategy, though researchers often fail to make mention of additional health benefits the technique may offer simply through the application of compassionate and healing touch.

The authors are to be commended for exploring preventive measures against the development of lymphedema secondary to treatment of breast cancer. It is true that their conclusion regarding lack of clinical benefit of MLD in this setting are weakened by the fact that two of the therapists providing care were not experts in the field, though they had received specialized training prior to the study; however, the majority of MLD was performed by the two experienced therapists, and most all of the women in the intervention group received more than 30 MLD sessions.

In light of recent data suggesting that even women with abnormal sentinel node biopsy results may not need to undergo axillary node dissection,1 it is likely that fewer women will be at risk for the development of this life-altering disorder (thankfully). This is welcome news, because an effective program of prevention against the development of arm edema has yet to be identified. MLD does not appear to be the answer.

References

1. Spiguel L, et al. Sentinel node biopsy alone for node-positive breast cancer: 12-year experience at a single institution. J Am Coll Surg 2011;213:122-128.