Lymphoedema occurs in about 16 per cent of people after breast cancer. According to the recommendations of the International Society of Lymphology (ISL), lymphoedema needs to be treated with decongestive lymphatic therapy (DLT), which consists of skin care, manual lymph drainage (MLD), compression therapy and exercise therapy. However, the value of the MLD as a component in this regimen is uncertain. A Cochrane systematic review with six randomised trials did not demonstrate any added value from MLD. Recently, the results of a randomised controlled, three-group trial (conducted in UH Leuven, UH Ghent, Antwerp UH, CHU UCL St.—Pierre and GH Groeninge; Belgium) have been published, supporting these previous findings.
A small Q&A with the study team!
What was already known on this topic: For decades, manual lymph drainage has been widely used to treat breast cancer-related lymphoedema but its effectiveness remains unclear. Recently, manual lymph drainage has been optimised by making it patient-tailored using fluoroscopy.
What this study adds: In patients with chronic breast cancer-related lymphoedema, manual lymph drainage did not provide any clinically important additional benefits when added to other components of decongestive lymphatic therapy
- What type of patients were enrolled in your trial?
Only patients with chronic (at least 3 months) breast cancer-related unilateral hand and/or arm lymphoedema (ISL stages I up to IIb, with signs of pitting) were included for this trial.
- What interventions did all participants receive and what were the randomised interventions?
All participants were treated with DLT consisting of skin care, compression therapy (multilayer bandaging followed by a compression sleeve and hand glove), exercises under compression and education regarding self-management. The only treatment modality that differed among the three groups was the type of MLD added. Patients were either randomized to a fluoroscopy-guided MLD group (in which the draining techniques were patient-specific and based on findings of a fluoroscopic investigation), a traditional MLD group or a placebo MLD group.
All participants received 14 treatment sessions during the 3-week intensive treatment period. Each intensive treatment session lasted for 60 minutes: 30 minutes of standard treatment (skin care, bandaging, exercises) and 30 minutes of MLD. Treatment started with drainage of the shoulder and trunk, followed by removal of the bandage and circumference measurements of the arm using a perimeter. Afterwards, drainage of the arm (and hand), shoulder and trunk was continued. After MLD, skin care and bandaging were applied and the session ended with exercises.
During the subsequent 6-month maintenance period, participants received 18 sessions in decreasing frequency from two sessions per week initially down to one session per month during months 5 and 6. In the maintenance phase, therapeutic sessions lasted for 30 minutes because they only consisted of skin care and MLD. Additionally, participants performed exercises at home and wore the compression sleeve and glove during the day.
- What outcomes did you measure and over what period?
The primary outcomes of this trial were reduction in excess volume of the arm/hand and accumulation of excess volume at the shoulder/trunk, with the end of the intensive phase as the primary endpoint. Secondary outcomes included daily functioning, quality of life, erysipelas and treatment satisfaction. All outcomes were measured at baseline; after the intensive phase; after 1, 3 and 6 months of maintenance phase; and after 6 months of follow-up.
- Were any worthwhile effects of the manual lymphatic drainage (either with or without the fluoroscopy guidance) identified in the study?
The findings of this trial support the conclusions of systematic reviews and meta-analyses that the added value of MLD (compared with placebo/no MLD) to the other modalities of DLT for the treatment of BCRL is rather limited. Moreover, traditional MLD and fluoroscopy-guided MLD as adjuncts to DLT were not superior to placebo MLD in reducing arm/hand volume or fluid accumulation at the level of the shoulder/trunk in patients with chronic BCRL.
- What could physiotherapists offer these patients if, as you recommend, they cease offering manual lymphatic drainage?
In patients with chronic breast cancer-related lymphoedema, MLD does not provide any clinically important additional benefits on volume reduction when added to other components of DLT. However, it is crucial to still offer proper treatment and management of the oedema in these patients. Therefore, during the treatment sessions, more time should be spent on other evidence-based treatment options such as compression therapy and exercise therapy, together with a great emphasis on evaluation, education and self-management.
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Tessa De Vrieze