Rehabilitation interventions for the management of breast cancer–related lymphedema: developing a patient-centered, evidence-based plan of care throughout survivorship

Abstract

Purpose

A work group from the American Physical Therapy Association Academy of Oncologic Physical Therapy developed and published a clinical practice guideline (CPG) to aid clinicians in identifying interventions for individuals with breast cancer–related lymphedema (BCRL). This guideline reviewed the evidence for risk mitigation and volume reduction beginning at cancer diagnosis and continuing through survivorship. Application of CPGs can be challenging due to the variability of clinical settings, heterogeneous patient populations, and range of rehabilitation clinician expertise. The purpose of this paper is to assist these clinicians in implementing the recommendations from the CPG to develop a patient-centered, evidence-based plan of care.

Methods/results

This publication presents important considerations for the implementation of recommended rehabilitation interventions across the trajectory of BCRL.

Conclusion

Current evidence supports specific interventions to treat or mitigate the risk for the various stages of BCRL. As clinicians implement these recommendations into practice, they also need to address other impairments that may exist in every individual. Continued collaboration between clinicians and researchers is necessary to further develop optimal treatment modalities and parameters.

Implications for Cancer Survivors

By implementing evidence-based interventions as outlined in the CPG, clinicians can improve the quality of care for survivors of breast cancer.

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References

  1. 1.

    Ahmed RL, Prizment A, Lazovich D, Schmitz KH, Folsom AR. Lymphedema and quality of life in breast cancer survivors: the Iowa Women’s health study. J Clin Oncol. 2008;26:5689–96.

    PubMed  PubMed Central  Article  Google Scholar 

  2. 2.

    Davies CC, Levenhagen K, Ryans K, Perdomo M, Gilchrist L. Interventions for breast cancer-related lymphedema: clinical practice guideline from the academy of oncologic physical therapy of APTA. Phys Ther. 2020;100(7):1163–79.

    PubMed  PubMed Central  Article  Google Scholar 

  3. 3.

    Levenhagen K, Davies C, Perdomo M, Ryans K, Gilchrist L. Diagnosis of upper quadrant lymphedema secondary to cancer: clinical practice guideline from the oncology section of the American Physical Therapy Association. Phys Ther. 2017;97:729–45.

    PubMed  PubMed Central  Article  Google Scholar 

  4. 4.

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

    Google Scholar 

  5. 5.

    American Physical Therapy Association Clinical Practice Guideline Process Manual, Alexandria VA, Sackett DL. 2018 Evidence-based medicine. Semin Perintol. 1997;21(1):3–5.

    Article  Google Scholar 

  6. 6.

    Koelmeyer LA, Borotkanics RJ, Alcorso J, Prah P, Winch CJ, Nakhel K, et al. Early surveillance is associated with less incidence and severity of breast cancer-related lymphedema compared with a traditional referral model of care. Cancer. 2019;125(6):854–62.

    PubMed  Article  Google Scholar 

  7. 7.

    Soran A, Ozmen T, McGuire KP, et al. 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. Lymphat Res Biol. 2014;12:289–94.

    PubMed  PubMed Central  Article  Google Scholar 

  8. 8.

    Stout Gergich NL, Pfalzer LA, McGarvey C, Springer B, Gerber LH, Soballe P. Preoperative assessment enables the early diagnosis and successful treatment of lymphedema. Cancer. 2008;112(12):2809–19.

    PubMed  Article  Google Scholar 

  9. 9.

    Stout NL, Pfalzer LA, Springer B, Levy E, McGarvey CL, Danoff JV, et al. Breast cancer-related lymphedema: comparing direct costs of a prospective surveillance model and a traditional model of care. Phys Ther. 2012;92(1):152–63.

    PubMed  Article  Google Scholar 

  10. 10.

    Shah C, Vicini FA. Breast cancer-related arm lymphedema: incidence rates, diagnostic techniques, optimal management and risk reduction strategies. Int J Radiat Oncol Biol Phys. 2011;81(4):907–14.

    PubMed  Article  Google Scholar 

  11. 11.

    Lymphoedema Framework (2006) Best practice for the management of lymphoedema. International consensus London: MEP Ltd.

  12. 12.

    Armer JM, Hulett JM, Bernas M, et al. Best practice guidelines in assessment, risk reduction, management, and surveillance for post-breast cancer lymphedema. Curr Breast Cancer Rep. 2013;2:134–44.

    Article  Google Scholar 

  13. 13.

    Campbell KL, Winters-Stone KM, Wiskemann J, et al. Exercise guidelines for cancer survivors: consensus statement from international multidisciplinary roundtable. Med Sci Sports Exerc. 2019;51(11):2375–90. https://doi.org/10.1249/MSS.0000000000002116.

    Article  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Cohen SR, Payne DK, Tunkel RS. Lymphedema: strategies for management. Cancer. 2001;92(4 Suppl):980–7.

    CAS  PubMed  Article  Google Scholar 

  15. 15.

    Bendz I, Fagevik OM. Evaluation of immediate versus delayed shoulder exercises after breast cancer surgery including lymph node dissection a randomised controlled trial. Breast. 2002;11(3):241–8.

    CAS  PubMed  Article  Google Scholar 

  16. 16.

    Cormie P, Galvão DA, Spry N, Newton RU. Neither heavy nor light load resistance exercise acutely exacerbates lymphedema in breast cancer survivor. Integr Cancer Ther. 2013;12(5):423–32.

    PubMed  Article  Google Scholar 

  17. 17.

    Courneya KS, Segal RJ, Mackey JR, Gelmon K, Reid RD, Friedenreich CM, et al. Effects of aerobic and resistance exercise in breast cancer patients receiving adjuvant chemotherapy: a multicenter randomized controlled trial. J Clin Oncol. 2007;25(28):4396–404.

    PubMed  Article  Google Scholar 

  18. 18.

    Hayes SC, Reul-Hirche H, Turner J. Exercise and secondary lymphedema: safety, potential benefits, and research issues. Med Sci Sports Exerc. 2009;41(3):483–9.

    PubMed  Article  Google Scholar 

  19. 19.

    Tidhar D, Katz-Leurer M. Aqua lymphatic therapy in women who suffer from breast cancer treatment-related lymphedema: a randomized controlled study. Support Care Cancer. 2010;18(3):383–92.

    PubMed  Article  Google Scholar 

  20. 20.

    Bracha J, Katz-Leurer M. The immediate effect of upper arm exercise compared with lower or combined upper and lower arm exercise on arm volume reduction in women with breast cancer related lymphedema: a randomize preliminary study. Rehabil Oncol. 2012;30(3):3–8.

    Article  Google Scholar 

  21. 21.

    Sagen A, Kåresen R, Risberg MA. Physical activity for the affected limb and arm lymphedema after breast cancer surgery. A prospective, randomized controlled trial with two years follow-up. Acta Oncol. 2009;48(8):1102–10.

    PubMed  Article  Google Scholar 

  22. 22.

    Todd J, Scally A, Dodwell D, Horgan K, Topping A. A randomised controlled trial of two programmes of shoulder exercise following axillary node dissection for invasive breast cancer. Physiotherapy. 2008;94(4):265–73.

    Article  Google Scholar 

  23. 23.

    Kilbreath S, Refshauge KM, Beith J, Lee MJ. Resistance and stretching shoulder exercises early following axillary surgery for breast cancer. Rehabil Oncol. 2006;24(2):9–14.

    Article  Google Scholar 

  24. 24.

    Schmitz KH, Ahmed RL, Troxel A, Cheville A, Smith R, Lewis-Grant L, et al. Weight lifting in women with breast-cancer-related lymphedema. N Engl J Med. 2009;361(7):664–73.

    CAS  PubMed  Article  Google Scholar 

  25. 25.

    Schmitz KH, Ahmed RL, Troxel AB, Cheville A, Lewis-Grant L, Smith R, et al. Weight lifting for women at risk for breast cancer-related lymphedema: a randomized trial. JAMA. 2010;304(24):2699–705.

    CAS  PubMed  Article  Google Scholar 

  26. 26.

    Jonsson C, Johansson K. The effects of pole walking on arm lymphedema and cardiovascular fitness in women treated for breast cancer: a pilot and feasibility study. Physiother Theory Pract. 2014;30(4):236–42.

    PubMed  Article  Google Scholar 

  27. 27.

    Hayes SC, Rye S, Disipio T, et al. Exercise for health: a randomized, controlled trial evaluating the impact of a pragmatic, translational exercise intervention on the quality of life, function and treatment-related side effects following breast cancer. Breast Cancer Res Treat. 2013;137(1):175–86.

    PubMed  Article  Google Scholar 

  28. 28.

    Buchan J, Janda M, Box R, et al. A randomized trial on the effect of exercise mode on breast cancer-related lymphedema. Med Sci Sports Exerc. 2016;48(10):1866–74.

    CAS  PubMed  Article  Google Scholar 

  29. 29.

    Zhang X, Brown JC, Paskett ED, Zemel BS, Cheville AL, Schmitz KH. Changes in arm tissue composition with slowly-progressive weight-lifting among women with breast cancer-related lymphedema. Breast Cancer Res Treat. 2017;164(1):79–88.

    PubMed  PubMed Central  Article  Google Scholar 

  30. 30.

    Ammitzbøll G, Johansen C, Lanng C, Andersen EW, Kroman N, Zerahn B, et al. Progressive resistance training to prevent arm lymphedema in the first year after breast cancer surgery: results of a randomized controlled trial. Cancer. 2019;125(10):1683–92.

    PubMed  Article  Google Scholar 

  31. 31.

    Srivastava V, Basu S, Shukla VK. Seroma formation after breast cancer surgery: what we have learned in the last two decades. J Breast Cancer. 2012;15(4):373–80.

    PubMed  PubMed Central  Article  Google Scholar 

  32. 32.

    Ochalek KGT, Partsch H. Preventing early postoperative arm swelling and lymphedema manifestation by compression sleeves after axillary lymph node interventions in breast cancer patients: a randomized controlled trial. J Pain Symptom Manag. 2017;54(3):346–54.

    Article  Google Scholar 

  33. 33.

    Hopkins A. A community nursing guide: multilayer lymphoedema bandaging. Br J Community Nurs. 2008 Apr;13(4):S18–S20-4.

    PubMed  Article  Google Scholar 

  34. 34.

    Tambour M, Holt M, Speyer A, Christensen R, Gram B. Manual lymphatic drainage adds no further volume reduction to Complete Decongestive Therapy on breast cancer-related lymphoedema: a multicentre, randomised, single-blind trial. Br J Cancer. 2018;119(10):1215–22.

    PubMed  PubMed Central  Article  Google Scholar 

  35. 35.

    Mobarakeh ZS, Mokhtari-Hesari P, Lotfi-Tokaldany M, Montazeri A, Heidari M, Zekri F. Combined decongestive therapy and reduction of pain and heaviness in patients with breast cancer-related lymphedema. Support Care Cancer. 2019;27:3805–11. https://doi.org/10.1007/s00520-019-04681-9.

    Article  PubMed  Google Scholar 

  36. 36.

    Dayes IS, Whelan TJ, Julian JA, Parpia S, Pritchard KI, D'Souza DP, et al. Randomized trial of decongestive lymphatic therapy for the treatment of lymphedema in women with breast cancer. J Clin Oncol. 2013;31(30):3758–63.

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  37. 37.

    Ochalek K, Gradalski T, Szygula Z. Five-year assessment of maintenance combined physical therapy in postmastectomy lymphedema. Lymphat Res Biol. 2015;13(1):54–8.

    PubMed  Article  PubMed Central  Google Scholar 

  38. 38.

    Gradalski T, Ochalek K, Kurpiewska J. Complex decongestive lymphatic therapy with or without Vodder II manual lymph drainage in more severe chronic postmastectomy upper limb lymphedema: a randomized noninferiority prospective study. J Pain Symptom Manag. 2015;50(6):750–7.

    Article  Google Scholar 

  39. 39.

    Yang EJ, Ahn S, Kim EK, Kang E, Park Y, Lim JY, et al. Use of a prospective surveillance model to prevent breast cancer treatment-related lymphedema: a single-center experience. Breast Cancer Res Treat. 2016;160(2):269–76.

    PubMed  PubMed Central  Article  Google Scholar 

  40. 40.

    Johansson K, Tibe K, Weibull A, Newton RC. Low intensity resistance exercise for breast cancer patients with arm lymphedema with or without compression sleeve. Lymphology. 2005;38(4):167–80.

    CAS  PubMed  Google Scholar 

  41. 41.

    Singh B, Newton RU, Cormie P, et al. Effects of compression on lymphedema during resistance exercise in women with breast cancer-related lymphedema: a randomized cross-over trial. Lymphology. 2015;48(2):80–92.

    CAS  PubMed  Google Scholar 

  42. 42.

    Lai YT, Hsieh CC, Huang LS, Liu WS, Lin SH, Wang LL, et al. The effects of upper limb exercise through yoga on limb swelling in Chinese breast cancer survivors - a pilot study. Rehabil Nurs. 2017;42(1):46–54.

    PubMed  Article  Google Scholar 

  43. 43.

    Mazor M, Lee JQ, Peled A, Zerzan S, Irwin C, Chesney MA, et al. The effect of yoga on arm volume, strength, and range of motion in women at risk for breast cancer-related lymphedema. J Altern Complement Med. 2018;24(2):154–60.

    PubMed  Article  Google Scholar 

  44. 44.

    Douglass J, Immink MA, Piller N, Ullah S. Yoga for women with breast cancer-related lymphedema: a preliminary 6-month study. J Lymphoedema. 2012;7(2):30–8.

    Google Scholar 

  45. 45.

    Box RC, Reul-Hirche HM, Bullock-Saxton JE, Furnival CM. Physiotherapy after breast cancer surgery: results of a randomised controlled study to minimise lymphoedema. Breast Cancer Res Treat. 2002;75(1):51–64.

    PubMed  Article  Google Scholar 

  46. 46.

    Földi M FE, Strößenreuther C, Kubik S. (2012) Földi’s textbook of lymphology for physicians and lymphedema therapists. 3rd edition ed: Urban and Fischer.

  47. 47.

    Todd M. Compression bandaging: types and skills used in practical application. Br J Nurs. 2011;20(11):681–7.

    PubMed  Article  Google Scholar 

  48. 48.

    Pujol-Blaya V, Salinas-Huertas S, Catasus ML, et al. 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. Clin Rehabil. 2019;33(4):631–42.

    PubMed  Article  Google Scholar 

  49. 49.

    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. Lymphat Res Biol. 2018;16(5):446–52.

    PubMed  Article  Google Scholar 

  50. 50.

    Baxter GD, Liu L, Tumilty S, Petrich S, Chapple C, Anders JJ, et al. Low level laser therapy for the management of breast cancer-related lymphedema: a randomized controlled feasibility study. Lasers Surg Med. 2018;50(9):924–32.

    PubMed  Article  Google Scholar 

  51. 51.

    Assis L, Moretti AI, Abrahao TB, de Souza HP, Hamblin MR, Parizotto NA. Low-level laser therapy (808nm) contributes to muscle regeneration and prevents fibrosis in rat tibialis anterior muscle after cryolesion. Lasers Med Sci. 2013;28(3):947–55.

    PubMed  Article  Google Scholar 

  52. 52.

    Kaviani A, Fateh M, Nooraie RY, Nooraie RY, Alinagi-zadeh MR, Ataie-Fashtami L. Low-level laser therapy in management of postmastectomy lymphedema. Lasers Med Sci. 2006;21:90–4.

    PubMed  Article  Google Scholar 

  53. 53.

    Ridner SH, Poage-Hooper E, Kanar C, Doersam JK, Bond SM, Dietrich MS. A pilot randomized trial evaluating low-level laser therapy as an alternative treatment to manual lymphatic drainage for breast cancer-related lymphedema. Oncol Nurs Forum. 2013;40(4):383–93.

    PubMed  Article  Google Scholar 

  54. 54.

    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. Support Care Cancer. 2012;20(11):2977–84.

    PubMed  Article  Google Scholar 

  55. 55.

    Storz MA, Gronwald B, Gottschling S, Schöpe J, Mavrova R, Baum S. Photobiomodulation therapy in breast cancer-related lymphedema: a randomized placebo-controlled trial. Photodermatol Photoimmunol Photomed. 2017;33(1):32–40.

    PubMed  Article  Google Scholar 

  56. 56.

    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. Support Care Cancer. 2009;17(11):1353–60.

    PubMed  Article  Google Scholar 

  57. 57.

    Smykla A, Walewicz K, Trybulski R, et al. Effect of kinesiology taping on breast cancer-related lymphedema: a randomized single-blind controlled pilot study. Biomed Res Int. 2013;2013:767106.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  58. 58.

    Fife CE, Davey S, Maus EA, Guilliod R, Mayrovitz HN. A randomized controlled trial comparing two types of pneumatic compression for breast cancer-related lymphedema treatment in the home. Support Care Cancer. 2012;20(12):3279–86.

    PubMed  PubMed Central  Article  Google Scholar 

  59. 59.

    Ridner SH, Murphy B, Deng J, Kidd N, Galford E, Dietrich MS. Advanced pneumatic therapy in self-care of chronic lymphedema of the trunk. Lymphat Res Biol. 2010;8(4):209–15.

    PubMed  PubMed Central  Article  Google Scholar 

  60. 60.

    Szuba A, Achalu R, Rockson SG. Decongestive lymphatic therapy for patients with breast carcinoma-associated lymphedema. A randomized, prospective study of a role for adjunctive intermittent pneumatic compression. Cancer. 2002;95(11):2260–7.

    PubMed  Article  Google Scholar 

  61. 61.

    Wilburn O, Wilburn P, Rockson SG. A pilot, prospective evaluation of a novel alternative for maintenance therapy of breast cancer-associated lymphedema [ISRCTN76522412]. BMC Cancer. 2006;6:84.

    PubMed  PubMed Central  Article  Google Scholar 

  62. 62.

    Ridner SH, Murphy B, Deng J, Kidd N, Galford E, Bonner C, et al. A randomized clinical trial comparing advanced pneumatic truncal, chest, and arm treatment to arm treatment only in self-care of arm lymphedema. Breast Cancer Res Treat. 2012;131(1):147–58.

    CAS  PubMed  Article  Google Scholar 

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All authors contributed to the study conception and design, material preparation, and writing of the manuscript. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Kathryn Ryans.

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Ryans, K., Perdomo, M., Davies, C.C. et al. Rehabilitation interventions for the management of breast cancer–related lymphedema: developing a patient-centered, evidence-based plan of care throughout survivorship. J Cancer Surviv (2021). https://doi.org/10.1007/s11764-021-00991-2

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Keywords

  • Breast cancer
  • Lymphedema
  • Interventions