Clinical effectiveness of decongestive treatments on excess arm volume and patient-centered outcomes in women with early breast cancer-related arm lymphedema: a systematic review

Eunice Jeffs, Emma Ream, Cath Taylor, Debra Bick. JBI Database of Systematic Reviews and Implementation Reports, 2018

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Clinical effectiveness of decongestive treatments on excess arm volume and patient-centered outcomes in women with early breast cancer-related arm lymphedema: a systematic review

Eunice Jeffs,  Emma Ream, Cath Taylor, Debra Bick. JBI Database of Systematic Reviews and Implementation Reports, 2018

Objective: To identify the effect of decongestive lymphedema treatment on excess arm volume or patient-centered
outcomes in women presenting within either 12 months or a mean nine months of developing arm lymphedema
following breast cancer treatment.

Introduction: Lymphedema is a common consequence of breast cancer treatment requiring life-long treatment to
reduce symptoms and prevent complications. Currently, evidence to inform the optimal decongestive lymphedema
treatment package is lacking.

Inclusion criteria: The review included studies on women who received lymphedema treatment within either 12
months or a mean of nine months of developing unilateral breast cancer-related arm lymphedema. The intervention
was any decongestive lymphedema treatment delivered with the purpose of reducing arm lymphedema, compared
to another form of lymphedema treatment (whether self or practitioner-administered), placebo or no treatment. The
clinical outcome was excess arm volume; patient-centered outcomes were health-related quality of life, arm
heaviness, arm function, patient-perceived benefit and satisfaction with treatment. Experimental study designs
were eligible, including randomized and non-randomized controlled trials, quasi-experimental, prospective and
retrospective before and after studies were considered.

Methods: A three-step search strategy was utilized to find published and unpublished studies. The search identified
studies published fromthe inception of each database to July 6, 2016. Reference lists were scanned to identify further
eligible studies. Studies were critically appraised using appropriate standardized critical appraisal instruments fromthe

Joanna Briggs Institute. Details describing each study and treatment results regarding outcomes of interest
were extracted from papers included in the review using appropriate standardized data extraction tools from the
Joanna Briggs Institute. Due to heterogeneity in included studies, results for similar outcome measures were not pooled in statistical meta-analysis. A narrative and tabular format was used to synthesize results from identified and included studies.

Results: Seven studies reporting results for outcomes of interest were critically appraised and included in the
review: five randomized controlled trials and two descriptive (uncontrolled) studies. Reported outcomes included
excess arm volume (five studies), health-related quality of life (three studies), arm heaviness (one study), arm function (two studies) and patient-perceived benefit (two studies). There was some evidence that decongestive treatments were effective for women presenting within either 12 months or a mean of nine months of developing breast cancer related arm lymphedema, but the wide range of data prevented comparison of treatment findings which limited our ability to answer the review questions.

Main findings

  • The aim of this review was to identify the effect of decongestive lymphedema treatment on excess arm volume and patient-centered outcomes for women presenting within either 12 months or a mean of nine months of developing a swollen arm due to BCRL. A key challenge was the limited number of published studies that have measured and reported results of treatment for women with early BCRL.
  • Further research is necessary to determine whether women could benefit from costlier intensive treatment or achieve similar outcomes with more convenient and less resource intense self-management. The recent move towards surveillance of women following breast cancer treatment, with the potential to introduce treatment at a pre-clinical stage, does not preclude a need to determine the most effective – and cost-effective – treatment for women who present with clinical symptoms of BCRL.
  • As with previous reviews, they found heterogeneity of interventions and assessment methods, and variations in quality of study design and reporting, which limited comparison of results.
  • The variation in treatment protocols emerged as a major limitation of the review.
  • A consistent method of reporting outcomes is necessary to permit comparison between studies and meta-analysis in order to build the evidence base.
  • Collaborations should be encouraged between groups of lymphedema researchers, particularly with regard to creating comparable treatment protocols, outcome measures and reporting methods.