Pilot Study: The Effectiveness of Complex Decongestive Therapy for Lymphedema in Palliative Care Patients with Advanced Cancer

Sinead Cobbe, BSc, MSc, Kathy Nugent, BSc, and Shirley Real, MA, BSc. Journal of Palliative Medicine Volume 21, Number 4, 2018.

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Pilot Study: The Effectiveness of Complex Decongestive Therapy for Lymphedema in Palliative Care Patients with Advanced Cancer

Sinead Cobbe, BSc, MSc, Kathy Nugent, BSc, and Shirley Real, MA, BSc. Journal of Palliative Medicine Volume 21, Number 4, 2018.

Background: Complex decongestive therapy (CDT) is a regimen of physical treatment for lymphedema. Its effectiveness is unknown in advanced cancer patients. This study evaluates effectiveness of CDT in this population.

Method: This is a prospective observational cohort study for 18 months of advanced cancer patients with lymphedema, who received three or more CDT interventions. Measurements were taken before the first (T1), third (T3), and sixth (T6) treatments as follows: limb volume using circumferential measurements, quality of life (QOL) using qualitative questions, skin quality using a locally developed scale measuring color, thickness, and texture. The treating physiotherapists collected data. Analysis was carried out using Microsoft Excel and SPSS.

Results: Twelve patients, age range 42–73 years (median 69.5) were included. Survival from last recorded treatment ranged from 3 to 262 days (median 40). At T3 (n=21 limbs), volume reduction was significant (Wilcoxin Signed Rank Test Z=-2.5, p=0.01, r=0.5). At T6 (n=13 limbs), volume reduction was significant (Z=-2.4, p=0.013, r=0.66). At both time points, there were significant reductions in abnormal skin thickness and surface, but not color. Improvements occurred independent of volume changes. QOL changes included better function, improved limb aesthetics, and less pain and tightness.

Conclusion: For the first time, this study shows that CDT is effective for a cohort of palliative cancer patients with limited survival. Improvements in limb volume, skin quality, and lymphedema-related QOL were recorded. Valid skin and QOL measures need to be developed. Larger, blinded trials need to be conducted to determine which patients benefit from CDT.

Main findings

  • The intervention used an individually tailored program of CDT using a range of the following: bandaging, lymphatic massage (also known as manual lymphatic drainage [MLD]), compression garments, kinesiotaping, exercise, deep breathing techniques, education, and skincare.
  • Outcome measures included limb volume via circumferential measurements and the volume was calculated using a truncated cone. Skin changes were noted including color, thickness and surface. Quality of life changes was measured by The Lymphoedema Quality of Life Questionnaire (LYMQOL).
  • 16/21 limbs reduced in volume. Abnormal skin colour did not change. Skin thickness and surface abnormalities reduced significantly. Symptom improvement was noted. CDT reduced discomfort, improved function and limb aesthetics, and there was a return toward normalcy. These findings prompt the development of a lymphedema specific QOL tool for palliative care patients. Qualitative research is needed on the experience of CDT in palliative care patients to guide this.
  • Limitations include:
    • Clinical tools to measure both skin integrity and lymphedema-specific QOL need to be developed, while keeping patient burden to a minimum.
    • It was a convenience sample of patients, and sample size was small. Larger studies would allow for more rigorous statistical analysis of effectiveness.
    • The treating physiotherapists both recruited and recorded results; therefore, gatekeeping and bias toward reporting good effects were possibilities. Independent recruitment and blinding of researchers are obvious requirements for future studies.
    • This study was pragmatic, with varying treatment regimens and time frames, which could be standardized in future trials.
    • It would be beneficial to note albumin levels and physical function at initial time point to determine whether these affect volume reduction or predict completion of program.