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Quality-of-Life Outcomes in Surgical vs Nonsurgical Treatment of Breast Cancer–Related LymphedemaA Systematic Review

Educational Objective
To identify the health-related quality of life outcomes of the various treatment modalities of breast cancer–related lymphedema (BCRL) and review the outcomes of complex decongestive therapy vs vascularized lymph node transfer for BCRL.
1 Credit CME
Key Points

Question  What are the health-related quality-of-life outcomes of different treatment modalities for breast cancer–related lymphedema?

Findings  In this systematic review including 16 articles, health-related quality of life in patients with breast cancer–related lymphedema was associated with improvement following treatment with vascularized lymph node transfer, whereas complex decongestive therapy, the criterion-standard treatment, had variable associations with health-related quality of life. Inconsistencies in patient-reported outcomes prevents direct comparison of these 2 treatment modalities.

Meaning  The optimal treatment strategy for breast cancer–related lymphedema remains uncertain; additional studies are needed to better understand the best treatment options and direct evidence-based care.

Abstract

Importance  Secondary lymphedema is a debilitating complication of breast cancer therapy and affects more than 1 in 5 breast cancer survivors. Patient-reported outcomes may be more important in predicting long-term health-related quality of life (HRQoL) than clinician-measured outcomes.

Objective  To summarize published evidence on HRQoL outcomes for vascularized lymph node transfer (VLNT) and complex decongestive therapy (CDT) used in the treatment of breast cancer–related lymphedema.

Evidence Review  A literature search of PubMed/MEDLINE and Embase was conducted to identify articles on HRQoL in patients undergoing lymphedema treatment with CDT or VLNT published from January 1980 through April 2019. Studies using validated measurement instruments to assess HRQoL in patients with breast cancer–related lymphedema relative to baseline were included. This review is reported according to the PRISMA guidelines.

Findings  A total of 16 articles were included in this review. Evidence regarding VLNT was reviewed from 2 studies involving 65 patients, and HRQoL was evaluated using the Lymphoedema Quality of Life Study questionnaire. Data on VLNT indicated favorable HRQoL outcomes at 12-month postoperative follow-up. Evidence regarding CDT was reviewed from 14 studies involving 569 patients, and HRQoL was evaluated using the 36-Item Short Form Health Survey, Functional Assessment of Cancer Therapy–Breast, European Organization for Research and Treatment of Cancer, and Functional Living Index–Cancer measures. Data on CDT demonstrated variable association with HRQoL, and a majority of articles reported improvement in at least 1 subscale. The use of diverse patient-reported outcome measures and variability in CDT protocol limited interpretation of results in this population and between treatment modalities.

Conclusions and Relevance  According to this review, in deciding among breast cancer–related lymphedema treatment modalities, HRQoL outcomes are an important consideration that cannot be compared based on currently available data. Health-related quality-of-life outcomes obtained through coordinated use of preference-based health utility measures may be required to compare outcomes among patients undergoing surgical and nonsurgical treatments of breast cancer–related lymphedema. Additional studies are needed to better understand the best lymphedema treatment options and direct evidence-based care.

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Article Information

Accepted for Publication: January 20, 2020.

Corresponding Author: Morgan L. Fish, MD, Department of Plastic Surgery, Cleveland Clinic, 9500 Euclid Ave, A60 Crile Building, Cleveland, OH 44195 (morganfish8@gmail.com).

Published Online: April 29, 2020. doi:10.1001/jamasurg.2020.0230

Author Contributions: Dr Fish had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Fish, Schwarz.

Critical revision of the manuscript for important intellectual content: Grover, Schwarz.

Administrative, technical, or material support: Fish, Grover.

Study supervision: Grover, Schwarz.

Conflict of Interest Disclosures: None reported.

References
1.
Ezzo  J , Manheimer  E , McNeely  ML ,  et al.  Manual lymphatic drainage for lymphedema following breast cancer treatment.   Cochrane Database Syst Rev. 2015;(5):CD003475. doi:10.1002/14651858.CD003475.pub2PubMedGoogle Scholar
2.
Taghian  NR , Miller  CL , Jammallo  LS , O’Toole  J , Skolny  MN .  Lymphedema following breast cancer treatment and impact on quality of life: a review.   Crit Rev Oncol Hematol. 2014;92(3):227-234. doi:10.1016/j.critrevonc.2014.06.004PubMedGoogle ScholarCrossref
3.
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(35):5689-5696. doi:10.1200/JCO.2008.16.4731PubMedGoogle ScholarCrossref
4.
Chang  DW , Masia  J , Garza  R  III , Skoracki  R , Neligan  PC .  Lymphedema: surgical and medical therapy.   Plast Reconstr Surg. 2016;138(3)(suppl):209S-218S. doi:10.1097/PRS.0000000000002683PubMedGoogle ScholarCrossref
5.
Morgan  PA , Franks  PJ , Moffatt  CJ .  Health-related quality of life with lymphoedema: a review of the literature.   Int Wound J. 2005;2(1):47-62. doi:10.1111/j.1742-4801.2005.00066.xPubMedGoogle ScholarCrossref
6.
Shih  YC , Xu  Y , Cormier  JN ,  et al.  Incidence, treatment costs, and complications of lymphedema after breast cancer among women of working age: a 2-year follow-up study.   J Clin Oncol. 2009;27(12):2007-2014. doi:10.1200/JCO.2008.18.3517PubMedGoogle ScholarCrossref
7.
Basta  MN , Fox  JP , Kanchwala  SK ,  et al.  Complicated breast cancer-related lymphedema: evaluating health care resource utilization and associated costs of management.   Am J Surg. 2016;211(1):133-141. doi:10.1016/j.amjsurg.2015.06.015PubMedGoogle ScholarCrossref
8.
Gould  DJ , Mehrara  BJ , Neligan  P , Cheng  MH , Patel  KM .  Lymph node transplantation for the treatment of lymphedema.   J Surg Oncol. 2018;118(5):736-742. doi:10.1002/jso.25180PubMedGoogle ScholarCrossref
9.
Ciudad  P , Mouchammed  A , Manrique  OJ , Chang  WL , Huang  TCT , Chen  HC .  Comparison of long-term clinical outcomes among different vascularized lymph node transfers: 6-year experience of a single center’s approach to the treatment of lymphedema.   J Surg Oncol. 2018;117(6):1346-1347. doi:10.1002/jso.24957PubMedGoogle ScholarCrossref
10.
Mirolo  BR , Bunce  IH , Chapman  M ,  et al.  Psychosocial benefits of postmastectomy lymphedema therapy.   Cancer Nurs. 1995;18(3):197-205. doi:10.1097/00002820-199506000-00004PubMedGoogle ScholarCrossref
11.
Mondry  TE , Riffenburgh  RH , Johnstone  PAS .  Prospective trial of complete decongestive therapy for upper extremity lymphedema after breast cancer therapy.   Cancer J. 2004;10(1):42-48. doi:10.1097/00130404-200401000-00009PubMedGoogle ScholarCrossref
12.
Sitzia  J , Sobrido  L .  Measurement of health-related quality of life of patients receiving conservative treatment for limb lymphoedema using the Nottingham Health Profile.   Qual Life Res. 1997;6(5):373-384. doi:10.1023/A:1018487411186PubMedGoogle ScholarCrossref
13.
Sackey  H , Johansson  H , Sandelin  K ,  et al.  Self-perceived, but not objective lymphoedema is associated with decreased long-term health-related quality of life after breast cancer surgery.   Eur J Surg Oncol. 2015;41(4):577-584. doi:10.1016/j.ejso.2014.12.006PubMedGoogle ScholarCrossref
14.
Liberati  A , Altman  DG , Tetzlaff  J ,  et al.  The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.   PLoS Med. 2009;6(7):e1000100. doi:10.1371/journal.pmed.1000100PubMedGoogle Scholar
15.
Korpan  MI , Crevenna  R , Fialka-Moser  V .  Lymphedema: a therapeutic approach in the treatment and rehabilitation of cancer patients.   Am J Phys Med Rehabil. 2011;90(5)(suppl 1):S69-S75. doi:10.1097/PHM.0b013e31820be160PubMedGoogle ScholarCrossref
16.
Ridner  SH , Fu  MR , Wanchai  A , Stewart  BR , Armer  JM , Cormier  JN .  Self-management of lymphedema: a systematic review of the literature from 2004 to 2011.   Nurs Res. 2012;61(4):291-299. doi:10.1097/NNR.0b013e31824f82b2PubMedGoogle ScholarCrossref
17.
Aljaaly  HA , Fries  CA , Cheng  MH .  Dorsal wrist placement for vascularized submental lymph node transfer significantly improves breast cancer-related lymphedema.   Plast Reconstr Surg Glob Open. 2019;7(2):e2149. doi:10.1097/GOX.0000000000002149PubMedGoogle Scholar
18.
Gratzon  A , Schultz  J , Secrest  K , Lee  K , Feiner  J , Klein  RD .  Clinical and psychosocial outcomes of vascularized lymph node transfer for the treatment of upper extremity lymphedema after breast cancer therapy.   Ann Surg Oncol. 2017;24(6):1475-1481. doi:10.1245/s10434-016-5614-4PubMedGoogle ScholarCrossref
19.
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):446-452. doi:10.1089/lrb.2017.0061PubMedGoogle ScholarCrossref
20.
Haghighinejad  HA , Hadi  N , Banihashemi  S ,  et al.  The effect of complex decongestive therapy on post-breast surgery quality of life in breast cancer patients with unilateral lymphedema and its predictive factors.   Shiraz E Med J. 2016;17(1):e29200. doi:10.17795/semj29200Google Scholar
21.
Noh  S , Hwang  JH , Yoon  TH , Chang  HJ , Chu  IH , Kim  JH .  Limb differences in the therapeutic effects of complex decongestive therapy on edema, quality of life, and satisfaction in lymphedema patients.   Ann Rehabil Med. 2015;39(3):347-359. doi:10.5535/arm.2015.39.3.347PubMedGoogle ScholarCrossref
22.
Pekyavaş  NÖ , Tunay  VB , Akbayrak  T , Kaya  S , Karataş  M .  Complex decongestive therapy and taping for patients with postmastectomy lymphedema: a randomized controlled study.   Eur J Oncol Nurs. 2014;18(6):585-590. doi:10.1016/j.ejon.2014.06.010PubMedGoogle ScholarCrossref
23.
Dayes  IS , Whelan  TJ , Julian  JA ,  et al.  Randomized trial of decongestive lymphatic therapy for the treatment of lymphedema in women with breast cancer.   J Clin Oncol. 2013;31(30):3758-3763. doi:10.1200/JCO.2012.45.7192PubMedGoogle ScholarCrossref
24.
Kim  DS , Sim  YJ , Jeong  HJ , Kim  GC .  Effect of active resistive exercise on breast cancer-related lymphedema: a randomized controlled trial.   Arch Phys Med Rehabil. 2010;91(12):1844-1848. doi:10.1016/j.apmr.2010.09.008PubMedGoogle ScholarCrossref
25.
Kim  SJ , Yi  CH , Kwon  OY .  Effect of complex decongestive therapy on edema and the quality of life in breast cancer patients with unilateral leymphedema.   Lymphology. 2007;40(3):143-151.PubMedGoogle Scholar
26.
Gurdal  SO , Kostanoglu  A , Cavdar  I ,  et al.  Comparison of intermittent pneumatic compression with manual lymphatic drainage for treatment of breast cancer-related lymphedema.   Lymphat Res Biol. 2012;10(3):129-135. doi:10.1089/lrb.2012.0002PubMedGoogle ScholarCrossref
27.
Melam  GR , Buragadda  S , Alhusaini  AA , Arora  N .  Effect of complete decongestive therapy and home program on health-related quality of life in post mastectomy lymphedema patients.   BMC Womens Health. 2016;16:23. doi:10.1186/s12905-016-0303-9PubMedGoogle ScholarCrossref
28.
Do  JH , Kim  W , Cho  YK ,  et al.  Effects of resistance exercises and complex decongestive therapy on arm function and muscular strength in breast cancer related lymphedema.   Lymphology. 2015;48(4):184-196.PubMedGoogle Scholar
29.
Yesil  H , Eyigör  S , Caramat  İ , Işık  R .  Effects of complex decongestive therapy on quality of life, depression, neuropathic pain, and fatigue in women with breast cancer-related lymphedema.   Turk J Phys Med Rehabil. 2017;63(4):329-334. doi:10.5606/tftrd.2017.779PubMedGoogle ScholarCrossref
30.
Karadibak  D , Yavuzsen  T , Saydam  S .  Prospective trial of intensive decongestive physiotherapy for upper extremity lymphedema.   J Surg Oncol. 2008;97(7):572-577. doi:10.1002/jso.21035PubMedGoogle ScholarCrossref
31.
Brown  JC , Cheville  AL , Tchou  JC , Harris  SR , Schmitz  KH .  Prescription and adherence to lymphedema self-care modalities among women with breast cancer-related lymphedema.   Support Care Cancer. 2014;22(1):135-143. doi:10.1007/s00520-013-1962-9PubMedGoogle ScholarCrossref
32.
Ridner  SH , Dietrich  MS , Kidd  N .  Breast cancer treatment-related lymphedema self-care: education, practices, symptoms, and quality of life.   Support Care Cancer. 2011;19(5):631-637. doi:10.1007/s00520-010-0870-5PubMedGoogle ScholarCrossref
33.
Tsai  H-J , Hung  H-C , Yang  J-L , 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):1353-1360. doi:10.1007/s00520-009-0592-8PubMedGoogle ScholarCrossref
34.
Javid  SH , Anderson  BO .  Mounting evidence against complex decongestive therapy as a first-line treatment for early lymphedema.   J Clin Oncol. 2013;31(30):3737-3738. doi:10.1200/JCO.2013.51.8373PubMedGoogle ScholarCrossref
35.
Dionyssiou  D , Demiri  E , Tsimponis  A ,  et al.  A randomized control study of treating secondary stage II breast cancer-related lymphoedema with free lymph node transfer.   Breast Cancer Res Treat. 2016;156(1):73-79. doi:10.1007/s10549-016-3716-0PubMedGoogle ScholarCrossref
36.
Coons  SJ , Kaplan  RM . Cost-utility analysis. In: Bootman  JL , Townsend  RJ , McGhan  WF , eds.  Principle of Pharmacoeconomics. 2nd ed. Wharvey Whitney Books; 1996:102-126.
37.
Brazier  JE , Yang  Y , Tsuchiya  A , Rowen  DL .  A review of studies mapping (or cross walking) non-preference based measures of health to generic preference-based measures.   Eur J Health Econ. 2010;11(2):215-225. doi:10.1007/s10198-009-0168-zPubMedGoogle ScholarCrossref
38.
Torrance  GW .  Preferences for health outcomes and cost-utility analysis.   Am J Manag Care. 1997;3(suppl):S8-S20.PubMedGoogle Scholar
39.
Thoma  A , Strumas  N , Rockwell  G , McKnight  L .  The use of cost-effectiveness analysis in plastic surgery clinical research.   Clin Plast Surg. 2008;35(2):285-296. doi:10.1016/j.cps.2007.10.012PubMedGoogle ScholarCrossref
40.
Weinstein  MC , Torrance  G , McGuire  A .  QALYs: the basics.   Value Health. 2009;12(suppl 1):S5-S9. doi:10.1111/j.1524-4733.2009.00515.xPubMedGoogle ScholarCrossref
41.
Thoma  A , Ignacy  TA , Ziolkowski  N , Voineskos  S .  The performance and publication of cost-utility analyses in plastic surgery: making our specialty relevant.   Can J Plast Surg. 2012;20(3):187-193. doi:10.1177/229255031202000319PubMedGoogle ScholarCrossref
42.
Versteegh  MM , Leunis  A , Uyl-de Groot  CA , Stolk  EA .  Condition-specific preference-based measures: benefit or burden?   Value Health. 2012;15(3):504-513. doi:10.1016/j.jval.2011.12.003PubMedGoogle ScholarCrossref
43.
Brazier  J , Tsuchiya  A .  Preference-based condition-specific measures of health: what happens to cross programme comparability?   Health Econ. 2010;19(2):125-129. doi:10.1002/hec.1580PubMedGoogle ScholarCrossref
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