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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.


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.

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