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Clinical practice guidelines for the care and treatment of breast cancer: 11. Lymphedema

Dr. Harris is Professor in the School of Rehabilitation Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC; Dr. Hugi is with Providence Health Care, Vancouver, BC; Dr. Olivotto is Clinical Professor in the Division of Radiation Oncology, BC Cancer Agency-Vancouver Island Cancer Centre and the University of British Columbia, Victoria, BC; and Dr. Levine is with the Cancer Care Ontario Hamilton Regional Cancer Centre, and the Departments of Medicine and of Clinical Epidemiology and Biostatistics, McMaster University, and is the Buffett Taylor Chair in Breast Cancer Research, McMaster University, Hamilton, Ont.*The steering committee is part of Health Canada's Canadian Breast Cancer Initiative. A list of committee members appears in Appendix 1.

Objective: To provide information and recommendations for women and their physicians when making decisions about the management of lymphedema related to breast cancer.

Options: Compression garments, pneumatic compression pumps, massage and physical therapies, other physical therapy modalities, pharmaceutical treatments.

Outcomes: Symptom control, quality of life, cosmetic results.

Evidence: Systematic review of English-language literature retrieved primarily from MEDLINE (1966 to April 2000) and CANCERLIT (1985 to April 2000). Nonsystematic review of breast cancer literature published to October 2000.

Recommendations: · Pre- and postoperative measurements of both arms are useful in the assessment and diagnosis of lymphedema. Circumferential measurements should be taken at 4 points: the metacarpal-phalangeal joints, the wrists, 10 cm distal to the lateral epicondyles and 15 cm proximal to the lateral epicondyles. · Clinicians should elicit symptoms of heaviness, tightness or swelling in the affected arm. A difference of more than 2.0 cm at any of the 4 measurement points may warrant treatment of the lymphedema, provided that tumour involvement of the axilla or brachial plexus, infection and axillary vein thrombosis have been ruled out. · Practitioners may want to encourage long-term and consistent use of compression garments by women with lymphedema. · One randomized trial has demonstrated a trend in favour of pneumatic compression pumps compared with no treatment. Further randomized trials are required to determine whether pneumatic compression provides additional benefit over compression garments alone. · Complex physical therapy, also called complex decongestive physiotherapy, requires further evaluation in randomized trials. In one randomized trial no difference in outcomes was detected between compression garments plus manual lymph drainage versus compression garments alone. · Clinical experience supports encouraging patients to consider some practical advice regarding skin care, exercise and body weight. [A patient version of these guidelines appears in Appendix 2.]

Validation: An initial draft of this document was developed by a task force sponsored by the BC Cancer Agency. It was updated and revised substantially by a writing committee and then submitted for further review, revision and approval by the Steering Committee for Clinical Practice Guidelines for the Care and Treatment of Breast Cancer.

Sponsor: The steering committee was convened by Health Canada.

Completion date: October 2000.

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