1.1. Review question

In people who have, or have had, breast cancer and have lymphoedema, what non-pharmacological strategies are effective and cost-effective, for managing it:

1. Complete Decongestive Therapy (CDT)
2. Exercise and Movement
3. Skincare
4. Lymphoedema Education
5. Pneumatic Compression Devices
6. Complementary therapy
7. Psychological interventions
8. Kinesiotaping
9. Wired vs non-wired bras, foam inserts, spaghetti foam
10. Surgical interventions

1.1.2. Summary of the protocol

Table 1

PICOS inclusion criteria.

For the full protocol see appendix A.

2.1. Summary of studies included in the evidence

Table 2

Summary of studies included in the evidence.

Table 3

Included studies in systematic reviews.

See appendix D for full evidence tables

2.2. Summary of the effectiveness evidence

Table 4

Manual lymphatic drainage vs control.

Table 5

Manual lymphatic drainage vs control.

Table 6

Manual lymphatic drainage vs compression bandaging.

Table 7

MLD + bandaging + exercise vs standard (bandaging + exercise).

Table 8

Fluoroscopy guided MLD vs MLD.

Table 9

SLD + compression therapy vs compression therapy.

Table 10

Pressure garments vs no pressure.

Table 11

Mobiderm vs conventional multilayered bandages.

Table 12

Compression garment (night and day for 90 days) vs compression garment (daytime).

Table 13

Negative pressure massage vs MLD.

Table 14

CDT vs MLD.

Table 15

CDT vs compression bandaging.

2.3. Narrative summary of the effectiveness evidence

For some of the evidence, it was not possible to complete GRADE because the data reporting was incomplete. Specifically, the original studies or reports did not provide standard deviations or other measures of variability for their outcomes. Therefore, assessing the precision of effect estimates was not possible. and as such evidence statements were produced to summarise the evidence narratively.

3.1. Summary of studies included in the evidence

Table 16

Summary of studies included in the evidence.

Table 17

Included studies in systematic reviews.

See appendix D for full evidence tables.

3.2. Summary of the effectiveness evidence

Table 18

Resistance exercise vs standard care.

Table 19

Aerobic + resistance exercise vs standard care/CDT.

Table 20

Water-based exercise and yoga vs standard care/CDT.

Table 21

CDT + resistance exercise vs standard care/CDT.

Table 22

CDT + compression pump + resistance exercise vs CDT + compression pump.

Table 23

Complex physical therapy vs multimodal approaches.

Table 24

Aquatic therapy vs standard care.

Table 25

Aqua therapy vs exercise.

Table 26

Continuous passive motion + CDT vs CDT.

Table 27

Pilates vs exercise + self care.

Table 28

Exercise vs no exercise/info on exercise.

Table 29

Progressive resistance exercise vs self-directed resistance exercise.

4.1. Summary of studies included in the evidence

No evidence was identified that met the criteria in the protocol for skincare interventions for managing breast cancer-related lymphoedema.

5.1. Summary of studies included in the evidence

Table 30

Summary of included studies.

See appendix D for full evidence tables.

5.2. Summary of the effectiveness evidence

Table 31

Education on SLD + lifestyle recs vs usual care.

Table 32

Group education vs control.

Table 33

Social network-based education vs control.

Table 34

Group-based education vs social network education.

5.3. Narrative summary of the effectiveness evidence

For some of the evidence, it was not possible to complete GRADE and as such evidence statements were produced to summarise the evidence narratively.1 RCT (Ridner et al., 2020) at high risk of bias (n=160) found that:

• A web-based multimedia intervention (WBMI) had a significantly lower completion rate compared to an educational pamphlet (58.8% vs 77.5%, p=0.011).
• There were no statistically significant differences between the WBMI and pamphlet groups in reducing most symptoms at 1 or 12 months post-intervention (effect sizes 0.05-0.28, p>0.05), as measured by the Lymphoedema Symptom Intensity and Distress Scale–Arm (LSIDS-A).
• The WBMI group showed a greater reduction in biobehavioral (mood) symptoms compared to the pamphlet group at 1 month (25% of WBMI participants had ≤2 mood symptoms vs. no reduction in the pamphlet group, effect size=0.53, p<0.05). This difference was maintained at 12 months (25% of WBMI participants had ≥2 symptom reduction vs. 25% of pamphlet participants with ≥1 symptom reduction, effect size=0.47, p<0.05).
• There were no significant differences between groups in function as measured by the Quick-Disabilities of Arm, Shoulder, and Hand (QuickDASH) scale (median change from baseline at 12 months: −2.3 for both groups, effect size=-0.04, p>0.05).
• The WBMI required significantly more time to complete than the pamphlet (median 525 vs 60 minutes, p<0.001).

6.1. Summary of studies included in the evidence

Table 35

Summary of included studies.

See appendix D for full evidence tables.

6.2. Summary of the effectiveness evidence

Table 36

Novel pneumatic compression devices vs traditional advanced pneumatic compression devices.

Table 37

Intermittent pneumatic CB + bandaging vs MLD + CB.

6.3. Narrative summary of the effectiveness evidence

For some of the evidence, it was not possible to complete GRADE and as such evidence statements were produced to summarise the evidence narratively.

1. 1 RCT (Uzkeser et al., 2013) at low risk of bias (n=25) found that:

   • pneumatic compression therapy significantly improved shoulder flexion (median 152° to 170°, p=0.018), abduction (130° to 165°, p=0.017), and internal rotation (57° to 70°, p=0.01) at 1-month follow-up compared pre-treatment scores.
   • Manual lymphatic drainage combined with bandaging and exercise (control group) significantly improved shoulder flexion (median 160° to 170°, p=0.018), abduction (160° to 170°, p=0.018), internal rotation (60° to 80°, p=0.008), and external rotation (75° to 90°, p=0.041) at 1-month follow-up compared to pre-treatment scores.
   • pneumatic compression therapy significantly reduced shoulder dysfunction (as measured by the Constant-Murley scale; median 54 to 59, p=0.002) and self-reported pain (as measured by the Visual Analogue Scale; 20 to 5, p=0.01) at 1-month follow-up compared to pre-treatment scores.
   • manual lymphatic drainage combined with bandaging and exercise (control group) significantly reduced shoulder dysfunction (as measured by the Constant-Murley scale; 52 to 57, p=0.001) and self-reported pain (as measured by the Visual Analogue Scale; 40 to 20, p=0.004) at 1-month follow-up compared to pre-treatment scores.
   • no statistically significant differences between pneumatic compression therapy and manual lymphatic drainage combined with bandaging and exercise in terms of improving shoulder range of motion, reducing shoulder dysfunction, or reducing self-reported pain either immediately after treatment or at 1-month follow-up.

7.1. Summary of studies included in the evidence

Table 38

Summary of included studies.

Table 39

Included studies in Gao et al. 2021.

See appendix D for full evidence table.

7.2. Summary of the effectiveness evidence

Table 40

Moxibustion vs pneumatic circulation.

Table 41

Acupuncture plus moxibustion vs usual care.

Table 42

Acupuncture plus moxibustion vs diosmin.

8.1. Summary of studies included in the evidence

No evidence was identified that met the criteria in the protocol for psychological interventions for managing breast cancer-related lymphoedema.

9.1. Summary of studies included in the evidence

Table 43

Summary of included studies included.

Table 44

Included studies in Kasawara et al. 2018.

See appendix D for full evidence tables

9.2. Summary of the effectiveness evidence

Table 45

KT vs control.

Table 46

KT vs usual care.

Table 47

KT vs CDT.

Table 48

KT vs compression garment (Ozsoy-Unbol 2019).

Table 49

KT vs compression garments (Tantawy 2019).

Table 50

KT vs MLD.

9.3. Narrative summary of the effectiveness evidence

For some of the evidence, it was not possible to complete GRADE and as such evidence statements were produced to summarise the evidence narratively.

10.1. Summary of studies included in the evidence

No evidence was identified that met the criteria in the protocol for bras, foam inserts or spaghetti foam for managing breast cancer-related lymphoedema.

11.1. Summary of studies included in the evidence

Table 51

Summary of included studies.

Table 52

Included studies in Winters et al. 2021.

See appendix D for full evidence tables.

11.2. Summary of the effectiveness evidence

Table 53

LVA vs CDT.

11.3. Narrative summary of the effectiveness evidence

For some of the evidence, it was not possible to complete GRADE and as such evidence statements were produced to summarise the evidence narratively.

1. One systematic review of 8 RCTs and 9 cohort studies (Winters et al., 2021), at high risk of bias found data from:

   • 8 studies at unclear risk of bias (N not reported) found that vascularised lymph node transfer (VLNT) reduced the arm volume difference between healthy and affected arms by an average of 40.31% (95% CI 31.44% to 49.17%).
   • 5 studies at unclear risk of bias (N not reported) found that VLNT significantly improved quality of life scores on various assessment tools, but pooled analysis was not possible due to heterogeneity in measurement methods.
   • 3 studies at unclear risk of bias (N not reported) found that VLNT significantly reduced annual skin infection rates compared to pre-surgical rates.
   • 3 studies at unclear risk of bias (N=60) found that 45% of patients were able to discontinue compression garment use after VLNT.
   • 16 studies at unclear risk of bias (N=369 for recipient site, N=338 for donor site) reported overall complication rates of 12.1% at the donor site and 7.3% at the recipient site following VLNT.

12.1. Included studies

A search was performed to identify published economic evaluations of relevance to this guideline update (Appendix G) This search retrieved 121 studies. Based on title and abstract screening, 118 of the studies were excluded for this question. Following the full-text review, we excluded a further study. Thus, the review for this question includes 2 studies from the existing literature.

12.2. Excluded studies

1 study was included due to inapplicability and very serious limitations. See Appendix J – Excluded studies for detailed reasons for exclusion.

12.3. Summary of included economic evidence

Table 54

Lymphovenous bypass vs complete decongestive therapy.

Table 55

Complete decongestive therapy with Kinesio tape vs complete decongestive therapy with low-stretch bandages.

12.4. Economic model

No economic model was developed for this review question.

12.5. Unit costs

Table 56

Service planning recommended guide for treatment pathways.

12.6. Evidence statements

• One cost-comparison from Denmark found that complete decongestive therapy with Kinesiotaping is less expensive than a complete decongestive therapy with low-stretch bandages. The analysis was assessed as partially applicable with potentially serious limitations.
• One cost-comparison analysis from Canada found that lymphovenous bypass is less expensive than complete decongestive therapy. The analysis was assessed as partially applicable with potentially serious limitations.

13.1. The outcomes that matter most

The committee discussed the range of outcomes and agreed that measures of the severity of lymphoedema, including reduction in upper limb, breast or chest wall volume and adverse events such as infections or surgical complications were the most important in decision making for lymphoedema management.

They also recognised the importance of patient-centred outcomes such as quality of life, pain, psychological well-being, and skin/tissue changes for example, softening, hardening, tension.

Reducing acute inflammatory episodes or cellulitis is an important outcome to consider in lymphoedema management. The committee noted by minimising these acute complications, effective lymphoedema management can improve patient comfort, reduce the risk of long-term lymphatic damage, and enhance overall quality of life. However this was not commonly reported in the evidence.

The committee also wanted to consider cosmetic impact (changes in tissues and skin condition) of lymphoedema and its effect on people’s body image as potential outcomes, but these were not reported in the available literature. This suggests a need for future research to better understand and address these aspects of the patient experience.

13.2. The quality of the evidence

The evidence summarised for the review was heterogeneous, both in terms of intervention and comparator characteristics and also in terms of the outcome measures used. Although most of the studies reported some measure of limb circumference or volume, they were inconsistent in the ways that they measured and reported this. Therefore, no meta-analysis was performed and GRADE was used for some of the outcomes to determine confidence where possible. Some of the systematic reviews reported narratively in this review did undertake meta-analysis and this is reported where relevant. For all papers reported in this review the quality of the evidence is based on critical appraisal of the study using the appropriate checklist as set out in the NICE manual.

While the quality of the evidence varied, most of the papers identified were at moderate to high risk of bias. This was mainly due to lack of blinding, imbalanced baseline characteristics, selective reporting of outcomes, and unclear definitions of outcome measures.

The committee noted significant inconsistencies in how the severity of lymphoedema was measured and reported across studies. This variability made it extremely challenging to pool, analyse, and interpret the evidence effectively. Furthermore, the committee recognized the importance of stratifying evidence by baseline lymphoedema severity. However, this stratification was rarely possible due to inadequate reporting in the included studies, which prevented the committee from fully considering severity in their discussions.

This led to the committee’s decision to make a research recommendation for the development of a core outcome set for lymphoedema studies. The committee believed a core outcome set would establish a standardized approach to measuring and reporting lymphoedema severity, addressing the current inconsistencies that hinder data synthesis and interpretation. The committee also highlighted that only one study in this review included people with breast lymphoedema, whereas the remaining studies focused on upper limb lymphoedema. They were in agreement that this underscored a significant gap in the current evidence base. The committee concluded that there is a pressing need for future research specifically targeting interventions for breast lymphoedema management and therefore made a research recommendation. There were several challenges and limitations with the included studies. The committee were cautious that across all of the studies there were no definitive diagnostic criteria for lymphoedema; studies used different methods to diagnose and recruit people into the studies (such as circumference measurements, volume displacement, bioimpedance), and different cut-off points to diagnose lymphoedema, and therefore there was significant heterogeneity in the population making it very difficult to compare the evidence. The committee were concerned that the majority of the studies had a small sample size.

There was variability in measurement techniques for example the location of circumference measurements and timing of assessment, some studies reported follow-ups for up to 3 months while other studies recorded the outcomes immediately after treatment. The committee noted that many of the studies did not report long-term follow-up. This also indicates that there is a need for longitudinal studies to understand the natural history of the BCRL and the long-term effects of different management strategies.

The committee were also concerned that the studies did not report detailed information on the interventions, such as the type of compression therapies provided, the components of complete decongestive therapy, or the duration and frequency of treatments, which made it difficult to make detailed recommendations.

13.3. Benefits and harms

13.4. Cost effectiveness and resource use

Two health economic studies were included for this review.

The first study compared CDT with Kinesio taping and CDT with low-stretch bandages and was assessed as partially applicable (Denmark) and with potentially serious limitations. The main limitations were the extremely small sample size of the pilot study (10 people), the lack of clarity regarding the source of unit costs and the short time horizon (4 weeks). The study assumed that a Kinesio taping therapy would require 8 sessions (twice a week for 4 weeks), whereas “standard” CDT would require 20 sessions (5 days a week for 4 weeks). As a result, Kinesio taping was found to be cost saving, as it costed £558 (2015/2016) less than standard CDT. The systematic review included in the analysis reported a significant heterogeneity in Kinesio taping protocols, with some requiring 9 and other 20 sessions. Therefore, it is uncertain whether consistent cost savings would occur. Unit costs were presented to the committee. The NHS Supply Chain catalogue reports a cost of £2.76 for standard 5cm x 5 m Kinesio tape. The corresponding cost for a 6cm x 5m compression bandage is £0.39 making Kinesio tape almost 10 times more expensive than the compression bandage. The committee noted that people are often required to buy their own tape/bandage after their CDT session, and therefore, part of the cost is borne by them. In addition, the committee highlighted that CDT is not typically delivered in the UK in the same manner as in the study, and services do not currently support CDT being given at this intensity. Therefore, there were also concerns regarding the generalisability of the study.

The second economic study was a cost-comparison analysis looking at lifetime savings of lymphaticovenous anastomosis (LVA). The analysis was assessed as partially applicable (Canada) with potentially serious limitations. Treatment effects were estimated from a meta-analysis that included a few studies on congenital non-cancer related lymphoedema, that do not match the population specified in the protocol. Moreover, the size of the effect, 56.3% of people discontinuing compression garments therapy, was well above the treatment effect reported in the studies included in the clinical review, around 40%. Notably, the latter figure is just above the threshold of 36% identified by the authors as the minimum treatment effect for LVA to be cost-saving. Finally, the analysis did not include potentially important outcomes such as adverse events of surgery and recurrence. Given the study’s limitations, the cost-effectiveness of LVA in the UK remains uncertain.

The committee noted that LVA and Vascularized Lymph Node Transfer (VLNT) differ considerably, as the first requires around 3 hours in surgery and can be conducted out either under local or general anaesthesia, while the second requires most of the day in surgery and is performed under general anaesthesia. The clinical review found no statistically significant improvement with LVA but statistically significant benefits to arm volume following VLNT. The studies also reported that 41% of people partially or completely discontinue compression therapy after LVA, with a comparable figure of 45% following VLNT. Although this could potentially reduce future costs associated with future management of lymphoedema and improve quality of life, it remains unclear whether these benefits would offset the considerably large initial investment necessary for two types of microsurgeries, particularly if performed in isolation. The committee also acknowledged that, in current practice, management or preventive lymphoedema surgeries are done alongside other interventions, such as breast reconstruction or axillary lymph node dissection. In such scenarios, the cost of a lymphoedema surgery could be significantly lower, making this procedure more cost-effective if performed alongside other surgeries. Given the lack of strong economic and clinical evidence, the committee made a research recommendation for surgery, acknowledging the importance, particularly for people living with lymphoedema, of providing a variety of treatments, including surgery for severe cases. As there are currently only a few centres in the country providing lymphoedema microsurgery, any recommendation would potentially require more investment to make this service equally accessible for people across the country. Downstream NHS savings due to a reduced need for compression therapy would be expected to be approximately 40% of those undergoing surgery.

There was no economic evidence for manual lymphatic drainage (MLD) and the clinical review did not find any clear effect on lymphoedema. The committee acknowledged that MLD is labour intensive and is often carried out by specialist lymphoedema practitioners for several sessions, and therefore, could bear a significant cost for the NHS. Given the lack of strong evidence and the potential cost for the public healthcare, the committee decided not to make any recommendation on MLD.

The committee acknowledged that there is wide variability in access to lymphoedema services, noting that people are often required to buy their own garments and tapes. Of particular concern are items like Kinesio tapes, which are often not available on prescription, potentially exacerbating inequality and limiting access to treatments.

13.5. Other factors the committee took into account

The committee acknowledged the variable provision of lymphoedema services across the UK and recognised potential equality issues beyond just geography and cost. While access to services and the affordability of treatments like kinesiology tape are crucial concerns, the committee also considered other potential barriers identified in the EHIA. The committee considered that kinesiology tape is necessary to consider as an alternative, which allows for access of treatment for when compression therapy is inappropriate.

The committee considered that all the included studies only included women in their studies, they highlighted that men also are at risk of lymphoedema, however they decided it would be appropriate to extrapolate the findings for men.

13.6. Recommendations supported by this evidence review

This evidence review supports recommendations 2.1.1 to 2.1.6 and the research recommendations on developing lymphoedema core outcomes set, breast oedema management and surgical techniques for the management of lymphoedema.

14.1. Effectiveness

Randomised controlled trials and Randomised clinical trials included in systematic reviews

• Ali, Khadra Mohamed; El Gammal, Eid Rizk; Eladl, Hadaya Mosaad (2021) Effect of Aqua Therapy Exercises on Postmastectomy Lymphoedema: A Prospective Randomized Controlled Trial. Annals of rehabilitation medicine 45(2): 131–140 [PMC free article: PMC8137385] [PubMed: 33849087]
• Bahtiyarca, Zeynep Tuba, Can, Asli, Eksioglu, Emel et al. (2019) The addition of self-lymphatic drainage to compression therapy instead of manual lymphatic drainage in the first phase of complex decongestive therapy for treatment of breast cancer-related lymphoedema : A randomized-controlled, prospective study. Turkish journal of physical medicine and rehabilitation 65(4): 309–317 [PMC free article: PMC6935737] [PubMed: 31893267]
• Basoglu, C, Sindel, D, Corum, M et al. (2021) Comparison of complete decongestive therapy and kinesiology taping for unilateral upper limb breast cancer-related lymphoedema : A randomized controlled trial. Lymphology 54(1): 41–51 [PubMed: 34506086]
• Blom, Katarina Y, Johansson, Karin I, Nilsson-Wikmar, Lena B et al. (2022) Early intervention with compression garments prevents progression in mild breast cancer-related arm lymphoedema : a randomized controlled trial. Acta oncologica (Stockholm, Sweden) 61(7): 897–905 [PubMed: 35657063]
• Buchan, Jena, Janda, Monika, Box, Robyn et al. (2016) A Randomized Trial on the Effect of Exercise Mode on Breast Cancer-Related Lymphoedema. Medicine and science in sports and exercise 48(10): 1866–74 [PubMed: 27187092]
• Chmielewska, DD, Stania, M, Blaszczak, E et al. (2016) Intermittent pneumatic compression in patients with postmastectomy lymphoedema. Family medicine and primary care review 18(4): 419–424
• Cormie, Prue, Pumpa, Kate, Galvao, Daniel A et al. (2013) Is it safe and efficacious for women with lymphoedema secondary to breast cancer to lift heavy weights during exercise: a randomised controlled trial. Journal of cancer survivorship : research and practice 7(3): 413–24 [PubMed: 23604998]
• De Vrieze, Tessa, Gebruers, Nick, Nevelsteen, Ines et al. (2022) Manual lymphatic drainage with or without fluoroscopy guidance did not substantially improve the effect of decongestive lymphatic therapy in people with breast cancer-related lymphoedema (EFforT-BCRL trial): a multicentre randomised trial. Journal of physiotherapy 68(2): 110–122 [PubMed: 35428594]
• De Vrieze, Tessa, Gebruers, Nick, Nevelsteen, Ines et al. (2022) Does Manual Lymphatic Drainage Add Value in Reducing Suprafascial Fluid Accumulation and Skin Elasticity in Patients With Breast Cancer-Related Lymphoedema?. Physical therapy 102(12) [PubMed: 36209432]
• Dhar, Anita, Srivastava, Anurag, Pandey, Ravindra M et al. (2023) Safety and Efficacy of a Mobiderm Compression Bandage During Intensive Phase of Decongestive Therapy in Patients with Breast Cancer-Related Lymphoedema: A Randomized Controlled Trial. Lymphatic research and biology 21(1): 52–59 [PubMed: 35675677]
• Duygu-Yildiz, Elif; Bakar, Yesim; Hizal, Mustafa (2023) The effect of complex decongestive physiotherapy applied with different compression pressures on skin and subcutaneous tissue thickness in individuals with breast cancer-related lymphoedema : a double-blinded randomized comparison trial. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer 31(7): 383 [PMC free article: PMC10244831] [PubMed: 37285046]
• Ergin, Gulbin, Sahinoglu, Ertan, Karadibak, Didem et al. (2019) Effectiveness of Kinesio Taping on Anastomotic Regions in Patients with Breast Cancer-Related Lymphoedema: A Randomized Controlled Pilot Study. Lymphatic research and biology 17(6): 655–660 [PubMed: 31329507]
• Jonis, Y M J, Wolfs, J A G N, Hummelink, S et al. (2024) The 6 month interim analysis of a randomized controlled trial assessing the quality of life in patients with breast cancer related lymphoedema undergoing lymphaticovenous anastomosis vs. conservative therapy. Scientific reports 14(1): 2238 [PMC free article: PMC10817972] [PubMed: 38278856]
• Karafa, M; Karafova, A; Szuba, A (2018) The effect of different compression pressure in therapy of secondary upper extremity lymphoedema in women after breast cancer surgery. Lymphology 51(1): 28–37 [PubMed: 30248729]
• Kilbreath, S L, Ward, L C, Davis, G M et al. (2020) Reduction of breast lymphoedema secondary to breast cancer: a randomised controlled exercise trial. Breast cancer research and treatment 184(2): 459–467 [PubMed: 32812177]
• Kizil, Ramazan, Dilek, Banu, Sahin, Ebru et al. (2018) Is Continuous Passive Motion Effective in Patients with Lymphoedema? A Randomized Controlled Trial. Lymphatic research and biology 16(3): 263–269 [PubMed: 29338639]
• Lampinen, Riikka, Lee, Jeannette Q, Leano, Janella et al. (2021) Treatment of Breast Cancer-Related Lymphoedema Using Negative Pressure Massage: A Pilot Randomized Controlled Trial. Archives of physical medicine and rehabilitation 102(8): 1465–1472e2 [PubMed: 33872573]
• Ligabue, M B, Campanini, I, Veroni, P et al. (2019) Efficacy of self-administered complex decongestive therapy on breast cancer-related lymphoedema : a single-blind randomized controlled trial. Breast cancer research and treatment 175(1): 191–201 [PubMed: 30712198]
• Liu, Ying, Zhao, Xiaoyi, Song, Jian et al. (2023) The Effect of Manual Lymph Drainage and Compression Bandaging for Stage 2 Breast Cancer-Related Lymphoedema: A Randomized Controlled Trial. Lymphatic research and biology 21(5): 479–484 [PubMed: 37140566]
• Loudon, Annette, Barnett, Tony, Piller, Neil et al. (2016) The effects of yoga on shoulder and spinal actions for women with breast cancer-related lymphoedema of the arm: A randomised controlled pilot study. BMC complementary and alternative medicine 16: 343 [PMC free article: PMC5010718] [PubMed: 27590865]
• Loudon, Annette, Barnett, Tony, Piller, Neil et al. (2014) Yoga management of breast cancer-related lymphoedema: a randomised controlled pilot-trial. BMC complementary and alternative medicine 14: 214 [PMC free article: PMC4083036] [PubMed: 24980836]
• McNeely, Margaret L, Dolgoy, Naomi D, Rafn, Bolette Skjodt et al. (2022) Nighttime compression supports improved self-management of breast cancer-related lymphoedema : A multicenter randomized controlled trial. Cancer 128(3): 587–596 [PubMed: 34614195]
• Mestre, S, Calais, C, Gaillard, G et al. (2017) Interest of an auto-adjustable nighttime compression sleeve (MOBIDERM R Autofit) in maintenance phase of upper limb lymphoedema : the MARILYN pilot RCT. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer 25(8): 2455–2462 [PMC free article: PMC5486732] [PubMed: 28281052]
• Ochalek, Katarzyna; Kurpiewska, Joanna; Gradalski, Tomasz (2023) Adjustable Compression Wraps (ACW) vs. Compression Bandaging (CB) in the Acute Phase of Breast Cancer-Related Arm Lymphoedema Management-A Prospective Randomized Study. Biology 12(4) [PMC free article: PMC10135916] [PubMed: 37106735]
• Omar, Mohammed T A, Gwada, Rehab F M, Omar, Ghada S M et al. (2020) Low-Intensity Resistance Training and Compression Garment in the Management of Breast Cancer-Related Lymphoedema: Single-Blinded Randomized Controlled Trial. Journal of cancer education : the official journal of the American Association for Cancer Education 35(6): 1101–1110 [PubMed: 31243692]
• Omidi, Zahra, Kheirkhah, Masoomeh, Abolghasemi, Jamileh et al. (2020) Effect of lymphoedema self-management group-based education compared with social network-based education on quality of life and fear of cancer recurrence in women with breast cancer: a randomized controlled clinical trial. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation 29(7): 1789–1800 [PMC free article: PMC7295820] [PubMed: 32152817]
• Ozsoy-Unubol, T, Sanal-Toprak, C, Bahar-Ozdemir, Y et al. (2019) Efficacy of kinesio taping in early stage breast cancer associated lymphoedema : A randomized single blinded study. Lymphology 52(4): 166–176 [PubMed: 32171183]
• Park, Jin-Hyuck (2017) The effects of complex exercise on shoulder range of motion and pain for women with breast cancer-related lymphoedema : a single-blind, randomized controlled trial. Breast cancer (Tokyo, Japan) 24(4): 608–614 [PubMed: 28008557]
• Park, Yun-Jin; Na, Song-Ju; Kim, Myung-Ki (2023) Effect of progressive resistance exercise using Thera-band on edema volume, upper limb function, and quality of life in patients with breast cancer-related lymphoedema. Journal of exercise rehabilitation 19(2): 105–113 [PMC free article: PMC10164527] [PubMed: 37163184]
• Pasyar, Nilofar, Barshan Tashnizi, Nazanin, Mansouri, Parisa et al. (2019) Effect of yoga exercise on the quality of life and upper extremity volume among women with breast cancer related lymphoedema : A pilot study. European journal of oncology nursing : the official journal of European Oncology Nursing Society 42: 103–109 [PubMed: 31479846]
• Pujol-Blaya, Vicenta, Salinas-Huertas, Sira, Catasus, M Luisa et al. (2019) Effectiveness of a precast adjustable compression system compared to multilayered compression bandages in the treatment of breast cancer-related lymphoedema: a randomized, single-blind clinical trial. Clinical rehabilitation 33(4): 631–641 [PubMed: 30607986]
• Ridner, Sheila H, Dietrich, Mary S, Davis, Amanda J et al. (2020) A Randomized Clinical Trial Comparing the Impact of a Web-Based Multimedia Intervention Versus an Educational Pamphlet on Patient Outcomes in Breast Cancer Survivors with Chronic Secondary Lymphoedema. Journal of women’s health (2002) 29(5): 734–744 [PMC free article: PMC7247047] [PubMed: 31314661]
• Rockson, Stanley G, Whitworth, Pat W, Cooper, Andrea et al. (2022) Safety and effectiveness of a novel nonpneumatic active compression device for treating breast cancer-related lymphoedema : A multicenter randomized, crossover trial (NILE). Journal of vascular surgery. Venous and lymphatic disorders 10(6): 1359–1366e1 [PubMed: 35952956]
• Sanal-Toprak, C, Ozsoy-Unubol, T, Bahar-Ozdemir, Y et al. (2019) The efficacy of intermittent pneumatic compression as a substitute for manual lymphatic drainage in complete decongestive therapy in the treatment of breast cancer related lymphoedema. Lymphology 52(2): 82–91 [PubMed: 31525829]
• Schmitz, Kathryn H, Troxel, Andrea B, Dean, Lorraine T et al. (2019) Effect of Home-Based Exercise and Weight Loss Programs on Breast Cancer-Related Lymphoedema Outcomes Among Overweight Breast Cancer Survivors: The WISER Survivor Randomized Clinical Trial. JAMA oncology 5(11): 1605–1613 [PMC free article: PMC6696732] [PubMed: 31415063]
• Selcuk Yilmaz, Sedef and Ayhan, Fikriye Figen (2023) The Randomized Controlled Study of Low-Level Laser Therapy, Kinesio-Taping and Manual Lymphatic Drainage in Patients With Stage II Breast Cancer-Related Lymphoedema. European journal of breast health 19(1): 34–44 [PMC free article: PMC9806938] [PubMed: 36605467]
• Sen, Ekin Ilke, Arman, Sina, Zure, Mert et al. (2021) Manual Lymphatic Drainage May Not Have an Additional Effect on the Intensive Phase of Breast Cancer-Related Lymphoedema: A Randomized Controlled Trial. Lymphatic research and biology 19(2): 141–150 [PubMed: 33058746]
• Sener, Hulya Ozlem, Malkoc, Mehtap, Ergin, Gulbin et al. (2017) Effects of Clinical Pilates Exercises on Patients Developing Lymphoedema after Breast Cancer Treatment: A Randomized Clinical Trial. The journal of breast health 13(1): 16–22 [PMC free article: PMC5351459] [PubMed: 28331763]
• Singh, Ben, Buchan, Jena, Box, Robyn et al. (2016) Compression use during an exercise intervention and associated changes in breast cancer-related lymphoedema. Asia-Pacific journal of clinical oncology 12(3): 216–24 [PubMed: 26935243]
• Tantawy, Sayed A, Abdelbasset, Walid K, Nambi, Gopal et al. (2019) Comparative Study Between the Effects of Kinesio Taping and Pressure Garment on Secondary Upper Extremity Lymphoedema and Quality of Life Following Mastectomy: A Randomized Controlled Trial. Integrative cancer therapies 18: 1534735419847276 [PMC free article: PMC6509974] [PubMed: 31068019]
• Torres-Lacomba, Maria, Navarro-Brazalez, Beatriz, Prieto-Gomez, Virginia et al. (2020) Effectiveness of four types of bandages and kinesio-tape for treating breast-cancer-related lymphoedema: a randomized, single-blind, clinical trial. Clinical rehabilitation 34(9): 1230–1241 [PubMed: 32580577]
• Uzkeser, H and Karatay, S (2013) Intermittent pneumatic compression pump in upper extremity impairments of breast cancer-related lymphoedema. Turkish journal of medical sciences 43(1): 99–103

Systematic reviews

• Gao, Yu, Ma, Tingting, Han, Mei et al. (2021) Effects of Acupuncture and Moxibustion on Breast Cancer-Related Lymphoedema: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Integrative cancer therapies 20: 15347354211044107 [PMC free article: PMC8447094] [PubMed: 34521235]
• Jeffs, Eunice, Ream, Emma, Taylor, Cath et al. (2018) Clinical effectiveness of decongestive treatments on excess arm volume and patient-centered outcomes in women with early breast cancer-related arm lymphoedema: a systematic review. JBI database of systematic reviews and implementation reports 16(2): 453–506 [PMC free article: PMC5828398] [PubMed: 29419623]
• Kasawara, Karina Tamy, Mapa, Jessica Monique Rossetti, Ferreira, Vilma et al. (2018) Effects of Kinesio Taping on breast cancer-related lymphoedema: A meta-analysis in clinical trials. Physiotherapy theory and practice 34(5): 337–345 [PubMed: 29308967]
• Lin, Yan, Yang, Yan, Zhang, Xiaoyu et al. (2022) Manual Lymphatic Drainage for Breast Cancer-related Lymphoedema: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Clinical breast cancer 22(5): e664–e673 [PubMed: 35370085]
• Lytvyn, Lyubov (2020) Conservative intervention strategies for adult cancer-related lymphoedema: a systematic review and network meta-analysis. Number 5/September 2020 47(5): e171–e189 [PubMed: 32830803]
• Qiao, Jia, Yang, Li-Ning, Kong, Yu-Han et al. (2023) Effect of Manual Lymphatic Drainage on Breast Cancer-Related Postmastectomy Lymphoedema: A Meta-analysis of Randomized Controlled Trials. Cancer nursing 46(2): 159–166 [PubMed: 35324506]
• Rangon, Flavia Belavenuto, da Silva, Jessica, Dibai-Filho, Almir Vieira et al. (2022) Effects of Complex Physical Therapy and Multimodal Approaches on Lymphoedema Secondary to Breast Cancer: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Archives of physical medicine and rehabilitation 103(2): 353–363 [PubMed: 34407446]
• Rafn, B. S., Bodilsen, A., von Heymann, A., Lindberg, M. J., Byllov, S., Andreasen, T. G., Johansen, C., Christiansen, P., & Zachariae, R. (2023). Examining the efficacy of treatments for arm lymphoedema in breast cancer survivors: an overview of systematic reviews with meta-analyses. EClinicalMedicine, 67, 102397. 10.1016/j.eclinm.2023.102397 [PMC free article: PMC10751832] [PubMed: 38152415] [CrossRef]
• Winters, H, Tielemans, HJP, Paulus, V et al. (2021) A Systematic Review and Meta-Analysis of Vascularised Lymph Node Transfer for Breast Cancer Related Lymphoedema. Journal of vascular surgery. Venous and lymphatic disorders [PubMed: 34508873]
• Yeung, Wai and Semciw, Adam I (2018) Aquatic Therapy for People with Lymphoedema: A Systematic Review and Meta-analysis. Lymphatic research and biology 16(1): 9–19 [PubMed: 28346851]

14.2. Economic

• Linden, M. (2019). Economics of Lymphovenous Bypass. Plastic and reconstructive surgery; 2019; vol. 144 (no. 5); 751e–759e [PubMed: 31688749]
• Melgaard, D. (2016). What is the effect of treating secondary lymphoedema after breast cancer with complete decongestive physiotherapy when the bandage is replaced with Kinesio Textape? - A pilot study. Physiotherapy theory and practice 32(6): 446–451 [PubMed: 27260219]

Appendix A. Review protocols

Review protocol for the non-pharmacological management of lymphoedema in people who have, or have had, breast cancer (PDF, 198K)

Appendix B. Literature search strategies

Appendix C. Effectiveness evidence study selection

Download PDF (155K)

Appendix D. Effectiveness evidence

Appendix E. Forest plots

No meta-analyses of data were conducted; therefore no forest plots were produced.

Appendix F. GRADE tables

Appendix G. Economic evidence study selection

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Appendix H. Economic evidence tables

Download PDF (275K)

Appendix I. Excluded studies

Appendix J. Research recommendations – full details