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CPG EXECUTIVE SUMMARY

An Executive Summary of the APTA Academy for Oncologic Physical Therapy Clinical Practice Guideline: Interventions for Breast Cancer–Related Lymphedema

Davies, Claire C. PT, PhD1; Levenhagen, Kimberly PT, DPT2; Ryans, Kathryn PT, DPT3; Perdomo, Marisa PT, DPT, MS4; Gilchrist, Laura PT, PhD5

Author Information
doi: 10.1097/01.REO.0000000000000223
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Abstract

Breast cancer–related lymphedema (BCRL), a sequela of cancer treatments, results in increased limb volume, which is associated with activity and participation restrictions.1 Incidence of BCRL varies depending on lymphedema definitions, assessments, and criteria. Significant factors associated with BCRL include high body mass index, axillary lymph node dissection (ALND), and regional lymph node radiation.2–5 McDuff et al2 reported the 5-year rate of lymphedema was highest in individuals receiving ALND and radiation therapy (31.2%). In this same study, early-onset BCRL (<12 months) was associated with ALND (Hazard Ratio [HR] = 3.86; P = .0001), whereas radiation therapy was associated with lymphedema occurring at greater than 12 months.2 Although onset of lymphedema varies with differences in breast cancer treatments, the overall risk of lymphedema peaked between 12 and 30 months.2

Interventions are necessary at various time points throughout the cancer trajectory, beginning at diagnosis and continuing through survivorship. Evidence-based recommendations can guide clinical decision-making for selecting appropriate interventions based on an individual's clinical presentation. A lymphedema staging model6 (Table 1) was adapted from the International Society of Lymphology (ISL) criteria,7 using patient presentation8 across trajectory of treatment and survivorship. This model6 was used as a framework to develop recommendations based on clinical implementation. Initially, this clinical practice guideline (CPG) was intended to address all secondary upper-quadrant lymphedemas. Unfortunately, because of lack of high-quality evidence in populations other than breast cancer, an evidence-based guideline could only be developed for BCRL.

TABLE 1 - Lymphedema Staging Modela
Patient Presentation8 Stages From the International Society of Lymphology7 Description of Stages
At risk Not applicable Individuals with insult to the lymphatic system but without symptoms or signs of lymphatic transport impairment.
Subclinical Stage 0 Subclinical state where swelling is not visible, but lymphatic transport is impaired by clinical measures. Symptoms and subtle tissue changes may be noted.
Early lymphedema Stage I Early onset of swelling that is visible and subsides with elevation. Pitting may be present.
Moderate lymphedema Stage II Consistent volume change with pitting present. Elevation rarely reduces the swelling and progressive tissue fibrosis occurs.
Late lymphedema Stage III Skin changes such as thickening, hyperpigmentation, increased skinfolds, fat deposits, and warty overgrowths occur. Tissue is very fibrotic and pitting is absent.
aReprinted by permission of Oxford University Press on behalf of the American Physical Therapy Association from the full-text guideline published in Physical Therapy at https://doi.org/10.1093/ptj/pzaa087.6

The Academy of Oncologic Physical Therapy of the APTA supported a CPG development in appropriate interventions for BCRL as a continuation of previous work on diagnosis. As stated in the full CPG,

The aim of this CPG was to identify interventions targeting the core impairments of increased interstitial fluid and volume of the upper extremity as a direct impact of BCRL. Although many other impairments, activity limitations, and participation restrictions can occur in individuals impacted by BCRL, this CPG was constructed to identify interventions that target these core impairments. Clinicians should consider the evidence presented in this guideline along with the clinical presentation of an individual, their goals, and patient preferences when establishing an appropriate plan of care.6

The purpose of this paper is to provide an executive summary of the full CPG for interventions for those with BCRL; the full CPG can be accessed here (https://academic.oup.com/ptj/article-lookup/doi/10.1093/ptj/pzaa087).

CRITICAL APPRAISAL PROCESS

Relevant research on the topic was amassed from multiple electronic databases, including PubMed and CINHAL, from January 2000 through March 2019. The APTA's Critical Appraisal Tool for Experimental Intervention Studies (CAT-EI) review tool was used to assess the quality of studies and assign a quality rating (Table 2).9

TABLE 2 - Quality Rating Scale for Individual Articlesa
Level Criteria
I High-quality RCTs: Met all 8 essential scoring items on Critical Appraisal Tool for Experimental Intervention Studies (CAT-EI), including randomized controlled trial of appropriate patient population and sample size, blinding of assessment, reliable and valid outcome measure, adequate follow-up, and appropriate statistical analysis.
II Acceptable quality: Evidence obtained from lesser quality clinical trials and met 6 of 8 quality indicators (eg, no blinding, short follow-up), high-quality prospective cohort studies or outcomes research.
III Low quality: Case-controlled studies, retrospective cohort studies, or other low-quality trials; met between 2 and 5 of essential scoring items on CAT-EI.
Unacceptable: Met 0 or 1 of the essential scoring items on CAT-EI
aReprinted by permission of Oxford University Press on behalf of the American Physical Therapy Association from the full-text guideline published in Physical Therapy at https://doi.org/10.1093/ptj/pzaa087.

The guideline development group assigned each intervention an evidence grade (Table 3) based on an overall appraisal of the quality of evidence available. High- and acceptable quality evidence, when available, was synthesized to produce recommendations.

TABLE 3 - Evidence Grades Based on the Quality of Evidencea
Grade Recommendation Criteria and Strength of Recommendation
A Strong High-quality studies (level I) with moderate to substantial benefit/harm—“must/should” or “must not/should not”
B Moderate High-quality studies (level I) with slight benefit/harm OR acceptable quality studies (level II) for moderate-level benefit/harm—“should” or “should not”
C Weak Acceptable quality studies (level II) for slight benefit/harm OR low-quality studies (level III) for substantial benefit/harm—“may” or “may not”
Best practice Best practice Based on current clinical norms or expert opinion
aReprinted by permission of Oxford University Press on behalf of the American Physical Therapy Association from the full-text guideline published in Physical Therapy at https://doi.org/10.1093/ptj/pzaa087.

INTERVENTION RECOMMENDATIONS

For the evidence that supports each recommendation, see the full CPG.6 The included information in the italics below is reprinted by permission of Oxford University Press on behalf of the American Physical Therapy Association© from the full text guideline published in Physical Therapy at https://doi.org/10.1093/ptj/pzaa087.

EARLY POSTOPERATIVE CARE/EARLY PREVENTIVE INTERVENTION10–17

Prior to the initiation of an intervention, the therapist should perform a thorough examination to identify impairments, activity, and participation restrictions. Due to of the complexity of each person's medical history and oncologic treatment plan, it is imperative that the therapist constructs the plan of care in collaboration with the interprofessional team. Therapists should perform a systems review due to the multisystem side effects from cancer-related treatments and variations in surgical approaches, comorbid conditions, and oncologic management. These side effects may require variances from the recommendations due to their effect on exercise tolerance. The therapist is a critical member of the interprofessional care team and should monitor the initiation and progression of an exercise program.

  • Postoperative exercise and resumption of activity should be coordinated with the interprofessional team and an individualized exercise program should be gradually increased while monitoring for adverse events. (Best practice)
  • Individually tailored exercises should be included postoperatively and gradually progressed. (Grade B)
  • In individuals who have undergone ALND:
    • The addition of therapist-provided manual lymphatic drainage (MLD) to the postoperative care plan may not reduce the risk of developing BCRL. (Grade C)
    • Provision of a fitted compression garment to patients at high risk of developing lymphedema, when paired with upper extremity exercise and diaphragmatic breathing, may reduce development of lymphedema. (Grade B)

PROSPECTIVE SURVEILLANCE MODEL AND IDENTIFIED SUBCLINICAL (ISL STAGE 0) LYMPHEDEMA18–26

  • Early identification of subclinical lymphedema in high-risk groups through prospective surveillance may improve outcomes. (Grade C)
    • Monitoring with bioimpedance spectroscopy or volume measures may begin with a preoperative assessment, repeated every 3 months for the first year postoperatively and then biannually for up to 5 years. (Grade C)
  • Intervention for subclinical lymphedema may include education, self-massage, and use of compression garments. (Grade C)
  • If early subclinical lymphedema persists or progresses after initial conservative intervention, individuals may benefit from more intensive interventions, such as complete decongestive therapy (CDT). (Grade C)

EXERCISE FOR INDIVIDUALS AT RISK FOR OR WITH SUBCLINICAL (ISL STAGE 0) BCRL27–32

  • Progressive resistance training is safe when an individualized program is supervised beginning at least 1 month postsurgery. (Grade A)
  • Individualized aerobic exercise programs should be provided. (Grade A)
  • Monitoring for exercise tolerance and adverse effects should initially occur at least weekly and then taper according to clinical presentation. (Grade A)

INTERVENTIONS RECOMMENDED FOR INDIVIDUALS DIAGNOSED WITH BCRL33–66

Early Lymphedema (ISL Stage I)

  • If early signs and/or symptoms of lymphedema are noted, the patient should be individually fitted with a compression garment, instructed in an exercise program, and provided education as first-line treatment. (Grade A)
    • If first-line treatment is not successful for early lymphedema, then CDT may be recommended. (Grade B)
    • Compression (garment or bandaging) should be tailored for the individual's lymphedema stage and impairments in consultation with the patient. (Grade A)

Moderate and Late Lymphedema (ISL Stages II and III)

  • CDT should be used to reduce limb volume in those diagnosed with moderate and late BCRL. (Grade B)
    • Compression bandaging and exercise are key components of CDT and should be used. (Grade A)
    • Modifying CDT, specifically shortening or omitting the MLD component, may yield similar results on long-term volume reduction. (Grade B)
    • In all treatment phases, compression interventions should be tailored to the individual's lymphedema stage, impairments, and preferences. (Grade A)
    • Kinesio tape may reduce volume but cannot be recommended to replace short-stretch compression bandaging in stage II and III BCRL. (Grade B)
      • If Kinesio tape is used in BCRL, clinicians should closely monitor for adverse events. (Grade B)
    • Once a stable volume reduction is achieved with phase I clinical treatment, a program of home care including self-MLD, individually fitted compression garment, appropriate nightly compression if indicated, and exercise should be recommended. (Grade B)
    • Use of a standard or advanced intermittent pneumatic compression device may be considered in phase II home care treatment. (Grade C)
    • Monitoring for volume changes with follow-up care may be an important component for optimal long-term volume reduction. (Grade C)
  • Low-level laser therapy may be considered in combination with either compression or CDT in patients with established lymphedema of the upper extremity. (Grade B)

For All Stages (ISL Stages 0-III) in Relation to Exercise29,32,67–78

  • Individualized programs of aerobic and resistance exercise should be provided for those who have BCRL (stages 0-III). (Grade A)
    • Resistance exercise should be initiated at low-level intensity and progressed slowly. (Best practice)
    • Individuals with comorbidities or complications due to cancer-related treatments should be referred to a specialist for evaluation and exercise prescription. (Best practice)
  • Sequential proximal to distal exercises incorporating diaphragmatic breathing should be used to improve volume reduction. (Grade B)
  • Compression use with exercise may have benefits. (Grade B)
  • Yoga may be a safe form of exercise but does not show evidence of effectiveness for lymphedema volume reduction. (Grade C)

For All Stages (ISL Stages 0-III) in Relation to Other Therapeutic Modalities79–82

  • The addition of myofascial therapy to stretching, exercise, and scar massage may be safe in patients greater than 3 months post–radiation therapy who are at risk for BCRL. (Grade C)
  • Acupuncture has insufficient evidence to support use for volume reduction. (Grade C)

OVERALL CLINICAL PRACTICE RECOMMENDATIONS

The recommendations in this Executive Summary are intended to guide the clinician in selecting the most appropriate and effective interventions based on BCRL stage. Since the aim of this Executive Summary was to identify interventions that reduce excess interstitial fluid and overall limb volume, other intervention studies that investigated quality of life, function, and pain were not included. Therefore, use of additional interventions to target these impairments, activity limitations, and participation restrictions is likely warranted on the basis of an individual's needs. It is important to consider that literature published after the evidence review was completed could change these recommendations. Readers are encouraged to refer to the full CPG and original articles for specific information regarding the interventions and their related research studies. As cancer treatments and the patients' response to these treatments are heterogeneous in nature, it is important to consider the individual's presentation, impairments, activities and participation restrictions, goals, as well as clinical expertise, when incorporating the recommendations into practice.

The limitations of this Executive Summary are that patients were not included in the development of the recommendations, there was limited input by clinicians other than physical therapists, and high-level evidence for interventions was scarce. High-quality research is needed that stratifies the outcomes of interventions by well-defined lymphedema stages and investigates other forms of cancer-related lymphedema.

ACKNOWLEDGMENTS

The following people were involved in quality reviews of the literature; Kathy Bartley, PT, DPT, MHA, CLT; Chris Beuthin, PT, DPT, GCS, CLT; Linda Boyle, PT, CLT-LANA; Jennifer Brooks, PT, DPT, CLT-LANA; Barbara Feltman, PT, DHS, CLT-LANA; Amy Flinn, PT, CLT-LANA; Brandi Johnson, PT, DPT, CLT-LANA; Megan Kaley, PT, DPT, WCS, CLT-LANA; Jean Kastner, PT, DPT, CLT-LANA; Kiersten Kilczewski, PT, DPT, CLT-LANA; Linda Koehler, PT, PhD, CLT-LANA; Vince Lepak, PT, DPT, MPH, CWS; Anne Lehman, PT, CLT-LANA, CMTPT; Vicki Naugler, PT, CLT-LANA; Lisa O'Block, PT, DPT; Nancy Potter, PT; Kristin Ryan, PT, DPT, CLT; and Christina Wright, PT, DPT, CLT.

The following people provided feedback on initial drafts of the CPG: Connie Brenna, BSN, RN; Cheryl Brunelle, PT, MS, CCS, CLT; Carmela Claypool, PT, CLT-LANA; Diane Galvin, PT; Nancy Hutchison, MD; Leslen Keith, OTD, CLT-LANA; Guenter Klose, CLT-LANA; Linda Koehler, PT, PhD, CLT-LANA; Jenette Lee, PT, PhD, CLT, CSCS; Patricia O'Brien, PT, MD; Lucinda Pfalzer, PT, PhD; Antionette Sanders, PT, DPT; Betty Smoot, PT, DPTSc; Bryan Spinelli, PT, PhD; Nicole Stout, PT, DPT, CLT-LANA; Linda Tripp, PT, DPT; Nadia Van Diepen, PT, DPT, CLT-LANA, WCC; Megan Webster, PT; Jan Weiss, PT, CLT-LANA; and Jodi Winicour, PT, CLT-LANA

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Keywords:

breast neoplasm; evidence-based practice; secondary lymphedema; treatment

© 2020 Academy of Oncologic Physical Therapy, APTA.