Practice Uncertainties

Which are the best conservative interventions for lymphoedema after breast cancer surgery?

BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2330 (Published 01 June 2017) Cite this as: BMJ 2017;357:j2330
  1. Martijn M Stuiver, clinical epidemiologist,, associate professor1 2 3,
  2. Marieke R ten Tusscher, physiotherapist1,
  3. Margaret L McNeely, associate professor4
  1. 1Netherlands Cancer Institute, Department of Physiotherapy. Amsterdam, Netherlands
  2. 2Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
  3. 3ACHIEVE, Faculty of Health, University of Applied Sciences Amsterdam, Amsterdam, Netherlands
  4. 4University of Alberta and Cross Cancer Institute, Department of Physical Therapy, Edmonton, Canada
  1. Correspondence to m.stuiver{at}nki.nl
  • Accepted 2 May 2017

What you need to know

  • An estimated 20% of women who have been treated for breast cancer will develop lymphoedema

  • Advise patients to watch for early symptoms such as swelling, feelings of heaviness, or tension in the skin of the arm or the breast

  • Lymphoedema might be prevented or treated using one or more conservative approaches including patient education, physical exercise, manual lymphatic drainage, and compression therapy

  • Evidence for the effectiveness of any of these interventions, alone or in combination, is limited

Lymphoedema is a common complication of breast cancer surgery with or without adjuvant cancer treatments.1 Fluid accumulates because of damage to the lymphatic system, most commonly after axillary lymph node dissection. Box 1 shows factors associated with lymphoedema. Swelling is commonly in the arm but can involve the chest or back; it can result in pain, dysfunction, and disturbance of body image.3

Box 1: Risk factors for breast cancer related lymphoedema with reported ranges of odds ratios (OR)1

Factors related to disease and treatment
  • Higher number of metastatic lymph nodes: OR 1.1-2.8

  • Axillary lymph node dissection: OR 1.3-6.7

  • Greater number of lymph nodes dissected: OR 1.0-2.1

  • Mastectomy: OR 2.7-7.4

  • Radiotherapy: OR 1.7-3.8

  • Chemotherapy: OR 1.6-2.0

Other factors
  • High BMI: OR 0.1-5.5 per point increase

  • Lack of participation in regular physical activity: OR 2.1-6.1

  • Development of an infection in the limb at any time after breast cancer treatment: OR 2.17; 95% confidence interval: 0.93-5.082

Nearly 1 in 5 women who survive breast cancer develops lymphoedema within two years of diagnosis or surgery, with the incidence increasing with time.13 In recent years, sentinel lymph node biopsy has been implemented as standard care and has greatly reduced the incidence of lymphoedema. This means that women with clinically positive lymph nodes undergo the higher risk axillary lymph node dissection, but others can avoid the procedure.

Lymphoedema cannot be completely cured, although it can be managed and perhaps prevented. Box 2 and figure 1 outline non-surgical strategies …

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