MD, PhD, FMedSci, FSB, FRCP, FRCPEd

Lymph oedema in the arms or legs is a frequent complication after lymph-node dissections for cancer. Treatment or prevention can be difficult, and the results  are often unsatisfactory. Consequently, the burden of suffering of cancer patients affected by this problem is immense.

Amongst several options, a little-known massage technique, called lymph-drainage (or lymphatic drainage, LD), is sometimes recommended. It consists of gentle manual movements which lightly push the lymph fluid through the lymphatic vessels that eventually enter into the blood circulation. During a session of lymph-drainage, a specially trained massage therapist lightly moves his or her hands along the lymph vessels to facilitate the lymph flow. The treatment is agreeable and relaxing, but does it really reduce the oedema?

A recent systematic review and meta-analysis of RCTs evaluated the effectiveness of LD in the prevention and treatment of breast-cancer related lymph-oedema. The primary outcome for prevention was the incidence of postoperative lymph-oedema. The outcome for management of  was a reduction in oedema volume.

In total, 10 RCTs with altogether 566 patients were identified. Two studies evaluating the preventive outcome of LD found no significant difference in the incidence of lymph-oedema between the LD and standard treatments. Seven studies assessed the reduction in arm volume, and found no significant difference between the LD and standard treatments.

The authors conclusion was negative about the value of LD: The current evidence from RCTs does not support the use of LD in preventing or treating lymph-oedema. However, clinical and statistical inconsistencies between the various studies confounded our evaluation of the effect of LD on breast-cancer-related lymph-oedema.

Perhaps a brand-new clinical trial which had not been included in the above assessment would have persuaded the authors to be a little more optimistic. This study evaluated the effectiveness of LD in the prevention of lymph-oedema after treatment of breast cancer. The study-population consisted of 67 women, who had undergone surgery for breast cancer. From the second day of surgery, 33 randomly chosen women were given LD. The control group consisted of 34 women who did not receive LD. Measurements of the volumes of both arms were taken before surgery and on days 2, 7, 14, and at 3 and 6 months after surgery.

Among the women who did not have LD, a significant increase in the arm volume on the operated side was observed after 6 month. There was no statistically significant  increase in the volume of the upper limb on the operated side in women who underwent LD.

The authors conclude that regardless of the surgery type and the number of the lymph nodes removed, LD effectively prevented lymph-oedema of the arm on the operated side. Even in high risk breast cancer treatments (operation plus irradiation), LD was demonstrated to be effective against arm volume increase. Even though confirmatory studies are needed, this study demonstrates that LD administered early after operation for breast cancer should be considered for the prevention of lymph-oedema.

So, does LD reduce oedema or not? This does not seem to be such a difficult question that it should take decades to resolve! And who would doubt that it is an important one? Lymph-oedema has the potential to seriously impede the quality of life of many patients, and it can even contribute to unnecessary mortality. The fact that the few available studies are too small and too weak to generate reliable results is disappointing and shines a dim light on the supposedly patient-centred research in oncology, in my view.

The concept of LD is plausible, at least some of the findings from clinical trials are encouraging, and the problem of lymph-oedema is both prevalent and relevant. So what is stopping us from funding a large, well-designed and definitive study?

13 Responses to Lymph-drainage, a hope for cancer patients?

  • I enjoyed reading your article. It would be nice to have a large clinical trial.

  • Yes we definitely need robust RCT ‘s into Manula lymphatic Drainage Massage.(mld) I use it daily as a component of treatment in lymphoedema of the limbs., alongside compression hosiery. However lymphoedema of the face, breast and genitals is more difficult to control. Effective compression garments for these areas is very difficult to achieve, but MLD CAN effectively redirect lymph away from areas of congestion to alternative drainage pathways. Patients who perform daily lymph drainage massage for these areas can prevent lymph accumulating in areas with damaged drainage pathology.
    BUT, unlike a limb, we cannot accurately measure volume of head/neck/face/breast/genital swelling.
    Although L dex devices being developed may in the future be able to do so, thus opening the way for far more robust investigations.

  • SUE HANSARD said:

    Yes we definitely need robust RCT ‘s into Manula lymphatic Drainage Massage.(mld) I use it daily…

    What RCTs do you think are needed?

  • We definitely need robust RCT to establish the effectiveness/not of MLD for the treatment and control of secondary lymphoedema of the face (common after treatment for head and neck cancers due to surgical removal and radiotherapy damage of superficial and deeper lymphatics), genital lymphoedema ( male and female) secondary to radiotherapy/ surgery and also trauma such as sports cycling, breast oedema, secondary to treatment for breast cancer with surgery and radiotherapy. None of which are successfully fully managed with compression bandaging and / compression garments, due to inability to achieve therapeutic graduated compression on these body areas. The impact of such oedema is life changing for patients.
    Anecdotally (and photographically recorded) MLD/LYMPHOEDEMA specialists DO achieve reduction in volume of swelling and softening of subcutaneous tissues, with improvement to skin condition and comfort for patients, but as yet we have no means to measure this accurately.

    • Can you explain why you provide these treatments knowing you have no good evidence that they are safe or effective?

      Why aren’t these trials being done?

      • @ Alan – you asked: “Can you explain why you provide these treatments knowing you have no good evidence that they are safe or effective?”

        In her comment, Sue said “MLD/LYMPHOEDEMA specialists DO achieve reduction in volume of swelling and softening of subcutaneous tissues, with improvement to skin condition and comfort for patients…”

        I would assume that Sue is suggesting study so that more people will try it…not because she’s questioning whether or not it works. But that’s an assumption.

  • Yes Jim, that is what I meant. We follow the Best Practice document of the British and European Lymphology societies (all peer reviewed) and based on international concensus on the management of this life long life changing condition. We know a lot about the physiology and anatomy of the systems and have robust scientific research (Leduc, Olzewski , Mortimer and many others ) to support this, but only relatively small studies on the actual `live’ physiological changes which MLD achieves within the superficial lymphatics over which we work. Limbs are easier to measure and monitor than the other body parts I mentioned, for obvious reasons.

    • I’m not sure any of that makes much difference: you are still doing something for which you have no good evidence for efficacy and, I assume, safety (other than a few small trials). It may be efficacious and safe, but it would appear you have no good evidence to substantiate that.

      This brings us back to doing trials: are any being done and if not, why not? You mentioned difficulties measuring volumes: this doesn’t sound like a particularly difficult problem to resolve with modern metrology.

  • I think the reason is cost/funding. Lymphoedema is a cinderella medical condition which although life long, patients have to constantly battle for funding for treatment in the uk . The majority of Lymphoedema service provision in the UK are charity funded and small, only a few are NHS led, and they often only treat limb swelling, not head, neck, breast or genital oedema.

    Equipment for measuring limb volume is available and used in all services (usually tape measures and a calculator/computer programme!), but not for measuring volume in genital/facial/breast regions. Cash strapped services haven’t got surplus for research/ expensive equipment: it is used to provide treatment for those with this debilitating, life changing, life long condition.

    So we do need some ££’s put into it.

    • I’m still don’t understand why this research that seems so desperately needed is not being done now! Surely it is imperative that you (collectively) do the research that (perhaps) gives you good evidence that what you do is both effective and safe – not for your sake, but for theirs? What if you are harming patients?

      How much would it cost?

  • I use LD regularly. There is clearly no doubt that it achieves results that can be measured as I do.

    Problem is that it is temporary. Lasts about a day or two.
    So I consider it palliative. The patient knowing it is palliative, temporary but happy and relieved to have an almost normal limb for a day or two.

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