Try Compression Sleeves First for Early Lymphedema

Fran Lowry

September 25, 2013

A trial that randomized women with early lymphedema to receive either complex decongestive therapy (CDT) or compression garments was unable to show that CDT is better than the more conservative, less expensive approach.

Several cohort studies have suggested that CDT — which consists of manual lymphatic massage or drainage, daily bandaging, exercise, and skin care — is superior to compression sleeves for the treatment of lymphedema.

However, a group of Canadian researchers who thought the evidence for such superiority was not good enough decided to conduct a randomized trial to find a definitive answer.

"I actually thought that our study was going to show that complex decongestive therapy was better, but, in fact, it didn't seem to be any more beneficial than elastic compression sleeves, which are much, much cheaper," said lead author Ian S. Dayes, MD, from McMaster University in Hamilton, Ontario.

The results were published online September 16 in the Journal of Clinical Oncology.

More Evidence to Start Conservatively

Dr. Benjamin Anderson

These results add to the mounting evidence against CDT as a first-line treatment for early lymphedema, write Sara H. Javid, MD, and Benjamin O. Anderson, MD, both from the University of Washington in Seattle, in an accompanying editorial.

However, medical insurers should not take these results to mean that CDT is of no value and use them to justify not paying for the treatment, Dr. Anderson emphasized in an interview with Medscape Medical News.

"That is a very specific concern of mine, and is addressed in the editorial," he said.

"As the authors point out, CDT adds a significant cost beyond that of compression garments alone," the editorialists write. "In the modern era of pay-for-performance, this study provides sound evidence that CDT should not be employed as a first-line therapy for those with early lymphedema. Because this study is likely to be cited by insurers as a rationale for denying payment for CDT lymphedema management, the limitations of the study should be clearly noted."

Those limitations are that CDT was tested as a first-line treatment and was not tested in women with advanced disease who have longer-standing, more extensive, or progressive lymphedema.

"The women in the study were enrolled between 2003 and 2009 and their lymphedema was not advanced; it was early," Dr. Anderson explained.

Study Results

In the study, Dr. Dayes and his team enrolled 103 women from 6 centers who had been previously treated for breast cancer and who had lymphedema.

The women, who had a minimum volume difference of 10% between their arms, were randomized to either CDT or compression sleeves. The primary outcome measure was the percent reduction in excess arm volume from baseline to 6 weeks.

The mean reduction in excess arm volume with CDT was 29.0% and with compression sleeves was 22.6% (95% confidence interval [CI], –6.8% to 20.5%; P = .34).

Absolute volume loss was greater with CDT than with compression sleeves (250 vs 143 mL; 95% CI, 13 to 203; P = .03). However, there was no difference between groups in the proportion of patients who lost 50% or more of their excess arm volume.

In addition, quality of life, measured with the Short Form-36 Health Survey, and arm function were similar in the 2 groups.

"I would like for patients and caregivers to recognize that massage-based treatments should not be the first line of treatment, which I think has been the case," Dr. Dayes noted.

"Despite the fact that a couple of previous randomized trials showed a lack of benefit, people were still recommending massage-based treatments for patients with lymphedema," he told Medscape Medical News. "I think it's probably in the patient's best interest to realize that the benefit really wasn't there, or rather that the benefit is no greater, or marginally greater, than an elastic sleeve. In addition, those women didn't have to go for daily massage and bandaging for 4 weeks in a row."

Resistant Lymphedema: A Different Story

This study does not address more advanced disease, nor does it address disease that has failed first-line therapy, Dr. Anderson emphasized.

"It would be quite logical to use CDT as second-line treatment for resistant lymphedema," he said.

Dr. Anderson, who is a breast surgeon, explained that lymphedema has become a major concern because it has been neglected for so long.

"In the 1980s, we surgeons really didn't pay attention to lymphedema because we thought it was incurable. In those days, when complete axillary lymph node dissection was the only option, and when physical therapy techniques were not well accepted or established, we largely ignored this problem," he said.

"It was the patient community that raised awareness that there are things that can be done, and they can be effective," Dr. Anderson pointed out. "The fact that people are concerned about this, in part, has to do with the fact that we did not do a good job in the past. We're doing much better in terms of paying attention and trying to identify the best treatment strategies. I think this research into the best treatment is part of our trying to correct that."

Dr. Dayes and Dr. Anderson have disclosed no relevant financial relationships.

J Clin Oncol. Published September 16, 2013. Abstract, Editorial

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