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The Risk Reduction and Management of Secondary Lymphedema Guideline Summary

(O): Sept. 26, 2011 (R):
Date Signed:
May 23, 2012
Tumor Group:
Breast Disease Site Group
Issuing Authority:
Dr. Kara Laing, Clinical Chief,
Cancer Care Program
Adapted From:
The Northern Ireland, Clinical Resource Efficency Support Team's "guideline for the diagnosis, assessment and management of lymphodema", February 2008 (18).

Target Population:
These recommendations are aimed toward patients whom are at risk for or whom have been diagnosed with secondary lymphedema.

All patients diagnosed with secondary lymphedema, related to cancer or its treatment, should have access to effective and efficient management of the condition.

Supporting Evidence:
Lymphedema management requires a comprehensive approach that includes assessment, therapy, early detection, and education of risk reduction strategies. The current “gold standard” of managing lymphedema is called complete or complex decongestive therapy (CDT) which includes manual lymphatic drainage (MLD), various forms of compression, skin care and exercise (1,2). Though, literature is limited, there does appear to be consensus among the available clinical trials, that combination CDT is more effective than the individual components alone (3-12).

CDT may need to be modified in the presence of complex co-morbidities (ie. advanced localized cancer) or due to patient choice. CDT has been divided into 2 phases, the intensive and the maintenance phases. In the intensive phase of treatment, the goal is the initial reduction of the lymphedema volume of the affected area. It may require daily treatments (5 days per week) with a therapist for 2-6 weeks. Once maximum volume reduction of the area is achieved, the patient is transitioned to a long-term maintenance phase. This phase of treatment encourages the transfer of care from the professional to patient/caregivers and continues for the rest of the patient’s life. It may include regular follow-ups or further intensive treatment when necessary.

Consistent evidence suggests that limb circumference measurement is a reliable method, with a finding of a 2 cm or more difference between that of the affected and unaffected limb, being indicative of lymphedema (13-15).

Since 2005, the Dr. H. Bliss Murphy Cancer Centre has employed a full time lymphedema nurse coordinator, who has completed specialized training in the care and management of cancer- related lymphedema. The service is available upon request from health professionals, but self-referrals from patients are also accepted. The referral form has been included in the complete guideline on this topic and is also available on-line at .

NOTE: The coordinator or lymphedema therapist will require the patient to have undergone a clinical examination by the family physician, surgeon or oncologist prior to commencement of treatment.

Qualifying Statements:

  • Two main classes of drugs have been used in the treatment of lymphedema, benzopyrones and diuretics. A Cochrane review of benzopyrones was completed and revealed no conclusive evidence of their effectiveness in secondary lymphedema treatment (16). The steering committee for Health Canada’s Canadian Breast Cancer Initiative warned against the use of diuretics for lymphedema, due to the possible adverse effects of hypotension, dehydration and electrolyte imbalance (17). Therefore, benzopyrones or diuretics are not recommended for use in the treatment of lymphedema.
  • Other therapies have been researched to determine their usefulness in the treatment of lymphedema, such as low-level laser (LLL) therapy and the use of hyperbaric oxygen therapy. To date there is not enough evidence to support the use of either in the treatment of lymphedema.
  • To view a list of Lymphedema Risk Reduction Practices or an Antibiotic Treatment Table for lymphedema-induced cellulitis, please see our complete guideline “the risk reduction and management of secondary lymphedema” on our website as seen below.

These guidelines are a statement of consensus of the Breast Disease Site Group regarding their views of currently accepted approaches to diagnosis and treatment. Any clinician seeking to apply or consult the guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment.

Contact Information:
For more information on this guideline, please contact:
Ms. Martina Reddick RN, Lymphedema Coordinator
Dr. H. Bliss Murphy Cancer Center
St. John’s, NL
Telephone 709-777-8713
For the complete guideline on this topic or for access to any of our guidelines, please visit our Cancer Care Program website

Literature Support:
  1. Preston NJ, Seers K, et al. Physical therapies for reducing and controlling lymphoedema of the limbs. Cochrane Database Systematic Reviews 2004 (Rev. 2008), Issue 4, Art. No.: CD003141. DOI: 10.1002/14651858.CD003141.pub2.
  2. Poage E, Singer MB, et al. Oncology Nursing Society demystifying lymphedema: Development of the lymphedema ‘putting evidence into practice® card’. Clin J Oncol Nur. 2008;12(6):951-964.
  3. Hinrichs CS, Gibbs JF, et al. The effectiveness of complete decongestive physiotherapy for the treatment of lymphedema following groin dissection for melanoma. J Surg Oncol. 2004; 85:187-192.
  4. Didem K, Ufuk YS, et al. The comparison of two different physiotherapy methods in treatment of lymphedema after breast surgery. Breast Cancer Res Treat. 2005; 93:49-54.
  5. Howell D, Watson M. Evaluation of a pilot nurse-led, community-based treatment programme for lymphoedema. Inter J Pallat Nurs. 2005; 11(2):62-69.
  6. Vignes S, Porcher R, et al. Predictive factors of response to intensive decongestive physiotherapy in upper limb lymphedema after breast cancer treatment: a cohort study. Breast Cancer Res Treat. 2006; 98:1-6.
  7. Vignes S, Porcher R, et al. Long-term management of breast cancer-related lymphedema after intensive decongestive physiotherapy. Breast Cancer Res Treat. 2007;101:285-290.
  8. Moseley AL, Carati CJ, et al. A systematic review of common conservative therapies for arm lymphoedema secondary to breast cancer treatment. Ann Oncol. 2007; 18(4):639-646.
  9. Koul R, Dufan T, et al. Efficacy of complete decongestive therapy and manual lymphatic drainage on treatment-related lymphedema in breast cancer. Int J Radiation Oncol Biol Phys. 2007; 67(3):841-846.
  10. Hamner JB, Fleming MD. Lymphedema therapy reduces the volume of edema and pain in patients with breast cancer. Ann Surg Oncol. 2007;14(6):1904-1908.
  11. Karadibak D, Yavuzsen T, et al. Prospective trial of intensive decongestive physiotherapy for upper extremity lymphedema. J Surg Oncol. 2008;97:572-577.
  12. National Breast and Ovarian Cancer Centre. Review of research evidence on secondary lymphoedema: incidence, prevention, risk factors and treatment. Australia. March 2008.
  13. Taylor R, Jayasinghe UW, et al. Reliability and validity of arm volume measurements for assessment of lymphedema. Phys Ther. 2006;86(2):205-214.
  14. Chen YW, Tsai HJ, et al. Reliability study of measurements for lymphedema in breast cancer patients. Am J Phys Med Rehabil. 2008;87(1):33-38.
  15. Lymphatic Research Foundation. Lymphedema glossary. Updated 2010-11-03.
  16. McNeely ML, Peddle CJ, et al. Conservative and dietary interventions for cancer-related lymphedema: A systematic review and meta-analysis. Cancer. 2011;117:1136-1148.
  17. McWayne J, Heiney SP. Psychologic and social sequelae of secondary lymphedema: a review. Cancer. 2005; 104(3):457-466.
  18. Clinical Resource Efficiency Support Team (CREST). Guidelines for the diagnosis, assessment and management of lymphoedema. Northern Ireland. February 2008.





Downloadable Documents:
Risk Reduction and Management

Updated Aug 17, 2012