This review found the use of compression bandages were likely to reduce upper limb volume and lymphoedema in patients with breast cancer who have had a breast and surrounding nodes removed. The review was well conducted, but the authors' conclusions on compression bandages are based on the results of one trial and the evidence may change in the future.

To evaluate the effectiveness and potential harms of physiotherapy methods in the treatment of lymphoedema in patients with breast cancer, and the treatment practices and costs of this treatment in Finland.

MEDLINE, CINAHL, PEDro and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for relevant studies from January 2004 to March 2008. Search terms were reported. EMBASE was also searched to November 2007. Reference lists from reviews and retrieved articles were also searched. Danish, English, Finnish, French, German, Norwegian and Swedish languages were included.

Published randomised controlled trials (RCTs) of patients experiencing lymphoedema after breast cancer treatment, who received physiotherapy treatment, were included in the review. Trials of surgical, dietary or pharmaceutical interventions were excluded.

The main outcome reported in all trials was change in lymphoedema. Follow-up periods were classified as either short term (less than six months), or long term (six months or longer).

The included trials evaluated compression bandages, compression sleeves, manual or mechanical lymphatic massage or drainage, pneumatic compression pumps, therapeutic exercise, and therapy modalities including lasers, heat, electricity or these in combination. Comparators included no treatment, sham therapy or other physiotherapy interventions.

Two reviewers independently screened the identified articles and any disagreements were resolved by a third reviewer.

Two reviewers assessed methodological quality using validity criteria and decision rules modified from Van Tulder in terms of selection, concealment, blinding, compliance, outcome assessment, completeness of follow-up, and the use of intention-to-treat analyses. The risk of bias was evaluated using the Cochrane Handbook.

Two reviewers extracted data on patients, interventions and outcomes.

The results from the included studies were presented in a narrative summary with accompanying tables.

Fourteen RCTs were included in the review (n=658 patients). The trials ranged in size from 10 to 150 patients. The risk of bias in two trials was judged to be moderate; the results of the remaining 12 RCTs were judged to have a high risk of bias. Follow-up in the trials ranged from two weeks to 12 months.

In one small trial with moderate risks of bias (n=50 patients), the combination of manual lymph drainage and compression bandages was compared with the use of compression bandages only in patients who had one breast and axillary nodes removed. Lymphoedema was significantly decreased in both groups (695mL to 260mL for the manual lymph drainage and compression bandages group; 672mL to 246mL for the compression bandages group). The difference between groups was not significant (between group difference 14mL, 95% CI 103 to 301), suggesting that there was no additional benefit from lymph drainage than that attained by the use of compression bandages alone.

In the second trial with moderate risk of bias (n=80 patients) evaluating the comparison of a pneumatic compression pump with no treatment, a decrease of 25% of lymphoedema was observed in both groups of patients who had partial or whole removal of one breast and axillary nodes.

Of the remaining 12 trials, which had a high risk of bias, 10 RCTs had compression bandages or compression sleeves as an add-on treatment in both groups. Decreases between 4 to 60% in lymphoedema were observed across the trials, although no statistically significant between-group differences were found.

Lymph therapy treatment for each patient (based on 2007 prices) would be 799 Euros, based on ten therapy sessions per year with compression bandages and gloves.

The available evidence suggested that compression bandages were likely to decrease upper limb lymphoedema in patients with breast cancer. Due to the poor quality of the trials, there was limited evidence of other physiotherapy methods and combinations, and there was no evidence for any outcomes except upper limb volume.

The review addressed a clear set of questions and criteria for inclusion were stipulated. Multiple electronic sources were searched. There may be some risk of publication and language biases due to the limited search for unpublished studies and the language restrictions applied. Steps were taken by the reviewers to minimise errors and bias through all parts of the review process.

The reviewers' decision to summarise the results in a narrative review appears justified, particularly as a variety of methods were used to estimate upper limb volume. The findings from the included studies were acknowledged by the authors to be associated with moderate to high levels of bias.

This was a well-conducted review and the authors' conclusions seem reasonable. However, the evidence regarding compression bandages was based on a single small trial. At the time of publication, there were several trials in progress and the evidence may change. The authors conclusions regarding the results and the paucity of good quality trials is likely to be reliable.

Practice: The authors did not state any implications for practice, but noted that the available evidence suggests that the use of compression bandages is likely to decrease upper limb lymphoedema in patients with breast cancer.

Research: The authors stated that further well-designed trials are required to ascertain the effectiveness of manual lymph drainage, guidance and therapeutic exercise using standardised outcomes. They also recommended that patient-related outcomes should also be measured, including the use of range of motion exercises, occurrence of soft tissue infections, overall functioning, work ability, experienced harms, and quality of life. Future systematic reviews should also include long-term observational studies.

Finohta (Finnish Office for Health Technology Assessment).

Anttila H, Karki A, Rautakorpi UM. Lymfaturvotuksen fysioterapia rintasyopapotilailla. Vaikuttavuus, kaytannot ja kustannukset. [Lymphoedema therapy in breast cancer patients. Effectiveness, current practices and costs.] Finohta report 30; 2007.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.