McNeely, M.L., Peddle, C.J., Yurick, J.L., Dayes, I.S., & Mackey, J.R. (2011). Conservative and dietary interventions for cancer-related lymphedema: A systematic review and meta-analysis. Cancer, 117(6), 1136–1148.

To update evidence from randomized controlled trials (RCTs) regarding benefits of conservative and dietary interventions for all cancer-related lymphedema

Databases searched were MEDLINE, EMBASE, CINAHL, PubMed, Dissertation Abstracts, PEDro, and Cochrane Collaboration. Keywords were neoplasm, axillary dissection lymph node excision, lymphedema, conservative treatments (e.g., stockings compression, manual drainage), and publication types of random allocation and clinical trial. Studies were included in the review if they were RCTs with a sample of at least 80% patients with cancer comparing a conservative or dietary intervention to placebo, control, or comparison intervention in secondary lymphedema from cancer. Exclusion criteria were not specified.

Of the 157 papers that were initially retrieved, a final set of 25 were included. A modified Jadad scoring was used to evaluated the quality of the evidence. Only eight studies met criteria for high quality. Meta-analysis was done for studies examining the effect of manual lymph drainage (MLD)for upper-extremity lymphedema with breast cancer.

• The final sample of 25 papers involved 1,018 participants.
• Study sample sizes ranged from 11–90.
• Of the 25 papers, 21 were in patients with breast cancer.

Results were synthesized in terms of effects on lymphedema volume and patient-rated outcomes of pain, heaviness, tenderness and quality of life for nine interventions. Most studies were limited to upper extremities; where lower extremities were included is stated below.

• Strong evidence from three studies on exercise showed neutral impact on volume and benefit in symptoms and quality of life with upper extremities.
• There was moderate evidence from one study on compression bandaging for lower- and upper-extremity volume reduction and no evidence related to symptoms
• Compression Garments
• Moderate evidence found volume reduction for upper and lower extremities with compression garments. No evidence was found related to symptoms.
• Three studies had no evidence of benefit of MLD for symptoms; volume of lymphedema was not reported.
• One study showed moderate benefit related to short-term volume for deep mechanical oscillation with MLD and moderate evidence of benefit for symptoms in the short term but not at follow up.
• One study showed no evidence of any benefits from mechanically stimulated MLD.
• One study showed limited short-term benefit in lymphedema volume, but no evidence of benefit for symptoms with dietary modification.
• Four studies showed limited evidence of benefit in the short and long term for laser therapy ,and three showed limited evidence for benefit related to pain.
• One study provided no evidence of benefit from electrically-stimulated lymphatic drainage
• Four studies provided conflicting evidence, with two showing benefit in volume and two showing no benefit from intermittent pneumatic compression.
• Meta-analysis results found five studies including 198 cases examined the addition of MLD to compression therapy alone or compression therapy along with other interventions. 
• Analysis showed that the addition of MLD was beneficial (SD = 0.37, 95% CI 0.07–0.67, p = 0.02)

Meta-analysis demonstrated significant but relatively small benefit from the addition of MLS in patients with breast cancer-related lymphedema. Findings support the growing body of evidence that participation in exercise does not exacerbate lymphedema and can reduce the severity of symptoms. Only two studies were found that examined nutrition and dietary interventions; these reported benefit in terms of volume reduction, but were of relatively low quality. Evidence suggests that compression garments and bandaging are effective in reducing limb volume with various types of cancer.

Only eight studies in this review were deemed to be of high quality.

Inclusion of MLD provides a relatively small added benefit and may be associated with substantial costs. It is not clear if the benefits outweigh the cost and MLD may be most useful for patients who do not achieve sufficient improvement with other effective approaches. Findings related to dietary interventions are promising, pointing to the value of additional research in this area. Breast cancer continues to be the most frequently studied group. Research in other groups and with lower-limb lymphedema is needed.