Original Article

Manual lymphatic drainage for breast cancer-related

lymphoedema
Y. SHAO, PHD, MEDICAL ONCOLOGIST, Department of Oncology, Tianjin Medical University General Hospital,
Tianjin, & D.-S. ZHONG, MD, PROFESSOR OF ONCOLOGY, Department of Oncology, Tianjin Medical University
General Hospital, Tianjin, China

SHAO Y. & ZHONG D.-S. (2016) European Journal of Cancer Care

Manual lymphatic drainage for breast cancer-related lymphoedema

Breast cancer-related lymphoedema (BCRL) is a common sequela of surgical or radiation therapy of breast
cancer. Although being an important part of conservative therapy, the role of manual lymphatic drainage
(MLD) on BCRL is still debating. The objective of the current systematic review and meta-analysis was to
determine whether the addition of MLD to the standard therapy (ST) could manage BCRL more effectively.
We searched PubMed, EMBASE and Cochrane Library for related randomised clinical trials to compare the
volume reduction, improvement of symptoms and arm function between groups with or without MLD.
Four randomised controlled trials, with 234 patients, were included. Results showed there was a significant
difference in volume reduction between MLD plus routine treatment and sole routine treatment. Current
trials show that adding MLD to the ST could enhance the effectiveness of treating volume reduction of
lymphoedema, but might not improve subjective symptoms or arm function.

Keywords: breast cancer, lymphoedema, manual lymphatic drainage, meta-analysis.

exercise and skin care. MLD is a massage technique which

I N TR O DU C TI O N
Breast cancer-related lymphoedema (BCRL) is a common
sequela of surgical or radiation therapy of breast cancer
caused by insufficient transport capacity of the lymph sys-
tem. The incidence of BCRL ranges from 6% to 50% (Pet-
rek & Heelan 1998; Ramos et al. 1999), depending on the
nature of treatment and definition of lymphoedema. It can
cause cosmetic deformity, physical discomfort, reduction
of arm function, distress and impairs the quality of life
dramatically. Management is important in symptom
improvement and mobility function rescue.
Decongestive lymphatic therapy is a widespread combi-
nation management for lymphoedema, which contains
manual lymphatic drainage (MLD), compression therapy,
Correspondence address: Dian-Sheng Zhong and Yi Shao, Department of
Oncology, Tianjin Medical University General Hospital, No. 154 Anshan
Road, Heping Dist, Tianjin 300052, China (e-mails: zhongdsh@
hotmail.com, happyonco@163.com; shaoshao_0709@aliyun.com).
Accepted 15 April 2016
DOI: 10.1111/ecc.12517
European Journal of Cancer Care, 2016
helps to stimulate excess fluid reflux by mimicking pump-
ing action of lymphatic vessels (International Society of
Lymphology 2013). MLD as an important part of deconges-
tive lymphatic therapy is often given to patients to
improve the effectiveness of treating lymphoedema.
A series of clinical trials and systematic reviews have
tried to evaluate the effect of MLD (Huang et al. 2013;
Johansson et al. 2015). However, the results were contro-
versial and not high evidence-based. So a systematic
review of all the data of randomised controlled trials is
needed to compare the standard therapy (ST) with or with-
out MLD in this situation. So we run this systematic
review and meta-analysis to compare the effectiveness of
MLD for the management of BCRL, and provide the solid
evidence for clinical decision.
METHODS
Literature search
We searched electronic databases PubMed, EMBASE and
Cochrane Library for articles published from 1990 to

© 2016 John Wiley & Sons Ltd

SHAO & ZHONG
September 2015 using the following search terms: “lym-
phedema” OR “lymphoedema”. The results were identi-
fied with breast cancer, breast neoplasms, breast
carcinoma and mammary neoplasms.
Inclusion criteria
Patients undergoing treatment of breast carcinoma and
having lymphoedema defined as a minimum of 10% or
2 cm or 150 mL volume difference between the affected
and unaffected arms were included.
Types of outcome measures
Primary outcome was volume reduction. Secondary out-
comes were improvement of symptoms and arm function.
Types of intervention
Types of intervention were ST of BCRL with or without
MLD.
Data extraction
All the identified trials were screened by two independent
reviewers to confirm fulfilment of inclusion criteria. Dis-
agreements were resolved by consensus and if necessary,
in consultation with a third reviewer. Data extraction was
done independently by the same reviewers using standard
data extraction forms.
Quality assessment of studies
The quality of the included studies was evaluated inde-
pendently by two reviewers. Disagreements were resolved
by discussion with another reviewer. The quality ele-
ments assessed were randomisation process, blinding,
allocation concealment, loss of follow-up and intention-
to-treat analysis. Each trial was classified into categories
A, B or C by the criteria set up in the Cochrane Handbook
for Systematic Reviews of Interventions with the aim of
evaluating all kinds of biases.
Statistical analysis
Quantitative meta-analysis was carried out to assess the
differences in volume reduction between groups with or
without MLD. Statistical analysis was performed using
the Review Manager software application. Weighted mean
difference or standard mean difference was calculated for
continuous outcomes. Statistical heterogeneity between
2 © 2016 John Wiley & Sons Ltd
the studies was assessed by means of chi-squared statistic
and the extent of inconsistency was assessed by I2 statis-
tic. I2 < 25% means low level heterogeneity, 25–50%
means moderate level and higher than 50% means high
level. A fixed-effect model was applied for calculations of
summary effects. Furthermore, if significant heterogene-
ity existed, a random-effects model was used. Descriptive
techniques were used when heterogeneity existed or no
adequate data could be used in statistical analysis.
RESULTS
Study selection
We identified 732 studies. Of which, 728 studies were
excluded because of irrelevant content, non-randomisa-
tion and not up to the inclusion criteria. Four randomised
controlled clinical trials (Andersen et al. 2000; McNeely
et al. 2004; Didem et al. 2005; Dayes et al. 2013) with 234
patients, were included. Among them, three randomised
controlled trials (Andersen et al. 2000; McNeely et al.
2004; Dayes et al. 2013) with 181 patients were available
for a meta-analysis.
The characteristics of included studies and the quality
assessment of included studies (Tables 1–2)
All the four studies (Andersen et al. 2000; McNeely et al.
2004; Didem et al. 2005; Dayes et al. 2013) mentioned
randomisation. Dayes et al.’s (2013) study used automated
randomisation system and a computer-generated predeter-
mined allocation schedule, and Didem et al.’s (2005)
study used unmarked cards. The other two studies (Ander-
sen et al. 2000; McNeely et al. 2004) did not describe the
details of randomisation. All the four trials (Andersen
et al. 2000; McNeely et al. 2004; Didem et al. 2005;
Dayes et al. 2013) did not mention allocated concealment.
Two studies (Didem et al. 2005; Dayes et al. 2013) were
single-blinded. Two studies (Andersen et al. 2000;
McNeely et al. 2004) did not describe blinding. One study
(Andersen et al. 2000) had loss of follow-up and did inten-
tion-to-treat analysis, one (Dayes et al. 2013) reported loss
of follow-up without intention-to-treat analysis, the other
two (McNeely et al. 2004; Didem et al. 2005) did not
describe loss of follow-up.
Outcomes
Volume reduction
Three trials (Andersen et al. 2000; McNeely et al.
2004; Dayes et al. 2013) reported volume reduction.
 Manual lymphatic drainage for lymphoedema

Table 1. The characteristics of included studies

Time of Time of
Study Group No Definition of BCRL Protocol treatment follow-up
Andersen MLD + ST 20 Affected arm volume MLD: 8 times in 2 weeks 2 weeks 12 months
et al. (2000) ST 21 ≥200 mL or 2 cm ST: compression garments,
than unaffected arm exercise, skin care,
education
Dayes MLD + ST 57 Affected arm volume MLD everyday, 4 weeks for a 4 weeks 6 weeks
et al. (2013) ≥10% than unaffected total of 20 sessions
ST 46 arm ST: compression garments
McNeely MLD + ST 22 Affected arm volume MLD: every day, 4 weeks 4 weeks 4 weeks
et al. (2004) ST 20 ≥150 mL than ST: bandaging
unaffected arm
Didem MLD + ST 27 Affected arm circumference MLD: every day, 3 days a 4 weeks 4 weeks
et al. (2005) >2 cm than unaffected arm week for 4 weeks
ST 26 ST: bandaging, exercise, skin care
MLD, manual lymphatic drainage; ST, standard therapy.

Table 2. Quality assessment of included studies

Study Randomisation Allocated concealment Blinding Loss of follow-up and dropout Quality grade
Andersen et al. (2000) Unclear Unclear No Yes with intention-to-treat analysis B
Dayes et al. (2013) Adequate Unclear Yes Yes without intention-to-treat analysis B
McNeely et al. (2004) Unclear Unclear No No B
Didem et al. (2005) Adequate Unclear Yes No B

Andersen et al.’s (2000) data were reported in the form
of percentage of reduction, and were converted to abso-
lute volume reduction for comparison. Heterogeneity
did not exist between trials (P = 0.61, I² = 0%), so a
fixed-effect model was used for calculation. The result
of meta-analysis showed the significant difference
existing between the two groups [RR = 72.10, 95% CI
(13.65–130.55)] (Fig. 1). Didem et al.’s (2005) study
reported the mean percentage volume reduction was
55.7% in the MLD plus ST group and 36% in the ST
group (P < 0.05) but standard mean difference or other
data were not specified. From the results above, we
may conclude that the addition of MLD could signifi-
cantly help to reduce lymphoedema volume.
Subjective symptoms
Two trials (Andersen et al. 2000; Dayes et al. 2013)
reported subjective symptoms improvement. In Andersen
et al.’s (2000) study, each group experienced a significant
reduction in all the symptoms, but no significant differ-
ences were suggested between the groups. In Dayes
et al.’s (2013) study, the symptoms measured by Short
Form-36 Health Survey showed no significant difference
between groups (P > 0.1). So we expected that deconges-
tive lymphatic therapy techniques might improve symp-
toms, but no differences existed whether MLD was
added or not.
Arm function
Two trials (Didem et al. 2005; Dayes et al. 2013) reported
arm function. In Dayes et al.’s (2013) study, no significant
difference was found in arm function measured by DASH
scale (Disabilities of the Arm, Shoulder and Hand)
between groups (P > 0.1). In Didem et al.’s (2005) study,
mobility measured by standard techniques of goniometry
found no differences existed between groups, either.

Figure 1. Volume reduction. MLD, manual lymphatic drainage; ST, standard therapy.

© 2016 John Wiley & Sons Ltd 3

SHAO & ZHONG
D I S C U S S I ON
Breast cancer-related lymphoedema is a chronic disabling
complication caused by breast cancer treatment.
Although lymphoedema is not life-threatening, the swel-
ling of the arm may induce disability with subjective feel
of heaviness and pain and arm function impairment.
According to a population-based study, about one quarter
of breast cancer patients with lymphoedema manifesta-
tion had not been diagnosed, and only minority of them
received complete decongestive lymphatic therapy
(Oksana et al. 2013). So the efficacy evaluation and util-
ity of decongestive lymphatic therapy is urged. As an
important part of decongestive lymphatic therapy, MLD
is a gentle massage technique which stimulates lym-
phatic flow by delivering pressure to the oedematous tis-
sues. It is often inadequate as an isolated treatment for
lymphoedema and is used in combination with other
approaches of decongestive lymphatic therapy to enhance
the compression effect (F€oldi 1998; Leduc et al. 1998).
The 2013 Consensus Document of the International
Society of Lymphology urged more studies to convince
the utility of MLD (International Society of Lymphology
2013).
The results of this systematic review show that the
addition of MLD to the standard conservative therapy for
the management of BCRL leads to a significant relief of
lymphoedema, but may not help to additionally alleviate
the subjective symptoms and arm function. Other compli-
cations of breast cancer itself and treatment, such as neu-
ropathy, shoulder mobility inconvenience, fatigue, etc.
may all contribute to the function impairment. Besides,
the lymphatic system in mild or moderate lymphoedema
would still be functioning, but when it develops to severe
stage, available lymphatic vessels, which are necessary for
MLD to be effective, would be missing. MLD could not
target all the aetiology. Maybe that is the reason why
symptoms and function could not improve significantly.
Our results are in accordance with a previous meta-analy-
sis (McNeely et al. 2011) which showed relative benefit of
the addition of MLD in reducing BCRL, but two studies
of McNeely’s meta-analysis comparing different methods
of lymphatic drainage were wrongly incorporated. In
another study which failed to support the use of MLD in
treating BCRL (Huang et al. 2013), the authors included
researches not only comparing the addition of MLD to ST
but also MLD versus ST. In the current meta-analysis, we
abided by the precise inclusion standard robustly, which
was one of the strengths of this study. In addition, we only
included the randomised clinical trials to make the study
a relatively high-quality one.
4 © 2016 John Wiley & Sons Ltd
There were some limitations in this systematic review.
First, although there were no heterogeneities between
studies, variations did exist in different studies consider-
ing inclusion criteria, length and frequency of the inter-
ventions and follow-up, the methods of measurement
and the time point of evaluating outcomes. Among
which, Ancukiewicz et al. (2010) recommended the ratio
of volume ratios (relative volume change) is the most
precise method to quantify the lymphoedema volumes
and temporal changes. The second limitation was that
some of the included trials did not report outcomes ade-
quately. Didem et al.’s (2005) study missed standard
mean difference of the per cent of volume reduction. And
some other outcomes such as symptom or mobility were
absent (McNeely et al. 2004; Dayes et al. 2013), which
made it impossible to carry out a pooled analysis. More-
over, the quality of the included studies was all category
B, which might make the conclusion less convincing.
Two trials (Didem et al. 2005; Dayes et al. 2013)
reported the methods of randomisation, the other two
(Andersen et al. 2000; McNeely et al. 2004) did not men-
tion the details of randomisation. None of the trials spec-
ified whether they had carried out allocated
concealment, which may produce selection bias. Further-
more, single blinding was conducted in only two trials
(Didem et al. 2005; Dayes et al. 2013), which may cause
performance and measuring bias. Two trials (Andersen
et al. 2000; Dayes et al. 2013) mentioned loss of follow-
up during the study course and only one (Dayes et al.
2013) employed intention-to-treat analysis, which may
induce attrition bias. So we recommend the consistent
criteria and more randomised controlled trials of high
quality in the future.
Current clinical studies might show that the addition of
MLD to ST helped to reduce BCRL more effectively. As for
improved subjective symptoms or arm function, there was
no superiority of the adding of MLD. So the severity of
lymphoedema, clinical cost and patients’ quality of life
and convenience should also be considered for the
selection of conservative therapies of BCRL. The clinical
outcomes still need to be confirmed by large-sample, high-
quality randomised controlled trials.
C ON F L I C T O F I N TE R E S T
The authors declare that they have no conflict of interest.
ACKNOWLEDGEMENT
No specific funding, financial disclosures or assistance
declared.

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