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Complementary and Alternative Medicine and Lymphedema
Seminars in Oncology Nursing, Vol 29, No 1 (February), 2013: pp 41-49
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COMPLEMENTARY AND ALTERNATIVE MEDICINE AND LYMPHEDEMA AUSANEE WANCHAI, JANE M. ARMER, AND BOB R. STEWART OBJECTIVES: To review the evidence for the effectiveness of complementary and alternative medicine (CAM) on cancer-related lymphedema.
DATA SOURCES: CINAHL, PsycINFO, and PubMed (1990-2012). CONCLUSION: To date, there is insufficient evidence to draw conclusions about the benefits of CAM use for cancer patients with lymphedema. Although some CAM types may offer positive effects for the management of lymphedema, negative adverse effects have also been observed.
IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses and therapists should be aware of and ready to educate cancer patients about the potential effects of CAM. A conversation about the potential risks and benefits of CAM use should be provided. KEY WORDS: Complementary medicine, alternative medicine, lymphedema, cancer-related lymphedema
ANCER-related lymphedema is considered to be one of the most distressing conditions resulting from the effects of cancer treatment, such as surgery and/or radiation, and it may occur more than 5 years after surgery.1,2 The conservative ‘gold standard’ treatment for lymphedema includes complete decongestive therapy, which is composed of a combination of: 1) compression
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by garments, bandages, or sleeve; 2) manual lymphatic drainage; 3) individualized exercise; and 4) patient education regarding skin care and infection prevention.3 Other variations of therapy methods, such as non- manual lymph drainage (MLD) massage and exercise, are also practiced. According to Clodius,4 lymphedema is a chronic condition that requires extended periods of time for treatment. Consequently, the first priority for
Ausanee Wanchai, RN, PhD: Nursing Instructor, Boromarajonani College of Nursing, Buddhachinaraj, Thailand; Research Assistant, University of Missouri Sinclair School of Nursing, Columbia, MO. Jane M. Armer, RN, PhD, FAAN: Professor, University of Missouri Sinclair School of Nursing, Columbia, MO. Bob R. Stewart, EdD: Professor Emeritus, University of Missouri Sinclair School of Nursing, Columbia, MO.
Address correspondence to Ausanee Wanchai, RN, PhD, Boromarajonani College of Nursing, Buddhachinaraj, Ellis Fischel Cancer Center, DC 116.05 Suite 408 EFCC, University of Missouri-Columbia, Columbia, MO 65211. e-mail: [email protected] Ó 2013 Elsevier Inc. All rights reserved. 0749-2081/2901-$36.00/0. http://dx.doi.org/10.1016/j.soncn.2012.11.006
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A. WANCHAI, J.M. ARMER, AND B.R. STEWART
these patients may not be trying to reduce the volume or swelling of the affected region, but rather to focus on their emotions, as well as their own subjective values, before embarking on treatment. The majority of patients choose Western medicine methods of treatment for lymphedema because they want to use the most contemporary, evidence-based treatment available. However, they may also seek complementary and alternative medicine (CAM) treatments because these approaches are viewed more humanistic and holistic.5 CAM is defined by the National Center for Complementary and Alternative Medicine6 as a group of diverse medical and health care systems, practices, and products that are not generally considered part of Western medicine. CAM can be categorized into four types, including: 1) natural products (ie, herbal medicines, vitamins, or minerals), 2) mind and body medicine (ie, meditative, yoga, tai chi, or acupuncture), 3) manipulation and body-based practices (ie, massage, spinal manipulation, or chiropractic), and 4) other practices (ie, movement therapy, traditional healers, energy medicine, or whole medical systems).6 Astin et al7 reported that the incidence of CAM use in women with breast cancer is 17% to 75%, with a mean of 45%. A systematic review by Wanchai et al8 reported that the most often reported reason for CAM use by women with breast cancer was to promote overall healing as well as emotional health. One of the reported reasons for CAM use among women with breast cancer was to reduce the side effects of treatment.9-11 With regard to CAM and lymphedema, a crosssectional study by Yap et al12 found that women with breast cancer who used CAM were more likely to have experienced symptoms (eg, stiffness, pain, numbness, swelling) in the shoulder or arm before use of CAM than non-users. Similarly, a crosssectional study conducted by Finnane et al13 reported that approximately 45% of women with lymphedema (N ¼ 95) used CAM to treat their lymphedema, and more than half of those who used CAM reported using at least two forms of CAM. This study also reported that more than 27 types of CAM were used by women with cancer-related lymphedema, with the use of a chi machine, vitamin E, yoga, and meditation most commonly reported. Moreover, Finnane et al13 also found that younger women with lymphedema and those with lymphedema-associated symptoms were
more likely than older patients and those with infrequent symptoms to use CAM. Interestingly, when comparing the perceived effectiveness of CAM and mainstream treatments, they reported that participant perception of CAM effectiveness was rated just as high as mainstream treatments. A challenge in interpreting these claims is that relatively few studies have been conducted that examine the clinical efficacy of CAM in persons with lymphedema. As a result, serious adverse interactions between CAM and mainstream treatments may occur if the safety of CAM is unknown.14 Therefore, the purpose of this article is to review the literature related to the effectiveness of CAM use among cancer patients with lymphedema (see Table 1).15-25
NATURAL PRODUCTS AND LYMPHEDEMA The following natural products have been examined to determine whether or not they are beneficial to lymphedema treatment, including coumarin, Ginkor Fort, horsechestnut complex, and vitamin E, as discussed below. Coumarin Coumarin is a chemical compound found naturally in some plants such as tonka beans, the tropical beans which are known by the French as coumarou. The chemical name for coumarin is benzopyrone. Coumarin may reduce lymphedema and the incidence of secondary infections because it decreases the volume of protein by stimulating proteolysis.15 Casley-Smith et al15 conducted a randomized, double-blind, placebo-controlled, cross-over trial to examine the effect of coumarin in 31 women with post-mastectomy lymphedema and 21 men and women with lymphedema of the lower extremity of various causes. Patients received 400 mg of coumarin or placebo for 6 months. The findings showed that coumarin was reported to be more effective than the placebo in reducing the limb volume and skin temperature and in increasing the softness of the limb tissue, with mild side effects, such as mild nausea and diarrhea arising in seven patients who took coumarin. However, Loprinzi et al16 duplicated the randomized trial of Casley-Smith et al with a larger sample size (N ¼ 140) and reported that coumarin did not have a significant impact on limb volume or lymphedema-associated symptoms. In addition, the investigators reported that 6% of the study
TABLE 1. Clinical Trials Examining Complementary and Alternative Medicine in Cancer-Related Lymphedema Study Natural Products: Coumarin Casley-Smith et al, 199315
Loprinzi et al, 199916
Horsechestnut Wheat et al, 200918
Vitamin E. Gothard et al, 200419
Measures
Results
A randomized, double-blind, placebo-controlled trial Cancer patients with lymphedema (N ¼ 31 for breast cancer; N ¼ 21 for other cancer types)
Participants were randomized to receive either 400 mg of the 5,6benzopyrone or placebo once a day for 6 months
Water displacement Limb circumference Tissue tonometry Symptom report CIG Medishield Medical Digital Skin Thermometer
A randomized, double-blind, placebo-controlled trial Breast cancer patients with lymphedema (N ¼ 140)
Participants were randomized to Limb circumference receive either 200 mg of coumarin Symptom report or placebo twice a day for 6 months
Arm volume reduced Skin temperature increased Limb tissues were soft Feeling pain, hardness, tightness, tension, swelling, heaviness, and limb mobility improved Mild side effects–nausea and diarrhea were observed No significant differences of arm volume changes from baseline and between two groups Symptom reports from both groups were similar Incidence of hepatotoxic effects was observed higher in coumarin group than placebo group
3-arm, double-blind, placebocontrolled trial Breast cancer patients with lymphedema (N ¼ 48)
Participants were randomized to receive: 1) BN165-2 active capsules, 2) BN165-3 active capsules, or 3) placebo twice a day for 2 months
A prospective trial with repeated measures Normal volunteers (N ¼ 15)
Each participant received one tablet Lymphoscintigraphy of Horsechestnut complex twice daily for 3 months
Lymphatic migration significantly increased 1.56% over a 2-hour sampling window
A randomized clinical trial Breast cancer patients with lymphedema (N ¼ 68)
Participants were randomized to Perometer receive either dl-alpha tocopheryl Photographs acetate 500 mg plus pentoxifylline Patient self-assessment: EORTC 400 mg or placebo twice a day for QLQ-C30) and BR23 to measure 6 months quality of life
At 12 month: No significant differences were found for all outcomes
Participants received moxibustion and acupuncture for 15-20
None of participants in group 1 developed lymphedema (Continued )
Mind and Body Medicine: Acupuncture Kanakura et al, 200220 A randomized clinical trial Cancer patients underwent
Lymphoscintigraphy Sign and symptom report (Visual Analogue Scale)
Leg circumference A Core Temp CTM-205 to measure
Lymphatic migration speed significantly increased at a dose of 2 active capsules, but not at the 3 capsules a day No significant differences between three groups for lymphatic migration speed Limb heaviness was improved
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Intervention
COMPLEMENTARY AND ALTERNATIVE MEDICINE AND LYMPHEDEMA
Ginkor Fort Cluzan et al, 200417
Design & Sample
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TABLE 1. Study
Design & Sample intrapelvic lymph nodes dissection (N ¼ 24)
de Valois et al, 201121 An exploratory single-arm, observational clinical trial Cancer patients with upper body lymphedema (N ¼ 30)
Alem & Gurgel 200822
A randomized clinical trial Breast cancer patients with lymphedema (N ¼ 29)
Cassileth et al, 201123 A randomized clinical trial Breast cancer patients with chronic lymphedema (N ¼ 9) Manipulative and Body-Based Practices: Massage A randomized clinical trial Barclay et al, 200624 Cancer patients with lymphedema (N ¼ 75)
Moseley et al, 200925
A randomized clinical trial Breast cancer patients with lymphedema (N ¼ 22)
Intervention minutes 5 times a week during hospitalization and twice a week at the outpatient clinic either 1) after surgery (group 1) or 2) after the occurrence of lymphedema (group 2) Participants received seven individualized moxibustion and acupuncture treatments (group 1) and six optional additional treatments (group 2)
Participants received 24 acupuncture treatments once a week
Participants received acupuncture treatments twice a week for 4 weeks
Participants were randomized to receive either 1) aromatherapy and massage or 2) massage alone (no more details available)
Measures
Results
change in deep body temperature Hardness and swollen lower extremities became gradually Ultrasonography to measure lymph cyst softened after treatment for group 2 Deep body temperature increased in both groups MYMOP to measure well-being Mean MYMOP profile scores were SF-36 to measure well-being significantly improved 1.28 points PANAS to measure mood states for group 1 and 1.41 points for group 2 SF-36 scores were significantly improved at 4 weeks PANAS scores were not significantly improved Arm circumference Range of movement of shoulder Goniometry to measure shoulder significantly improved range of movement Sense of heaviness and tightening in Visual Analogue Scale to measure the affected limbs improved perceptions about heaviness and No significant improvement for arm tightening in arm circumferences Arm circumference Four of nine participants showed at least a 30% arm volume reduction at 4 weeks
MYMOP2 Limb circumference
Participants used the handheld Bioimpedance massage unit for 25 minutes each Perometry evening for 1 month Tonometry Subjective arm symptoms
No significant difference for limb volume changes and also symptoms and well-being perception between two groups Combined two groups together, more participants improved than declined After 1 month: Arm volume reduced 51 mL Participants reported significant improvement in limb size and range of movement
Abbreviations: EORTC QLQ-C30, the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire; BR23, Breast cancer-specific quality of life data; MYMOP, the Measure Yourself Medical Outcome Profile; SF-36, the Medical Outcomes Study Short Form; PANAS, the Positive and Negative Affect Schedule.
A. WANCHAI, J.M. ARMER, AND B.R. STEWART
(Continued)
COMPLEMENTARY AND ALTERNATIVE MEDICINE AND LYMPHEDEMA
group experienced hepatotoxicity resulting from coumarin. Therefore, with only a few studies and contrary findings, it is difficult to conclude whether coumarin is an effective therapy for cancer-related lymphedema. Although the pros and cons of coumarin are still disputed, particularly with respect to the risk of hepatotoxicity, Farinola and Piller26 argue that toxicity alone should not prevent future investigators from reevaluating the potential benefits of coumarin for lymphedema treatment. They suggested that the use of pharmacogenetics could significantly lower the risk of coumarin-associated hepatotoxicity. Therefore, further research with rigorous design and larger samples is needed to re-evaluate the effectiveness of coumarin in treating lymphedema. Ginkor Fort Ginkor Fort (BN165) is a combination of several compounds related to the gamma benzopyrones. In 2004, Cluzan and colleagues17 conducted a double-blind, placebo-controlled study in 48 breast cancer patients with upper extremity lymphedema. The participants were randomized to receive two active capsules of BN165, three active capsules of BN165, or a placebo, which were to be taken twice a day for 2 months. Lymphoscintigraphic parameters were used to assess the lymphokinetic action of BN165. The reported findings were that the feeling of limb heaviness as perceived by the participants was significantly improved, and lymphatic migration speed was significantly increased at a dose of two active capsules per day, but, counter intuitively, not at the three capsules per day dosage. However, lymphatic migration speed was also reported to be increased in the placebo group. Therefore, it is difficult to conclude whether Ginkor Fort is effective for cancer-related lymphedema until additional evidence is obtained. Horsechestnut Seed Extract, Butcher’s Broom, and Ginkgo (Horsechestnut Complex) Horsechestnut seed extract and butcher’s broom are herbal medicines that have been used to treat chronic venous insufficiency.27 Horsechestnut seed extract is an herbal medicine that contains the saponin complex, known as aescin and aesculin. Butcher’s broom is a prickly, berry-producing shrub that contains steroidal saponins, namely as ruscinogen.27 Wheat et al18 reported on a potentially effective herbal formulation, a combination of horsechestnut seed extract,
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butcher’s broom, and ginkgo in treating lymphedema. Although the possible mechanism of horsechestnut seed extract and butcher’s broom for the treatment of lymphedema is unknown, they explained that a possible mechanism may be related to the ability of horsechestnut seed extract to inhibit the activity of enzymes elastase and hyaluronidase, and the ability of butcher’s broom to inhibit macromolecular permeability. A prospective study has been conducted to examine the effect of this herbal formulation on lymphatic flow in 15 normal volunteers using a repeated-measure design. All participants of the study received one tablet twice a day for 3 months. Lymphoscintigraphy was performed to measure lymphatic flow. The findings of the study revealed a significant increase in the percentage of lymphatic migration of 1.6% after herbal treatment over a 2-hour sampling window. However, there were several limitations associated with the study: 1) samples were normal populations who did not have lymphedema; 2) there were no control or placebo groups, and 3) sample size was too small for definitive conclusions. Therefore, a randomized controlled-trial in lymphedema patients with a larger sample size is needed to examine whether or not this herbal formulation is potentially beneficial for cancer patients with lymphedema. Vitamin E (Alpha-Tocopherol) in Combination with Pentoxifylline The effect of vitamin E and pentoxifylline in treating lymphedema was reported by Gothard et al.19 With a double-blind, placebo-controlled, randomized trial , 68 patients with chronic arm lymphedema and fibrosis after surgery and radiotherapy for breast cancer were randomized to receive 500 mg alpha-tocopheryl acetate plus pentoxifylline 400 mg twice a day orally or a placebo for 6 months. The investigators reported that after treatment at 6 months and 12 months, there were no significant differences in any of the outcomes evaluated, including arm volume; fibrosis of the breast, chest wall, pectoral fold, axilla, or supraclavicular fossa; or psychosocial measures such as quality of life. In conclusion, there is no firm evidence to support the effectiveness of herbal medicines in treating lymphedema. Despite the potential beneficial effects of herbal medicines in small studies, it is difficult to be confident of the quality of the evidence because of limitations such as a small sample size or no randomly assigned control group
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comparison. Moreover, because some herbal medicine, such as coumarin, was reported to have potential negative and even life-threatening side effects, such as hepatotoxicity, caution is warranted. Future research with rigorous designs should be undertaken to answer questions as to whether herbal medicines are effective and safe for treating lymphedema.
MIND AND BODY MEDICINE AND LYMPHEDEMA There are a few published reports that have examined the effects of mind and body medicine methods for the treatment of cancer-related lymphedema. Based on the current review of the literature, four studies have been reported on the use of acupuncture for lymphedema. Acupuncture is a form of Traditional Chinese Medicine that has been applied to manage lymphedema by inserting fine, solid, stainless steel needles under the skin to stimulate selected anatomic sites on the body.21 The first two studies reported a potential benefit of acupuncture in combination with moxibustion treatment on the management of lymphedema.20,21 Moxibustion is another form of Traditional Chinese Medicine using heat from the smoldering herb artemesia vulgaris or mugwort to stimulate anatomic points by warming them.21 Kanakura et al20 conducted a small study to examine the effect of acupuncture and moxibustion treatments on the management of lymphedema. Their study included 24 patients with gynecologic cancer undergoing pelvic lymph node dissection, 12 were treated with acupuncture and moxibustion after surgery (group 1), and 12 patients were treated after lymphedema occurred (group 2). The treatment was performed for 15 to 20 minutes for five times a week during hospitalization and twice a week after discharge. Objective outcomes for the study included limb volume, calculated using circumference measures, deep body temperature was recorded using a Core Temp CTM-205 (Terumo Corp., Tokyo, Japan)., and lymphatic cysts were measured using ultrasonography. The findings showed that no evidence of lymphedema was observed in the patients in group 1. For patients in group 2, who had already experienced lymphedema, the swelling and hardness of extremities gradually decreased following treatment with acupuncture and moxibustion. Deep body temperature was also reported to increase more than body surface temperature after the
start of acupuncture and moxibustion treatment. The investigators hypothesized that the increase in deep body temperature was associated with the success of lymphedema treatment by improving lymph flow. Thus, additional research with a rigorous design and larger sample is required before making recommendations for traditional acupuncture practice as an effective treatment for cancer-related lymphedema. Recently, de Valois et al21 conducted a singlearm, observational study to examine the benefits of traditional acupuncture practice in cancer survivors with lymphedema. The sample included breast cancer as well as head and neck cancer survivors with mild to moderate lymphedema (N ¼ 30). Participants received seven individualized treatment sessions once a week for a total of seven sessions and they could choose to continue with six optional additional treatments. The Measure Yourself Medical Outcome Profile (MYMOP)28 was used to measure holistic and participative principles. The Medical Outcomes Study Short Form (SF-36)29 was used to measure wellbeing; and the Positive and Negative Affect Schedule30 was used to assess mood states. The investigators reported that there were significant good positive changes in the MYMOP scores at all measurement points (after each session, at follow-up 4 and 12 weeks later). Only bodily pain and vitality subscales of the SF-36 showed significant improvements. There were no changes in volume or exacerbations of swelling measured by the circumference method. No serious adverse effects were reported, except minor adverse effects such as bruising, bleeding, pain, and fatigue after treatment. The primary aim of this study was to assess the feasibility of using acupuncture and moxibustion for improving well-being for cancer survivors with lymphedema, rather than focusing on its effect as a method of achieving volume reduction. As with other CAM studies, the limitations of the study included small sample size and study design (no control group). Alem and Gurgel22 also examined the effect of acupuncture on lymphedema reduction and rehabilitation of women after breast cancer surgery. All 29 patients received 24 acupuncture sessions with a 30-minute needle insertion time once a week for 11 months. Significant improvement was noted in range of movement of the shoulder, degree of lymphedema, and sense of heaviness and tightening. However, there was no significant improvement in arm circumference, which the authors noted
COMPLEMENTARY AND ALTERNATIVE MEDICINE AND LYMPHEDEMA
may have resulted from an insufficient number of acupuncture sessions and suggested alternative protocols with an increased number of sessions. Given the noted benefits of the study, future research should be considered with a larger, randomized controlled trial to provide a comparative group and provide an estimate of the magnitude of the effects. Cassileth et al23 conducted a pilot study to examine the effects of acupuncture in nine breast cancer survivors with chronic lymphedema. Participants received acupuncture twice a week for 4 consecutive weeks. After 4 weeks of treatment, at least a 30% reduction in lymphedema volume measured by the circumference method was observed. No serious adverse events occurred during 73 treatment sessions or during the 6month follow-up period. However, some patients reported minor pain and slight bruising at the acupuncture site shortly after treatment. The limitations of the study were a small sample size and no control group. Further research using a larger, randomized controlled trial is required. In conclusion, although there are a few studies that demonstrate encouraging results associated with acupuncture as a preventive and therapeutic treatment for cancer patients with lymphedema, the true risks and benefits of acupuncture are unknown given the methodologic quality issues of the studies. Controlled clinical trials with quality assessments are recommended to further evaluate this treatment for cancer-related lymphedema.
MANIPULATIVE AND BODY-BASED PRACTICES AND LYMPHEDEMA Massage is a popular type of manipulative and body-based practice that has been commonly used by cancer patients. However, only a few studies have been conducted to examine whether it is effective in treating lymphedema. It should be noted that the term ‘‘massage’’ in this article is not synonymous with the term ‘‘manual lymph drainage (MLD),’’ but rather refers to direct manipulation of soft tissues performed by hands. According to Zuther,31 the term ‘‘massage’’ refers specifically to forms of ‘‘classical’’ or ‘‘Swedish’’ massage that are applied with more pressure than MLD, which is an important component of complete decongestive therapy. Swedish massage was introduced in the 19th century by Per Henrik Ling and was brought to the United States in the
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1850s by George and Charles Taylor, who studied in Sweden.32 With respect to the effects of aromatherapy massage for lymphedema, Barclay et al24 conducted a clinical randomized trial to compare the effects of self-limb massage by using a base cream alone versus a base cream containing aromatherapy oils for limb volume reduction in cancer patients (N ¼ 80). Limb circumference was used to measure limb volume changes and symptom improvements, activity, and well-being were measured with the ‘‘Measure Yourself Medical Outcome Profile 2 (MYMOP2).’’28 In this study, limb volume reduction was reported at 3 months after self-massage, with improvement in symptoms and well-being over time until 6 months follow-up. However, there were no significant differences in terms of limb volume reduction, symptom relief, and well-being between the two groups. Therefore, the authors concluded that aromatherapy did not appear to be an added benefit to massage alone, with respect to the measured outcomes. Moseley and colleagues,25 conducted a pilot study to examine the effect of a new handheld massage unit that delivered vibration to the arm tissues in women with secondary lymphedema after breast cancer treatment (N ¼ 30). Participants were asked to use the handheld massage unit for 25 minutes each evening for 1 month. Bioimpedance, perometry, tonometry, and subjective arm symptoms were measured at baseline, at the end of week 1, 2, 3, and 4, and at 1-month follow-up. After 1 month there was a reduction in arm fluid of 5 mL, with significant improvements in limb size and range of movement. No adverse side effects were observed. Limitations of the study include the lack of a control group and a small sample size. In conclusion, in contrast to MLD, which is accepted as an effective method in treating lymphedema with gentle pressure,33 massage stroke with more pressure may increase the lymphatic load of fluid resulting from an increased local arterial blood flow exacerbating lymphedema.31 Therefore, it is essential that MLD be taught by an experienced and qualified lymphedema practitioner.32,34 Moreover, massage with high pressure may cause damage to the lymphatic system that can lead to a decrease in the lymphatic system’s transport capacity. Thus, it is recommended that massage therapy should not be applied in lymphedemateous extremities or
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bordering truncal quadrants. Additionally, deep tissue massage for patients who are at risk for lymphedema, such as those who have undergone a lymph node dissection or radiation of the axillary lymph nodes, is also contraindicated.31,32
CONCLUSION Many cancer patients with lymphedema choose to use CAM to manage their symptoms. Based on this review, there is limited evidence to date to support the effectiveness of CAM in treating or preventing cancer-related lymphedema. In addi-
tion, some CAM types, such as herbal medicine or acupuncture, have been associated with adverse side effects. Therefore, it is critical that among all health care providers that oncology nurses in particular remain current in their knowledge of CAM and recognize studies with rigorous research methods that will likely provide the best evidence related to the effectiveness and risks of CAM use in cancer-related lymphedema. Patients must also be educated on this body of literature so that they are aware of the evidence base for CAM use to prevent the potential adverse side effects that may occur.
REFERENCES 1. Norman SA, Localio AR, Potashnik SL, et al. Lymphedema in breast cancer survivors: incidence, degree, time course, treatment, and symptoms. J Clin Oncol 2009;27:390-397. 2. Armer JM, Stewart BR. Post-breast cancer lymphedema: Incidence increases from 12 to 30 to 60 months. Lymphology 2010;43:118-127. 3. Sieggreen MY, Kline RA. Current concepts in lymphedema management. Adv Skin Wound Care 2004;17:174-178. 4. Clodius L. Psycholymphology: why not all patients with chronic lymphedema want therapy. Lymphology 2006; 39:104-107. 5. Cho MO. Health care seeking behavior of Korean women with lymphedema. Nurs Health Sci 2004;6:149-159. 6. National Center for Complementary and Alternative Medicine. What is complementary and alternative medicine? 2011. Available at: http://nccam.nih.gov/health/whatiscam/#types. (accessed June 26, 2012). 7. Astin JA, Reilly C, Perkins C, et al. Breast cancer patients’ perspectives on and use of complementary and alternative medicine: a study by the Susan G. Komen breast cancer foundation. J Soc Integr Oncol 2006;4:157-169. 8. Wanchai A, Armer JM, Stewart BR. Complementary and alternative medicine (CAM) use among women with breast cancer: a systematic review. Clin J Oncol Nurs 2010;14: e45-e55. 9. Hann D, Allen S, Ciambrone D, et al. Use of complementary therapies during chemotherapy: Influence of patients’ satisfaction with treatment decision making and the treating oncologist. Integr Cancer Ther 2006;5:224-231. 10. Kremser T, Evans A, Moore A, et al. Use of complementary therapies by Australian women with breast cancer. Breast 2008;17:387-394. 11. Owens B, Dirksen SR. Review and critique of the literature of complementary and alternative therapy use among Hispanic/Latino women with breast cancer. Clin J Oncol Nurs 2004;8:151-156. 12. Yap KPL, McCready DR, Fyles A, et al. Use of alternative therapy in postmenopausal breast cancer patients treated with tamoxifen after surgery. Breast J 2004;10:481-486. 13. Finnane A, Liu Y, Battistutta D, et al. Lymphedema after breast or gynecological cancer: Use and effectiveness of mainstream and complementary therapies. J Altern Complement Med 2011;17:867-869.
14. Rokovitch E, Pignol JP, Chartier C, et al. Complementary and alternative medicine use is associated with an increased perception of breast cancer risk and death. Breast Cancer Res Treat 2005;90:139-148. 15. Casley-Smith JR, Morgan RG, Piller NB. Treatment of lymphedema of the arms and legs with 5,6-benzo-[alpha]-pyrone. N Engl J Med 1993;329:1158-1163. 16. Loprinzi CL, Kugler JW, Sloan JA, et al. Lack of effect of coumarin in women with lymphedema after treatment for breast cancer. N Engl J Med 1999;340:346-350. 17. Cluzan RV, Pecking AP, Mathiex-Fortunet H, et al. Efficacy of BN165 (Ginkor Fort) in breast cancer related upper limb lymphedema: a preliminary study. Lymphology 2004;37:47-52. 18. Wheat J, Currie G, Kiat H, et al. Improving lymphatic drainage with herbal preparations: a potentially novel approach to management of lymphedema. Aus J Med Herb 2009;21:66-70. 19. Gothard L, Cornes P, Earl J, et al. Double-blind placebocontrolled randomised trial of vitamin E and pentoxifylline in patients with chronic arm lymphoedema and fibrosis after surgery and radiotherapy for breast cancer. Radiother Oncol 2004;73:133-139. 20. Kanakura Y, Niwa K, Kometani K, et al. Effectiveness of acupuncture and moxibustion treatment for lymphedema following Intrapelvic lymph node dissection: a preliminary report. Am J Chin Med 2002;30:37. 21. Valois BA, Young TE, Melsome E. Assessing the feasibility of using acupuncture and moxibustion to improve quality of life for cancer survivors with upper body lymphoedema. Eur J Oncol Nurs 2012;16:301-309. 22. Alem M, Gurgel MS. Acupuncture in the rehabilitation of women after breast cancer surgery. Acupunct Med 2008;26: 86-93. 23. Cassileth BR, Van Zee KJ, Chan Y, et al. A safety and efficacy pilot study of acupuncture for the treatment of chronic lymphoedema. Acupunct Med 2011;29:170-172. 24. Barclay J, Vestey J, Lambert A, et al. Reducing the symptoms of lymphoedema: Is there a role for aromatherapy? Eur J Oncol Nurs 2006;10:140-149. 25. Moseley A, Piller N, Heidenreich B, et al. Pilot study of a handheld massage unit. J Lymphoedema 2009;4:24-28. 26. Farinola N, Piller N. Pharmacogenomics: Its role in reestablishing coumarin as treatment for lymphedema. Lymphat Res Biol 2005;3:81-86.
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27. Abascal K, Yarnell E. botanicals for chronic venous insufficiency. Altern Complement Ther 2007;13:304-311. 28. Paterson C. Measuring outcomes in primary care: a patient generated measure, MYMOP, compared with the SF36 health survey. BMJ 1996;312:1016-1020. 29. Garratt AM, Ruta DA, Abdalla MI, et al. The SF36 health survey questionnaire: an outcome measure suitable for routine use within the NHS? BMJ 1993;306:1440-1444. 30. Watson D, Clark LA, Tellegen A. Development and validation of brief measures of positive and negative affect: the PANAS scales. J Pers Soc Psychol 1988;54:1063-1070.
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31. Zuther J. Traditional massage therapy in the treatment and management of lymphedema. Massage Today 2002;2: 1-5. 32. Collinge W, MacDonald G, Walton T. Massage in supportive cancer care. Semin Oncol Nurs 2012;28:45-54. 33. Bernas M, White M, Kriederman B, et al. Massage therapy in the treatment of lymphedema. IEEE Med Biol Mag 2005;24:58-68. 34. Pyke C. Massage: a helping hand for people with chronic oedema and lymphoedema. Br J Community Nurs 2010;15: s28-s30.
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COMPLEMENTARY AND ALTERNATIVE MEDICINE AND LYMPHEDEMA AUSANEE WANCHAI, JANE M. ARMER, AND BOB R. STEWART OBJECTIVES: To review the evidence for the effectiveness of complementary and alternative medicine (CAM) on cancer-related lymphedema.
DATA SOURCES: CINAHL, PsycINFO, and PubMed (1990-2012). CONCLUSION: To date, there is insufficient evidence to draw conclusions about the benefits of CAM use for cancer patients with lymphedema. Although some CAM types may offer positive effects for the management of lymphedema, negative adverse effects have also been observed.
IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses and therapists should be aware of and ready to educate cancer patients about the potential effects of CAM. A conversation about the potential risks and benefits of CAM use should be provided. KEY WORDS: Complementary medicine, alternative medicine, lymphedema, cancer-related lymphedema
ANCER-related lymphedema is considered to be one of the most distressing conditions resulting from the effects of cancer treatment, such as surgery and/or radiation, and it may occur more than 5 years after surgery.1,2 The conservative ‘gold standard’ treatment for lymphedema includes complete decongestive therapy, which is composed of a combination of: 1) compression
C
by garments, bandages, or sleeve; 2) manual lymphatic drainage; 3) individualized exercise; and 4) patient education regarding skin care and infection prevention.3 Other variations of therapy methods, such as non- manual lymph drainage (MLD) massage and exercise, are also practiced. According to Clodius,4 lymphedema is a chronic condition that requires extended periods of time for treatment. Consequently, the first priority for
Ausanee Wanchai, RN, PhD: Nursing Instructor, Boromarajonani College of Nursing, Buddhachinaraj, Thailand; Research Assistant, University of Missouri Sinclair School of Nursing, Columbia, MO. Jane M. Armer, RN, PhD, FAAN: Professor, University of Missouri Sinclair School of Nursing, Columbia, MO. Bob R. Stewart, EdD: Professor Emeritus, University of Missouri Sinclair School of Nursing, Columbia, MO.
Address correspondence to Ausanee Wanchai, RN, PhD, Boromarajonani College of Nursing, Buddhachinaraj, Ellis Fischel Cancer Center, DC 116.05 Suite 408 EFCC, University of Missouri-Columbia, Columbia, MO 65211. e-mail: [email protected] Ó 2013 Elsevier Inc. All rights reserved. 0749-2081/2901-$36.00/0. http://dx.doi.org/10.1016/j.soncn.2012.11.006
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these patients may not be trying to reduce the volume or swelling of the affected region, but rather to focus on their emotions, as well as their own subjective values, before embarking on treatment. The majority of patients choose Western medicine methods of treatment for lymphedema because they want to use the most contemporary, evidence-based treatment available. However, they may also seek complementary and alternative medicine (CAM) treatments because these approaches are viewed more humanistic and holistic.5 CAM is defined by the National Center for Complementary and Alternative Medicine6 as a group of diverse medical and health care systems, practices, and products that are not generally considered part of Western medicine. CAM can be categorized into four types, including: 1) natural products (ie, herbal medicines, vitamins, or minerals), 2) mind and body medicine (ie, meditative, yoga, tai chi, or acupuncture), 3) manipulation and body-based practices (ie, massage, spinal manipulation, or chiropractic), and 4) other practices (ie, movement therapy, traditional healers, energy medicine, or whole medical systems).6 Astin et al7 reported that the incidence of CAM use in women with breast cancer is 17% to 75%, with a mean of 45%. A systematic review by Wanchai et al8 reported that the most often reported reason for CAM use by women with breast cancer was to promote overall healing as well as emotional health. One of the reported reasons for CAM use among women with breast cancer was to reduce the side effects of treatment.9-11 With regard to CAM and lymphedema, a crosssectional study by Yap et al12 found that women with breast cancer who used CAM were more likely to have experienced symptoms (eg, stiffness, pain, numbness, swelling) in the shoulder or arm before use of CAM than non-users. Similarly, a crosssectional study conducted by Finnane et al13 reported that approximately 45% of women with lymphedema (N ¼ 95) used CAM to treat their lymphedema, and more than half of those who used CAM reported using at least two forms of CAM. This study also reported that more than 27 types of CAM were used by women with cancer-related lymphedema, with the use of a chi machine, vitamin E, yoga, and meditation most commonly reported. Moreover, Finnane et al13 also found that younger women with lymphedema and those with lymphedema-associated symptoms were
more likely than older patients and those with infrequent symptoms to use CAM. Interestingly, when comparing the perceived effectiveness of CAM and mainstream treatments, they reported that participant perception of CAM effectiveness was rated just as high as mainstream treatments. A challenge in interpreting these claims is that relatively few studies have been conducted that examine the clinical efficacy of CAM in persons with lymphedema. As a result, serious adverse interactions between CAM and mainstream treatments may occur if the safety of CAM is unknown.14 Therefore, the purpose of this article is to review the literature related to the effectiveness of CAM use among cancer patients with lymphedema (see Table 1).15-25
NATURAL PRODUCTS AND LYMPHEDEMA The following natural products have been examined to determine whether or not they are beneficial to lymphedema treatment, including coumarin, Ginkor Fort, horsechestnut complex, and vitamin E, as discussed below. Coumarin Coumarin is a chemical compound found naturally in some plants such as tonka beans, the tropical beans which are known by the French as coumarou. The chemical name for coumarin is benzopyrone. Coumarin may reduce lymphedema and the incidence of secondary infections because it decreases the volume of protein by stimulating proteolysis.15 Casley-Smith et al15 conducted a randomized, double-blind, placebo-controlled, cross-over trial to examine the effect of coumarin in 31 women with post-mastectomy lymphedema and 21 men and women with lymphedema of the lower extremity of various causes. Patients received 400 mg of coumarin or placebo for 6 months. The findings showed that coumarin was reported to be more effective than the placebo in reducing the limb volume and skin temperature and in increasing the softness of the limb tissue, with mild side effects, such as mild nausea and diarrhea arising in seven patients who took coumarin. However, Loprinzi et al16 duplicated the randomized trial of Casley-Smith et al with a larger sample size (N ¼ 140) and reported that coumarin did not have a significant impact on limb volume or lymphedema-associated symptoms. In addition, the investigators reported that 6% of the study
TABLE 1. Clinical Trials Examining Complementary and Alternative Medicine in Cancer-Related Lymphedema Study Natural Products: Coumarin Casley-Smith et al, 199315
Loprinzi et al, 199916
Horsechestnut Wheat et al, 200918
Vitamin E. Gothard et al, 200419
Measures
Results
A randomized, double-blind, placebo-controlled trial Cancer patients with lymphedema (N ¼ 31 for breast cancer; N ¼ 21 for other cancer types)
Participants were randomized to receive either 400 mg of the 5,6benzopyrone or placebo once a day for 6 months
Water displacement Limb circumference Tissue tonometry Symptom report CIG Medishield Medical Digital Skin Thermometer
A randomized, double-blind, placebo-controlled trial Breast cancer patients with lymphedema (N ¼ 140)
Participants were randomized to Limb circumference receive either 200 mg of coumarin Symptom report or placebo twice a day for 6 months
Arm volume reduced Skin temperature increased Limb tissues were soft Feeling pain, hardness, tightness, tension, swelling, heaviness, and limb mobility improved Mild side effects–nausea and diarrhea were observed No significant differences of arm volume changes from baseline and between two groups Symptom reports from both groups were similar Incidence of hepatotoxic effects was observed higher in coumarin group than placebo group
3-arm, double-blind, placebocontrolled trial Breast cancer patients with lymphedema (N ¼ 48)
Participants were randomized to receive: 1) BN165-2 active capsules, 2) BN165-3 active capsules, or 3) placebo twice a day for 2 months
A prospective trial with repeated measures Normal volunteers (N ¼ 15)
Each participant received one tablet Lymphoscintigraphy of Horsechestnut complex twice daily for 3 months
Lymphatic migration significantly increased 1.56% over a 2-hour sampling window
A randomized clinical trial Breast cancer patients with lymphedema (N ¼ 68)
Participants were randomized to Perometer receive either dl-alpha tocopheryl Photographs acetate 500 mg plus pentoxifylline Patient self-assessment: EORTC 400 mg or placebo twice a day for QLQ-C30) and BR23 to measure 6 months quality of life
At 12 month: No significant differences were found for all outcomes
Participants received moxibustion and acupuncture for 15-20
None of participants in group 1 developed lymphedema (Continued )
Mind and Body Medicine: Acupuncture Kanakura et al, 200220 A randomized clinical trial Cancer patients underwent
Lymphoscintigraphy Sign and symptom report (Visual Analogue Scale)
Leg circumference A Core Temp CTM-205 to measure
Lymphatic migration speed significantly increased at a dose of 2 active capsules, but not at the 3 capsules a day No significant differences between three groups for lymphatic migration speed Limb heaviness was improved
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Intervention
COMPLEMENTARY AND ALTERNATIVE MEDICINE AND LYMPHEDEMA
Ginkor Fort Cluzan et al, 200417
Design & Sample
44
TABLE 1. Study
Design & Sample intrapelvic lymph nodes dissection (N ¼ 24)
de Valois et al, 201121 An exploratory single-arm, observational clinical trial Cancer patients with upper body lymphedema (N ¼ 30)
Alem & Gurgel 200822
A randomized clinical trial Breast cancer patients with lymphedema (N ¼ 29)
Cassileth et al, 201123 A randomized clinical trial Breast cancer patients with chronic lymphedema (N ¼ 9) Manipulative and Body-Based Practices: Massage A randomized clinical trial Barclay et al, 200624 Cancer patients with lymphedema (N ¼ 75)
Moseley et al, 200925
A randomized clinical trial Breast cancer patients with lymphedema (N ¼ 22)
Intervention minutes 5 times a week during hospitalization and twice a week at the outpatient clinic either 1) after surgery (group 1) or 2) after the occurrence of lymphedema (group 2) Participants received seven individualized moxibustion and acupuncture treatments (group 1) and six optional additional treatments (group 2)
Participants received 24 acupuncture treatments once a week
Participants received acupuncture treatments twice a week for 4 weeks
Participants were randomized to receive either 1) aromatherapy and massage or 2) massage alone (no more details available)
Measures
Results
change in deep body temperature Hardness and swollen lower extremities became gradually Ultrasonography to measure lymph cyst softened after treatment for group 2 Deep body temperature increased in both groups MYMOP to measure well-being Mean MYMOP profile scores were SF-36 to measure well-being significantly improved 1.28 points PANAS to measure mood states for group 1 and 1.41 points for group 2 SF-36 scores were significantly improved at 4 weeks PANAS scores were not significantly improved Arm circumference Range of movement of shoulder Goniometry to measure shoulder significantly improved range of movement Sense of heaviness and tightening in Visual Analogue Scale to measure the affected limbs improved perceptions about heaviness and No significant improvement for arm tightening in arm circumferences Arm circumference Four of nine participants showed at least a 30% arm volume reduction at 4 weeks
MYMOP2 Limb circumference
Participants used the handheld Bioimpedance massage unit for 25 minutes each Perometry evening for 1 month Tonometry Subjective arm symptoms
No significant difference for limb volume changes and also symptoms and well-being perception between two groups Combined two groups together, more participants improved than declined After 1 month: Arm volume reduced 51 mL Participants reported significant improvement in limb size and range of movement
Abbreviations: EORTC QLQ-C30, the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire; BR23, Breast cancer-specific quality of life data; MYMOP, the Measure Yourself Medical Outcome Profile; SF-36, the Medical Outcomes Study Short Form; PANAS, the Positive and Negative Affect Schedule.
A. WANCHAI, J.M. ARMER, AND B.R. STEWART
(Continued)
COMPLEMENTARY AND ALTERNATIVE MEDICINE AND LYMPHEDEMA
group experienced hepatotoxicity resulting from coumarin. Therefore, with only a few studies and contrary findings, it is difficult to conclude whether coumarin is an effective therapy for cancer-related lymphedema. Although the pros and cons of coumarin are still disputed, particularly with respect to the risk of hepatotoxicity, Farinola and Piller26 argue that toxicity alone should not prevent future investigators from reevaluating the potential benefits of coumarin for lymphedema treatment. They suggested that the use of pharmacogenetics could significantly lower the risk of coumarin-associated hepatotoxicity. Therefore, further research with rigorous design and larger samples is needed to re-evaluate the effectiveness of coumarin in treating lymphedema. Ginkor Fort Ginkor Fort (BN165) is a combination of several compounds related to the gamma benzopyrones. In 2004, Cluzan and colleagues17 conducted a double-blind, placebo-controlled study in 48 breast cancer patients with upper extremity lymphedema. The participants were randomized to receive two active capsules of BN165, three active capsules of BN165, or a placebo, which were to be taken twice a day for 2 months. Lymphoscintigraphic parameters were used to assess the lymphokinetic action of BN165. The reported findings were that the feeling of limb heaviness as perceived by the participants was significantly improved, and lymphatic migration speed was significantly increased at a dose of two active capsules per day, but, counter intuitively, not at the three capsules per day dosage. However, lymphatic migration speed was also reported to be increased in the placebo group. Therefore, it is difficult to conclude whether Ginkor Fort is effective for cancer-related lymphedema until additional evidence is obtained. Horsechestnut Seed Extract, Butcher’s Broom, and Ginkgo (Horsechestnut Complex) Horsechestnut seed extract and butcher’s broom are herbal medicines that have been used to treat chronic venous insufficiency.27 Horsechestnut seed extract is an herbal medicine that contains the saponin complex, known as aescin and aesculin. Butcher’s broom is a prickly, berry-producing shrub that contains steroidal saponins, namely as ruscinogen.27 Wheat et al18 reported on a potentially effective herbal formulation, a combination of horsechestnut seed extract,
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butcher’s broom, and ginkgo in treating lymphedema. Although the possible mechanism of horsechestnut seed extract and butcher’s broom for the treatment of lymphedema is unknown, they explained that a possible mechanism may be related to the ability of horsechestnut seed extract to inhibit the activity of enzymes elastase and hyaluronidase, and the ability of butcher’s broom to inhibit macromolecular permeability. A prospective study has been conducted to examine the effect of this herbal formulation on lymphatic flow in 15 normal volunteers using a repeated-measure design. All participants of the study received one tablet twice a day for 3 months. Lymphoscintigraphy was performed to measure lymphatic flow. The findings of the study revealed a significant increase in the percentage of lymphatic migration of 1.6% after herbal treatment over a 2-hour sampling window. However, there were several limitations associated with the study: 1) samples were normal populations who did not have lymphedema; 2) there were no control or placebo groups, and 3) sample size was too small for definitive conclusions. Therefore, a randomized controlled-trial in lymphedema patients with a larger sample size is needed to examine whether or not this herbal formulation is potentially beneficial for cancer patients with lymphedema. Vitamin E (Alpha-Tocopherol) in Combination with Pentoxifylline The effect of vitamin E and pentoxifylline in treating lymphedema was reported by Gothard et al.19 With a double-blind, placebo-controlled, randomized trial , 68 patients with chronic arm lymphedema and fibrosis after surgery and radiotherapy for breast cancer were randomized to receive 500 mg alpha-tocopheryl acetate plus pentoxifylline 400 mg twice a day orally or a placebo for 6 months. The investigators reported that after treatment at 6 months and 12 months, there were no significant differences in any of the outcomes evaluated, including arm volume; fibrosis of the breast, chest wall, pectoral fold, axilla, or supraclavicular fossa; or psychosocial measures such as quality of life. In conclusion, there is no firm evidence to support the effectiveness of herbal medicines in treating lymphedema. Despite the potential beneficial effects of herbal medicines in small studies, it is difficult to be confident of the quality of the evidence because of limitations such as a small sample size or no randomly assigned control group
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A. WANCHAI, J.M. ARMER, AND B.R. STEWART
comparison. Moreover, because some herbal medicine, such as coumarin, was reported to have potential negative and even life-threatening side effects, such as hepatotoxicity, caution is warranted. Future research with rigorous designs should be undertaken to answer questions as to whether herbal medicines are effective and safe for treating lymphedema.
MIND AND BODY MEDICINE AND LYMPHEDEMA There are a few published reports that have examined the effects of mind and body medicine methods for the treatment of cancer-related lymphedema. Based on the current review of the literature, four studies have been reported on the use of acupuncture for lymphedema. Acupuncture is a form of Traditional Chinese Medicine that has been applied to manage lymphedema by inserting fine, solid, stainless steel needles under the skin to stimulate selected anatomic sites on the body.21 The first two studies reported a potential benefit of acupuncture in combination with moxibustion treatment on the management of lymphedema.20,21 Moxibustion is another form of Traditional Chinese Medicine using heat from the smoldering herb artemesia vulgaris or mugwort to stimulate anatomic points by warming them.21 Kanakura et al20 conducted a small study to examine the effect of acupuncture and moxibustion treatments on the management of lymphedema. Their study included 24 patients with gynecologic cancer undergoing pelvic lymph node dissection, 12 were treated with acupuncture and moxibustion after surgery (group 1), and 12 patients were treated after lymphedema occurred (group 2). The treatment was performed for 15 to 20 minutes for five times a week during hospitalization and twice a week after discharge. Objective outcomes for the study included limb volume, calculated using circumference measures, deep body temperature was recorded using a Core Temp CTM-205 (Terumo Corp., Tokyo, Japan)., and lymphatic cysts were measured using ultrasonography. The findings showed that no evidence of lymphedema was observed in the patients in group 1. For patients in group 2, who had already experienced lymphedema, the swelling and hardness of extremities gradually decreased following treatment with acupuncture and moxibustion. Deep body temperature was also reported to increase more than body surface temperature after the
start of acupuncture and moxibustion treatment. The investigators hypothesized that the increase in deep body temperature was associated with the success of lymphedema treatment by improving lymph flow. Thus, additional research with a rigorous design and larger sample is required before making recommendations for traditional acupuncture practice as an effective treatment for cancer-related lymphedema. Recently, de Valois et al21 conducted a singlearm, observational study to examine the benefits of traditional acupuncture practice in cancer survivors with lymphedema. The sample included breast cancer as well as head and neck cancer survivors with mild to moderate lymphedema (N ¼ 30). Participants received seven individualized treatment sessions once a week for a total of seven sessions and they could choose to continue with six optional additional treatments. The Measure Yourself Medical Outcome Profile (MYMOP)28 was used to measure holistic and participative principles. The Medical Outcomes Study Short Form (SF-36)29 was used to measure wellbeing; and the Positive and Negative Affect Schedule30 was used to assess mood states. The investigators reported that there were significant good positive changes in the MYMOP scores at all measurement points (after each session, at follow-up 4 and 12 weeks later). Only bodily pain and vitality subscales of the SF-36 showed significant improvements. There were no changes in volume or exacerbations of swelling measured by the circumference method. No serious adverse effects were reported, except minor adverse effects such as bruising, bleeding, pain, and fatigue after treatment. The primary aim of this study was to assess the feasibility of using acupuncture and moxibustion for improving well-being for cancer survivors with lymphedema, rather than focusing on its effect as a method of achieving volume reduction. As with other CAM studies, the limitations of the study included small sample size and study design (no control group). Alem and Gurgel22 also examined the effect of acupuncture on lymphedema reduction and rehabilitation of women after breast cancer surgery. All 29 patients received 24 acupuncture sessions with a 30-minute needle insertion time once a week for 11 months. Significant improvement was noted in range of movement of the shoulder, degree of lymphedema, and sense of heaviness and tightening. However, there was no significant improvement in arm circumference, which the authors noted
COMPLEMENTARY AND ALTERNATIVE MEDICINE AND LYMPHEDEMA
may have resulted from an insufficient number of acupuncture sessions and suggested alternative protocols with an increased number of sessions. Given the noted benefits of the study, future research should be considered with a larger, randomized controlled trial to provide a comparative group and provide an estimate of the magnitude of the effects. Cassileth et al23 conducted a pilot study to examine the effects of acupuncture in nine breast cancer survivors with chronic lymphedema. Participants received acupuncture twice a week for 4 consecutive weeks. After 4 weeks of treatment, at least a 30% reduction in lymphedema volume measured by the circumference method was observed. No serious adverse events occurred during 73 treatment sessions or during the 6month follow-up period. However, some patients reported minor pain and slight bruising at the acupuncture site shortly after treatment. The limitations of the study were a small sample size and no control group. Further research using a larger, randomized controlled trial is required. In conclusion, although there are a few studies that demonstrate encouraging results associated with acupuncture as a preventive and therapeutic treatment for cancer patients with lymphedema, the true risks and benefits of acupuncture are unknown given the methodologic quality issues of the studies. Controlled clinical trials with quality assessments are recommended to further evaluate this treatment for cancer-related lymphedema.
MANIPULATIVE AND BODY-BASED PRACTICES AND LYMPHEDEMA Massage is a popular type of manipulative and body-based practice that has been commonly used by cancer patients. However, only a few studies have been conducted to examine whether it is effective in treating lymphedema. It should be noted that the term ‘‘massage’’ in this article is not synonymous with the term ‘‘manual lymph drainage (MLD),’’ but rather refers to direct manipulation of soft tissues performed by hands. According to Zuther,31 the term ‘‘massage’’ refers specifically to forms of ‘‘classical’’ or ‘‘Swedish’’ massage that are applied with more pressure than MLD, which is an important component of complete decongestive therapy. Swedish massage was introduced in the 19th century by Per Henrik Ling and was brought to the United States in the
47
1850s by George and Charles Taylor, who studied in Sweden.32 With respect to the effects of aromatherapy massage for lymphedema, Barclay et al24 conducted a clinical randomized trial to compare the effects of self-limb massage by using a base cream alone versus a base cream containing aromatherapy oils for limb volume reduction in cancer patients (N ¼ 80). Limb circumference was used to measure limb volume changes and symptom improvements, activity, and well-being were measured with the ‘‘Measure Yourself Medical Outcome Profile 2 (MYMOP2).’’28 In this study, limb volume reduction was reported at 3 months after self-massage, with improvement in symptoms and well-being over time until 6 months follow-up. However, there were no significant differences in terms of limb volume reduction, symptom relief, and well-being between the two groups. Therefore, the authors concluded that aromatherapy did not appear to be an added benefit to massage alone, with respect to the measured outcomes. Moseley and colleagues,25 conducted a pilot study to examine the effect of a new handheld massage unit that delivered vibration to the arm tissues in women with secondary lymphedema after breast cancer treatment (N ¼ 30). Participants were asked to use the handheld massage unit for 25 minutes each evening for 1 month. Bioimpedance, perometry, tonometry, and subjective arm symptoms were measured at baseline, at the end of week 1, 2, 3, and 4, and at 1-month follow-up. After 1 month there was a reduction in arm fluid of 5 mL, with significant improvements in limb size and range of movement. No adverse side effects were observed. Limitations of the study include the lack of a control group and a small sample size. In conclusion, in contrast to MLD, which is accepted as an effective method in treating lymphedema with gentle pressure,33 massage stroke with more pressure may increase the lymphatic load of fluid resulting from an increased local arterial blood flow exacerbating lymphedema.31 Therefore, it is essential that MLD be taught by an experienced and qualified lymphedema practitioner.32,34 Moreover, massage with high pressure may cause damage to the lymphatic system that can lead to a decrease in the lymphatic system’s transport capacity. Thus, it is recommended that massage therapy should not be applied in lymphedemateous extremities or
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A. WANCHAI, J.M. ARMER, AND B.R. STEWART
bordering truncal quadrants. Additionally, deep tissue massage for patients who are at risk for lymphedema, such as those who have undergone a lymph node dissection or radiation of the axillary lymph nodes, is also contraindicated.31,32
CONCLUSION Many cancer patients with lymphedema choose to use CAM to manage their symptoms. Based on this review, there is limited evidence to date to support the effectiveness of CAM in treating or preventing cancer-related lymphedema. In addi-
tion, some CAM types, such as herbal medicine or acupuncture, have been associated with adverse side effects. Therefore, it is critical that among all health care providers that oncology nurses in particular remain current in their knowledge of CAM and recognize studies with rigorous research methods that will likely provide the best evidence related to the effectiveness and risks of CAM use in cancer-related lymphedema. Patients must also be educated on this body of literature so that they are aware of the evidence base for CAM use to prevent the potential adverse side effects that may occur.
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14. Rokovitch E, Pignol JP, Chartier C, et al. Complementary and alternative medicine use is associated with an increased perception of breast cancer risk and death. Breast Cancer Res Treat 2005;90:139-148. 15. Casley-Smith JR, Morgan RG, Piller NB. Treatment of lymphedema of the arms and legs with 5,6-benzo-[alpha]-pyrone. N Engl J Med 1993;329:1158-1163. 16. Loprinzi CL, Kugler JW, Sloan JA, et al. Lack of effect of coumarin in women with lymphedema after treatment for breast cancer. N Engl J Med 1999;340:346-350. 17. Cluzan RV, Pecking AP, Mathiex-Fortunet H, et al. Efficacy of BN165 (Ginkor Fort) in breast cancer related upper limb lymphedema: a preliminary study. Lymphology 2004;37:47-52. 18. Wheat J, Currie G, Kiat H, et al. Improving lymphatic drainage with herbal preparations: a potentially novel approach to management of lymphedema. Aus J Med Herb 2009;21:66-70. 19. Gothard L, Cornes P, Earl J, et al. Double-blind placebocontrolled randomised trial of vitamin E and pentoxifylline in patients with chronic arm lymphoedema and fibrosis after surgery and radiotherapy for breast cancer. Radiother Oncol 2004;73:133-139. 20. Kanakura Y, Niwa K, Kometani K, et al. Effectiveness of acupuncture and moxibustion treatment for lymphedema following Intrapelvic lymph node dissection: a preliminary report. Am J Chin Med 2002;30:37. 21. Valois BA, Young TE, Melsome E. Assessing the feasibility of using acupuncture and moxibustion to improve quality of life for cancer survivors with upper body lymphoedema. Eur J Oncol Nurs 2012;16:301-309. 22. Alem M, Gurgel MS. Acupuncture in the rehabilitation of women after breast cancer surgery. Acupunct Med 2008;26: 86-93. 23. Cassileth BR, Van Zee KJ, Chan Y, et al. A safety and efficacy pilot study of acupuncture for the treatment of chronic lymphoedema. Acupunct Med 2011;29:170-172. 24. Barclay J, Vestey J, Lambert A, et al. Reducing the symptoms of lymphoedema: Is there a role for aromatherapy? Eur J Oncol Nurs 2006;10:140-149. 25. Moseley A, Piller N, Heidenreich B, et al. Pilot study of a handheld massage unit. J Lymphoedema 2009;4:24-28. 26. Farinola N, Piller N. Pharmacogenomics: Its role in reestablishing coumarin as treatment for lymphedema. Lymphat Res Biol 2005;3:81-86.
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27. Abascal K, Yarnell E. botanicals for chronic venous insufficiency. Altern Complement Ther 2007;13:304-311. 28. Paterson C. Measuring outcomes in primary care: a patient generated measure, MYMOP, compared with the SF36 health survey. BMJ 1996;312:1016-1020. 29. Garratt AM, Ruta DA, Abdalla MI, et al. The SF36 health survey questionnaire: an outcome measure suitable for routine use within the NHS? BMJ 1993;306:1440-1444. 30. Watson D, Clark LA, Tellegen A. Development and validation of brief measures of positive and negative affect: the PANAS scales. J Pers Soc Psychol 1988;54:1063-1070.
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31. Zuther J. Traditional massage therapy in the treatment and management of lymphedema. Massage Today 2002;2: 1-5. 32. Collinge W, MacDonald G, Walton T. Massage in supportive cancer care. Semin Oncol Nurs 2012;28:45-54. 33. Bernas M, White M, Kriederman B, et al. Massage therapy in the treatment of lymphedema. IEEE Med Biol Mag 2005;24:58-68. 34. Pyke C. Massage: a helping hand for people with chronic oedema and lymphoedema. Br J Community Nurs 2010;15: s28-s30.