Jeffs, E. (2006). Treating breast cancer-related lymphoedema at the London Haven: Clinical audit results. European Journal of Oncology Nursing, 10(1), 71–79.

To treat breast cancer-related lymphedema based on clinical audit results

Clinical audit of effective and ineffective treatment programs Inform the decision-making process regarding focus of care and funding efforts. The study surveyed three years of treatment data on onset and duration of swelling, severity (size and extent), lymphedema treatment received, and changes in severity over time. of 2,486 treatment sessions, 65% (1608) were manual lymph drainage (MLD) optimal intensive offered to all with moderate to severe lymphedema. Only 19 patients were willing to commit to the program. This was followed by MLD and compression garments. All patients with moderate to severe lymphedema were taught daily skin care, exercise, 

• Of the patients at London Haven, 268 patients were eligible.
• Patients were excluded if they had advanced disease or bilateral lymphedema.
• Ninety-five patients declined treatment.
• The sample was comprised of 168 patients.
• Seventy-four (44%) had follow-up data for 12 months for analysis.

The study took place at London Haven.

• Severity of swelling at first presentation measured by perometer excess limb volume (percentage excess limb volume [ELV])
• ELV mild swelling was less than 20%, ELV moderate 20%-40%, and ELV severe more than 40%.
• Breast and trunk swelling clinically determined by observation and palpation and patient report. 

Of patients with mild, uncomplicated lymphedema, 75% (39/52) received standard self-care regimen of hosiery, exercise, and skin care. Those patients had a mean reduction of 30% ELV was achieved by 13 patients for whom 12-month data were available. Thirteen (25%) received a short course of MLD (six sessions over two weeks). Mean reduction was 20% ELV, which is less than that achieved by self-care measures alone. Some patients in self-care group had stopped wearing their hosiery because at three and six months they had such improvement. Thirty-nine patients presented with breast or trunk edema and were treated with MLD and also taught self-massage. Of the 20 patients for whom 12-month data were available, 14 had complete resolution of edema. Moderate-to-severe lymphedema Intensive therapy was offered to 77 patients. Only 19 (25%) underwent one or more courses of intensive therapy. Twelve-month data was available on only 16 patients. At 12 months, swelling had reduced by 40% and six patients had little or no remaining edema. For those patients unable to do intensive therapy, mean reduction was 25%.

Breast edema treatment showed most improvement with MLD, self-care

• The results are based on cohort, observational data.
• The study only reflects the experience of one institution. 
• Costs of intensive therapy in terms of time, finances, and access were not fully addressed.

The audit reinforced the need for programs to offer full-service intensive therapy for patients with moderate to severe lymphedema. For patients unable or unwilling to commit to multilayer bandaging, MLD and self-care hosiery provided 25% reduction in ELV and warrants further investigation. Early treatment is advocated because almost 60% of patients developed symptoms within the first year postsurgery; only half had sought assistance from a lymphedema specialist within three months of onset of symptoms.