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Are there any references I can send my insurer to show that MLD improves a patient's health when added to compression alone?

It is important to lymphedema patients seeking proper treatment of their medical condition before it becomes disabling, and to the medical institutions and insurers who can be mislead into paying for substandard medical treatment and then dealing with the consequences of that under-treatment.

Editorial Note: The Canadian DELTA study was done in 2007-2009 and first documented in the ASTRO 2009 conference as a poster. Results showed modest gains for the addition of MLD to the Canadian "standard CDT" which comprised compression garment, exercise and skin care. Be careful in reading up on this subject. Sometimes "standard" implies the Canadian "standard" and sometimes, out of Canada, the term "standard" refers to the globally accepted standard CDT which includes MLD, compression, exercise and skin care.

The Dayes 2013 study compared elastic compression alone against the standard decongestive therapy which uses elastic compression after manual lymph drainage and bandaging. In almost every respect decongestive therapy including manual lymph drainage and compression bandaging outperformed compression garments alone – for new patients as well as longtime patients with lymphedema.

"This trial was unable to demonstrate a significant improvement in lymphedema with decongestive therapy compared with a more conservative approach. The failure to detect a difference may have been a result of the relatively small size of our trial," the researchers wrote. Statistically speaking this is correct. Significant differences cannot be shown with so small a study. But let us look at the results that were reported with the international standard CDT compared with the compression only:

The study results were widely publicized in the popular press, and were highly exaggerated and misquoted. This was done eagerly by those who would "save" money by eliminating the "expensive" MLD. The key to understanding these results is in understanding that this was a very small cohort (95 patients) and the authors were looking for statistical significance —very difficult to achieve with a small cohort.

The report you are looking for to refute the contention that there is no benefit to MLD is a 2011 study by McNeely et al., whose conclusions based on the meta-analysis of five previous studies were "specific to breast cancer, a statistically significant beneficial effect was found from the addition of manual lymph drainage massage to compression therapy for reducing upper extremity lymphedema volume."

You may also quote the results of a one-day MEDCAC review of lymphedema measurement and treatment held in November 2009, where it was found by an expert committee convened for the purpose of determining whether there was sufficient evidence to support commonly used measurement and treatment modalities.

Another recently studied lymphedema care delivery model based on lymphedema early detection and intervention would provide manual lymph drainage (MLD) to the limb of a breast cancer patient from two days after treatment and throughout the first year. This concept is applied in a six-month study to trial groups undergoing sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND), with and without radiotherapy. The investigators measured percent excess arm fluid and provided intervention to all members of the intervention group. While average excess fluid due to lymphedema in the women in the control group, who received no MLD, grew monotonically from zero to +10% at 6 months, the average excess fluid dropped monotonically in the MLD group from +1% to 1.5%.

"This study demonstrates that regardless of the surgery type and the number of the lymph nodes removed, MLD effectively prevented lymphedema of the arm on the operated side. Even in high risk breast cancer treatments (operation plus irradiation), MLD was demonstrated to be effective against arm volume increase." [Zimmermann 2012].

So instead of selecting patients who have already experienced 10% excess fluid, would we be better off providing MLD as a preventive protocol to all breast cancer treatment survivors so they never reach 10% excess fluid?

Ian S. Dayes, Tim J. Whelan, Jim A. Julian, et al. Randomized Trial of Decongestive Lymphatic Therapy for the Treatment of Lymphedema in Women With Breast Cancer. JCO October 20, 2013; 31(30): 3758-63.

McNeely ML, Peddle CJ, Yurick JL, et al: Conservative and dietary interventions for cancer related lymphedema: A systematic review and meta-analysis. Cancer 2011;117:11361148.

A. Zimmermann, M. Wozniewski, A. Szklarska, Efficacy of Manual Lymphatic Drainage in Preventing Secondary Lymphedema After Breast Cancer Surgery. Lymphology 2012; 45:103-112.