Comments to "The Randomized Controlled Study of Low-Level Laser Therapy, Kinesio-Taping and Manual Lymphatic Drainage in Patients With Stage II Breast Cancer-Related Lymphedema".

Letter to the Editor Eur J Breast Health 2023; 19(2): 184-185 DOI: 10.4274/ejbh.galenos.2023.2023-1-2 Comments to “The Randomized Controlled Study of Low-Level Laser Therapy, Kinesio-Taping and Manual Lymphatic Drainage in Patients With Stage II Breast Cancer-Related Lymphedema” Anke Bergmann1, Mauro Figueiredo Carvalho Andrade2, Mirella Dias3 Program of Clinical Epidemiology, National Cancer Institute, Rio de Janeiro, Brazil Department of Surgery, Faculty of Medicine, University of São Paulo (USP), São Paulo, Brazil 3 Department of Physiotherapy, Faculty of Medicine, Santa Catarina State University, Florianópolis, Brazil 1 2 Cite this article as: Bergmann A, Andrade MFC, Dias M. Comments to “The Randomized Controlled Study of Low-Level Laser Therapy, Kinesio-Taping and Manual Lymphatic Drainage in Patients With Stage II Breast Cancer-Related Lymphedema”. Eur J Breast Health 2023; 19(2): 184-185 We read with great interest the article published by Selcuk Yilmaz and Ayhan (1). The authors focused on a topic of utmost importance in clinical practice related to the most common and debilitating side effect of breast cancer treatment. Currently, the gold standard approach to lymphedema patients is decongestive physical therapy, which includes manual lymphatic drainage (MLD), compressive therapy, skin care and exercises. However, other forms of adjuvant treatment have been increasingly highlighted, aiming for better therapeutic results and lower treatment related costs (2). For that matter, the randomized clinical study performed by Selcuk Yilmaz and Ayhan (1) compared efficacy and tolerability of kinesio-taping (KT) or low-level laser therapy (LLLT) as alternatives to MLD in breast cancer survivors who developed unilateral stage II lymphedema, meaning their excess volume on the affected arm reached 5 to 20%. Patients were randomized in three groups and treated with MLD, KT or LLLT. Treatment was undertaken for three weeks, five sessions a week, and all women were oriented about self-massaging techniques, skin care and exercises. At the end of each session, the therapist applied multilayer bandaging in all groups, which was kept for 23–24 hours and supervised remedial exercises performed by the patients. After the end of the three treatment weeks, flat-knitted garments were prescribed to all patients to be worn during the maintenance phase. Outcomes were assessed immediately after treatment and up to 12 weeks of follow-up. Based on their results, the authors concluded that KT was more effective in volume reduction than MLD and that KT was as effective as LLLT. However, we believe that some critical issues should be considered regarding their conclusions: • Despite randomization, the MLD group presented a significant predominance of obese patients, a longer duration of swelling in months, and lesser caregiver support. Those factors are known to be related to transcription factor decoy (TFD) response (3-5). In the results published in the article, the authors did not control the influence of those variables in the statistical analysis (models of adjusted multiple regression). Therefore, the favorable outcome observed in the KT group may be due to the diverse clinical and demographic characteristics among groups and not to the intervention itself. • Fan-cut kinesio-tape was applied using the lymphedema kinesiotaping technique of paper-off tension. The supporters of this technique argue that its beneficial effect lies in the fact that lifting the skin induces opening of initial lymph vessels and enhances fluid absorption and transport (6). In this study, patients in the KT group also had multilayer bandaging, causing this supposed skin lifting effect to be replaced by the wellestablished compressive effect. Therefore, edema reduction may be attributed not to the lymphatic effect of the taping, but to the overlapping compression provided by bandaging. • LLLT was applied in the axillary and cubital areas. This technique intends to stimulate lymphatic motricity and promote lymphangiogenesis. However, these effects of LLLT are not expected to be observed in so short a follow-up (7). 184 Corresponding Author: Anke Bergmann; Received: 06.01.2023 Accepted: 13.01.2023 Available Online Date: 01.04.2023 ©Copyright 2023 by the Turkish Federation of Breast Diseases Societies / European Journal of Breast Health published by Galenos Publishing House. Bergmann et al. Comments to Selcuk Yilmaz and Ayhan (2023) In conclusion, we believe that the results obtained by Selcuk Yilmaz and Ayhan (1) emphasize the role of multilayer bandaging associated to exercises and skin care as the best therapeutic approach to breast cancer treatment related lymphedema. So, even if adjuvant therapies may be incorporated to selected patients, namely MLD alone, LLLT, KT, and others, they still need further evaluation for they do not offer better outcomes as compared to TFD. Patients With Stage II Breast Cancer-Related Lymphedema. Eur J Breast Health 2023; 19: 34-44. (PMID: 36605467) [Crossref ] 2. Bergmann A, Baiocchi JMT, de Andrade MFC. Conservative treatment of lymphedema: the state of the art. J Vasc Bras 2021; 20: e20200091. (PMID: 34777487) [Crossref ] 3. Duyur Cakıt B, Pervane Vural S, Ayhan FF. Complex Decongestive Therapy in Breast Cancer-Related Lymphedema: Does Obesity Affect the Outcome Negatively? Lymphat Res Biol 2019; 17: 45-50. (PMID: 30281384) [Crossref ] 4. Eyigör S, Cinar E, Caramat I, Unlu BK. Factors influencing response to lymphedema treatment in patients with breast cancer-related lymphedema. Support Care Cancer 2015; 23: 2705-2710. (PMID: 25663541) [Crossref ] 5. Keskin D, Dalyan M, Ünsal-Delialioğlu S, Düzlü-Öztürk Ü. The results of the intensive phase of complete decongestive therapy and the determination of predictive factors for response to treatment in patients with breast cancer related-lymphedema. Cancer Rep (Hoboken) 2020; 3: e1225. (PMID: 32672004) [Crossref ] 6. Bosman J. Lymphtaping for lymphoedema: an overview of the treatment and its uses. Br J Community Nurs 2014; Suppl: S12-S18. (PMID: 24704750) [Crossref ] 7. Wang Y, Ge Y, Xing W, Liu J, Wu J, Lin H, et al. The effectiveness and safety of low-level laser therapy on breast cancer-related lymphedema: An overview and update of systematic reviews. Lasers Med Sci 2022; 37: 1389-1413. (PMID: 34779937) [Crossref ] Peer-review: Internally peer-reviewed. Authorship Contributions Concept: A.B., M.F.C.A., M.D.; Data Collection or Processing: A.B., M.F.C.A., M.D.; Analysis or Interpretation: A.B., M.F.C.A., M.D.; Literature Search: A.B., M.F.C.A., M.D.; Writing: A.B., M.F.C.A., M.D. Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study received no financial support. References 1. Selcuk Yilmaz S, Ayhan FF. The Randomized Controlled Study of LowLevel Laser Therapy, Kinesio-Taping and Manual Lymphatic Drainage in 185  (...truncated)