Background

Lymphedema is the abnormal accumulation of lymphatic fluid in the interstitial tissue, characterized by high protein content, due to obstruction or compression in lymphatic outflow [1]. It can occur anywhere in the body; however, upper limb lymphedema is most commonly associated with breast malignancy, often as a symptom of advanced cancer or squeale of anti-cancer treatments [2].

Approximately 12% to 60% of lymphedema cases have been reported in breast cancer patients, with around 27% presenting with upper limb lymphedema [3]. In these patients, this condition is typically caused by surgical removal of axillary lymph nodes, radiotherapy, tumor obstruction, or a combination of these factors. It may also result from postoperative infections or lymph node metastasis [2,4].

Common symptoms include tightness, heaviness of the affected limb, a bursting sensation, pain, functional impairment, restricted mobility, and difficulty finding well-fitting clothing or footwear. Complications may include lymphangiectasis, hyperkeratosis, papillomatosis, cutaneous fibrosis, and lymphorrhea [5]. Lymphedema can further increase the risk of infections, reduce range of motion, alter sensory perception, lower self-esteem, and lead to greater dependency, psychological distress, and social isolation [6,7]. If left untreated, it can significantly impair a patient’s quality of life [8].

Early detection through proper assessment, followed by timely and appropriate treatment, is essential to prevent the progression of this debilitating condition. In palliative care settings, the primary management approach for lymphedema is conservative therapy, with Complex Decongestive Therapy (CDT) recognized as the gold standard. CDT primarily consists of compression (via multilayer bandaging or compression garments), manual lymphatic drainage (MLD), skin care, and therapeutic exercise. It remains the most effective and widely adopted method for managing lymphedema [9].

Complex Decongestive Therapy (CDT) is typically administered in two phases. Intensive CDT, or Phase 1, is recommended for patients with moderate to severe lymphedema and includes manual lymphatic drainage (MLD), compression bandaging (CB), therapeutic exercise, and skin care. Modified CDT, or Phase 2, is generally used for mild to moderate cases and focuses on maintenance through compression garments or bandaging, continued skin care, and additional MLD or exercise as needed [10,11]. These four core components are adapted based on patient needs and tolerance. When administered appropriately by trained professionals, CDT can achieve a limb volume reduction of 50% to 70%, with results sustained over time [11].

In Bangladesh, palliative care services remain limited, ranking among the lowest globally in terms of availability and accessibility, despite a high burden of unmet palliative care needs. Since 2007, the Centre for Palliative Care at Bangladesh Medical University (BMU) has been at the forefront of palliative care development in the country. As part of its services, the university established a dedicated lymphedema clinic that operates weekly, providing much needed care to patients with lymphedema.

However, studies on lymphedema management in palliative care patients in Bangladesh remain scarce. In our experience, delayed presentation, limited resources, inadequate healthcare facilities, and restricted treatment options pose significant challenges in the effective management of lymphedema symptoms, particularly among breast cancer patients. In this context, the present study aims to evaluate the effectiveness of Complex Decongestive Therapy (CDT) in managing lymphedema among this patient population and to explore the therapeutic benefits of CDT despite existing systemic limitations.

Methods

Results

The mean age of the participants was 50.2 ± 8.6 years. The majority of patients (54.8%) were diagnosed at stage III cancer. Nearly half of the patients (47.6%) were diagnosed with lymph node (LN) metastasis during the study period, and the majority (71.4%) were symptomatic but fully ambulant. All patients presented with unilateral lymphedema, with the left upper limb being the most frequently affected site (54.8%). More than half (66.6%) patients had Grade 2 lymphedema. Almost all the patients (92.9%) underwent surgery, followed by chemotherapy in 90.5% and radiotherapy in 76.2%. Mean duration of development of lymphedema from last treatment was 16.6 ± 10 months (Table 1).

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Table 1. Distribution of the participants according to socio-demographic characteristics (n = 42).

https://doi.org/10.1371/journal.pone.0326040.t001

After receiving CDT, the volume of the affected upper limbs in patients decreased from baseline to subsequent follow-up visits (Table 2).

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Table 2. Association of volume changes of lymphedema limbs among different visits (n = 42).

https://doi.org/10.1371/journal.pone.0326040.t002

Significant volume reduction in both the right and left upper limbs was observed from baseline to the 2nd follow-up visit, as well as from the 1st to the 2nd follow-up visit. However, no significant volume change was noted from baseline to the 1st follow-up visit. This indicates that CDT effectively reduced limb volume over the study period. However, we did not find any association between cancer stage and the volume reduction of the affected limb (Table 3).

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Table 3. Difference of mean volume change of lymphedema limbs over subsequent visits (n = 42).

https://doi.org/10.1371/journal.pone.0326040.t003

No statistically significant improvement in skin edema was observed between the baseline visit and the 2nd follow-up visit. However, visible clinical improvement in the skin texture was noted. Approximately 76.2% of patients presented with dry, shiny skin on the affected limb at baseline. After receiving CDT and proper skin care, 59.5% of patients regained normal skin on the affected limb, although this improvement was not statistically significant. However, the improvement in skin condition can be attributed to CDT, as it not only resulted in volume reduction but also included proper skin care (Table 4).

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Table 4. Comparison of skin conditions between different visits (n = 42).

https://doi.org/10.1371/journal.pone.0326040.t004

Most patients (92.9%) initially reported a sensation of heaviness, while 90.5% experienced tightness in the affected limb, along with difficulties in finding well-fitting clothes. However, following subsequent visits, there was a significant reduction in tightness, heaviness, and pain in the affected limb (Table 5).

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Table 5. Comparison of self-reported symptoms and observed signs between different visits (n = 42).

https://doi.org/10.1371/journal.pone.0326040.t005

Discussion

Lymphedema is a chronic condition that markedly impairs both physical function and quality of life of the patients. Although no definitive cure currently exists, various treatment modalities are available to mitigate its impact. Among these, Complex Decongestive Therapy (CDT) is widely regarded as the first-line treatment approach.

In our study, most patients were diagnosed at stage III of the disease and developed lymphedema an average of 16.6 ± 10 months after completing their last treatment. This finding aligns with a large-scale study reporting that breast cancer patients developed lymphedema within 12 months of surgery [17]. In contrast, an Iranian study reported a longer average duration of 37 months for the onset of lymphedema post-surgery. Additionally, another study found that patients who underwent both axillary dissection and radiation therapy had a higher risk of developing upper limb lymphedema compared to those treated with either modality alone [18]. Our findings are consistent with this, as the majority of our patients received multiple treatment modalities for breast cancer.

All of our patients presented with moderate to severe upper limb lymphedema and received the intensive phase of Complex Decongestive Therapy (CDT). We observed significant limb volume reduction in both right and left upper limbs across follow-up visits, with an average decrease of 906.08 mL from the baseline to the 6-week follow-up. Sezgin Ozcan et al. similarly reported a reduction of 248.9 mL after 10 days of intensive CDT [19], while another study observed a median reduction of 328.7 mL following just 6 days of treatment [20]. Comparable outcomes have been documented in studies conducted in Poland, the USA, Brazil, Iran, and Ireland, where patients receiving CDT demonstrated significant reductions in limb volume [16,21–24]. A retrospective study from the USA also found meaningful volume reduction in post-mastectomy patients following CDT, irrespective of prior lymphedema therapy [13].

However, in most of these studies, the intensive phase of CDT lasted between 6 days and 3 weeks. Only two studies involving palliative lymphedema patients reported extended treatment durations ranging from 12 weeks to 6 months [16,22]. While the mean volume reduction observed in our study was notably higher than in previous reports, this may be attributed to the longer treatment duration of 6 weeks. Therefore, our findings suggest that CDT alone is effective in reducing edema among palliative lymphedema patients, even in resource-limited settings such as Bangladesh.

Regarding skin changes following CDT, we observed a reduction in non-pitting edema over consecutive visits, whereas pitting edema remained relatively unchanged during the second and third visits. In terms of skin texture, improvements were noted in dryness and shininess, with nearly half of the patients regaining normal skin appearance by the second and third follow-up visits; however, these changes were not statistically significant. In contrast, a study conducted in Ireland reported significant improvements in both skin texture and edema reduction following CDT [16].

In our study, skin changes were assessed clinically due to the unavailability of validated assessment tools and advanced hospital facilities. Conversely, Lee et al. utilized ultrasonography to evaluate the effects of CDT in patients with breast cancer-related lymphedema (BCRL). Their findings demonstrated a significant reduction in soft tissue thickness at the elbow and at a point 10 cm proximal to the elbow during follow-up. This suggests that combining arm circumference measurements with ultrasonographic evaluation of soft tissue thickness may serve as effective methods for assessing CDT outcomes in BCRL patients [25].

Furthermore, we observed significant improvement in limb tightness, heaviness, and pain following the intensive phase of CDT. This aligns with findings from a Korean study, which reported notable improvements in physical function and bodily pain after CDT [26]. In that study, reductions in pain, heaviness, and impaired limb mobility were significant during Phase I and sustained during Phase II. Similarly, Liang et al. reported significant improvements in general health and vitality after three months of CDT [19,27]. Collectively, these findings underscore the effectiveness of CDT in alleviating both physical symptoms and discomfort in patients with upper limb lymphedema.

Conclusion

Lymphedema management utilizing all components of Complex Decongestive Therapy (CDT) was found to be effective in reducing limb volume and alleviating distressing symptoms in patients. To sustain these improvements, continued application of CDT over time is essential. Longer-term follow-up studies are warranted to determine the optimal treatment duration and to assess the long-term efficacy of CDT. Timely referral of lymphedema patients to specialized clinics and early initiation of CDT can play a crucial role in reducing their ongoing suffering, particularly in resource-limited settings such as Bangladesh.

Acknowledgments

The authors gratefully acknowledge the contribution of Dr. Sohel Rahman for his assistance in analyzing the data for this study.