Abstract
Dear Editor:
We read with great interest the article written by Sinead Cobbe et al. 1 who confirmed our study 2 that complex decongestive therapy (CDT), comprising skin care, manual lymphatic drainage, compression, and exercises, 3 may be effective also in advanced cancer: Fifteen patients with unilateral upper/lower limb lymphedema had been treated for two weeks. Limb volumes based on circumferential measurements were calculated using a simplified frustrum formula. CDT effectiveness was measured by comparing the volumes of both the affected limb and edema (affected/contralateral limb difference) initially and after the last session. The quality of life (QoL) was assessed with the use of the Edmonton Symptom Assessment Scale (ESAS). A reduction in the volume of the limb (mean 8.3–7.7 L; p = 0.05) and edema (2.5–1.2 L; p = 0.001) was observed. A tendency for QoL improvement was noticed (mean ESAS 3.2–2.7; p = 0.1) but not correlated with volume reduction.
Being aware of the importance of these studies, we would like to raise some questions concerning the edema conservative management and its assessment at the end of life:
1. There are widespread problems with recruitment processes (willingness and ability to participate) and attrition rate both of which may have an impact on the results and be the source of bias. 2. It is difficult in practice to arbitrarily differentiate the participants with predominant lymphatic congestive failure (lymphedema) from the patients with coexisting causes of swelling (e.g., bilateral leg edema with hypoalbuminemia and immobility in advanced pancreatic cancer). 3. A substantial number of terminally ill patients tolerate only certain CDT components or merely additional therapeutical techniques, such as kinesiotaping that can also interfere with the results. 4. Conclusions as to the effectiveness of treatment based only on affected limb volume changes may be misleading, as the absolute change in limb size depends strongly on the patient's body weight, which, in turn, may be fluctuating, for example, due to variation in hydration. Relative limb volume change (i.e., in relation to the opposite limb or to body weight) is more independent and should be considered a standard measure.
4
5. The potential adverse effects of CDT consisting in tissue fluid shift into cardiovascular system should also be recognized. 6. The adaptation (simplification) of lymphedema-specific assessment tools to the end-of-life population is warranted.