The Oncology Nursing Society (ONS) released clinical practice guidelines focused on approaches to prospectively follow patients at risk of cancer treatment-related lymphedema, reduce the likelihood of the condition developing in these patients, and conservatively treat those who develop lymphedema secondary to cancer treatment. The guidelines were published in the Oncology Nursing Forum.1

Lymphedema is a chronic condition that is typically characterized by an accumulation of lymphatic fluid in the soft tissues of an arm or leg as a result of lymph node damage.

Most often occurring secondary to treatment, cancer survivors with damaged lymphatic systems have a lifetime risk of developing lymphedema. Hence, approaches to monitor its occurrence and reduce the risk of it developing are key elements of management. Furthermore, although lymphedema is not considered curable, multimodality, nonsurgical approaches may be employed as a means of reducing its associated morbidity.

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The guidelines, developed by a panel comprising oncology nurses at all levels of practice, a lymphedema specialist, and a patient representative, are based on evidence from 2 systematic reviews and meta-analyses of randomized and nonrandomized prospective studies.2,3

Specifically, these guidelines are organized into 3 main sections representing prospective surveillance, risk reduction, and treatment. The strength of the evidence associated with each recommendation is classified as strong, conditional, no recommendation, or research and/or knowledge gap. In addition, the certainty of the evidence was also described.

Regarding these guidelines, the authors noted that involvement of a therapist knowledgeable about diagnosis and treatment of lymphedema — a trained, certified lymphedema therapist — is important. They further stated that patient education is an important component of self-care and should be included throughout the surveillance and treatment trajectory for lymphedema.

Key recommendations regarding surveillance of patients considered at risk of cancer treatment-related lymphedema include:

  • Prospective surveillance is recommended for all patients who have undergone cancer-related surgery.
  • Pretreatment assessment for women scheduled for breast cancer surgery or radiation therapy is recommended; followed by posttreatment assessment by a nurse or lymphedema therapist; interval assessments conducted at 1, 3, 6, 9, and 12 months; then bi-annual assessments for 1 to 3 years subsequently moving to annually.

With respect to approaches to reduce the likelihood of developing cancer treatment-related lymphedema, recommendations include:

  • Delay initiating exercise until at least 7 days after surgery for those at risk of truncal/extremity edema;
  • Initiate programmed and supervised exercise that includes resistance and strengthening exercises at least 7 days after surgery for those at risk of truncal/extremity edema;
  • Use of compression garments for those at risk for lower extremity lymphedema; and
  • Postsurgical scar massage for those at risk of extremity, truncal, or head and neck lymphedema.

Finally, the panel recommended complete decongestive therapy (CDT) as the standard of care for patients who develop cancer treatment-related lymphedema, including manual lymphatic drainage (MLD) through a light, skin stretching massage; compression therapy; skin care approaches; resistance exercise; and water-based exercise or yoga.

Moreover, although the guideline panel recommended that the first phase of CDT be conducted by a certified lymphedema specialist, they recommend a second phase of CDT corresponding to lifelong self-management to be carried out by the patient and/or caregiver

Of note, the strength of all of the highlighted recommendations was classified as “conditional,” and the certainty of the related evidence was listed as low or very low.

The guideline authors stated, “evidence-based guidance for clinicians on the surveillance, risk reduction, and treatment of lymphedema has the potential to improve patient care and outcomes.”


1. Armer JM, Ostby PL, Ginex PK, et al, ONS Guidelines™ for cancer treatment–related lymphedema. Oncol Nurs Forum. 2020;47(5):518-538. doi:10.1188/20.ONF.518-538.

2. Ding FJ, Hasan B, Malandris K, et al. Prospective surveillance and risk reduction of cancer treatment-related lymphedema: systematic review and meta-analysis. Oncol Nurs Forum. 2020;47(5):E161-E17. doi:10.1188/20.ONF.E161-E170

3. Lytvyn L, Zeraatkar D, Anbari AB, et al. Conservative intervention strategies for adult cancer-related lymphedema: a systematic review and network meta-analysis. Oncol Nurs Forum. 2020;47(5):E171-E189. doi:10.1188/20.ONF.E171-E189