Aim: Lower limb lymphedema (LLL) is a recognised complication of cervical cancer (CC) treatment and can result in significant long-term morbidity. We conducted a literature review (LR) to better understand the impact of different cervical cancer treatment modalities on the risk of LLL and to inform evidence-based recommendations in the first Australian Cervical Cancer Management Guidelines.
Methods: A LR was undertaken, with a systematic search of the Medline, Embase and Cochrane Central Register of Controlled Trials databases, to identify studies evaluating LLL after treatment for cervical or gynaecological cancer published from 2010 to the current date. This identified 60 articles which warranted a full text review.
Results: The reported incidence of LLL varied widely across studies, reflecting both heterogeneity in assessment methods of LLL and treatment modalities. The LLL risk was consistently higher following radical hysterectomy with pelvic lymph node dissection (PLND) [range: 19.1%-35.0%] compared with those who had surgery and sentinel lymph node biopsy (SLNB) [range: 0%-5.6%]. Recent evidence, including the PHENIX-1 trial, demonstrated equivalent oncological outcomes for SLNB and PLND for the eligible population. A substantially higher risk of LLL was reported with multimodality treatment, particularly surgery with PLND followed by adjuvant radiotherapy/chemoradiotherapy (RT/CCRT) [51.1%] compared with treatment with RT/CCRT alone (9.5%). This supports using primary radical CCRT with brachytherapy when post-surgical adjuvant treatment is anticipated. The prevention and management of LLL is important because it has a negative impact on the wellbeing of patients and affects their quality of life.
Conclusion: The risk of LLL should be considered during multidisciplinary treatment planning for cervical cancer. Where appropriate, strategies such as SLNB and preference for primary radical CCRT should be considered to minimise treatment-related morbidity. Health services should incorporate evidence-based recommendations on LLL risk assessment, prevention and management into routine CC care to improve survivorship outcomes.