Rédacteurs : Johan Nguyen, Claude Pernice

Sommaire

Lymphedema

Lymphœdème : évaluation de l'acupuncture

1. Systematic Reviews and Meta-Analysis

☆☆☆ Evidence for effectiveness and a specific effect of acupuncture
☆☆ Evidence for effectiveness of acupuncture
☆ Limited evidence for effectiveness of acupuncture
Ø No evidence or insufficient evidence

1.1. Generic acupuncture

Yang R, Zhang YX, Zhang CC, Yan QF, Han L. Acupuncture and moxibustion treatment for breast cancer-related lymphoedema： a systematic review and Meta-analysis. Zhen Ci Yan Jiu. 2024 Jul 25;49(7):715-725. https://doi.org/10.13702/j.1000-0607.20230903

Objectives To evaluate the efficacy of acupuncture in treating breast cancer-related lymphedema (BCRL) by using systematic review and Meta analysis method.
Methods Searching CNKI, Wanfang Data Knowledge Service Platform, VIP Chinese Journal Service Platform, Chinese Biomedical Literature Database, PubMed, Cochrane Library, Embase and Web of Science, the randomized controlled trials (RCTs) literature of acupuncture for BCRL was collected from the establishment of the databases to October 1st, 2023. After data extraction and risk of bias evaluation of the included literature, Meta-analysis was performed using RevMan5.4 software.
Results A total of 14 RCTs with 952 patients were included. The Meta-analysis results showed that compared with comprehensive decongestive therapy (CDT), CDT-associated methods and other interventions of the contro group, acupuncture was able to decrease the circumference of the proximal 10 cm to elbow crease (MD=-1.95, P=0.000 5), reduce the difference in arm circumference (MD=-1.30, P<0.000 01), and increase the effective index (MD=27.47, P<0.000 01；RR=1.23, P=0.000 5)；acupuncture improves the range of motion(ROM) scores of shoulder joint in four areas：anteflexion(SMD=0.47, P=0.04), posterior extension (SMD=0.87, P<0.000 01), abduction (SMD=0.48, P=0.03), and adduction (SMD=0.72, P=0.000 5)；acupuncture also could alleviate pain and improve visual analog scale (VAS) scores (MD=-1.15, P<0.000 01). No serious adverse reactions were reported in the literatures.
Conclusions Acupuncture can effectively improve the degree of limb edema and subjective symptoms in BCRL patients.

1.1.2. Cheung 2023 (Head and Neck Cancer-Associated Lymphedema)

Cheng JT, Leite VF, Tennison JM, Gutierrez C, Kline-Quiroz C, Capozzi LC, Yu S, Krause KJ, Langelier D, Parke SC. Rehabilitation Interventions for Head and Neck Cancer-Associated Lymphedema: A Systematic Review. JAMA Otolaryngol Head Neck Surg. 2023 Aug 1;149(8):743-753. https://doi.org/10.1001/jamaoto.2023.1473

Importance Head and neck cancer-associated lymphedema (HNCaL) affects up to 90% of survivors of head and neck cancer and is a substantial contributor to disability following head and neck cancer treatment. Despite the prevalence and morbidity associated with HNCaL, rehabilitation interventions are not well studied.
Objective To identify and appraise the current evidence for rehabilitation interventions in HNCaL.
Evidence review Five electronic databases were searched systematically from inception to January 3, 2023, for studies on HNCaL rehabilitation interventions. Study screening, data extraction, quality rating, and risk of bias assessment were performed by 2 independent reviewers.
Findings Of 1642 citations identified, 23 studies (1.4%; n = 2147 patients) were eligible for inclusion. Six studies (26.1%) were randomized clinical trials (RCTs) and 17 (73.9%) were observational studies. Five of the 6 RCTs were published during 2020 to 2022. Most studies had fewer than 50 participants (5 of 6 RCTs; 13 of 17 observational studies). Studies were categorized by intervention type, including standard lymphedema therapy (11 studies [47.8%]) and adjunct therapy (12 studies [52.2%]). Lymphedema therapy interventions included standard complete decongestive therapy (CDT) (2 RCTs, 5 observational studies), modified CDT (3 observational studies), therapy setting (1 RCT, 2 observational studies), adherence (2 observational studies), early manual lymphatic drainage (1 RCT), and inclusion of focused exercise (1 RCT). Adjunct therapy interventions included advanced pneumatic compression devices (APCDs) (1 RCT, 5 observational studies), kinesio taping (1 RCT), photobiomodulation (1 observational study), acupuncture/moxibustion (1 observational study), and sodium selenite (1 RCT, 2 observational studies). Serious adverse events were either not found (9 [39.1%]) or not reported (14 [60.9%]). Low-quality evidence suggested the benefit of standard lymphedema therapy, particularly in the outpatient setting and with at least partial adherence. High-quality evidence was found for adjunct therapy with kinesio taping. Low-quality evidence also suggested that APCDs may be beneficial.
Conclusions and relevanceThe results of this systematic review suggest that rehabilitation interventions for HNCaL, including standard lymphedema therapy with kinesio taping and APCDs, appear to be safe and beneficial. However, more prospective, controlled, and adequately powered studies are needed to clarify the ideal type, timing, duration, and intensity of lymphedema therapy components before treatment guidelines can be established.

Gao Y, Ma T, Han M, Yu M, Wang X, Lv Y, Wang X. Effects of Acupuncture and Moxibustion on Breast Cancer-Related Lymphedema: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Integr Cancer Ther. 2021. [222770]. https://doi.org/10.1177/15347354211044107

ObjectiveThe aim of this systematic review and meta-analysis of randomized controlled trials (RCTs) was to evaluate the effects of acupuncture and moxibustion (AM) in women with breast cancer-related lymphedema (BCRL).
MethodsWe retrieved RCTs published before January 24, 2021, from the MEDLINE, EMBASE, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), Chongqing VIP (VIP), and Wanfang databases. RCTs that compared acupuncture and/or moxibustion intervention with other treatments were included. A random effects or fixed effects model was used based on the heterogeneity findings. Study quality was evaluated using the Cochrane risk of bias tool.
Results We included 14 RCTs in the analyses, of which 4 RCTs adopted acupuncture, 4 RCTs used moxibustion, and the rest used both. AM significantly reduced arm circumference at the elbow crease compared to routine care (Mean deviation (MD) = -7.26, 95% confidence interval (CI) = -8.30 to -6.21, P < .00001). There was a significant difference between AM and diosmin tablets in the effective index for upper limb lymphedema (MD = 24.68, 95% CI = 24.82-30.53, P < .00001), the range of motion of the shoulder during protraction (MD = 6.77, 95% CI = 2.81-10.73, P = .0008), and adduction (MD = 4.17, 95% CI = 1.02-7.32, P = .01). There was a significant difference between moxibustion and pneumatic circulation (MD = -0.51, 95% CI = -0.85 to -0.17, P = .003) in the visual analog score (VAS) for swelling. Finally, compared to the blank control, acupuncture reduced the VAS for pain (MD = -1.33, 95% CI = -1.52 to -1.15, P < .00001; heterogeneity (I2) = 0%, P = .57).
Conclusion Our results suggest that AM is effective in the treatment of BCRL. AM may reduce arm circumference at the elbow crease (compared to routine care), increase effective index for upper limb lymphedema (compared to oral diosmin tablets), improve the range of motion of the shoulder during protraction and adduction (compared to oral diosmin tablets), and decrease the VAS for both swelling (compared to pneumatic circulation) and pain (compared to blank control).

Hou W , Pei L , Song Y , Wu J , Geng H , Chen L , Wang Y , Hu Y , Zhou J , Sun J. Acupuncture therapy for breast cancer-related lymphedema: A systematic review and meta-analysis. J Obstet Gynaecol Res. 2019;45(12):2307-2317. [209925]. doi

AimThis study aimed to conduct a comprehensive analysis of clinical studies on acupuncture treatment for breast cancer-related lymphedema (BCRL), so as to explore the efficacy and safety of acupuncture treatment and provide evidence for the clinical decision-making.
MethodsPublic databases, mainly including China Academic Journals Full-text Database, Database of Chinese Sci-Tech Journal, Wanfang, PubMed, Embase and the Cochrane Library, from the establishment of databases to December 2018 were searched for randomized controlled trials (RCT) of acupuncture for BCRL. Clinical RCT on the treatment of BCRL with acupuncture combined with drugs or functional exercise were enrolled for the analysis. Bias risk and quality were assessed by two investigators according to the Cochrane Handbook 5.1.0 standard, and the Revman 5.3 software was used for meta-analysis. A total of 13 studies were enrolled, comprising 747 patients (377 in the treatment group and 370 in the control group).
ResultsThe results of meta-analysis showed that acupuncture intervention could improve the total effective rate for the treatment of BCRL (odds ratio = 4.62; 95% confidence interval 2.61-8.17). Recent studies suggest that acupuncture therapy can alleviate the upper limb swelling and improve the subjective pain and discomfort in patients with BCRL, regardless of the control intervention used. However, the number of high-quality RCT is low. Moreover, most of the studies adopted inconsistent efficacy indicators.
ConclusionsHence, additional blinded, large sample, randomized, well-controlled studies with objective and uniform efficacy indicators are needed, especially in China, to confirm the findings.

Jin H, Xiang Y, Feng Y, et al. Effectiveness and Safety of Acupuncture Moxibustion Therapy Used in Breast Cancer-Related Lymphedema: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med. 2020:3237451. [209234]. doi

Objective To evaluate the effectiveness and safety of acupuncture moxibustion therapy (AMT) for the breast cancer-related lymphedema (BCRL).
Methods Four English databases (MEDLINE, PubMed, Embase, and Cochrane CENTRAL) and four Chinese databases were searched from their inception to Feb 1, 2020. Eligible randomized controlled trials (RCTs) investigating AMT against any type of controlled intervention in patients for BCRL and assessing clinically relevant outcomes (total effective rate, circumference difference, and Karnofsky performance score) were included. The methodological quality of all selected trials was estimated in accordance with the guidelines published by the Cochrane Collaboration. Review Manager 5.3 was used to conduct analyses.
Results Twelve eligible RCTs are confirmed. Most of the trials selected are regarded as low methodological quality. Compared with Western medicine, physiotherapy, and functional training, traditional AMT has significantly higher treatment effect (RR 1.03 (95% CI: 1.22, 1.45); p < 0.00001). In comparison with physiotherapy, AMT is better in reducing edema symptoms (MD = -0.77; 95% CI (-1.13-0.41); p < 0.00001). Moreover, pooled results demonstrate that AMT results in better outcomes than functional training and Western medicine in improving Karnofsky performance score of BCRL patients (SMD = 0.69; 95% CI (0.38-1.00); p < 0.00001).
Conclusion This systematic review and meta-analysis provides evidence that AMT is serviceable and safe in treating BCRL. With the limited number of available studies and methodology drawbacks, further high-quality RCTs with reasonable designs are still warranted.

Yu S, Zhu L, Xie P, Jiang S, Yang Z, He J, Ren Y. Effects of acupuncture on breast cancer-related lymphoedema: A systematic review and meta-analysis. Explore (NY). 2020;16(2):97-102. [212520]. doi

Background Lymphoedema is a common complication of axillary dissection surgery, especially for breast cancer patients. Approximately 20% of breast cancer survivors develop breast cancer-related lymphoedema (BCRL). Acupuncture (AC) has become an alternative treatment for BCRL. In this study, we investigated whether AC was a good method for treating limb oedema in women after breast cancer surgery.
Methods We performed a systematic review and meta-analysis of published randomized controlled trials (RCTs) to evaluate the effectiveness of AC in the prevention of BCRL. Searching strategies were performed with the following keywords: “Breast cancer,” “Acupuncture,” “neoplasm,” and “lymphoedema,” with derivations and different combinations of these keywords. The following databases were searched: PubMed, Cochrane Library, EMBASE, Web of Science, CNKI, WanFang, and CBM. Studies published in English and Chinese were considered for inclusion in this study. Study selection, risk of bias assessment and data extraction were independently conducted. Statistical analyses were conducted with RevMan software (version 5.3).
Results Eight studies were identified by the search strategy, and 519 patients were included in this study. The effective rate was higher (odds ratios (OR): 4.23; 95% confidence interval (CI): 2.11 to 8.49; Z = 4.07, p < 0.0001) in the experimental group than that in the control group. There were no significant improvements in the front flexion (mean difference (MD): 0.19; 95% CI: -3.68 to 4.06; Z = 0.09, p = 0.92) or the back extension (MD: 0.42; 95% CI: -2.22 to 3.06; Z = 0.31, p = 0.75) movements of the shoulder between the experimental and control groups.
Conclusions AC may be an effective method for improving the condition of breast cancer-related lymphoedema. However, due to the high risk of bias and the low quality of the available studies, further high-quality RCTs are needed to confirm the efficacy of AC for breast cancer-related lymphoedema patients.

Chien TJ, Liu CY, Fang CJ. The Effect of Acupuncture in Breast Cancer-Related Lymphoedema (BCRL): A Systematic Review and Meta-Analysis. Integr Cancer Ther. 2019. [200089].

BackgroundBreast cancer-related lymphedema (BCRL) is hard to control. Management may include lymphatic drainage, skin care, bandaging, or even surgery. Since acupuncture has been proven to affect the neurophysiology and neuroendocrine systems, it has the potential to control BCRL.
AimTo evaluate the effect of acupuncture in BCRL in randomized controlled trials.
Design A literature search was performed, following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement and without language restrictions. Data Sources: Five databases were searched from inception through September 2018. Only studies that fulfilled the eligibility criteria of evaluating the effect of acupuncture on lymphedema in breast cancer were included. The methodological quality of these trials was assessed using the Cochrane criteria, and meta-analysis software (RevMan 5.3) was used for analysis.
ResultsWe examined 178 breast cancer patients from 6 trials. All included randomized controlled trials had medium to high quality, based on the modified Jadad scale. The systematic review showed that acupuncture is safe and has a trend to improve symptoms, but trials did not consistently measure outcomes. The meta-analysis showed that acupuncture produced no significant improvement in the extent of lymphedema as compared with the control intervention (-1.90; 95% confidence interval = -5.39 to 1.59, P = .29). None of the studies reported severe adverse events.
Conclusions Acupuncture is safe and has a trend to improve the lymphedema related to breast cancer, yet it did not significantly change arm circumference in BCRL. Future studies should include both subjective and objective measurements and large-scale studies are warranted.

Zhang X, Wang X, Zhang B, Yang S, Liu D. Effects of acupuncture on breast cancer-related lymphoedema: a systematic review and meta-analysis of randomised controlled trials. Acupuncture in Medicine. 2019;37(1):16-24. [203263].

ObjectiveBreast cancer-related lymphoedema (BCRL) is a common complication after breast cancer treatment. We investigated whether acupuncture could be used to manage limb oedema in women after breast cancer surgery.
Methods The Cochrane Library, PubMed, Embase, Web of Science, CINAHL, and four Chinese databases were electronically searched for papers published through November 2017. Randomised controlled trials (RCTs) of acupuncture for BCRL were included.
Results In total, six RCTs with 318 patients were identified. The main analysis revealed a positive overall effect of acupuncture intervention on pre/post-treatment differences in the diameter of the elbow joint, reductions in upper limb lymphoedema and effectiveness index based on arm measurement data in patients with breast cancer. Two studies evaluating the outcome of acupuncture on the diameter of the elbow joint found a significant reduction in diameter between the acupuncture and control groups (weighted mean difference (WMD) 6 cm, 95% CI 5.11 to 6.89 cm; P<0.001). The same two studies investigated the effect of acupuncture on upper limb lymphoedema reduction and found a significant difference between the acupuncture and control groups (risk ratio 1.4, 95% CI 1.17 to 1.67; P<0.001). Two other studies used the effectiveness index to assess the arm and found a significant difference between the acupuncture and control groups (WMD 23.34, 95% CI 10.74 to 35.94; P<0.001). The fifth study used bioelectrical impedance spectroscopy to assess lymphoedema at several points on the arm before and after acupuncture; this study also reported a significant reduction in lymphoedema. The sixth study reported no significant difference in bioimpedance between the groups.
ConclusionsThe present meta-analysis and systematic review suggests that acupuncture is effective at reducing BCRL in patients after breast cancer treatment.

Li L, Yuan L, Chen X, Wang Q, Tian J, Yang K, Zhou E. Current Treatments for Breast Cancer-Related Lymphoedema: A Systematic Review Asian Pac J Cancer Prev. 2016;17(11):4875-488. [190226].

Objectives Breast cancer-related lymphoedema (BCRL) is a disabling complication with long term impact on quality on life after breast cancer treatment. Its management remains a major challenge for patients and health care professionals; the goal of this overview was to summarize effects of different treatment strategies for patients with BCRL.
Methods A thorough search was undertaken to allow a systematic review or meta-analysis of treatments for BCRL. Two investigators independently selected studies and abstracted the data.
Results Combined physical therapy (CPT) with different combinations of surgery, oral pharmaceuticals, low-level laser therapy, weight reduction, mesenchymal stem cell therapy, kinesio tex taping, and acupuncture might be effective in reducing lymphoedema, but exercise demonstrated no obvious benefit. The results of direct comparisons showed CPT might be more effective than standard physiotherapy (ST). Manual lymphatic drainage (MLD) may not offer additional benefits to ST for swelling reduction, but could facilitate compression bandaging. MLD seemed to have similar effects with self-administered simple lymphatic drainage (SLD) or using an intermittent pneumatic compression pump (IPC). IPC might also not be associated with additional effectiveness for CPT. Efficacy of stem cell therapy vs. Compression sleeve or CPT, as well as the effects of daflon and coumarin could not be established.
Conclusions Although many treatments for BCRL might reduce lymphoedema volume, their effects were not well established. The quality of many of the original studies in the included reviews was not optimal, so that in future randomized control trials are a high priority.

1.1.10. Lau 2016 Ø

Lau CH, Wu X, Chung VC, Liu X, Hui EP, Cramer H, Lauche R, Wong SY, Lau AY, Sit RS, Ziea ET, Ng BF, Wu JC. Acupuncture and related therapies for symptom management in palliative cancer care: systematic review and meta-analysis. Medicine (Baltimore). 2016;95(9):e2901. [160606].

Purpose The aim of this systematic review and meta-analysis was to summarize current best evidence on acupuncture and related therapies for palliative cancer care.
Methods Five international and 3 Chinese databases were searched. Randomized controlled trials (RCTs) comparing acupuncture and related thérapies with conventional or sham treatments were considered. Primary outcomes included fatigue, paresthesia and dysesthesias, chronic pain, anorexia, insomnia, limb edema, constipation, and health-related quality of life, of which effective conventional interventions are limited.
Results Thirteen RCTs were included. Compared with conventional interventions, meta-analysis demonstrated that acupuncture and related therapies significantly reduced pain (2 studies, n=175, pooled weighted mean difference-0.76, 95% confidence interval: -0.14 to -0.39) among patients with liver or gastric cancer. Combined use of acupuncture and related therapies and Chinese herbal medicine improved quality of life in patients with gastrointestinal cancer (2 studies, n¼111, pooled standard mean difference: 0.75, 95% confidence interval: 0.36–1.13). Acupressure showed significant efficacy in reducing fatigue in lung cancer patients when compared with sham acupressure. Adverse events for acupuncture and related therapies were infrequent and mild.
Conclusion Acupuncture and related therapies are effective in reducing pain, fatigue, and in improving quality of life when compared with conventional intervention alone among cancer patients. Limitations on current evidence body imply that they should be used as a complement, rather than an alternative, to conventional care. Effectiveness of acupuncture and related therapies for managing anorexia, reducing constipation, paresthesia and dysesthesia, insomnia, and limb edema in cancer patients is uncertain, warranting future RCTs in these areas.

1.1.11. Rodrick 2013 Ø

Rodrick JR, Poage E, Wanchai A, Stewart BR, Cormier JN, Armer JM. Complementary, alternative, and other noncomplete decongestive therapy treatment methods in the management of lymphedema: a systematic search and review. PM &R. 2013;6(3):250-74. [160442].

Objectives (1) To provide a critical analysis of the contemporary published research that pertains to complementary, alternative, and other noncomplete decongestive therapies for treatment of lymphedema (LE), and (2) to provide practical applications of that evidence to improve care of patients with or at risk for LE.
Methods TYPE: This study meets the defining criteria as a systematic search and review because it includes varied study types. All studies that met the inclusion criteria were evaluated for weight of evidence and value. LITERATURE SURVEY: The systematic search and review includes articles published in the contemporary literature (2004-2012). Publications published from 2004-2011 were retrieved from 11 major medical indices by using search terms for LE and management approaches. Literature archives were examined through 2012. Data extraction included study design, objectives pertaining to LE, number and characteristics of participants, interventions, and outcomes. Study strengths and weaknesses were summarized. Study evidence was categorized according to the Oncology Nursing Society Putting Evidence into Practice level-of-evidence guidelines after achieving consensus among the authors. No authors participated in development of nor benefitted from the review of these modality methods or devices. METHODOLOGY: Extracted data from 85 studies were reviewed in 4 subcategories: botanical, pharmaceutical, physical agent modality, and modalities of contemporary value. After review, 47 articles were excluded, which left 16 articles on botanicals and pharmaceuticals and 22 articles for physical agent modality and/or modalities of contemporary value. Pharmaceuticals were later excluded. The authors concluded that botanicals had generated sufficient studies to support a second, more specific systematic review; thus, botanicals are reported elsewhere.
Synthesis It was found that limited high-level evidence was available for all categories. Well-constructed randomized controlled trials related specifically to LE were limited. Objective outcome measures over time were absent from several studies. The rationale for the use and benefits of the specific modality, as related to LE, was often anecdotal. Subject numbers were fewer than 50 for most studies.
Conclusions No interventions were ranked as “recommended for practice” based on the Putting Evidence into Practice guidelines. Two treatment modalities in 3 studies were ranked as “likely to be effective” in reducing LE or in managing secondary LE complications. Consideration should be given that many of the PAMs demonstrate long-standing support within the literature, with broad parameters for therapeutic application and benefit for secondary conditions associated with LE. However, further investigation as to their individual contributory value and the factors that contribute to their efficacy, specific to LE, has not been done. It also is significant to mention that the majority of these studies focused on breast cancer-related LE. Studies that explored treatment interventions for LE-related vascular disorders (eg, chronic venous insufficiency, congenital dysphasia, trauma) were sparse. Limitations of the literature support the recommendations for future research to further examine the level of evidence in these modalities for LE management.
Acupuncture Chao et al noted only 1 study that explored the direct effects of acupuncture on breast cancer—related LE. This was the Alem et al study, It was stated that the study presented with a small sample size, lack of controls, and lack of reported long-term outcomes that “increased doubts about the conclusions, which supports the previous acupuncture ranking as “effectiveness not established.”

1.2. Special acupuncture techniques

1.2.1. Comparison of acupuncture techniques

1.2.1.1. Wang 2023

Wang S, Zhang F, Tang H, Ning W. The efficacy and safety of acupuncture and moxibustion for breast cancer lymphedema: a systematic review and network meta-analysis. Gland Surg. 2023 Feb 28;12(2):215-224. https://doi.org/10.21037/gs-22-767

BackgroundBreast cancer lymphedema (BCL) is one of the most common complications of breast cancer. Common western medical treatments for BCL, such as western medicine and lymphatic drainage, are ineffective, and recurrence may easily occur, making treatment more challenging and placing a heavier burden on patients. Acupuncture therapy is commonly used to treat BCL in China, and there are many acupuncture therapies, including acupuncture, moxibustion, and the combination of acupuncture and moxibustion. Given the difference in operation difficulty, efficacy and safety of these acupuncture types, how to the most effective therapy is controversial. Therefore, the purpose of this study was to compare the efficacy and safety of different acupuncture and moxibustion methods, so as to provide guidance for clinical practice.
MethodsThe PubMed, Web of Science, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang, VIP, and SinoMed databases were searched to September 30, 2022. Participants were diagnosed with CL. Acupuncture was used in the intervention group, and other acupuncture were used in the control group. Outcomes included arm circumference, visual analogue scale (VAS), and safety evaluation. Risk of Bias Assessment Tool 2 (ROB2) was used to assess the risk of bias, Stata 16 was used for network meta-analysis.
ResultsA total of 7 studies were included, with 422 patients. The interventions included fire acupuncture, acupuncture (face), moxa-moxibustion, heat-sensitive moxibustion, moxibustion [traditional Chinese medicine (TCM)], acupuncture combine with moxibustion, acupoint application. The risk of overall bias was low or some concerns. The meta-analysis showed that: (I) arm circumference: acupuncture combined with moxibustion was superior to acupoint application [mean difference (MD) =-0.54; 95% confidence interval (CI): (-0.67, -0.41); P<0.05]. The surface under the cumulative ranking probability area (SUCRA) ranking results showed that acupuncture combined with moxibustion may be the optimal method. (II) VAS: acupuncture (face) was more effective than acupuncture (body) [MD =-0.85; 95% CI: (-1.09, -0.61); P<0.01]. The SUCRA ranking results showed that acupuncture (face) had the best effect.
ConclusionsBased on the current evidence, acupuncture and moxibustion is of great efficacy and safety for the treatment of BCL. Acupuncture combined with moxibustion is the most effective in reducing the arm circumference, and acupuncture (face) is of the greatest analgesic effect.

1.3. Special outcome

1.3.1. Safety

1.3.1.1. Kim 2023

Kim JK, Loo C, Kim JS, Pranskevich C, Gordon OK. Can Acupuncture be a Part of the Treatment for Breast Cancer-Related Lymphedema? A Systematic Review of the Safety and Proposed Model for Care. Lymphology. 2023;56(1):27-39. PMID: 38019877.

Background Acupuncture is a potential therapy for breast cancer-related lymphedema (BCRL). Despite a recent meta-analysis on efficacy, data on acupuncture safety in BCRL are lacking. Current clinical guidelines recommend avoiding needling in the upper extremity affected by lymph node dissection.
Methods We undertook a systematic review focusing on acupuncture safety and treatment protocols in clinical trials for BCRL. Literature searches were conducted in PubMed, Ovid, CINAHL, and Cochrane library. Eight clinical trials on acupuncture for BCRL were analyzed. The Standards of Acupuncture intervention (STRICTA 2010) and Cochrane risk of bias (RoB2 2019) were applied to assess methods for acupuncture interventions within Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework. Quantity and severity of adverse events (AE) were reviewed.
Results A total of 189 subjects participated in 8 clinical trials with 2965 acupuncture treatments. No serious adverse events (SAE) were reported regardless of treatment laterality or protocol, with only a single grade 2 skin infection in 2,965 total treatments (0.034%), including 1,165 bilateral and 225 ipsilateral treatments.
ConclusionOur comprehensive review of clinical trials of acupuncture for BCRL demonstrated no significant adverse events in 2,965 treatments, including 1,390 in the affected limb. An approach for routine integration of acupuncture into BCRL maintenance therapy is proposed.

2. Clinical Practice Guidelines

⊕ positive recommendation (regardless of the level of evidence reported)
Ø negative recommendation (or lack of evidence)

2.1. Arbeitsgemeinschaft Gynäkologische Onkologie 2018 (AGO, Allemagne) 2018 Ø

Diagnosis and Treatment of Patients with Primary and Metastatic Breast Cancer. Complementary Therapy Survivorship. Arbeitsgemeinschaft Gynäkologische Onkologie (AGO). 2018.35P. [182073].

Chronic lymph edema after breast cancer treatment : Level of evidence 2b (individual cohort study), grade of evidence (B), AGO recommendation grade (+/-) This examination or therapeutic intervention has for the patient no advantage shown. It can be done in individual cases. Based on current knowledge, there is currently no general recommendation to be pronounced.