Low level laser therapy for the management of breast cancer-related lymphedema: A randomized controlled feasibility study

Effects of photobiomodulation on colon cancer cell line HT29 according to mitochondria

BACKGROUND/AIM

Although photobiomodulation therapy (PBMt) is available to alleviate post-operative side effects of malignant diseases, its application is still controversial due to some potential of cancer recurrence and occurrence of a secondary malignancy. We investigated effect of PBMt on mitochondrial function in HT29 colon cancer cells.

METHODS

HT29 cell proliferation was determined with MTT assay after PBMt. Immunofluorescent staining was performed to determine mitochondrial biogenesis and reactive oxygen species (ROS). Mitochondrial membrane potential was measured with Mitotracker. Western blotting was executed to determine expression of fission, fusion, UCP2, and cyclin B1 and D1 proteins. In vivo study was performed by subcutaneously inoculating cancer cells into nude mice and immunohistochemistry was done to determine expression of FIS1, MFN2, UCP2, and p-AKT.

RESULTS

The proliferation and migration of HT29 cells reached maximum with PBMt (670 nm, light emitting diode, LED) at 2.0 J/cm2 compared to control (P < 0.05) with more expression of cyclin B1 and cyclin D1 (P < 0.05). Immunofluorescent staining showed that ROS and mitochondrial membrane potential were enhanced after PBMt compared to control. ATP synthesis of mitochondria was also higher in the PBMt group than in the control (P < 0.05). Expression levels of fission and fusion proteins were significantly increased in the PBMt group than in the control (P < 0.05). Electron microscopy revealed that the percentage of mitochondria showing fission was not significantly different between the two groups. Oncometabolites including D-2-hydoxyglutamate in the supernatant of cell culture were higher in the PBMt group than in the control with increased UCP2 expression (P < 0.05). Both tumor size and weight of xenograft in nude mice model were bigger and heavier in the PBMt group than in the control (P < 0.05). Immunohistologically, mitochondrial biogenesis proteins UCP2 and p-AKT in xenograft of nude mice were expressed more in the PBMt group than in the control (P < 0.05).

CONCLUSIONS

Treatment with PBM using red light LED may induce proliferation and progression of HT29 cancer cells by increasing mitochondrial activity and fission.

Efficacy of photobiomodulation therapy combined with mobile health education in patients with head and neck cancer suffering from chronic xerostomia after radiotherapy: protocol for a three-arm, randomised, placebo-controlled, double-blinded study

INTRODUCTION

The role of photobiomodulation (PBM) therapy for oral tissue damage induced by cancer treatment is currently unclear, and there is low-quality to moderate-quality evidence supporting the use of this approach for treating xerostomia and/or hyposalivation. Consequently, patients with head and neck cancer increasingly turn to basic oral hygiene to alleviate salivary gland dysfunction, and their adherence can be improved by mobile health (mHealth) education. The primary objective of this study will be to analyse the effects of different doses of PBM therapy (7.5 J/cm2 vs 3 J/cm2) plus mHealth education on quality of life (QoL), oral health, salivary secretion and salivary gland ultrasound assessment at postintervention and at the 6-month follow-up in patients with head and neck cancer after radiotherapy compared with those in control group.

METHODS AND ANALYSIS

A prospective, three-arm, randomised, placebo-controlled, double-blinded study will be conducted among patients with head and neck cancer suffering from chronic xerostomia. A total of 20 patients per arm will be included and randomly assigned to receive 7.5 J/cm2 of PBM, 3 J/cm2 of PBM or placebo therapy. PBM therapy will be applied during 24 sessions at 22 points extra and intraorally two times per week for 3 months, combined with a mobile application (https://www.laxer.es). The assessments will be recorded at the beginning of the study, at postintervention and at the 6-month follow-up. The primary outcomes will be QoL, oral health, salivary secretion and salivary gland ultrasound. The pain pressure threshold, functional performance, mood and sleep quality will be secondary indicators.

ETHICS AND DISSEMINATION

This study received ethics approval from the Andalusian Biomedical Research Ethics Portal (2402-N-21 CEIM/CEI Provincial de Granada) according to the Declaration of Helsinki for Biomedical Research. The results of this study will be presented at national and international conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT05106608.

Effect of various photobiomodulation regimens on breast cancer-related lymphedema: A systematic review and meta-analysis

Breast cancer-related lymphedema (BCRL) is common among patients who have completed their cancer treatment. Although low-level laser therapy (LLLT) has been explored as a treatment option for BCRL, we could not find a regimen that is more effective than others. This meta-analysis aimed to organize existing research and determine the optimal combination of LLLT parameters for BCRL treatment. Studies were collected from four online databases: Embase, Ovid Medline, Cochrane, and Cinahl. The collected studies were reviewed by two of the authors. We focused on the aspects of the treatment area, treatment regimen, and total treatment sessions across the included studies. The comparisons between LLLT and non-LLLT were performed through a meta-analysis. Post-treatment QOL was significantly better in the axillary group. The group treated "three times/week with a laser density of 1.5-2 J/cm2" had significantly better outcomes in terms of swelling reduction, both immediately post-treatment and at 1-3 months follow-ups. The group with > 15 treatment sessions had significantly better post-treatment outcomes regarding reduced swelling and improved grip strength. According to these results, LLLT can relieve the symptoms of BCRL by reducing limb swelling and improving QOL. Further exploration found that a treatment approach targeting the axilla, combined with an increased treatment frequency, appropriate laser density, and extended treatment course, yielded better outcomes. However, further rigorous, large-scale studies, including long-term follow-up, are needed to substantiate this regimen.

Recent Advances in Therapeutic Modalities Against Breast Cancer-Related Lymphedema: Future Epigenetic Landscape

Background: Lymphedema is a significant postsurgical complication observed in the majority of breast cancer patients. These multifactorial etiopathogenesis have a significant role in the development of novel diagnostic/prognostic biomarkers and the development of novel therapies. This review aims to ascertain the epigenetic alterations that lead to breast cancer-related lymphedema (BCRL), multiple pathobiological events, and the underlying genetic predisposing factors, signaling cascades pertinent to the lapses in effective prognosis/diagnosis, and finally to develop a suitable therapeutic regimen. Methods and Results: We have performed a literature search in public databases such as PubMed, Medline, Google Scholar, National Library of Medicine and screened several published reports. Search words such as epigenetics to induce BCRL, prognosis/diagnosis, primary lymphedema, secondary lymphedema, genetic predisposing factors for BRCL, conventional therapies, and surgery were used in these databases. This review described several epigenetic-based predisposing factors and the pathophysiological consequences of BCRL, which affect the overall quality of life, and the interplay of these events could foster the progression of lymphedema in breast cancer survivors. Prognosis/diagnostic and therapy lapses for treating BCRL are highly challenging due to genetic and anatomical variations, alteration in the lymphatic vessel contractions, and variable expression of several factors such as vascular endothelial growth factor (VEGF)-E and vascular endothelial growth factor receptor (VEGFR) in breast cancer survivors. Conclusion: We compared the efficacy of various conventional therapies for treating BCRL as a multidisciplinary approach. Further substantial research is required to decipher underlying signaling epigenetic pathways to develop chromatin-modifying therapies pertinent to the multiple etiopathogenesis to explore the correlation between the disease pathophysiology and novel therapeutic modalities to treat BCRL.

Rehabilitation interventions for the management of breast cancer-related lymphedema: developing a patient-centered, evidence-based plan of care throughout survivorship

PURPOSE

A work group from the American Physical Therapy Association Academy of Oncologic Physical Therapy developed and published a clinical practice guideline (CPG) to aid clinicians in identifying interventions for individuals with breast cancer-related lymphedema (BCRL). This guideline reviewed the evidence for risk mitigation and volume reduction beginning at cancer diagnosis and continuing through survivorship. Application of CPGs can be challenging due to the variability of clinical settings, heterogeneous patient populations, and range of rehabilitation clinician expertise. The purpose of this paper is to assist these clinicians in implementing the recommendations from the CPG to develop a patient-centered, evidence-based plan of care.

METHODS/RESULTS

This publication presents important considerations for the implementation of recommended rehabilitation interventions across the trajectory of BCRL.

CONCLUSION

Current evidence supports specific interventions to treat or mitigate the risk for the various stages of BCRL. As clinicians implement these recommendations into practice, they also need to address other impairments that may exist in every individual. Continued collaboration between clinicians and researchers is necessary to further develop optimal treatment modalities and parameters.

IMPLICATIONS FOR CANCER SURVIVORS

By implementing evidence-based interventions as outlined in the CPG, clinicians can improve the quality of care for survivors of breast cancer.

Clinical application of low-level laser therapy (Photo-biomodulation therapy) in the management of breast cancer-related lymphedema: a systematic review

Background

Breast cancer-related lymphedema (BCRL) is a frequent issue that arises after mastectomy surgery in women and compromises physical and mental function. Previously published studies have shown positive effects with the use of Low-level laser therapy in another term Photo-biomodulation therapy (PBM). This research investigated the efficacy of clinical use of LLLT (PBM) in the treatment of metastatic breast cancer-related lymphedema.

Methods

PubMed, PEDro, Medline, and the Cochrane Library were searched for LLLT clinical trials published before October 2021. The methodological quality of randomized trials and the effectiveness of Laser Therapy for BCRL were evaluated. The primary objectives were arm circumference or arm volume, whereas the secondary goals were to assess shoulder mobility and pain severity.

Results

Eight clinical trials were analyzed in total. Typically, the included RCTs had good research quality. At four weeks, there was a considerable reduction in arm circumference/volume, and this continued with long-term follow-up. However, no statistically significant change in shoulder mobility or pain severity was seen between the laser and placebo groups at 0-, 1-, 2-, and 3-month short-term follow-up.

Conclusions

The findings of this comprehensive study demonstrated that LLLT (PBM) was successful in diminishing arm circumference and volume than improving shoulder mobility and pain. Data indicates that laser therapy (PBM) may be a beneficial treatment option for females with PML. Because of the scarcity of evidence, there is a strong need for well-conducted and longer-duration trials in this field.

Trial registration

Details of the protocol for this systematic review were registered on PROSPERO and can be accessed at www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42022315076.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-10021-8.

The effectiveness and safety of low-level laser therapy on breast cancer-related lymphedema: An overview and update of systematic reviews

The objective of our overview of systematic reviews was to critically analyze the evidence from existing systematic reviews investigating the effectiveness and safety of low-level laser therapy (LLLT) in patients with breast cancer–related lymphedema (BCRL). In addition, an updated and comprehensive systematic review was conducted, which aimed to provide updated evidence about this topic. PubMed, EMBASE, and Cochrane Library databases were systematically searched for systematic reviews and randomized controlled trials (RCTs) investigating the effectiveness and safety of LLLT in patients with BCRL. The methodological quality for each of included systematic reviews or RCTs was assessed using the Assessing the Methodological Quality of Systematic Reviews 2 (AMSTAR 2) tool or Cochrane risk of bias tool, respectively. The updated systematic review separately compared the effectiveness of LLLT to each of active or negative interventions. Data were pooled with random-effects models for each outcome per comparison. The evidence quality of outcomes was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) or GRADE-Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) for quantitative studies and qualitative studies, respectively. Seven systematic reviews and ten RCTs met the eligibility criteria. Conflicting results regarding the effectiveness of LLLT were presented by the overview of systematic reviews. The AMSTAR 2 showed that the methodological quality of included systematic reviews was low or critically low quality due to one or more critical weaknesses. The GRADE and GRADE-CERQual showed that the evidence quality was low to very low for most outcomes. The updated systematic review showed that LLLT may offer additional benefits as compared to compression therapies (pneumatic compression or compression bandage), placebo laser, or no treatment for patients with BCRL. However, when compared to other types of active interventions, LLLT did not improve outcomes significantly. None of the treatment-related adverse event was reported. Many trials had a high or unclear risk of bias for two or more items, and our updated systematic review showed low quality of evidence per outcome using GRADE approach. Due to insufficient data and poor quality of evidence, there is uncertain to reach these conclusions that LLLT is superior to another active or negative intervention and is safe. More RCTs of high methodological quality, with large sample sizes and long-term follow-up, are needed to inform clinical guidelines and routine practice.

Long-Term Effectiveness of Combined Intermittent Pneumatic Compression Plus Low-Level Laser Therapy in Patients with Postmastectomy Lymphedema: A Randomized Controlled Trial

Background: Upper limb lymphedema may be revealed after breast cancer and its treatment. Among different treatment approaches, intermittent pneumatic compression (IPC) therapy and low-level laser therapy (LLLT) are reported as effective modalities in the treatment of postmastectomy upper limb lymphedema (PML). The aim of the current study is to investigate the long-term effectiveness of combined IPC plus LLLT versus IPC therapy alone in patients with PML. Methods and Results: The patients were allocated into two groups in this single-blinded, controlled clinical trial. Group I received combined treatment with IPC plus LLLT (n = 21) and group II received only IPC (n = 21). IPC treatment was given 5 sessions per week for 4 weeks (20 sessions). LLLT was also performed 5 sessions per week for 4 weeks (20 sessions). Clinical evaluations were performed before and after the treatment at the 3, 6, and 12-month follow-up visits. According to within-group analysis, statistically significant improvements in the circumference difference (C_diff) and grip strength were observed in both groups (for C_diff, p = 0.018 and p = 0.032, respectively; for grip strength, p = 0.001 and p = 0.046, respectively). Visual analog scale values for arm pain and shoulder pain during motion were decreased only in group I. Conclusion: Both interventions have positive effects on lymphedema, grip strength, and pain. Long-term effects of combined therapy, especially on pain, are slightly superior to the pneumatic compression alone.

Safety and Clinical Impact of a Single Red Light Irradiation on Breast Tumor-Bearing Mice

Low-level light therapy has been used in health care as a therapeutic strategy for different diseases. However, its effects on cancer are controversial. This work evaluated the effects of three energies on breast cancer-bearing mice after a single red light-emitting diode (LED) irradiation. 4T1 cells were inoculated into the mammary fat pad of female BALB/c mice. When tumor volume reached 100 mm³ , animals were irradiated by a LED irradiator (660 ± 11 nm) with energies of 1.2, 3.6, and 6.0 J. Control without irradiation and healthy animals were also evaluated. Mice were monitored regarding tumor volume and total blood count. After euthanasia, their organs were examined. We observed that a single irradiation does not increase tumor volume. All irradiated groups exhibited better clinical conditions than control, which presented a significant decrease in platelet and red blood cell levels compared with healthy mice. The energy of 3.6 J arrested neutrophil-lymphocyte rate besides promoting longer survival and a lower number of metastatic nodules in the lungs. These findings suggest that a single red LED irradiation causes no impact on the course of the disease. Besides, the intermediary dose-effect should be further investigated since it seems to promote better outcomes on breast cancer-bearing mice.

Kinesio taping and low-level laser therapy in breast cancer-related lymphedema in an arm with arteriovenous fistula for hemodialysis

Secondary lymphedema mainly occurs as a result of impairment or obstruction of the lymphatic system. Although complex decongestive therapy is recognized as the best management technique of lymphedema, we encounter various patient profiles in our clinical practice and may need to apply alternative treatment options. In this article, we report a 57-year-old female patient with breast cancer-related lymphedema and arteriovenous (AV) fistula for hemodialysis in the same arm. We performed low-level laser therapy treatment for 12 sessions, kinesio taping, and remedial exercises to the patient as the compression part of complex decongestive therapy was contraindicated in the AV fistula. Self-manual lymphatic drainage training and skin care education were also given. The arm volume difference was decreased from 691 mL to 454 mL after the treatments. Low-level laser therapy and kinesio taping should be kept in mind as alternative techniques for appropriate cases in the treatment of lymphedema.

Comparison of the short-term effects of hyperbaric oxygen therapy and complex decongestive therapy on breast cancer-related lymphedema: A pilot study

Although there have been some reports that hyperbaric oxygen therapy (HBOT) is effective in treating breast cancer-related lymphedema (BCRL), controversy regarding its therapeutic effects remains.We sought to evaluate the efficacy of HBOT in addition to conventional complex decongestive therapy (CDT) for BCRL.A prospective observational study was conducted on 10 patients with BCRL. After screening, the subjects were stratified into a CDT-only group and a CDT and HBOT combination (CDT-HBOT) group. All patients received a total of 10 treatments over 2 weeks. Changes in the circumference of the upper limbs, quality-of-life questionnaire results, and bioelectrical impedance values were compared between the 2 groups.Between both groups, there were no significant differences in demographic or clinical characteristics and in the quality-of-life outcomes for lymphedema of the limbs. The parameters measured by bioimpedance spectroscopy showed more significant improvements in the CDT-HBOT group than in the CDT-only group.In patients with BCRL, HBOT may be recommended as an adjunct treatment to the existing therapies.

The Effect of Acupuncture in Breast Cancer-Related Lymphoedema (BCRL): A Systematic Review and Meta-Analysis

Background: Breast 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. Aim: To 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 tthrough 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. Results: We 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.

Effects of photobiomodualtion therapy on breast cancer-related lymphoedema: A systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

Lymphoedema characterised by the persistent accumulation of the interstitial fluid in peripheral tissues post breast cancer treatments. Photobiomodualtion therapy (PBMT) is widely used as supportive care in patients with breast cancer or breast cancer-related lymphoedema (BCRL). This systematic review and meta-analysis analysed the effectiveness and safety of PBMT for the treatment of BCRL.

METHOD

PubMed, EMBASE, PEDro, SCOPUS, CINAHL, and Cochrane Central Register of Controlled Trials were searched for RCTs on PBMT published before July 2019. Randomised controlled trials (RCTs) that evaluated the efficacy of PBMT on BCRL were included. The primary outcome was the arm circumference or volume, and secondary outcomes were grip strength and pain scores. This study is registered with PROSPERO (number CRD 42018102107).

RESULTS

We reviewed nine RCTs that included 316 patients and six studies for mata-analysis. We found no significant difference in the reduction of the arm circumference or arm volume after treatment, one month, and three month follow-up between the PBMT and control groups. Studies revealed no significant differences in the reduction in grip strength and pain scores at 0, 1, 2, and 3 month between the PBMT and control groups.

CONCLUSIONS

Although PBMT demonstrated a slight improvement in reducing arm circumference and arm volume, the results of our meta-analysis did not show significant benefits in relieving of lymphoedema. Further trials are needed to recruit more participants, and to evaluate the long-term efficacy and safety of PBMT in management of breast cancer-related lymphoedema.