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

Yuping Wang, Yonggui Ge, Wenting Xing, Junping Liu, Jiqi Wu, Haijuan Lin, Yaqin Lu, Yuping Wang, Yonggui Ge, Wenting Xing, Junping Liu, Jiqi Wu, Haijuan Lin, Yaqin Lu

Abstract

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.

Keywords: Breast cancer–related lymphedema; Low-level laser therapy; Overview; Photobiomodulation therapy; Systematic reviews.

Conflict of interest statement

The authors declare no competing interests.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
PRISMA flow diagram illustrating the selection of systematic reviews. BCRL breast cancer–related lymphedema, LLLT low-level laser therapy
Fig. 2
Fig. 2
Methodological quality of the included systematic reviews with AMSTAR 2 checklist
Fig. 3
Fig. 3
PRISMA flow diagram illustrating the selection of randomized controlled trials. BCRL breast cancer–related lymphedema, LLLT low-level laser therapy, RCTs randomized controlled trials
Fig. 4
Fig. 4
The bubble plot regarding to all outcomes at different comparison categories for management of breast cancer related lymphedema. The x-axis represented seven comparison categories in all trials. The y-axis represented each clinical outcome at different assessment times. The bubble size represented effectiveness estimate of each outcome. The different colors represented statistical differences (red bubbles indicated that the difference was statistically significant, blue bubbles indicated that the difference was not statistically significant). LLLT low-level laser therapy, MLD manual lymphatic drainage, CDT complex decongestive therapy, DASH Disability of Arm, Shoulder, and Hand

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