Breast Cancer-Related Lymphedema: Nursing-Led Strategies – A Narrative Review

Abstract

Breast cancer-related lymphedema (BCRL) is a prevalent and chronic complication that significantly impairs the quality of life of breast cancer survivors. As survivorship increases, the role of nursing in BCRL management has become increasingly critical. This review synthesizes current evidence on nursing-led strategies across the continuum of care, including early symptom recognition, risk stratification, perioperative prevention, conservative and surgical interventions, psychosocial support, patient education, and interdisciplinary collaboration. Special attention is given to the integration of novel technologies such as bioimpedance spectroscopy and wearable devices. Despite progress, gaps remain in standardized protocols, high-quality randomized controlled trials (RCTs), and patient-reported outcome research. In summary, nursing plays a central role in the management of BCRL, encompassing risk assessment, intervention implementation, and patient support. It is a key force in improving treatment outcomes and enhancing patients’ quality of life.

Graphical Abstract

Introduction

Breast cancer remains the most commonly diagnosed malignancy among women worldwide.¹ Over recent decades, advances in cancer biology, early detection, and multimodal treatment strategies-including surgery, radiotherapy, chemotherapy, targeted therapy, and immunotherapy-have substantially improved survival outcomes.^2,3 As emphasized by Sonkin and Thomas, contemporary cancer care has progressively shifted from a singular focus on tumor control toward long-term survivorship, where treatment-related chronic conditions have become increasingly prominent clinical and public health challenges.⁴

Among these long-term sequelae, breast cancer–related lymphedema (BCRL) represents one of the most prevalent and disabling complications.^5,6 BCRL is primarily caused by disruption of lymphatic drainage following axillary lymph node dissection and/or radiotherapy, leading to chronic upper-limb swelling, heaviness, pain, restricted mobility, and recurrent infections.^7–9 Epidemiological studies estimate that approximately 20–40% of breast cancer survivors develop BCRL, with risk persisting throughout the survivorship trajectory. Importantly, even mild or subclinical lymphedema can significantly impair physical function, body image, emotional well-being, and social participation.^8,10,11

Beyond its physical manifestations, BCRL exerts a profound psychosocial burden. Survivors frequently report anxiety, depression, fear of disease progression, and long-term self-management stress.^12–14 These impacts underscore that BCRL is not merely a biomedical complication but a complex, chronic condition requiring sustained assessment, education, and supportive care. Consequently, effective BCRL management extends far beyond episodic medical intervention and necessitates continuous, patient-centered care across the cancer continuum.

Nurses occupy a pivotal position in this continuum. As the healthcare professionals with the most sustained patient contact, nurses play central roles in early symptom surveillance, risk assessment, perioperative prevention, patient education, psychosocial support, and long-term self-management guidance.^15,16 However, despite the abundance of reviews addressing the medical, surgical, and rehabilitative aspects of BCRL, nursing-related evidence remains fragmented across disciplines and is often embedded as secondary considerations rather than synthesized as a coherent body of knowledge.^17,18

This lack of an integrated nursing-focused synthesis creates a critical gap between evidence generation and clinical practice. Without a structured nursing perspective, opportunities for early identification, individualized prevention, and sustained symptom management may be missed, particularly during the survivorship phase when patients are no longer under intensive oncologic follow-up. Therefore, a dedicated nursing-centered review is urgently needed to consolidate existing evidence, clarify the unique contributions of nursing practice, and guide the development of standardized, feasible, and patient-centered care pathways for BCRL.

Accordingly, this narrative review aims to synthesize current evidence on breast cancer–related lymphedema from a nursing perspective, focusing on six core domains: i) assessment and early detection, ii) patient education and risk reduction strategies, iii) nursing-led preventive and therapeutic interventions, iv) psychosocial and emotional care, v) self-management and patient empowerment, and vi) nursing education and multidisciplinary collaboration. By articulating these dimensions within a unified framework, this review seeks to support evidence-based nursing practice and improve long-term outcomes and quality of life for breast cancer survivors.

Methods

This narrative review employed a structured and transparent literature search strategy to synthesize current evidence on breast cancer–related lymphedema (BCRL) from a nursing perspective. While the review is narrative in nature, we followed systematic procedures to enhance reproducibility and rigor.

Literature Search Strategy

A comprehensive search was conducted in PubMed, Scopus, and Google Scholar covering publications from 2010 to 2026. Search terms included combinations of: “breast cancer–related lymphedema,” “lymphedema,” “nursing care,” “symptom assessment,” “perioperative prevention,” “rehabilitation,” “patient education,” and “quality of life.” To identify additional relevant studies, reference lists of included articles were manually screened.

Study Selection and Eligibility Criteria

Eligible studies included peer-reviewed journal articles (quantitative, qualitative, and mixed-method studies), reviews, clinical guidelines, conference proceedings, and authoritative reports from organizations such as the Ministry of Public Health or the World Health Organization. Studies were included if they focused on adult breast cancer patients with or at risk of BCRL and addressed nursing assessment, prevention, intervention, symptom management, patient education, or multidisciplinary care. Studies not related to nursing practice or not published in English were excluded.

Study Selection Process

Titles and abstracts were initially screened for relevance, followed by full-text review of potentially eligible studies. Although a formal PRISMA flow diagram was not applied due to the narrative review design, the selection process was conducted in a structured, stepwise manner with clearly defined inclusion and exclusion criteria to ensure transparency and reproducibility.

Quality Appraisal and Evidence Consideration

Formal quality assessment tools such as AMSTAR-2 or ROBINS-I were not applied to all included studies. However, the quality, reliability, and clinical relevance of each study were critically appraised based on study design, sample size, consistency of findings, and applicability to nursing practice. High-level evidence, including randomized controlled trials (RCTs), systematic reviews, and clinical guidelines, was prioritized. Evidence was graded informally according to its quality and relevance.

Evidence Synthesis

Findings were synthesized narratively and organized thematically according to key nursing domains: symptom assessment, perioperative prevention, nursing-led interventions, psychosocial care, patient empowerment, and multidisciplinary collaboration. This thematic approach enables the integration of both quantitative and qualitative evidence while highlighting practical implications for nursing practice.

Etiology and Pathogenesis of BCRL

BCRL is a common chronic complication that arises following breast cancer treatment, particularly in patients who have undergone axillary lymph node dissection (ALND) or radiotherapy.^19–21 The condition results primarily from damage or obstruction of lymphatic drainage pathways during treatment, leading to the accumulation of lymphatic fluid in the interstitial tissues. This fluid retention manifests as chronic swelling, heaviness, restricted mobility, and in severe cases, tissue fibrosis or recurrent infections such as cellulitis.^22–25 Importantly, BCRL is not a direct consequence of breast cancer itself, but rather a secondary condition caused by therapeutic injury to the lymphatic system.^5,26

Studies have shown that the incidence of BCRL 20–40% among patients who undergo axillary lymph node dissection (ALND), with onset potentially occurring months to years after treatment.^22,27 Beyond its physical manifestations, BCRL significantly affects patients’ psychological well-being, often contributing to emotional distress, anxiety, depression, and sleep disturbances.^28–30 Therefore, the management of BCRL is not only a clinical medical concern but also a critical focus of nursing care, requiring proactive intervention across physical and psychosocial dimensions.

Primary Causes

BCRL primarily results from damage or obstruction of the lymphatic system, leading to impaired lymphatic drainage and interstitial fluid accumulation that ultimately progresses to chronic swelling. This condition predominantly develops as a consequence of breast cancer treatments, including radiotherapy, chemotherapy, and surgical interventions.^9,31,32 Extensive clinical evidence identifies axillary lymph node dissection (ALND) as the most significant risk factor, with 20–40% of patients developing BCRL following ALND. Regional radiotherapy, particularly when targeting the axillary or supraclavicular areas, further substantially elevates this risk.

A predictive study demonstrated that the extent and location of lymph node dissection serve as primary determinants of lymphedema development, while body mass index (BMI) emerged as the sole patient-related predictive factor in their model.³³ Additional contributing factors include postoperative infections, trauma, overuse of the affected limb, and obesity. Patient-specific characteristics such as age, baseline lymphatic function, and the adequacy of nursing interventions may also influence BCRL incidence rates. Figure 1 systematically illustrates these pathogenic factors.^34–37 Understanding these risk factors enables clinicians to identify high-risk patients earlier and implement targeted preventive strategies. Effective multidisciplinary management incorporating these insights can significantly reduce BCRL incidence and improve patient outcomes.

Figure 1.

Pathophysiological Mechanisms and Risk Factors Contributing to BCRL Development.

Molecular Mechanisms of BCRL

The molecular pathogenesis of BCRL involves a complex interplay among mechanical disruption of lymphatic vessels, persistent local inflammation, and progressive tissue fibrosis.^38–41 Surgical and radiation-induced damage to lymphatic vessels and nodes leads to fluid stasis in the interstitial space, which activates fibroblasts and triggers the release of profibrotic mediators such as transforming growth factor-beta (TGF-β). This process promotes collagen deposition and tissue hardening.^42,43 This process suggests that inflammatory and fibrotic alterations may occur well before overt limb swelling becomes clinically apparent. Therefore, early symptom surveillance, assessment of sensory changes in the affected limb, and baseline measurements are critical for identifying optimal windows for intervention. Nurses’ ability to recognize mild but persistent symptom changes during follow-up enables the initiation of preventive measures before irreversible tissue damage develops.

Persistent inflammation further accelerates disease progression. Elevated levels of pro-inflammatory cytokines, including interleukin-4 (IL-4), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α), together with sustained infiltration of M2-type macrophages, exacerbate tissue remodeling and fibrosis.^40,44–46 As illustrated in Figure 2, this complex molecular interplay involves both immune-mediated and stromal responses.⁴⁷ From a nursing perspective, these biological mechanisms provide an important rationale for early assessment and timely intervention. Inflammatory and fibrotic processes may be initiated prior to clinically evident limb swelling, underscoring the importance of early symptom monitoring and longitudinal follow-up.^48,49 For example, Vang et al⁵⁰ demonstrated that bioimpedance spectroscopy and near-infrared fluorescence imaging can detect lymphatic dysfunction and extracellular fluid accumulation before clinical diagnosis. In patients who later developed BCRL, elevated preoperative plasma levels of cytokines such as MIP-1β, IL-6, IL-15, and IL-3 suggested the presence of a subclinical inflammatory state.

Figure 2.

Schematic representation of the molecular mechanisms involved in breast cancer–related lymphedema.

These findings indicate the potential value of integrating biological indicators with nurse-led assessment strategies. By combining symptom surveillance, limb volume measurement, and interpretation of bioimpedance or imaging results, nurses can contribute to early risk stratification and timely preventive interventions. Understanding the inflammation–fibrosis cascade also informs patient education, strengthens adherence to preventive behaviors, and supports referral decision-making, thereby helping to delay or mitigate irreversible tissue changes and improve long-term functional outcomes and quality of life.

The Role of Nursing in BCRL

Symptom-Based Assessment and Its Clinical Significance in BCRL

BCRL manifests as symptoms including swelling, heaviness, tightness, pain, and restricted mobility in the affected limb. These symptoms may emerge months to years after treatment, significantly impairing patients’ daily function and psychological well-being.^51–53 Recent research has increasingly emphasized the clinical value of patient-reported symptoms for early BCRL identification, demonstrating that subjective symptoms often precede objective limb volume changes and may serve as important early warning signals.^54,55

Symptom Count: A Simple and Sensitive Nursing Screening Indicator

In nursing assessment of BCRL, symptom count has been shown to be a feasible and clinically meaningful screening indicator. A prospective study reported that 64% of patients experienced heaviness, tightness, or dull pain up to six months prior to a clinical diagnosis of lymphedema.⁵⁶ Similarly, Fu et al demonstrated in a cross-sectional diagnostic study that breast cancer survivors with subclinical lymphedema reported significantly more upper-limb symptoms than healthy controls, with symptom count positively correlated with limb volume change. Reporting three or more symptoms effectively distinguished lymphedema cases from controls (Table 1), achieving a sensitivity of 94% and a specificity of 97% (AUC = 0.98), while reporting nine or more symptoms identified patients at high risk prior to diagnosis (AUC = 0.72). These findings suggest that, when objective assessments are unavailable or costly, self-reported symptom count may serve as a low-cost and effective early screening tool to identify potential subclinical lymphedema and predict progression to clinically overt disease.^52,57,58 From a nursing practice perspective, symptom count reflects not only the presence of risk but also disease progression over time. Pooled data analyses indicate a positive correlation between limb volume change (LVC) and symptom count (Table 2). As LVC increases, the mean number of reported symptoms rises substantially. For example, patients with LVC ≥15.0% reported an average of 12.5 symptoms, compared with 4.2 symptoms among those with LVC <5.0% (p < 0.05).^52,57,58 This relationship supports the use of symptom count as a complementary indicator to volume-based measures, enabling nurses to detect early progression trends before diagnostic thresholds are reached.

Table 1.

Diagnostic Performance of Symptom Count in Early Lymphedema Screening

Diagnostic Threshold (Symptom Count)	Sensitivity	Specificity	AUC (Diagnostic Accuracy)	Target Population
≥ 3 symptoms	94%	97%	0.98	Lymphedema patients vs healthy controls
≥ 9 symptoms	64%	80%	0.72	High Risk vs Patients

Note: Data primarily originate from the Fu series of studies;^51–53 generalizability to other populations may be limited.

Table 2.

Mean Symptom Count by LVC Stage

LVC	Mean Symptom Count
< 5.0%	4.2
5.0–9.9%	5.5
10.0–14.9%	7.0
≥ 15.0%	12.5

Note: Data mainly from Fu et al⁵² caution is advised in extrapolation.

Abbreviation: LVC, limb volume change.

Symptom Type: Clinical Clues for Risk Identification and Disease Progression

Beyond symptom quantity, individual symptom types differ in their predictive value for BCRL risk. Bivariate analyses across studies demonstrate that arm swelling is most strongly associated with lymphedema development and is considered a key diagnostic indicator (Table 3). Arm swelling showed the strongest association (OR = 561.00, 95% CI: 76.04–71644.49, p < 0.0001), supporting its role as a diagnostic reference standard. Other symptoms, including heaviness, firmness, and increased skin temperature, also exhibited significant predictive value. Importantly, these symptoms often occur prior to measurable limb volume changes, providing a critical window for early intervention.^52,59

Table 3.

Symptom Risk Associations

Symptom	OR (95% CI)	P	Clinical Significance
Firmness	561.00 (76.04–71644.49)	< 0.0001	Strongest predictor (pathognomonic)
Heaviness	17.46 (8.22–39.25)	< 0.0001	Very high association
Firmness	10.33 (5.04–22.16)	< 0.0001
Elevated Skin Temperature	9.07 (2.98–29.94) 2.98–29.94	< 0.0001	High association
Fluid accumulation	8.61 (3.54–21.54) 3.54–21.54	< 0.0001
Tightness	7.78 (3.84–16.84)	< 0.0001
Restricted mobility	5.86 (2.94–11.93)	< 0.0001	Moderate association
Tingling sensation	5.54 (2.79–11.260)	< 0.0001
Aching pain	5.14 (2.60–10.46)	< 0.0001

Note: Data are primarily from Fu et al⁵³ repeated “Firmness” entries reflect different measurement approaches.

In nursing practice, symptom types should not be interpreted in isolation but assessed in relation to their timing, persistence, and progression. Transient or reversible discomfort may reflect temporary lymphatic overload, whereas persistent or progressively worsening heaviness or tightness is more suggestive of underlying lymphatic dysfunction. By systematically eliciting and documenting symptom trajectories, nurses can identify patients at elevated risk and implement stratified management strategies, such as intensified follow-up, education on limb-protective behaviors, reinforcement of exercise and pressure management, or timely referral to lymphedema specialists.

Diagnostic Value and Nursing Application of Symptom Assessment

In clinical practice, several objective methods are commonly used to diagnose BCRL, including circumferential measurement, water displacement, bioimpedance spectroscopy (BIS), optical coherence tomography (OCT), and infrared thermography (IRT). Symptom assessment is not intended to replace these objective techniques but rather to provide complementary clinical information that supports nursing decision-making, particularly during the early and dynamic stages of BCRL. Table 4 summarizes the comparative advantages of symptom-based approaches; however, their clinical relevance lies in how symptom assessment informs risk stratification, referral timing, and prioritization of nursing interventions.^60–62

Table 4.

Comparison of BCRL Diagnostic Approaches

Diagnostic Method	Advantages	Limitations	Clinical Utility
Circumferential measurement	Low-cost; Easy to perform	Low sensitivity for subclinical edema	Primary care screening63–65
Water displacement	Gold-standard accuracy	Cumbersome; Requires patient cooperation	Research settings66,67
BIS	Quantifies fluid changes; Enables early detection	Contraindicated with implants/cardiac devices	Specialized clinics31,68
OCT/IRT	High-resolution data	High cost; Technical expertise required	Experimental use69,70
Symptom Assessment	Detects early subtle symptom changes; Low-cost and universally applicable; Enables longitudinal monitoring; Enables longitudinal monitoring	Subjective nature; May be influenced by patient factors (eg, BMI, fatigue)	All settings, especially nurse-led care52,53,60,71

Abbreviations: BIS, bioimpedance spectroscopy; OCT, optical coherence tomography; IRT, infrared thermography.

Importantly, symptom assessment captures patients’ subjective experiences that may not be reflected by volume-based thresholds alone. Some patients experience substantial symptom burden and quality-of-life impairment despite not meeting objective diagnostic criteria, highlighting the limitations of relying exclusively on instrumental measurements. In such cases, nurses’ interpretation of symptom patterns becomes critical for identifying patients who may benefit from closer monitoring or early supportive interventions.

Several standardized assessment scales have been developed for symptom evaluation, such as the Breast Cancer and Lymphedema Symptom Experience Index (BCLE-SEI) and the Lymphedema Symptom Intensity and Distress Survey-Arm (LSIDS-A).^72,73 These scales systematically quantify symptom type, frequency, intensity and quality of life impact, complementing objective measures. In clinical practice, nurses often lead the implementation of these assessments and provide timely feedback to multidisciplinary teams to help develop personalized intervention plans.^74,75

Importantly, symptom assessment captures patients’ subjective experiences that may not be reflected by volume-based thresholds alone. Some patients experience substantial symptom burden and impaired quality of life despite not meeting objective diagnostic criteria, highlighting the limitations of relying exclusively on instrumental measurements. In such cases, nurses’ interpretation of symptom patterns becomes essential for identifying individuals who may benefit from closer monitoring or early supportive interventions. Moreover, during long-term follow-up, changes in symptom patterns can serve as practical indicators for evaluating intervention effectiveness and adjusting individualized nursing care plans. Moreover, symptom assessment is more feasible and universally applicable in cases where BIS is contraindicated or in patients with special anatomical considerations.

Therefore, symptom assessment should be viewed as a decision-support tool within a nurse-led care pathway, rather than merely a simplified alternative to objective measurements. Nurses serve as key connectors in this process and are the core force in achieving high-quality, continuous management. This will help build a multidimensional, multistage comprehensive diagnostic system to improve long-term outcomes and quality of life for breast cancer patients.

Perioperative Prevention: Nursing Strategies Aimed at Risk Reduction

Perioperative prevention refers to nursing strategies implemented in patients without established breast cancer–related lymphedema (BCRL), with the primary aim of reducing disease risk rather than managing existing symptoms. At this stage, nursing care focuses on identifying individuals at high risk, minimizing iatrogenic lymphatic injury, and fostering sustainable protective behaviors during surgery and the early postoperative period. Stout et al proposed the “Prospective Surveillance Model,” positioning nurses as the central coordinators of BCRL prevention and follow-up through continuous assessment, exercise guidance, psychosocial support, and structured monitoring.⁷⁶ Evidence suggests that this nurse-led model contributes to reduced BCRL incidence and improved quality of life.^77,78

Precision Risk Stratification

With the advancement of precision nursing, BCRL prevention has gradually shifted from empirical judgment toward data-informed risk stratification. During the preoperative and early postoperative phases, nurses, as primary providers of continuous care, play a pivotal role in collecting risk information, conducting initial assessments, and translating risk estimates into patient-centered care plans. Logistic regression analyses across multiple cohorts have identified several stable predictors of BCRL, including the extent of lymph node dissection, postoperative complications, body mass index (BMI), and the number of lymph nodes removed, with reported model sensitivities exceeding 80%.^33,79,80

In recent years, artificial intelligence (AI)–assisted predictive models have been introduced to enhance the granularity of risk assessment. However, from a nursing practice perspective, the clinical implementation of these tools faces several challenges. First, predictive performance is highly dependent on data quality, and the completeness and standardization of nursing documentation directly affect model reliability. Second, model outputs must be interpretable to support nursing communication and shared decision-making. Third, effective integration of AI tools requires structured training, workflow adaptation, and consideration of time and workload constraints.^81–83 Taking the DIMLP model proposed by Rattay et al as an example, this model has a prediction accuracy of approximately 73%, with a sensitivity of 81.6% and a specificity of 72.9% in identifying high-risk patients. Its advantage lies in emphasizing model interpretability, thus providing possibilities for nurses to participate in risk stratification and patient education.⁸⁴ However, its widespread adoption still requires consideration of technical support, time costs, and the burden of training nursing staff. Nevertheless, broader implementation remains contingent upon technical support, staff training, and institutional readiness.

Accordingly, predictive models should currently be viewed as supportive tools rather than substitutes for clinical nursing judgment. In practice, nurses are required to integrate model outputs with objective measurements and patient-reported symptoms to perform dynamic risk assessment and to tailor follow-up intensity and preventive interventions accordingly.

Perioperative Nursing Preventive Strategies

The perioperative period—particularly the first 24 hours to three months post-surgery—is considered a critical window for BCRL prevention. During this time, nursing interventions are not only feasible but often decisive for long-term outcomes. Systematic reviews suggest that early implementation of limb protection and functional exercises can reduce the incidence of BCRL.^6,85,86 Core nursing strategies initiated in the early postoperative period include: (1) Limb protection education, focusing on avoidance of trauma and infection risk;^87–90 (2) Stage-specific functional exercise guidance, adjusted according to surgical procedures and recovery status. Studies have shown that patients who began shoulder mobility training within one-two weeks post-surgery experienced significantly lower limb circumference increases compared to control groups;^89–92 (3) Dynamic Monitoring and Documentation: Regular limb assessments should be performed using BIS or circumference measurement, accompanied by symptom questionnaires such as the LSIDS-A. A dynamic, individualized care record should be maintained to track progress and inform clinical decisions.^73,93,94 Symptom assessment at this stage serves as a risk-alert and surveillance tool, helping to identify early warning signs that may prompt closer monitoring or referral, rather than as an indication for active treatment.

By integrating risk stratification with practical, executable nursing measures, perioperative prevention can be translated from conceptual recommendations into routine nursing practice, thereby enhancing both feasibility and long-term effectiveness.

Nursing Interventions for Established BCRL: Symptom Control and Disease Management

Nursing intervention is initiated once persistent symptoms or diagnostic criteria of BCRL are present, with the primary objectives of symptom alleviation, disease progression control, and quality-of-life improvement. BCRL management encompasses a range of therapeutic strategies, including surgical procedures, physical therapies, and emerging technologies. At this stage, nursing care shifts from risk reduction to active management. Their responsibilities extend beyond clinical safety assurance to enhancing patient adherence and improving long-term outcomes, ultimately optimizing therapeutic efficacy.

Surgical Interventions

A variety of surgical options are available for managing moderate to severe or treatment-refractory BCRL. Each technique is based on distinct mechanisms—either restoring lymphatic function or mechanically reducing limb volume—and is selected according to the patient’s disease stage and clinical profile. To support clinical decision-making and highlight the role of nursing across these approaches, Table 5 summarizes the key features of three commonly used surgical interventions: lymphaticovenular anastomosis (LVA), vascularized lymph node transfer (VLNT), and liposuction. The table provides an overview of their mechanisms of action, clinical indications, benefits, limitations, and the corresponding nursing responsibilities required to ensure optimal outcomes.

Table 5.

Comparison of Surgical Interventions for BCRL

Surgical Method	Mechanism	Indications	Advantages	Limitations	Key Nursing Considerations
Lymphaticovenular Anastomosis (LVA)	Microsurgical bypass of lymphatic vessels to nearby venules	Early-stage BCRL with patent lymphatics	Minimally invasive; effective in early disease	Requires viable lymphatic vessels; not suitable for late-stage	Pre-op: Limb assessment (BIS, edema mapping); patient education; psychological prep; comorbidity evaluation. Post-op: Monitor anastomosis patency; wound care; early mobilization; compression garment guidance; pain management; report complications95–97
Vascularized Lymph Node Transfer (VLNT)	Transplantation of functional lymph nodes to affected region	Moderate-to-severe or fibrotic BCRL	Can restore lymphatic function; promotes lymphangiogenesis	Risk of donor site morbidity; technically demanding	Pre-op: Psychological preparation; donor site assessment; education on rehab stages. Post-op: Monitor graft viability; staged rehabilitation; compression garment training; patient adherence evaluation98–101
Liposuction	Physical removal of excess adipose and fibrotic tissue	Advanced-stage BCRL with non-functioning lymphatics	Immediate volume reduction	Does not restore lymphatic function; requires lifelong compression	Post-op: Ensure compliance with ≥23 hrs/day compression; wound care; monitor for recurrence; coordinate long-term follow-up102–104

Complete Decongestive Therapy (CDT)

Complete Decongestive Therapy (CDT) is the internationally recognized gold standard for the management of BCRL, comprising four core components: manual lymphatic drainage (MLD), compression therapy, therapeutic exercise, and skin care.^105–107 Nurses play a central role in CDT, not only implementing interventions but also continuously assessing patient responses, adjusting care plans, and providing education, thereby ensuring safe, effective, and sustainable treatment outcomes.^108,109

The selection of MLD techniques depends on the stage and severity of lymphedema. The Vodder method is generally applied for early or mild cases, whereas the Földi technique is preferred for patients with extensive tissue fibrosis.^110–113 In this process, nurses should be familiar with the basic principles and core procedures of CDT, assist patients with donning and using compression garments, guide low- to moderate-intensity exercise programs, and monitor skin integrity and limb swelling. They should also provide fundamental education, instructing patients and caregivers on daily self-monitoring, hygiene practices, and adherence to prescribed treatment schedules.

Compression therapy requires high precision and standardization.^114–116 Lymphedema specialist nurses, who possess more advanced clinical skills, select appropriate MLD techniques based on disease progression and tissue condition, evaluate tissue hardness and skin elasticity, and design individualized exercise programs tailored to the patient’s strength, endurance, and disease status.^110,117 These exercises typically involve low-resistance activities (≤60% 1RM) to promote lymphatic return while minimizing the risk of strain or injury.^118,119

All nurses should also pay attention to psychosocial factors, including anxiety, body image concerns, and reduced quality of life, and provide psychological support or referrals as needed. Through education, empowerment, and evidence-based nursing care, nurses can help patients actively engage in their rehabilitation, improve adherence, enhance treatment outcomes, and promote long-term quality of life.

In summary, the role of nurses in CDT is multidimensional: they serve as treatment implementers, evaluators, educators, and providers of psychosocial support. While the skill levels differ between general and specialist nurses, their shared goal is to ensure that patients receive safe, individualized, and sustainable management for BCRL.^110,120

Emerging Technologies and Nursing Integration

Innovative technologies are reshaping the landscape of BCRL management. Low-level laser therapy (LLLT), indocyanine green (ICG) lymphography, and wearable smart devices offer new possibilities for personalized treatment, with nurses playing a key role in implementation and monitoring.

LLLT has been shown to stimulate lymphangiogenesis and improve microcirculation. Nurses are responsible for patient preparation-shaving the treatment area, applying conductive gel-and monitoring skin temperature during therapy to prevent thermal injuries.^110,121,122 ICG lymphography enables real-time imaging of lymphatic structures and pathways. Nurses ensure appropriate pre-procedure preparation, including fasting and skin cleansing, and strictly enforce post-procedure photoprotection protocols. They must also be prepared to manage rare allergic reactions, maintaining emergency medications such as epinephrine on hand.^123–125 Wearable devices, such as smart compression garments (eg, Dayspring™), allow for real-time pressure monitoring and data transmission via mobile applications. Nurses guide patients in proper usage, interpret transmitted data, and intervene promptly when abnormal patterns—such as abrupt pressure increases-are detected. These technologies have been associated with improved self-management and reduced clinic visits.^126,127 In addition, there are also Extracorporeal shock wave therapy, Hyperbaric oxygen therapy, Stellate ganglion block, Mesenchymal stem cell therapy, Acupuncture Kinesio, all of which require precise and individualized care procedures along with the treatment as well. There are also other therapies that are still in the experimental stage and will not be discussed here.

Discharge Education and Patient Empowerment

BCRL is a chronic and progressive complication that requires long-term self-management. Thus, discharge education and patient empowerment are critical components of continuity of care. Clinical observations have shown that although many patients receive initial rehabilitation guidance during hospitalization, knowledge gaps and poor adherence often emerge after discharge, particularly regarding limb care, lifestyle adaptation, and symptom monitoring—ultimately compromising prevention efforts.

Discharge Education

Comprehensive discharge education should be led by primary nurses in collaboration with the multidisciplinary care team. Core topics include: fundamental knowledge of BCRL, principles of limb protection, early symptom recognition, self-monitoring techniques, and lifestyle modifications. For instance, patients should learn to identify early signs such as arm tightness, morning discomfort, or pitting edema, and be instructed in appropriate upper limb exercises to promote lymphatic drainage. In addition to in-person instruction, nurses should provide printed leaflets, digital manuals, and access to online platforms to improve accessibility, repetition, and retention of information.^88,128,129

Psychological Support and Empowerment Strategies

Psychological counseling is an essential element during the discharge phase. BCRL often leads to distress related to body image, self-worth, and social functioning. Patients in the early postoperative stage commonly experience anxiety, fear, and helplessness. Nurses should routinely assess psychological status using validated screening tools (eg, GAD-7, PHQ-9) and apply supportive communication techniques to help patients rebuild confidence and acceptance of their bodies. When feasible, participation in in-person or virtual support groups can offer emotional support and peer exchange, helping to alleviate post-discharge loneliness. Patients with moderate to severe emotional disorders should be referred promptly for professional mental health care.^130–132 At the same time, nurses should guide patients from passive recipients to active self-managers. This includes collaboratively developing personalized rehabilitation plans, such as compression garment wearing schedules and daily exercise goals. Through continuous feedback and reinforcement—such as goal setting, symptom tracking, and involving family members as support partners—patients’ sense of control and adherence can be further enhanced.^133,134

Others

Multidisciplinary Collaboration Teams

As a chronic complication that profoundly impacts quality of life, BCRL is often insidious in onset, prolonged in course, and psychologically burdensome. Its effective management requires coordination across multiple disciplines; no single specialty can adequately address the multifaceted needs of these patients. With the growing emphasis on integrative medicine, nurse-led multidisciplinary collaboration (MDC) models are gaining recognition in the prevention, early detection, intervention, and long-term follow-up of BCRL.

In clinical practice, nurses are not merely executors of treatment plans—they are central coordinators, educators, and care continuity facilitators throughout the entire patient journey. By acting as a bridge among professionals, nurses help integrate resources from physical therapists, dietitians, psychologists, surgeons, and radiologists to form a patient-centered collaborative care network. Particularly in “Preventive Lymphedema Clinics” or specialized oncology navigation systems, nurses serve as frontline leaders responsible for screening high-risk individuals, developing personalized interventions, and ensuring timely referrals.

To better illustrate the composition and role of each discipline in BCRL management—and the nurse’s role in collaborative coordination—Table 6 outlines the core responsibilities of each team member and how nurses interact with and support each domain.

Table 6.

Role Allocation in Multidisciplinary Collaboration for BCRL Management

Discipline	Core Responsibilities	Nursing Role in Collaboration	Coordination Example
Nurse	Lead care coordination: perform risk assessment, health education, treatment pathway planning, and follow-up care	Serve as coordinator and communicator; ensure care continuity and patient adherence	Weekly MDT meetings; shared EHR updates; care pathway checklists
Physical Therapist	Assess limb function, prescribe exercise plans, perform manual lymphatic drainage (MLD)	Monitor treatment response, assess limb status, and reinforce patient education to promote adherence	Joint patient review; report functional changes
Dietitian	Evaluate nutritional status and design anti-inflammatory, weight-control diets	Provide ongoing dietary guidance, monitor weight and body metrics, and reinforce dietary interventions	Share dietary logs; coordinate nutrition sessions
Psychologist	Conduct psychological assessments, manage anxiety, depression, and body image distress	Identify emotional risks during routine care; offer basic psychological support and refer when needed	Flag emotional risk; communicate to multidisciplinary Team
Surgeon	Evaluate eligibility for surgical interventions (eg, LVA, liposuction); develop surgical plans	Assist in pre- and postoperative education, rehabilitation, and coordination of recovery resources	Pre-op briefings; recovery plan updates
Radiologist/Nuclear Medicine	Provide imaging diagnostics (eg, ICG lymphography, MRI) to assist staging and treatment planning	Manage pre-scan preparation and patient communication; follow up on results to guide nursing decisions	Provide timely results; alert nurse for abnormal findings

Trends and Gaps in Nursing Research

While clinical awareness of BCRL has increased, the research foundation supporting nursing interventions remains fragmented and underdeveloped. This is particularly problematic in the context of long-term survivorship care, where nurses are expected to deliver personalized, evidence-based strategies. A closer examination of current literature reveals four interrelated gaps that limit the advancement of BCRL nursing science and its translation into practice.

First, high-quality randomized controlled trials (RCTs) led by nursing teams are scarce. Existing studies are predominantly observational or exploratory, and even when RCTs exist, they are often led by rehabilitation specialists and lack rigorous methodological controls. Strengthening the evidence base with well-designed, nursing-led RCTs focusing on practical, implementable interventions is therefore a priority. In the next five years, pragmatic trials comparing different nurse-led approaches to early symptom assessment, compression therapy adherence, or patient education could generate high-value, generalizable evidence.

Second, there is a lack of standardized, individualized frameworks for evaluating nursing interventions. Techniques such as MLD and compression therapy vary widely across institutions, and adherence is typically measured by self-report. Developing standardized outcome metrics—such as objective limb volume monitoring, validated adherence scales, and functional mobility assessments—would enable cross-study comparisons and clarify which components of care are most effective. Research integrating wearable technologies or mobile monitoring apps could provide real-time, objective data to enhance intervention fidelity.

Third, systematic evidence synthesis in nursing is limited. BCRL care decisions often rely on anecdotal experience or local protocols, rather than consolidated high-level evidence. In the near future, targeted systematic reviews, meta-analyses, and even network meta-analyses focusing specifically on nursing-led interventions could provide actionable guidance for clinical practice. Integration of individual patient data from multiple trials would further strengthen the precision and applicability of findings.

Finally, patient-reported outcomes remain underutilized relative to biomedical measures such as limb volume reduction. Tools like LYMQOL exist, but their cultural adaptability and sensitivity to psychosocial dimensions are limited. Future research should prioritize patient-centered outcomes—including self-efficacy, functional status, psychosocial well-being, and quality of life—and develop culturally responsive, lymphedema-specific instruments. Such approaches would ensure nursing interventions address the full spectrum of patient needs, rather than focusing narrowly on clinical metrics.^135,136

Conclusion

Breast cancer–related lymphedema (BCRL) remains a complex and long-term condition that extends well beyond the acute treatment phase of breast cancer. Rather than reiterating disease burden, this review provides an integrative nursing perspective that conceptualizes BCRL management as a multi-stage, symptom-guided, and continuous care process, in which nurses play a central and decision-making role.

The evidence synthesized in this review highlights that symptom assessment is not merely a descriptive tool, but a core mechanism that links early identification, risk stratification, timely referral, and ongoing evaluation of intervention effectiveness. By integrating patient-reported symptoms with objective measures, nurses are uniquely positioned to detect subclinical changes, personalize care pathways, and bridge gaps between prevention and intervention across the disease trajectory.

Importantly, this review delineates clear distinctions between perioperative prevention and nursing intervention for established BCRL, emphasizing how nursing objectives evolve from risk reduction to symptom control and long-term self-management support. It also highlights the central role of nurses in risk assessment, health education, clinical intervention, and long-term follow-up, and proposes optimized nursing pathways across key stages, including perioperative evaluation, postoperative prevention, therapeutic integration, discharge education, and multidisciplinary collaboration. This staged framework clarifies nursing responsibilities across different clinical contexts and underscores the value of continuity, education, and psychosocial care in improving patient outcomes and quality of life. From a practice perspective, the findings support the adoption of nurse-led, symptom-centered care models that prioritize early surveillance, individualized education, and multidisciplinary coordination. For future research, nurse-led studies should move beyond broad calls for randomized controlled trials and instead focus on specific, practice-relevant priorities, including validation of symptom-based screening strategies, optimization of perioperative risk-tailored education, and evaluation of long-term patient-reported outcomes and self-management interventions.

In summary, this review advances current understanding by framing BCRL care as a dynamic, nursing-driven process that integrates prevention, early detection, intervention, and survivorship care. Strengthening this nursing-centered approach has the potential to improve clinical outcomes, enhance patient experience, and support sustainable, high-quality management of BCRL in breast cancer survivors.

Data Sharing Statement

Data is provided within the article.

Disclosure

No conflict of interest is declared by the authors.