Breast cancer-related lymphedema in Africa: incidence, risk factors, and management strategies: semi-systematic review, narrative review

¹Department of Gynaecology and Obstetrics, Faculty of Medicine and Health Sciences, Walter Sisulu University, Mthatha Campus, South Africa, ²Department of Industrial and Organisational Psychology, University of South Africa, Pretoria, Gauteng, South Africa

^&Corresponding author
Jean Paul Muambangu Milambo, Department of Gynaecology and Obstetrics, Faculty of Medicine and Health Sciences, Walter Sisulu University, Mthatha Campus, South Africa

Introduction    

Breast cancer (BC) remains a major global public health concern, with a particularly high burden in low- and middle-income countries (LMICs). According to GLOBOCAN 2012, 25% of women worldwide are diagnosed with BC, leading to approximately 521,900 deaths annually [1]. Age-standardized incidence rates exhibit significant geographic variation, ranging from 19.3 per 100,000 in Eastern Africa to 89.7 per 100,000 in Western Europe [2]. Despite lower reported incidence rates in Africa, largely attributed to inadequate screening and registry systems, BC remains the most common cancer among women in sub-Saharan Africa [3].

A frequent and debilitating consequence of BC treatment is breast cancer-related lymphedema (BCRL), which is associated with a marked reduction in survivors' quality of life [4]. Although BCRL affects millions globally, comprehensive data on its prevalence and burden in Africa remains limited [5]. The incidence of BCRL in the global context varies, ranging from 6% to 83%, with a pooled incidence of approximately 40% within two years post-treatment [6]. Various risk factors have been identified, including surgical procedures (such as axillary lymph node dissection), chemotherapy, hormonal therapy, older age, higher body mass index (BMI), and postmenopausal status [7]. Methods for diagnosing lymphedema include clinical assessments, tape measurements, bioelectrical impedance, and other imaging techniques [8]. The standard treatment for BCRL involves complex decongestive therapy (CDT), which integrates compression garments, lymphatic massage, exercise, and self-care practices [9].

With the increasing survival rates of breast cancer globally, particularly in Africa, the burden of BCRL on survivors has become more pronounced. However, much of the existing literature on BCRL management and risk factors comes from developed countries, where healthcare systems are better equipped, and research is more extensive. In contrast, Africa faces unique challenges, including limited access to specialized care and inadequate diagnostic tools [10]. There is a critical need for region-specific data to better understand the incidence, risk factors, and management strategies for BCRL in Africa.

There are significant gaps in the current body of research on BCRL in Africa. The absence of standardized diagnostic criteria and treatment protocols poses a major challenge to managing this condition effectively. Furthermore, while the risk factors for BCRL in developed countries are well documented, similar studies in African contexts are sparse. The effectiveness of current treatment modalities, such as manual lymphatic drainage (MLD) and CDT, in African settings remains underexplored. Additionally, the lack of comprehensive data on BCRL´s impact on health-related quality of life (HRQOL) among African breast cancer survivors further underscores the need for research.

Hypothesis: we hypothesize that the incidence and risk factors for BCRL in Africa are similar to those observed in developed countries, but are exacerbated by limited healthcare infrastructure and access to specialized care. The management of BCRL in African countries may differ from global standards, which could lead to poorer outcomes for survivors.

Research: this review seeks to answer the following questions: 1) What is the incidence of BCRL among breast cancer survivors in African countries? 2) What diagnostic methods and management strategies are currently being used to treat BCRL in Africa, and how do they compare to global standards?

Objective: the primary objective of this systematic review is to assess the burden of BCRL among breast cancer survivors in Africa, including the incidence, risk factors, and management strategies. This review aims to provide a comprehensive understanding of the current state of BCRL care in Africa, identify gaps in research and healthcare practices, and suggest directions for future studies to improve the diagnosis, management, and treatment outcomes for African survivors.

Methods     

Study design: we conducted a semi-systematic review and meta-analysis of the literature on breast cancer-related lymphedema (BCRL) in African countries, based on PRISMA guidelines and following a scoping review methodology [11]. The study protocol was registered with PROSPERO (CRD42017072735) and is accessible online [12]. Figure 1 illustrates the PRISMA flow diagram.

Eligibility criteria

Inclusion: primary studies (qualitative, quantitative, or mixed method) reporting on BCRL among patients in African countries, regardless of publication year.

Exclusion: narrative reviews, expert opinions, commentaries, duplicated studies, and literature not specific to Africa.

Language: articles published in English and French were considered.

Information sources and search strategy: we systematically searched MEDLINE, EMBASE, PubMed, and the Cochrane Breast Cancer Registry. The search included a combination of MeSH terms and keywords such as “lymphedema,” “breast neoplasm,” “axillary lymph node dissection”, and others, tailored to prioritize African-context studies [13,14].

Population: all included studies involved breast cancer patients diagnosed with BCRL in African settings, without restrictions based on age, menopausal status, or treatment type [15-18].

Study selection: two independent reviewers screened titles and abstracts, with disagreements resolved by a third reviewer. Full texts were assessed against the inclusion criteria. In cases of duplicates, the most comprehensive study was retained.

Types of studies included: twelve studies were included: 4 qualitative, 6 quantitative observational studies, and 2 randomized controlled trials (RCTs). All provided data on incidence, risk factors, diagnosis, and/or management of BCRL [13].

Data collection and extraction: data extraction was conducted independently by two reviewers using a validated questionnaire, preceded by a pilot test to assess reliability [19]. Extracted variables included study design, sample size, patient age, incidence rates, diagnostic tools, management strategies, risk factors, and outcomes. The authors´ conclusions were also recorded.

Indicators and outcomes: this review followed PRISMA and PICO frameworks to assess diagnostic indicators, treatment strategies, and health outcomes. Diagnostic criteria were aligned with the International Society of Lymphology (ISL), including clinical assessments, limb measurements, MRI/CT imaging, bioimpedance spectroscopy (BIS), and water displacement [16]. Recommended management strategies included complete decongestive therapy (CDT), manual lymphatic drainage (MLD), compression bandaging, exercise, skincare, and elastic garments [17]. Knowledge-sharing and international collaboration were also endorsed by the ISL [18].

Primary outcomes: prevalence and incidence of BCRL in African settings.

Secondary outcomes: risk factors, diagnostic tools, and management protocols.

Risk of bias assessment: the Newcastle-Ottawa Scale (NOS) was used to assess the quality of observational studies, while the Cochrane Risk of Bias Tool was applied to RCTs [20]. Observational studies demonstrated a high risk of bias, with an average NOS score of 3/8. The two RCTs showed low risk of bias due to adequate randomization, blinding, and outcome handling [21]. Study quality is summarized in Table 1 [22-32].

Synthesis of results: quantitative synthesis (meta-analysis) was conducted using RevMan software. A random-effects model was used due to expected heterogeneity. The pooled incidence of BCRL was calculated, and narrative synthesis was used to summarize risk factors and management practices. Forest plots were generated where applicable.

Risk of bias across studies: overall, observational studies exhibited high heterogeneity and risk of bias. This limited the ability to generalize findings and contributed to inconsistency across reported outcomes.

Additional analyses: meta-regression and subgroup analyses were not performed due to significant methodological and clinical heterogeneity across studies. Differences in study designs, populations, diagnostic criteria, and treatment approaches-along with varied sample sizes and limited geographic distribution-precluded meaningful cross-country or subgroup comparisons. Most studies originated from a few African countries, which limited regional representativeness. These limitations highlight the need for larger, standardized multicentre studies to better inform BCRL care in Africa.

Results     

Study selection and characteristics: the initial literature search yielded 2,579 records related to breast cancer-related lymphedema (BCRL), including 2,000 from PubMed, 287 from Cochrane, and 890 from EMBASE. After duplicate removal and title screening, 25 full-text articles were assessed for eligibility. Ultimately, 12 studies met the inclusion criteria and were included in the final review [23-33]. The included studies comprised eight quantitative observational studies, two randomized controlled trials (RCTs), and four qualitative studies, all conducted in African settings.

The included studies varied in design, settings, and methodologies, with sample sizes ranging from 30 to over 400 participants. A summary of the study characteristics is presented in Table 1, and the PRISMA flow diagram is shown in Figure 1.

Age groups and meta-analysis: pooled data from the quantitative studies revealed a mean age of 52.71 years for BCRL patients in Africa (I² = 0%, P < 0.001; 95% CI: 52.17-53.28) [23-33]. Reported age ranges across studies spanned from 30 to 78 years, capturing both pre- and post-menopausal populations.

Incidence and prevalence: the overall pooled incidence of BCRL across the studies was 86.7% (I² = 0%, P = 0.003; 95% CI: 82.5%-90.8%). However, country-specific prevalence rates varied: Zambia: 60% overall; 28% moderate; 12% severe [22,23]; Egypt: 83.4% overall; stage 1 - 35.9%, stage 2 - 39.1%, stage 3 - 25% [33]; Tunisia: 69.3% [27]; Ghana: 96.3% [27]. Figure 2 and Figure 3 provide forest plots of the pooled incidence estimates.

Risk factors and diagnosis: common risk factors identified included type of surgery (e.g., axillary lymph node dissection, modified radical mastectomy); radiotherapy, chemotherapy, and hormonal therapy; older age and postmenopausal status; and elevated body mass index (BMI).

Diagnostic tools varied across studies and included patient self-reports and symptom diaries; limb circumference measurements using tape; perometry and water displacement; clinical observation and staging (ISL guidelines). Challenges included limited access to diagnostic tools, low awareness among healthcare providers, and a lack of standard protocols for diagnosis and staging [23-33].

Qualitative synthesis: health-related quality of life and system challenges: qualitative studies revealed that BCRL significantly impairs health-related quality of life (HRQOL) through persistent pain, disfigurement, emotional distress, and reduced functional capacity. Themes of psychosocial burden, lack of knowledge, limited specialist services, and cultural stigma emerged frequently [27-32].

Management strategies: studies reported various non-surgical management strategies: 1) Complete Decongestive Therapy (CDT): demonstrated up to 60% volume reduction over 10 weeks in a South African case series; 2) Manual Lymphatic Drainage (MLD) and pneumatic compression also showed beneficial effects; 3) elastic compression garments, self-care education, and exercise were recommended but inconsistently applied [16-18].

Evidence from Randomized Controlled Trials (RCTs): two RCTs from Egypt provided high-quality evidence on adjunctive therapies: 1) ozone therapy + CDT: led to greater volume reduction in the intervention group than CDT alone [24]; Low-Level Laser Therapy (LLLT): improved range of motion and grip strength, suggesting functional gains and symptom relief compared to controls [24].

Risk of bias across studies: 1) observational studies: high risk of bias (average NOS score: 3/8); 2) RCTs: low risk of bias based on appropriate randomization, blinding, and data handling [20,21]. For study quality assessments [22-32] (Table 1).

Limitations and heterogeneity: subgroup analyses and meta-regression were not conducted due to significant clinical and methodological heterogeneity. These included differences in diagnostic definitions, management protocols, sample sizes, and healthcare infrastructure across countries. This heterogeneity, compounded by a limited number of high-quality studies and regionally concentrated data, limits the generalizability of findings and highlights the need for standardized, multicenter research.

The quality assessment of the included studies revealed considerable variability in methodological rigor. Observational studies generally scored low to moderate on the Newcastle-Ottawa Scale, with common limitations related to sample selection, control for confounders, and outcome assessment, resulting in moderate to high risk of bias. In contrast, the randomized controlled trials (RCTs) demonstrated a lower risk of bias due to more rigorous design features such as randomization and blinding. Reporting quality based on PRISMA adherence varied, with some studies providing comprehensive search strategies and clear inclusion criteria, while others lacked transparency in methodological details. Overall, the heterogeneity in study quality and risk of bias underscores the need for more robust, standardized research methodologies in investigating breast cancer-related lymphedema across African populations. Table 2 provides the quality assessment of the included studies.

Rationale for limited quality assessment and omission of funnel plot or subgroup analyses: this study was designed as a semi-systematic review, incorporating elements of both systematic and scoping review methodologies to capture the breadth and variability of available evidence on breast cancer-related lymphedema (BCRL) in African settings. As with scoping reviews, the primary objective was to map the existing literature, identify key themes, report on the range of incidence and risk factors, and highlight knowledge and practice gaps-rather than to provide a definitive synthesis of effectiveness or causality.

Quality assessment: a comprehensive quality assessment was not conducted for all included studies because: 1) scoping reviews and semi-systematic reviews are exploratory by design and do not aim to produce summary effect estimates for intervention efficacy or causality; 2) many included studies were heterogeneous in design, including qualitative research, case studies, and mixed-methods papers, which are not uniformly compatible with traditional quality appraisal tools (e.g., GRADE or ROBIS); 3) instead, a limited risk of bias assessment was applied to quantitative studies using the Newcastle-Ottawa Scale and the Cochrane Risk of Bias Tool for RCTs, where applicable, to provide an overview of methodological rigor without excluding potentially informative studies of lower quality.

Funnel plot and publication bias: a funnel plot was not generated due to the small number of included studies (n = 12), which is below the commonly recommended threshold (≥10 studies) needed to reliably detect asymmetry and publication bias; the wide heterogeneity in study design and outcomes, which undermines the assumptions necessary for interpreting funnel plots or conducting Egger´s or Begg´s tests.

Subgroup and meta-regression analyses: subgroup and meta-regression analyses were not conducted due to high clinical and methodological heterogeneity across studies, including differences in diagnostic tools, staging systems (e.g., ISL classification), definitions of BCRL, and variations in healthcare settings; the limited availability of stratified data by age group, treatment type, or geographic region precluded meaningful comparisons; the inclusion of qualitative studies and small-sample observational studies, which are not statistically suitable for such analyses.

In summary, these limitations reflect the current state of the literature on BCRL in Africa and underscore the urgent need for high-quality, standardized, multicentre research to enable robust synthesis, evidence grading, and data-driven policy recommendations in the future.

Discussion     

This review is the first to comprehensively summarize studies on breast cancer-related lymphedema (BCRL) in African clinical contexts. A key finding is that one Zambian study reported prevalence rates for BCRL as 60%, 28%, and 12% for mild, moderate, and severe cases, respectively. The risk factors and impacts of BCRL on survivors align closely with those found in studies from developed countries. Factors related to breast cancer treatment, such as surgery, chemotherapy, radiation, and hormonal therapy, were identified. Additionally, both modifiable and non-modifiable personal risk factors were noted, including obesity (BMI >30 kg/m²), cellulitis, older age, and postmenopausal status [21-32].

In Africa, management pathways for BCRL are not standardized compared to ISL recommendations, and only two clinical trials evaluating the effectiveness of complete decongestive therapy (CDT) and other conventional treatments were found. Other studies focused on patient knowledge and perspectives regarding BCRL risk reduction and its effect on health-related quality of life (HRQOL). Common interventions reported included manual lymph drainage (MLD), compression sleeves, and exercises, often supplemented by follow-up programs. Diagnostic tools varied, with tape measurements, self-reports, and blood tests being utilized [16-18].

Barriers to effective management include inadequate information on BCRL risk reduction, a lack of specialized lymphedema services, and insufficient healthcare awareness regarding management pathways. All studies indicated that BCRL significantly affects daily activities and the physical, psychosocial, and emotional well-being of survivors [7-9].

The findings regarding the mean age, incidence, risk factors, and management strategies in this review are consistent with a study conducted in China, which found that approximately 84% of breast cancer patients who underwent surgery and radiation developed BCRL within three years, with a mean onset interval of 1.91 years [27]. In contrast, a 2010 review indicated a lower incidence of BCRL (40%) in developed countries, and a U.S. study reported a cumulative incidence of 42% [7,9]. Moreover, a Brazilian study revealed a 33% incidence of BCRL in women followed for an average of 57 months after breast surgery [32].

The discrepancies in BCRL incidence estimates can largely be attributed to the absence of standardized management pathways, varying diagnostic tools, and limited healthcare awareness in African countries [25-32]. The ISL recommends bioimpedance spectroscopy (BIS) as a reliable and cost-effective diagnostic tool. However, while spirometry may be more accurate, its cost limits its clinical application, leading to reliance on less accurate methods such as symptom assessments and limb circumference measurements in resource-limited settings [32].

Despite the identification of several candidate genes linked to BCRL development in studies from developed nations, no research has been conducted in Africa focusing on molecular risk factors for BCRL. Thus, the current evidence base for the clinical management and diagnosis of BCRL in Africa is limited, highlighting the need for studies to evaluate the effectiveness of recommended diagnostic tools and to explore genetic diversity among affected populations [23-27].

Additionally, while CDT is considered the standard treatment for lymphedema globally, many trained therapists in Africa do not implement all four components of this complex therapy. Most only provide MLD and compression sleeves, which do not encompass the full range of CDT's benefits. Although some randomized trials in developed countries have confirmed the effectiveness of CDT, its applicability and efficacy in African contexts require further investigation [23-30].

This semi-systematic review provides one of the first consolidated syntheses of breast cancer-related lymphedema (BCRL) research conducted specifically in African settings. A major strength of this study lies in its inclusive approach, which incorporates both quantitative and qualitative studies across multiple African countries. This allowed for a broader understanding of the clinical burden, risk factors, and lived experiences associated with BCRL, particularly within under-researched, resource-constrained healthcare environments. The review followed PRISMA guidelines and applied a limited meta-analysis to estimate pooled incidence and mean age, offering some degree of statistical synthesis despite study heterogeneity. Moreover, this work identifies systemic gaps-such as limited diagnostic tools, lack of standardized care pathways, and inadequate patient education-which are rarely addressed in the literature from high-income countries.

In contrast, studies from the USA, Europe, Canada, and Australia are generally more robust, benefiting from prospective cohort designs, larger sample sizes, standardized diagnostic criteria (e.g., ISL or BIS protocols), and longer follow-up periods. These regions also have comprehensive cancer registries and integrated survivorship programs that track lymphedema outcomes more systematically. Similarly, in Asia, recent studies-particularly from South Korea, Japan, and China-have demonstrated increasing methodological rigor, though disparities still exist between urban and rural healthcare systems. Compared to these global studies, African research is limited by small sample sizes, high heterogeneity, underreporting, and the lack of national surveillance systems. The absence of advanced imaging tools and multidisciplinary lymphedema clinics further compounds these challenges. Nevertheless, this review highlights the adaptability and resilience of local clinicians using low-cost methods such as manual lymph drainage and compression therapy in the absence of high-tech interventions, demonstrating the need for context-specific guidelines rather than wholesale adoption of Western models.

This review acknowledges several limitations, including the predominance of qualitative and observational studies with lower evidence levels. The small sample sizes in the RCTs restrict the external validity of the findings. The burden of BCRL across Africa is underreported, and the observational studies may not represent the continent as a whole due to limited management pathways and published research on BCRL in various African countries. Future epidemiological studies addressing both molecular and clinical risk factors for BCRL in diverse African populations are essential for enhancing understanding, management, and program development related to this condition.

Conclusion     

There is a notable scarcity of data on BCRL risk reduction in Africa, with incidence rates significantly high and often underreported. The risk factors and impacts of BCRL on HRQOL in African settings are similar to those in developed countries. However, no evidence-based standardized guidelines have been established for assessing the efficacy of treatments such as CDT, MLD, exercises, and psychosocial support. This review highlights critical gaps in information on BCRL risk reduction for both patients and healthcare providers, as well as a lack of specialized services in Africa. More comprehensive studies are needed across African countries to improve knowledge, skills, and awareness regarding lymphedema.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Jean Paul Muambangu Milambo contributed to study design, search strategy, protocol writing, data extraction, risk assessment, analysis, and manuscript writing; Charles Businge supported critical appraisal, research, designing, data extraction, and supervision. All the authors read and approved the final version of this manuscript.

Tables and figures     

Table 1: summary of the breast cancer-related lymphedema studies included in the review

Table 2: quality assessment of included breast cancer-related lymphedema studies based on the Newcastle-Ottawa Scale (NOS) and PRISMA reporting

Figure 1: flow diagram based on PRISMA

Figure 2: pooled estimate of the average age of breast cancer-related lymphedema women

Figure 3: pooled incidence of breast cancer-related lymphedema in Africa

References