The patient survivorship journey is at its best when cancer care teams take appropriate measures to protect the whole health of a patient before, during, and after treatment. Sadly, one of the most dreaded consequences of breast cancer survivorship is lymphedema, [1] a condition that can cause significant and irreversible swelling due to fluid build-up in soft body tissue when the lymph system is damaged or blocked. For cancer patients, risk factors increase significantly due to treatment therapies including surgery, radiation, and/or chemotherapy and risk can range from 3% to 50% depending on the type of cancer, the form of treatment received, and patient disposition. [2] With the wide range of risk factors, clinicians experience difficulties in determining who is at high risk, what technology is appropriate for prospective monitoring of secondary lymphedema, and when interventions should be introduced to mitigate the progression of chronic lymphedema.

Early Detection is Key to Stopping Lymphedema Progression
Like many other medical conditions, it’s well documented that secondary lymphedema develops in stages and that the opportunity to stop lymphedema progression is at the subclinical stage – before signs and symptoms are physically evident.[3]

Figure 1.0: Stages of upper extremity arm lymphedema.

The PREVENT Trial, the largest randomized trial to assess lymphedema prevention found a significantly lower progression to chronic lymphedema using bioimpedance spectroscopy (BIS) for early detection of lymphedema and intervention compared to using circumferential tape measure assessment [4]

The traditional method for evaluating a patient’s risk of developing lymphedema is to calculate the limb volume by taking circumferential measurements using a tape measure. However, this method relies on the physical manifestation of swelling to trigger an intervention. Once symptoms are evident at this stage, it may be too late to introduce course-reversing treatment.  As the PREVENT trial demonstrated, tape measure did not provide the most accurate or timely assessment of lymphedema progression.

According to trial results, “[BIS], as compared to a tape measure, provides a more precise identification of patients likely to benefit from an early compression intervention.” [4] Early detection of lymphedema at the subclinical stage combined with timely therapy interventions for the patient is the best defense against chronic lymphedema.

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Advancements in Bioimpedance Spectroscopy (BIS) Technology for Clinical Assessment
What is BIS? BIS uses a mild electric current passed through the body to accurately measure fluid buildup. The impedance to the current is measured at 256 frequencies and a mathematical analysis converts the data collected into L-Dex®. An L-Dex increase of 6.5 over baseline is 80% sensitive and 90% specific in identifying lymphedema at the subclinical stage. [5]

In a recently published meta-analysis of 50 lymphedema studies and 67,000 patients, researchers found that early detection (at the subclinical stage) using BIS combined with intervention resulted in an 81% lower incidence rate of chronic cancer-related lymphedema than circumference monitoring. [6] When comparing assessment technologies, BIS should be considered the standard for accurate and objective detection of lymphedema.

Results from a study conducted by the University of Kansas found that “… utilizing BIS significantly lowers rates of BCRL [breast cancer-related lymphedema].” The study concluded, “Early detection with patient-directed interventions improves patient outcomes and decreases the risk of persistent BCRL.” [3] Study-after-study, the use of BIS technology is linked to positive treatment outcomes for cancer patients at risk of secondary lymphedema.

Breast Cancer-Related Lymphedema is a preventable side effect of cancer treatment
Detecting shifts in fluid volume at a subclinical level allows clinicians to intervene before lymphedema becomes chronic and disruptive to a patient’s quality of life. Clinicians who focus their efforts on prospective surveillance using BIS combined with timely intervention are more likely to see lower incidence rates of chronic secondary lymphedema in their patient population. Institutions that offer patients early monitoring and surveillance through a lymphedema prevention program to mitigate long-term risks can deliver better quality of care and keep the patient’s survivorship journey on track.

Clinical trials
Bioimpedance Spectroscopy Versus Tape Measure in Prevention of Lymphedema (PREVENT) – NCT02167659

[1] Hayes SC, Janda M, Cornish B, Battistutta D, Newman B. Lymphedema after breast cancer: incidence, risk factors, and effect on upper body function. J Clin Oncol. 2008 Jul 20;26(21):3536-42. doi: 10.1200/JCO.2007.14.4899. PMID: 18640935.
[2] Shaitelman SF, Cromwell KD, Rasmussen JC, Stout NL, Armer JM, Lasinski BB, Cormier JN. Recent progress in the treatment and prevention of cancer-related lymphedema. CA Cancer J Clin. 2015 Jan-Feb;65(1):55-81. doi: 10.3322/caac.21253. Epub 2014 Nov 19. Erratum in: CA Cancer J Clin. 2015 May-Jun;65(3):252. PMID: 25410402; PMCID: PMC4808814.
[3] Kilgore LJ, Korentager SS, Hangge AN, Amin AL, Balanoff CR, Larson KE, Mitchell MP, Chen JG, Burgen E, Khan QJ, O’Dea AP, Nye L, Sharma P, Wagner JL. Reducing Breast Cancer-Related Lymphedema (BCRL) Through Prospective Surveillance Monitoring Using Bioimpedance Spectroscopy (BIS) and Patient Directed Self-Interventions. Ann Surg Oncol. 2018 Oct;25(10):2948-2952. doi: 10.1245/s10434-018-6601-8. Epub 2018 Jul 9. PMID: 29987599.
[4] Ridner SH, Dietrich MS, Boyages J, Koelmeyer L, Elder E, Hughes TM, French J, Ngui N, Hsu J, Abramson VG, Moore A, Shah C. A Comparison of Bioimpedance Spectroscopy or Tape Measure Triggered Compression Intervention in Chronic Breast Cancer Lymphedema Prevention. Lymphat Res Biol. 2022 Jan 28. doi: 10.1089/lrb.2021.0084. Epub ahead of print. PMID: 35099283.
[5] Fu MR, Cleland CM, Guth AA, Kayal M, Haber J, Cartwright F, Kleinman R, Kang Y, Scagliola J, Axelrod D. L-dex ratio in detecting breast cancer-related lymphedema: reliability, sensitivity, and specificity. Lymphology. 2013 Jun;46(2):85-96. PMID: 24354107; PMCID: PMC4040962.
[6] Shah C, Zambelli-Weiner A, Delgado N, Sier A, Bauserman R, Nelms J. The impact of monitoring techniques on progression to chronic breast cancer-related lymphedema: a meta-analysis comparing bioimpedance spectroscopy versus circumferential measurements. Breast Cancer Res Treat. 2021 Feb;185(3):709-740. doi: 10.1007/s10549-020-05988-6. Epub 2020 Nov 27. PMID: 33245458; PMCID: PMC7921068.

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