A pilot randomized trial evaluating lymphedema self-measurement with bioelectrical impedance, self-care adherence, and health outcomes

A Low-Cost, Portable, and Mobile-Based Bioimpedance Lymphedema Diagnosis and Monitoring System (Mobilymph): A Validation Study

Background: Breast cancer-related lymphedema (BCRL) is a debilitating chronic illness. Early management and prevention of disease progression rely on lymphedema monitoring and assessment. At present, lymphedema monitoring systems are costly and do not promote remote monitoring. Thus, a low-cost, portable, mobile-based bioimpedance lymphedema monitoring system (Mobilymph) was developed to ensure continuous lymphedema surveillance. Method and Results: Forty-five healthy and 100 BCRL participants were recruited in this study. Mobilymph bioimpedance measurement was validated with a Quadscan 4000 on healthy participants' arms. The interarm bioimpedance ratio was determined to evaluate the discriminatory capability of Mobilymph to detect BCRL. Mobilymph's bioimpedance results show no significant difference compared to Quadscan 4000. The interarm bioimpedance ratios were significantly different (p < 0.001), between participants in healthy and Stage 1, Stage 0 and Stage 1, and Stage 1 and Stage 2. Healthy and Stage 0 participants had similar interarm impedance ratios (p = 0.63). Conclusion: The bioimpedance results show that Mobilymph bioimpedance measurement is comparable to Quadscan 4000 and can detect BCRL arms. Thus, Mobilymph lymphedema monitoring system offers a feasible solution for early lymphedema diagnosis and treatment monitoring. Clinical trial registration number: MREC ID No.: 2020316-8181.

Evaluating telehealth for the education and monitoring of lymphoedema and shoulder dysfunction after breast cancer surgery

PURPOSE

The primary aim of this study was to compare the attendance rates at a group lymphoedema education and same-day individual surveillance appointment between telehealth (TH) and in-person (IP) care for participants following breast cancer (BC) surgery. Secondary aims included evaluating participant satisfaction and costs between the two service models, while also determining the extent of technical issues and clinician satisfaction towards TH.

METHODS

Participants following axillary lymph node dissection surgery attended a group lymphoedema education and same-day 1:1 monitoring session via their preferred mode (TH or IP). Attendance rates, satisfaction and costs were recorded for both cohorts, and technical disruption and clinician satisfaction for the TH cohort.

RESULTS

Fifty-five individuals participated. All 28 participants who nominated the IP intervention attended, while 22/27 who nominated the TH intervention attended an appointment. Overall reported participant experience was positive with no significant differences between cohorts. All TH appointments were successfully completed. Clinicians reported high satisfaction for delivery of education (median = 4[IQR 4-5]) and individual assessment (median = 4[IQR 3-4]) via TH. Median attendance costs per participant were Australian $39.68 (Q1-Q3 $28.52-$68.64) for TH and Australian $154.26 (Q1-Q3 $81.89-$251.48) for the IP cohort.

CONCLUSION

Telehealth-delivered lymphoedema education and assessment for individuals following BC surgery was associated with favourable satisfaction, cost savings and minimal technical issues despite lower attendance than IP care. This study contributes to the growing evidence for TH and its potential applicability to other populations where risk for cancer-related lymphoedema exists.

Risk factors for breast cancer-related lymphedema in patients undergoing 3 years of prospective surveillance with intervention

Background

To evaluate risk factors (treatment‐related, comorbidities, and lifestyle) for breast cancer–related lymphedema (BCRL) within the context of a Prospective Surveillance and Early Intervention (PSEI) model of care for subclinical BCRL.

Methods

The parent randomized clinical trial assigned patients newly diagnosed with breast cancer to PSEI with either bioimpedance spectroscopy (BIS) or tape measurement (TM). Surgical, systemic and radiation treatments, comorbidities, and lifestyle factors were recorded. Detection of subclinical BCRL (change from baseline of either BIS L‐Dex ≥6.5 or tape volume ≥ 5% and < 10%) triggered an intervention with compression therapy. Volume change from baseline ≥10% indicated progression to chronic lymphedema and need for complex decongestive physiotherapy. In this secondary analysis, multinomial logistic regressions including main and interaction effects of the study group and risk factors were used to test for factor associations with outcomes (no lymphedema, subclinical lymphedema, progression to chronic lymphedema after intervention, progression to chronic lymphedema without intervention). Post hoc tests of significant interaction effects were conducted using Bonferroni‐corrected alphas of .008; otherwise, an alpha of .05 was used for statistical significance.

Results

The sample (n = 918; TM = 457; BIS = 461) was female with a median age of 58.4 years. Factors associated with BCRL risk included axillary lymph node dissection (ALND) (p < .001), taxane‐based chemotherapy (p < .001), regional nodal irradiation (RNI) (p ≤ .001), body mass index >30 (p = .002), and rurality (p = .037). Mastectomy, age, hypertension, diabetes, seroma, smoking, and air travel were not associated with BCRL risk.

Conclusions

Within the context of 3 years of PSEI for subclinical lymphedema, variables of ALND, taxane‐based chemotherapy, RNI, body mass index >30, and rurality increased risk.

The Prospective Surveillance and Early Intervention Model promotes identification and treatment of subclinical lymphedema, facilitating prevention of chronic lymphedema and risk reduction. Axillary lymph node dissection, taxane‐based chemotherapy, regional nodal irradiation, body mass index >30, and rurality are critical risk factors within the context of the Prospective Surveillance and Early Intervention Model for some patients.

Prospective surveillance model in the home for breast cancer-related lymphoedema: a feasibility study

PURPOSE

The aim of this study was to assess the feasibility of delivering a prospective surveillance model in the home over 6 months for women at high risk of developing lymphoedema.

METHODS

A single-group, intervention study recruited 20 women who had surgical and medical treatment for confirmed node-positive invasive breast cancer and therefore at high risk of developing arm lymphoedema. Participants received a package including Bioimpedance Spectroscopy (BIS) monitoring, lymphoedema education and support to promote self-management and physical activity.

RESULTS

Participants adhered to BIS monitoring 74% of the time, and felt extremely confident in using the device. By 6 months, mean BIS L-Dex scores had increased from 3.5 (SD 5.6) to 8.4 (SD 11.1); five women (25%) who experienced >  + 6.5 increase in L-Dex score were fitted with a compression garment. Self-reported symptoms and distress decreased by 0.4 out of 10 (95% CI 0.1 to 0.7); number of self-management strategies used increased by 0.6 (95% CI 0.1 to 1.2); and planned exercise increased by 2.8 h/week (95% CI 0.4 to 5.2).

CONCLUSIONS

These findings indicate a prospective surveillance model of care in the home with BIS is feasible and associated with increased self-management. A Phase II randomised trial is warranted as well as research exploring the costs associated with implementing this model of care for high-risk individuals.

Lower limb chronic edema management program: Perspectives of disengaged patients on challenges, enablers and barriers to program attendance and adherence

Background

Chronic edema (CO) is a progressive, physically disfiguring and currently incurable condition. A multifaceted program has been recommended to manage the swelling. However, there is little evidence investigating patients’ perspectives following the program, particularly for those who have poor adherence and/or are disengaged.

Aim

To investigate the perceived challenges faced by disengaged participants with lower limb CO by identifying their enablers and barriers to participating in a Physiotherapy CO program.

Method

An exploratory qualitative approach was used. A purposive sampling strategy was adopted to recruit participants. Those with more than three months swelling and who had low adherence and/or attendance (disengaged) to the CO program were invited to participate. Semi-structured interviews with six participants from a CO clinic in a tertiary hospital were conducted. Data were thematically analyzed and findings in terms of enablers and barriers were subsequently reflected in the light of a theoretical framework.

Results

All six participants were morbidly obese (BMI 47 ± 4 kg/m²) with multiple chronic comorbidities. Enablers and barriers detected included physical, psychological and social factors that interplay to present multidimensional challenges that influence the participants’ adjustment to managing their CO. For the disengaged participants in this study, their under-managed lower limb CO was a progression towards being housebound and having a gradually increasing level of disability.

Conclusion

This study has identified the multidimensional challenges faced by low adherent and/or disengaged participants with lower limb CO to participating in a hospital-based CO program. Perceived enablers and barriers included physical, psychological and social factors. These were mapped using a health behavior change theoretical framework. Understanding these challenges has implications for developing a multidisciplinary approach aimed at enhancing patient engagement and participation in the physiotherapy CO program.

Implementation of Single-Tab Electrodes for Bioimpedance Spectroscopy Measures

Background: Bioimpedance spectroscopy (BIS) demonstrates proficiency in early identification of breast cancer treatment-related lymphedema (BCRL) development. Dual-tab electrodes were designed for consistent and easy electrode placement, however, single-tab electrodes positioned to mimic dual-tab placement on the body may make BIS technology more accessible in community hospitals and outpatient settings. The purpose of this study is to evaluate use of single-tab electrodes for BIS measurements and assess whether single-tab electrodes provide consistent BIS measurements in controls and patients with BCRL. Methods and Results: Upper limb BIS ratios were obtained using ImpediMed L-Dex^® U400 in controls (n = 13; age = 23-75 years; 9 repeated measurements) using dual-tab and single-tab electrodes. BCRL patients (n = 17; Stage = 1.65 ± 0.49; number nodes removed = 16.3 ± 7.7; age = 50.9 ± 10.6 years; age range = 33-77 years) and healthy controls (n = 19) were evaluated to determine if single-tab electrodes provided discriminatory capacity for detecting BCRL. Intraclass correlation coefficients (ICC), linear mixed-effects models, Wilcoxon rank-sum tests, and linear regression with two-sided p-values <0.05 required for significance were applied. Single-tab electrodes were found to be statistically interchangeable with dual-tab electrodes (ICC = 0.966; 95% confidence interval = 0.937-0.982). No evidence of differences in single-tab versus dual-tab measurements were found for L-Dex ratios (p = 0.74) from the linear mixed-effects model. Repeated trials involving reuse of the same electrodes revealed a trend toward increases in L-Dex ratio for both styles of electrodes. Single-tab electrodes were significant (p < 0.0001) for discriminating between BCRL and control subjects. Conclusion: Findings expand upon the potential use of BIS in clinic and research settings and suggest that readily available single-tab electrodes provide similar results as dual-tab electrodes for BIS measurements.

Lipedema and Dercum's Disease: A New Application of Bioimpedance

Background: Lipedema and Dercum's disease (DD) are incompletely characterized adipose tissue diseases, and objective measures of disease profiles are needed to aid in differential diagnosis. We hypothesized that fluid properties, quantified as tissue water bioimpedance in the upper and lower extremities, differ regionally between these conditions. Methods and Results: Women (cumulative n = 156) with lipedema (n = 110), DD (n = 25), or without an adipose disease matched for age and body mass index to early stage lipedema patients (i.e., controls n = 21) were enrolled. Bioimpedance spectroscopy (BIS) was applied to measure impedance values in the arms and legs, indicative of extracellular water levels. Impedance values were recorded for each limb, as well as the leg-to-arm impedance ratio. Regression models were applied to evaluate hypothesized relationships between impedance and clinical indicators of disease (significance criteria: two-sided p < 0.05). Higher extracellular water was indicated (i) in the legs of patients with higher compared with lower stages of lipedema (p = 0.03), (ii) in the leg-to-arm impedance ratio in patients with lipedema compared with patients with DD (p ≤ 0.001), and (iii) in the leg-to-arm impedance ratio in patients with stage 1 lipedema compared with controls (p ≤ 0.01). Conclusion: BIS is a noninvasive portable modality to assess tissue water, and this device is available in both specialized and nonspecialized centers. These findings support that regional bioimpedance measures may help to distinguish lipedema from DD, as well as to identify early stages of lipedema.

Self-Measured Arm Circumference in Women With Breast Cancer Is Reliable and Valid

BACKGROUND

Prospective surveillance by physical therapists enables early detection and treatment of breast cancer-related lymphedema (BCRL). Strategies to increase access to prospective surveillance could reduce the burden of BCRL on patients and the health system. One potential solution is self-managed surveillance that does not require in-person assessment by a specialized physical therapist.

OBJECTIVE

The objective was to develop and test the reliability and validity of a written and video-supported protocol for women with breast cancer to self-measure arm circumference.

DESIGN

This was a cross-sectional reliability and validity study.

RESULTS

The intrarater reliability between CIRself_home and CIRself_lab and the interrater reliability between CIRself_lab and CIRther was high to excellent for both arms in both groups (intraclass correlation coefficient ≥0.86). VOLself_lab correlated strongly with VOLper (r ≥ 0.95), demonstrating excellent validity. Participants reported strong intention, self-efficacy, and positive attitude toward the performance of self-managed surveillance for BCRL, which was not perceived to increase worry about having or getting BCRL.

METHODS

Participants with (n = 20) and without (n = 21) BCRL completed self-measurement of arm circumference on both arms at home (CIRself_home) and at the lab (CIRself_lab) (intrarater reliability). The CIRself_lab was subsequently compared to measures performed by a specialized physical therapist (CIRther) (interrater reliability). To test validity, arm volume calculated from the self-measurements (VOLself_lab) was compared to perometry measurements (VOLper). Participants completed a questionnaire to assess attitudes for performing self-managed surveillance for BCRL.

LIMITATIONS

These findings need to be replicated in a clinical setting to confirm the reliability and acceptability of self-managed surveillance for BCRL among women newly diagnosed with breast cancer.

CONCLUSIONS

Self-measured arm circumference is reliable and valid among women with and without BCRL. Self-managed surveillance for BCRL can support self-efficacy without increasing anxiety.

Reducing Breast Cancer-Related Lymphedema (BCRL) Through Prospective Surveillance Monitoring Using Bioimpedance Spectroscopy (BIS) and Patient Directed Self-Interventions

BACKGROUND

Breast cancer-related lymphedema (BCRL) is a chronic progressive disease that results from breast cancer treatment and nodal surgery. NCCN guidelines support baseline measurements with prospective assessment for early diagnosis and treatment. We sought to determine if baseline measurement with bioimpedance spectroscopy (BIS) and serial postoperative evaluations provide early detection amenable to conservative interventions that reduce BCRL.

METHODS

Breast cancer patients with unilateral disease high-risk for BCRL from a single institution were evaluated from November 2014 to December 2017. High risk was defined as axillary lymph node dissection with radiation and/or taxane chemotherapy. Patients received preoperative baseline BIS measurements followed by postoperative measurements with at least two follow-ups. Patients with BIS results that were 2 standard deviations above baseline (10 + points) started home conservative interventions for 4-6 weeks. Postintervention measurements were taken to assess improvement.

RESULT

A total of 146 patients high-risk for BCRL were included. Forty-nine patients (34%) developed early BCRL and started self-directed treatment. Forty patients (82%) had elevated BIS measurements return to normal baseline range. Nine (6%) patients had persistent BCRL requiring referral for advanced therapy. Patients with persistent BCRL had significant nodal burden on surgical pathology; eight (89%) had N2/N3 disease. Six (76%) with BCRL refractory to conservative measures died of their breast cancer.

CONCLUSION

Our results demonstrated that early conservative intervention for breast cancer patients high risk for BCRL who were prospectively monitored by utilizing BIS significantly lowers rates of BCRL. These findings support early prospective screening and intervention for BCRL. Early detection with patient-directed interventions improves patient outcomes and decreases the risk of persistent BCRL.

A comprehensive overview on the surgical management of secondary lymphedema of the upper and lower extremities related to prior oncologic therapies

Secondary lymphedema of the upper and lower extremities related to prior oncologic therapies, including cancer surgeries, radiation therapy, and chemotherapy, is a major cause of long-term morbidity in cancer patients. For the upper extremities, it is most commonly associated with prior oncologic therapies for breast cancer, while for the lower extremities, it is most commonly associated with oncologic therapies for gynecologic cancers, urologic cancers, melanoma, and lymphoma. Both non-surgical and surgical management strategies have been developed and utilized, with the primary goal of all management strategies being volume reduction of the affected extremity, improvement in patient symptomology, and the reduction/elimination of resultant extremity-related morbidities, including recurrent infections. Surgical management strategies include: (i) ablative surgical methods (i.e., Charles procedure, suction-assisted lipectomy/liposuction) and (ii) physiologic surgical methods (i.e., lymphaticolymphatic bypass, lymphaticovenular anastomosis, vascularized lymph node transfer, vascularized omental flap transfer). While these surgical management strategies can result in dramatic improvement in extremity-related symptomology and improve quality of life for these cancer patients, many formidable challenges remain for successful management of secondary lymphedema. It is hopeful that ongoing clinical research efforts will ultimately lead to more complete and sustainable treatment strategies and perhaps a cure for secondary lymphedema and its devastating resultant morbidities.