Strengthening Patient Pathways With BIS for Lymphedema Surveillance

In this interview, Manpreet Kohli, MD, discusses the incorporation of bioimpedance spectroscopy into NAPBC standards, the impact of early lymphedema detection on survivorship, and how clinicians can better support patient-centered care throughout the breast cancer journey.

Please state your name, title, and any relevant experience you’d like to share.

Manpreet Kohli, MD: Hi, my name is Dr Manpreet Kohli. I am the director of breast surgery at Monmouth Medical Center in Long Branch, New Jersey, and I'm part of the advisory board for ImpediMed.

The National Accreditation Program for Breast Centers’ (NAPBC’s) 2024 standards now include bioimpedance spectroscopy (BIS) as a key tool for lymphedema prevention. What does this update mean for breast cancer patients and providers?

Dr Kohli: Having NAPBC accreditation is something that we're really proud to say we have because it means that we're functioning at the highest level according to the high standard of care within the field. This means that providers must push themselves to strive for the very best for the patient's benefit, because the whole importance of taking care of patients with breast cancer is not only getting them through the diagnosis but also providing them with an excellent long-term prognosis.

It reinforces how vital it is to consider long-term implications of what we do to get someone through a breast cancer diagnosis. Now it's much more than just surviving breast cancer—it’s surviving it with an excellent quality of life, while accounting for the collateral damage that some of our treatment options might have and the impact on long-term, quality of life for the patient.

Can you explain how BIS technology works and how it differs from other lymphedema screening methods?

Dr Kohli: In the past, when patients would develop swelling of the arm related to their breast cancer treatments, we would suspect lymphedema and we would perform measurements with a tape measure to compare the affected limb with the normal side. That was a good way to track response to interventions and monitor for worsening or improvement. However, what we found is that patients presenting with arm swelling are actually in one of the later stages of lymphedema. By virtue of it, having been there longer, it's a little bit more difficult to reverse.

The ideal way to detect lymphedema is in its earliest stage—before the patient notices swelling, heaviness of the arm, or a change in the way their jewelry or their garments fit. Tape measurements are not always as accurate because they’re subjective. It's based on who's doing the measurement and whether it is at the exact anatomic landmark that the last person used.

Using BIS is much more accurate. This is basically sending a very low-level electric impulse through the patient's body at different speeds and looking at the resistance as it travels through tissues. This allows detection of fluid differences at a very minute volume. Before the patient even notices they have swelling, we're detecting a fluid difference comparing one side to the other. As a result, we can intervene at a much earlier phase. When we're detecting lymphedema that early, it truly can be reversible.

If we look at the PREVENT trial and how BIS was used, lymphedema detected with BIS was reversible in 92% of patients. The vast majority of patients, if caught early, had great outcomes and were returned to their baseline.

What barriers exist to widespread adoption of BIS, and how can health care providers overcome them?

Dr Kohli: The biggest barrier is maintaining awareness of newer technologies and tools available. One challenge is acceptance on the patient side. Incorporating BIS into guidelines and reinforcing that it is now the standard of care allows payers to support this being covered. Patients will definitely pursue what they can if they know it's in their best interest and there is no cost to them.

That, I would say, is the biggest challenge. There are so many health care-related costs that patients often have to pick and choose what's truly necessary or vital in their care. Even if they want the ideal scenario of great care and no long-term side effects, sometimes using these additional tools can be challenging if it's not covered.

In what ways can clinicians better support patients in maintaining their quality of life during and after breast cancer treatment?

Dr Kohli: It starts with that initial consultation—addressing the fear and anxiety that patients have about what a breast cancer diagnosis looks like and what the treatments might be. Providing a sense of reassurance, even subconsciously, by expressing that you are confident in the survival rate you might be quoting to them and that there are great treatment options improving survival rates each year across all stages is vital. Discussing that at the time of the initial visit is really important.

It often becomes real for patients when they are on the BIS device and they're getting their measurement. Sometimes, it only then sinks in at that moment that we are now going to have to do something about this, and we're thinking about what this might look like in a year or 2 years compared with what their normal is now. Knowing that there might be a change from their normal and that their life could change as a result of their breast cancer diagnosis can be unsettling. But also knowing that we're cognizant of those changes that we anticipate down the road and that we have ways to troubleshoot them and focus on their quality of life—even after their cancer diagnosis—can be helpful.

How do you approach patient education regarding treatment-related side effects such as lymphedema, and what role does shared decision-making play?

Dr Kohli: Shared decision-making is huge because there are not many things that patients have control over when they're diagnosed with breast cancer. Being able to give them an active role in their care, when possible, is important. No one really gets to decide if whether they are going to be diagnosed with breast cancer, but if we're saying, for example, “You have to take this medication for 5 years,” then knowing the potential side effects is important to prime the patient with and help them decide what might suit them best if more than one option exists.

Additionally, when it comes to the things we do as surgeons—talking about lymph node management, the implications of that, and even just surgery in general—it’s important to explain what to anticipate in terms of recovery, both short-term and long-term, as well as what long-term surveillance will look like. All of these things are really important for the patient to buy in, be part of the team, and not feel like they're just subjected to care. That helps them achieve the best long-term outcome because they are truly part of the decision-making process.

You have to think of all the other aspects that are nonmedical. What is the patient's life like? What is their work like? What is their family life like? What responsibilities do they have in life? How does what we do impact all of those things too?

What do you hope to see in the next phase of advancements in survivorship care, both in clinical practice and policy?

Dr Kohli: Survivorship care, thankfully, has gotten more of a spotlight recently, but that population is going to keep growing because we're doing so much better every year in how we care for patients with breast cancer and in improving survival rates.

People in general are living healthier and living longer, so that group of breast cancer survivors—and cancer survivors—overall is going to grow exponentially. We’re here longer, and we're doing a much better job at treating cancer. Focusing on what life looks like after cancer is going to be a really important aspect of health care in the coming years.