Nurses Can Catch Breast Cancer Lymphedema Early With Baseline BIS

Breast cancer–related lymphedema is most reversible before swelling becomes visible. In the randomized PREVENT trial, 7.9% of patients whose subclinical fluid changes were detected with bioimpedance spectroscopy (BIS) and treated with compression progressed to chronic lymphedema, vs 19.2% of those monitored with tape measurement (P = .016).^1,2 Still, many programs rely on tape measures or screen only patients deemed high risk.

For Breast Cancer Awareness Month, Oncology Nursing News spoke with Manpreet K. Kohli, MD, medical director of breast surgery at Monmouth Medical Center, about how nurses can help lead baseline BIS screening and long-term surveillance.³

What practical role do oncology and navigation nurses play in performing baseline BIS screenings during pre-op or early intake?

Our workflow is that we get a baseline at the time of the initial consult, because oftentimes we might think a patient doesn’t need any intervention with their lymph nodes, but as the course of their care evolves, we might have further workup that then leads to a cancer diagnosis, lymph node intervention. So it’s always a good idea to have a baseline. We may not need to use it in the future, but oftentimes we do.

So that’s part of the workflow. It’s so important that all of the team—whether it’s the nurse navigators, the nurse who performs the intake, the techs—that everyone is knowledgeable about bioimpedance, because they are the ones that [explain] to the patient that this is something that we’re doing because it’s something we’re thinking about in the future, and we’re using [it] in your care as an important benchmark to see how you’re doing after your surgery, if we need to provide some additional layers of support for lymphedema prevention.

How can nursing teams lead the shift away from subjective tape measurements toward standardized BIS protocols in busy outpatient clinics?

I don’t think that this would meet much resistance from some of the nurses that have been doing this in the past. Any nurse who’s had to perform tape measurements to detect lymphedema probably understands that it is time consuming and it’s not always accurate. And it can vary based on who is doing the measurement. You’re using certain anatomic landmarks—say you’re using a bony prominence as your landmark and going 2 centimeters above it to do a measurement around the arm. The next person might be a couple millimeters off, and that can make a difference. It can totally change the measurement. So it may not be as accurate. It’s time consuming. And at the end of the day, you might not actually be getting a correct answer.

So bioimpedance is a much easier tool in terms of workflow. It’s done in a matter of seconds. It’s fully automated. It’s reproducible. You don’t need to have a certain person doing it. So it’s really something that is much easier, less time consuming, much more accurate. And I’ve had only overwhelmingly positive feedback from our ancillary staff that this is a much better workflow than they’ve ever had to do in the past.

Because late-onset fluid changes can surface in years 2 and 3, how should clinical workflows be structured so that long-term survivorship surveillance doesn’t fall through the cracks?

The initial visits in that first 6 months to a year are often very busy with us, accounting for: Did the patient get radiation? Are they on endocrine therapy? Did they complete chemotherapy? But after that first year, we often see that things do kind of change their pace in a good way. However, this is when we start noticing other aspects, such as lymphedema developing [in] years 2 and 3.

So [it’s about] starting early on, having that baseline measurement, [and] utilizing this as the way of assessing for lymphedema each time the patient comes in. Although some aspects we may not be paying as much attention to because they may not be in that active phase, this is when the lymphedema, the swelling, those aspects that kind of transition them from active care to [the] survivorship phase of care, start to really elevate to our attention and need a little bit more support.

So it’s a very important phase in the patient’s care, even though they’re through all of the active aspects of their care. It’s really picking up the pieces, trying to figure out how we can get them to be comfortable long-term and not have to troubleshoot lymphedema for many, many years. If you identify it early, you can reverse it and then have them have a higher level of awareness that this is something that they also need to be on the lookout for, too.

What key indicators should trigger immediate referral to physical therapy or lymphatic specialists when subclinical lymphedema is flagged?

Obviously, if there’s clinical lymphedema—swelling, heavy arm—absolutely. That definitely warrants further management. But when it’s subclinical lymphedema, the measurement is a 6.5-unit difference from the patient’s baseline. They may not have had a baseline. You can still utilize bioimpedance as a way of assessing for lymphedema, but it tends to be a more accurate reflection for that individual [with a baseline], because everyone’s baseline may be different. So it’s really looking at the change from baseline to tell us that we need to start that referral process to physical therapy, maybe get a compression garment fitting, maybe consider pneumatic pumps.

The other thing that I think is also important to keep track of is: How did your interventions impact that number? So I do call them back within 6 weeks because…as per the PREVENT trial…with 12 hours a day of compression, we usually see a reversal of subclinical lymphedema within 4 weeks. So the patients come back at the 6-week mark for a repeat measurement, because we want to make sure that intervention was effective.

If we’re seeing refractory cases, that’s when it warrants a little bit more attention. So if the patient had only tried a compressive sleeve, that’s when we might say, now maybe meet a physical therapist, or maybe you need a pump at home as well. Or maybe this is time for you to meet a plastic surgeon; we might need to talk about lymphovenous bypass [or] lymph node transplants. I really hope to not ever get to that point where we need to do something invasive, but it’s important to also track your response. Make sure that what your intervention is that you’re offering is effective.

How can surgeons and oncology nurses collaborate more effectively to establish universal lymphedema screening for all patients with breast cancer, regardless of their perceived initial risk?

Currently, the surgeons are the ones leading this initiative, because we’re the ones intervening surgically. We’re the ones that might be mechanically causing lymphedema by the procedures we’re offering. But ideally, this is a tool that should be present in cancer centers, with access not just to the surgeons, but [to] medical oncologists, radiation oncologists, all that [care] for the patient, because they might be coming in for a routine medical oncology follow-up. [They] may not be due to see me, but if they are reporting symptoms, they should be able to have access to bioimpedance…to really utilize this tool to assess: Is their swelling actually lymphedema? Is it worth a referral earlier on than when they might have come to see me?

And in other aspects of their care, there is also very useful information that you can get in terms of body composition that a medical oncologist might be able to use. So you can check for the patient’s sarcopenia status, if they’re having some muscle wasting; you can check their hydration status. And these are all things that are really important for a medical oncologist to factor into their care that they’re providing for the patient, too. So really looking at the body composition of an individual, not just in terms of lymphatic fluid, but their overall body composition can be super helpful in several aspects of cancer care.

References

1. Ridner SH, Dietrich MS, Boyages J, et al. A comparison of bioimpedance spectroscopy or tape measure triggered compression intervention in chronic breast cancer lymphedema prevention. Lymphat Res Biol. 2022;20(6):618-628. doi:10.1089/lrb.2021.0084
2. Fischer L. Bioimpedance spectroscopy is a better predictor of chronic lymphedema vs tape measurement. Oncology Nursing News. February 6, 2022. Accessed October 22, 2026. https://www.oncnursingnews.com/view/bioimpedance-spectroscopy-is-a-better-predictor-of-chronic-lymphedema-vs-tape-measurement
3. Ridner SH. Oncology nurses can help better prevent chronic lymphedema with BIS technology. Oncology Nursing News. April 6, 2022. Accessed October 22, 2026. https://www.oncnursingnews.com/view/oncology-nurses-can-help-better-prevent-chronic-lymphedema-with-bis-technology
4. Doran JF. Discussing Lymphedema Treatment Act, coverage with patients. Oncology Nursing News. January 17, 2024. Accessed October 22, 2026. https://www.oncnursingnews.com/view/discussing-lymphedema-treatment-act-coverage-with-patients