Sheila Ridner, PhD, RN, ACNP
Nashville, TN
Sheila.ridner@vanderbilt.edu

This will be my last message to you as Coordinator of the Lymphedema Management (LYM) SIG. The “business” of managing a SIG is only possible because of dedicated individuals who volunteer their time to write articles, serve on committees, etc. So, to all those who have served this SIG in any way during the past three years, please accept my sincere thanks for all of your contributions.

I am pleased to announce, that on the anniversary of my third year in this position, and on Ellen Poage’s fifth anniversary as editor, we are turning over our positions to two very talented and passionate individuals. Mei Fu, PhD, RN, from New York University (NYU) will assume the Coordinator position, and Joanne Ryan, MS, RN, a PhD student, also from NYU, will take over as editor. These two women helped save the LYM SIG from near extinction when they volunteered to be mentored by me and Ellen in 2007 to become SIG leaders in 2008 when others were unable to assume the roles as planned. So, I want to extend my heartfelt thanks to Mei Fu and Joanne, and I hope each of you will help them succeed in their new leadership positions.

Three years ago, when I became Coordinator, lymphedema was a severe problem for many patients with cancer. Unfortunately, it still is, as no curative treatment yet exists, and many cancer treatments continue to damage the lymphatic systems of our patients. Clearly, our patients perceive lymphedema as more than just a “swollen arm” or a “swollen leg”. It is a chronic, distressing, health condition that requires ongoing self-care.  Until a cure is found, our “business” as oncology nurses should be to continue helping patients and their families manage lymphedema-related symptoms and problems. Thus, until the day arrives when we can joyfully say that cancer treatment-related lymphedema no longer exists, the LYM SIG has a vital role to play in improving patient care. Thankfully, our door is open and we remain “in business.”

Best Wishes for a Successful 2008-2009!

Sheila

Newest Lymphedema Technology

Jack Butler
VP Business Development - ImpediMed, Inc.
Pittsford, New York
JButler@impedimed.com

Charles L. McGarvey, III, PT, MS, DPT, FAPTA
President, CLM Consulting LLC
Rockville, Maryland
CLMconsulting@version.net

In 2007, the U.S. Food and Drug Administration cleared the first of ImpediMed Limited’s novel medical devices for clinical assessment and monitoring of lymphedema. The technology employs a low-frequency current that passes through the patient via gel-backed electrodes placed on the skin. The procedure is painless, is imperceptible to the patient, and takes only minutes to perform. The low-frequency current produced travels only through extracellular space because of the high capacitance of lipids contained in the cellular membranes, thus preventing the current from traveling through intracellular space. The first ImpediMed device has been designed to compare impedance, or resistance to the flow of that current, through the patient's at-risk limb with that of his or her contralateral uninvolved limb. The results of that ratio are reported by the device as the Lymphedema Index, or L-Dex™ value. The more extracellular fluid contained in the arm, the higher the L-Dex value. In a study of healthy women, Cornish, et al. (2001) established normative ranges which have been standardized into an L-Dex range from -10 to +10.

L-Dex measurements can be used to prospectively manage the risk of lymphedema in patients with breast cancer and to monitor patients undergoing treatment for lymphedema. Clinical trials in the last decade (Armer and Stewart, 2005, Box, Reul-Hirche, Bullock-Saxton, and Furnival, 2002, Johansson, Ohlsson, Ingvar, Albertsson, and Ekdahl, 2002) investigated various impairments in patients diagnosed with breast cancer. These studies established the importance of early pre-operative baseline assessment of patients providing evidence-based rationale for this concept.

A recent example of the prospective paradigm of care, potential impact on severity of impairment, and relative cost of service was demonstrated by a five-year clinical trial conducted by the National Institutes of Health Clinical Center (2008) from 2000-2005 in a cohort of 196 newly diagnosed patients with breast cancer.

Preliminary results indicated the importance of a prospective model of care in the reduction of lymphedema severity and a positive therapeutic effect of early intervention. These findings were presented in poster format at one international professional and two national conferences in 2007 (Gergich, Pfalzer, Soballe, Washington, and McGarvey, 2007, March, 2007, June).

In addition, there is a growing international consensus among professional organizations in support of the prospective (pre-surgical) assessment of newly diagnosed cancer patients to identify and manage those patients at high risk for lymphedema (Harris, Hugi, Olivotto, Levine, and Steering Committee for Clinical Practice Guidelines for the Care and Treatment of Breast Cancer, 2001, International Society of Lymphology, 2003).

Current advances in bioimpedance spectroscopy have confirmed this new medical instrumentation as a valid and reliable method to detect early (subclinical) lymphedema. L-Dex devices will provide clinicians with an opportunity to diagnose and treat many of these impairments earlier and before they become visually apparent, thus reducing severity further and ultimately decreasing the cost of care.

References

Armer, J.M., and Stewart, B.R. (2005). A comparison of four
diagnostic criteria for lymphedema in a post-breast cancer population. Lymphatic Research and Biology, 3(4), 208-217. Available from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db
=PubMed&dopt=Citation&list_uids=16379589

Box, R. C., Reul-Hirche, H.M., Bullock-Saxton, J. E., and
Furnival, C. M. (2002). Physiotherapy after breast cancer surgery: results of a randomized controlled study to minimise lymphoedema. Breast Cancer Research and Treatment, 75(1), 51-64.

Cornish, B. (2006). Bioimpedance analysis: Scientific background. Lymphatic Research and Biology, 4(1), 47-50.

Cornish, B. H., Bunce, I. H., Ward, L. C., Jones, L. C., and Thomas, B. J. (1996). Bioelectrical impedance for monitoring the efficacy of lymphoedema treatment programmes. Breast Cancer Research and Treatment, 38(2), 169-176.

Cornish, B. H., Chapman, M., Hirst, C., Mirolo, B., Bunce, I. H., Ward, L. C., et al. (2001). Early diagnosis of lymphedema using multiple frequency bioimpedance. Lymphology, 34(1), 2-11.

Cornish, B. H., Thomas, B. J., Ward, L. C., Hirst, C., and Bunce, I. H. (2002). A new technique for the quantification of peripheral edema with application in both unilateral and bilateral cases. Angiology, 53(1), 41-47.

Gergich N, Pfalzer L, Soballe P, Washington F. and McGarvey C: "Preoperative Assessment Improves early Diagnosis and Treatment of Lymphedema" Poster, Society of Surgical Oncology, Washington DC, 15-18 Mar 2007.

Harris, S. R., Hugi, M. R., Olivotto, I. A., Levine, M., and
Steering Committee for Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. (2001). Clinical practice guidelines for the care and treatment of breast cancer: 11. Lymphedema. CMAJ, 164(2), 191-199.

International Society of Lymphology. (2003). The diagnosis and
treatment of peripheral lymphedema. Consensus document of the International Society of Lymphology. Lymphology, 36(2), 84-91. Available from PM:12926833

Johansson, K., Ohlsson, K., Ingvar, C., Albertsson, M., and
Ekdahl, C. (2002). Factors associated with the development of arm lymphedema following breast cancer treatment: A match pair case-control study. Lymphology, 35(2), 59-71. Available from PM:12081053

National Institutes of Health Clinical Center. (2008). Morbidity
following the diagnosis and treatment of patients with breast cancer: A multi-institutional study between the National Institutes of Health (NIH) Rehabilitation Medicine Department (RMD) and the National Naval Medical Center (NNMC) breast care (Protocol No. 02-CC-0044). Retrieved March 27, 2008, from
http://clinicalstudies.info.nih.gov/cgi/detail.cgi?B_2002-CC-0044.html

Editor's Note

Ellen Poage, MSN, ARNP, MPH, CLT-LANA
Fort Myers, FL
egpoage@mac.com

The ONS Putting Evidence Into Practice (PEP) lymphedema project is now in its final stages of development. The PEP card is finished and an article called “Demystifying Lymphedema: Development of ONS Lymphedema PEP Card” is being written and will be published at the end of the year. The PEP card will be ready for the annual ONS Congress in May 2008.

The project has required more work than we had imagined. Nevertheless, collaborating with the team of experts, both the volunteers and the ONS staff, has been very rewarding. Our team has been responsible for evaluating the most current and effective interventions for secondary lymphedema. Based on the literature, ONS guidelines, and expert opinions we ranked the interventions according to strength of evidence.  We soon discovered that there is plenty of opportunity for more research in the field of lymphedema treatment.

This will be my last newsletter. I began as editor about six years ago back when we still had paper newsletters. My time as editor has been very rewarding and has made me feel that, as a lymphedema nurse, I truly belong to ONS. The greatest benefit has been working with other nurses just as fascinated with lymphedema as I am. I’ve gotten to work with a lot of “rock-star” researchers, most recently Sheila Ridner, PhD, RN, ACNP, and Jane Armer, PhD, RN. They have been great mentors. Thank you both. Working with Carol Demarco and the copy editors at the ONS National Office has been a rewarding experience as well. They have been both professional and friendly, and they have kept me on track. The copy editors at ONS take our written contributions and polish them into a beautiful publication that is our newsletter. Just being a member of the SIG will not give you any real sense of this amazing group, but you could get involved by attending the SIG meeting at Congress. While you are at the meeting, contribute and then volunteer. Perhaps you can work on the Web site, write an article, or get friends and colleagues involved.

This month I asked Claire Hauenstein, MBA, of Fort Myers, FL, to write an article. Since her retirement, she has started Lymphedema Resources, INC. (LRI), a lymphedema non-profit organization. LRI recently applied for a $19,000 grant from Susan G. Komen for the Cure to provide not only sleeves but also therapy for uninsured and underserved individuals with lymphedema residing in southwest Florida. Today, I received an e-mail from Claire inviting the LRI board members to the Susan G. Komen for the Cure luncheon. She hinted that this likely indicates we are slated to receive the grant money, which would be great news for those with lymphedema in southwest Florida.

Lymphedema Resources, Inc.

Claire Hauenstein, MBA, President, Lymphedema Resources, Inc.
Estero, FL
Email: lymphedemares.org
Web site: www.lymphedemaresources.org

Lymphedema Resources, Inc. (LRI) was founded in 2005 as a 501c3 tax exempt organization to serve patients with lymphedema and those who are at risk for developing the condition. The group currently serves southwest Florida’s local needs. We also receive an abundance of calls from all over the United States because we are listed as a resource in the American Cancer Society database and in the United Way 211 directory.

Our mission as a community-based volunteer organization is to raise awareness of the potential for development of lymphedema, to assure availability of the resources for treatment, and to eliminate barriers of care for those with lymphedema. We are completing our third year as a grantee of Susan G. Komen for the Cure Southwest Florida Affiliate. The grant program provides for bandaging and compression garments for those breast cancer survivors who are underinsured and underserved. Additionally, it covers the cost of developing, printing, and distributing of brochures and other promotional materials on the signs and risks of lymphedema. During last year’s grant period, we served 20 clients in southwest Florida. We publish eligibility guidelines each year based on an income level dependent upon the size of the family. At present, we use 150% of the poverty guideline as a starting point for service, but we will increase this to 200% starting April 1, 2008. Referrals come to LRI from certified lymphedema therapists, doctors’ offices, radiology groups, etc. We receive many requests for assistance with locating therapists. While we do not recommend specific healthcare professionals, we do maintain a current list of certified lymphedema therapists, which we provide upon request.

For fledgling groups such as ours, sources of revenue are of the utmost importance. We are constantly seeking grant opportunities both large and small. We recently received funds for an educational tool we have developed called the “Lymphedema Awareness Tote,” which will include information about lymphedema and local certified lymphedema therapists, skin care lotion, bandages, insect repellent, antibiotic cream, etc. These will be distributed to physicians’ offices, hospitals, physical therapy offices, and health fairs to reach as many cancer survivors as possible who are at risk for lymphedema. Another grant currently in process would allow LRI to translate, print, and distribute brochures to the Hispanic/Latino demographic of southwest Florida. Yet another would provide funds for a specially designed gentle exercise program for breast cancer survivors that would include educational material on lymphedema prevention. Our latest proposal to Susan G. Komen for the Cure would provide funds for the treatment of lymphedema and the provision of compression garments. This is a new area for us, and we are eager to receive approval because it would allow LRI to provide much more for clients who most need our help.

We are amazed at how far we’ve come since we started in 2005, but we realize that we’ve only touched the tip of the iceberg. We are grateful to have a dedicated Board of Directors, most of whom are healthcare professionals keenly interested in pursuing our mission. And, most of all, we are grateful that we have been able to help as many people as we have in only a few short years.

ONS Lymphedema Management (LYM) SIG Meeting Unapproved Minutes

DATE: Tuesday, April 24, 2007
PLACE: Las Vegas, NV, Mandalay Bay Convention Center, South Pacific C/D, Table 3
TIME: 5:20–6:30 pm (PT)
RECORDER: Mei R. Fu, PhD, RN, CNS

The meeting was called to order at 5:20 pm by Dr. Sheila Ridner, PhD, RN, ACNP. Introductions of each attendee were made. Three door prizes were planned. Founding coordinator Saskia Thiadens, RN, was in attendance. Four core members contacted Dr. Ridner and expressed their regrets for not being able to attend this year’s meeting. Joanne Ryan, MS, RN, a doctoral student from the College of Nursing at New York University, will join LYM SIG as a new member. Currently, there are 102 LYM SIG members.

The minutes were reviewed and approved from the 2006 planning meeting in Boston.

III. Nominating Committee – Cathy Glennon

Cathy Glennon, RN, CNA, BC, MHS, OCN^®, from the ONS Nominating Committee, visited the meeting. She encouraged succession in LYM SIG leadership and applications for national ONS leadership offices from previous LYM SIG leaders. Upon C. Glennon’s request for concerns, Dr. Ridner and S. Thiadens expressed the SIG’s continuous concern regarding the provision of accurate lymphedema information to nurses and the use of LYM SIG members as experts for reviewing lymphedema-related manuscripts for the Clinical Journal of Oncology Nursing (CJON) and the Oncology Nursing Forum (ONF).

The prizes went to S. Thiadens and two members from other SIGs sharing the room.

Open Leadership Position: Newsletter editor position is open. J. Ryan expressed her interest to be mentored as the successor to current editor, Ellen Poage, MSN, ARNP, MPH, CLT-LANA. E. Poage will mentor J. Ryan.

Mission and Strategic Plan: The LYM SIG mission and strategic plan were reviewed, and some editorial changes were made.  LYM SIG leadership training was added as a goal, specifically the identification and mentoring of potential LYM SIG leaders.  Dr. Ridner will submit the revision to SIG members and to ONS for approval.

Instructional Sessions: Plans for 2008 Congress instructional sessions were discussed. It was proposed that we will suggest a program at either an introductory or intermediate level regarding lymphedema risk reduction and management based on ONS education blue prints. Dr. Ridner will send a communiqué to all SIG members regarding detailed proposals for the instruction sessions.

Medicare Reimbursement: Medicare reimbursement for lymphedema treatment was discussed, and an email from Ilisa Halpern Paul, MPP, regarding the Medicare reimbursement bill was shared. Because the ONS Board takes a neutral position regarding the bill, it was suggested that the LYM SIG should encourage its members to contact ONS to encourage the ONS Board to support the bill.

ONS PEP Lymphedema Card: We feel that it is very important for the LYM SIG to be involved in the production of the ONS PEP lymphedema card to ensure accurate lymphedema information will be distributed to the nurses. Dr. Ridner, S. Thiadens, Dr. Jane Armer, PhD, RN, and Dr. Mei Fu, PhD, RN, CNS, will work with ONS regarding the PEP card.

Recruitment of SIG Members: Ways to recruit more SIG members were discussed. Ideas included advertising the LYM SIG through local ONS chapters to encourage local ONS members, as well as graduate and doctoral nursing students, to join.

The meeting was adjourned at 6:30 pm.

Attendees List for LYM SIG Meeting

SIG Members

Mei Fu, PhD, RN, CNS, mf67@nyu.edu
Sheila Ridner, PhD, RN, ACNP, Sheila.ridner@vanderbilt.edu
Saskia Thiadens, RN, saskiat@lymphnet.org

Non SIG Member

Cathy Glennon, RN, CNA, BC, MHS, OCN^®, Nominating Committee Chair

Lymphedema Management SIG Pre-Congress Communiqué

• Would you like a chance to win a copy of the new book Voices of Lymphedema?
• Would you like to know more about the work of Lymphedema Management SIG members on the new ONS PEP lymphedema card?
• Would you like to meet the new Co-Coordinator of our SIG?
• Could you give us ideas on how to make the virtual Web site something you would use on a regular basis?
• Would you take five minutes to tell us what you would like to learn about lymphedema at Congress or Institutes of Learning?

If you answered “yes” to any of these questions, we want YOU at our Congress SIG Planning Meeting. Please join us Saturday, May 17, 2008, 10:30 am–12 pm in room 300 of the Pennsylvania Convention Center.

New Institute of Medicine Report on Psychosocial Care for Patients with Cancer

The Institute of Medicine (IOM) convened a special committee to look at the delivery of psychosocial services to patients with cancer and their families and to identify ways to improve provision of care. The recently released results (November 2007) are published in Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs, which is available from www.nap.edu.

The findings state that many patients with cancer have psychosocial needs. Although the supply of services is insufficient to address all patient needs, untapped resources do exist, frequently at no additional cost. Patients, however, are often unaware of these resources. The committee proposed that all components of the healthcare system incorporate attention to patient psychosocial needs into their practice. This new standard of care recommends that all cancer care should ensure the provision of appropriate psychosocial services by

• Facilitating effective communication between patients and providers
• Identifying patients’ psychosocial health needs
• Designing and implementing a plan that
• Links the patient with appropriate psychosocial services
• Coordinates biomedical and psychosocial care
• Engages and supports patients in managing their illness and health
• Systematically following up on, reevaluating, and adjusting plans.

Welcome to our Newest Members!

Mary Buchanan, RN
Friendswood, TX
mrsbuckie@gmail.com

Brenda Chervenak, RN, OCN^®
Preston, WA

Lin Marie Scott, RN
Boise, ID

Liana Wheatley, RN, BA, OCN^®
Beaumont, TX
lianawheatley@sbcglobal.net

Articles of Interest
Lymphedema Management Members May Enjoy These Recently Published Articles

Check out the Oncology Nursing Forum (ONF) for interesting articles about lymphedema management.

• “Arm Morbidity and Disability After Breast Cancer: New Directions for Care,” by Roanne L. Thomas-MacLean, PhD, Thomas Hack, PhD, Winkle Kwan, MD, Anna Towers, MD, Baukje Miedema, PhD, and Andrea Tilley, BScPT (Vol. 35, 65–71).
• “Self-Reported Comorbid Conditions and Medication Usage in Breast Cancer Survivors With and Without Lymphedema,” by Sheila H. Ridner, PhD, RN, and Mary S. Dietrich, PhD, (Vol. 35, 57–63).

For access to the full-text versions of these and other ONF and CJON articles, visit the Publications area of the ONS Web site.

The Clinical Journal of Oncology Nursing (CJON) is looking for reviewers. For more information, click here.

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ONS Membership/Leadership Team Contact Information

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