CANA Global CONNECT Vol. 1, Issue 3 – Research Highlights

The-Optimal-Lymph-Flow ™: Digital Therapy for Chronic Pain and  Lymphedema Symptoms Following Breast Cancer Treatment


Mei R. Fu, PhD, RN, FAAN

Tenured Associate Professor

Rory Meyers College of Nursing, New York University


Even with modern medical advances, chronic pain and lymphedema (i.e. the accumulation of lymph fluid in the affected upper limb or body) remain a major health problem affecting thousands of breast cancer survivors [1-2]. Currently, no current surgical or medical interventions can provide a cure for chronic pain and lymphedema [1]. More than 50% of women report chronic pain and multiple distressing symptoms related to fluid accumulation (hereafter, lymphedema symptoms) even years after cancer treatment. The abnormal accumulation of lymph fluid or lymphedema after breast cancer treatment is a result of obstruction or disruption of the lymphatic system associated with cancer treatment (e.g., removal of lymph nodes and/or radiotherapy), influenced by patient personal factors (e.g., obesity or higher body mass index), triggered by factors such as infections or trauma, or genomic predispositions [3-6].

Chronic pain and lymphedema symptoms following breast cancer treatment remain main debilitating late complications that impact the breast cancer survivors’ quality of life as well as create a tremendous burden on the health care system [1, 7]. Persistent pain and distressing symptoms related to fluid accumulation are considered stressful complications since it is perceived as a constant reminder of cancer and exert tremendous limitations on breast cancer survivors’ daily living. Chronic pain and distressing symptoms related to lymphedema can instigate fears and induce feelings of loss of control. Nonetheless, in clinical practice managing chronic pain and lymphedema symptoms are still under-recognized and undertreated [1,7].

 A technologically-driven delivery model for health care is the ultimate goal to provide universal access to health care. Digital therapy uses behavioral and lifestyle changes to treat or manage health conditions, such as treating chronic pain or symptoms or optimizing management of chronic illness by utilizing web-and-mobile-based digital technology to deliver treatment and monitor progress. The-Optimal-Lymph-Flow (TOL) [8-12] is part of the continuum of more than a decade ongoing program of research on lymphedema symptom science led by Dr. Mei R. Fu, Dr. Deborah Axelrod, Dr. Amber Guth and Dr. Yao Wang at New York University to advance the science on symptom management among breast cancer survivors and serves as a focal platform to garner the talents from across disciplines at New York University (NYU). This collaboration involves the NYU Rory Meyers College of Nursing, NYU Cancer Center, NYU School of Medicine (surgery, population health, pathology, and biostatistics), NYU Rusk rehabilitation, NYU Polytechnic School of Engineering, and NYU Asian Center (CSAAH).

Low cost and pragmatic behavioral strategies for pain and symptom management may hold great promise for improving patients’ quality of life. Grounded in research-driven behavioral strategies, The-Optimal-Lymph-Flow is a multi-language (English, Spanish and Chinese), patient-centered behavioral therapy focusing on behavioral strategies to lessen the symptom burden by promoting lymph flow and minimize inflammation. TOL digital therapy includes information about chronic pain, lymphedema, diagnosis and measurement of lymphedema, lymphatic system, risk of lymphedema, risk reduction for optimal lymph flow, self-care. Based on the findings of clinical trials using TOL system, patients love the web-and-mobile-based digital therapy, especially the avatar technology that demonstrates the complicated lymphatic system and illustrates the physiological functions of each therapy and detailed step-by-step instructions for each therapy. Patients can access to TOL digital therapy using computer, iPhone, iPad, or other smart phones [8-10]. Currently, we just completed a Randomized Clinical Trial (RCT) [11] supported by Pfizer Individual Learning and Change Grant on digital therapy for chronic pain and lymphedema symptoms. Findings from this trial have demonstrated that over 80% of patients improved their chronic pain and lymphedema symptoms. In China, a RCT is undergoing to test the effectiveness of Chinese Version of TOL digital therapy. A usability study supported by New York University Provost Grant is conducted to evaluate the Spanish version of TOL Digital Therapy in the United States. Our current research supported by National Institute uses machine learning and technology to provide precision digital therapy, precision detection of lymphedema and precision progress monitoring.

Dr. Fu and her team are conducting a R01 technology innovation research award from National Cancer Institute as part of the NSF/NIH (1R01CA214085-01) joint program on Smart and Connected Health. This project will develop precision assessment of lymphedema risk from patient self-reported symptoms through machine learning, as well as develop a Kinect-enhanced intervention training system, which can track patients’ movements and provide instant audio-visual feedback to the patient. This feedback will enable the patient to follow the prescribed movement more accurately, thereby making self-care intervention more effective. The innovation of precision risk prediction and precision delivery of digital therapy will be hosted in The-Optimal-Lymph-FlowTM mHealth system.  This project has the potential to enhance lymphedema risk assessment and risk reduction for patients worldwide to achieve automated precision symptom assessment, detection and prediction of lymphedema based on lymphedema symptom evaluation, as well as precision delivery of digital treatment. 


  1. Fu, M.R., Deng, J., Armer, J. (2014). Cancer-Related Lymphedema: Evolving Evidence for Treatment and Management from 2009 to 2014. Clinical Journal of Oncology Nursing, 18 (Supplement), 68-79. DOI: 1188/14.CJON.S3.68-79. PMID: 25427610.Fu, M.R., Ridner S., Hu, S.H., Steward, B., Cormier, J.N., & Armer, J.M., (2013). Psychosocial Impact of Lymphedema: A systematic review of literature from 2004 to 2011. Psycho-Oncology, 22(7) 1466-84. DOI: 10.1002/pon.3201. Epub 2012 Oct 9. PMID: 23044512
  2. Fu, R.M. (2014). Breast cancer-related lymphedema: Symptoms, diagnosis, risk reduction, and management. World Journal of Clinical Oncology, 10;5(3):241-7. doi: 10.5306/wjco.v5.i3.241. PMID: 25114841
  3. Fu, M.R., Axelrod, D., Cleland, C.M., Guth, A.A., Qiu, Z., Kleinman, R., Scagliola, J., & Haber, J., (2015). Symptom reporting in detecting breast cancer-related lymphedema. Breast Cancer: Targets and Therapy, 7; 345-352 (#1825502). DOI: http://dx.doi.prg/10.2147/BCTT.S87854 . PMID: 26527899
  4. Fu, M.R., Axelrod, D., Guth, A., Fletcher, J., Qiu, J.M., Scagliola, J., Kleinman, R., Ryan, C. E., Nicholas, C., Haber, J. (2015). Patterns of obesity and lymph fluid level during the first year of breast cancer treatment: A prospective study. Journal of Personalized Medicine, 5(3):326-40. PMID: 26404383 DOI: 10.3390/jpm5030326
  5. Fu, M.R., Axelrod, D., Guth, A., Cleland, C.M., Ryan, C. E., Weaver, K.R., Qiu, J.M., Kleinman, R., , Scagliola, J., Palamar, J.J., Melkus, G. (2015). Comorbidities and Quality of Life among Breast Cancer Survivors: A Prospective Study. Journal of Personalized Medicine, 5(3):229-42. doi: 10.3390/jpm5030229.
  6. Fu, M.R., Conley, Y.P., Axelrod, D., Amber, G.A., Yu, G., Fletcher, J., Zagzag, D. (2016). Precision assessment of heterogeneity of lymphedema phenotype, genotypes and risk prediction. The Breast. DOI: PMID: 27460425
  7. Fu, M.R., Ridner S., Hu, S.H., Steward, B., Cormier, J.N., & Armer, J.M., (2013). Psychosocial Impact of Lymphedema: A systematic review of literature from 2004 to 2011. Psycho-Oncology, 22(7) 1466-84. DOI: 10.1002/pon.3201. Epub 2012 Oct 9. PMID: 23044512
  8. Fu, M.R., Axelrod, D., Guth, A., Cartwright- Alcarese, F., Qiu, Z., Goldberg, J., Kim, J., Scagliola, J., Kleinman, R., Haber, J., & (2014). Proactive approach to lymphedema risk reduction: a prospective study. Annals of Surgical Oncology, 21(11), 3481-3498. Online First. DOI: 10.1245/s10434-014-3761-z
  9. Fu, M.R., Axelrod, D., Guth, A.A., Wang, Y., Scagliola, J., Hiotis, K., Rampertaap, K., El-Shammaa, N. (2016). Usability and Feasibility of Health IT Interventions to Enhance Self-Care for Lymphedema Symptom Management in Breast Cancer Survivors. Internet Interventions 5, 56-64. DOI:
  10. Fu, M.R., Axelrod, D., Guth, A.A., Rampertaap, K., El-Shammaa, N., Hiotis, K., Scagliola, J., Yu, G., Wang, Y. (2016) mHealth self-care interventions: managing symptoms following breast cancer treatment. mHealth 2016; 2:28. DOI: 10.21037/mhealth.2016.07.03. PMID: 27493951
  11. Fu, M.R., Axelrod, D., Guth, A., Scagliola, J., Rampertaap, K., El-Shammaa, N., Fletcher, J., Zhang, Y., Qiu, J.M., Schnabel, F., Hiotis, K., Wang, Y., D’Eramo Melkus, G. (2016). A Web- and Mobile-Based Intervention for Women Treated for Breast Cancer to Manage Chronic Pain and Symptoms Related to Lymphedema: Randomized Clinical Trial Rationale and Protocol. JMIR Research Protocol 2016;5(1):e7 URL: doi:10.2196/resprot.5104
  12. Fu, M.R., Deng, J., Armer, J.M., Lockwood, S., Beck, M., Ostby, P., Burns, B., Poage, E. (2016). Precision health and precision phenotype assessment of breast cancer-related lymphedema. ADVANCE for Nurses, 2(9): 14-16. [This article has been selected as the Continuing Education offering for this issue.]



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