Kathryn Ryans

Diagnosis of Upper Quadrant Lymphedema Secondary to Cancer: Clinical Practice Guideline From the Oncology Section of the American Physical Therapy Association

Abstract The Oncology Section of the American Physical Therapy Association (APTA) developed a clinical practice guideline to aid the clinician in diagnosing secondary upper quadrant cancer-related lymphedema. Following a systematic review of published studies and a structured appraisal process, recommendations were written to guide the physical therapist and other health care clinicians in the diagnostic process. Overall clinical practice recommendations were formulated based on the evidence for each diagnostic method and were assigned a grade based on the strength of the evidence for different patient presentations and clinical utility. In an effort to maximize clinical applicability, recommendations were based on the characteristics as to the location and stage of a patients upper quadrant lymphedema.

BREAST CANCER EDGE TASK FORCE OUTCOMES: Assessment Measures of Secondary Lymphedema in Breast Cancer Survivors

Background: The Breast Cancer EDGE Task Force reviewed the published evidence on assessment techniques to clinically measure breast cancer related lymphedema (BCRL). In order to identify lymphedema in a timely manner and to objectively document response to interventions, physical therapists need valid and reliable assessment tools. To date, there are several assessment tools used by physical therapists; however, the advantages and disadvantages of each tool and which tool(s) is most appropriate is not well known. Breast cancer related lymphedema assessment tools include: circumferential measurement (CM), water displacement, bioelectrical impedance spectroscopy (BIS), perometry, tonometry, and self‐report tools. Purpose: The purpose was to identify specific assessment techniques or tools that could be recommended for use in clinical practice to measure upper extremity secondary lymphedema in breast cancer survivors (BCS). Methods: A systematic literature review was used to appraise the evidence supporting the psychometric properties and clinical utility of assessment techniques in BCS with secondary lymphedema in the upper extremity. Results: Circumferential measurement, water displacement, and BIS received a recommendation of 4 (highly recommended), due to good reliability, validity, and clinical utility. Tonometry, perometry, the Lymphedema Breast Cancer Questionnaire (LBCQ) self‐report tool and the Visual Analog Scale, received a recommendation of 2A, unable to recommend at this time due to limited evidence available and/or clinical utility. Conclusion: Breast Cancer EDGE Task Force recommends CM, water displacement, and BIS as routine physical therapy assessment tools for early detection of BCRL and/or to document response to interventions. Perometry is not recommended at this time due to poor clinical utility. Further research is needed to determine psychometric properties for tonometry, the LBCQ, and the Visual Analog Scale. Research is also needed to standardize the diagnostic criteria for each assessment tool to detect early onset of BCRL.

Oncology Section Task Force on Breast Cancer Outcomes: Clinical Measures of Chemotherapy-induced Peripheral Neuropathy—A Systematic Review

Background: Chemotherapy‐induced peripheral neuropathy (CIPN) is a common adverse effect of breast cancer treatment that can limit cancer intervention options, and also impact balance, mobility, and quality of life long after chemotherapy ends. The purpose of this systematic review was to provide physical therapists (PT) with evidence‐based recommendations on tools for clinical assessment of CIPN in adult breast cancer survivors. Methods: A team of reviewers identified all published measures of CIPN meeting the criteria of: clinically feasible, addressing the CIPN experience (signs/symptoms/or both), and with published psychometric properties established in survivors of breast cancer, or a cancer for which the same chemotherapy agents are used. Identified measures were then systematically reviewed and scored according to the Breast Cancer EDGE Task Force Rating Scale from 1 (Do Not Recommend) to 4 (Highly Recommend). Results: Of 11 measures meeting the review criteria, only one, the Functional Assessment of Cancer Therapy/ Gynecologic Oncology Group‐Neurotoxicity Scale (FACT/GOG‐Ntx) received the highest rating of 4 (highly recommend). The FACT‐GOG‐Ntx has high clinical utility for PT, well‐established psychometric properties, and published validation with chemotherapies used in breast cancer survivors. The 10 remaining measures received ratings of 2 (unable to recommend at this time). Conclusions: The Oncology Section Breast Cancer EDGE Task Force on Clinical Measures of CIPN recommends the FACT/GOG‐Ntx during physical therapy screening or assessment of CIPN in breast cancer survivors who have received neurotoxic chemotherapy; however, it is not recommended for use in isolation. Therapists are encouraged to supplement with further tests and measures to capture sensory, motor, and autonomic deficits specific to each survivor, along with related activity and participation restrictions.

BREAST CANCER EDGE TASK FORCE OUTCOMES: Quality of Life and Functional Outcome Measures for Secondary Lymphedema in Breast Cancer Survivors

Background: Breast cancer survivors who develop lymphedema report a wide range of upper extremity impairments and functional limitations. The reported impairments can lead to difficulty with activities of daily living and a reduction in quality of life. It is important for physical therapists to assess and measure these functional deficits and their effect on quality of life using a reliable outcome measure. Purpose: The purpose of the Breast Cancer EDGE Task Force subgroup review was to identify specific outcome measurement tools that could be recommended to measure quality of life and functional deficits in patients with breast cancer related lymphedema (BCRL). Methods: A systematic literature review was used to appraise the evidence supporting the psychometric properties and clinical utility of outcome measures assessing quality of life and function in patients with BCRL. Results: The Functional Assessment of Cancer Therapy ‐ Breast (FACT‐B+4) and Disability of Arm, Shoulder and Hand (DASH) questionnaires received a recommendation of 4, highly recommended for use in patients with BCRL due to their psychometric properties and clinical utility. Three other outcome measures were reviewed. The Lymphoedema Functioning, Disability and Health Questionnaire (Lymph ‐ICF) and the Upper Limb Lymphedema Measure (ULL‐27) received a recommendation of 2A, unable to recommend at this time. The Lymphedema Quality of Life Measure for Limb (LYMQOL) received a 1, not recommended. Conclusion: The Breast Cancer EDGE Task Force recommends the FACT‐B+4 and DASH questionnaires to assess the quality of life and function in patients with BCRL. The Lymph‐ICF and ULL‐27 and LYMQOL tools cannot be recommended at this time. Further research is recommended to determine reliability, validity, and clinical utility of these outcome measures. Other shoulder functional outcome measures that are validated in other patient populations needs to be investigated to determine if application to the BCRL population is appropriate.