Mary Vargo

Purpose of review: An expanding array of diagnostic techniques for lymphedema detection and monitoring constitutes a growing aspect of lymphedema care. This discipline includes both the development and the clinical integration of methods to optimize and tailor clinical care for individuals affected by (or at risk for) lymphedema. A case-based approach highlights the practical application of these diagnostic modalities. Recent findings: A recent critical review synthesized the evidence base for a range of techniques used to diagnose, characterize and quantify lymphedema, including current and emergent methods. Available modalities include traditional methods, such as clinical examination and circumferential tape measurement, as well as recently developed digitally-based techniques. Their availability ranges widely from ubiquitous office-based approaches to advanced imaging tools. Evaluation of assessment approaches should emphasize their capacity to enhance clinical practice by advancing the core aims of lymphedema evaluation: screening, diagnosis, individualizing management, and monitoring treatment response. Summary: The use of cases illustrates how lymphedema assessment modalities are being integrated into clinical care, including their strengths and limitations, while highlighting the necessity of a person-centered approach, for each of the aims noted above.

Introduction: Individuals with lung cancer frequently experience functional limitations, yet best practice to achieve functional recovery has not been synthesized. This Clinical Practice Guideline generates evidence‐based recommendations to improve functional outcomes in this population. Methods: A multispecialty expert workgroup completed a systematic review of the literature from 2010 to 2021 examining interventions for improving patient function at any stage or phase of disease. National Institutes of Health Quality Assessment standards were employed for bias assessment. Recommendations were generated per GRADE methodology, for mobility, physical activity, general function, and social function outcomes, during phases of prehabilitation, surgical post‐operative acute (hospitalization), during‐or‐immediate post‐treatment (first year), and survivorship. Results: Fifty‐four studies were included. Combined exercise approaches should be used to improve mobility during the Prehabilitation and the During and Immediate Post‐Treatment phases. For physical activity, combined interventions may be beneficial during the Surgical Post‐Operative Acute phase, and multimodal interventions with exercise and education may improve function in the During and Immediate Post‐Treatment phase. Combined exercise may improve general function in the During and Immediate Post‐Treatment phase. Conclusion: Current evidence emphasizes mobility outcomes, in prehabilitation and early post‐treatment phases, with moderate level benefits of combined aerobic with resistance and/or breathing exercise. Further study is needed into sustainability of performing the interventions and durability of outcomes; increased breadth of interventions and functional outcome domains examined; and exploration of specific contexts including advanced disease, survivorship, high medical complexity and frailty, and caregiver‐related factors. These recommendations are applicable for clinicians including oncologists, rehabilitation specialists, surgeons, primary and pulmonary care providers, nurses, and other supportive care personnel.

Lymphedema evaluation entails multifaceted considerations for which options continue to evolve and emerge. This paper provides a critical review of the current status of diagnostic and quantitative measures for lymphedema, from traditional and novel bedside assessment tools for volumetric and fluid assessment, to advanced imaging modalities. Modalities are contrasted with regard to empirical support and feasibility of clinical implementation. The manuscript proposes a grid framework for comparing the ability of each modality to quantify specific lymphedema characteristics, including distribution, dysmorphism, tissue composition and fluid content, lymphatic anatomy and function, metaplasia, clinical symptoms, and quality of life and function. This review additionally applies a similar framework approach to consider how well assessment tools support important clinical needs, including: (1) screening, (2) diagnosis and differential diagnosis, (3) individualization of treatment, and (4) monitoring treatment response. The framework highlights which clinical needs are served by an abundance of assessment tools and identifies others that have problematically few. The framework clarifies which tools have greater or lesser empirical support. The framework is designed to assist stakeholders in selecting appropriate diagnostic and surveillance modalities, gauging levels of confidence when applying tools to specific clinical needs, elucidating overarching patterns of diagnostic and quantitative strengths and weaknesses, and informing future investigation.

Objective: To examine the impact of telemedicine on demographic and practice patterns between outpatients receiving virtual versus in‐person cancer rehabilitation physiatry care.Design: Multicenter retrospective study.Setting: Outpatient cancer rehabilitation physiatry clinics at four academic medical centers in the United States.Patients: Patients with cancer diagnoses or history of cancer diagnosis.Interventions: Cancer rehabilitation physiatry encounters.Main Outcome Measures: Visit mode (in‐person, telemedicine); disparities variables (age, race, and gender) by visit mode, and practice interventions (imaging, medications, procedures, other orders, and orders of any type) by visit mode.Results: Among a total of 7004 encounters, 2687 unique patients were found. In‐person participants were significantly older than the average telemedicine participant (mean 62.9 vs. 60.7 years; p < .001). A race effect was seen (p = .037) with individuals reporting as Asian or other being more likely to have telemedicine encounters. No gender disparities were seen. Using a random visit analysis model to compare populations receiving in‐person versus telemedicine care, a slight majority (53%) of follow‐up visits were via telemedicine, versus 40% of new patient visits (p < .001). No significant differences were seen in medication prescribing frequency (38.9% telemedicine vs. 36.7% in‐person, adjusted relative risk [RR]: 0.988, confidence interval [CI]: 0.73–1.34; p = .988) or imaging frequency (2.4% telemedicine vs. 7.6%; adjusted RR: 0.784, CI: 0.44–1.39; p = .408) between telemedicine versus in‐person visit types. Other orders were significantly less likely to be placed during telemedicine than in‐person visits (19.9% telemedicine vs. 28.6% in‐person; adjusted RR: 0.623, CI: 0.45–0.86, p = .004). Order(s) of any type were placed in 54% of visits (52% telemedicine vs. 56% in‐person; adjusted RR: 0.92 for telemedicine, CI: 0.83–1.01, p = .082).Conclusions: Telemedicine has been integrated into cancer rehabilitation physiatry practices and appears to be conducive for placing many types of orders, especially medications. Age was found to be the only major demographic difference between in‐person and telehealth patients.

Purpose of Review The current panorama of measurement tools for use in cancer rehabilitation is reviewed. For rehabilitation purposes, evaluating function is of the highest priority. Recent Findings From a patient-reported outcome (PRO) standpoint, SF-36 and EORTC-QLQ-C30 are in most common use in cancer rehabilitation research; these are quality of life measures that contain functional subdomains. Newer tools which are based on item response theory and have options for both computer assisted or short form (SF) administration, including the Patient-Reported Outcomes Measurement Information System (PROMIS) and Activity Measure for Post-acute Care (AMPAC) instruments, show increasing use, especially PROMIS Physical Function SF, and, recently, PROMIS Cancer Function Brief 3D, which has been validated in the cancer population, with domains of physical function, fatigue, and social participation, to track clinical rehabilitation outcomes. Evaluating objective measures of function in cancer patients is also crucial. Summary Utilization of clinically feasible tools for cancer rehabilitation, to employ for both screening purposes and for monitoring of rehabilitation treatment efficacy, is an evolving area, much needed to promote further research and improved, consistent clinical care for cancer patients and survivors.