Elizabeth Ann Loika, Linda H. Yoder, and Rebecca Richardson, The Journal for Nurse Practitioners 2018

Main findings

• The goal of this project was to determine the protocols primary care providers used in their practice settings to determine the development of BCRL.
• The needs assessment questionnaire was sent to 20 providers who were surveyed about their assessment of BCRL development. The assessment results revealed that 100% of the providers failed to assess symptom levels, functional abilities, and changes in QoL among breast cancer survivors.
• The providers indicated that they did not assess patients’ arm measurements, and no follow-up recommendations were being recorded in patients’ medical records.
• No consistent BCRL patient education was addressed during patient encounters. Symptom information and objective findings such as measurements for potentially existing disease were not discussed, and a standardized BCRL protocol for early detection was not used.
• An algorithm was produced that can guide the primary care provider. This included an early assessment symptoms questionnaire, BIS measurements if available, circumferential measurements as per a protocol and a skin assessment.
• A BCRL diagnosis will depend on the results of the initial response to questions that elicit symptoms of disease development. The diagnosis of BCRL generally includes > 1 accompanied symptom or physical change; however, a positive finding for 1 separate category can support referral. A thorough history and baseline measurements are crucial to the clinical assessment of the early onset of BCRL. Skin problems are commonly experienced by BCRL patients, and infections are frequently a consequence of chronic inflammatory disease progression. Therefore, it is prudent to include skin assessments, both subjective and objective.
• The protocol also includes anatomic diagrams to annotate specific symptom locations based on the answers to the questions in the assessment.
• Six symptom domains are assessed: pain, numbness/heaviness, infection, oedema, functionality, and range of movement. The patient is asked to rate the degree of impairment in each domain on a 6-point scale, where 0 indicates no impairment and 5 indicates severe impairment.
• Questions about early symptoms of BCRL include the following:
  • Location and degree of pain.
  • A feeling of numbness or heaviness in hands, wrists, arms, underarms, breast, back, or upper extremities.
  • Development of infections in hands, wrists, or upper extremities since breast cancer treatment.
  • Swelling hands, wrists, arms, underarms, breast, back, or upper extremities.
  • Functionality is evidenced by upper torso mobility difficulties, increased motion restrictions, activity restrictions or avoidance, difficulty lifting/pushing heavy objects, and arm-stretching limitations.
  • Difficulty completing household chores, preparing meals, combining hair, and/or dressing
• The BCRL protocol contains consolidated evidence and systematically guides health professionals to arrive at an early BCRL diagnosis and make the appropriate referral for further specialty intervention, as available. Using this protocol, BCRL assessment can be documented at the time of initial presentation and followed closely for changes with proactive attempts for appropriate referral.