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The number of cancer survivors is increasing globally due to better surveillance, treatment, and access to care. As such, more people are living with functional sequela of cancer and cancer treatment. The field of cancer rehabilitation has grown in an effort to meet this need. Specific functional measures are necessary to advance both research and clinical applications of cancer rehabilitation. Commonly used functional measures in cancer rehabilitation are introduced here.

Clinician-Reported Measures

The performance status (PS), or physical function, of an oncology patient commonly factors into cancer treatment decision making, clinical trial eligibility, and prognosis. The Eastern Cooperative Oncology Group Performance status (ECOG), a condensed version of the Karnofsky Performance Status (KPS), is the most commonly used PS scale.  High-functioning PS (ECOG PS 0-1 and KPS 80-100), the typical clinical trial inclusion criteria, is correlated with better survival compared with low-functioning PS (ECOG 2-4, KPS ≤70).1 Limitations of these scales include their sole emphasis on physical function, poor sensitivity for rehabilitation surveillance, poor reliability and validity, and limited use for toxicity risk stratification.

  • ECOG
    • 0 – Fully active, able to carry on all pre-disease performance without restriction.
    • 1 – Restricted in physically strenuous activity, but ambulatory and able to carry out work of a light and sedentary nature (e.g., light housework, office work)
    • 2 – Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of working hours.
    • 3 – Capable of only limited self-care, confined to bed or chair more than 50% of working hours.
    • 4 – Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair OK
    • 5 – Dead
  • KPS is an 11-point scale with KPS 100 indicating normal, no complaints, no evidence of disease, and able to carry on with his/her normal work or activity. KPS 40 (disabled, requires special care and assistance) to 70 (cares for self, unable to carry on normative activity or do active work) are thresholds where physiatry may show the most improvement on this scale. Patients with KPS scores bordering this range may also benefit from physiatric care, although improvement in KPS score due to physiatric care may be harder to show.
  • The Palliative Performance Scale (PPS) estimates median survival in days in patients with advanced cancer.  Five domains (ambulation, activity level and evidence of disease, self-care, intake, level of consciousness) are rated similarly to the KPS. The PPS has strong reliability and validity in outpatient cancer patients, although comprehensive validation studies on a larger scale are still required.2
  • The Common Terminology Criteria for Adverse Events developed by the US National Cancer Institute facilitates the reporting of adverse events from cancer treatments. Adverse events are graded from 1 to 5, with 1 indicating mild symptoms and 5 indicating an adverse event leading to death. For most of the musculoskeletal and neurological adverse effects, grade 2 indicates limitation of instrumental activity of daily living (IADL) and grade 3 indicates limitation of activity of daily living (ADL).3
  • The Functional Independence Measure (FIM) is widely used throughout the rehabilitation care spectrum including in inpatient cancer rehabilitation. Further details are described in Outcome Measurement in Rehabilitation. Studies have shown FIM improvement after inpatient rehabilitation of patients of all cancer subgroups including patients with metastatic disease, receiving radiation treatment, and with asthenia.4
  • The Katz Index of Independence with ADL is used in the general rehabilitation population and in the adult cancer population. Patients are given 1 point for each ADL that is independent with a maximum score of 6 indicating complete ADL independence. A score of 2 or less indicates severe functional disability.5
  • The Lawton IADL is used in the general rehabilitation population and in the adult cancer population. It is used widely in both clinical practice and research, in the hospital and in the community setting, and to assess baseline function and changes in function. It has good validity, reliability, and inter-rater reliability. Based on interview or questionnaire, 1 point is given for each of 8 IADLs that are independent. A maximum score of 8 indicates independence with IADLs.6 

Patient Reported Outcome Measures

Patient-reported outcome measures (PROMs) may serve as screening, monitoring, or outcome tools, with options ranging from generic to condition- or population-specific assessments. The advantage of PROMs is that they can assess subjective symptoms (e.g., presence and severity of fatigue or anxiety).

  • The European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC-QLQ-C30) is a 30-item questionnaire which includes scores that encompass global health status, functional scales (physical, role, emotional, cognitive, and social), and multiple symptom scales. EORTC-QLQ-C30 is valid and reliable in patients with breast, lung, or prostate cancers, and in patients treated with palliative radiotherapy. Derivatives of EORTC-QLQ-C30 have been created and validated for patients with head and neck cancers (EORTC QLQ-H&N35), breast cancer (EORTC QLQ-BR23), and palliative cancer patients (EORTC QLQ-C15-PAL).7
  • The Short Form Health Survey Questionnaire (SF-36) is a 36-item questionnaire that includes domains of physical functioning, physical role limitations, bodily pain, general health perceptions, energy/vitality, social functioning, and emotional role limitations. It is valid and reliable in brain tumor patients, breast cancer survivors, and long-term survivors of childhood cancer.8
  • Patient-Reported Outcomes Measurement Information System (PROMIS) is a comprehensive suite of measurement tools originating from the NIH Roadmap initiative. PROMIS instruments assess various aspects of physical, mental, and social health in both adults and children. Various derivative PROMIS instruments have been developed based on the full PROMIS set. Distinctively, the PROMIS Physical Function short form is a 10-item questionnaire strongly correlating with the full PROMIS physical function item bank and the SF-36 physical function scale.9 It has shown consistent performance in validity, reliability, and responsiveness across diverse demographics, including cancer patients.
  • Functional Assessment of Cancer Therapy (FACT) scales encompass a range of instruments, spanning from general to cancer-specific and symptom-focused tools. For example, FACT-General is a 27-item questionnaire designed to assess physical, social, emotional, and functional well-being. This sensitive scale can differentiate between cancer stage, performance status, and hospitalization status. Subsequently, the abridged FACT-G7 was developed and validated, concentrating on top-rated symptoms like fatigue and the ability to enjoy life. Additional FACT measures include but are not limited to FACT-Brain, FACT-Anemia, FACT-Breast, and FACT-Hepatobiliary.10
  • The Functional Assessment of Chronic Illness Therapy – Fatigue Scale is a 13-item questionnaire designed to evaluate the functional impact of fatigue, which is highly prevalent in the cancer population.10 This valid and reliable measure has been employed in research studies including cancer patients undergoing chemotherapy, long-term cancer survivors, childhood cancer survivors, and various other cancer and non-cancer populations.
  • The Activity Measure for Post-Acute Care (AMPAC) is widely used in the general rehabilitation and the cancer rehabilitation population. It is comprised of three primary domains: Basic Mobility, Daily Activity, and Applied Cognitive. Among its derivatives, the “AMPAC 6 Clicks” Inpatient Short Forms with six questions evaluate activity limitations in the post-acute care settings that correlates with discharge destination and risk of 30-day hospital readmission.11
  • Edmonton Symptom Assessment Scale (ESAS) assesses symptom burden in patients with advanced cancer. ESAS has been adopted worldwide to guide daily interdisciplinary clinical care, patient referral to higher complexity programs, and to monitor quality of care. It is an 11-point numeric rating scale for pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, well‐being, shortness of breath, and sleep. ESAS has been validated by multiple research groups and is a good discriminator for symptom changes with the minimal clinically important difference being a change of 1 point in either direction.12

Objective Measures of Physical Function

Comprehensive testing batteries offer a more holistic view of objective physical function than their individual components. The Short Physical Performance Battery (SPPB) has been used in various rehabilitation populations and cancer populations. SPPB is comprised of static standing balance, gait speed, and five times sit-to-stand (5STS). The Cancer Functional Assessment Set consists of 24 objective measures with broad generalizability in multiple cancer rehabilitation populations and demonstrated more responsiveness to changes than other tools.13 It includes evaluations of sitting, standing, transferring, walking, stair climbing, grip strength, overall strength, balance, shoulder and ankle range of motion, and sensory function.

Exercise capacity is commonly evaluated by outcome measures determined by provider preference, available resources, and a patient’s fitness level.

  • Cardiopulmonary exercise testing (CPET) is the gold standard and most comprehensive functional capacity exercise test evaluating cardiopulmonary disease severity and rehabilitation exercise intensity. Indications include evaluating exercise intolerance, dyspnea, restrictive lung disease, and preoperative evaluation prior to lung cancer resection surgery or transplantation surgery of the heart or lung. Contraindications to CPET are extensive and includes acute myocardial infarction, unstable angina, syncope, uncontrolled heart failure and uncontrolled asthma.14 
  • Six-minute walk test (6MWT) tests submaximal aerobic endurance. The 6MWT is valid in multiple cancer populations. It has been shown to correlate with peak oxygen uptake on CPET and patient-reported physical function.15 In breast cancer patients, 6MWT has been used to monitor cardiorespiratory fitness and can be used as a component of overall health in women with breast cancer.16
  • Two minute step test (2MST) is an adaptive functional fitness test that estimates aerobic capacity and is commonly used in geriatric and cancer populations to predict physical independence.17 It can be a practical choice relative to 6MWT for patients with limited mobility or balance and when there is limited space.

Functional mobility, balance, and walking ability are commonly evaluated in adult cancer survivors by the measures below. The most appropriate test is determined by provider preference, available resources, and time availability.

  • Gait speed is easily performed, takes less than five minutes, and can be performed with minimal space and equipment. Gait speed has been used to assess sarcopenia and cachexia and may prognosticate survival in patients with hematologic malignancies.18
  • Timed Up and Go (TUG) takes less than three minutes with minimal space. It requires a free-standing chair with armrests, a standardized seat height, and a 3-meter path. TUG is associated with 5-year mortality in older adults who underwent surgery for solid tumors.19
  • The Fullerton Advanced Balance scale is a 10-item test that takes about 12 minutes. The items assess standing balance with feet together and eyes closed, reaching forward to retrieve objects, turning left and right, stepping onto and over a 6-inch bench, tandem walking, standing on one leg, standing on foam with eyes closed, two-footed jump, walking with head turns, and reactive postural control. This measure has been endorsed by the Academy of Oncologic Physical Therapy of the American Physical Therapy Association as a recommended outcome measure for cancer patients.20
  • The Balance Systems Evaluation Test is a 36-item comprehensive test of balance that takes up to 30 minutes. It assesses postural control in six contexts including biomechanical constraints, stability limits, anticipatory postural adjustments, postural responses, sensory orientation, and gait stability.11
  • Sit to stand tests evaluate functional lower extremity strength and sit to stand transfer ability. Both 5STS and 30 Second Sit to Stand test (30STS) only require a chair of standardized height. Although 5STS is primarily a measure of leg strength, it has been recommended as an optional balance measure in adult cancer survivors. The 30STS better evaluates endurance than 5STS, which could be more feasible for routine use in physiatry clinic than the 6MWT.11 When comparing the 5STS to 30STS, 5STS is usually more time-efficient and better-tolerated by patients.

Special Topics

Cancer-related cognitive decline, especially related to chemotherapy or radiation, is common among various cancer populations. Common cognitive measures in cancer rehabilitation include the Montreal Cognitive Assessment Test, mini-mental state examination, Mini-Cog, Blessed Orientation Memory Concentration, and the clock-drawing test.11 The Fast Cognitive Evaluation has recently been created as a rapid, reliable, and sensitive tool for detecting minimal cognitive changes over time in cancer survivors.21 Patient-reported outcome measures for cognitive function include PROMIS Cognition short forms, FACT-Cog, NeuroQOL, and the Perceived Cognition Questionnaire. Currently, there is no universally accepted, standardized set of cognitive assessment measures for evaluating cancer-related cognitive changes.

Chemotherapy-induced peripheral neuropathy is a prevalent and potentially disabling side effect of cancer treatment, yet there is no consensus regarding its assessment or routine clinical surveillance. PROMs with the most supporting evidence for research use are the EORTC-QLQ-Chemotherapy-Induced Peripheral Neuropathy Questionnaire and FACT-Gynecologic Oncology Group-Neurotoxicity.11

Breast cancer survivors commonly have shoulder dysfunction and/or breast cancer-related lymphedema. For shoulder dysfunction, PROMs validated in breast cancer include the Disabilities of the Arm, Shoulder, and Hand outcome measure (DASH), QuickDASH, and Ultra-QuickDASH, Kwan’s Arm Problem Scale, Upper Limb Disability Questionnaire, and Wingate.22  DASH is a 30-item questionnaire evaluating upper extremity function. QuickDASH is a condensed version with 11 items rated on a 5-point Likert scale. The Ultra-QuickDASH, evaluates upper function specifically in lymphedema patients using 2 items assessing the ability to perform chores and limitations in work or daily activities.

Lymphedema is a persistent and incapacitating condition experienced by numerous cancer survivors. Screening and monitoring have traditionally relied on both subjective symptoms and objective measurements. Objective measures include tape measure-derived circumferential and volumetric evaluations, water displacement volumetrics, perometry-based volumetry, and bioimpedance spectroscopy. More recently, the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology for Breast Cancer and Survivorship newly mentioned that clinical examinations may include bioimpedance spectroscopy (BIS) for early detection and lymphedema monitoring.23 Currently, the only BIS device available is the SOZO® Digital Health Platform, which is increasingly being covered by health insurance companies. Although there is no consensus on PROMs for lymphedema, those with substantial supporting evidence include the Lymphedema Life Impact Scale, Lymphoedema Functioning, Disability and Health Questionnaire, Lymph-ICF for Lower Limb Lymphoedema, Patient Benefit Index-Lymphedema, Upper Limb-Lymphedema-27, and LYMPH-Q.11 For head and neck lymphedema, common measures are tape measurements, the MD Anderson Head and Neck Lymphedema Scale, and a laryngoscopy-based Patterson scale. In contrast, recently recommended tools are ultrasound, computed tomography measurements, and the Head and Neck Lymphedema and Fibrosis Symptom Inventory.24

Many other comorbid conditions impacting physical function are common and more prevalent in cancer patients. These conditions and their common outcome measures include anxiety (Generalized Anxiety Disorder Screener, The Hospital Anxiety Depression Scale), depression (Patient Health Questionnaire), obstructive sleep apnea (STOP-BANG score), poor sleep quality (Pittsburgh Sleep Quality Index), and malnutrition (Nutritional Risk Screening 2002, Malnutrition Universal Screening Tool, Mini Nutrition Assessment, and Malnutrition Screening Tool).25

Cutting Edge/Emerging and Unique Concepts and Practice

Rehabilitation services are gradually being incorporated into major national organizations’ recommended cancer care plans. The NCCN, American Cancer Society, and the 2020 Commission on Cancer Guidelines designate rehabilitation services as a critical component of care particularly in patients with cognitive, neurologic, or musculoskeletal impairments.26

Recently, the PROMIS Cancer Function Brief 3D profile was created for outpatient cancer physiatry practice. This 12-item PROM assesses physical function, fatigue, and social participation. It is sensitive to change and can be used as a surveillance tool for impaired function in cancer survivorship. However, it has not yet been studied as a screening tool. With increasing numbers of cancer rehabilitation practices implementing this tool, there is potential for larger, more diverse data sets.

Prehabilitation, which is physical and mental optimization before cancer treatment, has rapidly growing evidence. However, most prehabilitation studies use PROMs with fewer studies using objective physical function measures. Larger-scale studies utilizing objective outcome measures are needed to identify the ideal timing, components, and factors influencing adherence to cancer prehabilitation programs.27

Frailty is associated with diminished treatment response to chemotherapy and increased post-operative complications. The gold standard for frailty screening in older adults with cancer is geriatric screening followed by geriatric assessment. The American Society of Clinical Oncology Guidelines on geriatric oncology recommend that all patients over 65 with cancer receive a full geriatric assessment to identify vulnerabilities not captured by routine oncological assessment. The G8 Geriatric Screening Tool is a clinician-reported outcome measure designed to identify patients who could benefit from a comprehensive geriatric assessment. Other reliable and valid objective functional for older cancer survivors include the 5STS, 30STS, SPPB, and the Physical Performance Test – 7.11 Shorter frailty outcome measures primarily studied in older cancer patients include the Fried Frailty Criteria, Rockwood frailty index, and the Clinical Frailty Scale (CFS). Of these, CFS is the easiest to use and has been increasingly implemented clinically. CFS may predict cancer treatment outcomes, morbidity, mortality, and long-term toxicity, 28 The Multidimensional Oncological Frailty Scale is a recently-developed composite frailty scale (composite score from G8 Geriatric Screening Tool, CFS, and grip strength) for screening and stratifying the risk of mortality in geriatric cancer patients.29

Sarcopenia, the progressive loss of muscle function with age or inflammatory processes such as cancer, contributes to frailty. Sarcopenia has been associated with falls, fractures, physical disability, and mortality. Common screening tools used in the clinical setting for the assessment of sarcopenia include the SARC-F and SARC-CalF.30 Combining the SARC-F with calf circumference measurements has shown promise in improving the sensitivity of frailty detection leading to the creation of SARC-CalF. Objective measures include gait speed, grip strength, and body composition measures.

Cachexia can further contribute to muscle loss and decline in function in cancer patients. Several instruments assess physical function in cancer-associated cachexia by combining measures of muscle mass and muscle function. However, current instruments lack validation. Grip strength is commonly used, though insufficient for measuring associated functional decline. Further studies are required to better measure cancer-associated cachexia.

Virtual functional measures along with virtual exercise and rehabilitation care have seen increased usage following the COVID-19 pandemic in 2020. A virtually delivered exercise program to cancer survivors used a 35-item subjective symptom checklist and the McGill quality of Life Questionnaire. The virtual objective measures were TUG, partial curl-up, and modified sit and reach test.31

Gaps in the Evidence-Based Knowledge

Further research and consensus on functional measures for screening, surveillance, and outcome tracking are needed to advance the field of cancer rehabilitation and cancer physiatry. With telemedicine now a norm since the COVID-19 pandemic, virtual functional outcome measures in cancer rehabilitation also need further study.

Barriers to the implementation of functional measures in cancer rehabilitation medicine practices was explored in a 2022 survey of the Cancer Rehabilitation Physician Consortium of the American Academy of Physical Medicine and Rehabilitation. Of the twenty-four cancer rehabilitation physicians representing 22 institutions across the United States, the most common barrier to outcome measure collection was inadequate staffing and limited electronic medical record resources.11 As cancer survivorship and cancer rehabilitation grow rapidly, consensus on clinically feasible outcome measures and collaboration to address implementation barriers are critical to further establish the field of cancer physiatry.


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Original Version of the Topic

Andrea L. Cheville, MD. Functional outcomes after rehabilitation of cancers. 9/20/2014

Previous Revision(s) of the Topic

Arpit Arora, MD. Functional outcomes after rehabilitation of cancers. 5/12/2021

Author Disclosure

Marc Ramos Emos, MD
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Anam Purewal-Kossack, MD
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Sara Parke, MD
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Jessica Cheng, MD
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