J Rehabil Med 2004; Suppl. 44: 121–127
ICF CORE SETS FOR BREAST CANCER
Mirjam Brach,1 Alarcos Cieza,2 Gerold Stucki,1,2 Michaela Füßl,2 Andrew Cole,3 Bruce E. Ellerin,4
Veronika Fialka-Moser,5 Nenad Kostanjsek6 and John Melvin7
From the 1Department of Physical Medicine and Rehabilitation, Ludwig-Maximilians-University, Munich, 2ICF Research Branch,
WHO FIC Collaborating Center (DIMDI), IMBK, Ludwig-Maximilians-University, Munich, Germany, 3Braeside Hospital, Senior
Staff Specialist, Prairiewood NSW, Sydney, Australia, 4School of Medicine, New York University, New York, USA,
5
Department of Physical Medicine and Rehabilitation, University Vienna, Austria, 6Classification, Assessment,
Surveys and Terminology Team, World Health Organization, Geneva, Switzerland and 7Department of Rehabilitation
Medicine, Jefferson Medical College, Thomas Jefferson University, Philadelphia, USA
Objective: To report on the results of the consensus process
to develop the first version of both a Comprehensive ICF
Core Set and a Brief ICF Core Set for breast cancer.
Methods: A formal decision-making and consensus process
integrating evidence gathered from preliminary studies was
realized. Preliminary studies included a Delphi exercise, a
systematic review, and an empirical data collection. After
training in the ICF and based on these preliminary studies,
relevant ICF categories were identified in a formal consensus process by international experts from different backgrounds.
Results: The preliminary studies identified a set of 317 ICF
categories at the second, third, and fourth ICF levels with
150 categories on body functions, 44 on body structures, 77 on
activities and participation, and 46 on environmental factors.
Nineteen experts attended the consensus conference on
breast cancer (7 physicians with at least a specialization in
physical and rehabilitation medicine, 2 with a specialization
in internal medicine and one radiologist, 4 physical
therapists, 2 occupational therapists, one psychologist, one
epidemiologist and one nurse). Altogether 80 categories (73
second-level and 7 third-level categories) were included in
the Comprehensive ICF Core Set with 26 categories from the
component body functions, 9 from body structures, 22 from
activities and participation, and 23 from environmental
factors. The Brief ICF Core Set included a total of 40
second-level categories with 11 on body functions, 5 on body
structures, 11 on activities and participation, and
13 on environmental factors.
Conclusion: A formal consensus process integrating evidence
and expert opinion based on the ICF framework and classification led to the definition of ICF Core Sets for breast
cancer. Both the Comprehensive ICF Core Set and the Brief
ICF Core Set were selected.
Key words: breast cancer, function, disability, outcome
assessment, quality of life, ICF.
J Rehabil Med 2004; suppl. 44: 121–127
Correspondence address: Gerold Stucki, Department of
Physical Medicine and Rehabilitation, University of
Munich, DE-81377 Munich, Germany.
Tel: 49 89 7095 4050. Fax: 49 89 7095 8836.
E-mail: gerold.stucki@med.uni-muenchen.de
2004 Taylor & Francis. ISSN 1650–1977
DOI 10.1080/16501960410016811
INTRODUCTION
Breast cancer (BC) is the leading cause of cancer among women
worldwide (1). In 1990, 322,000 women died of BC and the
projected mortality from BC in women worldwide in 2010 is
437,000 (2).
Approximately 1 million women are diagnosed with BC each
year. However, incidence and mortality rates vary widely in
different countries: they are high in most industrialized countries
(except Japan), intermediate in Eastern and Southern Europe,
and low in Central and tropical South America, Africa and Asia
(3). In the USA in 2001, it is estimated that 192,200 women will
be diagnosed with invasive BC, 40,600 with in situ carcinoma
and 40,200 women will die of BC (4).
Of every 1000 women of 50 years of age, 2 will recently have
had BC diagnosed and about 15 will have had a diagnosis made
before the age of 50, giving a prevalence of BC of nearly 2% (5).
BC is a multifactorial disease. Both endogenous (including
genetic) and exogenous factors are involved in breast carcinogenesis and increased risk of BC (6).
With advances in the treatment of women with BC, including
the combined use of surgical intervention, radiation therapy and
chemotherapy, cancer survival rates are now above 50% (7).
Many BC survivors, however, will experience physical and
psychological sequelae that affect their everyday lives. Anxiety,
depression, less energy or fatigue and difficulty in sleeping are
common responses to stressors (8, 9). A significant proportion
of women suffer disturbances in body image and self-concept
(10, 11). Social isolation and disruptions in family and sexual
relationships are related to fears of recurrence and death (8,
12–14). Pain, limited range of motion, and lymphoedema of the
affected arm can result from primary surgical treatment (15–17).
The incidence of lymphoedema by axillary node dissection
alone is reported to be about 10% (18–21) but with a dissection
combined with radiation of the axilla the incidence varies up to
60% (21–24). Untreated lymphoedema gradually worsens with
time (25). The side-effects of treatment as well as inactivity
secondary to treatment, can impair activity and participation,
decrease independence and affect quality of life (8, 26).
Physical functioning can be measured by the Karnofsky
Performance Status Scale (KPS) (27, 28) and self concept can be
evaluated by the Tennessee Self-Concept Scale (TSCS) (29),
J Rehabil Med Suppl 44, 2004
122
M. Brach et al.
and the Brief Symptom Inventory (BSI) (30), while for body
image the Tennessee Self-Concept Scale – the Physical Self
(TSCS-PS) can be used. Psychosocial adjustment can be assessed by Psychosocial Adjustment to Illness (PAIS) (31, 32),
and the quality of life of BC patients can be evaluated by the
condition-specific module of the Quality of Life Questionnaire
(QLQ-BC) (33).
However, no systematic framework that covers the spectrum
of BC-related symptoms and limitations in functioning and
health has been established thus far. With the approval of the
new International Classification of Functioning, Disability
and Health (ICF, formerly ICIDH-2, http://www.who.int/
classification/icf) we can now rely on a globally agreed
framework and classification to define the typical spectrum of
problems in functioning of patients with BC. For practical
purposes and in line with the concept of condition-specific
health status measures, it would thus seem most helpful to link
specific conditions or diseases to salient ICF categories of
functioning (34). Such generally-agreed-on lists of ICF categories can serve as Brief ICF Core Set to be rated in all patients
included in a clinical study with BC or as Comprehensive ICF
Core Set to guide multidisciplinary assessments in patients with
BC. The objective of this paper is to report on the results the
consensus process integrating evidence from preliminary studies
to develop the first version of the ICF Core Sets for BC.
METHODS
The ICF Core Sets development for BC involved a formal decisionmaking and consensus process integrating evidence gathered from
preliminary studies including a Delphi exercise (35), a systematic review
(36), and an empirical data collection, using the ICF checklist (37). After
training in the ICF and based on these preliminary studies relevant ICF
categories were identified in a formal consensus process by international
experts from different backgrounds.
Nineteen experts from 5 different countries attended the consensus
process for BC. The professional background of the experts (7
physicians with at least a specialization in physical and rehabilitation
medicine, 2 with a specialization in internal medicine and 1 radiologist,
4 physical therapists, 2 occupational therapists, 1 psychologist, 1 epidemiologist and 1 nurse) covered the wide spectrum of limitations in
functioning that occurs in patients with BC. The decision-making
process for BC involved 3 working groups with 6–7 experts each. The
process was facilitated by the condition co-ordinator for BC (JM) and the
3 working-group leaders (AC, BE, VFM).
The tables on the pre-conference studies (35–37) presented to the
participants included 317 ICF categories at the second, third and fourth
levels (150 on body functions, 44 on body structures, 77 on activities and
participation, and 46 on environmental factors).
RESULTS
Tables I–IV show the second- and third-level ICF categories
included in the Comprehensive ICF Core Set. Table V shows the
second-level ICF categories that were selected for the Brief ICF
Core Set, as well as the percentage of experts willing to include
the respective category in the Brief ICF Core Set.
The number of second- and third-level categories in the Comprehensive ICF Core Set is 80, with 73 categories on the second
level and 7 categories on the third level. The 7 third-level
categories are a further specification of 5 categories on the
J Rehabil Med Suppl 44, 2004
Table I. International Classification of Functioning, Disability and
Health (ICF) – categories of the component body functions
included in the Comprehensive ICF Core Set for breast cancer
ICF code
2nd level
ICF category title
3rd level
b126
b130
b134
b152
b180
b1801
b265
b280
b2801
b435
b4352
b4353
b455
b530
b640
b650
b660
b670
b710
b720
b730
b740
b780
b810
b820
b840
Temperament and personality
functions
Energy and drive functions
Sleep functions
Emotional functions
Experience of self and time functions
Body image
Touch function
Sensation of pain
Pain in body part
Immunological system functions
Functions of lymphatic vessels
Functions of lymph nodes
Exercise tolerance functions
Weight maintenance functions
Sexual functions
Menstruation functions
Procreation functions
Sensations associated with genital
and reproductive functions
Mobility of joint functions
Mobility of bone functions
Muscle power functions
Muscle endurance functions
Sensations related to muscles and
movement functions
Protective functions of the skin
Repair functions of the skin
Sensation related to the skin
second level. The total number of second-level categories
included in the Brief ICF Core Set is 40. No third-level category
was selected for the Brief ICF Core Set.
Comprehensive ICF Core Set
The 80 categories of the Comprehensive ICF Core Set are made
up of 26 (33%) categories from the component body functions, 9
(11%) from the component body structures, 22 (27%) from the
component activities and participation, and 23 (29%) from the
component environmental factors.
Table II. International Classification of Functioning, Disability and
Health (ICF) – categories of the component body structures
included in the Comprehensive ICF Core Set for breast cancer
ICF code
2nd level
ICF category title
3rd level
s420
s4200
s4201
s630
s6302
s720
s730
s760
s810
Structure of immune system
Lymphatic vessels
Lymphatic nodes
Structure of reproductive system
Breast and nipple
Structure of shoulder region
Structure of upper extremity
Structure of trunk
Structure of areas of skin
ICF Core Sets for breast cancer
123
Table III. International Classification of Functioning, Disability
and Health (ICF) – categories of the component activities and
participation included in the Comprehensive ICF Core Set for
breast cancer
Table IV. International Classification of Functioning, Disability
and Health (ICF) – categories of the component environmental
factors included in the Comprehensive ICF Core Set for breast
cancer
ICF code
ICF category title
ICF code
ICF category title
d177
d230
d240
d430
d445
d510
d520
d540
d550
d560
d570
d620
d630
d640
d650
d660
d720
d750
d760
d770
d850
d920
Making decisions
Carrying out daily routine
Handling stress and other psychological demands
Lifting and carrying objects
Hand and arm use
Washing oneself
Caring for body parts
Dressing
Eating
Drinking
Looking after one’s health
Acquisition of goods and services
Preparing meals
Doing housework
Caring for household objects
Assisting others
Complex interpersonal interactions
Informal social relationships
Family relationships
Intimate relationships
Remunerative employment
Recreation and leisure
e110
e115
Products or substances for personal consumption
Products and technology for personal use in daily
living
Assets
Climate
Immediate family
Extended family
Friends
Acquaintances, peers, colleagues, neighbours and
community members
Personal care providers and personal assistants
Health professionals
Individual attitudes of immediate family members
Individual attitudes of extended family members
Individual attitudes of friends
Individual attitudes of acquaintances, peers,
colleagues, neighbours and community members
Individual attitudes of personal care providers and
personal assistants
Individual attitudes of health professionals
Social norms, practices and ideologies
Transportation services, systems and policies
Associations and organizational services,
systems and policies
Social security services, systems and policies
General social support services, systems and policies
Health services, systems and policies
Labour and employment services, systems
and policies
Add: d530 Toileting.
Twenty-two of the 26 categories of the component body
functions are at the second and 4 at the third level of the
classification. The 26 categories at the second level represent
15% of the total number of ICF categories at the second level in
this component. Chapter 1 mental functions is represented by
5 categories at the second level and by the third-level category
b1801 body image, which is a specification of the included
second-level category b180 experience of self and time functions. Chapter 2 sensory functions and pain is represented by
2 categories at the second level and by the third-level category
b2801 pain in a body part, which is a specification of the
selected second-level category b280 sensation of pain. Chapter 4
functions of the cardiovascular, haematological, immunological
and respiratory systems is represented by 2 categories at the
second level and by 2 categories at the third level of the
classification, which are specifications of the included secondlevel category b435 immunological system functions. Chapter 6
genitourinary and reproductive functions, chapter 7 neuromusculoskeletal and movement-related functions and chapter 8
functions of the skin and related structures are represented by 4,
5 and 3 categories at the second level, respectively.
Six of the 9 categories of the component body structures are at
the second and 3 categories are at the third level of
the classification. The 6 categories at the second level represent
11% of the total number of ICF categories at the second level
in this component. Chapter 4 structures of the cardiovascular,
immunological and respiratory systems is represented by 2 thirdlevel categories s4200 lymphatic vessels and s4201 lymphatic
nodes and by its corresponding second-level category s420
structure of immune system. Chapter 6 structures related to the
e165
e225
e310
e315
e320
e325
e340
e355
e410
e415
e420
e425
e440
e450
e465
e540
e555
e570
e575
e580
e590
genitourinary and reproductive systems is represented on the
third level by s6302 breast and nipple and by its corresponding
second-level category s630 structure of reproductive system of
which it is a member. Chapter 7 structures related to movement
is represented by 3 categories and chapter 8 skin and related
structures by 1 category at the second level of the classification.
The 22 categories of the component activities and participation are all at the second level of the ICF hierarchy. They represent 19% of the total number of ICF categories at the second
level in this component. Most of the activities and participation
categories belong to chapter 5 self care (6 categories), chapter 6
domestic life (5 categories) and chapter 7 interpersonal
interactions and relationships (4 categories). However, with
exception of chapter 3 communication, 8 chapters of this component are represented in the Comprehensive ICF Core Set.
Chapter 2 and chapter 4 are represented by 2 categories, respectively. Chapter 1 learning and applying knowledge, chapter 8
major life areas and chapter 9 community, social and civic life
are each represented by 1 category.
The 23 categories of the component environmental factors are
all at the second level of the ICF hierarchy. They represent 31%
of the total number of ICF categories at the second level of this
component. Most of the environmental-factors categories
belong to chapter 4 attitudes (7 categories), chapter 3 support
and relationships (6 categories) and chapter 5 services, systems
J Rehabil Med Suppl 44, 2004
124
M. Brach et al.
Table V. International Classification of Functioning, Disability and Health (ICF) – categories included in the Brief ICF Core Set for breast
cancer. The categories per component are listed according to the conceded rank order. 50% represent a preliminary cut-off. >50% is in
bold typeface
ICF component
%
ICF code
ICF category title
Body functions
100
100
100
100
95
79
79
74
42
37
37
100
100
79
47
5
100
100
100
100
100
95
84
79
42
32
16
100
100
100
100
100
100
95
79
74
58
47
37
16
b152
b280
b130
b180
b710
b640
b134
b435
b730
b126
b455
s630
s420
s720
s810
s730
d240
d770
d760
d445
d230
d640
d850
d430
d920
d570
d510
e310
e410
e420
e320
e355
e450
e570
e580
e115
e590
e165
e315
e465
Emotional functions
Sensation of pain
Energy and drive functions
Experience of self and time functions
Mobility of joint functions
Sexual functions
Sleep functions
Immunological system functions
Muscle power functions
Temperament and personality functions
Exercise tolerance functions
Structure of reproductive system
Structure of immune system
Structure of shoulder region
Structure of areas of skin
Structure of upper extremity
Handling stress and other psychological demands
Intimate relationships
Family relationships
Hand and arm use
Carrying out daily routine
Doing housework
Remunerative employment
Lifting and carrying objects
Recreation and leisure
Looking after one’s health
Washing oneself
Immediate family
Individual attitudes of immediate family members
Individual attitudes of friends
Friends
Health professionals
Individual attitudes of health professionals
Social security services, systems and policies
Health services, systems and policies
Products and technology for personal use in daily living
Labour and employment services, systems and policies
Assets
Extended family
Social norms, practices and ideologies
Body structures
Activities and participation
Environmental factors
and policies (6 categories). However, all 5 chapters of this
component are represented in the Comprehensive ICF Core Set.
Chapter 1 products and technology is represented by 3
categories and chapter 2 natural environment and humanmade changes to environment by 1 category.
process are presented in Table V. However, a preliminary cutoff was established at 50% to reflect majority opinion.
Brief ICF Core Set
The formal consensus process integrating evidence from
preliminary studies and expert knowledge at the third ICF
Core Sets conference led to the definition of the Comprehensive
ICF Core Set for multidisciplinary assessment and the Brief ICF
Core Set for clinical studies.
A major challenge during the development of the ICF Core
Sets for BC was comprehensively to cover the wide spectrum of
problems in BC and to avoid the inclusion of co-morbidities or a
treatment-specific perspective especially concerning systemic
medication therapy and related treatment problems or side-
The Brief ICF Core Set includes a total of 40 second-level
categories, which represents 11% of all second-level categories
that were chosen in the Comprehensive ICF Core Set.
Eleven categories were chosen from the component body
functions (representing 50% of selected second-level categories
in the Comprehensive ICF Core Set), 5 from body structures
(83%), 11 from activities and participation (50%), and 13 from
environmental factors (57%).
All ICF categories taken into account in the final decision
J Rehabil Med Suppl 44, 2004
DISCUSSION
ICF Core Sets for breast cancer
effects, which are drugs and not condition-specific. BC cannot
be seen without a treatment effect, as every patient is treated,
however systemic therapy can be regarded as a subset in patients
with BC smaller than patients with BC getting surgery and
radiation. Therefore, it was decided by the group of experts to
address BC taking only into account surgery and radiation
treatment.
The Comprehensive ICF Core Set for BC is one of the shortest
developed for the 12 most burdensome chronic conditions.
However, the Brief ICF Core Set for BC is the largest of the ICF
Core Sets developed. The fact that 40 categories are still
included in the Brief ICF Core Set reflects the important and
complex impairments, limitations and restrictions of body
functions, activities and participation involved, as well as the
numerous interactions with environmental factors.
As BC is a multifactorial disease, the number of included
body-functions categories in both ICF Core Sets for BC
demonstrate the complex range of impairments which affect
patients with BC. Both ICF Core Sets focus on global and
specific mental functions such as emotional functions, experience of self and time functions and energy and drive functions
besides impairments related to pain or neuromusculoskeletal
and movement-related functions. Furthermore, functions related
to specific organs, such as immunological system functions,
exercise tolerance functions and sexual functions are included in
both ICF Core Sets as well. In addition, the Comprehensive ICF
Core Set includes “functions of the skin”. All selected bodyfunctions categories in the ICF Core Sets are consistent with
current knowledge discussed in the literature. There is evidence
of the impact of BC on emotional and social well-being,
including symptoms of depression, anxiety, sleep disturbances,
sexual problems and problems with body image (10, 38–41).
Body image dissatisfaction is generally accompanied by
insecurity and diminished self-confidence (42) wherefore
lymphoedema is one of the greatest problems that women
express (43). Further problems in BC are loss of shoulder motion,
shoulder girdle and arm pain, upper extremity oedema and loss
of arm strength after treatment (20, 44–47). Even without
clinically manifest lymphoedema, the majority of patients with
BC suffer from an impaired function of the lymphatics (48).
The selection of body structures includes those structures that
are mainly affected by BC. The majority of patients with BC
show impairments of the reproductive system (s6302 breast and
nipple), of the immune system (s4200 lymphatic vessels and
s4201 lymphatic nodes), and of structures related to movement
such as shoulder region and upper extremity as well as skin and
related structures. All these body structures are also pointed out
as relevant body structures in patients with BC by the American
College of Radiology, the American College of Surgeons, the
College of American Pathologists and the Society of Surgical
Oncology (49). Additionally, structure of trunk was selected for
the Comprehensive ICF Core Set.
The fact that at the body level (body functions and body
structures) some categories at the third level of the classification, such as b1801 body image, b2801 pain in body part and
125
s6302 breast and nipple, were included, reflects that a deeper
and more detailed description is necessary to address the
problems in functioning.
Selected ICF categories in activities and participation
concern general aspects of carrying out tasks and handling
psychological demands, as well as life areas such as mobility,
self care, domestic life, interpersonal interactions and relationships, work and employment, community, and social and
civic life. The included ICF categories are consistent with the
problems, which are the subject of discussion in the majority of
psychosocial literature on BC. Changes in body image and selfconcept have a profound effect on sexuality and interpersonal
relationships. Women with lymphoedema showed statistically
significant impairments in the areas of vocational, domestic,
social, and sexual relationships and psychological distress on the
PAIS (43). The level of independence in executing activities, the
importance of positive relations (50, 51), and the amount of
social support is assumed to be a major factor in psychosocial
adjustment and influences patient health outcomes (52). The
category d530 toileting, which was not part of the tables on the
preliminary studies would have additionally been included by
the expert panel. Therefore the inclusion of this category in the
Comprehensive ICF Core Set for test studies is suggested.
The number of categories in the environmental-factors
component displays the extensive involvement of contextual
factors for the effective management of patients with BC.
Patients regard support and relationships and attitudes of family,
friends and health professionals to be of high importance (51,
53, 54). BC patients’ experiences, for example of lymphoedema
after mastectomy very much depend on the attitudes from people
in their surroundings, as a lymphoedematous arm is a difficultto-conceal reminder of the cancer itself and the impaired body
image (55, 56). Consistent with results from the psychosocial
literature on BC there was general agreement by all experts that
women with BC experience difficulties in vocational, domestic
and social roles and relationships. The selected ICF categories
confirm exactly such often expressed needs, as psychological,
physical, informational, household, legal, financial, and spiritual
needs (57, 58). Conclusions from the research literature
demonstrate the benefit from a strong individual and societal
network, the need for social and emotional support, and the
requirement of professional help in form of counselling
and medical treatment (59, 60). Patients are often least satisfied
with information about financial issues and availability of help
and facilities for use at home and other resources for health and
treatment. Therefore, health, social security, and labour and
employment services, systems and policies are important sources
of support for patients with BC (43, 55, 56, 61).
The ICF Core Sets for BC are based on a broad definition
of the underlying condition, BC. Validation and test studies will
show whether specific subsets of patients, for example breastconserving treatment vs mastectomy (62), radiation therapy vs
no radiation therapy (63), or younger vs older (40, 64), will
differ.
Regarding the comprehensiveness of the ICF, it is most interJ Rehabil Med Suppl 44, 2004
126
M. Brach et al.
esting to note that the panel of experts did not identify problems
of patients not contained in the ICF. This emphasizes the validity
of the ICF classification, which was based on an international
development process. The breadth of ICF chapters contained in
the Comprehensive ICF Core Set reflects the important and
complex impairments, limitations and restrictions of patients
with BC in the 4 ICF components. The selection of categories
for the Brief ICF Core Set does not result in a bandwidth
compression, i.e. the Brief ICF Core Set still contains most of
the chapters represented in the Comprehensive ICF Core Set.
The approach to patients with BC needs besides the predominantly medical one, a perspective that pays attention to aspects
of the impairment and limitation of the physiological and
psychological function, the deviation or loss of body structures,
restrictions in activities and participation, and environmental
factors or socio-cultural factors. The ICF Core Sets could foster
a more consistent communication and information process
among patients, relatives, and healthcare professionals in
the understanding and analysis of patient needs and problems
and promote the integration of care by representatives of health,
labour and employment services, systems and policies. In this
way the application of the ICF Core Sets could avoid the lack of
identification of patient problems.
Nevertheless, it should be borne in mind that the results of any
consensus process may differ with different groups of experts.
The importance of the extensive validation of this first version
of the ICF Core Sets from the perspectives of different professions and in different countries has to be, thus, emphasized.
The first version of the ICF Core Sets will also be tested from the
patients’ points of view and in different clinical settings. The
length of the ICF Core Sets may be reduced based on the results
of the test and validation studies. Thus, it is important to note
that this first version of the ICF Core Sets is only recommended
for validation or pilot studies.
ACKNOWLEDGEMENTS
We are grateful for the contributions made by the following experts
attending the conference: Thomas Brockow, Margrit Fäßler,
Veronika Fialka Moser, Christoph Gutenbrunner, Claudia Hauser,
Brigitte Hüllemann, Robert Jakob, Margot Knobel, Monika
Lauper, Susanne Schwarzkopf, Thierry Smets, Anna Sonderegger,
Tanja Stamm, Sigrid Stegner, Yvonne Wechsler and Genevieve
Zurbriggen.
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