Statistical Methods for Health Care Research

Summary Background The body of evidence related to breast-cancer-related lymphoedema incidence and risk factors has substantially grown and improved in quality over the past decade. We assessed the incidence of unilateral arm lymphoedema after breast cancer and explored the evidence available for lymphoedema risk factors. Methods We searched Academic Search Elite, Cumulative Index to Nursing and Allied Health, Cochrane Central Register of Controlled Trials (clinical trials), and Medline for research articles that assessed the incidence or prevalence of, or risk factors for, arm lymphoedema after breast cancer, published between Jan 1, 2000, and June 30, 2012. We extracted incidence data and calculated corresponding exact binomial 95% CIs. We used random effects models to calculate a pooled overall estimate of lymphoedema incidence, with subgroup analyses to assess the effect of different study designs, countries of study origin, diagnostic methods, time since diagnosis, and extent of axillary surgery. We assessed risk factors and collated them into four levels of evidence, depending on consistency of findings and quality and quantity of studies contributing to findings. Findings 72 studies met the inclusion criteria for the assessment of lymphoedema incidence, giving a pooled estimate of 16·6% (95% CI 13·6–20·2). Our estimate was 21·4% (14·9–29·8) when restricted to data from prospective cohort studies (30 studies). The incidence of arm lymphoedema seemed to increase up to 2 years after diagnosis or surgery of breast cancer (24 studies with time since diagnosis or surgery of 12 to Interpretation Our findings suggest that more than one in five women who survive breast cancer will develop arm lymphoedema. A clear need exists for improved understanding of contributing risk factors, as well as of prevention and management strategies to reduce the individual and public health burden of this disabling and distressing disorder. Funding The National Breast Cancer Foundation, Australia.

Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis

In certain surfactant solutions, such as aqueous cetyltrimethylammonium bromide (CTAB) in 0.1 M KBr, the amphiphiles are found to assemble reversibly into long, flexible worm-like micelles. Above a few per cent surfactant, these form an entangled viscoelastic fluid, reminiscent of a polymer solution. The authors review some recent experimental and theoretical progress concerning the equilibrium statistics and dynamics of these systems, which differ from normal polymer solutions in that the chains can break and reform reversibly.

http://iopscience.iop.org/article/10.1088/0953-8984/2/33/001/pdf

Statics and dynamics of worm-like surfactant micelles

The purpose of the American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline is to provide recommendations to assist primary care and other clinicians in the care of female adult survivors of breast cancer. A systematic review of the literature was conducted using PubMed through April 2015. A multidisciplinary expert workgroup with expertise in primary care, gynecology, surgical oncology, medical oncology, radiation oncology, and nursing was formed and tasked with drafting the Breast Cancer Survivorship Care Guideline. A total of 1,073 articles met inclusion criteria; and, after full text review, 237 were included as the evidence base. Patients should undergo regular surveillance for breast cancer recurrence, including evaluation with a cancer-related history and physical examination, and should be screened for new primary breast cancer. Data do not support performing routine laboratory tests or imaging tests in asymptomatic patients to evaluate for breast cancer recurrence. Primary care clinicians should counsel patients about the importance of maintaining a healthy lifestyle, monitor for post-treatment symptoms that can adversely affect quality of life, and monitor for adherence to endocrine therapy. Recommendations provided in this guideline are based on current evidence in the literature and expert consensus opinion. Most of the evidence is not sufficient to warrant a strong evidence-based recommendation. Recommendations on surveillance for breast cancer recurrence, screening for second primary cancers, assessment and management of physical and psychosocial long-term and late effects of breast cancer and its treatment, health promotion, and care coordination/practice implications are made.This guideline was developed through a collaboration between the American Cancer Society and the American Society of Clinical Oncology and has been published jointly by invitation and consent in both CA: A Cancer Journal for Clinicians and Journal of Clinical Oncology. All rights reserved. No part of this document may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without written permission by the American Cancer Society or the American Society of Clinical Oncology.

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American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline

Background: Lymphedema is a chronic, debilitating condition that has traditionally been seen as refractory or incurable. Recent years have brought new advances in the study of lymphedema pathophysiology. as well as diagnostic and therapeutic tools that are changing this perspective. Objective: To provide a systematic approach to evaluating and managing patients with lymphedema. Methods: We performed MEDLINE searches of the English-language literature (1966 to March 2006) using the terms lymphedema, breast cancer-associated lymphedema, lymphatic complications, lymphatic imaging, decongestive therapy, and surgical treatment of lymphedema. Relevant bibliographies and International Society of Lymphology guidelines were also reviewed. Results: In the United States, the populations primarily affected by lymphedema are patients undergoing treatment of malignancy, particularly women treated for breast cancer. A thorough evaluation of patients presenting with extremity swelling should include identification of prior surgical or radiation therapy for malignancy, as well as documentation of other risk factors for lymphedema, such as prior trauma to or infection of the affected limb. Physical examination should focus on differentiating signs of lymphedema from other causes of systemic or localized swelling. Lymphatic dysfunction can be visualized through lymphoscintigraphy; the diagnosis of lymphedema can also be confirmed through other imaging modalities, including CT or MRI. The mainstay of therapy in diagnosed cases of lymphedema involves compression garment use, as well as intensive bandaging and lymphatic massage. For patients who are unresponsive to conservative therapy; several surgical options with varied proven efficacies have been used in appropriate candidates, including excisional approaches, microsurgical lymphatic anastomoses, and circumferential suction-assisted lipectomy, an approach that has shown promise for long-term relief of symptoms. Conclusions: The diagnosis of lymphedema requires careful attention to patient risk factors and specific findings on physical examination. Noninvasive diagnostic tools and lymphatic imaging can be helpful to confirm the diagnosis of lymphedema or to address a challenging clinical presentation. Initial treatment with decongestive lymphatic therapy can provide significant improvement in patient symptoms and volume reduction of edematous extremities. Selected patients who are unresponsive to conservative therapy can achieve similar outcomes with surgical intervention, most promisingly suction-assisted lipectomy. (Less)

Lymphedema: a comprehensive review.

Lymphoedema after breast cancer surgery is a chronic condition. Lymphoedema treatment consists of information/advice, compression, physical exercise, skin care, and manual lymph drainage. Little is known about how patients experience, adapt, and respond to lymphoedema treatment. Thus, the purpose of the study was to investigate and describe women's perceptions of lymphoedema treatment after breast cancer surgery. Sixteen women with breast-cancer-related lymphoedema, recruited from four hospitals and two rehabilitation clinics, participated in the study. Semi-structured interviews were conducted and analysed using a phenomenographic method. Five qualitatively different categories of description could be identified: uncertainty, disappointment, guilt and shame, safety, and autonomy. The categories could be described based on a two-dimensional structure: the patients role (internal vs. external locus of control) and an understanding of lymphoedema as a chronic disease or a burden. The study has provided a deeper understanding of different ways in which patients perceive and respond to lymphoedema treatment. The present findings enable the lymphoedema therapist to individualise treatment and counselling based on each patient's approach to the patient role, ability to take responsibility for treatment, and acceptance of lymphoedema as a chronic disease.

Perceptions of lymphoedema treatment in patients with breast cancer - a patient perspective.

Background: Measurements of lower limb (LL) volume and local tissue water by tissue dielectric constant (TDC) are common in lymphedema management. Knowledge of normal variability in health subjects is important and can serve as a base for early lymphedema diagnosis but is currently lacking. The aim of this study was to evaluate test-retest reliability of LL volume and TDC values in healthy women and men. Methods and Results: Thirty-three women and 28 men were measured twice, 2 weeks apart. Volume was calculated from circumferential measurements every 4 cm and TDC in 14 points. Test-retest reliability was evaluated using intraclass correlation coefficient (ICC), changes in the mean, standard error of measurement in percentage (SEM%), and smallest real difference in percentage (SRD%). For volume, reliability was high (ICC 0.99) and measurement errors were low in both women and men (SEM%: 1.1%-1.3%; SRD%: 3.1%-3.6%). For TDC, reliability was fair to excellent in women (ICC 0.63-0.93) and poor to excellent in men (ICC 0.21-0.89). Measurement errors were acceptable in all points in women (SEM%: 3.9%-10.2%; SRD% 10.8%-28.2%), but only in 11 points in men (SEM%: 3.9%-14.5%; SRD%: 10.9%-40.1%). The points close to bone and tendons in men had lower reliability and higher measurement errors. Conclusion: Measurements of LL volume and TDC are reliable in healthy women and men; both methods can be recommended. However, TDC points close to bone and tendons in men should be used with caution.

Test-Retest Reliability of Volume and Local Tissue Water Measurements in Lower Limbs of Healthy Women and Men

Background: Breast edema is reported as a common complaint after breast conserving surgery and radiotherapy (RT). Measurements of local water in skin and upper subeutis with tissue dielectric constant (TDC) technique have the potential to detect breast edema in patients after breast cancer treatment. Objective: The purpose of the present study was to examine development of edema in breast, axilla and upper arm in women treated with breast conserving surgery and RT during a 2-year follow-up. Method: Sixty-five patients have been included and measured at It) time-points (before RT. three time-points during RT. 2 and 4 weeks after RT and then 3.6, 12 and 24 months after RT). Breast edema was measured by tissue water content in skin and upper subcutis at both sides with MoistureMeterD. TDC. directly proportional to tissue water content to the effective depth of 2.5 mm. was evaluated. Definition of breast edema was determined as a TDC ratio 1.40 between Ihe treated and healthy breast. Results: The TDC measurements demonstrated breast edema already before RT. The mean TDC ratios at three weeks of RT and at 3 and 6 months post-RT were exceeding the edema threshold limit (i.e. TDC ratio l .40). The largest proportions of patients exceeding the edema threshold limit were found at three and six month post-RT (63%) and the smallest proportions at two years post-RT (28%). Concerning axillary dissection or sentinel node biopsy, no statistically significant differences were found between the groups at any of the 10 different measurement time-points. Conclusion: Cancer treatment related edema in the breast is very frequent at three to six months after RT but decreases at one to two years after RT. Differences in the surgical procedure are unlikely to change the incidence of breast edema during a two-year follow- up period. (Less)

Two-year follow-up of temporal changes of breast edema after breast cancer treatment with surgery and radiation evaluated by tissue dielectric constant (TDC)

Artist or researcher? Tradition or innovation? Challenges for performing musician and arts education in Europe

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Karin Johansson

Papers

Perceptions of lymphoedema treatment in patients with breast cancer - a patient perspective.

Test-Retest Reliability of Volume and Local Tissue Water Measurements in Lower Limbs of Healthy Women and Men

Two-year follow-up of temporal changes of breast edema after breast cancer treatment with surgery and radiation evaluated by tissue dielectric constant (TDC)

Artist or researcher? Tradition or innovation? Challenges for performing musician and arts education in Europe

Real-time analysis of Oct protein-octamer interaction and transcription complex assembly.