Changes in metabolic risk,insulin resistance,leptin and adiponectin following a lifestyle intervention in overweight and obese breast cancer survivors

Adiposity and physical activity are modifiable factors that could be important determinants of breast cancer (BC) prognosis through their effects on endogenous reproductive hormones, chronic inflammation and metabolic changes. Therefore, it is necessary to evaluate whether offering lifestyle interventions to BC survivors could affect the levels of certain biomarkers involved in these mechanisms. We designed a pre–post intervention study offering diet and exercise sessions over 12 weeks to 42 overweight/obese BC survivors. Before and after the intervention, we obtained dietary information, anthropometry and cardiorespiratory fitness (CRF) measurements and blood samples to measure metabolic risk, insulin resistance and adipokines biomarkers. Wilcoxon signed‐rank tests and Spearman partial correlation coefficients were used to compare pre‐ and post‐measurements and assess the correlations between changes in biomarkers and changes in anthropometry and CRF. Breast cancer survivors showed significant improvements in metabolic risk biomarkers and insulin resistance indicators along with a non‐significant leptin decrease and a significant adiponectin decrease. The improvements in metabolic risk biomarkers, insulin resistance indicators and leptin were moderately correlated (0.32 ≤ |r| ≤ 0.55) with the decrease in body mass index and the increase in CRF. Diet and exercise interventions implemented in overweight/obese BC survivors may improve metabolic risk, insulin resistance and leptin biomarkers.     

Feasibility of a self‐help treatment for insomnia comorbid with cancer

Objective: Professionally administered cognitive‐behavioral therapy (CBT) is efficacious for treating insomnia in breast cancer survivors. However, given the limited accessibility to CBT for insomnia in cancer clinics, there is a need to develop other delivery formats for this intervention. This feasibility study examined patients' satisfaction with a self‐help CBT for insomnia comorbid with cancer and gathered some preliminary data on its effect on sleep and associated features. Methods: Eleven breast cancer patients reporting insomnia symptoms received a 6‐week intervention composed of a 60‐min video using an animated cartoon format and 6 short booklets developed in French. Patients completed a semi‐structured interview at post‐treatment, a battery of self‐report scales and a daily sleep diary (14 days) at pre‐ and post‐treatment and at a 3‐month follow‐up. Results: At post‐treatment interview, comments about the treatment material were uniformly positive. On a questionnaire, patients also reported to be satisfied with the treatment overall, with the video and the booklets' content, as well as with their sleep improvement at post‐treatment (scores from 2.7 to 3.1; scale from 0 to 4). From pre‐ to post‐treatment, moderate‐to‐large effect sizes and statistically and clinically significant differences were found on most sleep variables, as well as overall quality of life. These therapeutic gains were well sustained at a 3‐month follow‐up. Conclusions: Patients were satisfied with the treatment received. Although it is too early to draw any firm conclusion, treatment outcomes suggest a potential for integration into routine cancer care as a first‐line sleep management intervention. Copyright © 2010 John Wiley & Sons, Ltd.     

Individualised mindfulness‐based stress reduction for head and neck cancer patients undergoing radiotherapy of curative intent: a descriptive pilot study

People with head and neck cancer (HNC) experience elevated symptom toxicity and co‐morbidity as a result of treatment, which is associated with poorer psychosocial and quality‐of‐life (QoL) outcomes. This Phase I study examined whether an individualised mindfulness‐based stress reduction (IMBSR) programme could be successfully used with HNC patients undergoing curative treatment. Primary aims were to explore feasibility, compliance, acceptability and fidelity. Secondary aims were to determine whether (1) participation in the intervention was associated with changes in post‐intervention mindfulness and (2) post‐intervention mindfulness was associated with post‐intervention distress and QoL. Nineteen HNC patients participated in a seven‐session IMBSR programme with pre‐ and post‐test outcome measures of psychological distress, depression, anxiety and QoL. Primary aims were assessed by therapists or participants. Mindfulness, distress and QoL were assessed using self‐report questionnaires at pre‐ and post‐intervention. Longer time spent meditating daily was associated with higher post‐intervention mindfulness. After controlling for pre‐intervention mindfulness, there was an association between higher post‐intervention mindfulness and lower psychological distress and higher total, social and emotional QoL. This study offers important preliminary evidence than an IMBSR intervention can be administered to HNC patients during active cancer treatment. A randomised controlled trial is warranted to confirm these findings.     

Post‐diagnosis alcohol intake and prostate cancer survival: A population‐based cohort study

Alcohol consumption has been declared a Group 1 carcinogen by the International Agency for Research on Cancer (IARC) and is a potential risk factor for several types of cancer mortality. However, evidence for an association with prostate cancer survival remains inconsistent. We examined how alcohol consumption post‐diagnosis was associated with survival after prostate cancer diagnosis. Men diagnosed with prostate cancer (n = 829) in Alberta, Canada between the years 1997 and 2000 were recruited into a population‐based case–control study and then followed for up to 19 years for survival outcomes. Pre‐ and post‐diagnosis alcohol consumption, clinical characteristics and lifestyle factors were collected through in‐person interviews shortly after diagnosis and again 2–3 years post‐diagnosis. Cox proportional hazards were used to examine how post‐diagnosis alcohol consumption was associated with all‐cause and prostate cancer‐specific mortality (competing risk analysis too), in addition to first recurrence/progression or new primary cancer. Most participants reported drinking alcohol (≥once a month for 6 months) post‐diagnosis (n = 589, 71.0%). Exceeding Canadian Cancer Society (CCS) alcohol consumption recommendations (≥2 drinks/day) post‐diagnosis was associated with prostate cancer‐specific mortality relative to non‐drinkers (aHR: 1.82, 95% CI: 1.07–3.10) with borderline evidence of a linear trend. Interestingly, those in the highest quartile of drinks/week pre‐ and post‐diagnosis also had a twofold increase for prostate‐specific mortality (aHR: 2.67, 95% CI: 1.28–5.56) while controlling for competing risks. Our results support post‐diagnosis alcohol consumption was associated with increased mortality after prostate cancer diagnosis, specifically for prostate cancer‐related death. Future studies focused on confirming this burden of disease are warranted.     

Implications of a needs assessment intervention for people with progressive cancer: impact on clinical assessment, response and service utilisation

Objective: To assess the impact of the systematic use of the Palliative Care Needs Assessment Guidelines and Needs Assessment Tool: Progressive Disease‐Cancer (NAT: PD‐C) on clinical assessment, response and service utilisation. Study setting: Three major oncology treatment centres in NSW, Australia. Study design: Between March 2007 and December 2009, 219 people with advanced cancer were recruited to complete bi‐monthly telephone interviews. The intervention, introduced after at least two baseline interviews, involved training health professionals to complete the NAT: PD‐C with patients approximately monthly. Data collection: Rates of service use and referrals were compared pre‐ and post‐introduction of the NAT: PD‐C. Rates of completion of the tool; its impact on consultation length; and the types of needs and follow‐up care to address these were also assessed. Principal findings: The NAT: PD‐C had a high rate of completion; identified needs consistent with those self‐reported by patients in interviews; and did not alter consultation length. No changes in the number of health professionals seen by patients were found pre‐ and post‐intervention. Conclusion: The NAT: PD‐C is an efficient and acceptable strategy for supporting needs‐based cancer care that can potentially be incorporated into standard routine care without increasing the burden on care providers. Copyright © 2011 John Wiley & Sons, Ltd.     

A mindfulness‐based intervention for caregivers of allogeneic hematopoietic stem cell transplant patients: Pilot results

Despite high levels of stress, there are few empirically supported stress management interventions for caregivers of allogeneic hematopoietic stem cell transplant (HCT) cancer patients. This study examined the feasibility, acceptability, and various stress‐related outcomes from pre‐ to post‐treatment of a pilot, single‐arm trial of a 6‐week mindfulness‐based intervention (FOCUS) for stress management. Caregivers (N = 21; 76% female; mean age = 57.43) were enrolled prior to patient transplant and received FOCUS during the first 90 days post‐transplant. Findings indicated that FOCUS was highly feasible and acceptable (e.g., 71% attended at least four of six sessions; 100% reported using the skills learned at follow‐up; high treatment engagement). Significant increases in mindfulness, post‐traumatic growth, and general mental health were observed, along with significant decreases in negative affect (all ps < .05).     

A couples intervention for patients facing advanced cancer and their spouse caregivers: outcomes of a pilot study

Objective: The primary objective of this study was to evaluate the effectiveness of a couples intervention in improving marital functioning in advanced cancer patients and their spouse caregivers. A secondary objective was to determine its impact on other symptoms of psychosocial distress and its feasibility and acceptability as a clinical intervention. Methods: Using a one‐arm pre‐ and post‐intervention prospective design, 16 couples were provided 8 weekly sessions of Emotionally Focused Couple Therapy, modified and manualized for the cancer population. Subjects' marital functioning (Revised Dyadic Adjustment Scale [RDAS]), symptoms of depression (Beck Depression Inventory‐II [BDI‐II]), and hopelessness (Beck Hopelessness Scale) were assessed through self‐report at T0 (baseline), T1 (after four sessions), T2 (after eight sessions), and T3 (3 months post‐intervention follow‐up). Results: RDAS scores improved from T0 to T2, with 87.5% of the couples showing some improvement (0.5–5 points) or significant improvement (>5 points) in marital functioning and 68.8% scoring in the non‐distressed range (?48 RDAS). At T3, 60% of the couples (n=15) continued to score in the non‐distressed range on the RDAS. BDI‐II scores were significantly higher for patients than for caregivers. There was a significant reduction in the mean BDI‐II score from T0 to T3 in all subjects (n=30). This reduction was more significant for the patients (n=15). Conclusions: Providing support to couples at this challenging time may result in improved marital functioning and an opportunity for relational growth during end‐stage cancer. This study serves as the first step in the development of an empirically validated intervention for couples. Copyright © 2008 John Wiley & Sons, Ltd.     

Higher carbohydrate intake is associated with increased risk of all‐cause and disease‐specific mortality in head and neck cancer patients: results from a prospective cohort study

No studies have evaluated associations between carbohydrate intake and head and neck squamous cell carcinoma (HNSCC) prognosis. We prospectively examined associations between pre‐ and post‐treatment carbohydrate intake and recurrence, all‐cause mortality, and HNSCC‐specific mortality in a cohort of 414 newly diagnosed HNSCC patients. All participants completed pre‐ and post‐treatment Food Frequency Questionnaires (FFQs) and epidemiologic surveys. Recurrence and mortality events were collected annually. Multivariable Cox Proportional Hazards models tested associations between carbohydrate intake (categorized into low, medium and high intake) and time to recurrence and mortality, adjusting for relevant covariates. During the study period, there were 70 deaths and 72 recurrences. In pretreatment analyses, high intakes of total carbohydrate (HR: 2.29; 95% CI: 1.23–4.25), total sugar (HR: 3.03; 95% CI: 1.12–3.68), glycemic load (HR: 2.10; 95% CI: 1.15–3.83) and simple carbohydrates (HR 2.26; 95% CI 1.19–4.32) were associated with significantly increased risk of all‐cause mortality compared to low intake. High intakes of carbohydrate (HR 2.45; 95% CI: 1.23–4.25) and total sugar (HR 3.03; 95% CI 1.12–3.68) were associated with increased risk of HNSCC‐specific mortality. In post‐treatment analyses, medium fat intake was significantly associated with reduced risk of recurrence (HR 0.08; 95% CI 0.01–0.69) and all‐cause mortality (HR 0.27; 95% CI 0.07–0.96). Stratification by tumor site and cancer stage in pretreatment analyses suggested effect modification by these factors. Our data suggest high pretreatment carbohydrate intake may be associated with adverse prognosis in HNSCC patients. Clinical intervention trials to further examine this hypothesis are warranted.     

Effect of body size on breast‐cancer risk among Japanese women

With the use of data from the hospital‐based epidemiologic research program at Aichi Cancer Center (HERPACC), the effect of body size on the risk of breast cancer was evaluated among Japanese women, who are generally leaner than white women. In total, 1,359 breast‐cancer cases were included, and 24,207 women, confirmed as free of cancer, were recruited as a reference group. Odds ratios (OR) and 95% confidence intervals (95% CI) were determined by multiple‐logistic regression analysis. Separate analyses were performed for pre‐ and post‐menopausal women. Furthermore, stratification by decade of age was done to evaluate the effect of body size on the development of breast cancer. The results obtained from the present study were as follows. (1) Current body‐mass index (BMI) was positively associated with post‐menopausal breast cancer (OR 2.08, 95% CI 1.49–2.92 for highest quintile vs. lowest), although higher BMI did not affect the risk in pre‐menopausal women. (2) Estimates of risk were below unity for BMI at around age 20 in post‐menopausal women. (3) After stratifying BMI at around age 20, gaining BMI in later life was positively associated with increased risk, regardless of BMI in early life. These findings suggest that avoidance of marked weight gain during adult life, especially after natural menopause and/or after age 60, may reduce the risk of breast cancer. Int. J. Cancer 80:349–355, 1999. © 1999 Wiley‐Liss, Inc.     

Does removal of out‐of‐pocket costs for cervical and breast cancer screening work? A quasi‐experimental study to evaluate the impact on attendance,attendance inequality and average cost per uptake of a Japanese government intervention

Reducing out‐of‐pocket costs is known to improve mammography attendance, but an evidence gap remains concerning Pap smear testing. The Japanese government implemented a politically determined intervention to remove out‐of‐pocket costs for Pap smear tests and mammography attendance, costing US$148 million, in 2009. It targeted women when they reached the first year of a 5‐year age group (i.e., 20, 25, 30 years) with the aim of reducing attendance inequality. Our objective is to evaluate the intervention in terms of uptake and average cost per uptake for cancer screening attendance and to assess socioeconomic inequalities in cancer screening attendance pre‐ and postintervention. A quasi‐experimental study utilizing national repeated cross sections, observed pre‐ and postintervention, which compared intervention and comparison groups by the Difference‐in‐Differences method, was conducted. Outcome measures were uptake of cancer screening attendance resulting from the intervention with average cost per uptake and broad inequality indicators for cancer screening attendance according to socioeconomic inequality. In total, 34,043 age‐eligible, noninstitutionalized women were analyzed. Uptake among the overall population was 13.9% point in the age‐ and income‐adjusted model for Pap smear and 9.8% point for mammography, with an average cost of US$139 per uptake. The intervention increased inequality indicators in Pap smear attendance (more than +100%) but decreased inequality in mammography attendance (ranging from −12.9 to −74.1%) within the intervention group. In conclusion, removing out‐of‐pocket costs improves female cancer screening uptake in Japan but may not be cost‐saving. Although cost removal reduces inequalities in attendance for mammography, it appears to increase inequalities in Pap smear attendance.     

Mindfulness-based cognitive therapy reduces chronic cancer-related fatigue: a treatment study

Introduction: About one‐third of cancer survivors suffer from severe chronic fatigue. Aim of this study was to evaluate the efficacy of mindfulness‐based cognitive group therapy in reducing severe chronic fatigue in cancer survivors with mixed diagnoses. Patients and Methods: Participants (n = 100) were randomly selected from a cohort and allocated to an intervention and a waiting list condition. Analyses were based on 59 participants in the intervention condition and 24 in the waiting‐list condition. Fatigue severity (Checklist Individual Strength), functional impairment (Sickness Impact Profile) and well being (Health and Disease‐Inventory) were assessed before and after the 9‐week intervention. The intervention group had a follow‐up 6 months following the intervention. Results: At post‐treatment measurement the proportion of clinically improved participants was 30%, versus 4% in the waiting list condition ( χ ² (1) = 6.71; p = 0.007). The mean fatigue score at post‐measurement was significantly lower in the intervention group than in the waiting list group corrected for pre‐treatment level of fatigue. The mean well‐being score at post‐measurement was significantly higher in the intervention group than in the waiting list group corrected for pre‐treatment level of well‐being. The treatment effect was maintained at 6‐month follow‐up. No difference between the two conditions was found in functional impairment. Discussion: Mindfulness‐based cognitive therapy is an effective treatment for chronic cancer‐related fatigue. Copyright © 2010 John Wiley & Sons, Ltd.     

Discussing sexuality in the clinical setting: The impact of a brief training program for oncology health professionals to enhance communication about sexuality

Aim: Cancer and its treatments can profoundly affect a person's sexuality and self‐image. However, oncology health professionals (OHP) are often reluctant to discuss these issues with patients. Cancer Council Victoria developed a short workshop to increase OHP's discussion of sexuality issues with cancer patients. We examined the immediate and longer term effect of workshop participation on perceived barriers to these discussions, their confidence in initiating the discussions, and changes in the frequency of their discussing sexuality issues with patients. Method: Twenty‐one workshops were conducted involving 155 OHP. The workshops were run by trained facilitators and incorporated cognitive, behavioral and experiential components. A major part of the workshop involved role‐playing with simulated patients (trained actors). Questionnaires assessing 20 perceived barriers, seven confidence items and seven practices concerning sexuality discussion were completed by the participants pre‐workshop, immediately post‐workshop, and 8‐weeks post‐workshop. Results: Overall 89 participants completed all three assessment phases. Data were analysed to assess change in perceived barriers, confidence and behavior across the three assessment points. Mean scores on 16 of the 20 barriers significantly decreased and scores on all seven confidence measures significantly increased between pre‐ and immediate post‐workshop. Most these changes were maintained 8 weeks later. The mean frequency of sexuality issue discussion in the previous 2 months increased significantly from 3.34 times at pre‐workshop to 3.82 times 8 weeks later (P = 0.003). Conclusion: This workshop appeared to reduce perceived barriers, increase confidence and increase actual practices around discussing sexuality issues with cancer patients.     

Tumor genome analysis includes germline genome: Are we ready for surprises?

We sought to describe the spectrum of potential and confirmed germline genomic events incidentally identified during routine medium‐throughput somatic tumor DNA sequencing, and to provide a framework for pre‐ and post‐test consent and counseling for patients and families. Targeted tumor‐only next‐generation sequencing (NGS) had been used to evaluate for possible druggable genomic events obtained from consecutive new patients with metastatic gastroesophageal, hepatobiliary or colorectal cancer seen at the University of Chicago. A panel of medical oncologists, cancer geneticists and genetic counselors retrospectively grouped these patients (N = 111) based on probability of possessing a potentially inherited mutation in a cancer susceptibility gene, both prior to and after incorporating tumor‐only NGS results. High‐risk patients (determined from NGS results) were contacted and counseled in person by a genetic counselor (N = 21). When possible and indicated, germline genetic testing was offered. Of 8 evaluable high‐risk patients, 7 underwent germline testing. Three (37.5%) had confirmed actionable germline mutations (all in the BRCA2 gene). NGS offers promise, but poses significant challenges for oncologists who are ill prepared to handle incidental findings that have clinical implications for at risk family members. In this relatively small cohort of patients undergoing tumor genomic testing for gastrointestinal malignancies, we incidentally identified 3 BRCA2 mutations carriers. This report underscores the need for oncologists to develop a framework for pre‐ and post‐test communication of risks to patients undergoing routine tumor‐only sequencing.     

Association between vitamin D and calcium intake and breast cancer risk according to menopausal status and receptor status in Japan

Although several studies have investigated the possible association between elevated vitamin D and calcium intake and low breast cancer risk, findings have been inconsistent. We conducted a case‐control study to clarify the association between vitamin D and calcium intake and breast cancer risk among pre‐ and post‐ menopausal women in Japan. We also investigated whether these effects were modified by tumor receptor status, specifically estrogen receptor (ER), progesterone receptor (PR), or human epidermal growth factor receptor‐2 (HER2) status. We examined 1803 breast cancer patients and 3606 age‐ and menopausal status‐matched noncancer controls. Among cases, 713 were assessed for ER, PR, and HER2 status. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated using conditional or unconditional logistic models adjusted for potential confounders. A significant inverse association was observed between vitamin D and calcium intake and breast cancer risk among all subjects, with top quartile ORs of 0.76 (95% CI, 0.63–0.90; trend P = 0.001) and 0.83 (95% CI, 0.69–0.99; trend P = 0.038), respectively. In analyses stratified by menopausal status, a significant association between risk and vitamin D was observed only among premenopausal women (trend P < 0.001), whereas that between risk and calcium intake was seen only among postmenopausal women (trend P = 0.022). Heterogeneity by menopausal status for these associations was statistically significant. This association was modified by tumor receptor status. These findings suggest that the protective effects of vitamin D and calcium intake against breast cancer risk may differ by menopausal status and receptor status. (Cancer Sci 2010; 101: 1234–1240)     

Effects of a nursing intervention on quality of life outcomes in post-surgical women with gynecological cancers

Objective: Women with gynecological cancers have reported poor health‐related quality of life (QOL), with complex physical and psychological needs post‐surgery and during chemotherapy treatment. There are no studies reporting interventions addressing these needs post‐hospital discharge in this population. Methods: Patients were randomized into two groups. The intervention group received 6 months of specialized care by an Advanced Practice Nurse (APN); in addition, women with high distress were evaluated and monitored by a psychiatric consultation–liaison nurse (PCLN). The attention control group was assisted with symptom management by a research assistant. The effects of the 6‐month intervention were evaluated using self‐report questionnaires at baseline (24–48 h after surgery), 1, 3, and 6 months post‐ surgery. QOL assessments included the Center for Epidemiological Studies–Depression Scale , the ambiguity subscale of the Mishel Uncertainty in Illness Scale , the Symptom Distress Scale, and the Short‐Form Health Survey (SF‐12). The sample for the longitudinal analysis included 123 who completed QOL outcome measures across three occasions post‐surgery. Results: The APN intervention resulted in significantly less uncertainty than the attention control intervention 6 months after surgery. When the sub‐group who received the APN plus PCLN intervention was compared with the total attention control group, the sub‐group had significantly less uncertainty, less symptom distress, and better SF‐12 mental and physical QOL over time. Conclusion: Nurse tailored interventions that target both physical and psychological aspects of QOL in women recovering from cancer surgery and undergoing chemotherapy produce stronger outcomes than interventions that target solely one QOL aspect. Copyright © 2008 John Wiley & Sons, Ltd.     

Clinical 24 month experience of the first MRgFUS Unit for treatment of uterine fibroids in Australia

Aim: To describe and evaluate treatment of uterine fibroids using Magnetic Resonance Guided Focused Ultrasound (MRgFUS) during its first 24 months of use at The Royal Women's Hospital Melbourne. Methods: One hundred Victorian women were treated with MRgFUS using the ExAblate 2000 system. Treatment outcomes based on fibroid volume shrinkage measured at 4 and 12 months post‐treatment and symptom severity score assessment (Symptom Severity Score Quality of Life – SSS‐QOL) pre‐ and post‐ (4–6 weeks, 4, 6 and 12 months) treatment. Results: Mean non‐perfused volume of the treated fibroids were 67% ± 25% (n = 100) immediately post‐treatment. At 4 months post‐treatment, the treated fibroids demonstrated an average volume reduction of 29% ± 32% (n = 74) and at 12 months 38% ± 45% (n = 32). Mean symptom severity scores (SSS‐QOL) improved by 51% from 59 ± 21 (n = 97) at baseline to 29 ± 17 (n = 36) by 12 months. Conclusion: From our experience, we believe there is a role for MRgFUS in the treatment of uterine fibroids in selected women.     

Psychological wellness and health‐related stigma: a pilot study of an acceptance‐focused cognitive behavioural intervention for people with lung cancer

People with lung cancer experience health‐related stigma that is related to poorer psychosocial and quality of life outcomes. The present Phase 1 study applied mixed methods to test the acceptability of an acceptance‐focused cognitive behavioural intervention targeting stigma for this patient group. Fourteen lung cancer patients completed a 6‐week Psychological Wellness intervention with pre‐ and post‐test outcome measures of psychological and cancer‐specific distress, depression, health‐related stigma and quality of life. In‐depth interviews applying interpretative phenomenological analysis assessed participants' experiences of the intervention. Moderate to large improvements were observed in psychological (η_p² = 0.182) and cancer‐specific distress (η_p² = 0.056); depression (η_p² = 0.621); health‐related stigma (η_p² = 0.139). In contrast, quality of life declined (η_p² = 0.023). The therapeutic relationship; self‐management of distress; and relationship support were highly valued aspects of the intervention. Barriers to intervention included avoidance and practical issues. The lung cancer patients who completed the Psychological Wellness intervention reported improvements in psychological outcomes and decreases in stigma in the face of declining quality of life with patients reporting personal benefit from their own perspectives. A randomised controlled trial is warranted to establish the effectiveness of this approach.     

Pulmonary embolism: Are we there yet?

Introduction: Clinical prediction rules (such as Wells model) are a reliable assessment tool for diagnostic work‐up of suspected pulmonary embolism (PE). When used as part of a clinical algorithm and in combination with a D‐Dimer, the model can safely exclude PE in low‐risk groups and indicate when further investigations are unnecessary. The purpose of this study was to investigate the level of adherence to local diagnostic imaging guidelines for suspected PE and to ascertain the impact of interventions. Methods: Retrospective search of all patients referred from the Emergency Department (ED) of Royal Perth Hospital for computed tomography pulmonary angiography (CTPA) or V/Q scan between 11 September 2005 to 10 March 2006 (pre‐intervention) and 1 January 2008 to 31 March 2008 (post‐intervention) was conducted. The guidelines on ‘Diagnostic Imaging Pathways’ were considered as gold standard. Interventions included orienting ED doctors to guidelines and modified request forms for mandatory completion of Wells score. A prevalence‐ and bias‐adjusted kappa (PABAK) score analysed the level of agreement between documentation on notes (R‐score) and stamp (S‐score). Results: Thirty‐five per cent (n = 187) and 22% (n = 109) deviated from the pathway pre‐intervention and post‐intervention, respectively (13% absolute reduction; P = 0.017). Stamp compliance was only 55% despite mandatory filling requirement. PABAK for ‘PE as most likely diagnosis’ was 0.25 for V/Q group and – 0.26 for CTPA. In addition, 44/60 (73%) had an intermediate or high S‐score, yet only 11 of those 44 had a matched intermediate to high R‐Score. Conclusions: Interventions reduced inappropriate practice but did not eliminate it completely. Compliance issues may be managed in the future via the introduction of electronic request linked to decision support.     

The upper‐limb volumetric changes in breast cancer survivors with axillary web syndrome

Whether upper‐limb swelling is associated with axillary web syndrome (AWS) is unknown. We recruited unilateral breast cancer (BC) patients who were scheduled for surgical intervention and lymph node dissection. The pre‐operative assessment and post‐operative assessment 3–4 weeks after surgery evaluated the upper‐limb circumferential measurements, segmental limb volume, pain scores, grasp, shoulder range of motion (ROM), shoulder muscle power and quality‐of‐life scores. In the control group, the peri‐elbow volume and upper‐arm volume were significantly higher post‐operatively than pre‐operatively. In the AWS group, no significant difference was found. In comparison with the control group, the AWS group had significantly more pain, less active ROM in shoulder abduction and a lower upper‐limb volume at 0–10 cm proximal to the lateral epicondyle. The incidence of lymphedema was 9.9% and was not associated with AWS. AWS is a common morbidity of lymph node dissection and causes significant pain and restricted shoulder abduction in the affected limb in BC survivors. This study is the first to investigate post‐operative upper‐limb volumetric changes in BC survivors with and without AWS. Our findings are of great value for the clinical effect of AWS in BC survivors, for patient education, and for developing diagnostic tools for detecting AWS.     

Dietary intakes of mushrooms and green tea combine to reduce the risk of breast cancer in Chinese women

To investigate effects of dietary mushrooms and joint effects of mushrooms and green tea on breast cancer, a case–control study was conducted in southeast China in 2004–2005. The incident cases were 1,009 female patients aged 20–87 years with histologically confirmed breast cancer. The 1,009 age‐matched controls were healthy women randomly recruited from outpatient breast clinics. Information on frequency and quantity of dietary intake of mushrooms and tea consumption, usual diet, and lifestyle were collected by face‐to‐face interview using a validated and reliable questionnaire. Compared with nonconsumers, the Odds ratios (Ors) were 0.36 (95% CI = 0.25–0.51) and 0.53 (0.38–0.73) for daily intake of ≥10 g fresh mushrooms and ≥4 g dried mushrooms, based on multivariate logistic regression analysis adjusting for established and potential confounders. There were dose–response relationships with significant tests for trend (p < 0.001). The inverse association was found in both pre‐ and postmenopausal women. Compared with those who consumed neither mushrooms nor green tea, the ORs were 0.11 (0.06–0.20) and 0.18 (0.11–0.29) for daily high intake of fresh and dried mushrooms combined with consuming beverages made from ≥1.05 g dried green tea leaves per day. The corresponding linear trends were statistically significant for joint effect (p < 0.001). We conclude that higher dietary intake of mushrooms decreased breast cancer risk in pre‐ and postmenopausal Chinese women and an additional decreased risk of breast cancer from joint effect of mushrooms and green tea was observed. More research is warranted to examine the effects of dietary mushrooms and mechanism of joint effects of phytochemicals on breast cancer. © 2008 Wiley‐Liss, Inc.