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Evidence reviews for lifestyle
Evidence review K
NICE Guideline, No. 101
National Guideline Alliance (UK).
Lifestyle
This evidence report contains information on 1 review relating to lifestyle.
- Review question 11.1 What lifestyle changes improve breast cancer-specific outcomes in people treated for early and locally advanced breast cancer?
Review question 11.1. What lifestyle changes improve breast cancer-specific outcomes in people treated for early and locally advanced breast cancer?
Introduction
Survival rates in breast cancer are steadily improving thanks to earlier detection, better diagnostics and treatments. However, data is now emerging regarding the impact of lifestyle choices on outcomes following treatment for breast cancer.
Disease recurrence, survival and emotional well-being are all potentially affected by the lifestyle choices and changes people make following treatment for breast cancer. It is important that people can be advised and informed of the evidence-based benefits of lifestyle changes. This information will support and empower people in making informed decisions to support breast cancer survivorship, potentially improving disease specific outcome.
The aim of this review is to determine which lifestyle changes improve breast cancer-specific outcomes and develop recommendations to guide discussion and advice.
PICO table
See Table 1 for a summary of the population, intervention, comparison and outcome (PICO) characteristics of this review.
Table 1
Summary of the protocol (PICO table).
For full details see review protocol in appendix A.
Methods and process
This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual; see the methods chapter for further information.
Declarations of interest were recorded according to NICE’s 2014 conflicts of interest policy.
Clinical evidence
Included studies
Seven studies (number of participants, N=11,361) identified by literature search were included in the review. These included 3 randomized controlled trials (RCTs; Anderson 2008; Chlebowski 2006; Courneya 2014) and 4 cohort studies (Bertram 2011; Chen 2011; Fentiman 2005 & Kwan 2010). All 7 studies reported on disease free survival and 6 reported on overall survival rate. None of the studies reported on intervention-related morbidities or health related quality of life. Evidence from these studies are summarised in the clinical GRADE evidence profiles below (Table 3 to Table 8).
See also the study selection flow chart in appendix C, forest plots in appendix E, and study evidence tables in appendix D.
Excluded studies
Studies not included in this review with reasons for their exclusions are provided in appendix K.
Summary of clinical studies included in the evidence review
Table 2 provides a brief summary of the included studies
Table 2
Summary of included studies.
See appendix D for full evidence tables.
Quality assessment of clinical studies included in the evidence review
The clinical evidence profile for this review question (lifestyle changes to improve breast cancer-specific outcomes) is presented in Table 3 through to Table 8. The included evidence was of moderate to very low quality. Main reasons for downgrading evidence was inconsistency due to heterogeneity in outcomes, imprecision around the estimates due to a small number of events and indirectness due to use of recurrence data instead of disease free survival.
Table 3
Summary clinical evidence profile: Comparison 1. Stress management intervention versus standard care.
Table 4
Summary clinical evidence profile: Comparison 2. Physical activity intervention versus standard care.
Table 5
Summary clinical evidence profile: Comparison 3. Physical activity versus standard care.
Table 6
Summary clinical evidence profile: Comparison 4. Dietary intervention aimed at reducing fat intake versus standard care.
Table 7
Summary clinical evidence profile: Comparison 5. Smokers versus nonsmokers.
Table 8
Summary clinical evidence profile: Comparison 6. Alcohol versus no alcohol.
See appendix F for full GRADE tables.
Economic evidence
A systematic review of the economic literature was conducted but no relevant studies were identified which were applicable to this review question. Economic modelling was not undertaken for this question because other topics were agreed as higher priorities for economic evaluation.
Evidence statements
Comparison 1. Stress management intervention versus standard care
Critical outcomes
Overall survival
- There is moderate quality evidence from 1 RCT (N=227) that stress management intervention brings a clinically meaningful increase in overall survival at 11 years follow up compared with no intervention for people with invasive breast cancer.
Disease free survival
- There is low quality evidence from 1 RCT (N=227) that stress management intervention brings a clinically meaningful increase in disease free survival at 11 years follow up compared with no intervention for people with invasive breast cancer.
Important outcomes
Intervention related morbidity
- No evidence was found for this outcome.
Health-related quality of life
- No evidence was found for this outcome.
Comparison 2. Physical activity intervention versus standard care
Critical outcomes
Overall survival
- There is very low quality evidence from 1 RCT(N=242) that physical activity intervention does not bring a clinically meaningful change in overall survival at 7.4 years follow up compared with no intervention for people with invasive breast cancer.
Disease free survival
- There is very low quality evidence from 1 RCT(N=242) that physical activity intervention does not bring a clinically meaningful change in disease free survival at 7.4 years follow up compared with no intervention for people with invasive breast cancer.
Important outcomes
Intervention related morbidity
- No evidence was found for this outcome.
Health-related quality of life
- No evidence was found for this outcome.
Comparison 3. Physical activity versus standard care
Critical outcomes
Overall survival
- There is very low quality evidence from 2 cohort studies (N=6872) that physical activity brings a clinically meaningful increase in overall survival (4 to 7 years follow up) compared with no physical activity for people with invasive breast cancer.
Disease free survival
- There is very low quality evidence from 2 cohort studies (N=6872) that physical activity brings a clinically meaningful increase in disease free survival (4 to 7 years follow up) compared with no physical activity for people with invasive breast cancer.
Important outcomes
Intervention related morbidity
- No evidence was found for this outcome.
Health-related quality of life
- No evidence was found for this outcome.
Comparison 4. Dietary intervention aimed at reducing fat intake versus standard care
Critical outcomes
Overall survival
- There is low quality evidence from 1 RCT (N=2437) that dietary intervention does not bring a clinically meaningful change in overall survival at 5 years follow up compared with no intervention for people with invasive breast cancer.
Disease free survival
- There is moderate quality evidence from 1 RCT (N=2437) that dietary intervention brings a clinically meaningful increase in disease free survival at 5 years follow up compared with no intervention for people with invasive breast cancer.
Important outcomes
Intervention related morbidity
- No evidence was found for this outcome.
Health-related quality of life
- No evidence was found for this outcome.
Comparison 5. Smokers versus non-smokers
Critical outcomes
Overall survival
- There is very low quality evidence from 1 cohort study (N=166) that smoking status does not bring a clinically meaningful change in overall survival at 11 years follow up compared with no intervention for people with invasive breast cancer.
Disease free survival
- There is very low quality evidence from 1 cohort study (N=166) that smoking status does not bring a clinically meaningful change in disease free survival at 11 years follow up compared with no intervention for people with invasive breast cancer.
Important outcomes
Intervention related morbidity
- No evidence was found for this outcome.
Health-related quality of life
- No evidence was found for this outcome.
Comparison 6. Alcohol versus no alcohol
Critical outcomes
Overall survival
- No evidence was found for this outcome.
Disease free survival
- There is very low quality evidence from 1 cohort study (N=1417) that consuming ≥6 gm/day of alcohol brings clinically meaningful decrease in disease free survival at 7.4 years follow up compared with no drinking for people with invasive breast cancer.
Important outcomes
Intervention related morbidity
- No evidence was found for this outcome.
Health-related quality of life
- No evidence was found for this outcome.
The committee’s discussion of the evidence
Interpreting the evidence
The outcomes that matter most
Since this review question was about lifestyle interventions to improve breast cancer specific outcomes, disease free survival and overall survival were considered as most important and were included as critical outcomes. Health-related quality of life (HRQoL) and intervention-related morbidities were considered important outcomes. There was no evidence for health related quality of life or intervention related morbidities.
The quality of the evidence
The quality of evidence for this review was assessed using GRADE. For the comparison stress management intervention versus no intervention, the evidence was moderate to low quality due to imprecision because of small number of events and indirectness due to inclusion of relapse free survival events instead of disease free survival events.
For the comparison of physical activity intervention versus standard care, the evidence from one randomized controlled trial was very low quality due to imprecision because of small number of wide confidence intervals and indirectness due to two different types of physical activity groups in intervention group. For this comparison, evidence from two cohort studies was of very low quality. The evidence was downgraded due observational study design, inconsistency due to I2 of 89% and indirectness due to inclusion of some stage 3b cases in one study.
The evidence for comparison dietary intervention aimed at reducing fat intake versus standard care was moderate to low quality. The main reasons for downgrading evidence was risk of bias and imprecision due to wide confidence interval.
The evidence for comparisons smoking versus no smoking and alcohol consumption compared to no alcohol drinking was very low quality. The reason for downgrading for the comparison smoking versus no smoking was observational study design, imprecision due to small number of events, wide confidence intervals and indirectness due to inclusion of distant relapse free survival data for disease free survival. The main reason for downgrading evidence for the comparison of alcohol versus no alcohol was indirectness, as recurrence was reported instead of disease free survival, and also as this was an observational study.
Benefits and harms
The committee discussed that there is evidence that engaging in physical activity and maintaining a healthy weight are associated with improved disease-free survival in people with invasive breast cancer. The evidence for a dietary intervention was a reduced fat diet that led to weight loss, and the committee agreed that the benefit was likely to be due to weight loss, and not the low fat diet per se.
Evidence from one cohort study showed higher recurrence events for those adults with invasive breast cancer consuming greater than 3–4 alcohol drinks per week or 6g of alcohol per day. The committee discussed that this translates to approximately 5 units of alcohol per week and agreed that people with breast cancer should be advised that alcohol intake less than this limit is associated with a lower risk of recurrence.
The committee also discussed that there can also be general physical and mental health benefits with healthier lifestyle with potential of improvement in health related quality of life and reduced rates of depression in those who undertake regular exercise.
Although there was no evidence regarding clinically meaningful change in breast cancer outcomes from smoking, the committee agreed that doctors will raise smoking cessation with smokers as usual practice.
The committee discussed that potential harms from the recommendations could be people feeling guilty or stigmatised if recurrence is seen as their fault for not being healthier. Another potential harm discussed by the committee was the potential decrease in health-related quality of life (HRQoL) if people have to adjust their lifestyles (drinking less alcohol, taking more exercise) to fit with the advice.
There was evidence that the stress management intervention improves disease free survival and overall survival in people with invasive breast cancer. However, no separate recommendation was made for this intervention as stress management was already included in the recommendations on the provision of information and psychological support.
Cost effectiveness and resource use
A systematic review of the economic literature was conducted but no relevant studies were identified which were applicable to this review question.
The committee discussed that there could be potential increase in uptake of weight reduction and alcohol reduction services and possibly exercise classes, but these may also be accessed by many people on a ‘self-help’ basis and so may not increase costs to the NHS.
The committee also discussed that there may be a reduction in the cost to the NHS as a result of reduced breast cancer recurrence and associated management. There could be further cost savings as a result of people being generally healthier with a healthy weight which should result in a reduction in the rate of other comorbidities such as cardiovascular disease and diabetes.
Other factors the committee took into account
The committee were aware of a NICE alcohol and breast cancer fact sheet which provided similar advice. However, the fact sheet was aimed at preventing breast cancer, and the committee therefore did not feel it was relevant to a population who already had a diagnosis of breast cancer and therefore did not cross-refer to it in their recommendations. However, they were also aware of a NICE guideline on obesity, which defined healthy weight ranges, and so cross-referred to this instead of defining a healthy weight in their recommendations, and also referred to the NICE guideline on physical activity.
References
Andersen 2008
Andersen, B.L., Yang, H.C., Farrar, W.B., Golden-Kreutz, D.M., Emery, C.F., Thornton, L.M., Young, D.C., Carson, W.E. (2008) Psychologic intervention improves survival for breast cancer patients: a randomized clinical trial. Cancer, 113, 3450–3458. [PMC free article: PMC2661422] [PubMed: 19016270]Bertram 2011
Bertram, L. A. C., Stefanick, M. L., Saquib, N., Natarajan, L., Patterson, R. E., Bardwell, W., Flatt, S. W., Newman, V. A., Rock, C. L., Thomson, C. A., Pierce, J. P. (2011) Physical activity, additional breast cancer events, and mortality among early-stage breast cancer survivors: Findings from the WHEL Study. Cancer Causes and Control, 22, 427–435. [PMC free article: PMC3042101] [PubMed: 21184262]Chen 2011
Chen, X., Lu, W., Zheng, W., Gu, K., Matthews, C. E., Chen, Z., Zheng, Y., Shu, X. O. (2011) Exercise after diagnosis of breast cancer in association with survival. Cancer Prevention Research, 4, 1409–1418. [PMC free article: PMC3169008] [PubMed: 21795422]Chlebowski 2006
Chlebowski, R. T., Blackburn, G. L., Thomson, C. A., Nixon, D. W., Shapiro, A., Hoy, M. K., Goodman, M. T., Giuliano, A. E., Karanja, N., McAndrew, P., Hudis, C., Butler, J., Merkel, D., Kristal, A., Caan, B., Michaelson, R., Vinciguerra, V., Del Prete, S., Winkler, M., Hall, R., Simon, M., Winters, B. L., Elashoff, R. M. (2006) Dietary fat reduction and breast cancer outcome: Interim efficacy results from the women’s intervention nutrition study. Journal of the National Cancer Institute, 98, 1767–1776. [PubMed: 17179478]Courneya 2014
Courneya, K. S., Segal, R. J., McKenzie, D. C., Dong, H., Gelmon, K., Friedenreich, C. M., Yasui, Y., Reid, R. D., Crawford, J. J., Mackey, J. R. (2014) Effects of exercise during adjuvant chemotherapy on breast cancer outcomes. Medicine & Science in Sports & Exercise, 46, 1744–51. [PubMed: 24633595]Fentiman 2005
Fentiman, I. S., Allen, D. S., Hamed, H. (2005) Smoking and prognosis in women with breast cancer. International journal of clinical practice, 59, 1051–1054. [PubMed: 16115181]Kwan 2010
Kwan, M. L., Kushi, L. H., Weltzien, E., Tam, E. K., Castillo, A., Sweeney, C., Caan, B. J. (2010) Alcohol consumption and breast cancer recurrence and survival among women with early-stage breast cancer: the life after cancer epidemiology study. Journal of Clinical Oncology, 28, 4410–6. [PMC free article: PMC2988633] [PubMed: 20805458]
Appendices
Appendix A. Review protocols
Appendix B. Literature search strategies
Database: Medline & Embase (Multifile)
Last searched on Embase 1974 to 2017 September 12, Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations and Ovid MEDLINE(R) 1946 to Present.
Date of last search: 13 September 2017.
| # | Searches |
|---|---|
| 1 | exp breast cancer/ use oemezd |
| 2 | exp breast carcinoma/ use oemezd |
| 3 | exp medullary carcinoma/ use oemezd |
| 4 | exp intraductal carcinoma/ use oemezd |
| 5 | exp breast tumor/ use oemezd |
| 6 | exp Breast Neoplasms/ use prmz |
| 7 | exp “Neoplasms, Ductal, Lobular, and Medullary”/ use prmz |
| 8 | Carcinoma, Intraductal, Noninfiltrating/ use prmz |
| 9 | Carcinoma, Lobular/ use prmz |
| 10 | Carcinoma, Medullary/ use prmz |
| 11 | 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 |
| 12 | exp breast/ use oemezd |
| 13 | exp Breast/ use prmz |
| 14 | breast.tw. |
| 15 | 12 or 13 or 14 |
| 16 | (breast adj milk).tw. |
| 17 | (breast adj tender$).tw. |
| 18 | 16 or 17 |
| 19 | 15 not 18 |
| 20 | exp neoplasm/ use oemezd |
| 21 | exp Neoplasms/ use prmz |
| 22 | 20 or 21 |
| 23 | 19 and 22 |
| 24 | (breast$ adj5 (neoplasm$ or cancer$ or tumo?r$ or carcinoma$ or adenocarcinoma$ or sarcoma$ or leiomyosarcoma$ or dcis or duct$ or infiltrat$ or intraduct$ or lobul$ or medullary or tubular)).tw. use oemezd |
| 25 | (mammar$ adj5 (neoplasm$ or cancer$ or tumo?r$ or carcinoma$ or adenocarcinoma$ or sarcoma$ or leiomyosarcoma$ or dcis or duct$ or infiltrat$ or intraduct$ or lobul$ or medullary or tubular)).tw. use oemezd |
| 26 | (breast$ adj5 (neoplasm$ or cancer$ or tumo?r$ or carcinoma$ or adenocarcinoma$ or sarcoma$ or leiomyosarcoma$ or dcis or duct$ or infiltrat$ or intraduct$ or lobul$ or medullary or tubular)).mp. use prmz |
| 27 | (mammar$ adj5 (neoplasm$ or cancer$ or tumo?r$ or carcinoma$ or adenocarcinoma$ or sarcoma$ or leiomyosarcoma$ or dcis or duct$ or infiltrat$ or intraduct$ or lobul$ or medullary or tubular)).mp. use prmz |
| 28 | exp Paget nipple disease/ use oemezd |
| 29 | Paget’s Disease, Mammary/ use prmz |
| 30 | (paget$ and (breast$ or mammary or nipple$)).tw. |
| 31 | 23 or 24 or 25 or 26 or 27 or 28 or 29 or 30 |
| 32 | 11 or 31 |
| 33 | exp Smoking Cessation/ use prmz |
| 34 | exp “Tobacco Use Cessation”/ use prmz |
| 35 | exp “Tobacco Use Cessation Products”/ use prmz |
| 36 | exp “Tobacco Use Disorder”/ use prmz |
| 37 | Smoking/pc, th use prmz |
| 38 | exp smoking cessation/ use oemezd |
| 39 | exp nicotine gum/ use oemezd |
| 40 | exp smoking/pc, th use oemezd |
| 41 | (smoking adj3 (cessation or ceas$ or intervention or withdrawal or quit$ or stop$ or reduc$)).tw. |
| 42 | Weight Loss/ use prmz |
| 43 | weight reduction/ use oemezd |
| 44 | Weight Reduction Programs/ use prmz |
| 45 | weight loss program/ use oemezd |
| 46 | ((caloric or hypocaloric) adj2 (restrict* or diet*)).tw. |
| 47 | (weight adj3 (los$ or reduc$ or manag$ or intervention)).tw. |
| 48 | exp Diet Therapy/ use prmz |
| 49 | exp diet therapy/ use oemezd |
| 50 | Energy Intake/ use prmz |
| 51 | dietary intake/ use oemezd |
| 52 | (diet$ adj3 (manag$ or intervention or modif$)).tw. |
| 53 | ((health$ adj eat$) or (eat$ adj health$)).tw. |
| 54 | (balanced adj diet$).tw. |
| 55 | Alcohol Drinking/ use prmz |
| 56 | exp Drinking Behavior/ use prmz |
| 57 | drinking behavior/ use oemezd |
| 58 | ((alcohol$ or drink$) adj3 (cessation or ceas$ or intervention or withdrawal or quit$ or stop$)).tw. |
| 59 | ((alcohol$ or drink$) adj (level$ or consumption)).tw. |
| 60 | exp Life Style/ use prmz |
| 61 | exp lifestyle/ use oemezd |
| 62 | lifestyle modification/ use oemezd |
| 63 | ((lifestyle$ or life-style$) adj3 (advice$ or intervention$ or modif$ or change$ or recommend$)).tw. |
| 64 | Health Behavior/ use prmz |
| 65 | health behavior/ use oemezd |
| 66 | exp Cognitive Therapy/ use prmz |
| 67 | *Behavior Therapy/ use prmz |
| 68 | exp cognitive behavioral therapy/ use oemezd |
| 69 | *behavior therapy/ use oemezd |
| 70 | ((behaviour$ or behavior$ or psycholog$) adj3 (advice$ or intervention$ or modif$ or change$ or recommend$)).tw. |
| 71 | Stress, Psychological/ use prmz |
| 72 | exp Adaptation, Psychological/ use prmz |
| 73 | exp Mind-Body Therapies/ use prmz |
| 74 | stress management/ use oemezd |
| 75 | adaptive behavior/ use oemezd |
| 76 | alternative medicine/ use oemezd |
| 77 | (stress adj3 (manag$ or intervention$ or recommend$)).tw. |
| 78 | exp Exercise/ use prmz |
| 79 | exp Exercise Movement Techniques/ use prmz |
| 80 | exp Exercise Therapy/ use prmz |
| 81 | exp exercise/ use oemezd |
| 82 | exp kinesiotherapy/ use oemezd |
| 83 | exp physical activity/ use oemezd |
| 84 | ((exercis$ or activit$) adj3 (advice$ or intervention$ or modif$ or change$ or recommend$ or manag$)).tw. |
| 85 | or/33–84 |
| 86 | 32 and 85 |
| 87 | quality-adjusted life years/ use prmz |
| 88 | quality adjusted life year/ use oemezd |
| 89 | “quality of life index”/ use oemezd |
| 90 | short form 12/ or short form 20/ or short form 36/ or short form 8/ use oemezd |
| 91 | sickness impact profile/ use prmz |
| 92 | sickness impact profile/ use oemezd |
| 93 | (quality adj2 (wellbeing or well being)).ti,ab. |
| 94 | sickness impact profile.ti,ab. |
| 95 | disability adjusted life.ti,ab. |
| 96 | (qal* or qtime* or qwb* or daly*).ti,ab. |
| 97 | (euroqol* or eq5d* or eq 5*).ti,ab. |
| 98 | (qol* or hql* or hqol* or h qol* or HRQoL* or hr qol*).ti,ab. |
| 99 | (health utility* or utility score* or disutilit* or utility value*).ti,ab. |
| 100 | (hui or hui1 or hui2 or hui3).ti,ab. |
| 101 | (health* year* equivalent* or hye or hyes).ti,ab. |
| 102 | discrete choice*.ti,ab. |
| 103 | rosser.ti,ab. |
| 104 | (willingness to pay or time tradeoff or time trade off or tto or standard gamble*).ti,ab. |
| 105 | (sf36* or sf 36* or short form 36* or shortform 36* or shortform36*).ti,ab. |
| 106 | (sf20 or sf 20 or short form 20 or shortform 20 or shortform20).ti,ab. |
| 107 | (sf12* or sf 12* or short form 12* or shortform 12* or shortform12*).ti,ab. |
| 108 | (sf8* or sf 8* or short form 8* or shortform 8* or shortform8*).ti,ab. |
| 109 | (sf6* or sf 6* or short form 6* or shortform 6* or shortform6*).ti,ab. |
| 110 | 87 or 88 or 89 or 90 or 91 or 92 or 93 or 94 or 95 or 96 or 97 or 98 or 99 or 100 or 101 or 102 or 103 or 104 or 105 or 106 or 107 or 108 or 109 |
| 111 | disease-free survival/ use prmz |
| 112 | disease free survival/ use oemezd |
| 113 | recurrence free survival/ use oemezd |
| 114 | (disease$ adj free$ adj surviv$).tw. |
| 115 | (relaps$ adj free$ adj surviv$).tw. |
| 116 | (recurren$ adj free$ adj surviv$).tw. |
| 117 | (DFS or DFSR).tw. |
| 118 | (RFS or RFSR).tw. |
| 119 | ((disease$ adj free$) or (relaps$ adj free$) or (recurren$ adj free$)).tw. |
| 120 | *cancer survival/ use oemezd |
| 121 | cancer specific survival/ use oemezd |
| 122 | (breast$ adj cancer$ adj survival).tw. |
| 123 | (breast$ adj cancer$ adj specific$).tw. |
| 124 | 111 or 112 or 113 or 114 or 115 or 116 or 117 or 118 or 119 or 120 or 121 or 122 or 123 |
| 125 | meta-analysis/ |
| 126 | meta-analysis as topic/ |
| 127 | systematic review/ |
| 128 | meta-analysis/ |
| 129 | (meta analy* or metanaly* or metaanaly*).ti,ab. |
| 130 | ((systematic or evidence) adj2 (review* or overview*)).ti,ab. |
| 131 | ((systematic* or evidence*) adj2 (review* or overview*)).ti,ab. |
| 132 | (reference list* or bibliograph* or hand search* or manual search* or relevant journals).ab. |
| 133 | (search strategy or search criteria or systematic search or study selection or data extraction).ab. |
| 134 | (search* adj4 literature).ab. |
| 135 | (medline or pubmed or cochrane or embase or psychlit or psyclit or psychinfo or psycinfo or cinahl or science citation index or bids or cancerlit).ab. |
| 136 | cochrane.jw. |
| 137 | ((pool* or combined) adj2 (data or trials or studies or results)).ab. |
| 138 | or/125–126,129,131–136 use prmz |
| 139 | or/127–130,132–137 use oemezd |
| 140 | 138 or 139 |
| 141 | 86 and 110 |
| 142 | 86 and 124 |
| 143 | 86 and 140 |
| 144 | survival.tw. |
| 145 | 143 and 144 |
| 146 | 141 or 142 or 145 |
| 147 | remove duplicates from 146 [and general exclusions filter applied] |
Database: Cochrane Library via Wiley Online
Date of last search: 13 September 2017
| # | Searches |
|---|---|
| #1 | MeSH descriptor: [Breast Neoplasms] explode all trees |
| #2 | MeSH descriptor: [Neoplasms, Ductal, Lobular, and Medullary] explode all trees |
| #3 | MeSH descriptor: [Carcinoma, Intraductal, Noninfiltrating] explode all trees |
| #4 | MeSH descriptor: [Carcinoma, Lobular] this term only |
| #5 | MeSH descriptor: [Carcinoma, Medullary] this term only |
| #6 | #1 or #2 or #3 or #4 or #5 |
| #7 | MeSH descriptor: [Breast] explode all trees |
| #8 | breast:ti,ab,kw (Word variations have been searched) |
| #9 | #7 or #8 |
| #10 | (breast next milk):ti,ab,kw (Word variations have been searched) |
| #11 | (breast next tender*):ti,ab,kw (Word variations have been searched) |
| #12 | #10 or #11 |
| #13 | #9 not #12 |
| #14 | MeSH descriptor: [Neoplasms] explode all trees |
| #15 | #13 and #14 |
| #16 | (breast* near/5 (neoplasm* or cancer* or tumo?r* or carcinoma* or adenocarcinoma* or sarcoma* or leiomyosarcoma* or dcis or duct* or infiltrat* or intraduct* or lobul* or medullary or tubular)):ti,ab,kw (Word variations have been searched) |
| #17 | (mammar* near/5 (neoplasm* or cancer* or tumo?r* or carcinoma* or adenocarcinoma* or sarcoma* or leiomyosarcoma* or dcis or duct* or infiltrat* or intraduct* or lobul* or medullary or tubular)):ti,ab,kw (Word variations have been searched) |
| #18 | MeSH descriptor: [Paget’s Disease, Mammary] this term only |
| #19 | (paget* and (breast* or mammary or nipple*)):ti,ab,kw (Word variations have been searched) |
| #20 | #15 or #16 or #17 or #18 or #19 |
| #21 | #6 or #20 |
| #22 | MeSH descriptor: [Smoking Cessation] explode all trees |
| #23 | MeSH descriptor: [Tobacco Use Cessation] explode all trees |
| #24 | MeSH descriptor: [Tobacco Use Cessation Products] explode all trees |
| #25 | MeSH descriptor: [Tobacco Use Disorder] explode all trees |
| #26 | (smoking near/3 (cessation or ceas* or intervention or withdrawal or quit* or stop* or reduc*)):ti,ab,kw (Word variations have been searched) |
| #27 | MeSH descriptor: [Weight Loss] this term only |
| #28 | MeSH descriptor: [Weight Reduction Programs] this term only |
| #29 | (weight near/3 (los* or reduc* or manag* or intervention)):ti,ab,kw (Word variations have been searched) |
| #30 | ((caloric or hypocaloric) near/2 (restrict* or diet*)):ti,ab,kw (Word variations have been searched) |
| #31 | MeSH descriptor: [Diet Therapy] explode all trees |
| #32 | MeSH descriptor: [Energy Intake] this term only |
| #33 | (diet* near/3 (manag* or intervention or modif*)):ti,ab,kw (Word variations have been searched) |
| #34 | ((health* next eat*) or (eat* next health*)):ti,ab,kw (Word variations have been searched) |
| #35 | (balanced next diet*):ti,ab,kw (Word variations have been searched) |
| #36 | MeSH descriptor: [Alcohol Drinking] this term only |
| #37 | MeSH descriptor: [Drinking Behavior] explode all trees |
| #38 | ((alcohol* or drink*) near/3 (cessation or ceas* or intervention or withdrawal or quit* or stop*)):ti,ab,kw (Word variations have been searched) |
| #39 | ((alcohol* or drink*) next (level* or consumption)):ti,ab,kw (Word variations have been searched) |
| #40 | MeSH descriptor: [Life Style] explode all trees |
| #41 | ((lifestyle* or life-style*) near/3 (advice* or intervention* or modif* or change* or recommend*)):ti,ab,kw (Word variations have been searched) |
| #42 | MeSH descriptor: [Health Behavior] this term only |
| #43 | MeSH descriptor: [Cognitive Therapy] explode all trees |
| #44 | MeSH descriptor: [Behavior Therapy] this term only |
| #45 | ((behaviour* or behavior* or psycholog*) near/3 (advice* or intervention* or modif* or change* or recommend*)):ti,ab,kw (Word variations have been searched) |
| #46 | MeSH descriptor: [Stress, Psychological] this term only |
| #47 | MeSH descriptor: [Adaptation, Psychological] explode all trees |
| #48 | MeSH descriptor: [Mind-Body Therapies] explode all trees |
| #49 | (stress near/3 (manag* or intervention* or recommend*)):ti,ab,kw (Word variations have been searched) |
| #50 | MeSH descriptor: [Exercise] explode all trees |
| #51 | MeSH descriptor: [Exercise Movement Techniques] explode all trees |
| #52 | MeSH descriptor: [Exercise Therapy] explode all trees |
| #53 | ((exercis* or activit*) near/3 (advice* or intervention* or modif* or change* or recommend* or manag*)):ti,ab,kw (Word variations have been searched) |
| #54 | #22 or #23 or #24 or #25 or #26 or #27 or #28 or #29 or #30 or #31 or #32 or #33 or #34 or #35 or #36 or #37 or #38 or #39 or #40 or #41 or #42 or #43 or #44 or #45 or #46 or #47 or #48 or #49 or #50 or #51 or #52 or #53 |
| #55 | #21 and #54 |
Appendix C. Clinical evidence study selection
Appendix D. Clinical evidence tables
Table 9. Summary clinical evidence (PDF, 368K)
Appendix E. Forest plots
Comparison 1. Stress management intervention versus standard care
Comparison 2. Physical activity intervention versus standard care
Comparison 3. Physical activity versus standard care
Comparison 4. Dietary intervention aimed at reducing fat intake versus standard care
Comparison 5. Smokers versus non-smokers
Comparison 6. Alcohol versus no alcohol
Appendix F. GRADE tables
Table 9. Clinical evidence profile: Comparison 1. Stress management intervention versus standard care (PDF, 224K)
Table 10. Clinical evidence profile: Comparison 2. Physical activity intervention versus standard care (PDF, 286K)
Table 11. Clinical evidence profile: Comparison 3. Physical activity versus standard care (PDF, 242K)
Table 13. Clinical evidence profile: Comparison 5. Smokers versus non-smokers (PDF, 240K)
Table 14. Clinical evidence profile: Comparison 6. Alcohol versus no alcohol (PDF, 218K)
Appendix G. Economic evidence study selection
See Supplement 1: Health economics literature review for details of economic study selection.
Appendix H. Economic evidence tables
No health economic evidence was identified for this review.
Appendix I. Health economic evidence profiles
No health economic evidence was identified for this review.
Appendix J. Health economic analysis
A health economic analysis was not conducted for this review question.
Appendix K. Excluded studies
Clinical studies
Download PDF (307K)
Economic studies
See Supplement 1: Health economics literature review for the list of excluded economic studies.
Appendix L. Research recommendations
No research recommendations were made for this review question.
Final
Evidence reviews
developed by the National Guideline Alliance, hosted by the Royal College of Obstetricians and Gynaecologists
Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.
NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.
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- Paget's disease of the breast: the experience of the European Institute of Oncology and review of the literature.[Breast Cancer Res Treat. 2008]Paget's disease of the breast: the experience of the European Institute of Oncology and review of the literature.Caliskan M, Gatti G, Sosnovskikh I, Rotmensz N, Botteri E, Musmeci S, Rosali dos Santos G, Viale G, Luini A. Breast Cancer Res Treat. 2008 Dec; 112(3):513-21. Epub 2008 Feb 1.
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