Impact of secondary lymphedema after head and neck cancer treatment on symptoms, functional status, and quality of life

Lymphedema may disrupt local function and affect quality of life (QOL) in patients with head and neck cancer. The purpose of this study was to examine the associations among severity of internal and external lymphedema, symptoms, functional status, and QOL in patients with head and neck cancer.

[1]  P. Brennan,et al.  Lymphatic malformations of the head and neck-current concepts in management. , 2013, The British journal of oral & maxillofacial surgery.

[2]  S. Shridharani,et al.  Lymphedema , 2013, Eplasty.

[3]  Edie R. Hapner,et al.  Results of a large-scale head and neck cancer screening of an at-risk population. , 2011, Journal of voice : official journal of the Voice Foundation.

[4]  M. Su,et al.  Long-term result of management of otitis media with effusion in patients with post-irradiated nasopharyngeal carcinoma , 2011, European Archives of Oto-Rhino-Laryngology.

[5]  A. Carvalho,et al.  Hearing loss and complaint in patients with head and neck cancer treated with radiotherapy. , 2010, Archives of otolaryngology--head & neck surgery.

[6]  Y. Young,et al.  Comparison of otologic complications between intensity-modulated and two-dimensional radiotherapies in nasopharyngeal carcinoma patients , 2010, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[7]  Isabelle Barillot,et al.  Évaluation par le patient de la toxicité aiguë de la radiothérapie pelvienne selon la Common Terminology Criteria for Adverse Events, version 3.0 (CTCAE v3.0) : rêve ou réalité ? , 2010 .

[8]  A. Haimovitz-Friedman,et al.  Radiation therapy causes loss of dermal lymphatic vessels and interferes with lymphatic function by TGF-beta1-mediated tissue fibrosis. , 2010, American journal of physiology. Cell physiology.

[9]  D. Ronis,et al.  Predictors of poor sleep quality among head and neck cancer patients , 2010, The Laryngoscope.

[10]  J. Bogart,et al.  Radiation therapy-related toxicity (including pneumonitis and fibrosis). , 2010, Hematology/oncology clinics of North America.

[11]  J. Lewin,et al.  Lymphedema management in head and neck cancer , 2010 .

[12]  R. Speck,et al.  Changes in the Body Image and Relationship Scale following a one-year strength training trial for breast cancer survivors with or at risk for lymphedema , 2010, Breast Cancer Research and Treatment.

[13]  J. Werner,et al.  Postoperative morbidity after different types of selective neck dissection , 2010, The Laryngoscope.

[14]  H. Pau,et al.  Limited mouth opening after primary therapy of head and neck cancer , 2010, Oral and Maxillofacial Surgery.

[15]  F. Spijkervet,et al.  A systematic review of trismus induced by cancer therapies in head and neck cancer patients , 2010, Supportive Care in Cancer.

[16]  M. Williams,et al.  A systematic review of reliability and validity studies of methods for measuring active and passive cervical range of motion. , 2010, Journal of manipulative and physiological therapeutics.

[17]  K. Radhakrishnan,et al.  Anti-Inflammatory Pharmacotherapy with Ketoprofen Ameliorates Experimental Lymphatic Vascular Insufficiency in Mice , 2009, PloS one.

[18]  K. Harrington,et al.  Dysphagia in head and neck cancer. , 2009, Cancer treatment reviews.

[19]  A. Garden,et al.  Mucositis-related morbidity and resource utilization in head and neck cancer patients receiving radiation therapy with or without chemotherapy. , 2009, Journal of pain and symptom management.

[20]  B. Mehrara,et al.  Fibrosis Is a Key Inhibitor of Lymphatic Regeneration , 2009, Plastic and reconstructive surgery.

[21]  J. Netterville,et al.  Reliability and validity of the Vanderbilt Head and Neck Symptom Survey: A tool to assess symptom burden in patients treated with chemoradiation , 2009, Head & neck.

[22]  P. P. Heppner,et al.  Breast Cancer Survivors Coping with Lymphedema: What All Counselors Need to Know. , 2009 .

[23]  S. Ridner The psycho-social impact of lymphedema. , 2009, Lymphatic research and biology.

[24]  S. Rockson The unique biology of lymphatic edema. , 2009, Lymphatic research and biology.

[25]  L. Burkhead,et al.  Effect of comorbidity on post‐treatment quality of life scores in patients with head and neck squamous cell carcinoma , 2009, The Laryngoscope.

[26]  Ya-Chen Tina Shih,et al.  Incidence, treatment costs, and complications of lymphedema after breast cancer among women of working age: a 2-year follow-up study. , 2009, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[27]  S. Singer,et al.  Function, postoperative morbidity, and quality of life after cervical sentinel node biopsy and after selective neck dissection , 2009, Head & neck.

[28]  N. Futran,et al.  Influences and predictors of long-term quality of life in head and neck cancer survivors. , 2009, Archives of otolaryngology--head & neck surgery.

[29]  J. Tward,et al.  Relative contributions of radiation and cisplatin-based chemotherapy to sensorineural hearing loss in head-and-neck cancer patients. , 2009, International journal of radiation oncology, biology, physics.

[30]  M. Poulsen,et al.  Enhanced toxicity with concurrent cetuximab and radiotherapy in head and neck cancer. , 2009, Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology.

[31]  H. Christiansen,et al.  Toxicity of daily low dose cisplatin in radiochemotherapy for locally advanced head and neck cancer , 2008, Journal of Cancer Research and Clinical Oncology.

[32]  S. Mclaughlin,et al.  Prevalence of lymphedema in women with breast cancer 5 years after sentinel lymph node biopsy or axillary dissection: objective measurements. , 2008, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[33]  Ilsa Nielsen,et al.  Breast cancer-related lymphoedema risk reduction advice: a challenge for health professionals. , 2008, Cancer treatment reviews.

[34]  D. Ronis,et al.  The effect of neck dissection on quality of life after chemoradiation , 2008, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[35]  G. Bannister,et al.  Cervical range of movement in relation to neck dimension , 2008, European Spine Journal.

[36]  C. Cleeland,et al.  Psychometric testing of the MDASI-HF: a symptom assessment instrument for patients with cancer and concurrent heart failure. , 2008, Journal of cardiac failure.

[37]  N. Aaronson,et al.  Impact of late treatment-related toxicity on quality of life among patients with head and neck cancer treated with radiotherapy. , 2008, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[38]  A. Garden,et al.  Factors associated with severe late toxicity after concurrent chemoradiation for locally advanced head and neck cancer: an RTOG analysis. , 2008, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[39]  K. Syrjala,et al.  Physical and psychological long‐term and late effects of cancer , 2008, Cancer.

[40]  Jin Hee Park,et al.  Incidence and risk factors of breast cancer lymphoedema. , 2008, Journal of clinical nursing.

[41]  S. Rockson,et al.  Estimating the Population Burden of Lymphedema , 2008, Annals of the New York Academy of Sciences.

[42]  E. Hendriks,et al.  Clinimetric evaluation of active range of motion measures in patients with non-specific neck pain: a systematic review , 2008, European Spine Journal.

[43]  K. Morgan,et al.  Managing chronic oedema: a collaborative community approach. , 2008, British journal of community nursing.

[44]  A. Troxel,et al.  The body image and relationships scale: development and validation of a measure of body image in female breast cancer survivors. , 2008, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[45]  J. Goldman,et al.  The resolution of lymphedema by interstitial flow in the mouse tail skin. , 2008, American journal of physiology. Heart and circulatory physiology.

[46]  P. Delaere,et al.  The influence of xerostomia after radiotherapy on quality of life , 2008, Supportive Care in Cancer.

[47]  R. Pabst,et al.  Acquired lymphedema: an urgent need for adequate animal models. , 2008, Cancer research.

[48]  V. Miracle The Life and Impact of Florence Nightingale , 2008, Dimensions of critical care nursing : DCCN.

[49]  J. Buckner,et al.  Validation of single-item linear analog scale assessment of quality of life in neuro-oncology patients. , 2007, Journal of pain and symptom management.

[50]  Ethan Basch,et al.  Patient-reported outcomes and the evolution of adverse event reporting in oncology. , 2007, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[51]  A. G. Warren,et al.  Lymphedema: A Comprehensive Review , 2007, Annals of plastic surgery.

[52]  A. Hildreth,et al.  Measuring Edema in Irradiated Head and Neck Cancer Patients , 2007, The Annals of otology, rhinology, and laryngology.

[53]  J. Gilbert,et al.  Systemic and global toxicities of head and neck treatment , 2007, Expert review of anticancer therapy.

[54]  O. Micke,et al.  Influence of amifostine on late radiation-toxicity in head and neck cancer--a follow-up study. , 2007, Anticancer research.

[55]  A. G. Warren,et al.  Scar Lymphedema: Fact or Fiction? , 2007, Annals of plastic surgery.

[56]  M. Broome,et al.  A snapshot of children's postoperative tonsillectomy outcomes at home. , 2007, Journal for specialists in pediatric nursing : JSPN.

[57]  M. Sormani,et al.  Dosimetric predictors of laryngeal edema. , 2007, International journal of radiation oncology, biology, physics.

[58]  Joyce A Marrs Lymphedema and implications for oncology nursing practice. , 2007, Clinical journal of oncology nursing.

[59]  B. Murphy,et al.  Quality of life research in head and neck cancer: a review of the current state of the science. , 2007, Critical reviews in oncology/hematology.

[60]  P. Bradley,et al.  European Surgeons Were the First to Perform Neck Dissection , 2007, The Laryngoscope.

[61]  N. Macdonald Cancer cachexia and targeting chronic inflammation: a unified approach to cancer treatment and palliative/supportive care. , 2007, The journal of supportive oncology.

[62]  E. Paskett,et al.  The Epidemiology of Arm and Hand Swelling in Premenopausal Breast Cancer Survivors , 2007, Cancer Epidemiology Biomarkers & Prevention.

[63]  Constance M. Chen,et al.  A systematic review of patient-reported outcome measures in head and neck cancer surgery , 2007, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[64]  A. Vissink,et al.  Critical weight loss in head and neck cancer—prevalence and risk factors at diagnosis: an explorative study , 2007, Supportive Care in Cancer.

[65]  A. Soran,et al.  Breast Cancer‐Related Lymphedema – What Are the Significant Predictors and How They Affect the Severity of Lymphedema? , 2006, The breast journal.

[66]  M. Kris,et al.  Patient versus clinician symptom reporting using the National Cancer Institute Common Terminology Criteria for Adverse Events: results of a questionnaire-based study. , 2006, The Lancet. Oncology.

[67]  R. Roth,et al.  Quality-of-life and body image impairments in patients with lymphedema. , 2006, Lymphology.

[68]  H. Jung,et al.  [Factors influencing the emotional state of patients with lymphedema]. , 2006, Taehan Kanho Hakhoe chi.

[69]  G. Dennert,et al.  Selenium for alleviating the side effects of chemotherapy, radiotherapy and surgery in cancer patients. , 2006, The Cochrane database of systematic reviews.

[70]  S. Rockson,et al.  Inflammatory Manifestations of Experimental Lymphatic Insufficiency , 2006, PLoS medicine.

[71]  R. Podolsky,et al.  Racial Disparities in Patients With Head and Neck Squamous Cell Carcinoma , 2006, The Laryngoscope.

[72]  C. Dowrick,et al.  Can adjustment disorder and depressive episode be distinguished? Results from ODIN. , 2006, Journal of affective disorders.

[73]  Louis J. Wagner,et al.  Cancer‐related health worries and psychological distress among older adult, long‐term cancer survivors , 2006, Psycho-oncology.

[74]  S. S. Holcomb Identification and treatment of different types of lymphedema. , 2006, Advances in skin & wound care.

[75]  F. Ondrey,et al.  Decreased hearing after combined modality therapy for head and neck cancer. , 2006, American journal of otolaryngology.

[76]  L. Moldawer,et al.  The origins of cachexia in acute and chronic inflammatory diseases. , 2006, Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition.

[77]  H E Liu,et al.  Fatigue and associated factors in hemodialysis patients in Taiwan. , 2006, Research in nursing & health.

[78]  S. Kersting,et al.  Reduction of postoperative lymphedema after oral tumor surgery with sodium selenite , 2005, Biological Trace Element Research.

[79]  L. Clodius Textbook of Lymphology , 2005 .

[80]  R. Bryant,et al.  The course of psychological disorders in the 1st year after cancer diagnosis. , 2005, Journal of consulting and clinical psychology.

[81]  J. Sitzia,et al.  Incidence and risk of arm oedema following treatment for breast cancer: a three-year follow-up study. , 2005, QJM : monthly journal of the Association of Physicians.

[82]  S. Ridner Quality of life and a symptom cluster associated with breast cancer treatment-related lymphedema , 2005, Supportive Care in Cancer.

[83]  C. Moffatt,et al.  Health‐related quality of life with lymphoedema: a review of the literature , 2005, International wound journal.

[84]  Judith l. Reishtein Relationship between symptoms and functional performance in COPD. , 2005, Research in nursing & health.

[85]  Derick T Wade,et al.  Do biomedical models of illness make for good healthcare systems? , 2004, BMJ : British Medical Journal.

[86]  K. Vineberg,et al.  Dysphagia and aspiration after chemoradiotherapy for head-and-neck cancer: which anatomic structures are affected and can they be spared by IMRT? , 2004, International journal of radiation oncology, biology, physics.

[87]  J. Roodenburg,et al.  Trismus in head and neck oncology: a systematic review. , 2004, Oral oncology.

[88]  J. Coreil,et al.  Cultural Models of Illness and Recovery in Breast Cancer Support Groups , 2004, Qualitative health research.

[89]  J. Roodenburg,et al.  Morbidity of the neck after head and neck cancer therapy , 2004, Head & neck.

[90]  L. Nof,et al.  Incidence and prevalence of lymphedema in patients following burn injury: a five-year retrospective and three-month prospective study. , 2004, Lymphatic research and biology.

[91]  J. Netterville,et al.  Reliability and validity for the Vanderbilt Head and Neck Symptom Survey (VHNSS): A new tool to assess symptom burden in patients undergoing chemoradiation , 2004 .

[92]  D. Ronis,et al.  Disability in patients with head and neck cancer. , 2004, Archives of otolaryngology--head & neck surgery.

[93]  William Giese,et al.  Lymphedema Secondary to Postmastectomy Radiation: Incidence and Risk Factors , 2004, Annals of Surgical Oncology.

[94]  G. Weinstein,et al.  Pilot study of postoperative reirradiation, chemotherapy, and amifostine after surgical salvage for recurrent head-and-neck cancer. , 2004, International journal of radiation oncology, biology, physics.

[95]  D. Ronis,et al.  Clinical predictors of quality of life in patients with head and neck cancer. , 2004, Archives of otolaryngology--head & neck surgery.

[96]  S. Ridner,et al.  Psychological distress: concept analysis. , 2004, Journal of advanced nursing.

[97]  Davina Porock,et al.  Predicting Breast Cancer-Related Lymphedema Using Self-Reported Symptoms , 2003, Nursing research.

[98]  B. Geller,et al.  Factors associated with arm swelling after breast cancer surgery. , 2003, Journal of women's health.

[99]  Paul Glasziou,et al.  Whispered voice test for screening for hearing impairment in adults and children: systematic review , 2003, BMJ : British Medical Journal.

[100]  Christell O Bray,et al.  Holistic Healing for Women with Breast Cancer through a Mind, Body, and Spirit Self-Empowerment Program , 2003, Journal of holistic nursing : official journal of the American Holistic Nurses' Association.

[101]  A. Cheville,et al.  The grading of lymphedema in oncology clinical trials. , 2003, Seminars in radiation oncology.

[102]  M. Bremer,et al.  Current status of selenium and other treatments for secondary lymphedema. , 2003, The journal of supportive oncology.

[103]  G. Funk,et al.  Comprehensive head and neck oncology health status assessment , 2003, Head & neck.

[104]  A. Davis,et al.  Measuring postirradiation subcutaneous soft-tissue fibrosis: state-of-the-art and future directions. , 2003, Seminars in radiation oncology.

[105]  Lawrence B Marks,et al.  Normal tissue effects: reporting and analysis. , 2003, Seminars in radiation oncology.

[106]  C. N. Coleman,et al.  CTCAE v3.0: development of a comprehensive grading system for the adverse effects of cancer treatment. , 2003, Seminars in radiation oncology.

[107]  Wilfred Levin,et al.  Late radiation-related fibrosis: pathogenesis, manifestations, and current management. , 2003, Seminars in radiation oncology.

[108]  K. Kisters,et al.  Selenium in the treatment of radiation-associated secondary lymphedema. , 2003, International journal of radiation oncology, biology, physics.

[109]  M. Tamburrino,et al.  Body Image: A Handbook of Theory, Research, and Clinical Practice , 2003 .

[110]  A. Taghian,et al.  Risk of lymphedema after regional nodal irradiation with breast conservation therapy. , 2003, International journal of radiation oncology, biology, physics.

[111]  J. Sloan,et al.  The need for and characteristics of randomized, phase III trials to evaluate symptom management in patients with cancer. , 2002, Journal of the National Cancer Institute.

[112]  R. Bryant,et al.  Posttraumatic stress disorder following cancer. A conceptual and empirical review. , 2002, Clinical psychology review.

[113]  T. T. Haug,et al.  The validity of the Hospital Anxiety and Depression Scale. An updated literature review. , 2002, Journal of psychosomatic research.

[114]  P. Graham,et al.  Compression prophylaxis may increase the potential for flight-associated lymphoedema after breast cancer treatment. , 2002, Breast.

[115]  A. Eckardt,et al.  Reproducibility of Sonographic Soft-Tissue Measurement of the Head and Neck , 2002, American journal of physical medicine & rehabilitation.

[116]  M. R. del Turco,et al.  Prognostic factors for lymphedema after primary treatment of breast carcinoma , 2001, Cancer.

[117]  M. Radina,et al.  Post-Breast Cancer Lymphedema and the Family: A Qualitative Investigation of Families Coping With Chronic Illness , 2001 .

[118]  C. Gutenbrunner,et al.  Early Rehabilitation of Head-Neck Edema After Curative Surgery for Orofacial Tumors , 2001, American journal of physical medicine & rehabilitation.

[119]  L. Darga,et al.  Surgical outcomes after breast cancer surgery: measuring acute lymphedema. , 2001, Journal of Surgical Research.

[120]  R. Weichselbaum,et al.  Concomitant chemoradiotherapy as primary therapy for locoregionally advanced head and neck cancer. , 2000, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[121]  G. Hordijk,et al.  Long‐Term Quality of Life of Patients With Head and Neck Cancer , 2000, The Laryngoscope.

[122]  H. Bartelink,et al.  Consequences of voice impairment in daily life for patients following radiotherapy for early glottic cancer: voice quality, vocal function, and vocal performance. , 1999, International journal of radiation oncology, biology, physics.

[123]  D. Coward Lymphedema prevention and management knowledge in women treated for breast cancer. , 1999, Oncology nursing forum.

[124]  P. Fayers,et al.  Quality of life in head and neck cancer patients: validation of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-H&N35. , 1999, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[125]  J. Savard,et al.  Evaluating anxiety and depression in HIV-infected patients. , 1998, Journal of personality assessment.

[126]  A. Dietz,et al.  Das chronische Larynxödem als Spätreaktion nach Radiochemotherapie , 1998, HNO.

[127]  C. Bradford,et al.  Head and neck cancer-specific quality of life: instrument validation. , 1997, Archives of otolaryngology--head & neck surgery.

[128]  G. Snow,et al.  Assessment of malnutrition parameters in head and neck cancer and their relation to postoperative complications , 1997, Head & neck.

[129]  F. Suppe,et al.  The middle-range theory of unpleasant symptoms: an update. , 1997, ANS. Advances in nursing science.

[130]  E. Vokes,et al.  The performance status scale for head and neck cancer patients and the functional assessment of cancer therapy‐head and neck scale: A study of utility and validity , 1996, Cancer.

[131]  D. Cella,et al.  Quality of life and functional status measures in patients with head and neck cancer. , 1996, Archives of otolaryngology--head & neck surgery.

[132]  S. Passik,et al.  Predictors of psychological distress, sexual dysfunction and physical functioning among women with upper extremity lymphedema related to breast cancer , 1995 .

[133]  E. Weymuller,et al.  Assessment of quality of life in head and neck cancer patients , 1993, Head & neck.

[134]  M. Watson,et al.  The Factor Structure and Factor Stability of the Hospital Anxiety and Depression Scale in Patients with Cancer , 1991, British Journal of Psychiatry.

[135]  Huston Gj,et al.  The Hospital Anxiety and Depression Scale. , 1987, The Journal of rheumatology.

[136]  L. Derogatis,et al.  The prevalence of psychiatric disorders among cancer patients. , 1983, JAMA.

[137]  R. Firth Function , 1955, Yearbook of Anthropology.

[138]  F. L. Reichert,et al.  EXPERIMENTAL LYMPHEDEMA OF THE INTESTINAL TRACT AND ITS RELATION TO REGIONAL CICATRIZING ENTERITIS. , 1936, Annals of surgery.

[139]  J. Gilbert,et al.  Dysphagia in head and neck cancer patients treated with radiation: assessment, sequelae, and rehabilitation. , 2009, Seminars in radiation oncology.

[140]  A. McTiernan,et al.  Risk factors for arm lymphedema following breast cancer diagnosis in Black women and White women , 2008, Breast Cancer Research and Treatment.

[141]  Jonathan R. Clark,et al.  INTEGRATION OF PROSPECTIVE QUALITY OF LIFE AND NUTRITIONAL ASSESSMENT AS ROUTINE COMPONENTS OF MULTIDISCIPLINARY CARE OF PATIENTS WITH HEAD AND NECK CANCER , 2008, ANZ journal of surgery.

[142]  T. Watts,et al.  Alcohol drinking in never users of tobacco, cigarette smoking in never drinkers and the risk of head and neck cancer: pooled analysis in the international head and neck cancer epidemiology consortium , 2007, BDJ.

[143]  Margaret C Sneddon,et al.  Lymphoedema: a female health issue with implications for self care. , 2007, British journal of nursing.

[144]  J. Rychnovsky Postpartum fatigue in the active-duty military woman. , 2007, Journal of obstetric, gynecologic, and neonatal nursing : JOGNN.

[145]  BEST PRACTICE FOR THE MANAGEMENT OF LYMPHOEDEMA , 2006 .

[146]  A. Szuba,et al.  The integrated and interdisciplinary treatment of chronic lymphedema. , 2005, Roczniki Akademii Medycznej w Bialymstoku.

[147]  P. Liehr LOOKING AT SYMPTOMS WITH A MIDDLE-RANGE THEORY LENS* , 2005 .

[148]  J. Netterville,et al.  Reliability and validity for the Vanderbilt Head and Neck Symptom Survey (VHNSS): A new tool to assess symptom burden in patients undergoing chemoradiation. , 2004, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[149]  V. Raina,et al.  Prevalence and risk factors for development of lymphedema following breast cancer treatment. , 2004, Indian journal of cancer.

[150]  J. Werner,et al.  Metastases in Head and Neck Cancer , 2004, Springer Berlin Heidelberg.

[151]  F. Brunsa,et al.  Selenium in the Treatment of Head and Neck Lymphedema , 2004 .

[152]  Penny Hopwood,et al.  A body image scale for use with cancer patients. , 2001, European journal of cancer.

[153]  M. Földi Lymphology in the second millennium. , 2001, Lymphology.

[154]  A. Dietz,et al.  [Chronic laryngeal edema as a late reaction to radiochemotherapy]. , 1998, HNO.

[155]  B. J. Carter Women's experiences of lymphedema. , 1997, Oncology nursing forum.

[156]  D. Razavi,et al.  Screening for psychiatric disorders in a lymphoma out-patient population. , 1992, European journal of cancer.