Borderline malignant Ovarain Tumours-What we as Gynecologist should know?/

How many of us have come across “Borderline Ovarian Cancer per year?? Any guess??  Borderline Tumor-What we need to know??

Ans:-These are a subset of epithelial ovarian tumors that are  termed semimalignant. These lesions have a more favorable outcome than do other ovarian cancers, but they were not separately classified by the International Federation of Gynecology and Obstetrics (FIGO) and the World Health Organization(WHO) until the early 1970s.

The 2 major histologic tumor subtypes are serous and mucinous, with serous being more common. Serous tumors are presumed to originate from the germinal epithelium. Mucinous tumors do not have a clearly defined origin.

Should we remove the appendix while operating such borderline ovarian atumours ??  Ans:-Possibly yes. Substantial information indicates that many tumors may actually originate from the appendix; thus, this organ should be removed at the time of surgery.

What are the presenting symptoms of borderline ovarian tumors??

Borderline tumors, as with other ovarian tumors, are difficult to detect clinically until they are advanced in size or stage. In one study, the most common presenting symptoms were abdominal pain, increasing girth or abdominal distention, and abdominal mass. Approximately 23% of patients were asymptomatic.

What is the etiology of such border line tumors??

Ans:-The etiology of this disease remains unclear Based on molecular studies, some mucinous borderline tumors of the ovary may actually represent metastasis from the appendix.

Some presumed factors reportedly linked with borderline tumors include the following:

·        Oral contraceptive use

·        Early Menarche

·        Age at first pregnancy

·        Age at first delivery

·        Smoking history

·        Family history of ovarian cancer

What is the prevalence? Ans:-Incidence of borderline ovarian tumors

One woman in 55 (1.8%) develops some form of ovarian cancer in her lifetime. Approximately 90% of these cancers are tumors of epithelial origin. If benign lesions are included, epithelial tumors account for 60% of all ovarian tumors.

borderline tumors make up approximately 15% of all epithelial ovarian tumors. The mean age of occurrence is approximately 10 years younger than that of women with frankly malignant ovarian cancer.

Q .How to perform Tumor Staging??/

Comprehensive staging of borderline ovarian tumors is of significant prognostic value and is performed surgically. As opposed to its true malignant counterpart, epithelial ovarian carcinoma, borderline ovarian cancer is often found at an early stage.

Without comprehensive surgical staging, the prognosis for an individual patient is difficult to predict.

Borderline ovarian tumors are staged according to the FIGO classification of ovarian cancer. Many clinicians group stages II-IV together for prognostic consideration.Another common component of staging is the description of the type of implants, as these have significant prognostic value.

Preoperatively, borderline tumors are often presumed to be either benign or malignant ovarian masses; however, as with other ovarian masses, staging is performed surgically.

 Many sources recommend complete staging if a borderline tumor is found. Q. How to stage an possible Ovarian Ca ?? Biopsy from where??  Ans;-Current guidelines include biopsy specimens of the pelvic peritoneum (cul-de-sac, pelvic wall, and bladder peritoneum), abdominal peritoneum (paracolic gutters and diaphragmatic surfaces), omentum, intestinal serosa and mesentery, and retroperitoneal lymph nodes (pelvic and para-aortic).

Ans:- The diagnosis of borderline ovarian cancer is based on surgical staging. Pathologic diagnosis is difficult to confirm by frozen section. Borderline tumors are correctly diagnosed 60 -86% of the time by frozen section, depending on the experience of the pathologist and the site of the operation .

However, in one study at a tertiary referral center, benign disease was excluded in 94% of cases subsequently diagnosed as borderline tumor.

Q. 12: How  will be prognosis Borderline Ovarian Cancer ?? Ans;-Prognosis in

Women with borderline tumors have an excellent overall prognosis. These women have a 60% chance of having stage I disease when diagnosed. Postoperative treatment for any stage is controversial; therefore, recommending reoperation for surgical staging alone is difficult.  

Q.12: What is the prevalence of  diploid deoxyribonucleic acid (DNA)?? Ans:-. Approximately 95% of borderline ovarian tumors have diploid deoxyribonucleic acid (DNA -- Biomarkers and DNA Cytometry)---). This finding is almost always associated with an excellent prognosis. But if the tumor is aneuploid, the recurrence rate is high. Some authors suggest treating these as low-grade invasive carcinoma (also called micropapillary carcinoma).

Conflicting data exist with respect to overexpression of various oncogenes and tumor suppressor genes. Although TP 53 positivity and HER2 overexpression in invasive cancer have been associated with a worse prognosis, the same gene profile has conferred a survival advantage in borderline tumors. Q. 13: What is the “Recurrence and Survival Patients with stage I disease” ??  Ans: A recurrence rate of approximately 15%. The 5-year survival rate for such patients approaches 100%. However, the 10-year survival rate is 90-95%, depending on histologic findings.

In patients with stage II-IV disease, the prognosis is different; an increased stage is associated with a worse prognosis and only age at diagnosis and the presence of invasive implants are shown to influence prognosis.

recurrence, a median time to diagnosis of 3.1 years was reported if the recurrence was of the borderline type. In patients whose recurrence was invasive carcinoma, the median time to diagnosis was 8.3 years. It is believed that the former was a recurrence but that the latter was probably a new primary tumor. The cancer antigen 125 (CA-125) level was normal in 65% of the recurring cases. Death was noted only when invasive carcinoma was noted in the recurrence.

In patients with serous borderline tumors with invasive implants, the relapse rate was 31-45%, according to a study by Gershenson et al.

 The median time from diagnosis to recurrence was 24 months, although the time to progression of disease was significantly longer in patients who had no macroscopic disease remaining at the time of initial operation. Additionally, patients who received postoperative platinum-based chemotherapy had a significantly worse progression-free survival rate. However, the authors of this study believed that this finding might have been due to selection bias.

Postpartum contraceptives -timings

Then what option we have to offer to women coming for postpartum check up at clinic/OPD?? What exactly than the time of postpartum initiation of Contraceptive:

Care should be exercised in individualizing such timeframe one should remember that sperm retain fertilizing capacity in the female genital tract five days after intercourse. Thus, it would had been appropriate if women could have assessed first postpartum ovulation process 3-5 days prior to the occurrence of ovulation. So that appropriate contraceptive method may be initiated prior to first ovulation. Unfortunately till date there is no such subjective symptom or Laboratory test exist which can detect ovulation 5 days prior to ovulation. Thus individualizing of initiation of contraceptive and possibly to some extent unscientific.

The degree of lactation induced inhibition of ovulation is difficult to assess from  history and only a grass is possible. For instance, if frequent and prolonged breastfeeding is going on then early use of contraceptives may constitute and unnecessary double protection i.e. L.A.M. along with some other contraceptive what should be then, the take home message?

The international guideline is that a) for fully breastfed women (not giving any artificial milk, fruit juice honey etc.). Who has not yet started menstruation contraception should be commenced after six months of delivery. There is only two percent chance of conception during the last two months i.e. fifth and six month of postpartum period. One can use some contraceptive in those two months if one intends to avoid the said 2% risk though that is not the usual recommended protocol. B) Nonlactating women on the other hand and who partially breastfed they should definitely start contraceptive by two and four months after childbirth respectively unless the start menstruating earlier. C) After an abortion (spontaneous a induced) one should start using contraception after two weeks and not later. Before this timeframe for all practical purpose pregnancy is very unlikely though not impossible.

One may ask why not to initiate contraceptive from the very first sexual act in postpartum period? There is no harm if one opts using a contraceptive from the very first coital act after childbirth. But one has to consider that no contraceptive is 100% effective. If one accepts this philosophy of occasional ‘contraceptive accidents’, which is not uncommon, then above mentioned guideline is possibly more acceptable to couple rather than very early initiation of contraceptive.

Postpartum return of fertility

A.             Return of Ovulation in postpartum period :

Postpartum Return of ovulation release of eggs varies from woman to woman and as stated earlier, the timing of first ovulation in postpartum period primarly depend on frequency of breastfeeding and duration of breastfeeding. In nonlactating mothers ‘ovulation’ can rare occationally resume as early as twently one day after childbirth. Many nonlactating women do ovulate by sixty days postpartum.

By contrast who breastfeed as per international norm in them resumption of ovulation frequently precede the onset of menstruation. So the general belief of commencing contraceptive after resumption of menstrual period does not hold good. Unfortunately, many Indian women still believe that unless menstruation returns till then she is protected from pregnancy. This false sense of security is a common cause of unintended pregnancy in postpartum period.

B.              Return of menstruation and return of fertility :

S. long we have discussed about role of breastfeeding in preventing pregnancy. We now focus on the spatial relation of return of menstruation in postpartum period and possibility of fresh pregnancy.

Postpartum amenorrhoea i.e. nonoccurrence of menstruation is the interval between the birth of a child and resumption of menstruation. It is the period following childbirth during which a woman becomes temporarily and involuntarily infecund.

Admittedly the duration and frequency of breastfeeding primarily govern the length of postpartum amenorrhoea but there are other hitherto unknown factors as well. As breastfeeding practice varies in different parts of India so also the duration of postpartum amenorrhoea (nonoccurrence of menstruation). However the usual trend of amenorrhoea amongst India women is discussed below.

Postpartum initiation of sexual intercourse :

As this chapter is dedicated to fix up the time of initiation contraceptives in postpartum period it will be pertinent to highlight some aspects of human sexual behavior in postpartum period.

Postpartum coital behavior varies greatly in different parts of globe. Initiation of sexual activity depends on factors like socio cultural taboo, health of the partners, nature of delivery (natural or caesarean) whether the women stays at her father’s residence and obviously the educational status of the couple. By and large most couple start enjoying sex by three months after childbirth. A woman need not consider contraceptives if she is not exposed to the risk of pregnancy either because she is amenorrhoeic (true for first six months of after childbirth) or because she is abstaining from sexual intercourse.

A recent European study revealed that after a normal birth ninety-four percent abstain from sex in first month and as postpartum duration proceeds the rate of abstinence falls. As many as twenty percent of European women abstain from sexual intercourse eight month after birth and only as twelve percent retain from sex even twelve months after a birth! By contrast, a U.S. study, conducted in 1998 revealed that two thirds of new mothers report having resuming sexual activity by fourth month. Unfortunately, in the same study was also observed that fifteen percent of lactating women with last childbirth beyond six month report being sexually active but not using any contraceptive method and thus are at risk of unintended pregnancy. Due to lack of contraceptive knowledge they are simply unaware about the possibility of unintended pregnancy.

What about India? The proportion of mothers abstaining from sexual intercourse in the first month after a birth is nearly the same as the proportion amenorrhoeic (94 percent and 96 percent, respectively), but the proportion abstaining falls far more quickly with the passage of time since birth than does the proportion who are amenorrhoeic. Only one-quarter of mothers are still abstaining from sexual intercourse four months after a birth, and by six months, 85 percent of India women have resumed sexual relations (source : NFHS – 3).

Breast Feeding and Return of Fertility?

Return of Ovulation & menstruation depends on:-

a)        Frequency and duration of breast feeding per 24 hours

b)       Resumption of menstruation

c)         Initiation of sexual activity

d)       Return of ovulation (arbitary)

All these four factors have been discussed at length in the following pages. The relevance of al these four factors have been explained in details thus enabling couple to initiate contraceptive at a reasonably appropriate time. Admuttedly, till date there is as yet no set guideline about commencement of contraceptive in postpartum period due to inaccuracies fallancies of all these four indices to foretell about the probability of pregnancy.

A.                 Nature of breastfeeding and return of postpatum fecundity :

So far as duration of postpartum insusceptibility to pregnancy is concerned not only the total months for which the infant is breastfed is mportant but frequency and total duration of breast-feeding per twenty four hours are also important. Presumably, many educated couple are aware that frequent breastfeeding practice prevents conception by inhibiting release of eggs from ovaries but only few of them are aware that adoption of this method of natural contraception has been recently renamed as ‘Lactational Amenorrhoea Method (LAM)’ PARA. In LAM there are three factors to be considered. Unfortunately for lack of proper publicity few Indian couple have an clear idea on thest three essential criteria to make LAM method of natural contraception successful. These three criteria are a) exclusive breastfeeding including on or two feeds at night b) Persistence of postpartum ammenorrhoea (nonoccurence of menstruaton) and this contraceptive efficacy of LAM last only for first-six months after childbirth. Contraceptive effieacy fades after six months inspite of continued breastfeeding.

The importance of breastfeeding in preventing contraception can be easily ganzed by following observation. Sevently-five percent of non-lactating Indian women conceive within six to nine months of delivery if effective contraception is not practised as against only 7-10 percent of those who breastfeed as per international norms.

B.                 Partial breastfeeding and early return of fertility :

How vulnerable are women who breastfeed infrequently or for only short duration, ‘Menstruation’, ‘Ovulation’ and therefore ‘fertility’ return sooner than expected in such women and unintended pregnancy can occur quite early say within three or four months after childbirth inspite of continued partial breastfeeding.

Owing to lack of this particular scientific information many women fall prey to unintended pregnancy in lactation period. They are under the false impression that they are immune to pregnancy because of so called breastfeeding. In fact, partical breastfeeding confers little protection against pregnancy as suckling of breasts in infrequent and hence ovulation is not inhibited appropiately. The incidence of ‘escape ovulation’ during partial breastfeeding though not universal but is a distinct possibility.

C.                  What is then partial breastfeeding?

By partial breastfeeding we mean infreqent and short-lived breastfeding that needs to be supported and supplemented by edible extra-milk or non-milk products before six months of age. This practice of providing extra-feeding is the total negation of science. If partial breastfeeding practice is adopted then twenty percent of such women will menstruate as early as two months after childbirth! I wonder, how many partially breastfeeding Indian mothers are aware of this fact before they embark on unprotected intercourse.

In fact, they simply do not know that they are susceptible to pregnancy even as early as two months after childbirth! I am also convinced that majority of such Indian women do not use any contraceptive whats over as this early postpartum phase. It is thus importantto fully breastfeed for first six months to avail and enjoy contraceptive efficacy of breastfeeding. Some scientist however claim that ‘Lactation’ and ‘Ovulation’ are antagonistic but it has now been proved that this principle does not hold good after six months postpartum. What happens is that during lactation prolactin hormone in maternal blood (milk secreting hormone) is high and this hormone suppresses the action of gonadotrophins (hormone responsible for release of eggs from ovaries). To simplify, ovaries of breastfeeding women are to some extent refractory to the actions of gonadotrophin hormones responsible for release of eggs. So elease of eggs from ovaries remain suspended at least for first six months provided no supplementary feed is allowed and menstruation has not resumed. This is exactily what has been called earlier, Lactational Amenorrhoea Method of contraception (LAM).

Contraceptives during Breast feeding

There is a second group of women who start using contraceptives only when they discontinued breastfeeding : But this phylosopy is wrong and unscientific because many woman do omlete after six month of childbirth insitite of continued breastfeeding. There is a third group of couple who would like to commence contraceptive whenever menstruation resumes in postpartum period. This philosophy apparently sounds well but a doption of this method of initiating contraceptive is also unscientific such policy may giverise to unintended pregnancies because in many breastfeeding women ovulation precedes visible event of menstruation. Thus scientifically speaking restoration of menstruation also cannot be used as an index of initiation of contraception.

I.             What woman expects from Science ?

      Most couple would like to start contraceptive when ovulatin resumes and dislike using contraceptive unnecessarily before resortion of ovulation. There is a real taste of science in this belief. Thus return of ovulation as an indexx of starting contraception though scientifically correct but the process of ovulation can’t be gauged at the present state of knowledge.

      No cheap method for detection of resumption ovulation is available. It would have been easier on the part of couple and scientists too if there have been a easy ready made low cost but predictable monitoring method of assessing maturation and release of eggs. Unfortunately whatever home monitoring tests for ovulation exist that are too costly for planning contraceptive use. Till date the use of these tests are limited to infertility treatment only.

II.         On which factoros the present day woman should depend on initation of Contraceptive?

Thus till date couple as well as scientists are arbitrarily guided by three indices. These are a) nature and freqauently of breastfeeding b) the event of return of menstruation. And c) resumption of sexual activity. Return of ovulation though the most decisive index of commencing contraceptive cannot be used by couple as index of initiation of contraception population at the present state of knowledge.

Additionally in office seeting  i.e. when a couple come to clinic for advice in postpartum period the contraceptive specialists usually require on nature of breastfeeding practice and return of menstruation as the two indices for planning on contraceptive use in postpartum period and the HCP thus tries to correlate the possibility of return of ovulation with these to events. This is just a gress of prob ability of becoming pregnancy.Couple too have relied either on return of menstruation or initiation of sexual activity as indices of initiation of contraceptive and of they at all rely on nature of breastfeeding they consider wearing as the index.

Contraceptives which are licensed abroad but not available in India (Newer birth control options):

1)                   Extra-pleasure condms, Oscillating condms, Glow-in-dark condms, Extra strenth-Cond  ms, Extra thin-Condms , Baggy Design Condms etc etc.

2)                   Synthetic Male Condoms

3)                   Newer Oral Contraceptives, (Minesse, Sesonale).

4)                   Monthly Injectables (for women e.g. Lunella)

5)                   Newer quarterly shots (Sub cut route)

6)                   Contraceptive Impalnts (Implanon)

7)                   Transdermal patch (Ortho Evra patch), application weekly.

8)                   Vaginal rings (NUVARING)

9)                   Frameless IUD & other newer IUD’s

10)           Newer contraceptive sponge e.g. (conceptral & Protectaid sponge)

11)           Electronic Fertility Monitor (persona)

12)           Reddy Female Condom

13)           New certical barriers (Fem Cap/Lea’s shield)

This description does not cover all new contraceptive that have been released abroad.

III.      Summary of the present problem : Where we are now?

Principally there are four factors which control return of ovulation and the restoration of fertility and each of the factors mentioned below deserve detailed discussion. The factors are a> Frequency and duration of ‘breastfeeding’, b> Restoration of ovulation, c> Resumption of ‘menstruation’ after childbirth and above all, d> initiation of ‘sexual intercourse’. Let us now analyse the role of each of these four factors and each of these four factors incluence return of fecludity independently it is worth remembaring that though breastfeeding, take a lead role but the process of restoration of ovulation resumption of mensturation are usually but not always interrelated. We shall see in the following pages that always choice by benefit for and resumption of menstruation. The process of ‘ovulation’ and ‘resumption of menstruation’ are not always controlled by breastfeeding. Giving identical time in breasefeeding two woman will outlet in different times. Thus it is this natural ovulation which cause much concerned to couple to fix up a time for initiation of contraceptives.

Resumption of Ovulation after childbirth & how early sex act should be ideal??

I.             When fertility returns in lactation period? The answer not exactly known:

       The exact time of the fertility returns in postpartum period eludes the awareness of many women. The proper timing of initiation their understanding and appreciation. Scientists too are equally in dilemma so far as timing of initiation of contraceptives after childbirth is therefore not within the orbit of their understanding and appreciation. Scientist too are equally in dilemma so far as timing of initiation of contraceptives after childbirth is concerned. This is simply because there is no set chronology of events like ‘return of menstruation’, ‘resumption of sexual activity’ and ‘restoration of ovulation’. All these variations are primarily due to changes noticed in breast feeding practice and thus the possibility of further pregnancy. Return of ‘fertility’, though primarily depend upon frequency and duration of breastfeeding but there is gross individual and racial variation. It is all these variations which have prompted the author to write a special chapter on this issue i.e. timing of initiation of contraceptives in lactation period.

In spite of innumerable member of cross Country population breast studies the speculation on return of ovulation and thus possibility of face pregnancy in postpartum period still remains a matter of speculation  :

We know that pregnancy to occur there must be availability of egg released from ovary a process termed as ‘ovulation’. Sperms also must be available in female genital tract by the process of sexual intercourse. The act of intercourse however can be easily assessed by the couple themselves but the process o ovulation and thus presence or absence of ovum can’t be assessed neither by the wife nor by the husband. Because the process of ovulation do not cause any noticeable symptom or distress so that no woman can say with certainity when she has ovulated and thus in need of contraception unlike ‘menstruation’, ‘breast feeding’ and ‘sexual act’ unfortunately the process of ovulation remain asymptomatic.

       Due to lack of this scientific knowledge some women are unnecessarily initiating contraceptive too early. There is still another group who are eager to use contraceptive but they do so quite let in lactation period. This chapter critically analyze the different factors that influence the return of ‘fertility’ in postpartum period. This chapter also highlights the time of initiation of contraceptives at an appropriate time and taste of contraceptives which can be safely used in lactation period. The magnitude and impact of ‘unintended pregnancy in lactational period have also been discussed briefly.

II.         Where we were? What the couple used to do earlier in initiation of contraceptive?

At the present time of writing a conclutions couple has three choices about timing the initiation of contraceptive lactation period. Firstly, the couple consider initiation of contraceptive whenever they resume sexual activity after childbirth. Logically it is a good practice but, quite often the sexual activity resume after childbirth time when many women are naturally infecund due to lack of resumption of ovulation. Thus if initiation of sex is considered as the index of commencing contraceptive there will be always a chance of initiation contraceptives too early which is possibly a burden to the couple. As stated earlier, unlike menstruation and ‘sexual act’ the act of ovulation can not be perceived by the woman. Thus a woman remains unaware about resumption of ovulation in postpartum period.

There is a second group of women who start using contraceptives only when they discontinued breastfeeding : But this phylosopy is wrong and unscientific because many woman do omlete after six month of childbirth insitite of continued breastfeeding. There is a third group of couple who would like to commence contraceptive whenever menstruation resumes in postpartum period. This philosophy apparently sounds well but a doption of this method of initiating contraceptive is also unscientific such policy may giverise to unintended pregnancies because in many breastfeeding women ovulation precedes visible event of menstruation. Thus scientifically speaking restoration of menstruation also cannot be used as an index of initiation of contraception.

III.      What woman expects from Science ?

       Most couple would like to start contraceptive when ovulatin resumes and dislike using contraceptive unnecessarily before resortion of ovulation. There is a real taste of science in this belief. Thus return of ovulation as an indexx of starting contraception though scientifically correct but the process of ovulation can’t be gauged at the present state of knowledge.

       No cheap method for detection of resumption ovulation is available. It would have been easier on the part of couple and scientists too if there have been a easy ready made low cost but predictable monitoring method of assessing maturation and release of eggs. Unfortunately whatever home monitoring tests for ovulation exist that are too costly for planning contraceptive use. Till date the use of these tests are limited to infertility treatment only.

What do we mean by p-value as we place our figures in Table format as we receive after completion of any medical prospective study(may be interventional study or nonintervention Study) ??

In statistics, the p-value is the probability of obtaining results as extreme as the observed results of a statistical hypothesis test, assuming that the null hypothesis is correct.

 The p-value is used as an alternative to rejection points to provide the smallest level of significance at which the null hypothesis would be rejected.

Therefore , a smaller p-value means that there is stronger evidence in favor of the alternative hypothesis.

‎Null Hypothesis · ‎Hypothesis Testing · ‎Statistical Significance

The smaller the p-value, the more certainty there is that the null hypothesis can be rejected.- 

. A p value is used in hypothesis testing to help you support or reject the null hypothesis. The p value is the evidence against a null hypothesis. ... For example, a p value of 0.0254 is 2.54%. This means there is a 2.54% chance your results could be r statistics, the p-value is the probability of obtaining results as extreme as the observed results of a statistical hypothesis test, assuming that the null hypothesis is correct.

... A smaller p-value means that there is stronger evidence in favor of the alternative hypothesis.,Random (i.e. happened by chance).

P > 0.05 is the probability that the null hypothesis is true. 1 minus the P value is the probability that the alternative hypothesis is true.

A statistically significant test result (P ≤ 0.05) means that the test hypothesis is false or should be rejected. A  p value greater than 0.05 means that no effect was observed.

 P > 0.05 is the probability that the null hypothesis is true. 1 minus the P value is the probability that the alternative hypothesis is true. A statistically significant test result (P ≤ 0.05) means that the test hypothesis is false or should be rejected. A p value greater than 0.05 means that no effect was observed.

In statistics, the p-value is the probability of obtaining results as extreme as the observed results of a statistical hypothesis test, assuming that the null hypothesis is correct

, 41 indicates a rejection of the null hypothesis at the 5% significance level, 0 indicates a failure to reject the null hypothesis at the 5% significance level.

 If you are interested in your p-value, just do this: ... The smaller the p-value, the more certainty there is that the null hypothesis can be rejected.

In

A smaller p-value means that there is stronger evidence in favor of the alternative hypothesis.

How Is P-Value Calculated?

P-values are calculated using p-value tables or spreadsheets/statistical software. Because different researchers use different levels of significance when examining a question, a reader may sometimes have difficulty comparing results from two different tests. P-values provide a solution to this problem.

For example, if a study comparing returns from two particular assets were undertaken using by different researchers who used the same data but different significance levels, the researchers might come to opposite conclusions regarding whether the assets differ.

To avoid this problem, the researchers could report the p-value of the hypothesis test and allow the reader to interpret the statistical significance themselves. This is called a p-value approach to hypothesis testing.

P-Value Approach to Hypothesis Testing

The p-value approach to hypothesis testing uses the calculated probability to determine whether there is evidence to reject the null hypothesis. The null hypothesis, also known as the conjecture, is the initial claim about a population (or data generating process).