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Khera R, Valero-Elizondo J, Das SR, Virani SS, Kash BA, de Lemos JA, Krumholz HM, Nasir K. Cost-Related Medication Nonadherence in Adults With Atherosclerotic Cardiovascular Disease in the United States, 2013 to 2017. Circulation 2019; 140:2067-2075. [DOI: 10.1161/circulationaha.119.041974] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background:
Medication nonadherence is associated with worse outcomes in patients with atherosclerotic cardiovascular disease (ASCVD), a group who requires long-term therapy for secondary prevention. It is important to understand to what extent drug costs, which are potentially actionable factors, contribute to medication nonadherence.
Methods:
In a nationally representative survey of US adults in the National Health Interview Survey (2013–2017), we identified individuals ≥18 years with a reported history of ASCVD. Participants were considered to have experienced cost-related nonadherence (CRN) if in the preceding 12 months they reported skipping doses to save money, taking less medication to save money, or delaying filling a prescription to save money. We used survey analysis to obtain national estimates.
Results:
Of the 14 279 surveyed individuals with ASCVD, a weighted 12.6% (or 2.2 million [95% CI, 2.1–2.4]) experienced CRN, including 8.6% or 1.5 million missing doses, 8.8% or 1.6 million taking lower than prescribed doses, and 10.5% or 1.9 million intentionally delaying a medication fill to save costs. Age <65 years, female sex, low family income, lack of health insurance, and high comorbidity burden were independently associated with CRN, with >1 in 5 reporting CRN in these subgroups. Survey respondents with CRN compared with those without CRN had 10.8-fold higher odds of requesting low-cost medications and 8.9-fold higher odds of using alternative, nonprescription, therapies.
Conclusions:
One in 8 patients with ASCVD reports nonadherence to medications because of cost. The removal of financial barriers to accessing medications, particularly among vulnerable patient groups, may help improve adherence to essential therapy to reduce ASCVD morbidity and mortality.
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Affiliation(s)
- Rohan Khera
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (R.K., S.R.D., J.A.d.L.)
| | - Javier Valero-Elizondo
- Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (J.V.-E., H.M.K.)
| | - Sandeep R. Das
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (R.K., S.R.D., J.A.d.L.)
| | - Salim S. Virani
- Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX (S.S.V.)
| | - Bita A. Kash
- Center for Outcomes Research, Houston Methodist Research Institute, TX (B.A.K.)
- School of Public Health, Texas A&M University, College Station (B.A.K.)
| | - James A. de Lemos
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (R.K., S.R.D., J.A.d.L.)
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Health, CT (J.V.-E., H.M.K.)
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT (H.M.K.)
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.)
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness Houston Methodist DeBakey Heart & Vascular Center & Center for Outcomes Research Houston Methodist, Houston, TX (K.N.)
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Salsman JM, Bingen K, Barr RD, Freyer DR. Understanding, measuring, and addressing the financial impact of cancer on adolescents and young adults. Pediatr Blood Cancer 2019; 66:e27660. [PMID: 30756484 PMCID: PMC6777708 DOI: 10.1002/pbc.27660] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 01/09/2019] [Accepted: 01/22/2019] [Indexed: 01/06/2023]
Abstract
The financial impact of cancer treatment among adolescents and young adults (AYAs, 15-39 years) is deep and long lasting. Compared with other age groups, because of their life stage, AYAs are particularly vulnerable to the adverse economic effects of cancer treatment, also known as financial toxicity. Clinical manifestations of cancer-related financial toxicity include interrupted work and income loss, accumulated debt, treatment nonadherence, avoidance of medical care, and social isolation. Effective clinical interventions should include efforts to increase financial self-efficacy as well as direct support. Measures that are valid, reliable, multidimensional, and age-appropriate are needed to study and address financial toxicity in the AYA population.
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Affiliation(s)
- John M. Salsman
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Wake Forest Baptist Comprehensive Cancer Center,Winston-Salem, North Carolina
| | - Kristin Bingen
- Division of Hematology/Oncology/Blood and MarrowTransplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee,Wisconsin
| | - Ronald D. Barr
- Division of Hematology/Oncology, Department of Pediatrics, McMaster University, Hamilton, Canada
| | - David R. Freyer
- Children’s CenterforCancerand Blood Diseases,Children’s Hospital LosAngeles, Los Angeles,California
- USC Norris Comprehensive Cancer Center, Los Angeles, California
- Departments of Pediatrics and Medicine, Keck School of Medicine, University of Southern California, LosAngeles, California
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53
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How I treat chronic myeloid leukemia in children and adolescents. Blood 2019; 133:2374-2384. [PMID: 30917954 DOI: 10.1182/blood.2018882233] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 03/21/2019] [Indexed: 12/15/2022] Open
Abstract
Evidence-based recommendations have been established for treatment of chronic myeloid leukemia (CML) in adults treated with tyrosine kinase inhibitors (TKIs), but the rarity of this leukemia in children and adolescents makes it challenging to develop similar recommendations in pediatrics. In addition to imatinib, which was approved for pediatric CML in 2003, the second-generation TKIs dasatinib and nilotinib were recently approved for use in children, expanding the therapeutic options and pushing allogeneic stem cell transplantation to a third-line treatment of most pediatric cases. Yet, without sufficient data on efficacy and safety specific to pediatric patients, the selection of a TKI continues to rely on clinical experience in adults. Here, we present 4 case scenarios highlighting common yet challenging issues encountered in the treatment of pediatric CML (suboptimal response, poor treatment adherence, growth retardation, and presentation in advanced phases). Limited experience with very young children, the transition of teenagers to adult medicine, and the goal of achieving treatment-free remission for this rare leukemia are additional significant obstacles that require further clinical investigation through international collaboration.
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54
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Thom B, Benedict C. The Impact of Financial Toxicity on Psychological Well-Being, Coping Self-Efficacy, and Cost-Coping Behaviors in Young Adults with Cancer. J Adolesc Young Adult Oncol 2019; 8:236-242. [PMID: 30817217 DOI: 10.1089/jayao.2018.0143] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose: The increase in cost-sharing between patients and payers has resulted in financial toxicity in cancer patients, particularly among young adult (YA) patients and survivors (<40 years of age). This study explored financial toxicity and its impact on psychological well-being, self-efficacy for coping with cancer, and cost-coping behaviors among a sample of YA cancer patients and survivors. Methods: One hundred forty YAs completed an anonymous online survey. The Comprehensive Score for Financial Toxicity measured financial toxicity and the Cancer Behavior Inventory-Brief measured coping self-efficacy. The Patient Health Questionnaire-4 and items from the Impact of Cancer-Young Adult and the Cancer Needs Questionnaire-Young People assessed psychological well-being. A single item assessed cost-coping behaviors (i.e., skipping or delaying treatment because of its cost). Analyses included Pearson and Spearman correlation matrices and multivariate regression modeling. Results: Worse financial toxicity was associated with lower insurance satisfaction (r = 0.52, p < 0.001), higher levels of depressive and anxiety symptoms (r = -0.42, p < 0.001), greater worry (p < 0.001), and lower self-efficacy in coping with cancer (i.e., maintaining independence and a positive attitude, r = 0.41, p < 0.001; coping and stress management, r = 0.43, p < 0.001; and managing negative effect, r = 0.20, p = 0.02). In multivariate modeling, financial toxicity related to skipping or delaying treatment and greater anxiety and depression symptomology, controlling for relevant covariates. Conclusion: The findings suggest financial toxicity negatively impacts many facets of the YA cancer experience. There is a need to address the cost of cancer care with patients to ensure they are informed about the financial implications of treatment decisions and to support financial planning as needed.
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Affiliation(s)
- Bridgette Thom
- 1 Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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55
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Banegas MP, Emerson MA, Adams AS, Achacoso NS, Chawla N, Alexeeff S, Habel LA. Patterns of medication adherence in a multi-ethnic cohort of prevalent statin users diagnosed with breast, prostate, or colorectal cancer. J Cancer Surviv 2018; 12:794-802. [PMID: 30338462 DOI: 10.1007/s11764-018-0716-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 09/11/2018] [Indexed: 01/16/2023]
Abstract
PURPOSE To investigate the implications of a cancer diagnosis on medication adherence for pre-existing comorbid conditions, we explored statin adherence patterns prior to and following a new diagnosis of breast, colorectal, or prostate cancer among a multi-ethnic cohort. METHODS We identified adults enrolled at Kaiser Permanente Northern California who were prevalent statin medication users, newly diagnosed with breast, colorectal, or prostate cancer between 2000 and 2012. Statin adherence was measured using the proportion of days covered (PDC) during the 2-year pre-cancer diagnosis and the 2-year post-cancer diagnosis. Adherence patterns were assessed using generalized estimating equations, for all cancers combined and stratified by cancer type and race/ethnicity, adjusted for demographic, clinical, and tumor characteristics. RESULTS Among 10,177 cancer patients, statin adherence decreased from pre- to post-cancer diagnosis (adjusted odds ratio (ORadj):0.91, 95% confidence interval (95% CI):0.88-0.94). Statin adherence decreased from pre- to post-cancer diagnosis among breast (ORadj:0.94, 95% CI:0.90-0.99) and colorectal (ORadj:0.79, 95% CI:0.74-0.85) cancer patients. No difference in adherence was observed among prostate cancer patients (ORadj:1.01, 95% CI:0.97-1.05). Prior to cancer diagnosis, adherence to statins was generally higher among non-Hispanic whites and multi-race patients than other groups. However, statin adherence after diagnosis decreased only among these two populations (ORadj:0.85, 95% CI:0.85-0.92 and ORadj:0.86, 95% CI:0.76-0.97), respectively. CONCLUSIONS We found substantial variation in statin medication adherence following diagnosis by cancer type and race/ethnicity among a large cohort of prevalent statin users in an integrated health care setting. IMPLICATIONS FOR CANCER SURVIVORS Improving our understanding of comorbidity management and polypharmacy across diverse cancer patient populations is warranted to develop tailored interventions that improve medication adherence and reduce disparities in health outcomes.
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Affiliation(s)
- Matthew P Banegas
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Ave, Portland, OR, 97227-1110, USA.
| | - Marc A Emerson
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Alyce S Adams
- Division of Research, Kaiser Permanente, Oakland, CA, USA
| | | | - Neetu Chawla
- Division of Research, Kaiser Permanente, Oakland, CA, USA
| | | | - Laurel A Habel
- Division of Research, Kaiser Permanente, Oakland, CA, USA
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56
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Thom B, Benedict C, Friedman DN, Kelvin JF. The intersection of financial toxicity and family building in young adult cancer survivors. Cancer 2018; 124:3284-3289. [PMID: 29924381 PMCID: PMC6108923 DOI: 10.1002/cncr.31588] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/12/2018] [Accepted: 05/15/2018] [Indexed: 12/17/2022]
Abstract
Financial toxicity and family building difficulties may co-occur in young adult cancer survivors. We describe this intersection and propose steps to alleviate associated distress.
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Affiliation(s)
- Bridgette Thom
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Danielle N. Friedman
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joanne F. Kelvin
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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57
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Challapalli SD, Simpson MC, Adjei Boakye E, Pannu JS, Costa DJ, Osazuwa-Peters N. Head and Neck Squamous Cell Carcinoma in Adolescents and Young Adults: Survivorship Patterns and Disparities. J Adolesc Young Adult Oncol 2018; 7:472-479. [DOI: 10.1089/jayao.2018.0001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
| | - Matthew C. Simpson
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Eric Adjei Boakye
- Saint Louis University Center for Outcomes Research, St. Louis, Missouri
| | - Jay S. Pannu
- Saint Louis University School of Medicine, St. Louis, Missouri
| | - Dary J. Costa
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, St. Louis, Missouri
- Department of Pediatric Otolaryngology, Cardinal Glennon Children's Medical Center, St. Louis, Missouri
| | - Nosayaba Osazuwa-Peters
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, St. Louis, Missouri
- Saint Louis University Cancer Center, St. Louis, Missouri
- Department of Epidemiology, College for Public Health and Social Justice, Saint Louis University, St. Louis, Missouri
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Kaul S, Russell H, Livingston JA, Kirchhoff AC, Jupiter D. Emergency Department Visits by Adolescent and Young Adult Cancer Patients Compared with Pediatric Cancer Patients in the United States. J Adolesc Young Adult Oncol 2018; 7:553-564. [PMID: 29924663 DOI: 10.1089/jayao.2018.0026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
PURPOSE Limited information exists on emergency department (ED) visits for adolescent and young adult (AYA) patients with cancer. We examined the clinical reasons for ED visits, and outcomes, for AYAs with cancer compared to pediatric cancer patients. METHODS The 2013 Nationwide Emergency Department Sample data were used to identify 53,274 AYA (ages 15-39) and 6952 pediatric (ages 0-14) cancer ED visits. We evaluated patient (i.e., demographic and diagnosis) and hospital characteristics, and the ED event outcome (admitted to the same hospital or treated/released). Clinical reasons for visits were identified as procedures, infections, or noninfectious toxicities. Variables were compared between groups using chi-squared tests. Logistic regressions identified characteristics associated with the outcome between and within groups. RESULTS AYA cancer visits were more likely to be self-paid (15.8% vs. 1.9%, p < 0.001), and be from low-income households and nonmetro counties than pediatric visits. Toxicity was the most prevalent reason for AYA visits (46.0%) and infections for pediatrics (47.3%, p < 0.001). AYA cancer visits were less likely to be admitted (OR = 0.84, 95% CI = 0.71-0.98; p = 0.03) than pediatric cancer. Among AYAs, self-paid visits were less likely to be admitted compared with privately insured visits (OR = 0.58, 95% CI: 0.52-0.66, p < 0.001). Self-pay did not affect the outcome for pediatric visits. CONCLUSIONS In the United States, compared with pediatric cancer patients, AYAs with cancer visit EDs more often for toxicity-related problems, and are more often self-paid and from poorer households. These distinctive features impacting health service use should be incorporated into care plans aimed at delineating effective care for these patients.
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Affiliation(s)
- Sapna Kaul
- 1 Department of Preventive Medicine and Community Health, University of Texas Medical Branch , Galveston, Texas
| | - Heidi Russell
- 2 Section of Hematology-Oncology, Department of Pediatrics, Baylor College of Medicine , Houston, Texas
| | - John A Livingston
- 3 Division of Cancer Medicine, Department of Sarcoma Medical Oncology, The University of Texas MD Anderson Cancer Center , Houston, Texas
| | - Anne C Kirchhoff
- 4 Division of Hematology/Oncology, Department of Pediatrics, Huntsman Cancer Institute, University of Utah , Salt Lake City, Utah
| | - Daniel Jupiter
- 1 Department of Preventive Medicine and Community Health, University of Texas Medical Branch , Galveston, Texas
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Morse E, Fujiwara RJT, Mehra S. The Association of Industry Payments to Physicians with Prescription of Brand-Name Intranasal Corticosteroids. Otolaryngol Head Neck Surg 2018; 159:442-448. [PMID: 29865931 DOI: 10.1177/0194599818774739] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Objectives To examine the association of industry payments for brand-name intranasal corticosteroids with prescribing patterns. Study Design Cross-sectional retrospective analysis. Setting Nationwide. Subjects and Methods We identified physicians prescribing intranasal corticosteroids to Medicare beneficiaries 2014-2015 and physicians receiving payment for the brand-name intranasal corticosteroids Dymista and Nasonex. Prescription and payment data were linked by physician, and we compared the proportion of prescriptions written for brand-name intranasal corticosteroids in industry-compensated vs non-industry-compensated physicians. We associated the number and dollar amount of industry payments with the relative frequency of brand-name prescriptions. Results In total, 164,587 physicians prescribing intranasal corticosteroids were identified, including 7937 (5%) otolaryngologists; 10,800 and 3886 physicians received industry compensation for Dymista and Nasonex, respectively. Physicians receiving industry payment for Dymista prescribed more Dymista as a proportion of total intranasal corticosteroid prescriptions than noncompensated physicians (3.1% [SD = 9.6%] vs 0.2% [SD = 2.5%], respectively, P < .001). Similar trends were seen for Nasonex (12.0% [SD = 16.8%] vs 4.8% [SD = 13.6%], P < .001). The number and dollar amount of payment were significantly correlated to the relative frequency of Dymista (ρ = 0.26, P < .001 and ρ = 0.20, P < .001, respectively) and Nasonex prescriptions (ρ = 0.09, P < .001 and ρ = 0.15, P < .001, respectively). For Dymista, this association was stronger in otolaryngologists than general practitioners ( P < .001). There was a stronger correlation between the percentage of prescriptions and the number and dollar amount of payments for Dymista than for Nasonex ( P = .014 and P < .001). Conclusions Industry compensation for brand-name intranasal corticosteroids is significantly associated with prescribing patterns. The magnitude of association may depend on physician specialty and the drug's time on the market.
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Affiliation(s)
- Elliot Morse
- 1 Department of Surgery, Division of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Rance J T Fujiwara
- 1 Department of Surgery, Division of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Saral Mehra
- 1 Department of Surgery, Division of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, USA.,2 Yale Cancer Center, New Haven, Connecticut, USA
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Tran G, Zafar SY. Financial toxicity and implications for cancer care in the era of molecular and immune therapies. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:166. [PMID: 29911114 DOI: 10.21037/atm.2018.03.28] [Citation(s) in RCA: 124] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Molecular and immune therapies have revolutionized cancer treatment and improved patient outcomes and survival. However, the pricing of these drugs has become an issue as the cost of cancer care continues to rise significantly. Cost sharing policies have increased out-of-pocket expenses for patients, leading to poorer financial well-being, quality of life, psychosocial health, and treatment adherence. In this review, we briefly examine some factors affecting the pricing of these new targeted therapies; the effects of financial toxicity on patients; and highlight potential health policy and patient-provider level interventions to address these issues.
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Affiliation(s)
- George Tran
- Duke University School of Medicine, Durham, NC, USA
| | - S Yousuf Zafar
- Duke University School of Medicine, Durham, NC, USA.,Duke Cancer Institute, Duke-Margolis Center for Health Policy, Durham, NC, USA
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Allen PB, Flowers CR. Balancing patient value and payer cost in hematologic malignancies: can it be done? Expert Rev Pharmacoecon Outcomes Res 2018; 18:123-126. [PMID: 29486601 DOI: 10.1080/14737167.2018.1444478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Pamela B Allen
- a Department of Hematology and Medical Oncology , Winship Cancer Institute, Emory University School of Medicine , Atlanta , GA , USA
| | - Christopher R Flowers
- a Department of Hematology and Medical Oncology , Winship Cancer Institute, Emory University School of Medicine , Atlanta , GA , USA
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