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Kehoe LA, Sohn MB, Wang L, Mohile S, Kamen C, Van Orden K, Wells M, Gilmore N, Arana-Chicas E, Gudina A, Yilmez S, Griggs L, Loh KP. Associations of quality of social support and accurate beliefs about curability among older adults with advanced cancer. J Geriatr Oncol 2024; 15:102061. [PMID: 39260086 DOI: 10.1016/j.jgo.2024.102061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 07/08/2024] [Accepted: 08/30/2024] [Indexed: 09/13/2024]
Abstract
INTRODUCTION Supporting older adults with advanced cancer to better understand their disease and its prognosis is important for shared decision-making. Social support is a potentially modifiable factor that may influence disease understanding. In this study, we examined the associations of quantity and quality of social support with patients' beliefs about the curability of their advanced cancer. MATERIALS AND METHODS We performed a secondary analysis of a cluster-randomized trial that recruited older adults aged ≥70 with advanced incurable cancer. At enrollment, patients completed the Older Americans Resources and Services (OARS) Medical Social Support form that measures both quantity (number of close friends and relatives) and quality of social support. Quality of social support was measured using 12 questions in instrumental and emotional support, each ranging from 1 (none of the time) to 5 (all of the time). Higher cumulative scores indicated greater quality of support. For beliefs about curability, patients were asked, "What do you believe are the chances that your cancer will go away and never come back with treatment?" Responses were 0 %, <50 %, 50/50, >50 %, and 100 %. Ordinal logistic regression was used to investigate the association of quantity and quality of social support with beliefs about curability, adjusting for potential confounders. RESULTS We included 347 patients; mean age was 76.4 years and 91 % were white. Quantity of social support was not associated with belief in curability [adjusted odds ratio (AOR) 1.03, 95 % confidence interval (CI) (0.92, 1.16)]. For every unit increase in the quality of social support (OARS Medical Social Support score), the odds of believing in curability decreased by 26.7 % [AOR 0.73, 95 % CI (0.56, 0.97)]. DISCUSSION Our study demonstrated that the quality, but not the quantity, of social support was associated with patients' beliefs about curability. These findings suggest that bolstering social support may directly enhance disease understanding. This insight informs supportive care interventions that specifically address disease comprehension among patients.
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Affiliation(s)
- Lee A Kehoe
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States of America; Division of Supportive Care in Cancer, Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States of America; Roybal Center for Social Ties and Aging, Aging Institute, University of Rochester, Rochester, NY, United States of America; Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, United States of America.
| | - Michael B Sohn
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States of America.
| | - Lu Wang
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States of America.
| | - Supriya Mohile
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States of America; Division of Hematology/Oncology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States of America.
| | - Charles Kamen
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States of America; Division of Supportive Care in Cancer, Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States of America.
| | - Kim Van Orden
- Roybal Center for Social Ties and Aging, Aging Institute, University of Rochester, Rochester, NY, United States of America; Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, United States of America; Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States of America.
| | - Megan Wells
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States of America.
| | - Nikesha Gilmore
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States of America; Division of Supportive Care in Cancer, Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States of America.
| | - Evelyn Arana-Chicas
- Division of Supportive Care in Cancer, Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States of America; Division of Medical Oncology, Rutgers Cancer Institute, Rutgers University, New Brunswick, NJ, United States of America.
| | - Abdi Gudina
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States of America; Division of Supportive Care in Cancer, Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States of America.
| | - Sule Yilmez
- Division of Supportive Care in Cancer, Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States of America.
| | - Lorraine Griggs
- Stakeholders for Care in Oncology and Research for our Elders, Rochester, NY, United States of America.
| | - Kah Poh Loh
- James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States of America; Division of Hematology/Oncology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States of America.
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Contreras J, Wang C, Castillo WC, Caicedo J, Guerrero Vázquez M, Robalino T, Hidalgo-Arroyo A, Villalonga-Olives E. Cross-cultural adaptation of the awareness and beliefs about cancer measure for Hispanics/Latinos living in the United States. Front Public Health 2024; 12:1351729. [PMID: 39286745 PMCID: PMC11404523 DOI: 10.3389/fpubh.2024.1351729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 06/21/2024] [Indexed: 09/19/2024] Open
Abstract
Introduction The purpose of this study is to culturally adapt the Awareness and Beliefs about Cancer (ABC) measure for use in the Hispanic/Latino population living in the United States (US). Methods In accordance with Patient Reported Outcomes (PRO) Consortium guidelines for cross-cultural adaptation of measures for content and linguistic validity, we conducted: two forward-translations, reconciliation, two back-translations, revision and harmonization, six cognitive interviews, revision, external expert review, and finalization of the version. We used a mixed methods approach, conducting cognitive interviews with Hispanic/Latino community members while also convening an expert panel of six clinicians, health professionals, and community representatives and including the in the entire process. After cross-culturally adapting the ABC measure, we assessed the psychometric properties of the instrument using item response theory analysis. Item parameters, discrimination and category thresholds, and standard errors were calculated. For each of the adapted subdomains, we used item information curves to report the graphical profile of item effectiveness. Results Twenty-two Hispanic/Latino community members were enrolled in cognitive interviews, and Hispanics/Latinos fluent in Spanish completed the measure to assess its psychometric properties. Cognitive interviews revealed opportunities to improve items. Key changes from the original measure include the inclusion of gender inclusive language and an inquiry into e-cigarette use on items related to smoking habits. Psychometric property analyses revealed that the anticipated delay in seeking medical help, general cancer beliefs, and cancer screening beliefs and behaviors subdomains had some slope parameters that were < 1; this implies that those items were not able to adequately discriminate the latent trait and had poor performance. Discussion The adapted ABC measure for US Hispanics/Latinos meets content and linguistic validity standards, with construct validity confirmed for cancer symptom recognition and barriers to symptomatic presentation subdomains, but revisions are necessary for others, highlighting the need for ongoing refinement to ensure the cultural appropriateness of instruments.
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Affiliation(s)
- Jennifer Contreras
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, United States
| | - Chun Wang
- College of Education, University of Washington, Seattle, WA, United States
| | - Wendy Camelo Castillo
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, United States
| | - Juan Caicedo
- Heritage Care, Inc., Riverdale, MD, United States
| | | | - Tania Robalino
- Ezperanza Center, Catholic Charities of Baltimore, Baltimore, MD, United States
| | - Aida Hidalgo-Arroyo
- Latino Center for Health, University of Washington, Seattle, WA, United States
| | - Ester Villalonga-Olives
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, United States
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Abraham O, McCarthy TJ. An Introduction to the OutSMART Cancer Serious Game: Current and Future Directions. JMIR Cancer 2024; 10:e56168. [PMID: 38809587 PMCID: PMC11170044 DOI: 10.2196/56168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/21/2024] [Accepted: 04/24/2024] [Indexed: 05/30/2024] Open
Abstract
Given that cancer is a challenging disease that plagues millions of individuals of all age groups and socioeconomic statuses globally, developmentally appropriate education is often lacking for young people, particularly adolescents. Increasing cancer awareness and prevention education among adolescents using innovative strategies, such as game-based learning, is critical in reducing the burden of this disease. Adolescents are understudied in the field of cancer prevention and control, yet vulnerable as they tackle creating life-long health behavior patterns. Targeting cancer prevention education for adolescents has the potential to support long-term healthy behavior and reduce their risk of cancer. This paper provides an overview of the Collaborative Research on MEdication use and family health (CRoME) Lab's novel game-based cancer prevention education tool. OutSMART Cancer is an innovative, novel educational intervention in the form of a serious game. Serious games are educational tools that seek to impart knowledge and improve behaviors in their players. This game covers information related to breast cancer, colon cancer, and lung cancer. This viewpoint is a summary of the developmental process for the OutSMART Cancer game. We describe in detail the work preceding initial game development, the current version of the game, future directions for the game, and its educational potential. The long-term goal of OutSMART Cancer is to improve cancer awareness and knowledge regarding prevention behaviors in adolescents and support a lifetime of health and wellness.
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Affiliation(s)
- Olufunmilola Abraham
- Social and Administrative Sciences Division, School of Pharmacy, University of Wisconsin-Madison, Madison, WI, United States
| | - Tyler J McCarthy
- Social and Administrative Sciences Division, School of Pharmacy, University of Wisconsin-Madison, Madison, WI, United States
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Akbari P, Nemati S, Nahvijou A, Bolourinejad P, Forbes L, Zendehdel K. Survey of awareness and beliefs about cancer (ABC) in Tehran Province, Iran. BMC Cancer 2024; 24:579. [PMID: 38734656 PMCID: PMC11088007 DOI: 10.1186/s12885-024-12211-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 04/01/2024] [Indexed: 05/13/2024] Open
Abstract
INTRODUCTION Knowledge, attitudes, and practices are essential measures for planning and evaluating cancer control programs. Little is known about these in Iran. METHODS We conducted a population-based interview survey of adults aged 30-70 using the Farsi version of the Awareness and Beliefs about Cancer questionnaire in the capital province of Tehran, Iran, 2019. We calculated weighted estimates of levels of cancer knowledge, attitudes, and practices to allow for different selection probabilities and nonresponse. We used multivariate logistic regression to understand demographic factors associated with bowel, cervix, and breast screening practices. RESULTS We interviewed 736 men and 744 women. The mean number of recalled cancer warning signs was less than one; 57.7% could not recall any cancer warning signs. Participants recognized 5.6 out of 11 early cancer warning signs and 8.8 of 13 cancer risk factors. Most (82.7%) did not know that HPV infection was a cancer risk factor. Approximately, half had negative attitudes towards cancer treatment, but over 80% had positive attitudes towards the effectiveness of screening for improving survival. Colorectal, breast, and cervical screening rates were 24%, 42%, and 49%, respectively. Higher socioeconomic status increased the odds of taking up screening for cancer. Women aged 60-70 were less likely to report taking up breast and cervical screening than younger women. DISCUSSION The Iranian population has poor awareness and negative attitudes about cancer, and participation in screening programs is low. Public awareness and early detection of cancer should be promoted in Iran.
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Affiliation(s)
- Paria Akbari
- Cancer Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Saeed Nemati
- Cancer Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Azin Nahvijou
- Cancer Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Paria Bolourinejad
- Student Research Committee, School of Medicine, Isfahan University of Medical Science, Isfahan, Iran
| | - Lindsay Forbes
- Centre for Health Services Studies, University of Kent, Canterbury, UK
| | - Kazem Zendehdel
- Cancer Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran.
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Hong YR, Yadav S, Wang R, Vadaparampil S, Bian J, George TJ, Braithwaite D. Genetic Testing for Cancer Risk and Perceived Importance of Genetic Information Among US Population by Race and Ethnicity: a Cross-sectional Study. J Racial Ethn Health Disparities 2024; 11:382-394. [PMID: 36689121 PMCID: PMC9870197 DOI: 10.1007/s40615-023-01526-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 01/08/2023] [Accepted: 01/16/2023] [Indexed: 01/24/2023]
Abstract
BACKGROUND Genetic testing can help determine the risk of many cancers and guide cancer prevention and treatment plans. Despite increasing concern about disparities in precision cancer medicine, public knowledge and cancer genetic testing by race and ethnicity have not been well investigated. METHODS We analyzed data from the 2020 Health Information National Trends Survey in 2022. Self-reported cancer genetic testing (e.g., Lynch syndrome, BRCA1/2) knowledge and utilization were compared by race and ethnicity. Perceived importance of genetic information for cancer care (prevention, detection, and treatment) was also examined in relation to the uptake of cancer genetic testing. Multivariable logistic regression models were employed to examine factors associated with knowledge and genetic testing to calculate predicted probability of undergoing genetic testing by race and ethnicity. RESULTS Of 3551 study participants, 37.8% reported having heard of genetic testing for cancer risk and 3.9% stated that they underwent cancer genetic testing. Being non-Hispanic Black (OR=0.47, 95% CI=0.30-0.75) or Hispanic (OR=0.56, CI=0.35-0.90) was associated with lower odds of genetic testing knowledge. Although Hispanic or non-Hispanic Black respondents were more likely to perceive higher importance of genetic information versus non-Hispanic Whites, they had a lower predicted probability of cancer genetic testing. CONCLUSION Non-Hispanic Black and Hispanic adults had lower knowledge and were less likely to undergo cancer genetic testing than non-Hispanic Whites. Further research is needed on sources of genetic testing information for racial and ethnic minorities and the barriers to accessing genetic testing to inform the development of effective cancer risk genetic testing promotion.
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Affiliation(s)
- Young-Rock Hong
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, PO Box 100195, Gainesville, FL, 32610, USA.
- UF Health Cancer Center, Gainesville, USA.
| | - Sandhya Yadav
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, PO Box 100195, Gainesville, FL, 32610, USA
| | - Ruixuan Wang
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, PO Box 100195, Gainesville, FL, 32610, USA
| | - Susan Vadaparampil
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, USA
- Department of Oncological Sciences, Morsani College of Medicine, University of South Florida, Gainesville, USA
| | - Jiang Bian
- UF Health Cancer Center, Gainesville, USA
- Department of Health Outcomes and Biomedical informatics, College of Medicine, University of Florida, Gainesville, USA
| | - Thomas J George
- UF Health Cancer Center, Gainesville, USA
- Department of Medicine, Division of Hematology & Oncology, College of Medicine, University of Florida, Gainesville, USA
| | - Dejana Braithwaite
- UF Health Cancer Center, Gainesville, USA
- Department of Epidemiology, College of Public Health and Health Professions, University of Florida, Gainesville, USA
- Department of Surgery, College of Medicine, University of Florida, Gainesville, USA
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Wainwright JV, Mehta SJ, Clifton A, Bocage C, Ogden SN, Cohen S, Rendle KA. Persistent Barriers to Colorectal Cancer Screening Completion Amid Centralized Outreach: A Mixed Methods Study. Am J Health Promot 2021; 36:697-705. [PMID: 34970929 PMCID: PMC9109679 DOI: 10.1177/08901171211064492] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE To understand patient experiences and persistent barriers to colorectal cancer (CRC) screening amid centralized outreach at urban family medicine practices. APPROACH Following a pragmatic trial assessing mailed fecal immunochemical test (FIT) outreach, we invited a subset of participants to complete a semi-structured qualitative interview and structured questionnaire. SETTING Single urban academic healthcare system. PARTICIPANTS Sixty patients who were eligible and overdue for CRC screening at the time of trial enrollment. METHOD Using Andersen's Behavioral Model, we developed an interview guide to systematically assess factors shaping screening decisions and FIT uptake. Close-ended responses were analyzed using descriptive statistics. Qualitative data were analyzed using the constant comparative method. RESULTS Most participants (82%) self-reported that they had ever completed any modality of CRC screening, and nearly half (43%) completed the mailed FIT during the trial. Most patients (60%) preferred FIT to colonoscopy due to its private, convenient, and non-invasive nature; however, persistent barriers related to screening beliefs including fear of test results and cancer treatment still prevented some patients from completing any form of CRC screening. CONCLUSIONS Mailed FIT can overcome many structural barriers to CRC screening, yet clear communication and follow-up amid centralized outreach are essential. For some patients, tailored outreach or navigation to address screening-related fears or other screening beliefs may be needed to ensure timely completion of CRC screening.
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Affiliation(s)
- Jocelyn V Wainwright
- Department of Family Medicine and Community Health, Perelman School of Medicine, 14640University of Pennsylvania, Philadelphia, PA, USA
| | - Shivan J Mehta
- Department of Medicine, Perelman School of Medicine, 14640University of Pennsylvania, Philadelphia, PA, USA.,Penn Center for Cancer Care Innovation, Abramson Cancer Center, 14640University of Pennsylvania, Philadelphia, PA, USA
| | - Alicia Clifton
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, 14640University of Pennsylvania, Philadelphia, PA, USA
| | - Claire Bocage
- Department of Family Medicine and Community Health, Perelman School of Medicine, 14640University of Pennsylvania, Philadelphia, PA, USA
| | - Shannon N Ogden
- Department of Health Law, Policy and Management, 27118Boston University School of Public Health, Boston, MA, USA
| | - Sarah Cohen
- Department of Family Medicine and Community Health, Perelman School of Medicine, 14640University of Pennsylvania, Philadelphia, PA, USA
| | - Katharine A Rendle
- Department of Family Medicine and Community Health, Perelman School of Medicine, 14640University of Pennsylvania, Philadelphia, PA, USA.,Penn Center for Cancer Care Innovation, Abramson Cancer Center, 14640University of Pennsylvania, Philadelphia, PA, USA
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Graetz D, Rivas S, Fuentes L, Cáceres-Serrano A, Ferrara G, Antillon-Klussmann F, Metzger M, Rodriguez-Galindo C, Mack JW. The evolution of parents' beliefs about childhood cancer during diagnostic communication: a qualitative study in Guatemala. BMJ Glob Health 2021; 6:bmjgh-2020-004653. [PMID: 34039587 PMCID: PMC8160167 DOI: 10.1136/bmjgh-2020-004653] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 04/27/2021] [Accepted: 04/29/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Fatalistic cancer beliefs may contribute to delayed diagnosis and poor outcomes, including treatment abandonment, for children with cancer. This study explored Guatemalan parents' cancer beliefs during initial paediatric cancer communication, and the sociocultural and contextual factors that influence these beliefs. METHODS Twenty families of children with cancer were included in this study. We audio-recorded psychosocial conversations with psychologists and diagnostic conversations with oncologists, then conducted semi-structured interviews with parents to explore the evolution of their cancer beliefs. Audio-recordings were transcribed and translated from Spanish into English, with additional review in both languages by bilingual team members. All 60 transcripts were thematically analysed using a priori and novel codes. RESULTS Guatemalan parents' beliefs evolve as they learn about cancer through various sources. Sources of information external to the cancer centre, including prior experiences with cancer, media exposure, community discussion and clinical encounters, contribute to pre-existing beliefs. Many parents' pre-existing cancer beliefs are fatalistic; some are influenced by Mayan spirituality. Sources internal to the cancer centre include psychologists and oncologists, other providers, other patients and families. Psychologists acknowledge pre-existing beliefs and deliver cancer education using verbal explanations and hand-drawings. Oncologists provide diagnostic information and outline treatment plans. Both support hope by providing a path toward cure. Parents' lived experience is a culmination of sources and simultaneously independent. Ultimately most parents arrive at an understanding of cancer that is consistent with an allopathic medical model and offers optimism about outcomes. CONCLUSION An interdisciplinary communication process that includes cancer education, is attentive to pre-existing beliefs, and supports hope may encourage acceptance of the allopathic medical model and need for treatment. Providers in settings of all resource levels may be able to use these techniques to support cross-cultural cancer communication, reduce treatment abandonment and improve therapy adherence.
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Affiliation(s)
- Dylan Graetz
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Silvia Rivas
- Department of Palliative Care, Unidad Nacional de Oncologia Pediatrica, Guatemala, Guatemala
| | - Lucia Fuentes
- Department of Psychology, Unidad Nacional de Oncologia Pediatrica, Guatemala, Guatemala
| | - Ana Cáceres-Serrano
- Department of Psychology, Unidad Nacional de Oncologia Pediatrica, Guatemala, Guatemala
| | - Gia Ferrara
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Federico Antillon-Klussmann
- Department of Oncology, Universidad Francisco Marroquin Facultad de Medicina, Guatemala City, Guatemala.,Department of Oncology, Unidad Nacional de Oncologia Pediatrica, Guatemala, Guatemala
| | - Monika Metzger
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Carlos Rodriguez-Galindo
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jennifer W Mack
- Departments of Pediatric Oncology and Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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