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Duckett KA, Kassir MF, Nguyen SA, Brennan EA, Chera BS, Sterba KR, Halbert CH, Hill EG, McCay J, Puram SV, Jackson RS, Sandulache VC, Kahmke R, Osazuwa-Peters N, Ramadan S, Nussenbaum B, Alberg AJ, Graboyes EM. Factors Associated with Head and Neck Cancer Postoperative Radiotherapy Delays: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2024; 171:1265-1282. [PMID: 38842034 PMCID: PMC11499046 DOI: 10.1002/ohn.835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 05/02/2024] [Accepted: 05/12/2024] [Indexed: 06/07/2024]
Abstract
OBJECTIVE Initiating postoperative radiotherapy (PORT) within 6 weeks of surgery for head and neck squamous cell carcinoma (HNSCC) is included in the National Comprehensive Cancer Network Clincal Practice Guidelines and is a Commission on Cancer quality metric. Factors associated with delays in starting PORT have not been systematically described nor synthesized. DATA SOURCES PubMed, Scopus, and CINAHL. REVIEW METHODS We included studies describing demographic characteristics, clinical factors, or social determinants of health associated with PORT delay (>6 weeks) in patients with HNSCC treated in the United States after 2003. Meta-analysis of odds ratios (ORs) was performed on nonoverlapping datasets. RESULTS Of 716 unique abstracts reviewed, 21 studies were included in the systematic review and 15 in the meta-analysis. Study sample size ranged from 19 to 60,776 patients. In the meta-analysis, factors associated with PORT delay included black race (OR, 1.46, 95% confidence interval [CI]: 1.28-1.67), Hispanic ethnicity (OR, 1.37, 95% CI, 1.17-1.60), Medicaid or no health insurance (OR, 2.01, 95% CI, 1.90-2.13), lower income (OR, 1.38, 95% CI, 1.20-1.59), postoperative admission >7 days (OR, 2.92, 95% CI, 2.31-3.67), and 30-day hospital readmission (OR, 1.37, 95% CI, 1.29-1.47). CONCLUSION Patients at greatest risk for a delay in initiating guideline-adherent PORT include those who are from minoritized communities, of lower socioeconomic status, and experience postoperative challenges. These findings provide the foundational evidence needed to deliver targeted interventions to enhance equity and quality in HNSCC care delivery.
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Affiliation(s)
- Kelsey A. Duckett
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mohamed Faisal Kassir
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Shaun A. Nguyen
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Emily A. Brennan
- MUSC Libraries, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Bhisham S. Chera
- Department of Radiation Oncology, Hollings Cancer Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Katherine R. Sterba
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Chanita Hughes Halbert
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
| | - Elizabeth G. Hill
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jessica McCay
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sidharth V. Puram
- Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
- Department of Genetics, Washington University School of Medicine, St Louis, Missouri, USA
| | - Ryan S. Jackson
- Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Vlad C. Sandulache
- Bobby R. Alford Department of Otolaryngology–Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
- ENT Section, Operative CareLine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Russel Kahmke
- Department of Head and Neck Surgery and Communication Sciences, Duke University, Durham, North Carolina, USA
| | - Nosayaba Osazuwa-Peters
- Department of Head and Neck Surgery and Communication Sciences, Duke University, Durham, North Carolina, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, North Carolina, USA
| | - Salma Ramadan
- Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Brian Nussenbaum
- American Board of Otolaryngology–Head and Neck Surgery, Houston, Texas, USA
| | - Anthony J. Alberg
- Department of Epidemiology and Biostatistics, University of South Carolina Arnold School of Public Health, Columbia, South Carolina, USA
| | - Evan M. Graboyes
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
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Duckett KA, Kassir MF, Nguyen SA, Brennan EA, Chera BS, Sterba KR, Hughes Halbert C, Hill EG, McCay J, Puram SV, Sandulache VC, Kahmke R, Ramadan S, Nussenbaum B, Alberg AJ, Graboyes EM. Delays Starting Postoperative Radiotherapy Among Head and Neck Cancer Patients: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2024; 170:320-334. [PMID: 37731255 PMCID: PMC10840985 DOI: 10.1002/ohn.538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/10/2023] [Accepted: 09/02/2023] [Indexed: 09/22/2023]
Abstract
OBJECTIVE Initiating postoperative radiotherapy (PORT) within 6 weeks (42 days) of surgery is the first and only Commission on Cancer (CoC) approved quality metric for head and neck squamous cell carcinoma (HNSCC). No study has systematically reviewed nor synthesized the literature to establish national benchmarks for delays in starting PORT. DATA SOURCES Following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, we performed a systematic review of PubMed, Scopus, and CINAHL. REVIEW METHODS Studies that described time-to-PORT or PORT delays in patients with HNSCC treated in the United States after 2003 were included. Meta-analysis of proportions and continuous measures was performed on nonoverlapping datasets to examine the pooled frequency of PORT delays and time-to-PORT. RESULTS Thirty-six studies were included in the systematic review and 14 in the meta-analysis. Most studies utilized single-institution (n = 17; 47.2%) or cancer registry (n = 16; 44.4%) data. Twenty-five studies (69.4%) defined PORT delay as >6 weeks after surgery (the definition utilized by the CoC and National Comprehensive Cancer Network Guidelines), whereas 4 (11.1%) defined PORT delay as a time interval other than >6 weeks, and 7 (19.4%) characterized time-to-PORT without defining delay. Meta-analysis revealed that 48.6% (95% confidence interval [CI], 41.4-55.9) of patients started PORT > 6 weeks after surgery. Median and mean time-to-PORT were 45.8 (95% CI, 42.4-51.4 days) and 47.4 days (95% CI, 43.4-51.4 days), respectively. CONCLUSION Delays in initiating guideline-adherent PORT occur in approximately half of patients with HNSCC. These meta-analytic data can be used to set national benchmarks and assess progress in reducing delays.
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Affiliation(s)
- Kelsey A Duckett
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mohamed Faisal Kassir
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Shaun A Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Emily A Brennan
- MUSC Libraries, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Bhishamjit S Chera
- Department of Radiation Oncology, Hollings Cancer Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Katherine R Sterba
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Chanita Hughes Halbert
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
| | - Elizabeth G Hill
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jessica McCay
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sidharth V Puram
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
- Department of Genetics, Washington University School of Medicine, St Louis, Missouri, USA
| | - Vlad C Sandulache
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
- ENT Section, Operative CareLine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Russel Kahmke
- Department of Head and Neck Surgery and Communication Sciences, Duke University, Durham, North Carolina, USA
| | - Salma Ramadan
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Brian Nussenbaum
- American Board of Otolaryngology-Head and Neck Surgery, Houston, Texas, USA
| | - Anthony J Alberg
- Department of Epidemiology and Biostatistics, University of South Carolina Arnold School of Public Health, Columbia, South Carolina, USA
| | - Evan M Graboyes
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
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Rosas Herrera AM, Haskins AD, Hanania AN, Jhaveri PM, Chapman CH, Huang Q, Hernandez DJ. Timely delivery of PORT for head and neck squamous cell carcinoma in a county hospital. Laryngoscope Investig Otolaryngol 2024; 9:e1211. [PMID: 38362185 PMCID: PMC10866599 DOI: 10.1002/lio2.1211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 12/11/2023] [Accepted: 12/21/2023] [Indexed: 02/17/2024] Open
Abstract
Objectives The objective of this study was to compare the rate of post-operative radiation therapy (PORT) initiation within 6 weeks for head and neck squamous cell carcinoma patients treated at a safety net, academic institutio between 2019 and 2021 versus those treated in 2022 after implementation of a new clinical pathway. Methods A retrospective case-control study was performed at a single tertiary care, safety-net, academic institution. Patient demographics, tumor characteristics, dates of surgery, and other treatment dates were collected from the electronic medical record. The time from surgery to PORT was calculated. Patients who started radiation treatment within 42 days of surgery were regarded as having started PORT on time. The demographics, tumor characteristics, and rate of timely PORT for the two cohorts of patients were compared. Results From 2018 to 2021, our rate of PORT initiation within 6 weeks of surgery was 12% (n = 57). In 2022, our rate of timely PORT was 88% (n = 16), p < 0.5. Patient demographics and characteristics were similar with the exception of marital status and use of free-flap reconstruction. The 2022 cohort was more likely to be single (p < 0.5), and all patients underwent free-flap reconstruction in 2022 (p < 0.05). Conclusion Early referrals, frequent communication, and use of a secure registry were the key to the success found by our group despite the socioeconomic challenges of our underserved, safety-net hospital patient population. The changes made at our institution should serve as a template for other institutions seeking to improve the quality of care for their HNSCC patients.
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Affiliation(s)
- Ana Maria Rosas Herrera
- Bobby R. Alford Department of Otolaryngology – Head and Neck SurgeryBaylor College of MedicineHoustonTexasUSA
| | - Angela D. Haskins
- Bobby R. Alford Department of Otolaryngology – Head and Neck SurgeryBaylor College of MedicineHoustonTexasUSA
| | - Alexander N. Hanania
- Department of Radiation Oncology, Dan L. Duncan Cancer CenterBaylor College of MedicineHoustonTexasUSA
| | - Pavan M. Jhaveri
- Department of Radiation Oncology, Dan L. Duncan Cancer CenterBaylor College of MedicineHoustonTexasUSA
| | - Christina H. Chapman
- Department of Radiation Oncology, Dan L. Duncan Cancer CenterBaylor College of MedicineHoustonTexasUSA
| | - Quillan Huang
- Section of Hematology and Oncology, Department of MedicineBaylor College of MedicineHoustonTexasUSA
| | - David J. Hernandez
- Bobby R. Alford Department of Otolaryngology – Head and Neck SurgeryBaylor College of MedicineHoustonTexasUSA
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Xie X, Kang M, Qu Z, Gu K. A predictive model for patients with local-regionally advanced oropharyngeal squamous cell carcinoma treated after cervical lymph node dissection. J Cancer Res Clin Oncol 2023; 149:17241-17251. [PMID: 37804427 DOI: 10.1007/s00432-023-05379-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/30/2023] [Indexed: 10/09/2023]
Abstract
PURPOSE To develop a nomogram to predict the cancer-specific survival of patients with local-regionally advanced oropharyngeal squamous cell carcinoma after cervical lymph node dissection. METHODS The clinical variables of patients confirmed as having oropharyngeal squamous cell carcinoma between 2008 and 2015 were retrieved from the Surveillance, Epidemiology and End Results database. Univariate and multivariate analysis were performed, followed by the construction of nomograms for CSS. Nomogram' accuracy was evaluated through the concordance index, calibration curves and decision curve analysis. RESULTS A total of 1994 oropharyngeal squamous cell carcinoma patients who underwent surgery were included in this study. Sex, T-stage, American Joint Committee on Cancer-stage, positive lymph nodes, positive lymph node ratio, log odds of positive lymph nodes, and postoperative radiotherapy were selected to establish the nomogram for oropharyngeal squamous cell carcinoma. The concordance index of the nomogram was 0.747 (95% CI 0.714-0.780) in the training calibration cohort and 0.735 (95% CI 0.68-0.789) in the validationcohort and the time-dependent Area under the curve (> 0.7) indicated satisfactory discriminative ability of the nomogram. The calibration plot shows that there is a good consistency between the predictions of the nomogram and the actual observations in the training and validation cohorts. In addition, decision curve analysis showed that the nomogram was clinically useful and had a better ability to recognize patients at high risk than the American Joint Committee on Cancer tumor-node-metastasis staging. CONCLUSION The predictive model has the potential to provide valuable guidance to clinicians in the treatment of patients with locoregionally advanced OPSCC confined to the cervical lymph nodes.
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Affiliation(s)
- Xiaoque Xie
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Mei Kang
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Ziting Qu
- Department of Medical Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Kangsheng Gu
- Department of Medical Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, China.
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Hernandez DJ, Xu W, Lim Y, Dong JL, Huang AT, Chiu L, Awad S, Joseph L, Sandulache VC. Operationalizing a Free Flap Program for Head and Neck Reconstruction at a Veterans Affairs Hospital. OTO Open 2023; 7:e80. [PMID: 37693829 PMCID: PMC10487330 DOI: 10.1002/oto2.80] [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: 07/26/2023] [Accepted: 08/18/2023] [Indexed: 09/12/2023] Open
Abstract
Objectives We aimed to operationalize a head and neck microvascular free tissue transfer (MVFTT) program at a Veterans Affairs (VA) hospital with the emphasis on initiating radiotherapy within 6 weeks of surgery for cancer patients and minimizing readmissions. Study Design Case series. Setting Tertiary care VA hospital. Methods A retrospective analysis was performed on consecutive head and neck MVFTT patients from May 1, 2017 and April 30, 2022. Demographics, patient and disease characteristics, per-operative data and postoperative outcomes were recorded from the electronic medical record. We sought to compare our rate of 30-day readmissions with those published in the literature. Results One hundred and forty-one procedures were performed in the queried timeframe. Eighty-four percent (119) were performed after oncologic resections and 16% (22) were for nononcologic procedures. The rate of total flap loss was <1% and the rate of partial flap loss was 3.5%. For mucosal defects, the fistula rate was 2.3%. The rate of return to the OR for any reason within 30 days was 7.8%. The 30-day readmission rate was 6.4% while the rates reported in the literature range from 13% to 20%. One hundred and four patients required postoperative radiotherapy (PORT) and 76% started PORT within 42 days of surgery. Conclusion Operationalizing a head and neck MVFTT program with a VA hospital is safe and allows for the successful delivery of multimodality treatment to cancer patients. These resources can be expanded for the care of head and neck cancer treatment sequelae, such as osteoradionecrosis, and other nononcologic patient needs.
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Affiliation(s)
- David J. Hernandez
- Bobby R. Alford Department of Otolaryngology–Head and Neck SurgeryHoustonTexasUSA
- ENT Section, Operative Care LineMichael E. DeBakey Veterans Affairs Medical CenterHoustonTexasUSA
| | - William Xu
- Bobby R. Alford Department of Otolaryngology–Head and Neck SurgeryHoustonTexasUSA
- ENT Section, Operative Care LineMichael E. DeBakey Veterans Affairs Medical CenterHoustonTexasUSA
| | - Yuli Lim
- Bobby R. Alford Department of Otolaryngology–Head and Neck SurgeryHoustonTexasUSA
- ENT Section, Operative Care LineMichael E. DeBakey Veterans Affairs Medical CenterHoustonTexasUSA
| | - Jen L. Dong
- Bobby R. Alford Department of Otolaryngology–Head and Neck SurgeryHoustonTexasUSA
- ENT Section, Operative Care LineMichael E. DeBakey Veterans Affairs Medical CenterHoustonTexasUSA
| | - Andrew T. Huang
- Bobby R. Alford Department of Otolaryngology–Head and Neck SurgeryHoustonTexasUSA
- ENT Section, Operative Care LineMichael E. DeBakey Veterans Affairs Medical CenterHoustonTexasUSA
| | - Louisa Chiu
- General Surgery Section, Operative Care LineMichael E. DeBakey Veterans Affairs Medical CenterHoustonTexasUSA
| | - Samir Awad
- General Surgery Section, Operative Care LineMichael E. DeBakey Veterans Affairs Medical CenterHoustonTexasUSA
| | - Linda Joseph
- Anesthesia Section, Operative Care LineMichael E. DeBakey Veterans Affairs Medical CenterHoustonTexasUSA
| | - Vlad C. Sandulache
- Bobby R. Alford Department of Otolaryngology–Head and Neck SurgeryHoustonTexasUSA
- ENT Section, Operative Care LineMichael E. DeBakey Veterans Affairs Medical CenterHoustonTexasUSA
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Tranby EP, Heaton LJ, Tomar SL, Kelly AL, Fager GL, Backley M, Frantsve-Hawley J. Oral Cancer Prevalence, Mortality, and Costs in Medicaid and Commercial Insurance Claims Data. Cancer Epidemiol Biomarkers Prev 2022; 31:1849-1857. [PMID: 35732291 PMCID: PMC9437560 DOI: 10.1158/1055-9965.epi-22-0114] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 05/17/2022] [Accepted: 06/16/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND This study compared prevalence, incidence, mortality rates, treatment costs, and risk factors for oral and oropharyngeal cancer (OC/OPC) between two large United States adult cohorts in 2012-2019. METHODS Medicaid and commercial claims data came from the IBM Watson Health MarketScan Database. Logistic regression analyses estimated incidence and risk factors for OC/OPC. Mortality was calculated by merging deceased individuals' files with those of the existing cancer cohort. Summing costs of outpatient and inpatient services determined costs. RESULTS Prevalence of OC/OPC in Medicaid enrollees decreased each year (129.8 cases per 100,000 enrollees in 2012 to 88.5 in 2019); commercial enrollees showed a lower, more stable prevalence (64.7 per 100,000 in 2012 and 2019). Incidence trended downward in both cohorts, with higher incidence in the Medicaid (51.4-37.6 cases per 100,000) than the commercial cohort (31.9-31.0 per 100,000). Mortality rates decreased for Medicaid enrollees during 2012-2014 but increased in the commercial cohort. OC/OPC treatment costs were higher for commercial enrollees by $8.6 million during 2016-2019. OC/OPC incidence was higher among adults who were older, male, and white; used tobacco or alcohol; or had prior human immunodeficiency virus/acquired immune deficiency syndrome diagnosis and lower among those who had seen a dentist the prior year. CONCLUSIONS Medicaid enrollees experienced higher OC/OPC incidence, prevalence, and mortality compared with commercially insured adults. Having seen a dentist within the prior year was associated with a lower risk of OC/OPC diagnosis. IMPACT Expanding Medicaid dental benefits may allow OC/OPC to be diagnosed at earlier stages through regular dental visits.
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Affiliation(s)
- Eric P. Tranby
- Analytics and Evaluation, CareQuest Institute for Oral Health, Boston, Massachusetts
| | - Lisa J. Heaton
- Analytics and Evaluation, CareQuest Institute for Oral Health, Boston, Massachusetts.,Corresponding Author: Lisa J. Heaton, Science Writer, Analytics and Evaluation, CareQuest Institute for Oral Health, 465 Medford Street, Boston, MA 02129. Phone: 617-886-1047; E-mail:
| | - Scott L. Tomar
- Division of Prevention and Public Health Sciences, College of Dentistry, University of Illinois, Chicago, Illinois
| | | | | | - Mary Backley
- Maryland Dental Action Coalition, Columbia, Maryland
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