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Boehmer U, Ozonoff A, Winter M, Berklein F, Potter J, Hartshorn KL, Ward KC, Ceballos RM, Clark MA. Health-related quality of life among colorectal cancer survivors of diverse sexual orientations. Cancer 2021; 127:3847-3855. [PMID: 34237147 DOI: 10.1002/cncr.33762] [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: 03/02/2021] [Revised: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND The purpose of this study was to examine the health-related quality of life of sexual minority survivors in comparison with heterosexual survivors. METHODS Four hundred eighty eligible survivors participated in a telephone survey that measured survivors' outcomes, which consisted of physical and mental quality of life and self-rated fair or poor health. These survivors were diagnosed with stage I, II, or III colorectal cancer an average of 3 years before the survey and were recruited from 4 cancer registries. Using forward selection with generalized linear models or logistic regression models, the authors considered 4 domains-personal factors, environmental factors, health condition characteristics, and body function and structure-as correlates for each survivorship outcome. RESULTS The authors found that unadjusted physical quality of life and self-rated fair/poor health were similar for all survivors. Sexual minority survivors had poorer unadjusted mental quality of life in comparison with heterosexual survivors. After adjustments for covariates, this difference was no longer statistically significant. Three domains (personal factors, health condition characteristics, and body function and structure) explained colorectal cancer survivors' fair/poor health and 46% of the variance in physical quality of life, whereas 56% of the variance in mental quality of life was explained by personal factors, body function and structure, and environmental factors. CONCLUSIONS This study has identified modifiable factors that can be used to improve cancer survivors' quality of life and are, therefore, relevant to ongoing efforts to improve the survivorship experience.
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Affiliation(s)
- Ulrike Boehmer
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts
| | - Al Ozonoff
- Harvard Medical School, Boston, Massachusetts.,Boston Children's Hospital, Boston, Massachusetts
| | - Michael Winter
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | - Flora Berklein
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts
| | - Jennifer Potter
- Harvard Medical School, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Fenway Institute, Boston, Massachusetts
| | - Kevan L Hartshorn
- Section of Hematology Oncology, Boston University School of Medicine, Boston, Massachusetts
| | - Kevin C Ward
- Department of Epidemiology, Emory University, Atlanta, Georgia
| | - Rachel M Ceballos
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Melissa A Clark
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
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Follow-up surveillance among colorectal cancer survivors of different sexual orientations. J Cancer Surviv 2021; 16:445-454. [PMID: 33851339 DOI: 10.1007/s11764-021-01039-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 03/30/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The purpose of this study was to examine receipt of follow-up surveillance among sexual minority and heterosexual survivors and identify survivor-, physician-, and practice-level characteristics associated with follow-up surveillance. METHODS An average of 3 years after their stage I-III colorectal cancer diagnosis, we recruited survivors from four cancer registries. A questionnaire, which queried about sexual orientation and other eligibility criteria, was mailed to all cancer survivors. Subsequently, 418 eligible survivors without recurrent disease participated in a telephone survey. Colorectal cancer-specific follow-up surveillance was defined as colonoscopy, carcinoembryonic antigen (CEA) test, or imaging test. We used logistic regression with forward selection to obtain models that best explained each follow-up test. RESULTS About 10% of survivors received no follow-up surveillance, while 70% had colonoscopies. While survivors irrespective of sexual orientation received follow-up surveillance, sexual minority survivors had 3 times the odds of receiving imaging tests compared to heterosexual survivors. Having a designated provider of any specialty was most salient for the receipt of surveillance. CONCLUSIONS Sexual minority survivors' greater receipt of imaging tests may indicate providers perceive them at greater risk for recurrence than heterosexual survivors. Future studies need to examine provider behaviors towards monitoring colorectal cancer survivors of diverse sexual orientations. IMPLICATIONS FOR CANCER SURVIVORS Guidelines recommend surveillance of colorectal cancer survivors to improve survival. This study showed that having a designated provider for follow-up is most salient for the receipt of surveillance, most survivors receive surveillance, and sexual minority survivors had more imaging tests compared to heterosexual survivors.
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Huang D, Chervoneva I, Babinsky L, Hurwitz MD. Application of Forcing Functions to Electronic Health Records Is Associated With Improved Pain Control for Patients Undergoing Radiation Therapy for Bone Metastases. Am J Med Qual 2020; 35:479-485. [DOI: 10.1177/1062860619900791] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Boehmer U, Clark MA, Ozonoff A, Winter M, Potter J. Survivors' Perceptions of Quality of Colorectal Cancer Care by Sexual Orientation. Am J Clin Oncol 2020; 43:660-666. [PMID: 32889837 PMCID: PMC8011297 DOI: 10.1097/coc.0000000000000732] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE The objective of this study was to assess sexual minority and heterosexual survivors' perceived quality of cancer care and identify demographic, clinical, and psychosocial characteristics associated with patient-centered quality of care. MATERIALS AND METHODS Four cancer registries provided data on 17,849 individuals who were diagnosed with stage I, II, or III colorectal cancer an average of 3 years prior and resided in predetermined diverse geographic areas. A questionnaire, which queried about sexual orientation and other eligibility criteria was mailed to all cancer survivors. Of these, 480 eligible survivors participated in a telephone survey. Quality of cancer care was defined by 3 measures of interpersonal care (physician communication, nursing care, and coordination of care) and by rating cancer care as excellent. We used generalized linear models and logistic regression with forward selection to obtain models that best explained each quality of care measure. RESULTS Sexual minority survivors rated physician communication, nursing care, and coordination of care similarly to heterosexual survivors, yet a significantly higher percentage of sexual minority survivors rated the overall quality of their cancer care as excellent (59% vs. 49%). Sexual minority survivors' greater likelihood of reporting excellent care remained unchanged after adjusting for demographic, clinical, and psychosocial characteristics. CONCLUSIONS Sexual minority survivors' ratings of quality of colorectal cancer care were comparable or even higher than heterosexual survivors. Sexual minority survivors' reports of excellent care were not explained by their interpersonal care experiences.
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Affiliation(s)
- Ulrike Boehmer
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA
| | - Melissa A. Clark
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Al Ozonoff
- Harvard Medical School, Boston, MA
- Boston Children’s Hospital, Boston, MA
| | - Michael Winter
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA
| | - Jennifer Potter
- Harvard Medical School, Boston, MA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- The Fenway Institute, Boston, MA
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Mubita WM, Richardson C, Briggs M. Patient satisfaction with pain relief following major abdominal surgery is influenced by good communication, pain relief and empathic caring: a qualitative interview study. Br J Pain 2020; 14:14-22. [PMID: 32110394 DOI: 10.1177/2049463719854471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Monitoring and improving the quality of care is an ever increasing concern for health care organisations. Measuring the effectiveness of clinical outcomes is done by looking at specific markers of high quality care. Pain management is considered one of the markers of high quality care and satisfaction with pain management is a crucial and important quality assurance marker; yet, we know little about what contributes to a patient's decision about satisfaction. Methods A qualitative study drawing on phenomenological approach aiming to evaluate the perspective of patients experiencing post-operative pain. Patients undergoing major abdominal surgery were recruited from a Renal Transplant and Urology ward in the North of England, UK. Data were collected using in-depth semi-structured interviews and were analysed using Colaizzi's approach. Results Ten patients participated in the study and three themes emerged from the analysis. The findings of this study revealed that in order to achieve satisfaction with the management of pain, patient care has to include information delivery which is timely and adequate according to a patient's individual needs, nurses should have a caring attitude and pain should be well controlled. Conclusion Satisfaction with pain management is influenced by good communication and information transfer, appropriate pain management and an empathic presence throughout.
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Affiliation(s)
- Womba Musumadi Mubita
- Research and Innovation, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.,Clinical Trials Management Offices, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Cliff Richardson
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Michelle Briggs
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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Roydhouse JK, Gutman R, Keating NL, Mor V, Wilson IB. The Association of Proxy Care Engagement with Proxy Reports of Patient Experience and Quality of Life. Health Serv Res 2018; 53:3809-3824. [PMID: 29806212 PMCID: PMC6153170 DOI: 10.1111/1475-6773.12980] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To assess the association of proxy-specific covariates with proxy-reported patient cancer care experience, quality rating, and quality of life. DATA SOURCES/STUDY SETTING Secondary analysis of data from the Cancer Care Outcomes Research and Surveillance (CanCORS) study. STUDY DESIGN Cross-sectional observational study. The respondents were proxies for patients with incident colorectal or lung cancer. DATA COLLECTION/EXTRACTION METHODS Analyses used linear regression models and adjusted for patient sociodemographic and clinical characteristics. Outcomes included patients' experiences with medical care, nursing care, and care coordination, overall quality ratings, and physical and mental health, all scored on 0-100 scales (0 = worst, 100 = best). Independent variables included the proxy's relationship with the patient and engagement in patient care. PRINCIPAL FINDINGS Of 1,011 proxies, most were the patient's spouse (50 percent) or child (36 percent). Although most proxies (66 percent) always attended medical visits, 3 percent reported never attending. After adjustment, on average children reported worse experiences and poorer quality care than spouses (4-9 points lower across outcomes). Proxies who never attended medical visits reported significantly worse medical care (-11 points, 95 percent CI = -18 to -3) and care coordination (-13 points, 95 percent CI = -20 to -6). CONCLUSIONS Collecting data on proxy engagement in care is warranted if proxy responses are used.
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Affiliation(s)
- Jessica K. Roydhouse
- Department of Health Services, Policy and PracticeBrown University School of Public HealthProvidenceRI
| | - Roee Gutman
- Department of BiostatisticsBrown University School of Public HealthProvidenceRI
| | | | - Vincent Mor
- Department of Health Services, Policy and PracticeBrown University School of Public HealthProvidenceRI
| | - Ira B. Wilson
- Department of Health Services, Policy and PracticeBrown University School of Public HealthProvidenceRI
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Roydhouse JK, Gutman R, Keating NL, Mor V, Wilson IB. Proxy and patient reports of health-related quality of life in a national cancer survey. Health Qual Life Outcomes 2018; 16:6. [PMID: 29304818 PMCID: PMC5756370 DOI: 10.1186/s12955-017-0823-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 12/08/2017] [Indexed: 12/03/2022] Open
Abstract
Background Proxy respondents are frequently used in surveys, including those assessing health-related quality of life (HRQOL). In cancer, most research involving proxies has been undertaken with paired proxy-patient populations, where proxy responses are compared to patient responses for the same individual. In these populations, proxy-patient differences are small and suggest proxy underestimation of patient HRQOL. In practice, however, proxy responses will only be used when patient responses are not available. The difference between proxy and patient reports of patient HRQOL where patients are not able to report for themselves in cancer is not known. The objective of this study was to evaluate the difference between patient and proxy reports of patient HRQOL in a large national cancer survey, and determine if this difference could be mitigated by adjusting for clinical and sociodemographic information about patients. Methods Data were from the Cancer Care Outcomes Research and Surveillance (CanCORS) study. Patients or their proxies were recruited within 3–6 months of diagnosis with lung or colorectal cancer. HRQOL was measured using the SF-12 mental and physical composite scales. Differences of ½ SD (=5 points) were considered clinically significant. The primary independent variable was proxy status. Linear regression models were used to adjust for patient sociodemographic and clinical covariates, including cancer stage, patient age and education, and patient co-morbidities. Results Of 6471 respondents, 1011 (16%) were proxies. Before adjustment, average proxy-reported scores were lower for both physical (−6.7 points, 95% CI -7.4 to −5.9) and mental (−6 points, 95% CI -6.7 to −5.2) health. Proxy-reported scores remained lower after adjustment (physical: −5.8 points, −6.6 to −5; mental: −5.8 points, −6.6 to 5). Proxy-patient score differences remained clinically and statistically significant, even after adjustment for sociodemographic and clinical variables. Conclusions Proxy-reported outcome scores for both physical and mental health were clinically and significantly lower than patient-reported scores for these outcomes. The size of the proxy-patient score differences was not affected by the health domain, and adjustment for sociodemographic and clinical variables had minimal impact.
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Affiliation(s)
- Jessica K Roydhouse
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 S. Main Street, Providence, RI, 02912, USA.
| | - Roee Gutman
- Department of Biostatistics, School of Public Health, Brown University, 121 S. Main Street, Providence, RI, 02912, USA
| | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA, 02115, USA
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 S. Main Street, Providence, RI, 02912, USA
| | - Ira B Wilson
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, 121 S. Main Street, Providence, RI, 02912, USA
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Roydhouse JK, Gutman R, Keating NL, Mor V, Wilson IB. Differences between Proxy and Patient Assessments of Cancer Care Experiences and Quality Ratings. Health Serv Res 2017; 53:919-943. [PMID: 28255988 DOI: 10.1111/1475-6773.12672] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To assess the impact of proxy survey responses on cancer care experience reports and quality ratings. DATA SOURCES/STUDY SETTING Secondary analysis of data from Cancer Care Outcomes Research and Surveillance (CanCORS). Recruitment occurred from 2003 to 2005. STUDY DESIGN The study was a cross-sectional observational study. The respondents were patients with incident colorectal or lung cancer or their proxies. DATA COLLECTION/EXTRACTION METHODS Analyses used linear regression models with an independent variable for proxy versus patient responses as well as study site and clinical covariates. The outcomes were experiences with medical care, nursing care, care coordination, and care quality rating. Multiple imputation was used for missing data. PRINCIPAL FINDINGS Among 6,471 respondents, 1,011 (16 percent) were proxies. The proportion of proxy respondents varied from 6 percent to 28 percent across study sites. Adjusted proxy scores were modestly higher for medical care experiences (+1.28 points [95 percent CI:+ 0.05 to +2.51]), but lower for nursing care (-2.81 [95 percent CI: -4.11 to -1.50]) and care coordination experiences (-2.98 [95 percent CI: -4.15 to -1.81]). There were no significant differences between adjusted patient and proxy ratings of quality. CONCLUSIONS Proxy responses have small but statistically significant differences from patient responses. However, if ratings of care are used for financial incentives, such differences could be exaggerated across practices or areas if proxy use varies.
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Affiliation(s)
- Jessica K Roydhouse
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, 02912
| | - Roee Gutman
- Department of Biostatistics, Brown University School of Public Health, Providence, RI
| | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Vincent Mor
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, 02912
| | - Ira B Wilson
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, 02912
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The Influence of Pain Severity and Interference on Satisfaction with Pain Management among Middle-Aged and Older Adults. Pain Res Manag 2016; 2016:9561024. [PMID: 28100956 PMCID: PMC5215497 DOI: 10.1155/2016/9561024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 11/10/2016] [Indexed: 11/25/2022]
Abstract
Background. Health outcomes are often contingent on how effective the individual is able to manage existent illness-related symptoms. This is all the more relevant among chronic pain patients. Objective. This study aimed to identify indicators of pain treatment satisfaction among middle-aged and older adults (N = 150) receiving outpatient treatment from a comprehensive cancer center. Methods. Patients were surveyed on questions assessing pain treatment satisfaction, pain severity, and additional social characteristics. Results. Descriptive data showed that middle-aged adults reported more pain locations, greater pain severity, and less satisfaction with pain treatment. A multivariate model was specified, showing older adults being more satisfied with their pain treatment. For the middle-aged adults, treatment satisfaction was generally lower with greater pain severity. This counters that for the older adults, where treatment satisfaction remained consistent despite increased levels of pain severity. Conclusion. These findings address an important issue regarding how pain is experienced across the life course. This suggests that general assumptions cannot be made about the health outcomes of older adults. Beyond the descriptive definitions of pain, there remains the need to develop models that account for determinants that may account for the pain experience among a diverse adult population.
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Lathan CS, Cronin A, Tucker-Seeley R, Zafar SY, Ayanian JZ, Schrag D. Association of Financial Strain With Symptom Burden and Quality of Life for Patients With Lung or Colorectal Cancer. J Clin Oncol 2016; 34:1732-40. [PMID: 26926678 DOI: 10.1200/jco.2015.63.2232] [Citation(s) in RCA: 269] [Impact Index Per Article: 33.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To measure the association between patient financial strain and symptom burden and quality of life (QOL) for patients with new diagnoses of lung or colorectal cancer. PATIENTS AND METHODS Patients participating in the Cancer Care Outcomes Research and Surveillance study were interviewed about their financial reserves, QOL, and symptom burden at 4 months of diagnosis and, for survivors, at 12 months of diagnosis. We assessed the association of patient-reported financial reserves with patient-reported outcomes including the Brief Pain Inventory, symptom burden on the basis of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30, and QOL on the basis of the EuroQoL-5 Dimension scale. Multivariable linear regression models were fit for each outcome and cancer type, adjusting for age, race/ethnicity, sex, income, insurance, stage at diagnosis, and comorbidity. RESULTS Among patients with lung and colorectal cancer, 40% and 33%, respectively, reported limited financial reserves (≤ 2 months). Relative to patients with more than 12 months of financial reserves, those with limited financial reserves reported significantly increased pain (adjusted mean difference, 5.03 [95% CI, 3.29 to 7.22] and 3.45 [95% CI, 1.25 to 5.66], respectively, for lung and colorectal), greater symptom burden (5.25 [95% CI, 3.29 to .22] and 5.31 [95% CI, 3.58 to 7.04]), and poorer QOL (4.70 [95% CI, 2.82 to 6.58] and 5.22 [95% CI, 3.61 to 6.82]). With decreasing financial reserves, a clear dose-response relationship was present across all measures of well-being. These associations were also manifest for survivors reporting outcomes again at 1 year and persisted after adjustment for stage, comorbidity, insurance, and other clinical attributes. CONCLUSION Patients with cancer and limited financial reserves are more likely to have higher symptom burden and decreased QOL. Assessment of financial reserves may help identify patients who need intensive support.
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Affiliation(s)
- Christopher S Lathan
- Christopher S. Lathan, Angel Cronin, Reginald Tucker-Seeley, and Deborah Schrag, Dana-Farber Cancer Institute, Boston, MA; S. Yousuf Zafar, Duke University School of Medicine; John Z. Ayanian, University of Michigan; and Reginald Tucker-Seeley, Harvard T.H. Chan School of Public Health.
| | - Angel Cronin
- Christopher S. Lathan, Angel Cronin, Reginald Tucker-Seeley, and Deborah Schrag, Dana-Farber Cancer Institute, Boston, MA; S. Yousuf Zafar, Duke University School of Medicine; John Z. Ayanian, University of Michigan; and Reginald Tucker-Seeley, Harvard T.H. Chan School of Public Health
| | - Reginald Tucker-Seeley
- Christopher S. Lathan, Angel Cronin, Reginald Tucker-Seeley, and Deborah Schrag, Dana-Farber Cancer Institute, Boston, MA; S. Yousuf Zafar, Duke University School of Medicine; John Z. Ayanian, University of Michigan; and Reginald Tucker-Seeley, Harvard T.H. Chan School of Public Health
| | - S Yousuf Zafar
- Christopher S. Lathan, Angel Cronin, Reginald Tucker-Seeley, and Deborah Schrag, Dana-Farber Cancer Institute, Boston, MA; S. Yousuf Zafar, Duke University School of Medicine; John Z. Ayanian, University of Michigan; and Reginald Tucker-Seeley, Harvard T.H. Chan School of Public Health
| | - John Z Ayanian
- Christopher S. Lathan, Angel Cronin, Reginald Tucker-Seeley, and Deborah Schrag, Dana-Farber Cancer Institute, Boston, MA; S. Yousuf Zafar, Duke University School of Medicine; John Z. Ayanian, University of Michigan; and Reginald Tucker-Seeley, Harvard T.H. Chan School of Public Health
| | - Deborah Schrag
- Christopher S. Lathan, Angel Cronin, Reginald Tucker-Seeley, and Deborah Schrag, Dana-Farber Cancer Institute, Boston, MA; S. Yousuf Zafar, Duke University School of Medicine; John Z. Ayanian, University of Michigan; and Reginald Tucker-Seeley, Harvard T.H. Chan School of Public Health
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