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Gunn CM, Maschke A, Paasche-Orlow MK, Housten AJ, Kressin NR, Schonberg MA, Battaglia TA. Using Mixed Methods With Multiple Stakeholders to Inform Development of a Breast Cancer Screening Decision Aid for Women With Limited Health Literacy. MDM Policy Pract 2021; 6:23814683211033249. [PMID: 34350361 PMCID: PMC8295953 DOI: 10.1177/23814683211033249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 06/25/2021] [Indexed: 12/12/2022] Open
Abstract
Background. When stakeholders offer divergent input, it can be unclear how to prioritize information for decision aids (DAs) on mammography screening. Objectives. This analysis triangulates perspectives (breast cancer screening experts, primary care providers [PCPs], and patients with limited health literacy [LHL]) to understand areas of divergent and convergent input across stakeholder groups in developing a breast cancer screening DA for younger women with LHL. Design. A modified online Delphi panel of 8 experts rated 57 statements for inclusion in a breast cancer screening DA over three rounds. Individual interviews with 25 patients with LHL and 20 PCPs from a large safety net hospital explored informational needs about mammography decision making. Codes from the qualitative interviews and open-ended responses from the Delphi process were mapped across stakeholders to ascertain areas where stakeholder preferences converged or diverged. Results. Four themes regarding informational needs were identified regarding 1) the benefits and harms of screening, 2) different screening modalities, 3) the experience of mammography, and 4) communication about breast cancer risk. Patients viewed pain as the primary harm, while PCPs and experts emphasized the harm of false positives. Patients, but not PCPs or experts, felt that information about the process of getting a mammogram was important. PCPs believed that mammography was the only evidence-based screening modality, while patients believed breast self-exam was also important for screening. All stakeholders described incorporating personal risk information as important. Limitations. As participants came from one hospital, perceptions may reflect local practices. The Delphi sample size was small. Conclusions. Patients, experts, and PCPs had divergent views on the most important information needed for screening decisions. More evidence is needed to guide integration of multiple stakeholder perspectives into the content of DAs.
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Affiliation(s)
- Christine M Gunn
- Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, Massachusetts
| | - Ariel Maschke
- Department of Medicine, Section of General Internal Medicine, Women's Health Unit, School of Medicine, Boston University, Boston, Massachusetts
| | - Michael K Paasche-Orlow
- Department of Medicine, Section of General Internal Medicine, School of Medicine, Boston University, Boston, Massachusetts
| | - Ashley J Housten
- Department of Surgery, Division of Public Health Sciences, School of Medicine, Washington University, St. Louis, Missouri
| | - Nancy R Kressin
- Department of Medicine, Section of General Internal Medicine, School of Medicine, Boston University, Boston, Massachusetts
| | - Mara A Schonberg
- Harvard Medical School, Beth Israel Deaconess Medical Center, Brookline, Massachusetts
| | - Tracy A Battaglia
- Department of Medicine, Section of General Internal Medicine, Women's Health Unit, School of Medicine, Boston University, Boston, Massachusetts
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Gale RP. Is there a role for haematopoietic cell transplants after radiation and nuclear accidents? JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2021; 41:R43-R49. [PMID: 33652427 DOI: 10.1088/1361-6498/abeb24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 03/02/2021] [Indexed: 06/12/2023]
Abstract
My task is to consider whether haematopoietic cell transplants would be considered appropriate today in persons with features like victims of high-dose and dose-rate ionizing radiations after the Chernobyl nuclear power facility accident in 1986 given knowledge and experience gained over the past 35 years. First I consider the conceptual bases for considering an intervention appropriate and then the metric for deciding whether a transplant is appropriate in similar persons. Data needed to support this decision-making process include estimates of dose, dose-rate, dose uniformity, synchronous or metachronous injuries, donor availability and alternative interventions. Many of these co-variates have substantial uncertainties. Fundamental is a consideration of potential benefit-to-risk and risk-to-benefit ratios under conditions of substantial inaccuracy and imprecision. The bottom line is probably fewer transplants would be done and more victims would receive molecularly-cloned haematopoietic growth factors.
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Affiliation(s)
- Robert Peter Gale
- Centre of Haematology, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
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Gale RP. Standardizing haematopoietic cell transplants in China. J Hematol Oncol 2018; 11:34. [PMID: 29495965 PMCID: PMC5833050 DOI: 10.1186/s13045-018-0565-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 02/02/2018] [Indexed: 01/09/2023] Open
Affiliation(s)
- Robert Peter Gale
- Haematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, SW7 2AZ, UK.
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Barosi G, Gale RP. Is there expert consensus on expert consensus? Bone Marrow Transplant 2018; 53:1055-1060. [DOI: 10.1038/s41409-018-0128-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 01/11/2018] [Indexed: 01/09/2023]
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Medeiros BC, Gale RP. Why do subjects on clinical trials discontinue therapy? Do we really know? Leuk Res 2016; 51:19-21. [PMID: 27776289 DOI: 10.1016/j.leukres.2016.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 10/11/2016] [Accepted: 10/14/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Bruno C Medeiros
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - Robert Peter Gale
- Haematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, SW7 2AZ, UK
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Is there consensus on consensus? Leukemia 2016; 30:1229. [DOI: 10.1038/leu.2016.38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Breast Implant-associated Anaplastic Large Cell Lymphoma: Updated Results from a Structured Expert Consultation Process. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2015; 3:e296. [PMID: 25674377 PMCID: PMC4323400 DOI: 10.1097/gox.0000000000000268] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 12/01/2014] [Indexed: 12/25/2022]
Abstract
Background: Despite increased cases published on breast implant–associated anaplastic large cell lymphoma (BIA-ALCL), important clinical issues remain unanswered. We conducted a second structured expert consultation process to rate statements related to the diagnosis, management, and surveillance of this disease, based on their interpretation of published evidence. Methods: A multidisciplinary panel of 12 experts was selected based on nominations from national specialty societies, academic department heads, and recognized researchers in the United States. Results: Panelists agreed that (1) this disease should be called “BIA-ALCL”; (2) late seromas occurring >1 year after breast implantation should be evaluated via ultrasound, and if a seroma is present, the fluid should be aspirated and sent for culture, cytology, flow cytometry, and cell block to an experienced hematopathologist; (3) surgical removal of the affected implant and capsule (as completely as possible) should occur, which is sufficient to eradicate capsule-confined BIA-ALCL; (4) surveillance should consist of clinical follow-up at least every 6 months for at least 5 years and breast ultrasound yearly for at least 2 years; and (5) BIA-ALCL is generally a biologically indolent disease with a good prognosis, unless it extends beyond the capsule and/or presents as a mass. They firmly disagreed with statements that chemotherapy and radiation therapy should be given to all patients with BIA-ALCL. Conclusions: Our assessment yielded consistent results on a number of key, incompletely addressed issues regarding BIA-ALCL, but additional research is needed to support these statement ratings and enhance our understanding of the biology, treatment, and outcomes associated with this disease.
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Gale RP, Wiernik PH, Lazarus HM. Should persons with acute myeloid leukemia have a transplant in first remission? Leukemia 2014; 28:1949-52. [PMID: 24727674 DOI: 10.1038/leu.2014.129] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 03/21/2014] [Indexed: 11/09/2022]
Abstract
Despite more than 40 years of extensive study, it remains uncertain which individuals, if any, with acute myelogenous leukemia (AML) in first remission should receive a blood cell or bone marrow transplant versus post-remission chemotherapy (or both). Nevertheless, there is a recent trend toward recommending more transplants in this setting. We consider four myths underlying this recommendation: (1) only individuals achieving second remission benefit from a transplant; (2) there is no effective therapy for relapse other than an allotransplant; (3) we can accurately predict which individuals with AML in first remission need a transplant; and (4) detection of minimal residual disease in first remission will resolve this controversy. We discuss these misconceptions and suggest approaches to resolve this issue.
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Affiliation(s)
- R P Gale
- Haematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, UK
| | - P H Wiernik
- Cancer Research Foundation of New York, Chappaqua, NY, USA
| | - H M Lazarus
- University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, USA
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Carlson LE, MacRae JH. Quality of life issues following autologous bone marrow transplantation. Expert Rev Pharmacoecon Outcomes Res 2014; 2:129-46. [DOI: 10.1586/14737167.2.2.129] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Gale R, Barosi G, Barbui T, Cervantes F, Dohner K, Dupriez B, Gupta V, Harrison C, Hoffman R, Kiladjian JJ, Mesa R, Me Mullin M, Passamonti F, Ribrag V, Roboz G, Saglio G, Vannucchi A, Verstovsek S. What are RBC-transfusion-dependence and -independence? Leuk Res 2011; 35:8-11. [PMID: 20692036 PMCID: PMC8215731 DOI: 10.1016/j.leukres.2010.07.015] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2010] [Revised: 07/10/2010] [Accepted: 07/12/2010] [Indexed: 02/03/2023]
Abstract
The term RBC-transfusion-dependence is widely-used by hematologists to describe a condition of severe anemia typically arising when erythropoiesis is reduced such that a person continuously requires ≥1 RBC-transfusions over a specified interval. Defining a person as RBC-transfusion-dependent has important implications in diverse hematological disorders especially because it strongly-correlated with decreased survival. Conversely, becoming RBC-transfusion-independent or receiving fewer RBC-transfusions over a specified interval is defined as improvement or response in many disease- and/or therapy-setting. Whether this correlates with improved survival is controversial. We used a structured expert-panel consensus panel process to define RBC-transfusion-dependence and -independence or improvement. We suggest these definitions may prove useful to persons studying or treating these diseases.
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Affiliation(s)
- R.P. Gale
- Corresponding author. Tel.: +44 908 656 0484, fax: +44 908 673 2773. (R.P. Gale)
| | - G. Barosi
- University of Pavia Medical School, RCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - T. Barbui
- Hematology Division, Ospedali Riuniti, Bergamo, Italy
| | | | - K. Dohner
- Department of Internal Medicine III, University of Ulm, Ulm, Germany
| | - B. Dupriez
- Service Hématologie Clinique, Centre Hospitalier, Lens, France
| | - V. Gupta
- Department of Medicine, Princess Margaret Hospital, University of Toronto, Toronto, ON, Canada
| | - C. Harrison
- Department of Haematology Guy’s and St Thomas’ NHS Foundation Trust Great Maze Pond, London, UK
| | - R. Hoffman
- Mount Sinai School of Medicine, New York, NY, USA
| | - J.-J. Kiladjian
- Hopitaux de Paris, Hôpital Saint-Louis, Centre d’investigations Cliniques (CIC 9504); and Université Paris 7, Paris, France
| | - R. Mesa
- Mayo Clinic, Scottsdale, AZ, USA
| | - M.F. Me Mullin
- Centre for Cancer Research and Cell Biology, Queen’s University, Belfast, Ireland
| | - F. Passamonti
- Department of Hematology, University of Pavia, Pavia, Italy
| | - V. Ribrag
- Department of Medicine, Institute Gustave Roussy, Villejuif, France
| | - G. Roboz
- Weil Medical College of Cornell University, New York, NY, USA
| | - G. Saglio
- Dept of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | | | - S. Verstovsek
- Department of Hematology/Oncology, MD Anderson Cancer Center, Houston, TX, USA
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Jerant A, Srinivasan M, Bertakis KD, Azari R, Pan RJ, Kravitz RL. Attributes affecting the medical school primary care experience. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2010; 85:605-613. [PMID: 20354375 DOI: 10.1097/acm.0b013e3181d29af7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
PURPOSE Favorable primary care (PC) experiences might encourage more medical students to pursue generalist careers, yet academicians know little about which attributes influence the medical school PC experience. The authors sought to identify such attributes and weight their importance. METHOD Semistructured interviews with 16 academic generalist leaders of family medicine, general internal medicine, and general pediatrics led to the development of a Web-based survey, administered to a national sample of 126 generalist faculty. Survey respondents rated (on a nine-point Likert-like scale) the importance of each interview-generated PC medical school attribute and indicated (yes/no) whether outside experts' assessment of the attributes would be valid. The authors assessed interrater agreement. RESULTS Interview thematic analysis generated 58 institutional attributes in four categories: informal curriculum (23), institutional infrastructure (6), educational/curricular infrastructure (6), and specific educational experiences (23). Of these 58, 31 (53%) had median importance ratings of >7 (highly important). For 14 of these (45%), more than two-thirds of respondents indicated external expert surveys would provide a valid assessment. Of the 23 informal curriculum attributes, 20 (87%) received highly important ratings; however, more than two-thirds of respondents believed that external expert survey ratings would be valid for only 4 (20%) of them. Strong agreement occurred among respondents across the generalist fields. CONCLUSIONS Academic generalist educators identified several attributes as highly important in shaping the quality of the medical school PC experience. Informal curriculum attributes appeared particularly influential, but these attributes may not be validly assessed via expert surveys, suggesting the need for other measures.
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Affiliation(s)
- Anthony Jerant
- Department of Family and Community Medicine, University of California, Davis, School of Medicine, Sacramento, California, USA
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12
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For which glaucoma suspects is it appropriate to initiate treatment? Ophthalmology 2009; 116:710-6, 716.e1-82. [PMID: 19344823 DOI: 10.1016/j.ophtha.2008.12.065] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2008] [Revised: 12/27/2008] [Accepted: 12/31/2008] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Because uncertainty exists about which glaucoma suspects should be treated, this study sought to identify the glaucoma suspects who an expert panel could agree would be appropriate or inappropriate to treat. DESIGN The RAND/UCLA appropriateness method, a well-established procedure to synthesize the scientific literature with expert opinion to resolve uncertainty on a health topic. PARTICIPANTS Eleven-member panel composed of recognized international leaders in the field of glaucoma. METHODS Based on a systematic review of the literature on potentially important factors to consider when deciding to initiate treatment, more than 1000 scenarios of glaucoma suspects initially were created. The panel formally rated the appropriateness of initiating treatment for glaucoma suspects through a 2-round modified Delphi method, a technique that preserves the confidentiality of individual panelists'ratings but allows panelists to compare their own ratings with those of the entire panel. MAIN OUTCOME MEASURES Final ratings for scenarios were categorized as appropriate, uncertain, or inappropriate to treat according to typical prespecified statistical criteria previously used in projects using the RAND/UCLA appropriateness method. Tools were developed to help clinicians to approximate the panel ratings of glaucoma suspects. RESULTS The panel chose age, life expectancy, intraocular pressure (IOP), central corneal thickness, cup-to-disc ratio, disc size, and family history as the variables to consider when deciding whether to treat glaucoma suspects. Permutations of these variables created 1800 unique scenarios. The panel rated 587 (33%) scenarios as appropriate, 585 (33%) as uncertain, and 628 (35%) as inappropriate for treatment initiation. Analysis of variance determined that IOP had greater impact than any other variable on panel ratings. A point system was created with 96% sensitivity and 93% specificity for predicting panel ratings of appropriateness for a glaucoma suspect. CONCLUSIONS An expert panel can reach agreement on the appropriateness and inappropriateness of treatment for glaucoma suspects.
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Gale RP, Eapen M, Logan B, Zhang MJ, Lazarus HM. Are there roles for observational database studies and structured quantification of expert opinion to answer therapy controversies in transplants? Bone Marrow Transplant 2009; 43:435-46. [PMID: 19182830 DOI: 10.1038/bmt.2008.447] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Approaches to determine whether one transplant-related therapy is better than another include: (1) using experimental data, such as those from randomized controlled trials (RCTs); (2) using observational data, such as those from observational databases (ODBs) and (3) using conclusions from the structured quantification of expert opinion based on a consideration of evidence from RCTs, ODBs and other sources. Large RCTs are widely and appropriately regarded as the gold standard of clinical investigation. However, data from large RCTs are rarely available for transplant-related therapy questions. We discuss some of the limitations of RCTs in the transplant setting often including small size and short follow-up. These limitations are only partly solved by meta-analyses of RCTs. Data from high-quality ODBs are not only often useful in this setting but also have limitations. Biases may be difficult or impossible to identify and/or adjust for. However, ODBs have large numbers of diverse subjects receiving diverse therapies and analyses that often give answers more useful to clinicians than RCTs. Side-by-side comparisons suggest analyses from high-quality ODBs often give similar conclusions to meta-analyses of high-quality RCTs. Meta-analyses combining data from RCTs and ODBs are sometimes appropriate. Quantitation of expert opinion, when of high quality, is also useful: experts rarely disagree under precisely defined circumstances and their consensus conclusions are often concordant with results of high-quality RCTs and ODBs. We suggest increased use of ODBs and expert opinion as reliable and effective ways to determine relative efficacies of new therapies in transplant settings.
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Affiliation(s)
- R P Gale
- Center for International Blood and Marrow Research (CIBMTR), Medical College of Wisconsin, Milwaukee, WI, USA.
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Halbert RJ, Figlin RA, Atkins MB, Bernal M, Hutson TE, Uzzo RG, Bukowski RM, Khan KD, Wood CG, Dubois RW. Treatment of patients with metastatic renal cell cancer: a RAND Appropriateness Panel. Cancer 2007; 107:2375-83. [PMID: 17048248 DOI: 10.1002/cncr.22260] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND New developments in the treatment of patients with metastatic renal cell cancer (MRCC) have suggested a need to reevaluate the role of systemic therapies. The authors convened a panel of medical and urologic oncologists to rate the appropriateness of the main options. METHODS The authors used the RAND/University of California-Los Angeles Appropriateness Method to evaluate systemic therapy options and cytoreductive nephrectomy. After a comprehensive literature review, an expert panel rated the appropriateness of systemic options (108 permutations) and cytoreductive nephrectomy (24 permutations) for patients with MRCC. RESULTS The appropriateness evaluation indicated that 27.3% of permutations were rated "appropriate," 46.9% were rated "inappropriate," and 25.8% were rated "uncertain." There was a high rate of agreement (95%). Sunitinib and sorafenib were rated appropriate for patients with low-to-moderate risk regardless of prior treatment. Temsirolimus was rated appropriate for first-line therapy for higher risk patients. Interferon-alpha and low-dose interleukin-2 were rated inappropriate or uncertain. In patients who received prior immunotherapy, cytokines were rated inappropriate. In all permutations for evaluating systemic therapy, enrollment into an investigational trial was considered appropriate, treatment with bevacizumab was uncertain, and thalidomide was inappropriate regardless of risk status or prior therapy. For good surgical risk patients with planned immunotherapy, nephrectomy was rated appropriate in patients who had limited metastatic burden regardless of tumor-related symptoms and in symptomatic patients regardless of metastatic burden. Only the most favorable combination of surgical risk, metastatic burden, and symptoms generated an "appropriate" rating for patients with planned targeted therapy. CONCLUSIONS The current results begin the process of defining an appropriate role for cytokines, newer targeted therapies, and surgery in the treatment of MRCC.
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