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Noll JH, Levine BL, June CH, Fraietta JA. Beyond youth: Understanding CAR T cell fitness in the context of immunological aging. Semin Immunol 2023; 70:101840. [PMID: 37729825 DOI: 10.1016/j.smim.2023.101840] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 09/05/2023] [Accepted: 09/05/2023] [Indexed: 09/22/2023]
Abstract
Population aging, a pervasive global demographic trend, is anticipated to challenge health and social systems worldwide. This phenomenon is due to medical advancements enabling longer lifespans, with 20% of the US population soon to be over 65 years old. Consequently, there will be a surge in age-related diseases. Senescence, characterized by the loss of biological maintenance and homeostasis at molecular and cellular levels, either correlates with or directly causes age-related phenotypic changes. Decline of the immune system is a critical factor in the senescence process, with cancer being a primary cause of death in elderly populations. Chimeric antigen receptor (CAR) T cell therapy, an innovative approach, has demonstrated success mainly in pediatric and young adult hematological malignancies but remains largely ineffective for diseases affecting older populations, such as late-in-life B cell malignancies and most solid tumor indications. This limitation arises because CAR T cell efficacy heavily relies on the fitness of the patient-derived starting T cell material. Numerous studies suggest that T cell senescence may be a key driver of CAR T cell deficiency. This review examines correlates and underlying factors associated with favorable CAR T cell outcomes and explores potential experimental and clinically actionable strategies for T cell rejuvenation.
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Affiliation(s)
- Julia Han Noll
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Center for Cellular Immunotherapies, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Bruce L Levine
- Center for Cellular Immunotherapies, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Carl H June
- Center for Cellular Immunotherapies, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph A Fraietta
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Center for Cellular Immunotherapies, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Bowcock S, Atkin C, Iqbal G, Pratt G, Yong K, Neal RD, Planche T, Karunanithi K, Jenkins S, Stern S, Arnott S, Toth P, Wandroo F, Dunn J, Drayson MT. Presenting Symptoms in Newly Diagnosed Myeloma, Relation to Organ Damage, and Implications for Symptom-Directed Screening: A Secondary Analysis from the Tackling Early Morbidity and Mortality in Myeloma (TEAMM) Trial. Cancers (Basel) 2023; 15:3337. [PMID: 37444449 PMCID: PMC10341254 DOI: 10.3390/cancers15133337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/26/2023] [Accepted: 06/09/2023] [Indexed: 07/15/2023] Open
Abstract
Multiple myeloma (MM) patients risk diagnostic delays and irreversible organ damage. In those with newly diagnosed myeloma, we explored the presenting symptoms to identify early signals of MM and their relationships to organ damage. The symptoms were recorded in patients' own words at diagnosis and included diagnostic time intervals. Those seen by a haematologist >6 months prior to MM diagnosis were classified as precursor disease (PD). Most (962/977) patients provided data. Back pain (38%), other pain (31%) and systemic symptoms (28%) predominated. Patients rarely complain of 'bone pain', simply 'pain'. Vertebral fractures are under-recognised as pathological and are the predominant irreversible organ damage (27% of patients), impacting the performance status (PS) and associated with back pain (odds ratio (OR) 6.14 [CI 4.47-8.44]), bone disease (OR 3.71 [CI 1.88-7.32]) and age >65 years (OR 1.58 [CI 1.15-2.17]). Renal failure is less frequent and associated with gastrointestinal symptoms (OR 2.23 [CI1.28-3.91]), age >65 years (OR 2.14 [CI1.28-3.91]) and absence of back pain (OR 0.44 [CI 0.29-0.67]). Patients with known PD (n = 149) had fewer vertebral fractures (p = 0.001), fewer adverse features (p = 0.001), less decline in PS (p = 0.001) and a lower stage (p = 0.04) than 813 with de novo MM. Our data suggest subgroups suitable for trials of 'symptom-directed' screening: those with back pain, unexplained pain, a general decline in health or low-impact vertebral compression fractures.
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Affiliation(s)
- Stella Bowcock
- Department of Haematological Medicine, King’s College Hospital NHS Trust, London SE5 9RS, UK
- Princess Royal Hospital, King’s College Hospital NHS Trust, Orpington Common, London BR6 8ND, UK
| | - Catherine Atkin
- Institute of Inflammation and Ageing, University of Birmingham, Edgbaston, Birmingham B15 2GW, UK
| | - Gulnaz Iqbal
- Warwick Clinical Trials Unit, University of Warwick, Coventry CV4 7AL, UK
| | - Guy Pratt
- Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, Birmingham B15 2TH, UK
| | - Kwee Yong
- Department of Haematology, UCL Cancer Institute, London NW1 2BU, UK
| | - Richard D. Neal
- Department of Primary Care Medicine, University of Exeter, Exeter EX1 2LU, UK
| | - Tim Planche
- Department of Medical Microbiology, St George’s Hospital NHS Trust, London SW17 0QT, UK
| | - Kamaraj Karunanithi
- Royal Stoke University Hospital, University Hospitals North Midlands NHS Trust, Stoke-on-Trent ST4 6QG, UK
| | - Stephen Jenkins
- Russell Halls Hospital, The Dudley Group NHS Foundation Trust, Dudley DY1 2HQ, UK
| | - Simon Stern
- Epsom and St Helier NHS Trust, London SM5 1AA, UK
| | | | - Peter Toth
- Sheffield Teaching Hospitals NHS Trust, Sheffield S10 2JF, UK
| | - Farooq Wandroo
- Sandwell General Hospital, Lyndon, West Bromwich, West Midlands B71 4HJ, UK
| | - Janet Dunn
- Warwick Clinical Trials Unit, University of Warwick, Coventry CV4 7AL, UK
| | - Mark T. Drayson
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
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Black GB, Boswell L, Harris J, Whitaker KL. What causes delays in diagnosing blood cancers? A rapid review of the evidence. Prim Health Care Res Dev 2023; 24:e26. [PMID: 37039465 PMCID: PMC10156470 DOI: 10.1017/s1463423623000129] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 02/21/2023] [Accepted: 02/22/2023] [Indexed: 04/12/2023] Open
Abstract
OBJECTIVE We undertook a rapid review of literature relating to the diagnosis of blood cancers, to find out what factors contribute to delays in diagnosis, including symptom recognition, appraisal and help-seeking behaviours. METHODS We used rapid review methodology following Tricco et al. to synthesise current literature from two electronic databases. We searched for studies about symptom appraisal help-seeking for all blood cancers published between 2001 and 2021, written in English. RESULTS Fifteen studies were included in the review, of which 10 were published in the United Kingdom. We found a number of factors associated with delays in blood cancer diagnosis. These included patient factors such as gender, age and ethnicity, as well as health system factors such as poor communication and seeing a locum clinician in primary care. A narrative synthesis of the evidence produced four types of symptom interpretation by patients: (1) symptoms compatible with normal state of health, (2) event-linked problems, (3) mild or chronic illness and (4) non-specific unwell state. These four interpretations were linked to different help-seeking behaviours. After seeking help, patients often experienced delays due to healthcare professionals' (HCPs') non-serious interpretation of symptoms, misleading blood tests, discontinuity of care and other barriers in the diagnostic pathway. CONCLUSION Blood cancers are difficult to diagnose due to non-specific heterogeneous symptoms, and this is reflected in how those symptoms are interpreted by patients and managed by HCPs. It is important to understand how different interpretations affect delays in help-seeking, and what HCPs can do to support timely follow-up for patients.
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Affiliation(s)
- Georgia B. Black
- Reader in Applied Health Research, Wolfson Institute of Population Health,
Queen Mary University of London, London,
UK
| | - Laura Boswell
- PhD student, School of Health Sciences, University of
Surrey, Guildford, UK
| | - Jenny Harris
- Senior Lecturer in Cancer Care, School of Health Sciences,
University of Surrey, Guildford,
UK
| | - Katriina L. Whitaker
- Professor of Psychology and Lead for Cancer Care, School of Health
Sciences, University of Surrey, Guildford,
UK
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da Silva EF, de Vargas AS, Willig JB, de Oliveira CB, Zimmer AR, Pilger DA, Buffon A, Gnoatto SCB. Synthesis and antileukemic activity of an ursolic acid derivative: A potential co-drug in combination with imatinib. Chem Biol Interact 2021; 344:109535. [PMID: 34051208 DOI: 10.1016/j.cbi.2021.109535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/14/2021] [Accepted: 05/24/2021] [Indexed: 11/29/2022]
Abstract
Imatinib, a specific Bcr-Abl tyrosine kinase inhibitor, is the most commonly used drug in the treatment of chronic myeloid leukemia. However, optimal response is not achieved in up to 33% of patients. Therefore, development of novel therapeutic strategies for chronic myeloid leukemia is critical. Betulinic (1) and ursolic (2) acids are natural pentacyclic triterpenes that exhibit antileukemic activities. In this study, we evaluated the effects of pharmacomodulations at the C-3 position of the triterpene moiety of betulinic and ursolic acids on their activity against K562 leukemia cells. Six new derivatives (1a-2c) were synthesized and evaluated for pro-apoptotic and anti-proliferative effects in mammalian and leukemic cells. 2c derivative containing an amine group at the C-3 position of ursolic acid was the most active against leukemia cells with an IC50 value of 5.2 μM after 48 h of treatment. 2c did not exhibit cytotoxic effects against VERO and HepG2 cells and human lymphocytes, showing a good selectivity index for cancer over normal cells. Induced cell death by apoptosis via caspases 3 and 8, and also caused cell cycle arrest as evidenced by accumulation of cells in the G1 phase and decreased cell population in the G2 phase. Furthermore, co-treatment of 2c with imatinib, the chemotherapy drug most commonly used to treat leukemia, resulted in a synergistic effect. Our findings provide a strong rationale for further investigation of combination therapy using the 2c derivative and imatinib in pre-clinical studies.
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Affiliation(s)
- Elenilson F da Silva
- Laboratory of Phytochemistry and Organic Synthesis, Graduate Program in Pharmaceutical Sciences, Federal University of Rio Grande do Sul, Av. Ipiranga, 2752, Porto Alegre, RS, 90610-000, Brazil
| | - Artur S de Vargas
- Laboratory of Phytochemistry and Organic Synthesis, Graduate Program in Pharmaceutical Sciences, Federal University of Rio Grande do Sul, Av. Ipiranga, 2752, Porto Alegre, RS, 90610-000, Brazil
| | - Julia B Willig
- Laboratory of Biochemical and Cytological Analysis, Graduate Program in Pharmaceutical Sciences, Federal University of Rio Grande do Sul, Av. Ipiranga, 2752, Porto Alegre, RS, 90610-000, Brazil
| | - Cristiane B de Oliveira
- Laboratory of Phytochemistry and Organic Synthesis, Graduate Program in Pharmaceutical Sciences, Federal University of Rio Grande do Sul, Av. Ipiranga, 2752, Porto Alegre, RS, 90610-000, Brazil
| | - Aline R Zimmer
- Laboratory of Phytochemistry and Organic Synthesis, Graduate Program in Pharmaceutical Sciences, Federal University of Rio Grande do Sul, Av. Ipiranga, 2752, Porto Alegre, RS, 90610-000, Brazil
| | - Diogo A Pilger
- Laboratory of Biochemical and Cytological Analysis, Graduate Program in Pharmaceutical Sciences, Federal University of Rio Grande do Sul, Av. Ipiranga, 2752, Porto Alegre, RS, 90610-000, Brazil
| | - Andréia Buffon
- Laboratory of Biochemical and Cytological Analysis, Graduate Program in Pharmaceutical Sciences, Federal University of Rio Grande do Sul, Av. Ipiranga, 2752, Porto Alegre, RS, 90610-000, Brazil
| | - Simone C B Gnoatto
- Laboratory of Phytochemistry and Organic Synthesis, Graduate Program in Pharmaceutical Sciences, Federal University of Rio Grande do Sul, Av. Ipiranga, 2752, Porto Alegre, RS, 90610-000, Brazil.
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Atkin C, Iqbal G, Planche T, Pratt G, Yong K, Wood J, Raynes K, Low E, Higgins H, Neal RD, Dunn J, Drayson MT, Bowcock S. Diagnostic pathways in multiple myeloma and their relationship to end organ damage: an analysis from the Tackling Early Morbidity and Mortality in Myeloma (TEAMM) trial. Br J Haematol 2020; 192:997-1005. [PMID: 32798327 DOI: 10.1111/bjh.17044] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/26/2020] [Indexed: 11/27/2022]
Abstract
Multiple myeloma is associated with significant early morbidity and mortality, with considerable end organ damage often present at diagnosis. The Tackling EArly Morbidity and Mortality in Multiple Myeloma (TEAMM) trial was used to evaluate routes to diagnosis in patients with myeloma and the relationship between diagnostic pathways, time to diagnosis and disease severity. A total of 915 participants were included in the study. Fifty-one per cent were diagnosed by direct referral from primary care to haematology; 29% were diagnosed via acute services and 20% were referred via other secondary care specialties. Patients diagnosed via other secondary care specialties had a longer diagnostic interval (median 120 days vs. 59 days) without an increase in features of severe disease, suggesting they had a relatively indolent disease. Marked intrahospital delay suggests possible scope for improvement. A quarter of those diagnosed through acute services reported >30 days from initial hospital consultation to haematology assessment. Participants diagnosed through acute services had poorer performance status (P < 0·0001) and higher burden of end organ damage (P < 0·0001) with no difference in the overall length of diagnostic pathway compared to those diagnosed by direct referral (median 59 days). This suggests that advanced disease in patients presenting through acute services predominantly reflects disease aggression.
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Affiliation(s)
- Catherine Atkin
- Institute of Inflammation and Ageing, University of Birmingham, Edgbaston, Birmingham, UK
| | - Gulnaz Iqbal
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Tim Planche
- St George's University Hospitals NHS Trust, London, UK
| | - Guy Pratt
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Kwee Yong
- UCL Cancer Institute, University College London, London, UK
| | - Jill Wood
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Kerry Raynes
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | | | - Helen Higgins
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Richard D Neal
- Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Janet Dunn
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Mark T Drayson
- Institute of Immunology and Immunotherapy, University of Birmingham, Edgbaston, Birmingham, UK
| | - Stella Bowcock
- Department of Haematological Medicine, King's College Hospital NHS Trust, London, UK
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Zhang S, Zhang Q, Yin J, Wu X. Overlapped differentially expressed genes between acute lymphoblastic leukemia and chronic lymphocytic leukemia revealed potential key genes and pathways involved in leukemia. J Cell Biochem 2019; 120:15980-15988. [PMID: 31081970 DOI: 10.1002/jcb.28876] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 02/20/2019] [Accepted: 02/28/2019] [Indexed: 02/05/2023]
Abstract
Common differentially expressed genes (DEGs) in acute lymphoblastic leukemia (ALL) and chronic lymphocytic leukemia (CLL) might play critical roles in the pathogenesis and process of leukemia. We collected RNA sequencing (RNA-seq) data of human CLL, ALL samples, and normal peripheral blood CD19+ B cells as well as thymus samples, and analyzed similarities and differences between their transcriptomes using Cuffdiff2, DESeq, and edgeR. Compared with the RNA-seq data of normal peripheral blood CD19+ B cells and thymus samples, there were a large number of DEGs in ALL and CLL. DEGs in ALL and CLL not only have their distinguished features but also have a similar pattern. To figure out the common DEGs between CLL and ALL, we further identified 26 overlapped genes between CLL and ALL, among which 10 genes showed similar expression variation profiles whereas 16 genes showed opposite variation. The expression levels of 10 genes (SCML4, TNF-α, CD1C, FGFR1, MYO7B, DUSP1, PAP1GAP, MAN1C1, SLFN5, and CD8A) among the 26 genes were further confirmed by experiments, which was consistent with the results obtained by analyzing the RNA-seq data. The current study contributes to better understanding the pathophysiology of leukemia and unearthing novel potential prognostic markers and therapeutic targets of leukemia.
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Affiliation(s)
- Suwei Zhang
- Department of Clinical Laboratory, Shantou Central Hospital, Shantou, Guangdong, China
| | - Qiaoxin Zhang
- Department of Clinical Laboratory, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Jun Yin
- Department of Clinical Laboratory, The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Xianheng Wu
- Department of Radiology, Shantou Central Hospital, Shantou, Guangdong, China
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McShane CM, Murphy B, Santin O, Anderson LA. Low knowledge and awareness of monoclonal gammopathy of undetermined significance (MGUS) among general practitioners. BMC FAMILY PRACTICE 2019; 20:61. [PMID: 31088396 PMCID: PMC6518797 DOI: 10.1186/s12875-019-0944-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 04/10/2019] [Indexed: 12/24/2022]
Abstract
INTRODUCTION While multiple myeloma (MM) is a rare diagnosis within primary care, its precursor MGUS (monoclonal gammopathy of undetermined significance) is more common, particularly among older populations. Upon first detection, the majority of MGUS patients will be under the care of their General Practitioner (GP)/Family Doctor who is also often the first healthcare professional that patients report symptoms of progression to. However, our previous work with MGUS patients and haematology healthcare professionals has suggested that knowledge and awareness of MGUS is low among GPs. METHODS An online survey was undertaken to investigate knowledge and awareness of MGUS and services needed by GPs/GP trainees to support these patients. The survey was promoted at a large European primary care conference and via social media. Descriptive statistics were utilised to compare participant responses. RESULTS In total 58 GPs (n = 35 GPs and n = 23 GP trainees) from 24 countries responded. Overall, self-reported familiarity with the term MGUS was low (mean score: 2.21/5, standard deviation (SD): 1.09), but higher among GPs who reported having at least one MGUS patient (mean score: 2.83/5, SD 0.99). The majority (88.2%) of GPs/GP trainees stated they would feel uncomfortable discussing MGUS with patients. The increased risk of haematological malignancies was identified by 62.1% of GPs/GP trainees with MM, lymphoma and myelodysplastic syndromes the most commonly reported cancers associated with MGUS. The majority (81.6%) of GPs/GP trainees were supportive of patient follow-up via telephone clinics (phlebotomy performed in GP practice with patient management maintained by haematology) but only 27.1% stated they would be happy to solely manage all low/low-intermediate risk MGUS patients. A laboratory report alerting to the possibility of MGUS or a haematological malignancy was reported as the most useful service which could be implemented to help GPs manage MGUS patients. The need for MGUS focused information and education resources for GPs was also highlighted. CONCLUSIONS The findings of this study highlight a lack of knowledge and awareness of MGUS among GPs/ GP trainees. The majority of GPs/GP trainees are happy to support haematology in managing these patients but require assistance and support in providing these services.
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Affiliation(s)
- Charlene M. McShane
- Cancer Epidemiology Research Group, Centre for Public Health, Queen’s University Belfast, Grosvenor Road, Belfast, BT12 6BJ Northern Ireland
| | - Blain Murphy
- Cancer Epidemiology Research Group, Centre for Public Health, Queen’s University Belfast, Grosvenor Road, Belfast, BT12 6BJ Northern Ireland
| | - Olinda Santin
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast, Northern Ireland
| | - Lesley A. Anderson
- Cancer Epidemiology Research Group, Centre for Public Health, Queen’s University Belfast, Grosvenor Road, Belfast, BT12 6BJ Northern Ireland
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Bell C, Kerr K, Moore K, McShane C, Anderson L, McKnight AJ, McAneney H. Communication strategies for rare cancers: a systematic review protocol. Syst Rev 2019; 8:102. [PMID: 31014400 PMCID: PMC6477728 DOI: 10.1186/s13643-019-1017-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 04/05/2019] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Rare cancers comprise almost a quarter of all cancers in Europe, and patients generally have poorer outcomes than those suffering from more common cancers. This is attributed in part to a general lack of knowledge and awareness of rare cancers. This review aims to examine the communication strategies being used throughout the world to inform on rare cancers and to highlight any opportunities for improvement. METHODS A systematic review of literature published in English prior to November 2018 will be conducted, screening articles from the electronic databases MEDLINE, PubMed, EMBASE, Web of Science, PsycINFO, CINAHL Plus and the Cochrane Database of Systematic Reviews. Grey literature databases (GreyLit, OpenGrey) will also be searched in order to screen for any unpublished works. As well as primary literature, reference lists will be examined via forward and reverse citation screening. The review will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Titles and abstracts will first be examined for eligibility, with remaining studies undergoing a full-text screening before being included in the final review. Individual studies will be screened for bias, and a meta-analysis performed provided there is enough data. If insufficient homogenous literature exists, a narrative summary of the literature will be produced. DISCUSSION Despite the broad topic and width of study type that will be considered, this review hopes to provide a reflective summary of the communication strategies available for people living with and working with rare cancer. It aims to reveal any gaps in the resources available, to contribute to the long-term improvement of diagnosis and management of rare cancers. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018099784.
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Affiliation(s)
- Catherine Bell
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Katie Kerr
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Kerry Moore
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Charlene McShane
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Lesley Anderson
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Amy Jayne McKnight
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Helen McAneney
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
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9
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Howell DA, Hart RI, Smith AG, Macleod U, Patmore R, Roman E. Disease-related factors affecting timely lymphoma diagnosis: a qualitative study exploring patient experiences. Br J Gen Pract 2019; 69:e134-e145. [PMID: 30692091 PMCID: PMC6355261 DOI: 10.3399/bjgp19x701009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 09/24/2018] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Expediting cancer diagnosis is widely perceived as one way to improve patient outcomes. Evidence indicates that lymphoma diagnosis is often delayed, yet understanding of issues influencing this is incomplete. AIM To explore patients' and their relatives' perceptions of disease-related factors affecting time to diagnosis of Hodgkin and non-Hodgkin lymphoma. DESIGN AND SETTING Qualitative UK study involving patients with indolent and aggressive lymphomas, and their relatives, from an established population-based cohort in the north of England. METHOD Semi-structured interviews with 35 patients and 15 of their relatives. Interviews were audiorecorded and transcribed, and qualitative descriptive analysis was undertaken. RESULTS Participant accounts suggest that certain features of lymphoma can impact on patients' and healthcare providers' (HCPs) responses to disease onset. Three characteristics stand out: disease occurrence (rare), manifestation (varied), and investigative options (often inconclusive). Interviewees described how they, and some HCPs, lacked familiarity with lymphoma, seldom considering it a likely explanation for their symptoms. Symptoms reported were highly variable, frequently non-specific, and often initially thought to be associated with various benign, self-limiting causes. Blood tests and other investigations, while frequently able to detect abnormalities, did not reliably indicate malignancy. Interviewees reported the potential for improvements among HCPs in information gathering, communication of uncertainty, and re-presentation advice for non-resolving/progressive health changes. CONCLUSION This study demonstrates the complex characteristics of lymphoma, perceived by patients as prolonging time to diagnosis, often despite significant effort by themselves, their relatives, and HCPs to expedite this process. The findings also illustrate why simple solutions to delayed diagnosis of lymphoma are lacking.
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Affiliation(s)
- Debra A Howell
- Epidemiology and Cancer Statistics Group, professor of epidemiology, Department of Health Sciences, University of York, York
| | - Ruth I Hart
- Epidemiology and Cancer Statistics Group, professor of epidemiology, Department of Health Sciences, University of York, York
| | - Alexandra G Smith
- Epidemiology and Cancer Statistics Group, professor of epidemiology, Department of Health Sciences, University of York, York
| | - Una Macleod
- Hull York Medical School, University of Hull, Hull
| | - Russell Patmore
- Department of Haematology, Queen's Centre for Oncology and Haematology, Castle Hill Hospital, Hull
| | - Eve Roman
- Epidemiology and Cancer Statistics Group, professor of epidemiology, Department of Health Sciences, University of York, York
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Atkin C, Richter A, Sapey E. What is the significance of monoclonal gammopathy of undetermined significance? Clin Med (Lond) 2018; 18:391-396. [PMID: 30287433 PMCID: PMC6334115 DOI: 10.7861/clinmedicine.18-5-391] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Monoclonal gammopathy of undetermined significance (MGUS) is characterised by the presence of a monoclonal paraprotein in the blood, without the characteristic end organ damage seen in multiple myeloma. MGUS is more common in older age groups and has a risk of progression to myeloma of 1% per year. Population screening is not currently recommended, but retrospective studies have suggested improvements in myeloma outcomes in those under MGUS follow-up; in addition, MGUS has associated complications, including fracture, osteoporosis, renal disease and infection, which can be treated. Given this increasing evidence of disease related directly to MGUS, strategies for early identification might be needed. In this review, we discuss the complications of MGUS and whether MGUS fulfils the criteria needed to implement a screening programme. We also highlight areas where more evidence is needed, including identification of a higher risk population to make screening more practical and economically viable.
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Affiliation(s)
- Catherine Atkin
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Alex Richter
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Elizabeth Sapey
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
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Koshiaris C, Oke J, Abel L, Nicholson BD, Ramasamy K, Van den Bruel A. Quantifying intervals to diagnosis in myeloma: a systematic review and meta-analysis. BMJ Open 2018; 8:e019758. [PMID: 29934381 PMCID: PMC6020959 DOI: 10.1136/bmjopen-2017-019758] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES To quantify the duration of each step of the diagnostic pathway for patients with multiple myeloma from symptom onset to confirmation of diagnosis. DESIGN Systematic review and meta-analysis. DATA SOURCES AND SELECTION CRITERIA The MEDLINE and Embase databases were searched up until January 2018 to identify articles that reported time intervals from onset of symptoms to diagnosis. Articles focusing on children or adolescents and on the asymptomatic form of the disease (monoclonal gammopathies and smouldering myeloma) were excluded. DATA COLLECTION AND DATA ANALYSIS Data were extracted independently by two reviewers. Weighted estimates of the median and IQR were calculated. Risk of bias was assessed using the Aarhus checklist. MAIN RESULTS Nine studies were included. The patient interval (first symptom to first presentation) had a median of 26.3 days (IQR: 1-98, n=465, two studies). Subsequently, the primary care interval (first presentation to first referral) was 21.6 days (IQR: 4.6-55.8, n=326, two studies), the diagnostic interval (first presentation to diagnosis) was 108.6 days (IQR: 33.3-241.7, n=5395, seven studies) and the time to diagnosis (first symptom to diagnosis) interval was 163 days (IQR: 84-306, n=341, one study). No studies reported data for the referral to diagnosis interval. CONCLUSION The review demonstrates that there is scope for significant reductions in the time to myeloma diagnosis. At present, many patients experience a diagnostic interval longer than 3 months until diagnosis is confirmed. REVIEW REGISTRATION Not available. Protocol available in the appendix.
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Affiliation(s)
| | - Jason Oke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Lucy Abel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Karthik Ramasamy
- Department of Haematology, Oxford University Hospitals NHS Trust, Oxford, UK
- National Institute for Health Research (NIHR) Biomedical Research Center Blood Theme, Oxford, UK
| | - Ann Van den Bruel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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12
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Salguero DA, Barletta PA, Sierraalta W. Severe abdominal pain and diarrhea - unusual multiple myeloma presentation with a severe prognosis: a case report. J Med Case Rep 2018; 12:70. [PMID: 29549883 PMCID: PMC5857313 DOI: 10.1186/s13256-018-1598-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 01/30/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Multiple myeloma is a hematologic disease with high mortality rates all over the world. The diagnosis has always been challenging since the first case was reported in 1844. For that reason the diagnostic criteria have evolved over years to include the features of the disease more comprehensively. Unusual presentations are infrequent and a diagnostic challenge. For this reason we report this rare case in which diarrhea and abdominal pain were the initial presenting symptoms of multiple myeloma with a plasmacytoma. CASE PRESENTATION An 87-year-old Hispanic man with a past medical history of hypertension, diabetes, and constipation, presented to an emergency department complaining of severe generalized abdominal pain and profuse diarrhea for 3 days. A physical examination revealed generalized pallor and dehydration but no signs of abdominal peritoneal irritation. Laboratory tests revealed neutrophilia and an elevated total protein. He received intravenously administered fluids and antibiotics. His abdominal pain became localized in the infraumbilical area and a small mass was palpated on the right lower quadrant on subsequent examination. An abdominal computed tomography scan showed a tumor lesion surrounded by fluid collection and a computed tomography-guided biopsy of the lesion confirmed it to be a plasmacytoma. A bone marrow biopsy revealed plasmatic cell augmentation but his beta-2 microglobulin levels were inconclusive. The diagnosis of multiple myeloma was finally confirmed with urine immunofixation. Bortezomib was initiated to decrease disease progression, but unfortunately 4 days later he developed acute pulmonary edema, had a cardiac arrest, and died. CONCLUSIONS This case illustrates the protean initial manifestations of multiple myeloma and the importance of an accurate diagnosis. Our patient's initial presentation with gastrointestinal complaints is rare and the plasmacytoma location is even rarer, providing a challenging diagnostic problem. Prompt recognition of multiple myeloma is critical to institute appropriate therapy and prevention of disease progression.
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Affiliation(s)
- Douglas A Salguero
- Advance Simulation Center, University of Francisco Marroquin-UFM, 6 avenue zone 10, 01011, Guatemala, Guatemala.
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13
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Bosch X, Sanclemente-Ansó C, Escoda O, Monclús E, Franco-Vanegas J, Moreno P, Guerra-García M, Guasch N, López-Soto A. Time to diagnosis and associated costs of an outpatient vs inpatient setting in the diagnosis of lymphoma: a retrospective study of a large cohort of major lymphoma subtypes in Spain. BMC Cancer 2018; 18:276. [PMID: 29530002 PMCID: PMC5848556 DOI: 10.1186/s12885-018-4187-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 03/06/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Mainly because of the diversity of clinical presentations, diagnostic delays in lymphoma can be excessive. The time spent in primary care before referral to the specialist may be relatively short compared with the interval between hospital appointment and diagnosis. Although studies have examined the diagnostic intervals and referral patterns of patients with lymphoma, the time to diagnosis of outpatient compared to inpatient settings and the costs incurred are unknown. METHODS We performed a retrospective study at two academic hospitals to evaluate the time to diagnosis and associated costs of hospital-based outpatient diagnostic clinics or conventional hospitalization in four representative lymphoma subtypes. The frequency, clinical and prognostic features of each lymphoma subtype and the activities of the two settings were analyzed. The costs incurred during the evaluation were compared by microcosting analysis. RESULTS A total of 1779 patients diagnosed between 2006 and 2016 with classical Hodgkin, large B-cell, follicular, and mature nodal peripheral T-cell lymphomas were identified. Clinically aggressive subtypes including large B-cell and peripheral T-cell lymphomas were more commonly diagnosed in inpatients than in outpatients (39.1 vs 31.2% and 18.9 vs 13.5%, respectively). For each lymphoma subtype, inpatients were older and more likely than outpatients to have systemic symptoms, worse performance status, more advanced Ann Arbor stages, and high-risk prognostic scores. The admission time for diagnosis (i.e. from admission to excisional biopsy) of inpatients was significantly shorter than the time to diagnosis of outpatients (12.3 [3.3] vs 16.2 [2.7] days; P < .001). Microcosting revealed a mean cost of €4039.56 (513.02) per inpatient and of €1408.48 (197.32) per outpatient, or a difference of €2631.08 per patient. CONCLUSIONS Although diagnosis of lymphoma was quicker with hospitalization, the outpatient approach seems to be cost-effective and not detrimental. Despite the considerable savings with the latter approach, there may be hospitalization-associated factors which may not be properly managed in an outpatient unit (e.g. aggressive lymphomas with severe symptoms) and the cost analysis did not account for this potentially added value. While outcomes were not analyzed in this study, the impact on patient outcome of an outpatient vs inpatient diagnostic setting may represent a challenging future research.
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Affiliation(s)
- Xavier Bosch
- Quick Diagnosis Unit, Adult Day Care Center, Hospital Clínic, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain.
- Quick Diagnosis Unit, Department of Internal Medicine, Hospital Clínic, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain.
| | - Carmen Sanclemente-Ansó
- Quick Diagnosis Unit, Department of Internal Medicine, Hospital of Bellvitge, University of Barcelona, Barcelona, Spain
| | - Ona Escoda
- Quick Diagnosis Unit, Adult Day Care Center, Hospital Clínic, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - Esther Monclús
- Quick Diagnosis Unit, Adult Day Care Center, Hospital Clínic, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - Jonathan Franco-Vanegas
- Quick Diagnosis Unit, Department of Internal Medicine, Hospital of Bellvitge, University of Barcelona, Barcelona, Spain
| | - Pedro Moreno
- Department of Internal Medicine, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Mar Guerra-García
- Adult Day Care Center, Hospital Clínic, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - Neus Guasch
- Adult Day Care Center, Hospital Clínic, University of Barcelona, Villarroel 170, 08036, Barcelona, Spain
| | - Alfons López-Soto
- Department of Internal Medicine, Hospital Clínic, University of Barcelona, Barcelona, Spain
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14
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Koo MM, Hamilton W, Walter FM, Rubin GP, Lyratzopoulos G. Symptom Signatures and Diagnostic Timeliness in Cancer Patients: A Review of Current Evidence. Neoplasia 2018; 20:165-174. [PMID: 29253839 PMCID: PMC5735300 DOI: 10.1016/j.neo.2017.11.005] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 11/13/2017] [Accepted: 11/13/2017] [Indexed: 12/14/2022]
Abstract
Early diagnosis is an important aspect of contemporary cancer prevention and control strategies, as the majority of patients are diagnosed following symptomatic presentation. The nature of presenting symptoms can critically influence the length of the diagnostic intervals from symptom onset to presentation (the patient interval), and from first presentation to specialist referral (the primary care interval). Understanding which symptoms are associated with longer diagnostic intervals to help the targeting of early diagnosis initiatives is an area of emerging research. In this Review, we consider the methodological challenges in studying the presenting symptoms and intervals to diagnosis of cancer patients, and summarize current evidence on presenting symptoms associated with a range of common and rarer cancer sites. We propose a taxonomy of cancer sites considering their symptom signature and the predictive value of common presenting symptoms. Finally, we consider evidence on associations between symptomatic presentations and intervals to diagnosis before discussing implications for the design, implementation, and evaluation of public health or health system interventions to achieve the earlier detection of cancer.
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Affiliation(s)
- Minjoung M Koo
- University College London, 1-19 Torrington Place, London WC1E 6BT, UK.
| | - William Hamilton
- University of Exeter Medical School, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Fiona M Walter
- University of Cambridge, Primary Care Unit, Strangeways Research Laboratory, Cambridge, CB2 0SR, UK
| | - Greg P Rubin
- Institute of Health and Society, Newcastle University, Sir James Spence Institute, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, UK
| | - Georgios Lyratzopoulos
- University College London, 1-19 Torrington Place, London WC1E 6BT, UK; University of Cambridge, Primary Care Unit, Strangeways Research Laboratory, Cambridge, CB2 0SR, UK
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15
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Abel GA, Saunders CL, Lyratzopoulos G. Post-sampling mortality and non-response patterns in the English Cancer Patient Experience Survey: Implications for epidemiological studies based on surveys of cancer patients. Cancer Epidemiol 2016; 41:34-41. [PMID: 26797675 PMCID: PMC4819677 DOI: 10.1016/j.canep.2015.12.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 12/17/2015] [Accepted: 12/18/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Surveys of the experience of cancer patients are increasingly being introduced in different countries and used in cancer epidemiology research. Sampling processes, post-sampling mortality and survey non-response can influence the representativeness of cancer patient surveys. METHODS We examined predictors of post-sampling mortality and non-response among patients initially included in the sampling frame of the English Cancer Patient Experience Survey. We also compared the respondents' diagnostic case-mix to other relevant populations of cancer patients, including incident and prevalent cases. RESULTS Of 109,477 initially sampled cancer patients, 6273 (5.7%) died between sampling and survey mail-out. Older age and diagnosis of brain, lung and pancreatic cancer were associated with higher risk of post-sampling mortality. The overall response rate was 67% (67,713 respondents), being >70% for the most affluent patients and those diagnosed with colon or breast cancer and <50% for Asian or Black patients, those under 35 and those diagnosed with brain cancer. The diagnostic case-mix of respondents varied substantially from incident or prevalent cancer cases. CONCLUSIONS Respondents to the English Cancer Patient Experience Survey represent a population of recently treated cancer survivors. Although patient survey data can provide unique insights for improving cancer care quality, features of survey populations need to be acknowledged when analysing and interpreting findings from studies using such data.
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Affiliation(s)
- Gary A Abel
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK
| | - Catherine L Saunders
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK; RAND Europe, Westbrook Centre, Milton Road, Cambridge CB4 1YG, UK
| | - Georgios Lyratzopoulos
- Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK; Health Behaviour Research Centre, Department of Epidemiology & Public Health, University College London, 1-19 Torrington Place, London WC1 E 6BT, UK.
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16
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An observational study assessing peripheral neuropathy related to multiple myeloma. Neurol Sci 2016; 37:1141-3. [DOI: 10.1007/s10072-016-2542-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 02/26/2016] [Indexed: 01/27/2023]
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