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Krishnan R, Patel PS, Hakem R. BRCA1 and Metastasis: Outcome of Defective DNA Repair. Cancers (Basel) 2021; 14:cancers14010108. [PMID: 35008272 PMCID: PMC8749860 DOI: 10.3390/cancers14010108] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/22/2021] [Accepted: 12/24/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary BRCA1 has critical functions in accurately repairing double stand breaks in the DNA through a process known as homologous recombination. BRCA1 also has various functions in other cellular processes that safeguard the genome. Thus, mutations or silencing of this tumor suppressor significantly increases the risk of developing breast, ovarian, and other cancers. Metastasis refers to the spread of cancer to other parts of the body and is the leading cause of cancer-related deaths. In this review, we discuss the mechanisms by which BRCA1 mutations contribute to the metastatic and aggressive nature of the tumor cells. Abstract Heritable mutations in BRCA1 and BRCA2 genes are a major risk factor for breast and ovarian cancer. Inherited mutations in BRCA1 increase the risk of developing breast cancers by up to 72% and ovarian cancers by up to 69%, when compared to individuals with wild-type BRCA1. BRCA1 and BRCA2 (BRCA1/2) are both important for homologous recombination-mediated DNA repair. The link between BRCA1/2 mutations and high susceptibility to breast cancer is well established. However, the potential impact of BRCA1 mutation on the individual cell populations within a tumor microenvironment, and its relation to increased aggressiveness of cancer is not well understood. The objective of this review is to provide significant insights into the mechanisms by which BRCA1 mutations contribute to the metastatic and aggressive nature of the tumor cells.
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Affiliation(s)
- Rehna Krishnan
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 1L7, Canada; (R.K.); (P.S.P.)
| | - Parasvi S. Patel
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 1L7, Canada; (R.K.); (P.S.P.)
- Department of Medical Biophysics, University of Toronto, Toronto, ON M5G 1L7, Canada
| | - Razqallah Hakem
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 1L7, Canada; (R.K.); (P.S.P.)
- Department of Medical Biophysics, University of Toronto, Toronto, ON M5G 1L7, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON M5S 1A8, Canada
- Correspondence: or
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Breast cancer risk reduction: who, why, and what? Best Pract Res Clin Obstet Gynaecol 2021; 83:36-45. [PMID: 34991977 DOI: 10.1016/j.bpobgyn.2021.11.012] [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: 11/02/2021] [Revised: 11/25/2021] [Accepted: 11/30/2021] [Indexed: 11/20/2022]
Abstract
Women at increased risk of breast cancer have options to mitigate that risk. Understanding factors that increase risk and utilizing tools for quantitative estimates are important to be able to adequately counsel and target strategies for patients. On the basis of these estimates, patients may be able to engage in risk reduction interventions and increased screening, including chemoprevention or surgical risk reduction. Multiple organizations have published guidelines supporting risk assessment, genetic assessment, increased screening, and prevention measures for these women.
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Mocellin S, Goodwin A, Pasquali S. Risk-reducing medications for primary breast cancer: a network meta-analysis. Cochrane Database Syst Rev 2019; 4:CD012191. [PMID: 31032883 PMCID: PMC6487387 DOI: 10.1002/14651858.cd012191.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Breast cancer is the most frequently occurring malignancy and the second cause of death for cancer in women. Cancer prevention agents (CPAs) are a promising approach to reduce the burden of breast cancer. Currently, two main types of CPAs are available: selective estrogen receptor modulators (SERMs, such as tamoxifen and raloxifene) and aromatase inhibitors (AIs, such as exemestane and anastrozole). OBJECTIVES To assess the efficacy and acceptability of single CPAs for the prevention of primary breast cancer, in unaffected women, at an above-average risk of developing breast cancer.Using a network meta-analysis, to rank single CPAs, based on their efficacy and acceptability (an endpoint that is defined as the inverse of CPA-related toxicity). SEARCH METHODS We searched the Cochrane Breast Cancer Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, World Health Organization's International Clinical Trials Registry Platform (WHO ICTRP), and ClinicalTrials.gov on 17 August 2018. We handsearched reference lists to identify additional relevant studies. SELECTION CRITERIA We included randomized controlled trials (RCTs) that enrolled women without a personal history of breast cancer but with an above-average risk of developing a tumor. Women had to be treated with a CPA and followed up to record the occurrence of breast cancer and adverse events. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and conducted risk of bias assessments of the included studies, and assessed the certainty of the evidence using GRADE. Outcome data included incidence of breast carcinoma (both invasive and in situ carcinoma) and adverse events (both overall and severe toxicity). We performed a conventional meta-analysis (for direct comparisons of a single CPA with placebo or a different CPA) and network meta-analysis (for indirect comparisons). MAIN RESULTS We included six studies enrolling 50,927 women randomized to receive one CPA (SERMs: tamoxifen or raloxifene, or AIs: exemestane or anastrozole) or placebo. Three studies compared tamoxifen and placebo, two studies compared AIs (exemestane or anastrozole) versus placebo, and one study compared tamoxifen versus raloxifene. The risk of bias was low for all RCTs.For the tamoxifen versus placebo comparison, tamoxifen likely resulted in a lower risk of developing breast cancer compared to placebo (risk ratio (RR) 0.68, 95% confidence interval (CI) 0.62 to 0.76; 3 studies, 22,832 women; moderate-certainty evidence). In terms of adverse events, tamoxifen likely increased the risk of severe toxicity compared to placebo (RR 1.28, 95% CI 1.12 to 1.47; 2 studies, 20,361 women; moderate-certainty evidence). In particular, women randomized to receive tamoxifen experienced a higher incidence of both endometrial carcinoma (RR 2.26, 95% CI 1.52 to 3.38; high-certainty evidence) and thromboembolism (RR 2.10, 95% CI 1.14 to 3.89; high-certainty evidence) compared to women who received placebo.For the AIs versus placebo comparison, AIs (exemestane or anastrozole) reduced the risk of breast cancer by 53% (RR 0.47, 95% CI 0.35 to 0.63; 2 studies, 8424 women; high-certainty evidence). In terms of adverse events, AIs increased the risk of severe toxicity by 18% (RR 1.18, 95% CI 1.09 to 1.28; 2 studies, 8352 women; high-certainty evidence). These differences were sustained especially by endocrine (e.g. hot flashes), gastrointestinal (e.g. diarrhea), and musculoskeletal (e.g. arthralgia) adverse events, while there were no differences in endometrial cancer or thromboembolism rates between AIs and placebo.For the tamoxifen versus raloxifene comparison, raloxifene probably performed worse than tamoxifen in terms of breast cancer incidence reduction (RR 1.25, 95% CI 1.09 to 1.43; 1 study, 19,490 women; moderate-certainty evidence), but its use was associated with lower toxicity rates (RR 0.87, 95% CI 0.80 to 0.95; 1 study, 19,490 women; moderate-certainty evidence), particularly relating to incidence of endometrial cancer and thromboembolism.An indirect comparison of treatment effects allowed us to compare the SERMs and AIs in this review. In terms of efficacy, AIs (exemestane or anastrozole) may have reduced breast cancer incidence slightly compared to tamoxifen (RR 0.67, 95% CI 0.46 to 0.98; 5 RCTs, 31,256 women); however, the certainty of evidence was low. A lack of model convergence did not allow us to analyze toxicity data. AUTHORS' CONCLUSIONS For women with an above-average risk of developing breast cancer, CPAs can reduce the incidence of this disease. AIs appear to be more effective than SERMs (tamoxifen) in reducing the risk of developing breast cancer. AIs are not associated with an increased risk of endometrial cancer and thromboembolic events. However, long-term data on toxicities from tamoxifen are available while the follow-up toxicity data on unaffected women taking AIs is relatively short. Additional data from direct comparisons are needed to fully address the issues of breast cancer prevention by risk-reducing medications, with special regards to acceptability (i.e. the benefit/harm ratio).
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Affiliation(s)
| | | | - Sandro Pasquali
- Fondazione IRCCS Istituto Nazionale dei TumoriSarcoma ServiceVia G. Venezian 1MilanoItaly20133
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Abstract
Purpose
A significant subset of patients (12 per cent) with triple negative breast cancer (TNBC) is BRCA mutation carriers, which can be identified through genetic testing. The purpose of this paper is to evaluate the referral practice for TNBC patients with reference to New South Wales (NSW) referral guidelines at the time of diagnosis and to assess the effectiveness of such guidelines in identifying BRCA mutations. Robust health governance requires monitoring of adherence to evidence-based guidelines such as those that underpin referral for cancer genetic testing in this clinical scenario.
Design/methodology/approach
The authors conducted a retrospective clinical audit of identified TNBC patients at St Vincent’s Hospital (SVH) between 2006 and 2016 in NSW, comparing referral practice to guidelines extant at the time of diagnosis. Family history was considered for age guideline-inappropriate referrals to SVH while the results of BRCA gene testing were assessed for all referred.
Findings
Overall, of the 17 patients eligible for referral based on the age criterion, 10 (58.5 per cent) were referred appropriately; however, there were substantial improvements from 2012 with 100 per cent referred. Of note, 12 (33.4 per cent) of 36 patients referred to SVH were referred outside of guidelines, pointing to other reasons for referral, such as patient age (OR 0.945; 95% CI 0.914–0.978) and calendar year (OR: 1.332; 95% CI: 1.127–1.575) at TNBC diagnosis. Referral guidelines captured 66.67 per cent of identified deleterious BRCA mutations in those tested.
Originality/value
Substantial under-referral of guideline-eligible patients was identified, with evidence-based guidelines effective in identifying high-risk individuals for BRCA mutation testing. There was, however, a substantial proportion of guideline-inappropriate referrals.
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5
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Kotsopoulos J. BRCA Mutations and Breast Cancer Prevention. Cancers (Basel) 2018; 10:E524. [PMID: 30572612 PMCID: PMC6315560 DOI: 10.3390/cancers10120524] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 12/05/2018] [Accepted: 12/17/2018] [Indexed: 12/14/2022] Open
Abstract
Women who inherit a deleterious BRCA1 or BRCA2 mutation face substantially increased risks of developing breast cancer, which is estimated at 70%. Although annual screening with magnetic resonance imaging (MRI) and mammography promotes the earlier detection of the disease, the gold standard for the primary prevention of breast cancer remains bilateral mastectomy. In the current paper, I review the evidence regarding the management of healthy BRCA mutation carriers, including key risk factors and protective factors, and also discuss potential chemoprevention options. I also provide an overview of the key findings from the literature published to date, with a focus on data from studies that are well-powered, and preferably prospective in nature.
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Affiliation(s)
- Joanne Kotsopoulos
- Women's College Research Institute, Women's College Hospital, 76 Grenville Street, 6th Floor, Toronto, ON M5S 1B2, Canada.
- Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, ON M5T 3M7, Canada.
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Müllerian intra-abdominal carcinomatosis in hereditary breast ovarian cancer syndrome: implications for risk-reducing surgery. Fam Cancer 2017; 15:371-84. [PMID: 26875157 DOI: 10.1007/s10689-016-9878-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
More than 40 years ago Lynch et al. described several multigenerational breast cancer family pedigrees which demonstrated autosomal dominant inheritance of a trait(s) that increased risks for both breast and ovarian cancers. Mutation carriers in at least 90 % of these hereditary breast ovarian cancer (HBOC) syndrome families have been linked to cancer-associated mutations in the genes BRCA1 and BRCA2. This review focuses on the contributions of Lynch, colleagues and collaborators and pertinent literature, toward defining the HBOC syndrome, the cancer risks that the inherited adverse mutations convey, the gynecologic tissues and organs from which the malignancy may arise to disseminate throughout the pelvic and abdominal organs and peritoneum and how this information can be used to reduce the risk and morbidities of intra-abdominal carcinomatosis in effected individuals.
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Hunt KK, Euhus DM, Boughey JC, Chagpar AB, Feldman SM, Hansen NM, Kulkarni SA, McCready DR, Mamounas EP, Wilke LG, Van Zee KJ, Morrow M. Society of Surgical Oncology Breast Disease Working Group Statement on Prophylactic (Risk-Reducing) Mastectomy. Ann Surg Oncol 2016; 24:375-397. [PMID: 27933411 DOI: 10.1245/s10434-016-5688-z] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Indexed: 12/15/2022]
Abstract
Over the past several years, there has been an increasing rate of bilateral prophylactic mastectomy (BPM) and contralateral prophylactic mastectomy (CPM) surgeries. Since publication of the 2007 SSO position statement on the use of risk-reducing mastectomy, there have been significant advances in the understanding of breast cancer biology and treatment. The purpose of this manuscript is to review the current literature as a resource to facilitate a shared and informed decision-making process regarding the use of risk-reducing mastectomy.
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Affiliation(s)
- Kelly K Hunt
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | | | | | | | | | | | | | | | | | | | | | - Monica Morrow
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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8
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Mocellin S, Goodwin A, Pasquali S. Risk-reducing medication for primary breast cancer: a network meta-analysis. Hippokratia 2016. [DOI: 10.1002/14651858.cd012191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Simone Mocellin
- University of Padova; Dept. Surgery Oncology and Gastroenterology; Via Giustiniani 2 Padova Veneto Italy 35128
- IOV-IRCCS; Istituto Oncologico Veneto; Padova Italy 35100
| | - Annabel Goodwin
- The University of Sydney, Concord Repatriation General Hospital; Concord Clinical School; Concord NSW Australia 2137
- Concord Repatriation General Hospital; Medical Oncology Department; Concord Australia
- Sydney Local Health District and South Western Sydney Local Health District; Cancer Genetics Department; Sydney Australia
| | - Sandro Pasquali
- Veneto Institute of Oncology - IRCCS; Surgical Oncology Unit; Via Gattamelata 64 Padova Italy 35128
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Phillips KA, Steel EJ, Collins I, Emery J, Pirotta M, Mann GB, Butow P, Hopper JL, Trainer A, Moreton J, Antoniou AC, Cuzick J, Keogh L. Transitioning to routine breast cancer risk assessment and management in primary care: what can we learn from cardiovascular disease? Aust J Prim Health 2016; 22:255-261. [PMID: 25705982 DOI: 10.1071/py14156] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 12/20/2014] [Indexed: 02/11/2024]
Abstract
To capitalise on advances in breast cancer prevention, all women would need to have their breast cancer risk formally assessed. With ~85% of Australians attending primary care clinics at least once a year, primary care is an opportune location for formal breast cancer risk assessment and management. This study assessed the current practice and needs of primary care clinicians regarding assessment and management of breast cancer risk. Two facilitated focus group discussions were held with 17 primary care clinicians (12 GPs and 5 practice nurses (PNs)) as part of a larger needs assessment. Primary care clinicians viewed assessment and management of cardiovascular risk as an intrinsic, expected part of their role, often triggered by practice software prompts and facilitated by use of an online tool. Conversely, assessment of breast cancer risk was not routine and was generally patient- (not clinician-) initiated, and risk management (apart from routine screening) was considered outside the primary care domain. Clinicians suggested that routine assessment and management of breast cancer risk might be achieved if it were widely endorsed as within the remit of primary care and supported by an online risk-assessment and decision aid tool that was integrated into primary care software. This study identified several key issues that would need to be addressed to facilitate the transition to routine assessment and management of breast cancer risk in primary care, based largely on the model used for cardiovascular disease.
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Affiliation(s)
- Kelly-Anne Phillips
- Peter MacCallum Cancer Centre, Locked Bag 1, A'Beckett Street, East Melbourne, Vic. 8006, Australia
| | - Emma J Steel
- Peter MacCallum Cancer Centre, Locked Bag 1, A'Beckett Street, East Melbourne, Vic. 8006, Australia
| | - Ian Collins
- Peter MacCallum Cancer Centre, Locked Bag 1, A'Beckett Street, East Melbourne, Vic. 8006, Australia
| | - Jon Emery
- General Practice and Primary Care Academic Centre, The University of Melbourne, 200 Berkeley Street, Carlton, Vic. 3053, Australia
| | - Marie Pirotta
- General Practice and Primary Care Academic Centre, The University of Melbourne, 200 Berkeley Street, Carlton, Vic. 3053, Australia
| | - G Bruce Mann
- The Breast Service, Royal Melbourne and Royal Women's Hospital, 20 Flemington Road, Parkville, Vic. 3052, Australia
| | - Phyllis Butow
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Transient Building F12, Darlington, NSW 2006, Australia
| | - John L Hopper
- Centre for Molecular, Environmental, Genetic and Analytic Epidemiology, Melbourne School of Population and Global Health, The University of Melbourne, 207 Bouverie Street, Carlton, Vic. 3010, Australia
| | - Alison Trainer
- Peter MacCallum Cancer Centre, Locked Bag 1, A'Beckett Street, East Melbourne, Vic. 8006, Australia
| | - Jane Moreton
- Peter MacCallum Cancer Centre, Locked Bag 1, A'Beckett Street, East Melbourne, Vic. 8006, Australia
| | - Antonis C Antoniou
- Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Worts Causeway, Cambridge, CB1 8RN, United Kingdom
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, United Kingdom
| | - Louise Keogh
- Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne, 207 Bouverie Street, Carlton, Vic. 3010, Australia
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Mocellin S, Pilati P, Briarava M, Nitti D. Breast Cancer Chemoprevention: A Network Meta-Analysis of Randomized Controlled Trials. J Natl Cancer Inst 2015; 108:djv318. [PMID: 26582062 DOI: 10.1093/jnci/djv318] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 10/05/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Several agents have been advocated for breast cancer primary prevention. However, few of them appear effective, the associated severe adverse effects limiting their uptake. METHODS We performed a comprehensive search for randomized controlled trials (RCTs) reporting on the ability of chemoprevention agents (CPAs) to reduce the incidence of primary breast carcinoma. Using network meta-analysis, we ranked CPAs based simultaneously on efficacy and acceptability (an inverse measure of toxicity). All statistical tests were two-sided. RESULTS We found 48 eligible RCTs, enrolling 271 161 women randomly assigned to receive either placebo or one of 21 CPAs. Aromatase inhibitors (anastrozole and exemestane, considered a single CPA class because of the lack of between-study heterogeneity; relative risk [RR] = 0.468, 95% confidence interval [CI] = 0.346 to 0.634), arzoxifene (RR = 0.415, 95% CI = 0.253 to 0.682), lasofoxifene (RR = 0.208, 95% CI = 0.079 to 0.544), raloxifene (RR = 0.572, 95% CI = 0.372 to 0.881), tamoxifen (RR = 0.708, 95% CI = 0.595 to 0.842), and tibolone (RR = 0.317, 95% CI = 0.127 to 0.792) were statistically significantly associated with a therapeutic effect, which was restricted to estrogen receptor-positive tumors of postmenopausal women (except for tamoxifen, which is active also during premenopause). Network meta-analysis ranking showed that the new selective estrogen receptor modulators (SERMs) arzoxifene, lasofoxifene, and raloxifene have the best benefit-risk ratio. Aromatase inhibitors and tamoxifen ranked second and third, respectively. CONCLUSIONS These results provide physicians and health care regulatory agencies with RCT-based evidence on efficacy and acceptability of currently available breast cancer CPAs; at the same time, we pinpoint how much work still remains to be done before pharmacological primary prevention becomes a routine option to reduce the burden of this disease.
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Affiliation(s)
- Simone Mocellin
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy (SM, PP, MB, DN); Istituto Oncologico Veneto, IOV-IRCCS, Padova, Italy (SM); Sant'Antonio Hospital, Padova, Italy (PP).
| | - Pierluigi Pilati
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy (SM, PP, MB, DN); Istituto Oncologico Veneto, IOV-IRCCS, Padova, Italy (SM); Sant'Antonio Hospital, Padova, Italy (PP)
| | - Marta Briarava
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy (SM, PP, MB, DN); Istituto Oncologico Veneto, IOV-IRCCS, Padova, Italy (SM); Sant'Antonio Hospital, Padova, Italy (PP)
| | - Donato Nitti
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy (SM, PP, MB, DN); Istituto Oncologico Veneto, IOV-IRCCS, Padova, Italy (SM); Sant'Antonio Hospital, Padova, Italy (PP)
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11
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Goldberg K, Bar-Joseph H, Grossman H, Hasky N, Uri-Belapolsky S, Stemmer SM, Chuderland D, Shalgi R, Ben-Aharon I. Pigment Epithelium–Derived Factor Alleviates Tamoxifen-Induced Endometrial Hyperplasia. Mol Cancer Ther 2015; 14:2840-9. [DOI: 10.1158/1535-7163.mct-15-0523] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 09/21/2015] [Indexed: 11/16/2022]
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12
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Snyder CL, Casey MJ, Lynch HT. Should risk-reducing surgery in women from hereditary breast ovarian cancer families be confined to removal of the fallopian tubes with ovarian conservation? WOMENS HEALTH 2015; 11:423-7. [PMID: 26246179 DOI: 10.2217/whe.15.26] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Carrie L Snyder
- Department of Preventive Medicine & Public Health, Creighton University, HLSB Room 202, 2500 California Plaza, Omaha, NE 68178, USA
| | - Murray Joseph Casey
- Department of Preventive Medicine & Public Health, Creighton University, HLSB Room 202, 2500 California Plaza, Omaha, NE 68178, USA.,Department of Obstetrics & Gynecology, Creighton University, Omaha, NE 68178, USA
| | - Henry T Lynch
- Department of Preventive Medicine & Public Health, Creighton University, HLSB Room 202, 2500 California Plaza, Omaha, NE 68178, USA.,Department of Internal Medicine, Creighton University, Omaha, NE 68178, USA
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