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Devine SM, Owzar K, Blum W, Mulkey F, Stone RM, Hsu JW, Champlin RE, Chen YB, Vij R, Slack J, Soiffer RJ, Larson RA, Shea TC, Hars V, Sibley AB, Giralt S, Carter S, Horowitz MM, Linker C, Alyea EP. Phase II Study of Allogeneic Transplantation for Older Patients With Acute Myeloid Leukemia in First Complete Remission Using a Reduced-Intensity Conditioning Regimen: Results From Cancer and Leukemia Group B 100103 (Alliance for Clinical Trials in Oncology)/Blood and Marrow Transplant Clinical Trial Network 0502. J Clin Oncol 2015; 33:4167-75. [PMID: 26527780 DOI: 10.1200/jco.2015.62.7273] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
PURPOSE Long-term survival rates for older patients with newly diagnosed acute myeloid leukemia (AML) are extremely low. Previous observational studies suggest that allogeneic hematopoietic stem-cell transplantation (HSCT) may improve overall survival (OS) because of lower rates of relapse. We sought to prospectively determine the value of HSCT for older patients with AML in first complete remission. PATIENTS AND METHODS We conducted a prospective multicenter phase II study to assess the efficacy of reduced-intensity conditioning HSCT for patients between the ages of 60 and 74 years with AML in first complete remission. The primary end point was disease-free survival at 2 years after HSCT. Secondary end points included nonrelapse mortality (NRM), graft-versus-host disease (GVHD), relapse, and OS. RESULTS In all, 114 patients with a median age of 65 years received transplantations. The majority (52%) received transplantations from unrelated donors and were given antithymocyte globulin for GVHD prophylaxis. Disease-free survival and OS at 2 years after transplantation were 42% (95% CI, 33% to 52%) and 48% (95% CI, 39% to 58%), respectively, for the entire group and 40% (95% CI, 29% to 55%) and 50% (95% CI, 38% to 64%) for the unrelated donor group. NRM at 2 years was 15% (95% CI, 8% to 21%). Grade 2 to 4 acute GVHD occurred in 9.6% (95% CI, 4% to 15%) of patients, and chronic GVHD occurred in 28% (95% CI, 19% to 36%) of patients. The cumulative incidence of relapse at 2 years was 44% (95% CI, 35% to 53%). CONCLUSION Reduced-intensity conditioning HSCT to maintain remission in selected older patients with AML is relatively well tolerated and appears to provide superior outcomes when compared with historical patients treated without HSCT. GVHD and NRM rates were lower than expected. Future transplantation studies in these patients should focus on further reducing the risk of relapse.
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Affiliation(s)
- Steven M Devine
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA.
| | - Kouros Owzar
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - William Blum
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Flora Mulkey
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Richard M Stone
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Jack W Hsu
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Richard E Champlin
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Yi-Bin Chen
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Ravi Vij
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - James Slack
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Robert J Soiffer
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Richard A Larson
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Thomas C Shea
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Vera Hars
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Alexander B Sibley
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Sergio Giralt
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Shelly Carter
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Mary M Horowitz
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Charles Linker
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Edwin P Alyea
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
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