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Ciria-Suarez L, Jimenez-Fonseca P, Hernández R, Rogado J, Calderon C. Estimation of Risk of Recurrence and Toxicity Among Oncologists and Patients With Resected Breast Cancer: A Quantitative Study. Front Psychol 2020; 11:540083. [PMID: 33192784 PMCID: PMC7653019 DOI: 10.3389/fpsyg.2020.540083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 10/05/2020] [Indexed: 12/20/2022] Open
Abstract
Shared decision-making regarding adjuvant systemic therapy in breast cancer is based on both properly conveying information about the prognosis of the disease and the benefits and risks of adjuvant treatment, as well as the patient's ability to understand this information. This work proposed to analyze oncologists' and patients' perceptions of the risk of recurrence with and without chemotherapy and toxicity, and the factors influencing said impressions. This was a prospective, cross-sectional, multicenter study that involved 281 breast cancer patients and 23 oncologists. Prognosis (risk of recurrence with and without chemotherapy and risk of severe toxicity with chemotherapy) and shared decision making (SDM) questionnaires were completed by all participants; breast cancer patients also filled out the 18-item Brief Symptom Inventory (BSI-18). Oncologists' prediction of risk of relapse without and with chemotherapy (30.4 and 13.3%) and risk of severe toxicity (9.8%) were more optimistic than those of breast cancer patients (78.6, 29.6, and 61%, respectively). The greater the severity, the higher the risk of relapse according to the oncologists (p = 0.001); not so for the patients. Older physicians and more experienced ones predicted lower risk of relapse with and without chemotherapy and less severe toxicity than younger doctors and those with less experience (p < 0.001). Oncologists' SDM and their prediction of risk of relapsing with chemotherapy correlated negatively with patients' SDM and their prediction of risk of severe toxicity (p < 0.01). There is a positive correlation between psychological distress (BSI-18) and prognosis of risk of recurrence with chemotherapy in breast cancer patients (p < 0.001). These results stress the importance of improving doctor-patient communication in SDM. In breast cancer patients undergoing treatment with curative intent, expectations of being cured would increase and treatment-related anxiety would decrease by enhancing doctor-patient communication to coincide more with respect to risk of relapse and toxicity, thereby enhancing patients' quality of life.
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Affiliation(s)
- Laura Ciria-Suarez
- Department of Clinical Psychology and Psychobiology, Faculty of Psychology, University of Barcelona, Barcelona, Spain
| | - Paula Jimenez-Fonseca
- Department of Medical Oncology, Central University Hospital of Asturias, Oviedo, Spain
| | - Raquel Hernández
- Department of Medical Oncology, Canary University Hospital, Santa Cruz de Tenerife, Spain
| | - Jacobo Rogado
- Department of Medical Oncology, Infanta Leonor University Hospital, Madrid, Spain
| | - Caterina Calderon
- Department of Clinical Psychology and Psychobiology, Faculty of Psychology, University of Barcelona, Barcelona, Spain
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Caputo R, Cianniello D, Giordano A, Piezzo M, Riemma M, Trovò M, Berretta M, De Laurentiis M. Gene Expression Assay in the Management of Early Breast Cancer. Curr Med Chem 2020; 27:2826-2839. [PMID: 31804159 DOI: 10.2174/0929867326666191205163329] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 11/14/2019] [Accepted: 11/22/2019] [Indexed: 01/21/2023]
Abstract
The addition of adjuvant chemotherapy to hormonal therapy is often considered questionable in patients with estrogen receptor-positive early breast cancer. Low risk of disease relapse after endocrine treatment alone and/or a low sensitivity to chemotherapy are reasons behind not all patients benefit from chemotherapy. Most of the patients could be exposed to unnecessary treatment- related adverse events and health care costs when treatment decision-making is based only on classical clinical histological features. Gene expression profile has been developed to refine physician's decision-making process and to tailor personalized treatment to patients. In particular, these tests are designed to spare patients the side effects of unnecessary treatment, and ensure that adjuvant chemotherapy is correctly recommended to patients with early breast cancer. In this review, we will discuss the main diagnostic tests and their potential clinical applications (Oncotype DX, MammaPrint, PAM50/Prosigna, EndoPredict, MapQuant Dx, IHC4, and Theros-Breast Cancer Gene Expression Ratio Assay).
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Affiliation(s)
- Roberta Caputo
- Division of Breast Oncology, Istituto Nazionale Tumori "Fondazione G. Pascale", Napoli, Italy
| | - Daniela Cianniello
- Division of Breast Oncology, Istituto Nazionale Tumori "Fondazione G. Pascale", Napoli, Italy
| | - Antonio Giordano
- Division of Hematology/Oncology, Medical University of South Carolina, Charleston, SC, United States
| | - Michela Piezzo
- Division of Breast Oncology, Istituto Nazionale Tumori "Fondazione G. Pascale", Napoli, Italy
| | - Maria Riemma
- Division of Breast Oncology, Istituto Nazionale Tumori "Fondazione G. Pascale", Napoli, Italy
| | - Marco Trovò
- Division of Radiation Oncology, Centro di Riferimento Oncologico - CRO, Aviano, Italy
| | | | - Michelino De Laurentiis
- Division of Breast Oncology, Istituto Nazionale Tumori "Fondazione G. Pascale", Napoli, Italy
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Ozório GA, de Almeida MMFA, Faria SDO, Cardenas TDC, Waitzberg DL. Appetite Assessment of Hospitalized Cancer Patients in Brazil - A Validation Study. Clinics (Sao Paulo) 2019; 74:e1257. [PMID: 31618322 PMCID: PMC6784611 DOI: 10.6061/clinics/2019/e1257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 07/21/2019] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Appetite loss, a common symptom in cancer patients, contributes to worsened nutritional status. A validated specific tool to assess appetite is clinically useful for diagnosing and identifying symptoms and signs that could be reversed with nutritional and pharmacological therapies. The aim of this study is to produce a Brazilian Portuguese version of the Hill and Blundell visual analog scale (VAS) for appetite and investigate its validity among hospitalized cancer patients. METHODS The original English VAS version was translated into Brazilian Portuguese in full accordance with the guidelines in the literature and adapted to the Brazilian context by conducting interviews and meetings with an expert committee until the final version was reached. Afterwards, the version was validated in hospitalized cancer patients in a cross-sectional study at São Paulo Cancer Institute (ICESP), where the relationships between breakfast intake (rest-ingestion index) and VAS were compared. The Spearman test was used to verify the correlation between the rest-ingestion index and the VAS ratings. RESULTS Sixty-four patients with a mean age of 56.1 (±12.3) years answered the Portuguese VAS version, and their breakfast intake was evaluated. The mean rest-ingestion index was 18.8%. The correlations between the rest-ingestion index (food acceptance) and three questions of the Portuguese visual analog scale version were inverse and significant: first question (ρ -0.3028 p=0.0046), second question (ρ -0.2317 p=0.0319) and third question (ρ -0.3049 p=0.0043). CONCLUSION The "Appetite Assessment Scale of Brazilian Oncology Patients" is a valid instrument to assess appetite in hospitalized cancer patients in Brazil.
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Affiliation(s)
- Gislaine Aparecida Ozório
- Servico de Nutricao e Dietetica, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Maria Manuela Ferreira Alves de Almeida
- Servico de Nutricao e Dietetica, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Sheilla de Oliveira Faria
- Departamento de Medicina Preventiva, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | | | - Dan Linetzky Waitzberg
- Departamento de Gastroenterologia, LIM-35, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, So Paulo, SP, BR
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Gion M, Barioli P, Ponti A, Torri V, Mione R, Dittadi R. How Tumor Markers are used in the Routine Follow-up of Breast and Colorectal Cancer. A Survey of 29 Italian Hospitals. Int J Biol Markers 2018. [DOI: 10.1177/172460089801300302] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The impact of tumor markers on the outcome of several malignancies is still under debate. This relative uncertainty leads to a subjective approach to their use. Monitoring the use of tumor markers is a valuable tool to identify the need for educational policies. We conducted a survey to evaluate how tumor markers are routinely used in the follow-up of patients with breast, colorectal and ovarian carcinoma. The former two malignancies are considered in the present paper. We surveyed 35 Italian hospitals; 29 (83%, accounting for 26,622 hospital beds) filled in and returned the questionnaire. Overall, 467,361 tumor marker requests were scrutinized by the surveyed hospitals. We found a wide variability in the type and number of routinely used markers, the cutoff points chosen, and the clinical decisions taken on the basis of marker results. In addition, we observed a relative lack of communication between clinicians and clinical pathologists in around 50% of the surveyed hospitals. In these cases clinical information was not provided to the laboratory and methodological aspects were not communicated to clinicians. From the findings of the present study we conclude that the cooperation between clinicians and clinical pathologists must improve before guidelines for the use of tumor marker assays can be framed and the compliance with these guidelines can be checked. Request forms for tumor marker assays should therefore be designed to contain clinical information and the quality of filling in request forms with clinical data should be carefully monitored.
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Affiliation(s)
- M. Gion
- Center for the Study of Biological Markers of Malignancy and National Center for the Application of Biotechnologies in Oncology, Regional Hospital of Venezia, Venezia
| | - P. Barioli
- Center for the Study of Biological Markers of Malignancy and National Center for the Application of Biotechnologies in Oncology, Regional Hospital of Venezia, Venezia
| | - A. Ponti
- Epidemiology and Oncology Prevention Center for the Piedmont Region, Epidemiology Unit, Torino
| | - V. Torri
- Mario Negri Institute, Milano - Italy
| | - R. Mione
- Center for the Study of Biological Markers of Malignancy and National Center for the Application of Biotechnologies in Oncology, Regional Hospital of Venezia, Venezia
| | - R. Dittadi
- Center for the Study of Biological Markers of Malignancy and National Center for the Application of Biotechnologies in Oncology, Regional Hospital of Venezia, Venezia
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Extermann M. Cancer in the Elderly: Moving the Needle Toward Evidence-Based Personalized Oncology. Int J Radiat Oncol Biol Phys 2017; 98:718-720. [PMID: 28602406 DOI: 10.1016/j.ijrobp.2016.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 11/02/2016] [Indexed: 11/26/2022]
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Hosseini A, Khoury AL, Esserman LJ. Precision surgery and avoiding over-treatment. Eur J Surg Oncol 2017; 43:938-943. [PMID: 28238520 DOI: 10.1016/j.ejso.2017.02.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 02/04/2017] [Indexed: 10/20/2022] Open
Abstract
Over-diagnosis and over-treatment are consequences of greater awareness about breast cancer, more intensive screening, and the resultant identification of more cases of breast cancer that are low or ultralow risk. This area represents an important opportunity to optimize the delivery of appropriate targeted therapy for breast cancer patients. Despite the evolution of breast cancer care over the last few decades and our ability to tailor treatment to biology, a one-size fits all approach is still prevalent in the local and regional management of and screening for breast cancer, failing to reflect the unique biology and tumor characteristics of each patient. In this review, we explore how we can use new tools to better define tumor biology and also how we can change current clinical practices based on already available data. Every surgeon should be knowledgeable about how to craft personalized breast cancer care in the areas of systemic therapy, adjuvant radiation therapy, management of ductal carcinoma in situ (DCIS), precision surgery, and breast cancer screening.
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Affiliation(s)
- A Hosseini
- University of California, 1600 Divisadero, 2nd Floor Box 1710, San Francisco, CA 94115, USA.
| | - A L Khoury
- University of California, 1600 Divisadero, 2nd Floor Box 1710, San Francisco, CA 94115, USA.
| | - L J Esserman
- University of California, 1600 Divisadero, 2nd Floor Box 1710, San Francisco, CA 94115, USA.
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Yang LH, Tseng HS, Lin C, Chen LS, Chen ST, Kuo SJ, Chen DR. Survival benefit of tamoxifen in estrogen receptor-negative and progesterone receptor-positive low grade breast cancer patients. J Breast Cancer 2012; 15:288-95. [PMID: 23091541 PMCID: PMC3468782 DOI: 10.4048/jbc.2012.15.3.288] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 09/06/2012] [Indexed: 01/21/2023] Open
Abstract
Purpose This study aimed to analyze the efficacy and prognostic significance of adjuvant tamoxifen in breast cancer patients with various hormone receptor statuses. Methods Typically, 1,260 female breast cancer patients were recruited in this study. The correlation between estrogen receptor (ER)/progesterone receptor (PR) phenotypes and clinical characteristics was investigated, and the survival rate was assessed after 5-year follow-up. Results The 5-year overall survival (85%) was better in women under the age of 50 years. Patients with ER+/PR+ tumors had a better 5-year survival rate (94%); those with ER-/PR- tumors experienced the worst outcome (74% survival rate); whereas single-positive cases were in between. In 97 out of 128 patients with ER-/PR+ tumors, tamoxifen was given as adjuvant hormonal therapy, and it increased the survival benefit in the lower grade group in terms of overall survival and disease-free survival (p=0.01 and p=0.03, respectively). Conclusion For high-grade tumors with ER-/PR+, adjuvant tamoxifen therapy may have no survival benefit, whereas for the patients with low-grade ER-/PR+ tumors, adjuvant tamoxifen therapy is highly suggestive.
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Affiliation(s)
- Li-Heng Yang
- Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
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Gill S, Loprinzi C, Kennecke H, Grothey A, Nelson G, Woods R, Speers C, Alberts SR, Bardia A, O'Connell MJ, Sargent DJ. Prognostic web-based models for stage II and III colon cancer: A population and clinical trials-based validation of numeracy and adjuvant! online. Cancer 2011; 117:4155-65. [PMID: 21365628 DOI: 10.1002/cncr.26003] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Revised: 12/25/2010] [Accepted: 01/04/2011] [Indexed: 01/21/2023]
Abstract
BACKGROUND Numeracy and Adjuvant! are 2 web-based calculators that are used widely to estimate the prognosis and potential benefit of adjuvant 5-fluorouracil (5-FU)-based therapy for patients with stage II and III colon cancer. In this study, the authors compared the predicted survival estimates from these models with the actual observed estimates in independent datasets that were derived from a population cohort and from clinical trials. METHODS The population cohort was derived from the British Columbia Colorectal Cancer Outcomes Unit database, which identified referred patients with stage II and III colon cancer from 1995 to 1996 and from 1999 to 2003. Patients who were enrolled in North Central Cancer Trials Group (NCCTG) trials NCCTG 94651 and NCCTG 914653 were included in the trials dataset. Patient and disease data were used to predict 5-year relapse-free and overall survival using both tools. RESULTS In the population-based dataset (N = 2033), Adjuvant! offered more reliable predictions of prognosis for patients who underwent surgery alone, but it had reliability similar to that of Numeracy for predicting the prognosis for patients who received adjuvant 5-FU. Both models tended to overestimate survival for patients with stage II disease who received 5-FU. In the trials dataset of patients who underwent and received 5-FU (N = 1729), Numeracy and Adjuvant! demonstrated similar performance and improved correctness. CONCLUSIONS This independent validation analysis demonstrated that both Numeracy and Adjuvant! had similar predictive performance and acceptable reliability for patients with stage III disease. Survival outcomes of patients with stage II colon cancer who received adjuvant 5-FU were slightly lower than estimated by either model.
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Affiliation(s)
- Sharlene Gill
- Department of Medical Oncology, British Columbia Cancer Agency, Vancouver, British Columbia.
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Francescutti V, Farrokhyar F, Tozer R, Heller B, Lovrics P, Jansz G, Kahnamoui K. Primary tumor and patient characteristics in breast cancer as predictors of adjuvant therapy regimen: a regression model. Cancer Chemother Pharmacol 2010; 68:661-8. [PMID: 21125276 DOI: 10.1007/s00280-010-1532-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2010] [Accepted: 11/15/2010] [Indexed: 01/19/2023]
Abstract
PURPOSE Adjuvant therapy reduces the risk of recurrence of breast cancer. This study was undertaken to determine characteristics guiding choice of adjuvant therapy. METHODS A retrospective review was completed of characteristics of patients with breast cancer (stages I-III) at a regional center from 2004 to 2007. Univariate analysis was used to select factors (P < 0.1) for entry into multivariate stepwise logistic regressions. Odds ratios with 95% confidence intervals were calculated. A P value of <0.05 was significant, and comparisons were two-tailed. RESULTS Model 1 (n = 744) assessed the prescription of any adjuvant regimen (hormonal or chemotherapy). Indicators of choice of any regimen were positive lymph nodes [OR 16.5, CI (6.2, 44.0)], grade [4.0, (2.5, 6.0)], size [3.2, (2.1, 4.6)], PR [0.3, (0.1, 0.6)], and multicentricity [0.2 (0.04, 0.66)]. Model 2 (n = 663) assessed chemotherapy in ER+ patients. Indicators of addition of chemotherapy were stage [8.9 (4.3, 18.6), grade [5.5 (3.1, 9.6)], positive nodes [2.7 (1.1, 6.4)], physician experience [1.1 (1.0, 1.2)], age [0.8 (0.79, 0.86)], and year of treatment [0.8, (0.4, 0.9)]. Model 3 (n = 867) assessed prescription of a more aggressive chemotherapy regimen and indicators were treatment by a breast specialist oncologist [8.6 (1.7, 43.1)], stage [3.6 (2.4, 5.4)], positive nodes [2.6 (1.7, 4.1)], year of treatment [1.5 (1.3, 1.8)], size [1.2 (1.1, 1.4)], age [0.91 (0.89, 0.93)], and PR [0.4 (0.3, 0.6)]. CONCLUSIONS This study verifies known factors for choice of adjuvant therapy, excludes others thought to be important, and quantifies effects at our center. Further studies are required to compare these models where risk stratification is different.
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Bardia A, Loprinzi C, Grothey A, Nelson G, Alberts S, Menon S, Thome S, Gill S, Sargent D. Adjuvant chemotherapy for resected stage II and III colon cancer: comparison of two widely used prognostic calculators. Semin Oncol 2010; 37:39-46. [PMID: 20172363 DOI: 10.1053/j.seminoncol.2009.12.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Two Web-based prognostic calculators (Adjuvant! and Numeracy) are widely used to individualize decisions regarding adjuvant therapy among patients with resected stage II and III colon cancer. However, these tools have not been directly compared. Hypothetical scenarios were formulated for the Numeracy calculator based on all potential combinations of age, lymph nodes status, tumor stage, and grade of tumor. These were then applied to three postsurgical therapy choices: observation, 5-fluorouracil (5-FU), or FOLFOX (5-FU, leucovorin, and oxaliplatin chemotherapy) to obtain the predicted 5-year disease-free survival (DFS) and overall survival (OS). Wilcoxon signed rank tests were used to compare the numerical predictions between the Adjuvant! and Numeracy calculators for each combination. A total of 192 hypothetical patient scenarios were obtained. For these patients, DFS and OS predictions from Adjuvant! were statistically significantly different than Numeracy (P <.05), except for four of 144 categories. While the estimated benefit in DFS and OS for 5-FU compared to surgery obtained from Adjuvant! and Numeracy were similar, the benefit in DFS and OS for FOLFOX over 5-FU, obtained from the Adjuvant! tool was slightly lower than that estimated from Numeracy. Among patients with resected stage II and III colon cancer, the DFS and OS estimates obtained from Numeracy and Adjuvant!, regarding the benefit of 5-FU over surgery, are similar, but the benefits of FOLFOX over 5-FU differ. Validation studies are needed to clarify the discrepancy and to assess the accuracy of these tools for predicting actual patient outcomes.
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Affiliation(s)
- Aditya Bardia
- Department of Oncology, Johns Hopkins University, Baltimore, MD, USA
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Abstract
There is considerable evidence, across different clinical contexts, that treatment decisions are characterized by poor communication, significant knowledge gaps, and a lack of attention to patients' preferences for different health states. Over the past two decades, patient decision aids have been shown to be an effective means to improve the quality of decisions. More recently, the Internet has increased expectations about the impact of information and decision aids on the involvement of patients in decisions. However, there are several challenges to effective dissemination and implementation of decision support interventions, through the Internet or other media. The authors recommend specific policy and research initiatives to facilitate the local and system-level changes necessary to support patients more effectively in making treatment choices. More attention to measurement and policy-level interventions will be required to increase the use of proven tools and to achieve significant improvements in the quality of treatment decisions.
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Siminoff LA, Gordon NH, Silverman P, Budd T, Ravdin PM. A decision aid to assist in adjuvant therapy choices for breast cancer. Psychooncology 2006; 15:1001-13. [PMID: 16511899 DOI: 10.1002/pon.1040] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Decision aids are tools that help patients make specific and deliberative choices among options. This study was a group randomized controlled trial of a novel decision aid to help patients with breast cancer make adjuvant therapy (AT) decisions. METHODS Fourteen oncology practices (n=58 physicians) were randomized to receive the decision aid or a control pamphlet. Complete data were obtained from 405 patient-oncologist pairs. Eligible patients had stage I-III disease and had completed their primary treatment. The decision aid is a simple to use computer program, titled Adjuvant!, that provides estimates of outcome with and without AT. Graphical representations of outcome are shared with patients. Consultations were audiotaped, patients interviewed, and physicians completed a self-administered survey. RESULTS In a multivariable model, the 54 patients (13.3%) who took no AT were more likely to have received the decision aid (p=0.02). A differential effect of the Adjuvant! Decision Guide was noted between node negative and positive patients. It was stated by 86.2% of patients that the decision aid was influential when making their treatment decision. Over 95% of patients reported that the Adjuvant Decision Guide was easy to understand and 75% of physicians believed that it helped them understand their patient's treatment preferences and 81.4% reported the information as useful for themselves. CONCLUSIONS This study showed that a decision aid made a difference in the choice of whether or not to take AT. The decision aid allowed patients and physicians to consider the benefits of AT in an easy to understand format. Treatment decisions were more individualized for patients in the intervention than in the control group. The use of the decision aid was acceptable to both patients and physicians.
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Oestreicher N, Ramsey SD, Linden HM, McCune JS, van't Veer LJ, Burke W, Veenstra DL. Gene expression profiling and breast cancer care: What are the potential benefits and policy implications? Genet Med 2005; 7:380-9. [PMID: 16024969 DOI: 10.1097/01.gim.0000170776.31248.75] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Gene expression profiling has been proposed as an alternative to clinical guidelines to identify high-risk patients for adjuvant chemotherapy. However, the outcomes associated with gene expression profiling are not clear, and guidelines for the appropriate use of genomic technologies have not been established. METHODS We developed a decision analytic model to evaluate the incremental cost and quality-adjusted life years of gene expression profiling versus NIH clinical guidelines in a hypothetical cohort of premenopausal early stage breast cancer patients 44 years of age. We conducted empirical analyses and identified literature-based data to inform the model, and performed probabilistic sensitivity analyses to evaluate uncertainty in the results. We interpreted the implications of our findings for treatment guidelines and policies. RESULTS Use of gene expression profiling resulted in an absolute 5% decrease in the proportion of cases of distant recurrence prevented, 0.21 fewer quality-adjusted life years, and a cost savings of USD 2882. The chosen test cutoff value to identify a tumor as poor prognosis and the cost of adjuvant chemotherapy were the most influential parameters in the analysis, but our findings did not change substantially in sensitivity analyses. Regardless of the test cutoff used to identify a poor prognosis tumor, the gene expression profiling assay studied in our analysis, at its current level of performance, did not attain the threshold sensitivity (95%) necessary to produce equal or greater quality-adjusted life years than NIH guidelines. CONCLUSION Although the use of gene expression profiling in breast cancer care holds great promise, our analysis suggests additional refinement and validation are needed before use in clinical practice.
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Affiliation(s)
- Timothy J Whelan
- Juravinski Cancer Centre, 699 Concession St, Room 3-62, Hamilton, Ontario, L8V 5C2 Canada.
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Gill S, Loprinzi CL, Sargent DJ, Thomé SD, Alberts SR, Haller DG, Benedetti J, Francini G, Shepherd LE, Francois Seitz J, Labianca R, Chen W, Cha SS, Heldebrant MP, Goldberg RM. Pooled analysis of fluorouracil-based adjuvant therapy for stage II and III colon cancer: who benefits and by how much? J Clin Oncol 2004; 22:1797-806. [PMID: 15067028 DOI: 10.1200/jco.2004.09.059] [Citation(s) in RCA: 722] [Impact Index Per Article: 36.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Although it is well-established that fluorouracil- (FU-) based adjuvant therapy improves survival for patients with resected high-risk colon cancer, the magnitude of adjuvant therapy benefit across specific subgroups and for individual patients has been uncertain. PATIENTS AND METHODS Using a pooled data set of 3,302 patients with stage II and III colon cancer from seven randomized trials comparing FU + leucovorin or FU + levamisole to surgery alone, we performed an analysis based on a Cox proportional hazards regression model. Treatment, age, sex, tumor location, T stage, nodal status, and grade were tested for both prognostic and predictive significance. Model derived estimates of 5-year disease-free survival and overall survival (OS) for surgery alone and surgery plus FU-based therapy were calculated for a range of patient subsets. RESULTS Nodal status, T stage, and grade were the only prognostic factors independently significant for both disease-free survival and OS. Age was significant only for OS. In a multivariate analysis, adjuvant therapy showed a beneficial treatment effect across all subsets. Treatment benefits were consistent across sex, location, age, T-stage, and grade. A significant stage by treatment interaction was present, with treatment benefiting stage III patients to a greater degree than stage II patients. CONCLUSION Patients with high-risk resected colon cancer obtain benefit from FU-based therapy across subsets of age, sex, location, T stage, nodal status, and grade. Model estimates of survival stratified by T stage, nodal status, grade, and age are available at http://www.mayoclinic.com/calcs. This information may improve patients' and physicians' understanding of the potential benefits of adjuvant therapy.
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Affiliation(s)
- Sharlene Gill
- Mayo Clinic and Foundation, Rochester, MN 55905, USA
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Kaufman CS, Jacobson-Kaufman L, Thorndike-Christ T, Kaufman L, Tabár L. A treatment scale for axillary management in breast cancer. Am J Surg 2001; 182:377-83. [PMID: 11720675 DOI: 10.1016/s0002-9610(01)00741-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND We have investigated a method, the Kaufman axillary treatment scale (KATS), to help assign patients with a clinically negative axilla to one of three current options of axillary management: standard axillary dissection, sentinel node sampling followed by axillary dissection if the sentinel node is positive, or no axillary surgery at all. The KATS score uses preoperative data to guide the choice of axillary treatment. METHODS The KATS score is calculated by adding the preoperative values of tumor size, patient age, and pathologic grade. Values range from 1 to 4 for size (1 to 9 mm, 10 to 14 mm, 15 to 19 mm, and 20 to 30 mm), 1 to 3 for age (70 years and over, 50 to 69 years, less than 50 years), and 1 to 2 for grade (low or not low) to calculate the score. The KATS score ranges from 3 to 9. We have applied this score against the SEER (Surveillance, Epidemiology, and End Results) tumor registry of 529 patients with invasive breast cancer with known pathologic data. We then validated it by applying it to our own set of 190 patients using preoperative data. The chi-square test and logistic regression analysis were used for P values (all two sided), univariate and multivariate analysis, odds ratio and confidence intervals utilizing SPSS statistics software. RESULTS In the SEER database using American Joint Committee on Cancer pathologic size alone, no sizable group was identified with a positive node rate neither below 8% (T1a) nor above 48% (T2). KATS scores of 3 and 4 (68 patients, group 1) identify patients with an average node positive rate of 4.4% (P <0.02, group 1 versus 2). Those patients with KATS scores of 5, 6, and 7 (341 patients, group 2) carry an average node positive rate of 22% (P <0.001, group 2 versus 3). KATS scores of 8 and 9 (120 patients, group 3) identify patients with an average node positive rate of 50% (P <0.001, group 3 versus 1). Similar results were found on our own group of 190 patients using preoperative available data. KATS scores of 3 or 4 (11 patients, group 1) had no positive nodes. Group 2 (100 patients, KATS score 5, 6, and 7) had an average 30% node positive rate. Group 3 (79 patients, KATS score 8 and 9) had 61% node positive rate. The KATS score allows the clinician to separate patients into three axillary management groups. Group 1 are those patients who may need no axillary surgery at all. Group 2 are patients who would benefit from sentinel node mapping. Group 3 has a node positive rate (61%) similar to that of clinically palpable nodes (since not all clinically palpable nodes are positive). Group 3 patients may be considered for standard axillary dissection, similar to the palpable node patient. If group 3 patients have sentinel node mapping, more than half of these patients require axillary dissection and the impact of false negative sentinel node procedures may become clinically significant. CONCLUSIONS An axillary treatment score has been developed to aid in the triage of patients toward reasonable axillary treatment choices for the benefit of the patient. The KATS score is a guideline and not a mandate. The KATS score attempts to use breakpoints that are both clinically practical and validated by scientific data. Like many other attempts to categorize patients, there is a continuum of data points along any variable. The treating physician utilizing the full array of available data on each patient makes the final clinical decision of axillary management.
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Affiliation(s)
- C S Kaufman
- Bellingham Breast Center, 2940 Squalicum Parkway, Bellingham, WA 98225, USA.
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Sleeper AM. Assessing adjuvant breast cancer therapy benefit. J Clin Oncol 2001; 19:3157-8; author reply 3158-9. [PMID: 11408515 DOI: 10.1200/jco.2001.19.12.3157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Loprinzi CL, Thomé SD. Understanding the utility of adjuvant systemic therapy for primary breast cancer. J Clin Oncol 2001; 19:972-9. [PMID: 11181659 DOI: 10.1200/jco.2001.19.4.972] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Physicians and patients require quantitative information on the expected benefits of adjuvant therapy for primary breast cancer to make appropriate treatment decisions. To date, there has not been any widely available method for estimating the benefits from adjuvant systemic therapy, in terms of long-term disease-free survival probabilities, in patients with primary breast cancer. METHODS Baseline prognostic information for primary breast cancer patients was estimated by asking 11 breast cancer specialists to complete a questionnaire on baseline prognosis and then using mean values. Data on the relative benefits of adjuvant therapy were culled from systematic reviews and randomized controlled trials. A computer algorithm was developed to calculate 10-year absolute outcome data. Results from this evaluation were compared with a previously described actuarial algorithm. RESULTS Individual prognostic estimates varied within a group of breast cancer specialists, but mean values of their estimates closely followed published data. Translation of expected benefits of adjuvant therapy from relative to absolute terms was performed with a simple computer algorithm. The data were translated into tabular forms to facilitate user-friendly clinical use. CONCLUSION The provided data should facilitate a better understanding of the absolute magnitude of benefit for available systemic adjuvant therapies in individual women with primary breast cancer. This should allow patients to make more informed decisions about their options.
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Affiliation(s)
- C L Loprinzi
- Division of Medical Oncology, Mayo Clinic, Rochester, MN 55905, USA.
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Ravdin PM, Siminoff LA, Davis GJ, Mercer MB, Hewlett J, Gerson N, Parker HL. Computer program to assist in making decisions about adjuvant therapy for women with early breast cancer. J Clin Oncol 2001; 19:980-91. [PMID: 11181660 DOI: 10.1200/jco.2001.19.4.980] [Citation(s) in RCA: 749] [Impact Index Per Article: 32.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The goal of the computer program Adjuvant! is to allow health professionals and their patients with early breast cancer to make more informed decisions about adjuvant therapy. METHODS Actuarial analysis was used to project outcomes of patients with and without adjuvant therapy based on estimates of prognosis largely derived from Surveillance, Epidemiology, and End-Results data and estimates of the efficacy of adjuvant therapy based on the 1998 overviews of randomized trials of adjuvant therapy. These estimates can be refined using the Prognostic Factor Impact Calculator, which uses a Bayesian method to make adjustments based on relative risks conferred and prevalence of positive test results. RESULTS From the entries of patient information (age, menopausal status, comorbidity estimate) and tumor staging and characteristics (tumor size, number of positive axillary nodes, estrogen receptor status), baseline prognostic estimates are made. Estimates for the efficacy of endocrine therapy (5 years of tamoxifen) and of polychemotherapy (cyclophosphamide/methotrexate/fluorouracil-like regimens, or anthracycline-based therapy, or therapy based on both an anthracycline and a taxane) can then be used to project outcomes presented in both numerical and graphical formats. Outcomes for overall survival and disease-free survival and the improvement seen in clinical trials, are reasonably modeled by Adjuvant!, although an ideal validation for all patient subsets with all treatment options is not possible. Additional speculative estimates of years of remaining life expectancy and long-term survival curves can also be produced. Help files supply general information about breast cancer. The program's Internet links supply national treatment guidelines, cooperative group trial options, and other related information. CONCLUSION The computer program Adjuvant! can play practical and educational roles in clinical settings.
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Affiliation(s)
- P M Ravdin
- Division of Oncology, University of Texas Health Sciences Center, San Antonio, TX 78284, USA.
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Abstract
BACKGROUND The results of the Italian part of an international survey on therapeutic preferences and opinions about prognosis of patients affected by non-small-cell lung cancer (NSCLC) are shown. PATIENTS AND METHODS The investigation was conducted by the means of a postal questionnaire aiming to gather information on preferences about treatment and beliefs about survival of three hypothetical patients affected by NSCLC in different stages (T2N1M0, T2N3M0, M1); three sources of Italian physicians potentially treating patients affected by NSCLC were the target population: participants in the Adjuvant Lung Project Italy (Alpi) trial, a 20% random sample of the Italian Medical Oncology Association (AIOM) and representatives of almost all the pneumology wards in Italy. RESULTS Overall, there were 287 evaluable responses, 89% of respondents were males, mean age was 46 years, years from graduation 21 and charge of patients per clinician 82. The most important result is the wide variation of answers both about therapy and prognosis. Expectations about size of prognosis improvement with a new chemotherapy seem to be excessive. CONCLUSIONS The results are discussed in relation to the twin surveys of Canada and England and Wales and to the meta-analyses on the efficacy of chemotherapy as an adjunct to primary treatment and on postoperative radiotherapy in non-small-cell lung cancer.
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Affiliation(s)
- A Alexanian
- Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
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Sauerbrei W, Hübner K, Schmoor C, Schumacher M. Validation of existing and development of new prognostic classification schemes in node negative breast cancer. German Breast Cancer Study Group. Breast Cancer Res Treat 1997; 42:149-63. [PMID: 9138604 DOI: 10.1023/a:1005733404976] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Several prognostic classification schemes in node negative breast cancer are proposed, but only the Nottingham Prognostic Index (NPI) seems to be sufficiently validated. Validation, which is a prerequisite for a sensible assessment, is not published for two recent proposals according to Glick et al. [1] and Rubens [2]. The German Breast Cancer Study Group (GBSG) entered 662 eligible patients in a prospective observational study. 603 of them had complete data for seven 'standard' prognostic factors and median follow-up is about 5 years. As there is no accepted and informative measure of separation for classification schemes presently available, we propose a new one and use it additionally to the well known logrank-test and Kaplan-Meier estimates to investigate the predictive power of the three schemes. significant differences in survival and recurrence-free survival could be established for the NPI subgroups but not for others where even the ordering of the groups was different. With the Cox model and the classification and regression tree approach we develop two new proposals for the differentiation of subgroups of node negative patients. As in the NPI, tumor size and grade are the most important factors, but with a different weighting scheme. Young age (< or = 40 years) and very high estrogen receptor values (> 300 fmol) in a small subgroup of patients were associated with worse prognosis. The new proposals showed a better degree of separation, which demonstrates that an improvement seems possible using standard factors. Because the measures of separation give an overoptimistic impression for the new proposals, a validation with other studies is necessary before a general recommendation can be given.
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Affiliation(s)
- W Sauerbrei
- Institute of Medical Biometry and Informatics, University of Freiburg, Germany.
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Xing WR, Gilchrist KW, Harris CP, Samson W, Meisner LF. FISH detection of HER-2/neu oncogene amplification in early onset breast cancer. Breast Cancer Res Treat 1996; 39:203-12. [PMID: 8872329 DOI: 10.1007/bf01806187] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
HER-2/neu (c-erbB-2) gene amplification based on Southern blotting or immunohistochemistry has been shown to be predictive of poor outcome in breast cancer occurring in women over 40, but there is little data on the role of HER-2/neu in young women with breast cancer, many of whom may have inherited BRCA1 or other predisposing genes. The present study used fluorescent in situ hybridization (FISH) on archival specimens of breast cancer from 37 women under the age of 40 to evaluate the role of HER-2/neu amplification in this cohort, and to also evaluate the efficacy of FISH for quantifying amplification. The frequency of primary tumors with a greater than fourfold increase in gene copy number was found to be 38%, which is similar to the frequency of amplification reported in Southern blot studies in older women. However, the greater sensitivity of FISH enabled detection of low level amplification (more than 2 but less than 8 gene copies), which was found in an additional 30% of the tumors. Patients with low level amplification demonstrated a 54% recurrence rate, compared to 86% in those with high amplification and 17% in those with no amplification. HER-2/neu amplification appeared to be more prognostic of recurrence than nodal status, with 45% of node negative tumors recurring compared to 62% of those which were node positive, nor was tumor size predictive of recurrence in this cohort since tumors of 2 cm or less recurred in 44% of cases compared to 57% of those larger than 2 cm. Thus, this study demonstrates that FISH is a reproducible and sensitive technique for detecting HER-2/neu amplification, and that amplification of the oncogene is the strongest independent indicator of recurrence of breast cancer in young women.
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Affiliation(s)
- W R Xing
- National Evaluation Centre for the Toxicology of Fertility Regulating Drugs, Shanghai, China
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Abstract
Rapidly growing knowledge about the nature and behaviour of breast cancer has led to many treatment modalities. Consequently, the possibilities of individualizing the treatment of breast cancer increase. The major tool for the determination of an optimal treatment plan is the estimation of the extent of the disease: in other words, staging. As a consequence, together with the expected result of the treatment, the stage of the disease gives information on the prognosis of the patient. Current staging systems insufficiently describe the clinically important features of breast cancer with respect to management and outcome: local and regional extent, invasiveness, aggressiveness, the state of dissemination, and the effectiveness of different treatment modalities. For staging of the local and regional extent, histology plays a prominent role and should be incorporated in future staging systems. Histological workup therefore needs standardisation. Histological parameters as tumour size, grade, nodal status, and vascular invasion are also the most important prognostic factors. Many so-called biological prognostic factors are related to the invasiveness and aggressiveness (metastatic potential) of the tumour, and therefore to the prognosis of the patient. However, these factors do not necessarily predict the effectiveness of certain systemic treatments. Only if the biological foundation of a prognostic factor is completely clarified can treatment be based on this knowledge, and the factor will become a predictor for the treatment effect. Many "biological" prognostic factors do not fulfil this main criterion and are therefore not useful for clinical decision making. A clinically useful staging system covers three primary aims: (1) to guide locoregional treatment, (2) to prognosticate the chance of survival, and (3) to indicate who needs what kind of adjuvant treatment. For the conception of a new staging system the following steps should be taken: standardization of all aspects of histology, identification of regional nodal involvement, and validation of prognostic factors with respect to their predictive value to treatment outcome.
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Abstract
BACKGROUND Survival rates calculated from the date of diagnosis may not be predictive of future outcome for patients who have already survived several years after diagnosis. Conditional survival rates are more informative clinically because they take into account survival after diagnosis. METHODS Conditional relative survival rates were calculated by the life-table method using data from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute. RESULTS Survival rates up to 8 years for patients having survived 1, 2, 3, 4 or 5 years after diagnosis are presented by stage of disease for 56,268 women who were diagnosed as having invasive breast cancer from 1983 to 1987. CONCLUSIONS Women with Stage IV breast cancer had a better survival as they moved further in time from their diagnosis. Survival rates did not improve for those with Stage I and II disease regardless of the number of years they survived after diagnosis.
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Affiliation(s)
- D E Henson
- Division of Cancer Prevention and Control, National Cancer Institute, Bethesda, Maryland 20892, USA
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Lowenthal EA, Carpenter JT. The use of anthracyclines in the adjuvant treatment of breast cancer. Cancer Treat Rev 1995; 21:199-214. [PMID: 7656265 DOI: 10.1016/0305-7372(95)90001-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- E A Lowenthal
- Division of Hematology and Oncology, University of Alabama at Birmingham 35294, USA
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