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Fonseca AL, Ahmad R, Amin K, Tripathi M, Abdalla A, Hearld L, Bhatia S, Heslin MJ. Understanding Barriers to Guideline-Concordant Treatment in Foregut Cancer: From Data to Solutions. Ann Surg Oncol 2024; 31:6007-6016. [PMID: 38954093 PMCID: PMC11300473 DOI: 10.1245/s10434-024-15627-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 06/04/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND A large proportion of patients with foregut cancers do not receive guideline-concordant treatment (GCT). This study sought to understand underlying barriers to GCT through a root cause analysis approach. METHODS A single-institution retrospective review of 498 patients with foregut (gastric, pancreatic, and hepatobiliary) adenocarcinoma from 2018 to 2022 was performed. Guideline-concordant treatment was defined based on National Comprehensive Cancer Network guidelines. The Ishikawa cause and effect model was used to establish main contributing factors to non-GCT. RESULTS Overall, 34% did not receive GCT. Root causes of non-GCT included Patient, Physician, Institutional Environment and Broader System-related factors. In decreasing order of frequency, the following contributed to non-GCT: receipt of incomplete therapy (N = 28, 16.5%), deconditioning on chemotherapy (N = 26, 15.3%), delays in care because of patient resource constraints followed by loss to follow-up (N = 19, 11.2%), physician factors (N = 19, 11.2%), no documentation of treatment plan after referral to oncologic expertise (N = 19, 11.2%), loss to follow-up before oncology referral (N = 17, 10%), nonreferral to medical oncologic expertise (N = 16, 9.4%), nonreferral to surgical oncology in patients with resectable disease (N = 15, 8.8%), and complications preventing completion of treatment (N = 11, 6.5%). Non-GCT often was a function of multiple intersecting patient, physician, and institutional factors. CONCLUSIONS A substantial percentage of patients with foregut cancer do not receive GCT. Solutions that may improve receipt of GCT include development of automated systems to improve patient follow-up; institutional prioritization of resources to enhance staffing; financial counseling and assistance programs; and development and integration of structured prehabilitation programs into cancer treatment pathways.
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Affiliation(s)
- Annabelle L Fonseca
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL, USA.
- Institute for Cancer Outcomes and Survivorship, The University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Rida Ahmad
- Department of Surgery, The University of South Alabama, Mobile, AL, USA
| | - Krisha Amin
- Department of Surgery, The University of South Alabama, Mobile, AL, USA
| | - Manish Tripathi
- Kellogg School of Management, Northwestern University, Chicago, IL, USA
| | - Ahmed Abdalla
- Department of Surgery, The University of South Alabama, Mobile, AL, USA
| | - Larry Hearld
- Department of Health Services Administration, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Martin J Heslin
- Department of Surgery, The University of South Alabama, Mobile, AL, USA
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Smeltzer MP, Akinbobola OA, Ray MA, Fehnel C, Saulsberry A, Dortch KR, Pimenta K, Matthews AT, Osarogiagbon RU. Prevalence of Epidermal Growth Factor Receptor and Programmed Death Ligand 1 Testing in a Population-Based Lung Cancer Surgical Resection Cohort from 2018 to 2022. Cancer Epidemiol Biomarkers Prev 2024; 33:1098-1106. [PMID: 38884583 DOI: 10.1158/1055-9965.epi-23-1401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 01/30/2024] [Accepted: 05/16/2024] [Indexed: 06/18/2024] Open
Abstract
BACKGROUND Biomarker-directed therapy requires biomarker testing. We assessed the patterns of epidermal growth factor receptor (EGFR) and programmed death ligand 1 (PDL1) testing in a non-small cell lung cancer (NSCLC) resection cohort. We hypothesized that testing would increase but be unevenly distributed across patient-, provider- and institution-level demographics. METHODS We examined the population-based Mid-South Quality of Surgical Resection (MS-QSR) cohort of NSCLC resections. We evaluated the proportions receiving EGFR and PDL1 testing before and after approval of biomarker-directed adjuvant therapy (2018-2020 vs. 2021-2022). We used association tests and logistic regression to compare factors. RESULTS From 2018 to 2022, 1,687 patients had NSCLC resection across 12 MS-QSR institutions: 1,045 (62%) from 2018 to 2020 and 642 (38%) from 2021 to 2022. From 2018 to 2020, 11% had EGFR testing versus 38% in 2021 to 2022 (56% in those meeting ADAURA trial inclusion criteria, P < 0.0001). From 2018 to 2020, 8% had PDL1 testing versus 20% in 2021 to 2022 (P < 0.0001). EGFR testing did not significantly differ by age (P = 0.07), sex (P = 0.99), race (P = 0.33), or smoking history (P = 0.28); PDL1 testing did not differ significantly by age (P = 0.47), sex (P = 0.41), race (P = 0.51), or health insurance (P = 0.07). Testing was significantly less likely in nonteaching and non-Commission on Cancer-accredited hospitals and after resection by cardiothoracic or general surgeons (vs. general thoracic surgeons; all P < 0.05). CONCLUSIONS EGFR and PDL1 testing increased after approval of biomarker-directed adjuvant therapies. However, testing rates were still suboptimal and differed by institutional- and provider-level factors. IMPACT The association of institutional, pathologist, and surgeon characteristics with differences in testing demonstrate the need for more standardization in testing processes.
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Affiliation(s)
- Matthew P Smeltzer
- Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, Tennessee
| | - Olawale A Akinbobola
- Thoracic Oncology Research Group, Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee
| | - Meredith A Ray
- Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, Tennessee
| | - Carrie Fehnel
- Thoracic Oncology Research Group, Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee
| | - Andrea Saulsberry
- Thoracic Oncology Research Group, Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee
| | - Kourtney R Dortch
- Thoracic Oncology Research Group, Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee
| | - Kelly Pimenta
- Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, Tennessee
| | - Anberitha T Matthews
- Thoracic Oncology Research Group, Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee
| | - Raymond U Osarogiagbon
- Thoracic Oncology Research Group, Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee
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Morabito A, Mercadante E, Muto P, Manzo A, Palumbo G, Sforza V, Montanino A, Sandomenico C, Costanzo R, Esposito G, Totaro G, Cecio RD, Picone C, Porto A, Normanno N, Capasso A, Pinto M, Tracey M, Caropreso G, Pascarella G. Improving the quality of patient care in lung cancer: key factors for successful multidisciplinary team working. EXPLORATION OF TARGETED ANTI-TUMOR THERAPY 2024; 5:260-277. [PMID: 38751383 PMCID: PMC11093720 DOI: 10.37349/etat.2024.00217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 01/08/2024] [Indexed: 05/18/2024] Open
Abstract
International Guidelines as well as Cancer Associations recommend a multidisciplinary approach to lung cancer care. A multidisciplinary team (MDT) can significantly improve treatment decision-making and patient coordination by putting different physicians and other health professionals "in the same room", who collectively decide upon the best possible treatment. However, this is not a panacea for cancer treatment. The impact of multidisciplinary care (MDC) on patient outcomes is not univocal, while the effective functioning of the MDT depends on many factors. This review presents the available MDT literature with an emphasis on the key factors that characterize high-quality patient care in lung cancer. The study was conducted with a bibliographic search using different electronic databases (PubMed Central, Scopus, Google Scholar, and Google) referring to multidisciplinary cancer care settings. Many key elements appear consolidated, while others emerge as prevalent and actual, especially those related to visible barriers which work across geographic, organizational, and disciplinary boundaries. MDTs must be sustained by strategic management, structured within the entity, and cannot be managed as a separate care process. Furthermore, they need to coordinate with other teams (within and outside the organization) and join with the broad range of services delivered by multiple providers at various points of the cancer journey or within the system, with the vision of integrated care.
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Affiliation(s)
- Alessandro Morabito
- Thoracic Medical Oncology, Istituto Nazionale Tumori, IRCCS “Fondazione G. Pascale”, 80131 Naples, Italy
| | - Edoardo Mercadante
- Thoracic Surgery, Istituto Nazionale Tumori, IRCCS “Fondazione G. Pascale”, 80131 Naples, Italy
| | - Paolo Muto
- Radiotherapy, Istituto Nazionale Tumori, IRCCS “Fondazione G. Pascale”, 80131 Naples, Italy
| | - Anna Manzo
- Thoracic Medical Oncology, Istituto Nazionale Tumori, IRCCS “Fondazione G. Pascale”, 80131 Naples, Italy
| | - Giuliano Palumbo
- Thoracic Medical Oncology, Istituto Nazionale Tumori, IRCCS “Fondazione G. Pascale”, 80131 Naples, Italy
| | - Vincenzo Sforza
- Thoracic Medical Oncology, Istituto Nazionale Tumori, IRCCS “Fondazione G. Pascale”, 80131 Naples, Italy
| | - Agnese Montanino
- Thoracic Medical Oncology, Istituto Nazionale Tumori, IRCCS “Fondazione G. Pascale”, 80131 Naples, Italy
| | - Claudia Sandomenico
- Thoracic Medical Oncology, Istituto Nazionale Tumori, IRCCS “Fondazione G. Pascale”, 80131 Naples, Italy
| | - Raffaele Costanzo
- Thoracic Medical Oncology, Istituto Nazionale Tumori, IRCCS “Fondazione G. Pascale”, 80131 Naples, Italy
| | - Giovanna Esposito
- Thoracic Medical Oncology, Istituto Nazionale Tumori, IRCCS “Fondazione G. Pascale”, 80131 Naples, Italy
| | - Giuseppe Totaro
- Radiotherapy, Istituto Nazionale Tumori, IRCCS “Fondazione G. Pascale”, 80131 Naples, Italy
| | - Rossella De Cecio
- Pathology, Istituto Nazionale Tumori, IRCCS “Fondazione G. Pascale”, 80131 Naples, Italy
| | - Carmine Picone
- Radiology, Istituto Nazionale Tumori, IRCCS “Fondazione G. Pascale”, 80131 Naples, Italy
| | - Annamaria Porto
- Radiology, Istituto Nazionale Tumori, IRCCS “Fondazione G. Pascale”, 80131 Naples, Italy
| | - Nicola Normanno
- Cellular Biology and Biotherapy, Istituto Nazionale Tumori, IRCCS “Fondazione G. Pascale”, 80131 Naples, Italy
| | - Arturo Capasso
- WSB Merito University in Wroclaw, Fabryczna 29-31, 53-609 Wroclaw, Poland
| | - Monica Pinto
- Rehabilitative Medicine Unit, Istituto Nazionale Tumori, IRCCS “Fondazione G. Pascale”, 80131 Naples, Italy
| | - Maura Tracey
- Rehabilitative Medicine Unit, Istituto Nazionale Tumori, IRCCS “Fondazione G. Pascale”, 80131 Naples, Italy
| | - Giuseppe Caropreso
- Division of Medical Oncology, Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy
| | - Giacomo Pascarella
- Scientific Directorate, Istituto Nazionale Tumori, IRCCS “Fondazione G. Pascale”, 80131 Naples, Italy
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Huang RS, Mihalache A, Nafees A, Hasan A, Ye XY, Liu Z, Leighl NB, Raman S. The impact of multidisciplinary cancer conferences on overall survival: a meta-analysis. J Natl Cancer Inst 2024; 116:356-369. [PMID: 38123515 DOI: 10.1093/jnci/djad268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/11/2023] [Accepted: 12/16/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Multidisciplinary cancer conferences consist of regular meetings between diverse specialists working together to share clinical decision making in cancer care. The aim of this study was to systematically review and meta-analyze the effect of multidisciplinary cancer conference intervention on the overall survival of patients with cancer. METHODS A systematic literature search was conducted on Ovid MEDLINE, EMBASE, and the Cochrane Controlled Register of Trials for studies published up to July 2023. Studies reporting on the impact of multidisciplinary cancer conferences on patient overall survival were included. A standard random-effects model with the inverse variance-weighted approach was used to estimate the pooled hazard ratio of mortality (multidisciplinary cancer conference vs non-multidisciplinary cancer conference) across studies, and the heterogeneity was assessed by I2. Publication bias was examined using funnel plots and the Egger test. RESULTS A total of 134 287 patients with cancer from 59 studies were included in our analysis, with 48 467 managed by multidisciplinary cancer conferences and 85 820 in the control arm. Across all cancer types, patients managed by multidisciplinary cancer conferences had an increased overall survival compared with control patients (hazard ratio = 0.67, 95% confidence interval = 0.62 to 0.71, I2 = 84%). Median survival time was 30.2 months in the multidisciplinary cancer conference group and 19.0 months in the control group. In subgroup analysis, a positive effect of the multidisciplinary cancer conference intervention on overall survival was found in breast, colorectal, esophageal, hematologic, hepatocellular, lung, pancreatic, and head and neck cancer. CONCLUSIONS Overall, our meta-analysis found a significant positive effect of multidisciplinary cancer conferences compared with controls. Further studies are needed to establish nuanced guidelines when optimizing multidisciplinary cancer conference integration for treating diverse patient populations.
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Affiliation(s)
- Ryan S Huang
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Andrew Mihalache
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Asad Hasan
- University of British Columbia, Vancouver, BC, Canada
| | - Xiang Y Ye
- Department of Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Zhihui Liu
- Department of Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Natasha B Leighl
- Department of Medical Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Srinivas Raman
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
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Liao W, Ray M, Fehnel C, Goss J, Shepherd CJ, Patel A, Qureshi T, Caro F, Roma J, Derrick A, Matthews AT, Faris NR, Smeltzer M, Osarogiagbon RU. Program-Based Lung Cancer Care: A Prospective Observational Tumor Registry Linkage Study. JTO Clin Res Rep 2024; 5:100629. [PMID: 38322712 PMCID: PMC10845058 DOI: 10.1016/j.jtocrr.2023.100629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 12/19/2023] [Accepted: 12/21/2023] [Indexed: 02/08/2024] Open
Abstract
Introduction Low-dose computed tomography screening (LDCT) and lung nodule programs (LNP) promote early lung cancer detection, improve survival; Multidisciplinary Care Programs (MDC) promote guideline-concordant care. The impact of such program-based care on "real-world" lung cancer survival is unquantified. We evaluated outcomes of lung cancer care delivered through structured programs in a community health care system. Methods We conducted a cohort study linking institutional prospective observational LDCT, LNP and MDC databases with Tumor Registry of Baptist Cancer Center facilities. We categorized all patients diagnosed with lung cancer between 2011 and 2021 into program-based care versus non-program-based care cohorts. We compared patient characteristics, stage distribution, treatment modalities, survival and mortality in each pathway of care. Results Of 12,148 patients, 237, 1,165, 1,140 and 9,606 were diagnosed through the LDCT, LNP, MDC or no program, respectively; non-program-based care sequentially diminished from 96.3% to 66.5%, diagnosis through LDCT increased from 0.5% to 7.1%, LNP from 3.5% to 20.8%; and MDC alone decreased from a high of 12.8% in 2014 to 5.6% in 2021. Program-based care was associated with earlier stage (p < 0.001), higher surgical resection rates (p < 0.001), greater use of adjuvant therapy (p < 0.001), better aggregate and stage-stratified survival (p < 0.001), and lower all-cause and lung cancer-specific mortality (p < 0.001). Recipients of non-program-based care were considerably less likely to receive lung cancer treatment; results remained consistent when patients receiving no treatment were excluded. Conclusions Program-based care was associated with substantially better survival. Increasing access to program-based care should be explored as a matter of urgent public policy.
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Affiliation(s)
- Wei Liao
- Thoracic Oncology Research Group, Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee
| | - Meredith Ray
- Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, Tennessee
| | - Carrie Fehnel
- Thoracic Oncology Research Group, Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee
| | - Jordan Goss
- Thoracic Oncology Research Group, Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee
| | - Catherine J Shepherd
- Thoracic Oncology Research Group, Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee
| | - Anita Patel
- Thoracic Oncology Research Group, Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee
| | - Talat Qureshi
- Thoracic Oncology Research Group, Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee
| | - Federico Caro
- Thoracic Oncology Research Group, Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee
| | - Jessica Roma
- Thoracic Oncology Research Group, Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee
| | - Anna Derrick
- Thoracic Oncology Research Group, Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee
| | - Anberitha T Matthews
- Thoracic Oncology Research Group, Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee
| | - Nicholas R Faris
- Thoracic Oncology Research Group, Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee
| | - Matthew Smeltzer
- Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, Tennessee
| | - Raymond U Osarogiagbon
- Thoracic Oncology Research Group, Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee
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Shao H, Faris NR, Ward KD, Chen W, McHugh L, Smeltzer M, Ray MA, Osarogiagbon RU. Lung Cancer Patients' and Caregivers' Satisfaction With Multidisciplinary Versus Serial Care in a Community Healthcare Setting: A Prospective Comparative-Effectiveness Cohort Study. Clin Lung Cancer 2023; 24:e267-e274. [PMID: 37451932 DOI: 10.1016/j.cllc.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 05/25/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Multidisciplinary Care is recommended for complex oncologic conditions. We compared lung cancer patients' and caregivers' satisfaction with Multidisciplinary Care to routine, serial care. MATERIALS AND METHODS We analyzed validated surveys administered at baseline, 3 and 6 months to patients and their caregivers enrolled in a prospective cohort comparative-effectiveness study of Multidisciplinary versus Serial Care (clinicaltrials.gov NCT02123797). Multivariate mixed linear models examined the cross-group differences, time-related variances, and how interaction between groups and time-periods influenced satisfaction. RESULTS Compared to serial care (N = 297), the Multidisciplinary Care cohort (N = 159), was older (69 vs. 66 years), had earlier clinical stage (41% vs. 33% stage I/II), and less severe symptoms (45% vs. 35% asymptomatic). Demographic and social-economic characteristics of caregivers (N = 99 for Multidisciplinary and 123 for Serial Care, respectively) were similar. Multidisciplinary Care patients and caregivers were more likely to perceive their care to be better than that of other patients (p < .01). Although Serial Care patients and caregivers expressed greater satisfaction with their treatment plan (p < .01 patients, p = 0.04 caregivers), Multidisciplinary Care patients showed greater improvement at 6-months (p < .01). Multidisciplinary Care patients and caregivers reported better overall satisfaction with team members (p < .01) while Serial Care patients had greater improvement in their satisfaction with team members at 6-months (p = .04). Multidisciplinary Care patients perceived more financial burden at 6-months compared to Serial Care patients (p = .04). CONCLUSION Patient-caregiver dyads had mixed perceptions of their care experience. Recipients of Multidisciplinary Care perceived better experience with care and team members; Serial Care recipients expressed greater satisfaction with their treatment plan.
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Affiliation(s)
- Huibo Shao
- Thoracic Oncology Research Group, Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, TN, USA
| | - Nicholas R Faris
- Thoracic Oncology Research Group, Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, TN, USA
| | - Kenneth D Ward
- School of Public Health, University of Memphis, Memphis, TN, USA
| | - Weiyu Chen
- School of Public Health, University of Memphis, Memphis, TN, USA
| | - Laura McHugh
- Thoracic Oncology Research Group, Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, TN, USA
| | - Matthew Smeltzer
- School of Public Health, University of Memphis, Memphis, TN, USA
| | - Meredith A Ray
- School of Public Health, University of Memphis, Memphis, TN, USA
| | - Raymond U Osarogiagbon
- Thoracic Oncology Research Group, Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, TN, USA.
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