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Li M, Elsisi Z, Wong W, Kowal S, Veenstra DL, Garrison LP. Does Real Option Value Influence Oncologists' Treatment Recommendations? A Survey of US Oncologists. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024:S1098-3015(24)02804-3. [PMID: 39127254 DOI: 10.1016/j.jval.2024.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 07/03/2024] [Accepted: 07/31/2024] [Indexed: 08/12/2024]
Abstract
OBJECTIVES Survival benefit from anticancer treatments, even if modest, improves a patient's chances of accessing future innovations, thereby creating real option value. There is no empirical evidence on the impact of potential future innovations on oncologists' treatment recommendations. METHODS We conducted a national online survey of practicing medical and hematological oncologists. We presented a hypothetical metastatic cancer patient with median survival of 6 months under 4 decision-making scenarios with varying expected efficacy and time to arrival of future innovations. We assessed the likelihood of discussing future innovations with their patients and the likelihood that future innovations would influence their current treatment recommendation, as well as factors associated with these 2 outcomes using multivariate logistic regressions. RESULTS A total of 201 oncologists completed the survey. When future innovations were expected to improve survival by 6 months and be available in 6 months, 76% of oncologists were likely or very likely to discuss the innovations with their patients, and 68% reported they would influence their current treatment recommendations. A 1-month increase in the expected survival improvement of future innovation was associated with a 1.17 greater odds (95% CI 1.1-1.25) of reporting likely or very likely to discuss future innovations with their patients, whereas a 1-month increase in the expected time to arrival was associated with a 0.91 lower odds (95% CI 0.88-0.94). CONCLUSIONS Given that potential future innovations seem to influence oncologists' treatments recommendations, evidence to inform clinical guidelines and value assessments should consider data on real option value impacts to support informed treatment decision making.
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Affiliation(s)
- Meng Li
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA.
| | - Zizi Elsisi
- The Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle, WA, USA
| | | | | | - David L Veenstra
- The Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle, WA, USA
| | - Louis P Garrison
- The Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle, WA, USA
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Mitchell AP, Kinlaw AC, Peacock-Hinton S, Dusetzina SB, Winn AN, Sanoff HK, Lund JL. Commercial Versus Medicaid Insurance and Use of High-Priced Anticancer Treatments. Oncologist 2024; 29:527-533. [PMID: 38484395 PMCID: PMC11144993 DOI: 10.1093/oncolo/oyae035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/16/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND Because the markups on cancer drugs vary by payor, providers' financial incentive to use high-price drugs is differential according to each patient's insurance type. We evaluated the association between patient insurer (commercial vs Medicaid) and the use of high-priced cancer treatments. MATERIALS AND METHODS We linked cancer registry, administrative claims, and demographic data for individuals diagnosed with cancer in North Carolina from 2004 to 2011, with either commercial or Medicaid insurance. We selected cancers with multiple FDA-approved, guideline-recommended chemotherapy options and large price differences between treatment options: advanced colorectal, lung, and head and neck cancer. The outcome was a receipt of a higher-priced option, and the exposure was insurer: commercial versus Medicaid. We estimated risk ratios (RRs) for the association between insurer and higher-priced treatment using log-binomial models with inverse probability of exposure weights. RESULTS Of 812 patients, 209 (26%) had Medicaid. The unadjusted risk of receiving higher-priced treatment was 36% (215/603) for commercially insured and 27% (57/209) for Medicaid insured (RR: 1.31, 95% CI: 1.02-1.67). After adjustment for confounders the association was attenuated (RR: 1.15, 95% CI: 0.81-1.65). Exploratory subgroup analysis suggested that commercial insurance was associated with increased receipt of higher-priced treatment among patients treated by non-NCI-designated providers (RR: 1.53, 95% CI: 1.14-2.04). CONCLUSIONS Individuals with Medicaid and commercial insurance received high-priced treatments in similar proportion, after accounting for differences in case mix. However, modification by provider characteristics suggests that insurance type may influence treatment selection for some patient groups. Further work is needed to determine the relationship between insurance status and newer, high-price drugs such as immune-oncology agents.
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Affiliation(s)
- Aaron P Mitchell
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Alan C Kinlaw
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Sharon Peacock-Hinton
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Stacie B Dusetzina
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN, United States
- Vanderbilt-Ingram Cancer Center, Nashville, TN, United States
| | - Aaron N Winn
- University of Illinois at Chicago, Chicago, IL, United States
| | - Hanna K Sanoff
- Department of Hematology/ Oncology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Jennifer L Lund
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Knight TG, Aguiar M, Robinson M, Morse A, Chen T, Bose R, Ai J, Ragon BK, Chojecki AL, Shah NA, Sanikommu SR, Symanowski J, Copelan EA, Grunwald MR. Financial Toxicity Intervention Improves Outcomes in Patients With Hematologic Malignancy. JCO Oncol Pract 2022; 18:e1494-e1504. [DOI: 10.1200/op.22.00056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE: Patients with hematologic malignancies are extremely vulnerable to financial toxicity (FT) because of the high costs of treatment and health care utilization. This pilot study identified patients at high risk because of FT and attempted to improve clinical outcomes with comprehensive intervention. METHODS: All patients who presented to the Levine Cancer Institute's Leukemia Clinic between May 26, 2019, and March 10, 2020, were screened for inclusion by standardized two question previsit survey. Patients screening positive were enrolled in the comprehensive intervention that used nurse navigators, clinical pharmacists, and community pro bono financial planners. Primary outcomes were defined as improvement in mental and physical quality of life in all patients and improvement in overall survival in the high-risk disease group. RESULTS: One hundred seven patients completed comprehensive intervention. Patients experiencing FT had increased rates of noncompliance including to prescription (16.8%) and over-the-counter medications (15.9%). The intervention resulted in statistically significantly higher quality of life when measured by using Patient-Reported Outcomes Measurement Information System physical (12.5 ± 2.2 v 13.7 ± 1.8) and mental health scores (11.4 ± 2.2 v 12.4 ± 2.2; all P < .001). In patients with high-risk disease (as determined by using disease-specific scoring systems), risk of death in those receiving the intervention was 0.44 times the risk of death in those without the intervention after adjusting for race, and treatment with stem-cell transplant, oral chemotherapy, or immunotherapy (95% CI, 0.21 to 0.94; P = .034). CONCLUSION: Screening and intervention on FT for patients with hematologic malignancies is associated with increased quality of life and survival.
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Affiliation(s)
- Thomas G. Knight
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | | | - Myra Robinson
- Department of Cancer Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Allison Morse
- Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Tommy Chen
- Department of Cancer Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Rupali Bose
- Department of Cancer Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Jing Ai
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Brittany K. Ragon
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Aleksander L. Chojecki
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Nilay A. Shah
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Srinivasa R. Sanikommu
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - James Symanowski
- Department of Cancer Biostatistics, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Edward A. Copelan
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Michael R. Grunwald
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, NC
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Cardio-Oncology Care Delivered in the Non-academic Environment. Curr Treat Options Oncol 2022; 23:762-773. [DOI: 10.1007/s11864-022-00978-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2022] [Indexed: 11/29/2022]
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Kumar AJ, Chao CR, Rodday AM, Chang H, Xu L, Evens AM, Parsons SK. Treatment patterns for relapsed and refractory Hodgkin lymphoma in a community oncology setting. Leuk Lymphoma 2021; 63:1119-1126. [PMID: 34886751 DOI: 10.1080/10428194.2021.2012660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
There is little data about treatment practices for relapsed/refractory Hodgkin Lymphoma (HL) in nonacademic settings. We describe sequential treatments and outcomes among HL patients who experienced treatment failure in an integrated community-oncology setting. We performed a retrospective cohort study among patients ≥12 years diagnosed with Stage II-IV HL from 2007 to 2012 at Kaiser Permanente Southern California (KPSC). Of 463 HL patients, 75 (16.1%) experienced treatment failure. Patients with failure received between 1 and 8 salvage therapies; 28% received ≥4 lines of therapy. Fifty-nine of 75 (79%) were initially salvaged with ifosfamide-based therapy, 44 of whom underwent hematopoietic cell transplant. Ultimately, 47% of patients died, with most deaths due to HL. Survival was shorter with increasing age at diagnosis (p = 0.02) and with greater number of lines of therapy (p = 0.02). In a community oncology setting, HL patients received multiple lines of salvage. Despite extensive treatment, nearly half of patients died of HL following relapsed/refractory disease.
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Affiliation(s)
- Anita J Kumar
- Institute for Clinical Research & Health Policy Studies, Tufts Medical Center, Boston, MA, USA.,Division of Hematology/Oncology, Tufts Medical Center, Boston, MA, USA
| | - Chun R Chao
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Angie Mae Rodday
- Institute for Clinical Research & Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Hong Chang
- Institute for Clinical Research & Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Lanfang Xu
- MedHealth Statistical Consulting Inc., Solon, OH, USA
| | - Andrew M Evens
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Susan K Parsons
- Institute for Clinical Research & Health Policy Studies, Tufts Medical Center, Boston, MA, USA.,Division of Hematology/Oncology, Tufts Medical Center, Boston, MA, USA.,Department of Medicine and Pediatrics, Tufts University School of Medicine, Boston, MA, USA
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Mitchell AP, Mishra A, Panageas KS, Lipitz-Snyderman A, Bach PB, Morris MJ. Real-World Use of Bone Modifying Agents in Metastatic Castration-Sensitive Prostate Cancer. J Natl Cancer Inst 2021; 114:419-426. [PMID: 34597380 DOI: 10.1093/jnci/djab196] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 08/10/2021] [Accepted: 09/24/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Bone modifying agent (BMA) therapy is recommended for metastatic castration-resistant prostate cancer (mCRPC) but not metastatic castration-sensitive prostate cancer (mCSPC). BMA treatment in mCSPC may therefore constitute overuse. METHODS In this retrospective cohort study using linked Surveillance, Epidemiology, and End Results-Medicare data, we included patients diagnosed with stage IV prostate adenocarcinoma from 2007-2015, who were age ≥66 years at diagnosis and received androgen deprivation or antiandrogen therapy. We excluded patients who had previously received BMAs or had existing osteoporosis, osteopenia, hypercalcemia, or prior bone fracture. The primary outcome was receipt of BMA (zoledronic acid or denosumab) within 180 days of diagnosis (emergence of CRPC within this time frame is unlikely). Secondary outcome was BMA within 90 days. Exposures of interest included practice location (physician office vs. hospital outpatient) and specialty (medical oncologist vs. urologist) of treating physician. RESULTS Our sample included 2,627 patients, of which 52.9% were treated by medical oncologists and 47.1% by urologists; 77.7% and 22.3% received care in physician office and hospital outpatient locations, respectively. Overall, 23.6% received a BMA within 180 days; 18.4% did within 90 days. BMA therapy was more common among patients treated by oncologists (odds ratio = 8.23, 95% confidence interval = 6.41 to 10.57) and in physician office locations (odds ratio = 1.33, 95% confidence interval = 1.06 to 1.69). Utilization has increased: 17.3% of patients received BMAs from 2007-2009 (17.3% zoledronic acid, 0% denosumab), and 28.1% from 2012-2015 (8.4% zoledronic acid, 20.3% denosumab). CONCLUSIONS Among mCSPC patients who had no evidence of high osteoporotic fracture risk, over one-quarter received BMAs in recent years. This overuse may lead to excess costs and toxicity.
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Affiliation(s)
- Aaron P Mitchell
- Memorial Sloan Kettering Cancer Center, Department of Epidemiology and Biostatistics, New York, NY, USA.,Memorial Sloan Kettering Cancer Center, Department of Medicine, Division of Solid Tumor Oncology, New York, NY, USA
| | - Akriti Mishra
- Memorial Sloan Kettering Cancer Center, Department of Epidemiology and Biostatistics, New York, NY, USA
| | - Katherine S Panageas
- Memorial Sloan Kettering Cancer Center, Department of Epidemiology and Biostatistics, New York, NY, USA
| | - Allison Lipitz-Snyderman
- Memorial Sloan Kettering Cancer Center, Department of Epidemiology and Biostatistics, New York, NY, USA
| | - Peter B Bach
- Memorial Sloan Kettering Cancer Center, Department of Epidemiology and Biostatistics, New York, NY, USA
| | - Michael J Morris
- Memorial Sloan Kettering Cancer Center, Department of Medicine, Division of Solid Tumor Oncology, New York, NY, USA
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Khullar K, Plascak JJ, Parikh RR. Acute lymphoblastic leukemia (ALL) in adults: disparities in treatment intervention based on access to treatment facility. Leuk Lymphoma 2021; 63:170-178. [PMID: 34493143 DOI: 10.1080/10428194.2021.1975187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Adult acute lymphoblastic leukemia (ALL) is associated with poor outcomes. We evaluated differences by facility type in the parameters of 6766 adult ALL patients ≥ 40 years of age diagnosed from 2004 to 2015 in the National Cancer DataBase (NCDB) and survival outcomes using two-sample t-tests or chi-square tests and Cox proportional hazards models. Those treated in academic facilities were younger (mean 58.5 versus 61.7 years, p < 0.001), Black (8.1% versus 5.6%, p < 0.001), had private insurance (50.9% versus 44.0%, p < 0.001), and more likely to receive chemotherapy (93.2% versus 81.4%, p < 0.001), any radiotherapy (14.9% versus 7.3%, p < 0.001), stem cell transplant (9.4% versus 2.5%, p < 0.001), or total body irradiation (TBI) (11.3% versus 4.3%, p < 0.001). Patients treated at an academic facility had a higher hazard of death (p<.05) while those that received any chemotherapy or TBI or CNS radiation had a lower risk of death (all p < 0.05). These parameters should be evaluated in future studies.
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Affiliation(s)
- Karishma Khullar
- Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, New Brunswick, NJ, USA
| | - Jesse J Plascak
- Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Rahul R Parikh
- Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, New Brunswick, NJ, USA
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Navigating Ethical Practices in the Era of High Cost Hematology. Curr Hematol Malig Rep 2020; 15:401-407. [PMID: 33025550 DOI: 10.1007/s11899-020-00599-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE OF REVIEW In this review article, we will highlight ethical issues faced by hematologists due to a growing constellation of expensive diagnostics and therapeutics in hematology. We outline the important issues surrounding this topic including stakeholders, cost considerations, and various ethical challenges surrounding access to care, communication about costs, and individual vs. societal responsibilities. We review available tools to navigate these ethical themes and offer potential solutions. RECENT FINDINGS We identified several gaps in the literature on the topic of ethical issues in hematology treatment and supplement by non-hematological cancer and general medical literature. We propose proactive solutions to address these problems to include cost transparency, utilization of evidence-based decision making tools, application of the four quadrant approach to ethical care, and advanced systems-based practice curriculum for physician trainees.
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Mehta R, Paredes AZ, Tsilimigras DI, Moro A, Sahara K, Farooq A, Dillhoff M, Cloyd JM, Tsung A, Ejaz A, Pawlik TM. Influence of hospital teaching status on the chance to achieve a textbook outcome after hepatopancreatic surgery for cancer among Medicare beneficiaries. Surgery 2020; 168:92-100. [PMID: 32303348 DOI: 10.1016/j.surg.2020.02.024] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 01/13/2020] [Accepted: 02/26/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Assessing composite measures of quality such as textbook outcome may be superior to focusing on individual parameters when evaluating hospital performance. The aim of the current study was to assess the impact of teaching hospital status on the occurrence of a textbook outcome after hepatopancreatic surgery. METHODS The Medicare Inpatient Standard Analytic Files were used to identify patients undergoing hepatopancreatic surgery from 2013 to 2015 for a malignant indication. Stratified and multivariable regression analyses were performed to determine the relationship between teaching hospital status, hospital surgical volume and textbook outcome. RESULTS Among 8,035 Medicare patients (hepatectomy; 41.8%, pancreatectomy; 58.2%), 6,196 (77.1%) patients underwent surgery at a major teaching hospital, whereas 1,839 (22.9%) patients underwent surgery at a minor teaching hospital. Patients undergoing surgery for pancreatic cancer at a major teaching hospital had a greater likelihood of achieving a textbook outcome compared with patients treated at a minor teaching hospital (minor teaching hospital: 456, 40% versus major teaching hospital: 1,606, 45.4%; P = .002). The likelihood of textbook outcome was also greater among patients undergoing hepatopancreatic surgery at high-volume centers (pancreas, low volume: 875, 40.5% versus high volume: 1,187, 47.1% P < .001; liver, low volume: 608, 41.8% versus high volume: 886, 46.6%; P = .005). When examining only major teaching hospitals, patients undergoing a pancreatectomy at a high-volume center had 29% greater odds of achieving a textbook outcome (odds ratio 1.29, 95% confidence interval 1.12-1.49). In contrast, among patients undergoing pancreatic resection at high-volume centers, the odds of achieving a textbook outcome was comparable among major versus minor teaching hospital (odds ratio 1.17, 95% confidence interval 0.89-1.53). CONCLUSION The odds of achieving a textbook outcome after pancreatic and hepatic surgery was greater at major versus minor teaching hospitals; however, this effect was largely mediated by hepatopancreatic procedural volume. Patients and payers should focus on regionalization of pancreatic and liver resection to high-volume centers in an effort to optimize the chances of achieving a textbook outcome.
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Affiliation(s)
- Rittal Mehta
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Amika Moro
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Kota Sahara
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Ayesha Farooq
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Mary Dillhoff
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Allan Tsung
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH.
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