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Wang C, Shi L. Epidemiological trend of lung cancer burden caused by residential radon exposure in China from 1990 to 2019. Eur J Cancer Prev 2024; 33:232-240. [PMID: 37997905 DOI: 10.1097/cej.0000000000000855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Abstract
OBJECTIVE This study employed time series data to assess long-term changes in the burden of lung cancer (LC) caused by residential radon exposure, an important environmental risk factor, so as to develop evidence-based strategies for future public health management. METHODS Based on the open data from the Global Burden of Disease (GBD 2019) database, we conducted an analysis of the residential radon exposure-caused LC mortality, disability-adjusted life years (DALYs), and corresponding crude rates and age-standardized rates (ASRs) for various age groups. We employed the employed age-period-cohort (APC) model to investigate the age, period, and cohort effects of the data, allowing us to discern the trends in LC disease burden attributable to radon exposure in residential settings over time. RESULTS From 1990 to 2019, age-standardized mortality rates (ASMR) and age-standardized DALYs rates of LC caused by residential radon exposure in China demonstrated an overall increasing trend, with males higher than females. The CMR and crude DALYs rate for males were higher than those for females across all age groups. The APC analysis revealed that the local drift of LC death and DALYs rates in males and females showed a decreasing trend before 60 and an increasing trend after 60. CONCLUSION The persistent presence of residential radon exposure as a crucial risk factor for LC underscores the need for public health authorities and policymakers to take more proactive measures to reduce radon exposure. Particularly, attention should be paid on the elderly population and male patients.
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Affiliation(s)
- Chengzhi Wang
- Department of Oncology and Hematology, The People's Hospital of Tongliang District, Chongqing City, China
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Trojnar A, Knetki-Wróblewska M, Sobieraj P, Domagała-Kulawik J. Lung Cancer in Women-Sociodemographic, Clinical and Psychological Characteristics with Comparison to Men. J Clin Med 2024; 13:1450. [PMID: 38592288 PMCID: PMC10934020 DOI: 10.3390/jcm13051450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 02/25/2024] [Accepted: 02/29/2024] [Indexed: 04/10/2024] Open
Abstract
(1) Background: There is a difference in the course of lung cancer between women and men. Therefore, there is a need to evaluate various factors in the patient population treated in daily practice. The purpose of this study was to analyze the clinical, sociodemographic and psychological aspects of female lung cancer. To better express the results, we compared women and men. (2) Methods: Consecutive patients with a history of lung cancer treatment admitted to the outpatient oncology clinic (Department of Lung Cancer and Chest Tumours, Maria Skłodowska-Curie National Research Institute of Oncology in Warsaw) and the Department of Internal Medicine, Pulmonary Diseases and Allergy, were enrolled. We conducted analyses of the clinical, psychological and socioeconomic factors of women with lung cancer treated in everyday practice, including a comparison with a group of men. Demographic data were collected from a self-administered questionnaire. We used the Perceived Stress Scale (PSS-10) and Acceptance of Illness Scale (AIS) questionnaires for psychological evaluation. (3) Results: A total of 100 patients with confirmed primary lung cancer with a history of treatment were enrolled in the study (50 women and 50 men). We found a significantly shorter history of smoking in the group of women; at the same time, there were no differences in the reported incidence of COPD. Despite comparable results to men on the psychological questionnaire (PSS-10, AIS), women more often reported a willingness to be supported by a psychologist or psychiatrist due to lung cancer. However, they did not decide to consult them more often than men. Immunotherapy was a significantly less frequently used method in women. (4) Conclusions: We should be more active in finding out the willingness to consult a psychologist or psychiatrist among women with lung cancer. The diagnosis of COPD should be considered more often among women due to the lack of differences in the reported incidence of COPD between men and women, despite a clear contrast in the number of pack-years.
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Affiliation(s)
- Anna Trojnar
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Magdalena Knetki-Wróblewska
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, 02-091 Warsaw, Poland;
- Department of Lung Cancer and Chest Tumors, Maria Skłodowska-Curie National Research Institute of Oncology, 02-781 Warsaw, Poland
| | - Piotr Sobieraj
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Joanna Domagała-Kulawik
- Maria Skłodowska-Curie Medical Academy, Institute of Clinical Sciences, 00-136 Warsaw, Poland;
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3
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Viñolas N, Mezquita L, Corral J, Cobo M, Gil-Moncayo F, Paz-Ares L, Remon J, Rodríguez M, Ruano-Raviña A, Conde E, Majem M, Garrido P, Felip E, Isla D, de Castro J. The role of sex and gender in the diagnosis and treatment of lung cancer: the 6th ICAPEM Annual Symposium. Clin Transl Oncol 2024; 26:352-362. [PMID: 37490262 DOI: 10.1007/s12094-023-03262-x] [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: 02/28/2023] [Accepted: 06/20/2023] [Indexed: 07/26/2023]
Abstract
The incidence and mortality of lung cancer in women are rising, with both increasing by 124% between 2003 and 2019. The main risk factor for lung cancer is tobacco use, but indoor radon gas exposure is one of the leading causes in nonsmokers. The most recent evidence demonstrates that multiple factors can make women more susceptible to harm from these risk factors or carcinogens. For this consensus statement, the Association for Lung Cancer Research in Women (ICAPEM) invited a group of lung cancer experts to perform a detailed gender-based analysis of lung cancer. Clinically, female patients have different lung cancer profiles, and most actionable driver alterations are more prevalent in women, particularly in never-smokers. Additionally, the impact of certain therapies seems to be different. In the future, it will be necessary to carry out specific studies to improve the understanding of the role of certain biomarkers and gender in the prognosis and evolution of lung cancer.
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Affiliation(s)
- Nuria Viñolas
- Department of Medical Oncology, Barcelona Clinic Hospital, Translational Genomics and Targeted Therapies in Solid Tumours, IDIBAPS, C. de Villarroel, 170, 08036, Barcelona, Spain.
| | - Laura Mezquita
- Department of Medical Oncology, Barcelona Clinic Hospital, Translational Genomics and Targeted Therapies in Solid Tumours, IDIBAPS, C. de Villarroel, 170, 08036, Barcelona, Spain
| | - Jesús Corral
- Department of Medical Oncology, Jerez de la Frontera University Hospital, Cádiz, Spain
| | - Manuel Cobo
- Department of Medical Oncology, Virgen de la Victoria University Hospital, Málaga, Spain
| | - Francisco Gil-Moncayo
- Department of Psycho-Oncology, Catalan Institute of Oncology-Hospitalet, Barcelona, Spain
| | - Luis Paz-Ares
- Department of Medical Oncology, 12 de Octubre University Hospital, Madrid, Spain
| | - Jordi Remon
- Department of Medical Oncology, HM Nou Delfos Hospital, Barcelona, Spain
| | - María Rodríguez
- Department of Thoracic Surgery, Clínica Universidad de Navarra, Madrid, Spain
| | - Alberto Ruano-Raviña
- Department of Medicine and Public Health, Santiago de Compostela University, Santiago de Compostela, Spain
| | - Esther Conde
- Pathology Department, 12 de Octubre University Hospital, Universidad Complutense de Madrid, Research Institute 12 de Octubre University Hospital (Imas12), CIBERONC, Madrid, Spain
| | - Margarita Majem
- Department of Medical Oncology, Santa Creu y Sant Pau University Hospital, Barcelona, Spain
| | - Pilar Garrido
- Department of Medical Oncology, Ramón y Cajal University Hospital, Madrid, Spain
| | - Enriqueta Felip
- Department of Medical Oncology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Dolores Isla
- Department of Medical Oncology, Lozano Blesa University Clinical Hospital, Saragossa, Spain
| | - Javier de Castro
- Department of Medical Oncology, La Paz University Hospital, Madrid, Spain
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Gee K, Yendamuri S. Lung cancer in females-sex-based differences from males in epidemiology, biology, and outcomes: a narrative review. Transl Lung Cancer Res 2024; 13:163-178. [PMID: 38405003 PMCID: PMC10891406 DOI: 10.21037/tlcr-23-744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/19/2024] [Indexed: 02/27/2024]
Abstract
Background and Objective The role of biological sex is seldom considered in characterizing lung cancer, the deadliest cancer in both the United States and the world. Lung cancer has traditionally been regarded as a male disease; as such, research in female-specific phenomena is frequently conflicting or absent. Currently, disparities in lung cancer incidence are primarily driven by females, especially non-smokers and those of younger age. This narrative review provides insight into sex-specific characteristics of lung cancer, highlighting risk factors, diagnosis patterns, carcinogenesis, and treatment outcomes in females. Methods The PubMed database was searched on July 26, 2023 to identify research published between 2013 and 2023 in English. Sixty-three articles were considered relevant, and their full texts and citations were studied to compile information for this narrative review. Key Content and Findings Exposure-related risk factors, including personal tobacco use, are thought to impact female lung cancer risk more profoundly. However, studies on occupational exposures are underpowered to conclude risk in females. Data characterizing the effect of endogenous and exogenous hormonal exposures on female lung cancer risk remain two-sided. Screening guidelines are tailored to white males, exacerbating sex and race disparities. The effect of biological sex on carcinogenesis and the immune system response to cancer is not fully understood, though the female immune system clearly reacts more aggressively to lung cancer. In early-stage disease, females have greater survival in the perioperative setting and during follow-up of several years, attributed to favorable histopathology and healthier baseline status. Sex-specific response to systemic treatment continues to be optimized as lack of standardization in randomized trials makes interpreting results difficult when aggregated. Conclusions Biological sex plays a critical role in non-small cell lung cancer (NSCLC), though further study is needed to depict the complex web of factors that affect lung cancer risk, development, and outcomes. Female underrepresentation in studies has contributed to this lack of understanding. As these disparities are eliminated, we can move towards more effective treatment for both sexes in this pervasive yet deadly disease.
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Affiliation(s)
- Kaylan Gee
- Department of Thoracic Surgery, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Sai Yendamuri
- Department of Thoracic Surgery, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
- Jacobs School of Medicine and Biomedical Sciences, State University of New York, Buffalo, NY, USA
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Vera R, Juan-Vidal O, Safont-Aguilera MJ, de la Peña FA, Del Alba AG. Sex differences in the diagnosis, treatment and prognosis of cancer: the rationale for an individualised approach. Clin Transl Oncol 2023:10.1007/s12094-023-03112-w. [PMID: 36802013 DOI: 10.1007/s12094-023-03112-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 02/02/2023] [Indexed: 02/21/2023]
Abstract
BACKGROUND Precision medicine in oncology aims to identify the most beneficial interventions based on a patient's individual features and disease. However, disparities exist when providing cancer care to patients based on an individual's sex. OBJECTIVE To discuss how sex differences impact the epidemiology, pathophysiology, clinical manifestations, disease progression, and response to treatment, with a focus on data from Spain. RESULTS Genetic and environmental factors (social or economic inequalities, power imbalances, and discrimination) that contribute to these differences adversely affect cancer patient health outcomes. Increased health professional awareness of sex differences is essential to the success of translational research and clinical oncological care. CONCLUSIONS The Sociedad Española de Oncología Médica created a Task Force group to raise oncologists' awareness and to implement measures to address sex differences in cancer patient management in Spain. This is a necessary and fundamental step towards optimizing precision medicine that will benefit all individuals equally and equitably.
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Affiliation(s)
- Ruth Vera
- Department of Medical Oncology, University Hospital of Navarra, Pamplona. IdiSNA, Navarra's Health Research Institute, Irunlarrea 3, 31190, Pamplona, Spain.
| | - Oscar Juan-Vidal
- Department of Medical Oncology, University Hospital La Fe, Valencia, Spain
| | - María José Safont-Aguilera
- Department of Medical Oncology, University General Hospital of Valencia, Valencia University, Valencia. CIBERONC, Valencia, Spain
| | - Francisco Ayala de la Peña
- Medical Oncology, Department of Haematology and Oncology, University General Hospital Morales Meseguer, Murcia, Spain
| | - Aránzazu González Del Alba
- Genitourinary Tumour Unit, Department of Medical Oncology, University Hospital Puerta de Hierro, Majadahonda, Madrid, Spain
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Candal-Pedreira C, Ruano-Ravina A, Pérez-Ríos M. Is lung cancer in never smokers still an unknown disease? Transl Cancer Res 2022; 11:4223-4227. [PMID: 36644195 PMCID: PMC9834589 DOI: 10.21037/tcr-22-2345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 11/17/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Cristina Candal-Pedreira
- Preventive Medicine and Public Health, University of Santiago de Compostela, Santiago de Compostela, Spain;,Health Research Institute of Santiago de Compostela (IDIS-Instituto de Investigación Sanitaria de Santiago de Compostela), Santiago de Compostela, Spain
| | - Alberto Ruano-Ravina
- Preventive Medicine and Public Health, University of Santiago de Compostela, Santiago de Compostela, Spain;,Health Research Institute of Santiago de Compostela (IDIS-Instituto de Investigación Sanitaria de Santiago de Compostela), Santiago de Compostela, Spain;,Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública/CIBERESP), Madrid, Spain
| | - Mónica Pérez-Ríos
- Preventive Medicine and Public Health, University of Santiago de Compostela, Santiago de Compostela, Spain;,Health Research Institute of Santiago de Compostela (IDIS-Instituto de Investigación Sanitaria de Santiago de Compostela), Santiago de Compostela, Spain;,Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública/CIBERESP), Madrid, Spain
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Debieuvre D, Molinier O, Falchero L, Locher C, Templement-Grangerat D, Meyer N, Morel H, Duval Y, Asselain B, Letierce A, Trédaniel J, Auliac JB, Bylicki O, Moreau L, Fore M, Corre R, Couraud S, Cortot A. Lung cancer trends and tumor characteristic changes over 20 years (2000–2020): Results of three French consecutive nationwide prospective cohorts’ studies. Lancet Reg Health Eur 2022; 22:100492. [PMID: 36108315 PMCID: PMC9445429 DOI: 10.1016/j.lanepe.2022.100492] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background Long-term changes in lung cancer (LC) patients are difficult to evaluate. We report results from the French KBP-2020 real-life cohort. Methods KBP-2020 was a prospective cohort that included all patients diagnosed with LC in 2020, in nonacademic public hospital in France. Patient and tumour characteristics were described and compared with similarly designed cohorts in 2000 and 2010. Findings In 2020, 82 centers included 8,999 patients diagnosed with LC. The proportion of women increased: 34·6% (3114/8999) compared to, 24·3% (1711/7051) and 16·0% (904/5667) in 2010 and 2000 (p<0·0001). The proportion of non-smokers was higher in 2020 (12·6%, 1129/8983) than in previous cohorts (10·9% (762/7008) in 2010; 7·2% (402/5586) in 2000, p<0·0001). In 2020, at diagnosis, 57·6% (4405/7648) of patients had a metastatic/disseminated stage non-small-cell lung cancer (NSCLC) (58·3% (3522/6046) in 2010; 42·6% (1879/4411) in 2000, p<0·0001). Compared with 2000 and 2010 data, early survival improved slightly. In 2020, 3-month mortality of NSCLC varied from 3·0% [2·2 – 3·8] for localized to 9·6% [8·1 – 11·0] for locally advanced to 29·2% [27·8 – 30·6] for metastatic and was 24·8% [22·3 – 27·3] for SCLC. Interpretation To our knowledge KBP cohorts have been the largest, prospective, real-world cohort studies involving LC patients conducted in worldwide. The trend found in our study shows an increase in LC in women and still a large proportion of patients diagnosed at metastatic or disseminated stage. Funding The study was promoted by the French College of General Hospital Pulmonologists with financial support of industrials laboratories.
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Affiliation(s)
- Didier Debieuvre
- Respiratory Medicine Department, Groupe Hospitalier de la Région Mulhouse Sud-Alsace, Hôpital Emile Muller, Mulhouse, France
- Corresponding author at: Service de Pneumologie, GHRMSA, Hôpital Emile Muller, 20 rue du Dr Laënnec, BP 1370, 68070 Mulhouse CEDEX, France.
| | - Olivier Molinier
- Respiratory Medicine Department, Centre Hospitalier Le Mans, Le Mans, France
| | - Lionel Falchero
- Respiratory Medicine Department, L'Hôpital Nord-Ouest, Villefranche-Sur-Saône, France
| | - Chrystèle Locher
- Respiratory Medicine Department, Grand Hôpital de l'Est Francilien (GHEF), Meaux, France
| | | | - Nicolas Meyer
- Biostatistician, Public Health Department, CHU de Strasbourg, GMRC, Strasbourg, France
| | - Hugues Morel
- Respiratory Medicine Department, Centre Hospitalier Régional D'Orléans Hôpital de La Source, Orléans, France
| | - Yannick Duval
- Respiratory Medicine Department, Hôpital de Cannes Simone Veil, Cannes, France
| | - Bernard Asselain
- Methodologist, Groupe Statistique, ARCAGY - GINECO, Paris, France
| | | | - Jean Trédaniel
- Department of Thoracic Oncology, Groupe hospitalier Paris-Saint Joseph, Paris, France
| | - Jean-Bernard Auliac
- Respiratory Medicine Department, Centre Hospitalier Intercommunal Créteil, Créteil, France
| | - Olivier Bylicki
- Respiratory Medicine Department, Hôpital d'Instruction des Armées Sainte-Anne, Toulon, France
| | - Lionel Moreau
- Respiratory Medicine Department, Centre Hospitalier de Colmar, Colmar, France
| | - Mathieu Fore
- Respiratory Medicine Department, Groupe Hospitalier de la Région Mulhouse Sud-Alsace, Hôpital Emile Muller, Mulhouse, France
| | - Romain Corre
- Respiratory Medicine Department, Centre Hospitalier de Cornouaille, Quimper, France
| | - Sébastien Couraud
- Respiratory Medicine Department, Centre Hospitalier de Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Alexis Cortot
- Department of Thoracic Oncology, CHU de Lille, CNRS, Inserm, Institut Pasteur de Lille, UMR9020-U1277-CANTHER, Lille, France
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Banks KC, Sumner ET, Alabaster A, Hsu DS, Quesenberry CP, Sakoda LC, Velotta JB. Sociodemographic and clinical characteristics associated with never-smoking status in patients with lung cancer: findings from a large integrated health system. Transl Cancer Res 2022; 11:3522-3534. [PMID: 36388017 PMCID: PMC9641079 DOI: 10.21037/tcr-22-1438] [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: 05/21/2022] [Accepted: 08/26/2022] [Indexed: 01/17/2023]
Abstract
Background Evidence is limited characterizing sociodemographically diverse patient populations with lung cancer in relation to smoking status. Methods In a cross-sectional analysis of adults diagnosed with lung cancer at ages ≥30 years from 2007-2018 within an integrated healthcare system, overall and sex-specific prevalence of never smoking were estimated according to sociodemographic and clinical characteristics. Adjusted prevalence ratio (aPR) and 95% confidence interval (CI) were also estimated using modified Poisson regression to identify patient characteristics associated with never smoking, overall and by sex. Similar analyses were conducted to explore whether prevalence and association patterns differed between non-Hispanic White and Asian/Pacific Islander patients. Results Among 17,939 patients with lung cancer, 2,780 (15.5%) never smoked and 8,698 (48.5%) had adenocarcinoma. Overall prevalence of never smoking was higher among females than males (21.2% vs. 9.2%, aPR 2.13, 95% CI: 1.98-2.29); Asian/Pacific Islander (aPR 2.85, 95% CI: 2.65-3.07) and Hispanic (aPR 1.72, 95% CI: 1.51-1.95) than non-Hispanic White patients; patients who primarily spoke Spanish (aPR 1.60, 95% CI: 1.32-1.94), any Asian language (aPR 1.20, 95% CI: 1.10-1.30), or other languages (aPR 1.84, 95% CI: 1.27-2.65) than English; patients living in the least vs. most deprived neighborhoods (aPR 1.36, 95% CI: 1.24-1.50); and patients with adenocarcinoma (aPR 2.57, 95% CI: 2.18-3.03), other non-small cell lung cancer (NSCLC) (aPR 2.00, 95% CI: 1.63-2.45), or carcinoid (aPR 3.60, 95% CI: 2.96-4.37) than squamous cell carcinoma tumors. Patterns of never smoking associated with sociodemographic, but not clinical factors, differed by sex. The higher prevalence of never smoking associated with Asian/Pacific Islander race/ethnicity was more evident among females (aPR 3.30, 95% CI: 2.95-3.47) than males (aPR 2.25, 95% CI: 1.92-2.63), whereas the higher prevalence of never smoking associated with living in the least deprived neighborhoods was more evident among males (aPR 1.93, 95% CI: 1.56-2.38) than females (aPR 1.18, 95% CI: 1.06-1.31). Associations between primary language and never-smoking status were found only among females. Overall and sex-specific prevalence and association patterns differed between Asian/Pacific Islander and non-Hispanic white patients. Conclusions Our findings suggest that patterns of never-smoking status associated with sociodemographic and clinical characteristics are different across sex and race/ethnicity among patients with lung cancer. Such data are critical to increasing awareness and expediting diagnosis of this disease.
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Affiliation(s)
- Kian C. Banks
- Department of Thoracic Surgery, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Surgery, UCSF East Bay, Oakland, CA, USA
| | - Eric T. Sumner
- Department of Pulmonology and Critical Care Medicine, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Amy Alabaster
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Diana S. Hsu
- Department of Thoracic Surgery, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Surgery, UCSF East Bay, Oakland, CA, USA
| | | | - Lori C. Sakoda
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| | - Jeffrey B. Velotta
- Department of Thoracic Surgery, Kaiser Permanente Northern California, Oakland, CA, USA
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