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Grant SJ, Kay S, Lacey J, Kumar S, Kerin-Ayres K, Stehn J, Gonzalez M, Templeton S, Heller G, Cockburn J, Wahlroos S, Malalasekera A, Mak C, Graham S. Feasibility study of a multimodal prehabilitation programme in women receiving neoadjuvant therapy for breast cancer in a major cancer hospital: a protocol. BMJ Open 2024; 14:e080239. [PMID: 38508617 PMCID: PMC10961545 DOI: 10.1136/bmjopen-2023-080239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 02/27/2024] [Indexed: 03/22/2024] Open
Abstract
INTRODUCTION Neoadjuvant therapy has become a standard treatment for patients with stage II/III HER2 positive and triple negative breast cancer, and in well-selected patients with locally advanced and borderline resectable high risk, luminal B breast cancer. Side effects of neoadjuvant therapy, such as fatigue, cardiotoxicity, neurotoxicity, anxiety, insomnia, vasomotor symptoms, gastrointestinal disturbance as well as a raft of immune-related adverse events, may impact treatment tolerance, long-term outcomes, and quality of life. Providing early supportive care prior to surgery (typically termed 'prehabilitation') may mitigate these side effects and improve quality of life.During our codesign of the intervention, consumers and healthcare professionals expressed desire for a programme that 'packaged' care, was easy to access, and was embedded in their care pathway. We hypothesise that a multimodal supportive care programme including exercise and complementary therapies, underpinned by behavioural change theory will improve self-efficacy, quality of life, readiness for surgery and any additional treatment for women with breast cancer. We seek to explore cardiometabolic, residual cancer burden and surgical outcomes, along with chemotherapy completion (relative dose intensity). This article describes the protocol for a feasibility study of a multimodal prehabilitation programme. METHODS AND ANALYSIS This is a prospective, mixed-method, feasibility study of a multi-modal programme in a hospital setting for 20-30 women with breast cancer receiving neoadjuvant therapy. Primary outcomes are recruitment rate, retention rate, adherence and acceptability. Secondary outcomes include patient reported outcome measures (PROMs), surgical outcomes, length of stay, satisfaction with surgery, chemotherapy completion rates, changes in metabolic markers and adverse events. Interviews and focus groups to understand the experience with prehabilitation and different factors that may affect feasibility of the intervention . The output of this study will be a codesigned, evidence-informed intervention assessed for feasibility and acceptability by women with breast cancer and the healthcare professionals that care for them. ETHICS AND DISSEMINATION The study received ethics approval from the St Vincents Hospital HREC (HREC/2021/ETH12198). Trial results will be communicated to participants, healthcare professionals, and the public via publication and conferences. TRIAL REGISTRATION NUMBER ACTRN12622000584730.
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Affiliation(s)
- Suzanne J Grant
- Supportive Care and Integrative Oncology, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
- NICM Health Research Institute, Western Sydney University, Westmead, New South Wales, Australia
| | - Shelley Kay
- Supportive Care and Integrative Oncology, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
| | - Judith Lacey
- Supportive Care and Integrative Oncology, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
- NICM Health Research Institute, Western Sydney University, Westmead, New South Wales, Australia
| | - Sanjeev Kumar
- Medical Oncology Department, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
| | - Kim Kerin-Ayres
- Supportive Care and Integrative Oncology, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
| | - Justine Stehn
- Supportive Care and Integrative Oncology, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
| | - Maria Gonzalez
- Supportive Care and Integrative Oncology, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
- NICM Health Research Institute, Western Sydney University, Westmead, New South Wales, Australia
| | - Sandra Templeton
- Supportive Care and Integrative Oncology, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
| | - Gillian Heller
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Jane Cockburn
- Patient Advocate, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
| | - Sara Wahlroos
- Medical Oncology Department, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
| | - Ashanya Malalasekera
- Supportive Care and Integrative Oncology, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
- School of Medicine, University of Sydney SDN, Sydney, New South Wales, Australia
| | - Cindy Mak
- Surgical Oncology Department, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
| | - Susannah Graham
- Surgical Oncology Department, Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
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Witteman HO, Maki KG, Vaisson G, Finderup J, Lewis KB, Dahl Steffensen K, Beaudoin C, Comeau S, Volk RJ. Systematic Development of Patient Decision Aids: An Update from the IPDAS Collaboration. Med Decis Making 2021; 41:736-754. [PMID: 34148384 DOI: 10.1177/0272989x211014163] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The 2013 update of the evidence informing the quality dimensions behind the International Patient Decision Aid Standards (IPDAS) offered a model process for developers of patient decision aids. OBJECTIVE To summarize and update the evidence used to inform the systematic development of patient decision aids from the IPDAS Collaboration. METHODS To provide further details about design and development methods, we summarized findings from a subgroup (n = 283 patient decision aid projects) in a recent systematic review of user involvement by Vaisson et al. Using a new measure of user-centeredness (UCD-11), we then rated the degree of user-centeredness reported in 66 articles describing patient decision aid development and citing the 2013 IPDAS update on systematic development. We contacted the 66 articles' authors to request their self-reports of UCD-11 items. RESULTS The 283 development processes varied substantially from minimal iteration cycles to more complex processes, with multiple iterations, needs assessments, and extensive involvement of end users. We summarized minimal, medium, and maximal processes from the data. Authors of 54 of 66 articles (82%) provided self-reported UCD-11 ratings. Self-reported scores were significantly higher than reviewer ratings (reviewers: mean [SD] = 6.45 [3.10]; authors: mean [SD] = 9.62 [1.16], P < 0.001). CONCLUSIONS Decision aid developers have embraced principles of user-centered design in the development of patient decision aids while also underreporting aspects of user involvement in publications about their tools. Templates may reduce the need for extensive development, and new approaches for rapid development of aids have been proposed when a more detailed approach is not feasible. We provide empirically derived benchmark processes and a reporting checklist to support developers in more fully describing their development processes.[Box: see text].
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Affiliation(s)
- Holly O Witteman
- Department of Family and Emergency Medicine, Faculty of Medicine, Laval University, Quebec City, Canada.,VITAM Research Centre, Quebec City, Canada.,CHU de Québec Research Centre, Quebec City, Canada
| | - Kristin G Maki
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gratianne Vaisson
- Department of Family and Emergency Medicine, Faculty of Medicine, Laval University, Quebec City, Québec, Canada
| | - Jeanette Finderup
- Research Centre for Patient Involvement & Department of Renal Medicine, Aarhus University & Aarhus University Hospital, Aarhus, Denmark
| | - Krystina B Lewis
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada.,University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Karina Dahl Steffensen
- Center for Shared Decision Making/Department of Oncology, Lillebaelt University Hospital of Southern Denmark, Vejle, Denmark.,Institute of Regional Health Research, Faculty of Health Sciences, Vejle, Denmark
| | - Caroline Beaudoin
- Department of Family and Emergency Medicine, Laval University, Quebec, Canada
| | - Sandrine Comeau
- Department of Family and Emergency Medicine, Laval University, Quebec, Canada
| | - Robert J Volk
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Vromans R, Tenfelde K, Pauws S, van Eenbergen M, Mares-Engelberts I, Velikova G, van de Poll-Franse L, Krahmer E. Assessing the quality and communicative aspects of patient decision aids for early-stage breast cancer treatment: a systematic review. Breast Cancer Res Treat 2019; 178:1-15. [PMID: 31342311 PMCID: PMC6790198 DOI: 10.1007/s10549-019-05351-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 07/05/2019] [Indexed: 12/12/2022]
Abstract
Purpose Decision aids (DAs) support patients in shared decision-making by providing balanced evidence-based treatment information and eliciting patients’ preferences. The purpose of this systematic review was to assess the quality and communicative aspects of DAs for women diagnosed with early-stage breast cancer. Methods Twenty-one currently available patient DAs were identified through both published literature (MEDLINE, Embase, CINAHL, CENTRAL, and PsycINFO) and online sources. The DAs were reviewed for their quality by using the International Patient Decision Aid Standards (IPDAS) checklist, and subsequently assessed to what extent they paid attention to various communicative aspects, including (i) information presentation, (ii) personalization, (iii) interaction, (iv) information control, (v) accessibility, (vi) suitability, and (vii) source of information. Results The quality of the DAs varied substantially, with many failing to comply with all components of the IPDAS criteria (mean IPDAS score = 64%, range 31–92%). Five aids (24%) did not include any probability information, 10 (48%) presented multimodal descriptions of outcome probabilities (combining words, numbers, and visual aids), and only 2 (10%) provided personalized treatment outcomes based on patients and tumor characteristics. About half (12; 57%) used interaction methods for eliciting patients’ preferences, 16 (76%) were too lengthy, and 5 (24%) were not fully accessible. Conclusions In addition to the limited adherence to the IPDAS checklist, our findings suggest that communicative aspects receive even less attention. Future patient DA developments for breast cancer treatment should include communicative aspects that could influence the uptake of DAs in daily clinical practice. Electronic supplementary material The online version of this article (10.1007/s10549-019-05351-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ruben Vromans
- Department of Communication and Cognition, Tilburg University, Warandelaan 2, 5035 AB Tilburg, The Netherlands
| | - Kim Tenfelde
- Department of Communication and Cognition, Tilburg University, Warandelaan 2, 5035 AB Tilburg, The Netherlands
| | - Steffen Pauws
- Department of Communication and Cognition, Tilburg University, Warandelaan 2, 5035 AB Tilburg, The Netherlands
- Chronic Disease Management, Philips Research, Eindhoven, The Netherlands
| | - Mies van Eenbergen
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
| | - Ingeborg Mares-Engelberts
- Department of Medical Ethics and Philosophy of Medicine, Erasmus MC, Rotterdam, The Netherlands
- Department of Surgery, Sint Franciscus Vlietland Group, Rotterdam, The Netherlands
| | - Galina Velikova
- Leeds Institute of Medical Research at St Jame’s, University of Leeds, Leeds, UK
| | - Lonneke van de Poll-Franse
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
- Division of Psychosocial Research & Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands
| | - Emiel Krahmer
- Department of Communication and Cognition, Tilburg University, Warandelaan 2, 5035 AB Tilburg, The Netherlands
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Patient-reported outcomes with neoadjuvant vs adjuvant systemic therapy for operable breast cancer. Breast 2019; 46:25-31. [PMID: 31059987 DOI: 10.1016/j.breast.2019.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 03/19/2019] [Accepted: 04/15/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Neoadjuvant systemic therapy (NAST) is used for large operable or highly proliferative breast cancers. It is not known whether psychological outcomes differ according to the treatment sequence (chemotherapy or surgery first) or tumour response. METHODS This was a planned analysis of a multi-institutional single arm longitudinal study of patients considering NAST for operable breast cancer. Participants completed patient reported outcome questionnaires before and after the decision about NAST, between chemotherapy and surgery, and 12 months after diagnosis. RESULTS Fifty-nine women enrolled. Fourteen of 51 (28%) who received NAST experienced pathological complete response (pCR). Patients who had surgery first (n = 7) had higher baseline anxiety, and a greater decrease in anxiety at 12 months follow up, compared with patients who received NAST (n = 50) (a decrease from baseline of 34 pts vs 17 points; p = 0.033). Distress declined at a similar rate in surgery first and NAST groups. Mean satisfaction with decision score post-decision was significantly lower in the adjuvant group compared with NAST (22 vs 26, p = 0.02). No differences were seen between patients with pCR vs residual cancer in: distress, anxiety, satisfaction with decision, fear of progression, and decision regret. CONCLUSION Most patients in this study proceeded with NAST when their surgeon offered it as an option. This exploratory analysis suggests that patients who chose surgery first tended to be more anxious, and had lower satisfaction with their decision, than those who had NAST. In patients who had NAST, lack of pCR does not appear to correlate with adverse psychological outcomes.
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Chiba T, Hiraoka A, Mikami S, Shinozaki M, Osaki Y, Obu M, Ohki T, Mita N, Ledesma D, Yoshihara N, Beusterien K, Amos K, Bridges JFP, Yokosuka O. Japanese patient preferences regarding intermediate to advanced hepatocellular carcinoma treatments. Patient Prefer Adherence 2019; 13:637-647. [PMID: 31118587 PMCID: PMC6503324 DOI: 10.2147/ppa.s198363] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 04/03/2019] [Indexed: 01/05/2023] Open
Abstract
Purpose: This study aimed to evaluate Japanese patient preferences regarding features of intermediate or advanced (Progressed) hepatocellular carcinoma (HCC) treatments: transarterial chemoembolization (TACE), hepatic arterial infusion chemotherapy (HAIC), and oral anti-cancer therapy. Methods: Patients with HCC, recruited from clinical sites and a patient panel in Japan, completed a cross-sectional web-based survey. Preferences were quantified using best-worst scaling, where patients identified the best and worst among 13 treatment features. Direct elicitation was used to identify preference for TACE, HAIC, or oral therapy, including the likelihood of trying each. Additional items asked for the willingness to try an oral medication that delays progression by six months but has an 8% or 21% risk of severe hand-foot skin reaction (HFSR). Results: The sample (N=119; 29 early stage; 90 Progressed) most preferred "oral medication", "artery branches plugged", and "prevents formation of new blood vessels", and least preferred "risk of liver damage" and "risk of catheter-related complications". Overall, 51%, 40%, and 8% preferred oral therapy, TACE, and HAIC, respectively (p<0.05), and the mean likelihood of trying each were 59%, 52%, and 35%, respectively (p<0.001). Patients with sorafenib or TACE experience most preferred what they had received; however, both groups were equally willing to try the other treatment. Patients preferring oral therapy favored "oral medication" over "artery branches plugged", "surgery is repeated as required when the cancer grows again", and "risk of liver damage", compared to those preferring TACE (p<0.05). Sixty-eight percent would probably try therapy with an 8% risk of severe HFSR, compared to 50% with a 21% risk. Conclusion: Treatment type, mode of action, and risks may drive HCC patient preferences. Such features likely should be incorporated into physician-patient interactions regarding treatment decision-making.
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Affiliation(s)
- Tetsuhiro Chiba
- Department of Gastroenterology and Nephrology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Atsushi Hiraoka
- Gastroenterology Center, Ehime Prefectural Central Hospital, Matsuyama, Ehime Prefecture, Japan
| | - Shigeru Mikami
- Department of Internal Medicine, Kikkoman General Hospital, Noda-shi, Chiba Prefecture, Japan
| | - Masami Shinozaki
- Department of Gastroenterology, Numazu City Hospital, Shizuoka, Japan
| | - Yukio Osaki
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Masamichi Obu
- Department of Gastroenterology, Kimitsu Chuo Hospital, Kisarazu City, Chiba Prefecture, Japan
| | - Takamasa Ohki
- Department of Gastroenterology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Naoyuki Mita
- Market Access, Bayer Yakuhin, Ltd., Tokyo, Japan
| | | | | | - Kathleen Beusterien
- ORS Health, Washington DC, USA
- Correspondence: Kathleen BeusterienKantar Health, 700 Dresher Rd, Horsham, PA19044, USTel +1 484 442 1478Email
| | | | - John FP Bridges
- Department of Biomedical Informatics and Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Osamu Yokosuka
- Japan Community Health care Organization Funabashi Central Hospital, Funabashi, Chiba Prefecture, Japan
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Herrmann A, Boyle F, Butow P, Hall AE, Zdenkowski N. Exploring women's experiences with a decision aid for neoadjuvant systemic therapy for operable breast cancer. Health Sci Rep 2018; 1:e13. [PMID: 30623032 PMCID: PMC6266373 DOI: 10.1002/hsr2.13] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 06/19/2017] [Accepted: 06/30/2017] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Some women with operable breast cancer have a choice between receiving upfront surgery followed by chemotherapy or neoadjuvant systemic therapy (NAST) prior to receiving surgery. While survival outcomes are equivalent for both options, the decision about treatment sequence can be difficult due to its complexity and perceived urgency. A decision aid has been developed to help patients decide on whether to receive NAST. AIMS To explore, qualitatively, women's use and perceived benefit of a decision aid to help with their decision on NAST. METHODS A framework analysis process was conducted on a purposeful sample of 20, one-on-one, semistructured phone interviews with early-stage breast cancer patients eligible for NAST. Participants had recently decided on whether or not to have NAST. RESULTS Patients perceived the decision aid as useful to becoming more informed and involved in making a decision as to whether they receive NAST. They described the information provided in the decision aid as reliable, relevant, sufficient in terms of amount, and tailored to their needs. Reading and rereading the decision aid at home in-between the consultations with their surgeon and their medical oncologist allowed women to better understand their treatment options and easily integrate the decision aid into their care. The decision aid seemed to confirm but not change women's decisions on NAST. CONCLUSION The decision aid appears to help breast cancer patients support their decision about whether to receive NAST. Patients' ability to review the decision aid in-between two consultations seems to be an acceptable and feasible way of integrating the decision aid into patients' care.
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Affiliation(s)
- Anne Herrmann
- Priority Research Centre for Health BehaviourUniversity of Newcastle and Hunter Medical Research InstituteCallaghanAustralia
| | - Frances Boyle
- Patricia Ritchie Centre for Cancer Care and ResearchMater Hospital, North SydneySydneyAustralia
| | - Phyllis Butow
- Centre for Medical Psychology and Evidence‐based Decision‐making, School of PsychologyUniversity of SydneySydneyAustralia
| | - Alix E. Hall
- Priority Research Centre for Health BehaviourUniversity of Newcastle and Hunter Medical Research InstituteCallaghanAustralia
| | - Nicholas Zdenkowski
- Priority Research Centre for Health BehaviourUniversity of Newcastle and Hunter Medical Research InstituteCallaghanAustralia
- Department of Medical OncologyCalvary Mater NewcastleWaratahAustralia
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de Ligt KM, Spronk PER, van Bommel ACM, Vrancken Peeters MTFD, Siesling S, Smorenburg CH. Patients' experiences with decisions on timing of chemotherapy for breast cancer. Breast 2017; 37:99-106. [PMID: 29128583 DOI: 10.1016/j.breast.2017.10.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 10/18/2017] [Accepted: 10/30/2017] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Despite potential advantages, application of chemotherapy in the neo-adjuvant (NAC) instead of adjuvant (AC) setting for breast cancer (BC) patients varies among hospitals. The aim of this study was to gain insight in patients' experiences with decisions on the timing of chemotherapy for stage II and III BC. MATERIALS AND METHODS A 35-item online questionnaire was distributed among female patients (age>18) treated with either NAC or AC for clinical stage II/III invasive BC in 2013-2014 in the Netherlands. Outcome measures were the experienced exchange of information on the possible choice between both options and patients' involvement in the final decision on chemotherapy timing. Chemotherapy treatment experience was measured with the Cancer Therapy Satisfaction Questionnaire (CTSQ). RESULTS Of 805 invited patients, 49% responded (179 NAC, 215 AC). NAC-treated patients were younger and more often treated in teaching/academic hospitals and high-volume hospitals. Information on the possibility of NAC was given to a minority of AC-treated patients (AC, stage II:14%, stage III: 31%). Information on pros and cons of both NAC and AC was rated sufficient in about three fourth of respondents. Respondents not always felt having a choice in the timing of chemotherapy (stage II: 54% NAC vs 36% AC; stage III: 26% NAC, 54% AC). CONCLUSION The need to make a treatment decision on NAC was found to be made explicit in only a small number of adjuvant treated patients, in particular in BC stage II. Less than half of the respondents felt they had a real choice.
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Affiliation(s)
- K M de Ligt
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Godebaldkwartier 419, 3511 DT, Utrecht, The Netherlands; Department of Health Technology and Services Research, MIRA Institute for Biomedical Science and Technical Medicine, University of Twente, Drienerlolaan 5, 7522 NB, Enschede, The Netherlands.
| | - P E R Spronk
- Department of Surgery, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands; Dutch Institute for Clinical Auditing (DICA), Rijnsburgerweg 10, 2333 AA, Leiden, The Netherlands.
| | - A C M van Bommel
- Department of Surgery, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands; Dutch Institute for Clinical Auditing (DICA), Rijnsburgerweg 10, 2333 AA, Leiden, The Netherlands.
| | - M T F D Vrancken Peeters
- Department of Surgery, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
| | - S Siesling
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Godebaldkwartier 419, 3511 DT, Utrecht, The Netherlands; Department of Health Technology and Services Research, MIRA Institute for Biomedical Science and Technical Medicine, University of Twente, Drienerlolaan 5, 7522 NB, Enschede, The Netherlands.
| | - C H Smorenburg
- Department of Medical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
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