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Frank B, Ihorst G, Herget G, Schäfer H, Neubauer J, Calba MA, Textor D, Möller MD, Wenger S, Jung J, Waldschmidt J, Miething C, Rassner M, Greil C, Wäsch R, Engelhardt M. Multidisciplinary tumor board analysis: validation study of a central tool in tumor centers. Ann Hematol 2023; 102:603-611. [PMID: 36464695 PMCID: PMC9734518 DOI: 10.1007/s00277-022-05051-y] [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: 07/19/2022] [Accepted: 11/10/2022] [Indexed: 12/12/2022]
Abstract
The established standard to ensure state-of-the-art cancer treatment is through multidisciplinary tumor boards (TBs), although resource- and time-intensive. In this validation study, the multiple myeloma (MM)-TB was reexamined, aiming to validate our previous (2012-2014) results, now using the TB data from March 2020 to February 2021. We assessed MM-TB protocols, physicians' documentation, patient, disease, remission status, progression-free survival (PFS), and overall survival (OS) as left-truncated survival times. Moreover, TB-adherence, level of evidence according to grade criteria, time requirements, study inclusion rates, and referral satisfaction were determined. Within a 1-year period, 312 discussed patients were documented in 439 TB protocols. Patient and disease characteristics were typical for comprehensive cancer centers. The percentages of patients discussed at initial diagnosis (ID), with disease recurrence or in need of interdisciplinary advice, were 39%, 28%, and 33%, respectively. Reasons for the MM-TB presentation were therapeutic challenges in 80% or staging/ID-defining questions in 20%. The numbers of presentations were mostly one in 73%, two in 20%, and three or more in 7%. The TB adherence rate was 93%. Reasons for non-adherence were related to patients' decisions or challenging inclusion criteria for clinical trials. Additionally, we demonstrate that with the initiation of TBs, that the number of interdisciplinarily discussed patients increased, that TB-questions involve advice on the best treatment, and that levels of compliance and evidence can be as high as ≥ 90%. Advantages of TBs are that they may also improve patients', referrers', and physicians' satisfaction, inclusion into clinical trials, and advance interdisciplinary projects, thereby encouraging cancer specialists to engage in them.
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Affiliation(s)
- Benedikt Frank
- grid.5963.9Department of Internal Medicine I, Focus On Hematology, Oncology and Stem Cell Transplantation, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstraße 53, 79106 Freiburg, Baden-Württemberg Germany
| | - Gabriele Ihorst
- grid.5963.9Clinical Trials Unit, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Georg Herget
- Tumor Center Freiburg, Comprehensive Cancer Center Freiburg (CCCF), Freiburg, Germany ,grid.5963.9Clinic for Orthopedics and Trauma Surgery, Department of Surgery, Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Henning Schäfer
- Tumor Center Freiburg, Comprehensive Cancer Center Freiburg (CCCF), Freiburg, Germany ,grid.5963.9Clinic for Radiotherapeutics, University of Freiburg, Freiburg, Germany
| | - Jakob Neubauer
- Tumor Center Freiburg, Comprehensive Cancer Center Freiburg (CCCF), Freiburg, Germany ,grid.5963.9Department of Radiology, University of Freiburg, Freiburg, Germany
| | - Marc-Antoine Calba
- Tumor Center Freiburg, Comprehensive Cancer Center Freiburg (CCCF), Freiburg, Germany ,grid.5963.9Pathology, University of Freiburg, Freiburg, Germany
| | - Daniel Textor
- Tumor Center Freiburg, Comprehensive Cancer Center Freiburg (CCCF), Freiburg, Germany
| | - Mandy-Deborah Möller
- grid.5963.9Department of Internal Medicine I, Focus On Hematology, Oncology and Stem Cell Transplantation, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstraße 53, 79106 Freiburg, Baden-Württemberg Germany ,Tumor Center Freiburg, Comprehensive Cancer Center Freiburg (CCCF), Freiburg, Germany
| | - Sina Wenger
- grid.5963.9Department of Internal Medicine I, Focus On Hematology, Oncology and Stem Cell Transplantation, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstraße 53, 79106 Freiburg, Baden-Württemberg Germany ,Tumor Center Freiburg, Comprehensive Cancer Center Freiburg (CCCF), Freiburg, Germany
| | - Johannes Jung
- grid.5963.9Department of Internal Medicine I, Focus On Hematology, Oncology and Stem Cell Transplantation, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstraße 53, 79106 Freiburg, Baden-Württemberg Germany ,Tumor Center Freiburg, Comprehensive Cancer Center Freiburg (CCCF), Freiburg, Germany
| | - Johannes Waldschmidt
- grid.5963.9Department of Internal Medicine I, Focus On Hematology, Oncology and Stem Cell Transplantation, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstraße 53, 79106 Freiburg, Baden-Württemberg Germany ,Tumor Center Freiburg, Comprehensive Cancer Center Freiburg (CCCF), Freiburg, Germany
| | - Cornelius Miething
- grid.5963.9Department of Internal Medicine I, Focus On Hematology, Oncology and Stem Cell Transplantation, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstraße 53, 79106 Freiburg, Baden-Württemberg Germany ,Tumor Center Freiburg, Comprehensive Cancer Center Freiburg (CCCF), Freiburg, Germany
| | - Michael Rassner
- grid.5963.9Department of Internal Medicine I, Focus On Hematology, Oncology and Stem Cell Transplantation, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstraße 53, 79106 Freiburg, Baden-Württemberg Germany ,Tumor Center Freiburg, Comprehensive Cancer Center Freiburg (CCCF), Freiburg, Germany
| | - Christine Greil
- grid.5963.9Department of Internal Medicine I, Focus On Hematology, Oncology and Stem Cell Transplantation, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstraße 53, 79106 Freiburg, Baden-Württemberg Germany ,Tumor Center Freiburg, Comprehensive Cancer Center Freiburg (CCCF), Freiburg, Germany
| | - Ralph Wäsch
- grid.5963.9Department of Internal Medicine I, Focus On Hematology, Oncology and Stem Cell Transplantation, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstraße 53, 79106 Freiburg, Baden-Württemberg Germany ,Tumor Center Freiburg, Comprehensive Cancer Center Freiburg (CCCF), Freiburg, Germany
| | - Monika Engelhardt
- Department of Internal Medicine I, Focus On Hematology, Oncology and Stem Cell Transplantation, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstraße 53, 79106, Freiburg, Baden-Württemberg, Germany. .,Tumor Center Freiburg, Comprehensive Cancer Center Freiburg (CCCF), Freiburg, Germany.
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Gengenbach L, Graziani G, Reinhardt H, Rösner A, Braun M, Möller MD, Greil C, Wäsch R, Engelhardt M. Choosing the Right Therapy for Patients with Relapsed/Refractory Multiple Myeloma (RRMM) in Consideration of Patient-, Disease- and Treatment-Related Factors. Cancers (Basel) 2021; 13:4320. [PMID: 34503130 PMCID: PMC8430818 DOI: 10.3390/cancers13174320] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/13/2021] [Accepted: 08/24/2021] [Indexed: 02/02/2023] Open
Abstract
Treatment of relapsed/refractory multiple myeloma (RRMM) is more complex today due to the availability of novel therapeutic options, mostly applied as combination regimens. immunotherapy options have especially increased substantially, likewise the understanding that patient-, disease- and treatment-related factors should be considered at all stages of the disease. RRMM is based on definitions of the international myeloma working group (IMWG) and includes biochemical progression, such as paraprotein increase, or symptomatic relapse with CRAB criteria (hypercalcemia, renal impairment, anemia, bone lesions). When choosing RRMM-treatment, the biochemical markers for progression and severity of the disease, dynamic of disease relapse, type and number of prior therapy lines, including toxicity and underlying health status, need to be considered, and shared decision making should be pursued. Objectively characterizing health status via geriatric assessment (GA) at each multiple myeloma (MM) treatment decision point has been shown to be a better estimate than via age and comorbidities alone. The well-established national comprehensive cancer network, IMWG, European myeloma network and other national treatment algorithms consider these issues. Ideally, GA-based clinical trials should be supported in the future to choose wisely and efficaciously from available intervention and treatment options in often-older MM adults in order to further improve morbidity and mortality.
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Gay F, Günther A, Offidani M, Engelhardt M, Salvini M, Montefusco V, Patriarca F, Aquino S, Pönisch W, Spada S, Schub N, Gentili S, Wäsch R, Corradini P, Straka C, Palumbo A, Einsele H, Boccadoro M, Sonneveld P, Gramatzki M. Carfilzomib, bendamustine, and dexamethasone in patients with advanced multiple myeloma: The EMN09 phase 1/2 study of the European Myeloma Network. Cancer 2021; 127:3413-3421. [PMID: 34181755 DOI: 10.1002/cncr.33647] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 03/22/2021] [Accepted: 04/16/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Combined therapy with carfilzomib, bendamustine, and dexamethasone was evaluated in this multicenter phase 1/2 trial conducted within the European Myeloma Network (EMN09 trial). METHODS Sixty-three patients with relapsed/refractory multiple myeloma who had received ≥2 lines of prior therapy were included. The phase 1 portion of the study determined the maximum tolerated dose of carfilzomib with bendamustine set at 70 mg/m2 on days 1 and 8. After 8 cycles, responding patients received maintenance therapy with carfilzomib and dexamethasone until progression. RESULTS On the basis of the phase 1 results, the recommended phase 2 dose for carfilzomib was 27 mg/m2 twice weekly in weeks 1, 2, and 3. Fifty-two percent of patients achieved a partial response or better, and 32% reached a very good partial response or better. The clinical benefit rate was 93%. After a median follow-up of 21.9 months, the median progression-free survival was 11.6 months, and the median overall survival was 30.4 months. The reported grade ≥3 hematologic adverse events (AEs) were lymphopenia (29%), neutropenia (25%), and thrombocytopenia (22%). The main nonhematologic grade ≥3 AEs were pneumonia, thromboembolic events (10%), cardiac AEs (8%), and hypertension (2%). CONCLUSIONS In heavily pretreated patients who have relapsed/refractory multiple myeloma, combined carfilzomib, bendamustine, and dexamethasone is an effective treatment option administered in the outpatient setting. Infection prophylaxis and attention to patients with cardiovascular predisposition are required.
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Affiliation(s)
- Francesca Gay
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero Universitaria Città della Salute e della Scienza, Torino, Italy
| | - Andreas Günther
- Division of Stem Cell Transplantation and Immunotherapy, University of Kiel, Kiel, Germany
| | - Massimo Offidani
- Hematology Clinic, AOU Ospedali Riuniti di Ancona, Ancona, Italy
| | - Monika Engelhardt
- Department for Hematology and Oncology, University of Freiburg, Faculty of Freiburg, Freiburg, Germany
| | - Marco Salvini
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero Universitaria Città della Salute e della Scienza, Torino, Italy
| | - Vittorio Montefusco
- Hematology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | | | - Sara Aquino
- Ematologia e Centro Trapianti, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Wolfram Pönisch
- Department of Hematology, University of Leipzig, Leipzig, Germany
| | - Stefano Spada
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero Universitaria Città della Salute e della Scienza, Torino, Italy
| | - Natalie Schub
- Division of Stem Cell Transplantation and Immunotherapy, University of Kiel, Kiel, Germany
| | | | - Ralph Wäsch
- Department for Hematology and Oncology, University of Freiburg, Faculty of Freiburg, Freiburg, Germany
| | - Paolo Corradini
- Hematology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Christian Straka
- Department of Hematology and Oncology, Munich Clinic Schwabing, Munich, Germany
| | - Antonio Palumbo
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero Universitaria Città della Salute e della Scienza, Torino, Italy
| | - Hermann Einsele
- Department of Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Mario Boccadoro
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero Universitaria Città della Salute e della Scienza, Torino, Italy
| | - Pieter Sonneveld
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Martin Gramatzki
- Division of Stem Cell Transplantation and Immunotherapy, University of Kiel, Kiel, Germany
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Engelhardt M, Ihorst G, Schumacher M, Rassner M, Gengenbach L, Möller M, Shoumariyeh K, Neubauer J, Farthmann J, Herget G, Wäsch R. Multidisciplinary tumor boards and their analyses: the yin and yang of outcome measures. BMC Cancer 2021; 21:173. [PMID: 33596881 PMCID: PMC7891134 DOI: 10.1186/s12885-021-07878-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 02/04/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The standard to ensure utmost cancer treatment is a prerequisite in national cancer plans for comprehensive cancer centers (CCCs) and ensured through multidisciplinary tumor boards (MTBs). Despite these being compulsory for CCCs, various analyses on MTBs have been performed, since MTBs are resource-intensive. Outcome measures in these prior analyses had been survival (OS), MTB-adherence and -satisfaction, inclusion of patients into clinical trials and better cancer care. MAIN BODY A publication from Freytag et al. performed an analysis in multiple tumor entities and assessed the effect of number of MTBs. By matched-pair analysis, they compared response and OS of patients, whose cases were discussed in MTBs vs. those that were not. The analysis included 454 patients and 66 different tumor types. Only patients with > 3 MTBs showed a significantly better OS than patients with no MTB meeting. Response to treatment, relapse free survival and time to progression were not found to be better, nor was there any difference for a specific tumor entity with vs. without MTB discussions. An in-depth discussion of these results, with respect to the literature (PubMed search: "MTBs AND cancer") and within the author group, including statisticians specialized in data analysis of cancer patients and questions addressed in MTBs, was performed to interpret these findings. We conclude that the results by Freytag et al. are deceiving due to an "immortal time bias" that requires more careful data interpretation. CONCLUSIONS The result of Freytag et al. of a seemingly positive impact of higher number of MTBs needs to be interpreted cautiously: their presumed better OS in patients with > 3 MTB discussions is misleading, due to an immortal time bias. Here patients need to survive long enough to be discussed more often. Therefore, these results should not lead to the conclusion that more MTBs will "automatically" increase cancer patients' OS, rather than that the insightful discussion, at best in MTBs and with statisticians, will generate meaningful advice, that is important for cancer patients.
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Affiliation(s)
- Monika Engelhardt
- University of Freiburg Medical Center, Hematology & Oncology, Faculty of Medicine, Hugstetterstr. 53, 79106, Freiburg, Germany. .,Comprehensive Cancer Center Freiburg (CCCF), Freiburg im Breisgau, Germany.
| | - Gabriele Ihorst
- Comprehensive Cancer Center Freiburg (CCCF), Freiburg im Breisgau, Germany.,Clinical Trials Unit, Faculty of Medicine, Freiburg im Breisgau, Germany
| | - Martin Schumacher
- Comprehensive Cancer Center Freiburg (CCCF), Freiburg im Breisgau, Germany.,Medical Biometry and Statistics (IMBI), University of Freiburg, Faculty of Medicine, Freiburg im Breisgau, Germany
| | - Michael Rassner
- University of Freiburg Medical Center, Hematology & Oncology, Faculty of Medicine, Hugstetterstr. 53, 79106, Freiburg, Germany.,Comprehensive Cancer Center Freiburg (CCCF), Freiburg im Breisgau, Germany
| | - Laura Gengenbach
- University of Freiburg Medical Center, Hematology & Oncology, Faculty of Medicine, Hugstetterstr. 53, 79106, Freiburg, Germany.,Comprehensive Cancer Center Freiburg (CCCF), Freiburg im Breisgau, Germany
| | - Mandy Möller
- University of Freiburg Medical Center, Hematology & Oncology, Faculty of Medicine, Hugstetterstr. 53, 79106, Freiburg, Germany.,Comprehensive Cancer Center Freiburg (CCCF), Freiburg im Breisgau, Germany
| | - Khalid Shoumariyeh
- University of Freiburg Medical Center, Hematology & Oncology, Faculty of Medicine, Hugstetterstr. 53, 79106, Freiburg, Germany.,Comprehensive Cancer Center Freiburg (CCCF), Freiburg im Breisgau, Germany
| | - Jakob Neubauer
- Comprehensive Cancer Center Freiburg (CCCF), Freiburg im Breisgau, Germany.,Department of Radiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Juliane Farthmann
- Comprehensive Cancer Center Freiburg (CCCF), Freiburg im Breisgau, Germany.,Department of Obstetrics and Gynecology, University Medical Center, Faculty of Medicine, Freiburg im Breisgau, Germany
| | - Georg Herget
- Comprehensive Cancer Center Freiburg (CCCF), Freiburg im Breisgau, Germany.,Department of Orthopaedics and Trauma Surgery, Medical Center, University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Ralph Wäsch
- University of Freiburg Medical Center, Hematology & Oncology, Faculty of Medicine, Hugstetterstr. 53, 79106, Freiburg, Germany.,Comprehensive Cancer Center Freiburg (CCCF), Freiburg im Breisgau, Germany
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Herget GW, Wäsch R, Klein L, Schmal H, Terpos E, Engelhardt M. Prevention of bone disease and early detection of impending fractures in multiple myeloma patients can reduce morbidity and mortality: the necessity of interdisciplinary state-of-the-art treatment. Haematologica 2020; 105:859-861. [PMID: 32238466 DOI: 10.3324/haematol.2019.245423] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Georg W Herget
- Department of Orthopaedics and Trauma Surgery, Medical Center, University of Freiburg, Faculty of Medicine, Freiburg, Germany .,Comprehensive Cancer Center Freiburg (CCCF), Medical Center University of Freiburg, Freiburg, Germany
| | - Ralph Wäsch
- Comprehensive Cancer Center Freiburg (CCCF), Medical Center University of Freiburg, Freiburg, Germany.,Department of Medicine I Hematology and Oncology, Medical Center, University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Lukas Klein
- Department of Orthopaedics and Trauma Surgery, Medical Center, University of Freiburg, Faculty of Medicine, Freiburg, Germany.,Comprehensive Cancer Center Freiburg (CCCF), Medical Center University of Freiburg, Freiburg, Germany
| | - Hagen Schmal
- Department of Orthopaedics and Trauma Surgery, Medical Center, University of Freiburg, Faculty of Medicine, Freiburg, Germany.,Comprehensive Cancer Center Freiburg (CCCF), Medical Center University of Freiburg, Freiburg, Germany
| | - Evangelos Terpos
- Department of Clinical Therapeutics, University of Athens School of Medicine, Alexandra General Hospital, Athens, Greece
| | - Monika Engelhardt
- Comprehensive Cancer Center Freiburg (CCCF), Medical Center University of Freiburg, Freiburg, Germany.,Department of Medicine I Hematology and Oncology, Medical Center, University of Freiburg, Faculty of Medicine, Freiburg, Germany
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Graziani G, Herget GW, Ihorst G, Zeissig M, Chaidos A, Auner HW, Duyster J, Wäsch R, Engelhardt M. Time from first symptom onset to the final diagnosis of multiple myeloma (MM) - possible risks and future solutions: retrospective and prospective 'Deutsche Studiengruppe MM' (DSMM) and 'European Myeloma Network' (EMN) analysis .. Leuk Lymphoma 2020; 61:875-886. [PMID: 31779510 DOI: 10.1080/10428194.2019.1695051] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 10/30/2019] [Accepted: 11/06/2019] [Indexed: 01/10/2023]
Abstract
Multiple myeloma (MM) often presents with unspecific symptoms and is challenging to diagnose. We performed this DSMM/EMN-analysis via test-(retro-) and validation (prospective) study to determine the time interval from the onset of first symptoms to the diagnosis of MM. The retrospective and prospective analyses were performed in 101 and 176 patients, respectively. The median time from first symptoms to the MM diagnosis in both cohorts was 4 and 6 months, respectively. Frequencies of MM-related pathologic bone fractures, renal, and infectious complications at diagnosis occurred in 41%, 35%, and 16% of patients, respectively. Our MM-questionnaire determined that 39% of patients were dissatisfied with the diagnostic process. PFS and OS proved insignificantly different with shorter (≤6) and longer (>6 months) latency periods. In conclusion, our in depth studies demonstrate that delays in diagnosis do not decrease PFS or OS, but induce MM-related complications and influence patients' satisfaction with their medical care.
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Affiliation(s)
- Giulia Graziani
- Department of Medicine, Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Georg W Herget
- Department of Orthopedics and Trauma Surgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Comprehensive Cancer Center Freiburg (CCCF), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Gabriele Ihorst
- Clinical Trials Unit, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Mara Zeissig
- Myeloma Research Laboratory, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
- Precision Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, Australia
| | | | - Holger W Auner
- Centre for Hematology, Imperial College London, London, UK
| | - Justus Duyster
- Department of Medicine, Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Comprehensive Cancer Center Freiburg (CCCF), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ralph Wäsch
- Department of Medicine, Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Comprehensive Cancer Center Freiburg (CCCF), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Monika Engelhardt
- Department of Medicine, Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Comprehensive Cancer Center Freiburg (CCCF), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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