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Song L, Irajizad E, Rundle A, Sesso HD, Gaziano JM, Vykoukal JV, Do KA, Dennison JB, Ostrin EJ, Fahrmann JF, Perera F, Hanash S. Validation of a Blood-Based Protein Biomarker Panel for a Risk Assessment of Lethal Lung Cancer in the Physicians' Health Study. Cancers (Basel) 2024; 16:2070. [PMID: 38893188 PMCID: PMC11171146 DOI: 10.3390/cancers16112070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 05/16/2024] [Accepted: 05/25/2024] [Indexed: 06/21/2024] Open
Abstract
This study aimed to assess a four-marker protein panel (4MP)'s performance, including the precursor form of surfactant protein B, cancer antigen 125, carcinoembryonic antigen, and cytokeratin-19, for predicting lung cancer in a cohort enriched with never- and ever-smokers. Blinded pre-diagnostic plasma samples collected within 2 years prior to a lung cancer diagnosis from 25 cases and 100 sex-, age-, and smoking-matched controls were obtained from the Physicians' Health Study (PHS). The 4MP yielded AUC performance estimates of 0.76 (95% CI: 0.61-0.92) and 0.69 (95% CI: 0.56-0.82) for predicting lung cancer within one year and within two years of diagnosis, respectively. When stratifying into ever-smokers and never-smokers, the 4MP had respective AUCs of 0.77 (95% CI: 0.63-0.92) and 0.72 (95% CI: 0.17-1.00) for a 1-year risk of lung cancer. The AUCs of the 4MP for predicting metastatic lung cancer within one year and two years of the blood draw were 0.95 (95% CI: 0.87-1.00) and 0.78 (95% CI: 0.62-0.94), respectively. Our findings indicate that a blood-based biomarker panel may be useful in identifying ever- and never-smokers at high risk of a diagnosis of lung cancer within one-to-two years.
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Affiliation(s)
- Lulu Song
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (L.S.); (E.I.); (K.-A.D.)
| | - Ehsan Irajizad
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (L.S.); (E.I.); (K.-A.D.)
| | - Andrew Rundle
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY 10032, USA;
| | - Howard D. Sesso
- Divisions of Preventive Medicine and Aging, Department of Medicine, Brigham and Women’s Hospital, Boston, MA 02215, USA; (H.D.S.); (J.M.G.)
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA;
| | - John Michael Gaziano
- Divisions of Preventive Medicine and Aging, Department of Medicine, Brigham and Women’s Hospital, Boston, MA 02215, USA; (H.D.S.); (J.M.G.)
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston, MA 02115, USA
| | - Jody V. Vykoukal
- Department of Clinical Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (J.V.V.); (J.F.F.)
| | - Kim-Anh Do
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (L.S.); (E.I.); (K.-A.D.)
| | - Jennifer B. Dennison
- Department of Clinical Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (J.V.V.); (J.F.F.)
| | - Edwin J. Ostrin
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Johannes F. Fahrmann
- Department of Clinical Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (J.V.V.); (J.F.F.)
| | - Frederica Perera
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA;
| | - Samir Hanash
- Department of Clinical Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (J.V.V.); (J.F.F.)
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Chang GC, Chiu CH, Yu CJ, Chang YC, Chang YH, Hsu KH, Wu YC, Chen CY, Hsu HH, Wu MT, Yang CT, Chong IW, Lin YC, Hsia TC, Lin MC, Su WC, Lin CB, Lee KY, Wei YF, Lan GY, Chan WP, Wang KL, Wu MH, Tsai HH, Chian CF, Lai RS, Shih JY, Wang CL, Hsu JS, Chen KC, Chen CK, Hsia JY, Peng CK, Tang EK, Hsu CL, Chou TY, Shen WC, Tsai YH, Tsai CM, Chen YM, Lee YC, Chen HY, Yu SL, Chen CJ, Wan YL, Hsiung CA, Yang PC. Low-dose CT screening among never-smokers with or without a family history of lung cancer in Taiwan: a prospective cohort study. THE LANCET. RESPIRATORY MEDICINE 2024; 12:141-152. [PMID: 38042167 DOI: 10.1016/s2213-2600(23)00338-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/30/2023] [Accepted: 09/08/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND In Taiwan, lung cancers occur predominantly in never-smokers, of whom nearly 60% have stage IV disease at diagnosis. We aimed to assess the efficacy of low-dose CT (LDCT) screening among never-smokers, who had other risk factors for lung cancer. METHODS The Taiwan Lung Cancer Screening in Never-Smoker Trial (TALENT) was a nationwide, multicentre, prospective cohort study done at 17 tertiary medical centres in Taiwan. Eligible individuals had negative chest radiography, were aged 55-75 years, had never smoked or had smoked fewer than 10 pack-years and stopped smoking for more than 15 years (self-report), and had one of the following risk factors: a family history of lung cancer; passive smoke exposure; a history of pulmonary tuberculosis or chronic obstructive pulmonary disorders; a cooking index of 110 or higher; or cooking without using ventilation. Eligible participants underwent LDCT at baseline, then annually for 2 years, and then every 2 years up to 6 years thereafter, with follow-up assessments at each LDCT scan (ie, total follow-up of 8 years). A positive scan was defined as a solid or part-solid nodule larger than 6 mm in mean diameter or a pure ground-glass nodule larger than 5 mm in mean diameter. Lung cancer was diagnosed through invasive procedures, such as image-guided aspiration or biopsy or surgery. Here, we report the results of 1-year follow-up after LDCT screening at baseline. The primary outcome was lung cancer detection rate. The p value for detection rates was estimated by the χ2 test. Univariate and multivariable logistic regression analyses were used to assess the association between lung cancer incidence and each risk factor. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of LDCT screening were also assessed. This study is registered with ClinicalTrials.gov, NCT02611570, and is ongoing. FINDINGS Between Dec 1, 2015, and July 31, 2019, 12 011 participants (8868 females) were enrolled, of whom 6009 had a family history of lung cancer. Among 12 011 LDCT scans done at baseline, 2094 (17·4%) were positive. Lung cancer was diagnosed in 318 (2·6%) of 12 011 participants (257 [2·1%] participants had invasive lung cancer and 61 [0·5%] had adenocarcinomas in situ). 317 of 318 participants had adenocarcinoma and 246 (77·4%) of 318 had stage I disease. The prevalence of invasive lung cancer was higher among participants with a family history of lung cancer (161 [2·7%] of 6009 participants) than in those without (96 [1·6%] of 6002 participants). In participants with a family history of lung cancer, the detection rate of invasive lung cancer increased significantly with age, whereas the detection rate of adenocarcinoma in situ remained stable. In multivariable analysis, female sex, a family history of lung cancer, and age older than 60 years were associated with an increased risk of lung cancer and invasive lung cancer; passive smoke exposure, cumulative exposure to cooking, cooking without ventilation, and a previous history of chronic lung diseases were not associated with lung cancer, even after stratification by family history of lung cancer. In participants with a family history of lung cancer, the higher the number of first-degree relatives affected, the higher the risk of lung cancer; participants whose mother or sibling had lung cancer were also at an increased risk. A positive LDCT scan had 92·1% sensitivity, 84·6% specificity, a PPV of 14·0%, and a NPV of 99·7% for lung cancer diagnosis. INTERPRETATION TALENT had a high invasive lung cancer detection rate at 1 year after baseline LDCT scan. Overdiagnosis could have occurred, especially in participants diagnosed with adenocarcinoma in situ. In individuals who do not smoke, our findings suggest that a family history of lung cancer among first-degree relatives significantly increases the risk of lung cancer as well as the rate of invasive lung cancer with increasing age. Further research on risk factors for lung cancer in this population is needed, particularly for those without a family history of lung cancer. FUNDING Ministry of Health and Welfare of Taiwan.
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Affiliation(s)
- Gee-Chen Chang
- Department of Internal Medicine, Division of Pulmonary Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan; Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan; Institute of Biomedical Sciences, National Chung Hsing University, Taichung, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Internal Medicine, Division of Chest Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chao-Hua Chiu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Taipei Cancer Center, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan; Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chong-Jen Yu
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; National Taiwan University Hospital, Hsinchu, Taiwan
| | - Yeun-Chung Chang
- Department of Radiology, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Ya-Hsuan Chang
- Institute of Statistical Science, Academia Sinica, Taipei, Taiwan; Institute of Molecular and Genomic Medicine, National Health Research Institutes, Miaoli, Taiwan
| | - Kuo-Hsuan Hsu
- Division of Critical Care and Respiratory Therapy, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yu-Chung Wu
- Department of Surgery, Division of Thoracic Surgery, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan; Department of Surgery, Division of Thoracic Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chih-Yi Chen
- Department of Surgery, Division of Thoracic Surgery, Chung Shan Medical University Hospital, Taichung, Taiwan; Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Hsian-He Hsu
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ming-Ting Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Radiology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Cheng-Ta Yang
- Department of Thoracic Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Inn-Wen Chong
- Department of Biological Science and Technology, National Yang Ming Chiao Tung University, Taipei, Taiwan; Division of Pulmonary and Critical Care Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; College of Medicine, Graduate Institute of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yu-Ching Lin
- School of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Respiratory and Critical Care Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan; Department of Respiratory Care, Chang Gung University of Science and Technology, Taoyuan, Taiwan
| | - Te-Chun Hsia
- Department of Respiratory Therapy, China Medical University, Taichung, Taiwan; Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Meng-Chih Lin
- Division of Pulmonary and Critical Care Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung, Taiwan; Chang Gung Respirology Center of Excellence, Kaohsiung, Taiwan
| | - Wu-Chou Su
- Department of Oncology, National Cheng Kung University Hospital, Tainan, Taiwan; College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Bin Lin
- Department of Internal Medicine, Division of Chest Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Kang-Yun Lee
- Department of Pulmonary Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Internal Medicine, Division of Thoracic Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yu-Feng Wei
- Department of Internal Medicine, E-Da Cancer Hospital, Kaohsiung, Taiwan; School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Gong-Yau Lan
- Department of Medical Imaging, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan
| | - Wing P Chan
- Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Radiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Kao-Lun Wang
- Department of Radiology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Mei-Han Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medical Imaging, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Hao-Hung Tsai
- Department of Medical Imaging, Chung Shan Medical University Hospital, Taichung, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan; Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Chih-Feng Chian
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ruay-Sheng Lai
- Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Jin-Yuan Shih
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chi-Liang Wang
- Department of Thoracic Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Respiratory Therapy, Chang Gung University, Taoyuan, Taiwan
| | - Jui-Sheng Hsu
- Department of Medical Imaging, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Radiology, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Kun-Chieh Chen
- Department of Internal Medicine, Division of Pulmonary Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan; Department of Internal Medicine, Division of Chest Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Department of Applied Chemistry, National Chi Nan University, Nantou, Taiwan
| | - Chun-Ku Chen
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan; Division of Cardiopulmonary Radiology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jiun-Yi Hsia
- Department of Surgery, Division of Thoracic Surgery, Chung Shan Medical University Hospital, Taichung, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Chung-Kan Peng
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Department of Medical Planning, Medical Affairs Bureau Ministry of National Defense, Taipei, Taiwan
| | - En-Kuei Tang
- Department of Surgery, Division of Thoracic Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Shu-Zen Junior College of Medicine and Management, Kaohsiung, Taiwan
| | - Chia-Lin Hsu
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Teh-Ying Chou
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Pathology, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan
| | - Wei-Chih Shen
- Artificial Intelligence Center, Chung Shan Medical University Hospital, Taichung, Taiwan; Department of Medical Informatics, Chung Shan Medical University, Taichung, Taiwan
| | - Ying-Huang Tsai
- Department of Respiratory Therapy, Chang Gung University, Taoyuan, Taiwan; Department of Pulmonary and Critical Care, Xiamen Chang Gung Hospital, Xiamen, China
| | - Chun-Ming Tsai
- Department of Oncology, Taipei Veterans General Hospital, Taipei, Taiwan; Cathay General Hospital, Taipei, Taiwan
| | - Yuh-Min Chen
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu-Chin Lee
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Pulmonary Medicine, West Garden Hospital, Taipei, Taiwan
| | - Hsuan-Yu Chen
- Institute of Statistical Science, Academia Sinica, Taipei, Taiwan
| | - Sung-Liang Yu
- Department of Clinical Laboratory Sciences and Medical Biotechnology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chien-Jen Chen
- Genomics Research Center, Academia Sinica, Taipei, Taiwan
| | - Yung-Liang Wan
- Department of Medical Imaging and Intervention, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Medical Imaging and Radiological Sciences, Chang Gung University, Taoyuan, Taiwan
| | - Chao Agnes Hsiung
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan
| | - Pan-Chyr Yang
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan.
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9
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Chien LH, Jiang HF, Tsai FY, Chang HY, Freedman ND, Rothman N, Lan Q, Hsiung CA, Chang IS. Incidence of Lung Adenocarcinoma by Age, Sex, and Smoking Status in Taiwan. JAMA Netw Open 2023; 6:e2340704. [PMID: 37910104 PMCID: PMC10620613 DOI: 10.1001/jamanetworkopen.2023.40704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 09/19/2023] [Indexed: 11/03/2023] Open
Abstract
Importance Knowing whether the effects of smoking and other risk factors with lung adenocarcinoma (ADC) incidence varies by sex would provide information on lung cancer prevention strategies. Objective To evaluate whether women in Taiwan have higher age- and tumor stage-specific lung ADC incidence rates than men irrespective of smoking status (ie, ever smoker or never smoker). Design, Setting, and Participants This population-based cohort study used data sets synthesized from the Taiwan Cancer Registry (TCR) from 1979 to 2019; the TCR Long Form (TCRLF) from 2011 to 2019, which provides individual-level smoking and tumor stage information; the Taiwan Cause of Death Database (TCOD) from 1985 to 2019; the National Health Insurance Research Database (NHIRD) from 2000 to 2020; the Monthly Bulletin of Interior Statistics (MBIS) from 2011 to 2019; the National Health Interview Survey from 2001, 2005, 2009, 2013, and 2017; and Taiwan Biobank data from 2008 to 2021. Included patients were aged 40 to 84 years and had any invasive lung cancer from January 1, 2011, to December 31, 2019. Exposure Smoking status. Main Outcomes and Measures The main outcomes were age-specific female-to-male incidence rate ratios (IRRs) of lung ADC by smoking status and tumor stage. Linked data from the TCR, TCOD, NHIRD, Taiwan National Health Interview Survey, and MBIS were used to estimate the age- and sex-specific numbers of cancer-free individuals at midyears from 2011 to 2019 by smoking status. Using the TCR and TCRLF, age-, sex-, tumor stage-, and diagnosis year-specific numbers of patients with lung ADC from 2011 to 2019 by smoking status were estimated. Results A total of 61 285 patients (32 599 women [53.2%]) aged 40 to 84 years (mean [SD] age, 64.66 [10.79] years) in the Taiwanese population of approximately 23 million were diagnosed with invasive lung ADC as their first lifetime cancer between 2011 and 2019. Among smokers, men had higher tobacco use by almost all examined metrics, including nearly twice the mean (SD) number of pack-years smoked (eg, 7.87 [8.30] for men aged 30-34 years vs 4.38 [5.27] for women aged 30-34 years). For 5-year age bands between 40 and 84 years, incidence of lung ADC was significantly higher among females than males for nearly all age groups irrespective of tumor stage and smoking status (eg, for the age group 70-74 years, the female-to-male IRR for late-stage lung ADC among never smokers was 1.38 [95% CI, 1.30-1.50]). Conclusions and Relevance In this cohort study, women had higher age- and stage-specific lung ADC incidence rates than men in Taiwan for both never and ever smokers, suggesting the possibility of differential exposures between sexes to risk factors other than smoking and the potential modification of ADC risk factors by sex. Further work is needed to determine whether this pattern replicates in other populations, discover the causes of lung ADC, and put preventive measures in place.
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Affiliation(s)
- Li-Hsin Chien
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan
- Department of Applied Mathematics, Chung-Yuan Christian University, Chung-Li, Taiwan
| | - Hsin-Fang Jiang
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan
| | - Fang-Yu Tsai
- National Institute of Cancer Research, National Health Research Institutes, Zhunan, Taiwan
| | - Hsing-Yi Chang
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan
| | - Neal D. Freedman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Nathaniel Rothman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Qing Lan
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Chao A. Hsiung
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan
| | - I-Shou Chang
- National Institute of Cancer Research, National Health Research Institutes, Zhunan, Taiwan
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