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Malmgren JA, Guo B, Atwood MK, Hallam P, Roberts LA, Kaplan HG. COVID-19 related change in breast cancer diagnosis, stage, treatment, and case volume: 2019-2021. Breast Cancer Res Treat 2023; 202:105-115. [PMID: 37584882 PMCID: PMC10504101 DOI: 10.1007/s10549-023-06962-8] [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: 02/08/2023] [Accepted: 04/26/2023] [Indexed: 08/17/2023]
Abstract
PURPOSE Evaluate the COVID-19 pandemic impact on breast cancer detection method, stage and treatment before, during and after health care restrictions. METHODS In a retrospective tertiary cancer care center cohort, first primary breast cancer (BC) patients, years 2019-2021, were reviewed (n = 1787). Chi-square statistical comparisons of detection method (patient (PtD)/mammography (MamD), Stage (0-IV) and treatment by pre-pandemic time 1: 2019 + Q1 2020; peak-pandemic time 2: Q2-Q4 2020; pandemic time 3: Q1-Q4 2021 (Q = quarter) periods and logistic regression for odds ratios were used. RESULTS BC case volume decreased 22% in 2020 (N = 533) (p = .001). MamD declined from 64% pre-pandemic to 58% peak-pandemic, and increased to 71% in 2021 (p < .001). PtD increased from 30 to 36% peak-pandemic and declined to 25% in 2021 (p < .001). Diagnosis of Stage 0/I BC declined peak-pandemic when screening mammography was curtailed due to lock-down mandates but rebounded above pre-pandemic levels in 2021. In adjusted regression, peak-pandemic stage 0/I BC diagnosis decreased 24% (OR = 0.76, 95% CI: 0.60, 0.96, p = .021) and increased 34% in 2021 (OR = 1.34, 95% CI: 1.06, 1.70, p = .014). Peak-pandemic neoadjuvant therapy increased from 33 to 38% (p < .001), primarily for surgical delay cases. CONCLUSIONS The COVID-19 pandemic restricted health-care access, reduced mammography screening and created surgical delays. During the peak-pandemic time, due to restricted or no access to mammography screening, we observed a decrease in stage 0/I BC by number and proportion. Continued low case numbers represent a need to re-establish screening behavior and staffing.
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Affiliation(s)
- Judith A Malmgren
- HealthStat Consulting, Inc, 12025 9th Ave NW, Seattle, WA, 98177, USA.
- School of Public Health, University of Washington, Seattle, WA, USA.
| | - Boya Guo
- School of Public Health, University of Washington, Seattle, WA, USA
| | - Mary K Atwood
- Swedish Cancer Institute, 1221 Madison St, Seattle, WA, 98104, USA
| | - Paula Hallam
- Swedish Cancer Institute, 1221 Madison St, Seattle, WA, 98104, USA
| | - Laura A Roberts
- Swedish Cancer Institute, 1221 Madison St, Seattle, WA, 98104, USA
| | - Henry G Kaplan
- Swedish Cancer Institute, 1221 Madison St, Seattle, WA, 98104, USA
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Borella F, Bertero L, Di Giovanni F, Witel G, Orlando G, Ricci AA, Pittaro A, Castellano I, Cassoni P. COVID-19 and Breast Cancer: Analysis of Surgical Management of a Large Referral Center during the 2020-2021 Pandemic Period. Curr Oncol 2023; 30:4767-4778. [PMID: 37232817 DOI: 10.3390/curroncol30050359] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 04/27/2023] [Accepted: 05/01/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Coronavirus disease-19 (COVID-19) has spread worldwide since December 2019 and was officially declared a pandemic in March 2020. Due to the rapid transmission and the high fatality rate, drastic emergency restrictions were issued, with a negative impact on routine clinical activities. In particular, in Italy, many authors have reported a reduction in the number of breast cancer diagnoses and critical problems in the management of patients who accessed the breast units during the dramatic first months of the pandemic. Our study aims to analyze the global impact of COVID-19 in the two years of the pandemic (2020-2021) on the surgical management of breast cancer by comparing them with the previous two years. METHODS In our retrospective study, we analyzed all cases of breast cancer diagnosed and surgically treated at the breast unit of "Città della Salute e della Scienza" in Turin, Italy, making a comparison between the 2018-2019 pre-pandemic period and the 2020-2021 pandemic period. RESULTS We included in our analysis 1331 breast cancer cases surgically treated from January 2018 to December 2021. A total of 726 patients were treated in the pre-pandemic years and 605 in the pandemic period (-121 cases, 9%). No significant differences were observed regarding diagnosis (screening vs. no screening) and timing between radiological diagnosis and surgery for both in situ and invasive tumors. There were no variations in the breast surgical approach (mastectomy vs. conservative surgery), while a reduction in axillary dissection compared to the sentinel lymph node in the pandemic period was observed (p-value < 0.001). Regarding the biological characteristics of breast cancers, we observed a greater number of grades 2-3 (p-value = 0.007), pT stage 3-4 breast cancer surgically treated without previous neoadjuvant chemotherapy (p-value = 0.03), and a reduction in luminal B tumors (p-value = 0.007). CONCLUSIONS Overall, we report a limited reduction in surgical activity for breast cancer treatment considering the entire pandemic period (2020-2021). These results suggest a prompt resumption of surgical activity similar to the pre-pandemic period.
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Affiliation(s)
- Fulvio Borella
- Obstetrics and Gynecology Unit 1, Department of Surgical Sciences, University of Turin, 10126 Turin, Italy
| | - Luca Bertero
- Pathology Unit, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| | - Fabrizia Di Giovanni
- Pathology Unit, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| | - Gianluca Witel
- Pathology Unit, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| | - Giulia Orlando
- Pathology Unit, Department of Oncology, University of Turin, 10126 Turin, Italy
| | - Alessia Andrea Ricci
- Pathology Unit, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| | - Alessandra Pittaro
- Pathology Unit, Città della Salute e della Scienza University Hospital, 10126 Turin, Italy
| | - Isabella Castellano
- Pathology Unit, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
| | - Paola Cassoni
- Pathology Unit, Department of Medical Sciences, University of Turin, 10126 Turin, Italy
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Adachi K, Kimura F, Takahashi H, Kaise H, Yamada K, Ueno E, Kawate T, Miyahara K, Ueda A, Sato S, Asaoka M, Okazaki M, Uenaka N, Orimoto K, Wu R, Koyama Y, Ishikawa T. Delayed Diagnosis and Prognostic Impact of Breast Cancer During the COVID-19 Pandemic. Clin Breast Cancer 2023; 23:265-271. [PMID: 36717319 PMCID: PMC9829603 DOI: 10.1016/j.clbc.2023.01.001] [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: 08/03/2022] [Revised: 10/24/2022] [Accepted: 01/05/2023] [Indexed: 01/12/2023]
Abstract
BACKGROUND Breast screening services were suspended for several months owing to the coronavirus disease 2019 (COVID-19) pandemic. We estimated the potential impact on breast cancer mortality using long-term global observations. However, the magnitude of the impact may vary across countries; therefore, we conducted an analysis and modeling study of this impact in Japan. PATIENTS AND METHODS We compared the clinicopathological features of breast cancers between the nonpandemicgroup (April 1, 2019 to October 31, 2019) and the pandemic group (April 1, 2020 to October 31, 2020). We also compared the estimated 10-year survival rates between the two groups based on the weighted average of the 10-year survival rate by clinical stage and site (2004-2007). RESULTS Results...Pandemic-related disruption decreased the number of breast cancer cases from296 to 249 during both 7-month periods. The percentage of patients with stage IIB or higher disease was significantly higher in the pandemic group than in the non-pandemic group (22.0% vs. 31.3%, P = 0.0133). The percentage of cases with a Ki-67 labeling index higher than 20% tended to be higher in the pandemic group than in the non-pandemic group (62.2% vs. 54.4%). The estimated 10-year survival rate was lower in the pandemic group than in the non-pandemic group (83.9% vs. 87.9%, 95% confidence interval of the difference: 0.87-8.8, P > 0.05). CONCLUSION We found more aggressive and advanced disease afterthe suspension of breast cancer screening services owing to the COVID-19 pandemic. This may have affected the long-term clinical outcomes of patients with breast cancer.
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Affiliation(s)
- Kayo Adachi
- Tokyo Medical University Hospital, Tokyo, Japan.
| | - Fuyo Kimura
- Tokyo Medical University Hospital, Tokyo, Japan; The Second Kawasaki Saiwai Clinic, Kanagawa, Japan.
| | | | - Hiroshi Kaise
- Tokyo Medical University Ibaraki Medical Center, Ibakaki, Japan
| | - Kimito Yamada
- Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Ei Ueno
- Tsukuba International Breast Clinic, Ibaraki, Japan
| | | | | | - Ai Ueda
- Tokyo Medical University Hospital, Tokyo, Japan
| | - Saeko Sato
- Tokyo Medical University Hospital, Tokyo, Japan
| | | | | | | | | | - Rongrong Wu
- Tokyo Medical University Hospital, Tokyo, Japan
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Fujita M, Hashimoto H, Nagashima K, Suzuki K, Kasai T, Yamaguchi K, Onouchi Y, Sato D, Fujisawa T, Hata A. Impact of coronavirus disease 2019 pandemic on breast cancer surgery using the National Database of Japan. Sci Rep 2023; 13:4977. [PMID: 36973536 PMCID: PMC10041497 DOI: 10.1038/s41598-023-32317-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/25/2023] [Indexed: 03/29/2023] Open
Abstract
Various countries have reported a decrease in breast cancer surgeries during the coronavirus disease 2019 (COVID-19) pandemic; however, inconsistent results have been reported in Japan. This study revealed changes in the number of surgeries during the pandemic using the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) from January 2015 to January 2021, where insurance claims data from Japan as a whole are comprehensively accumulated. The number of breast-conserving surgeries (BCS) without axillary lymph node dissection (ALND) significantly decreased in July (- 846; 95% confidence interval (CI) - 1190 to - 502) and October 2020 (- 540; 95% CI - 861 to - 218). No decrease was observed for other types of surgery, BCS with ALND, and mastectomy with or without ALND. In the age-specific subgroup analysis, significant and transient reduction in BCS without ALND was observed in all age groups (0-49, 50-69, and ≥ 70 years). The number of BCS without ALND significantly decreased for a relatively short period in the early pandemic stages, suggesting reduced surgery for patients with a relatively low stage of cancer. Some patients with breast cancer might have been left untreated during the pandemic, and an unfavorable prognosis would be a concern.
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Affiliation(s)
- Misuzu Fujita
- Department of Health Research, Chiba Foundation for Health Promotion and Disease Prevention, 32-14 Shin-Minato, Mihama-Ku, Chiba, 261-0002, Japan.
- Department of Public Health, Chiba University Graduate School of Medicine, Chiba, 260-8670, Japan.
| | - Hideyuki Hashimoto
- Department of Health Research, Chiba Foundation for Health Promotion and Disease Prevention, 32-14 Shin-Minato, Mihama-Ku, Chiba, 261-0002, Japan
| | - Kengo Nagashima
- Biostatistics Unit, Clinical and Translational Research Center, Keio University Hospital, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Kiminori Suzuki
- Department of Health Research, Chiba Foundation for Health Promotion and Disease Prevention, 32-14 Shin-Minato, Mihama-Ku, Chiba, 261-0002, Japan
| | - Tokuzo Kasai
- Department of Health Research, Chiba Foundation for Health Promotion and Disease Prevention, 32-14 Shin-Minato, Mihama-Ku, Chiba, 261-0002, Japan
| | - Kazuya Yamaguchi
- Department of Health Research, Chiba Foundation for Health Promotion and Disease Prevention, 32-14 Shin-Minato, Mihama-Ku, Chiba, 261-0002, Japan
| | - Yoshihiro Onouchi
- Department of Public Health, Chiba University Graduate School of Medicine, Chiba, 260-8670, Japan
| | - Daisuke Sato
- Center for Next Generation of Community Health, Chiba University Hospital, Chiba, 260-0856, Japan
| | - Takehiko Fujisawa
- Department of Health Research, Chiba Foundation for Health Promotion and Disease Prevention, 32-14 Shin-Minato, Mihama-Ku, Chiba, 261-0002, Japan
| | - Akira Hata
- Department of Health Research, Chiba Foundation for Health Promotion and Disease Prevention, 32-14 Shin-Minato, Mihama-Ku, Chiba, 261-0002, Japan
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Prodhan AHMSU, Islam DZ, Khandker SS, Jamiruddin MR, Abdullah A, Godman B, Opanga S, Kumar S, Sharma P, Adnan N, Pisana A, Haque M. Breast Cancer Management in the Era of Covid-19; Key Issues, Contemporary Strategies, and Future Implications. BREAST CANCER (DOVE MEDICAL PRESS) 2023; 15:51-89. [PMID: 36733464 PMCID: PMC9888303 DOI: 10.2147/bctt.s390296] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 01/19/2023] [Indexed: 01/28/2023]
Abstract
During the COVID-19 pandemic, several priority diseases were not getting sufficient attention. Whilst breast cancer is a fatal disease affecting millions worldwide, identification and management of these patients did not initially attract critical attention to minimize the impact of lockdown, post-lockdown, and other measures. Breast cancer patients' conditions may not remain stable without proper care, worsening their prognosis. Proper care includes the timely instigation of surgery, systemic therapy, and psychological support. This includes low-and middle-income countries where there are already concerns with available personnel and medicines to adequately identify and treat these patients. Consequently, there was a need to summarize the current scenario regarding managing breast cancer care during COVID-19 across all countries, including any guidelines developed. We systematically searched three scientific databases and found 76 eligible articles covering the medical strategies of high-income countries versus LMICs. Typically, diagnostic facilities in hospitals were affected at the beginning of the pandemic following the lockdown and other measures. This resulted in more advanced-stage cancers being detected at initial presentation across countries, negatively impacting patient outcomes. Other than increased telemedicine, instigating neo-adjuvant endocrine therapy more often, reducing non-essential visits, and increasing the application of neo-adjuvant chemotherapy to meet the challenges, encouragingly, there was no other significant difference among patients in high-income versus LMICs. Numerous guidelines regarding patient management evolved during the pandemic to address the challenges posed by lockdowns and other measures, which were subsequently adopted by various high-income countries and LMICs to improve patient care. The psychological impact of COVID-19 and associated lockdown measures, especially during the peak of COVID-19 waves, and the subsequent effect on the patient's mental health must also be considered in this high-priority group. We will continue to monitor the situation to provide direction in future pandemics.
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Affiliation(s)
| | - Dewan Zubaer Islam
- Department of Microbiology, Jahangirnagar University, Dhaka, 1342, Bangladesh
| | - Shahad Saif Khandker
- Department of Biochemistry, Gonoshasthaya Samaj Vittik Medical College, Dhaka, 1344, Bangladesh
| | | | - Adnan Abdullah
- Unit of Occupational Medicine, Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia, (National Defence University of Malaysia), Kuala Lumpur, 57000, Malaysia
| | - Brian Godman
- Department of Pharmacoepidemiology, Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK,Centre of Medical and Bio-Allied Health Sciences Research, Ajman University, Ajman, United Arab Emirates,Division of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa
| | - Sylvia Opanga
- Department of Pharmacy, University of Nairobi, Nairobi, Kenya
| | - Santosh Kumar
- Department of Periodontology and Implantology, Karnavati School of Dentistry, Karnavati University, Gandhinagar, Gujarat, India
| | - Paras Sharma
- Department of Pharmacognosy, BVM College of Pharmacy, Gwalior, Madhya Pradesh, 474006, India
| | - Nihad Adnan
- Department of Microbiology, Jahangirnagar University, Dhaka, 1342, Bangladesh,Correspondence: Nihad Adnan, Department of Microbiology, Jahangirnagar University, Savar, Dhaka 1342, Bangladesh, Email ;Mainul Haque, The Unit of Pharmacology, Faculty of Medicine and Defence Health, Universiti Pertahanan, Nasional Malaysia (National Defence University of Malaysia), Kem Perdana Sugai Besi, Kuala Lumpur 57000, Malaysia, Tel +60109265543, Email
| | - Alice Pisana
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Mainul Haque
- The Unit of Pharmacology, Faculty of Medicine and Defence Health, Universiti Pertahanan, Nasional Malaysia (National Defence University of Malaysia), Kuala Lumpur, 57000, Malaysia
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Abd El Wahab MH, Ibrahim AH, Gado O, Bahbah AM, Fadlalla W, Fakhry S, Mamdouh MM, Kamel MM, Moaz I, Rabea A, Helal AM. Changes in breast cancer staging trends among Egyptian women after COVID-19: A retrospective single-center study. Int J Immunopathol Pharmacol 2023; 37:3946320231152835. [PMID: 36649477 PMCID: PMC9852965 DOI: 10.1177/03946320231152835] [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] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVES Since being declared a global pandemic, the SARS-CoV-2 virus had a significant impact on the entire globe. The pandemic has placed a heavy burden on healthcare systems worldwide, and cancer patients are particularly prone. Despite the fact that initial international reports suggest delays in breast cancer (BC) diagnosis and screening programs, the Egyptian context requires additional research on this topic. To examine whether COVID-19 has changed the pattern of disease presentation before and after the pandemic, focusing on the tumor, node, and metastasis (TNM) staging of the disease at the initial presentation. METHODS This single-center, retrospective study of female BC patients initially diagnosed at Baheya Foundation was conducted during the following time frames: from Jan 2019 to Jan 2020 (Pre COVID-19 cohort) and from Mar 2020 to Mar 2021 (post-COVID-19 cohort). We compared the two cohorts in terms of clinical characteristics, tumor characteristics, and the number of days from presentation to treatment. Our primary endpoint was the difference in the TNM stage of BC at the initial presentation. RESULTS This analysis included 710 BC patients, 350 from the pre-COVID cohort and 360 from the post-COVID group. We detected a 27.9% increase in late-stage BC (stages III-IV) in the post-pandemic cohort compared to the pre-pandemic (60.1% vs. 47%, p < 0.001). The time from diagnosis to commencement of treatment was significantly longer (28.34 ± 18.845 vs 36.04 ± 23.641 days, p < 0.001) in the post-COVID cohort (mean difference = 7.702, 95% CI 4.54-10.85, p < 0.001). A higher percentage of patients in the post-pandemic cohort received systemic neoadjuvant therapy (p-value for Exact's test for all treatment options = 0.001). CONCLUSIONS The number of patients requiring systemic neoadjuvant chemotherapy increased dramatically in the post-pandemic group with advanced stages of BC at presentation. This study highlights the need for proper management of cancer patients during any future pandemic.
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Affiliation(s)
| | - Ahmed H Ibrahim
- Baheya Charity’s Women Cancer Hospital, Cairo, Egypt 1. Baheya Centre for Early Detection and Treatment of Breast Cancer, Giza, Egypt
| | | | | | - Waleed Fadlalla
- Baheya Charity’s Women Cancer Hospital, Cairo, Egypt 1. Baheya Centre for Early Detection and Treatment of Breast Cancer, Giza, Egypt. ,National Cancer Institute, Cairo University, Cairo, Egypt
| | - Sherihan Fakhry
- Baheya Charity’s Women Cancer Hospital, Cairo, Egypt 1. Baheya Centre for Early Detection and Treatment of Breast Cancer, Giza, Egypt. ,Radiology Department, Cairo University, Cairo, Egypt
| | - Mona M Mamdouh
- Baheya Charity’s Women Cancer Hospital, Cairo, Egypt 1. Baheya Centre for Early Detection and Treatment of Breast Cancer, Giza, Egypt. ,National Cancer Institute, Cairo University, Cairo, Egypt
| | - Mahmoud M Kamel
- National Cancer Institute, Cairo University, Cairo, Egypt,Mahmoud M Kamel, National Cancer Institute, Cairo University, Kasr Al-Aini Street, from El-Khalig Square, Cairo 11796, Egypt.
| | - Inas Moaz
- Epidemiology and Preventive Medicine Department, National Liver Institute, Menofia, Egypt Epidemiology and Preventive Medicine Department, National Liver Institute, Menoufia University, Egypt
| | - Ahmed Rabea
- Baheya Charity’s Women Cancer Hospital, Cairo, Egypt 1. Baheya Centre for Early Detection and Treatment of Breast Cancer, Giza, Egypt. ,National Cancer Institute, Cairo University, Cairo, Egypt
| | - Amany M Helal
- Baheya Charity’s Women Cancer Hospital, Cairo, Egypt 1. Baheya Centre for Early Detection and Treatment of Breast Cancer, Giza, Egypt. ,National Cancer Institute, Cairo University, Cairo, Egypt
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Kim YI, Park IJ. Surgical safety in the COVID-19 era: present and future considerations. Ann Surg Treat Res 2022; 102:295-305. [PMID: 35800996 PMCID: PMC9204020 DOI: 10.4174/astr.2022.102.6.295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 05/11/2022] [Indexed: 11/30/2022] Open
Abstract
The impacts of coronavirus disease 2019 (COVID-19) have been globally paradigm shifting in all aspects. Surgeons have experienced unprecedented changes regarding operation schedules, preparations before surgery, and the precautions needed both during and after surgery. Many medical centers simultaneously reported a decrease in their numbers of surgeries, whether they were elective or emergent, or for cancerous or benign resections. However, accumulated surgical outcomes from the last 2 years of experience presented postoperative morbidity and mortality data that were comparable to the pre-pandemic era, whether in elective or urgent settings. Although COVID-19 showed a significant association with postoperative morbidity and mortality, the majority of noninfected patients could be treated successfully with stringent mitigation protocols. Initially recommended to be avoided at the start of the pandemic, minimally invasive surgery seems to be safe and feasible according to reported surgical outcomes. Numerous sets of guidelines have now been produced from medical societies and adhering to the basic precautions has been found to be practicable. It is crucial that health care systems and surgical staff remain vigilant and attentive to the ever-changing situation in this pandemic in order to provide optimal medical support to their patients.
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Affiliation(s)
- Young Il Kim
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In Ja Park
- Division of Colon and Rectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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