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Milosavljevic S, Milligan MG, Lam MB. The Opacity of Price Transparency: Loopholes, Enforcement Deficiencies, and a Path Forward. J Gen Intern Med 2024:10.1007/s11606-023-08522-8. [PMID: 38243109 DOI: 10.1007/s11606-023-08522-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/30/2023] [Indexed: 01/21/2024]
Affiliation(s)
| | - Michael G Milligan
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
- Harvard Radiation Oncology Program, Boston, MA, USA
| | - Miranda B Lam
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA.
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, 75 Francis Street, Boston, MA, 02115, USA.
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Patel AM, Dee EC, Hubbard A, Milligan MG, Ebner DK, Alcorn SR, LaVigne A, Kudner RF, Mayo C, Adler D, Suggs K, Greathouse A, Ludwig MS, Nguyen PL, Waddle MR, Thompson RF, Mahal BA, Yamoah K. Health Equity Achievement in Radiation Therapy (HEART) Score: A Social Prognosis. Int J Radiat Oncol Biol Phys 2023; 117:e612-e613. [PMID: 37785841 DOI: 10.1016/j.ijrobp.2023.06.1988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) The aim of this study was to develop a Health Equity Achievement in Radiation Therapy (HEART) score that can help identify patients at risk of experiencing suboptimal quality-of-care (QoC) early on in the patient-provider encounter and prior to initiation of treatment. Such a score may improve shared decision making to improve QoC. MATERIALS/METHODS A retrospective analysis was conducted using the National Cancer Database (NCDB) for prostate cancer cases between 2004-2017. Sociodemographic factors, clinical characteristics, and treatment information were collected. A composite HEART score was built to predict suboptimal QoC, defined as treatment refusal, incomplete treatment, or treatment delay. 70% of the data was allocated to training and 30% to validating a logistic regression model through which a nomogram was constructed. RESULTS A total of 1,599,785 patients were included in the analysis, of whom 126,917 (7.9%) had at least one suboptimal QoC. The strongest predictors were Black race, uninsured status, lower educational status, geographic location, and nodal disease (Table). The nomogram demonstrated a fair ability to predict quality metrics, with an area under the receiver operating characteristic curve (AUC) of 0.57 in the test group. The nomogram facilitated graphic interpretation of systemic factors in contributing to suboptimal QoC. CONCLUSION With observed potential for predicting suboptimal QoC outcomes in patients with prostate cancer by considering systemic barriers, this NCDB-based nomogram has potential utility as a tool for identifying patients who may benefit from additional social support, including the financial resources associated with these services, to improve access to care. Further validation in diverse datasets is needed to improve performance and generalizability to broader patient populations and different disease sites.
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Affiliation(s)
- A M Patel
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - E C Dee
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - A Hubbard
- American Society for Radiation Oncology, Arlington, VA
| | | | - D K Ebner
- Rhode Island Hospital, Providence, RI
| | - S R Alcorn
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - A LaVigne
- Johns Hopkins University School of Medicine, Baltimore, MA
| | - R F Kudner
- American Society for Radiation Oncology, Arlington, VA
| | - C Mayo
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - D Adler
- American Society for Radiation Oncology, Arlington, VA
| | - K Suggs
- American Society for Radiation Oncology, Arlington, VA
| | - A Greathouse
- American Society for Radiation Oncology, Arlington, VA
| | - M S Ludwig
- Department of Radiation Oncology, Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX
| | - P L Nguyen
- Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, MA
| | - M R Waddle
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - R F Thompson
- Department of Radiation Medicine, Oregon Health & Science University, Portland, OR
| | - B A Mahal
- Department of Radiation Oncology, University of Miami/Sylvester Comprehensive Cancer Center, Miami, FL
| | - K Yamoah
- H. Lee Moffitt Cancer Center and Research Institute, Department of Radiation Oncology, Tampa, FL
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King MT, Kehayias CE, Chaunzwa T, Rosen DB, Mahal AR, Wallburn TD, Milligan MG, Dyer MA, Nguyen PL, Orio PF, Harris TC, Buzurovic I, Guthier CV. Observer preference of artificial intelligence-generated versus clinical prostate contours for ultrasound-based high dose rate brachytherapy. Med Phys 2023; 50:5935-5943. [PMID: 37665729 DOI: 10.1002/mp.16716] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/21/2023] [Accepted: 08/23/2023] [Indexed: 09/06/2023] Open
Abstract
BACKGROUND For trans-rectal ultrasound (TRUS)-based high dose rate (HDR) prostate brachytherapy, prostate contouring can be challenging due to artifacts from implanted needles, bleeding, and calcifications. PURPOSE To evaluate the geometric accuracy and observer preference of an artificial intelligence (AI) algorithm for generating prostate contours on TRUS images with implanted needles. METHODS We conducted a retrospective study of 150 patients, who underwent HDR brachytherapy. These patients were randomly divided into training (104), validation (26) and testing (20) sets. An AI algorithm was trained/validated utilizing the TRUS image and reference (clinical) contours. The algorithm then provided contours for the test set. For evaluation, we calculated the Dice coefficient between AI and reference prostate contours. We then presented AI and reference contours to eight clinician observers, and asked observers to select their preference. Observers were blinded to the source of contours. We calculated the percentage of cases in which observers preferred AI contours. Lastly, we evaluate whether the presence of AI contours improved the geometric accuracy of prostate contours provided by five resident observers for a 10-patient subset. RESULTS The median Dice coefficient between AI and reference contours was 0.92 (IQR: 0.90-0.94). Observers preferred AI contours for a median of 57.5% (IQR: 47.5, 65.0) of the test cases. For resident observers, the presence of AI contours was associated with a 0.107 (95% CI: 0.086, 0.128; p < 0.001) improvement in Dice coefficient for the 10-patient subset. CONCLUSION The AI algorithm provided high-quality prostate contours on TRUS with implanted needles. Further prospective study is needed to better understand how to incorporate AI prostate contours into the TRUS-based HDR brachytherapy workflow.
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Affiliation(s)
- Martin T King
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Christopher E Kehayias
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Tafadzwa Chaunzwa
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Daniel B Rosen
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Amandeep R Mahal
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Tyler D Wallburn
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Michael G Milligan
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - M Aiven Dyer
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Paul L Nguyen
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Peter F Orio
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Thomas C Harris
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Ivan Buzurovic
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Christian V Guthier
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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Milligan MG, Lam MB. Radiation Therapy, the Oncology Care Model, and the Enhancing Oncology Model: Threats Remain. Int J Radiat Oncol Biol Phys 2023; 116:500-502. [PMID: 37270246 DOI: 10.1016/j.ijrobp.2023.01.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 01/18/2023] [Accepted: 01/18/2023] [Indexed: 06/05/2023]
Affiliation(s)
- Michael G Milligan
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Miranda B Lam
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.
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Milosavljevic S, Milligan MG, Lam MB. Barriers Patients Face in Predicting Cost of Care Despite Increasing Healthcare Price Transparency. J Gen Intern Med 2023:10.1007/s11606-023-08108-4. [PMID: 36849866 PMCID: PMC10361895 DOI: 10.1007/s11606-023-08108-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/13/2023] [Indexed: 03/01/2023]
Affiliation(s)
| | - Michael G Milligan
- Harvard Medical School, Boston, MA, USA.,Harvard Radiation Oncology Program, Boston, MA, USA.,Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA, USA
| | - Miranda B Lam
- Harvard Medical School, Boston, MA, USA. .,Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA, USA.
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Milligan MG, Orav EJ, Lam MB. Determinants of Commercial Prices for Common Radiation Therapy Procedures. Int J Radiat Oncol Biol Phys 2023; 115:23-33. [PMID: 36309073 DOI: 10.1016/j.ijrobp.2022.04.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/05/2022] [Accepted: 04/07/2022] [Indexed: 11/07/2022]
Abstract
PURPOSE Using hospital-reported price data, we analyzed whether various market factors including radiation oncology practice consolidation were associated with higher commercial prices for radiation therapy (RT). METHODS AND MATERIALS We evaluated commercial prices paid by private insurers for 4 common RT procedures-intensity modulated RT (IMRT) planning, IMRT delivery, 3-dimensional RT (3D-RT) planning, and 3D-RT delivery-reported among the 2096 hospitals in the United States that deliver RT according to the Medicare Provider of Service file. To assess price variation within hospitals, we evaluated the ratio of the 90th percentile price to the 10th percentile price among different private insurers. To assess regional variation, we similarly compared median commercial prices at the 90th and 10th percentile hospitals in each Hospital Referral Region. We generated multivariable models to test the association of various hospital, health system, regional, and market factors on median hospital commercial prices. RESULTS A total of 1004 hospitals (47.9%) reported at least 1 commercial price for any of the 4 RT procedures considered in this study. National median commercial prices for IMRT planning and IMRT delivery were $4073 (interquartile ratio [IQR], $2242-$6305) and $1666 (IQR, $1014-$2619), respectively. Prices for 3D-RT planning and 3D-RT delivery were $2824 (IQR, $1339-$4738) and $616 (IQR, $419-877), respectively. Within hospitals, the 90th percentile price paid by a private insurer was 2.3 to 2.5 times higher on average than the 10th percentile price, depending on the procedure. Within each Hospital Referral Region, the median price at the 90th percentile hospital was between 2.4 and 3.2 times higher than at the 10th percentile hospital. On multivariable analysis, higher prices were generally observed at hospitals with for-profit ownership, teaching status, and affiliation with large health systems. Levels of radiation oncology practice consolidation were not significantly associated with any prices. CONCLUSIONS Commercial prices for common RT procedures vary by more than a factor of 2 depending on a patient's private insurer and hospital of choice. Higher prices were more likely to be found at for-profit hospitals, teaching hospitals, and hospitals affiliated with large health systems.
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Affiliation(s)
- Michael G Milligan
- Harvard Radiation Oncology Program, Boston, Massachusetts; Department of Radiation Oncology, Brigham and Women's Hospital, Boston, Massachusetts; Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - E John Orav
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts
| | - Miranda B Lam
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, Massachusetts; Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.
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Liu KX, Milligan MG, Schoenfeld JD, Tishler RB, Ng AK, Devlin PM, Fite E, Rabinowits G, Hanna GJ, Silk AW, Yoon CH, Thakuria M, Margalit DN. Characterization of clinical outcomes after shorter course hypofractionated and standard-course radiotherapy for stage I-III curatively-treated Merkel cell carcinoma. Radiother Oncol 2022; 173:32-40. [PMID: 35595174 DOI: 10.1016/j.radonc.2022.05.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 05/08/2022] [Accepted: 05/09/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Limited data exists regarding the efficacy of curative hypofractionated radiotherapy (hypo-RT) regimens compared to conventionally-fractionated radiotherapy (conv-RT) for Merkel cell carcinoma (MCC). METHODS A retrospective analysis of 241 patients diagnosed with non-metastatic MCC from 2005-2021 and who received RT at Dana-Farber/Brigham & Women's Cancer Center. The primary outcome was cumulative incidence of in-field locoregional relapse using Gray's test with competing risks of death and isolated out-of-field recurrence. Secondary outcomes included overall survival (OS) and MCC-specific survival using log-rank tests, and risk factors of recurrence using Cox-proportional hazards regression. RESULTS There were 50 (20.6%) and 193 (79.4%) courses of hypo-RT and conv-RT, respectively. The hypo-RT cohort was older (≥73 years at diagnosis: 78.0% vs. 41.5%, p<0.01), and received a lower equivalent total RT dose in 2 Gy per fraction (<50 Gy: 58.0% vs. 5.2%, p<0.01). Median follow-up was 65.1 months (range: 1.2-194.5) for conv-RT and 25.0 months (range: 1.6-131.3) for hypo-RT cohorts. Two-year cumulative incidence of in-field locoregional relapse was low in both groups (1.1% conv-RT vs. 4.1% hypo-RT, p=0.114). While two-year OS was lower for the hypo-RT group (62.6% vs. 84.4%, p=0.0008), two-year MCC-specific survival was similar (84.7 vs. 86.6%, p=0.743). On multivariable analysis, immunosuppression, clinical stage III disease, and lymphovascular invasion were associated with any-recurrence when controlling for sex, age, and hypo-RT. CONCLUSIONS AND RELEVANCE There was no difference in cumulative incidence of in-field locoregional relapse or MCC-specific survival between hypo-RT and conv-RT. Prospective studies are needed to confirm hypo-RT as an efficacious treatment option for MCC.
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Affiliation(s)
- Kevin X Liu
- Department of Radiation Oncology, Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, United States
| | - Michael G Milligan
- Department of Radiation Oncology, Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, United States
| | - Jonathan D Schoenfeld
- Department of Radiation Oncology, Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, United States; Merkel Cell Carcinoma Center of Excellence, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts, United States
| | - Roy B Tishler
- Department of Radiation Oncology, Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, United States; Merkel Cell Carcinoma Center of Excellence, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts, United States
| | - Andrea K Ng
- Department of Radiation Oncology, Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, United States
| | - Phillip M Devlin
- Department of Radiation Oncology, Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, United States
| | - Elliott Fite
- Department of Radiation Oncology, Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, United States
| | - Guilherme Rabinowits
- Department of Medical Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, United States
| | - Glenn J Hanna
- Merkel Cell Carcinoma Center of Excellence, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts, United States; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, United States
| | - Ann W Silk
- Merkel Cell Carcinoma Center of Excellence, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts, United States; Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, United States
| | - Charles H Yoon
- Merkel Cell Carcinoma Center of Excellence, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts, United States; Division of Surgical Oncology, Department of Surgery, Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts, United States
| | - Manisha Thakuria
- Merkel Cell Carcinoma Center of Excellence, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts, United States; Department of Dermatology, Dana-Farber Cancer Institute, Boston, Massachusetts, United States
| | - Danielle N Margalit
- Department of Radiation Oncology, Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, United States; Merkel Cell Carcinoma Center of Excellence, Dana-Farber/Brigham & Women's Cancer Center, Boston, Massachusetts, United States.
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Milligan MG, Lennes IT, Hawari S, Khandekar MJ, Colson Y, Shepard JAO, Frank A, Sequist LV, Willers H, Keane FK. Incidence of Radiation Therapy Among Patients Enrolled in a Multidisciplinary Pulmonary Nodule and Lung Cancer Screening Clinic. JAMA Netw Open 2022; 5:e224840. [PMID: 35357454 PMCID: PMC8972030 DOI: 10.1001/jamanetworkopen.2022.4840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE The number of pulmonary nodules discovered incidentally or through screening programs has increased markedly. Multidisciplinary review and management are recommended, but the involvement of radiation oncologists in this context has not been defined. OBJECTIVE To assess the role of stereotactic body radiation therapy among patients enrolled in a lung cancer screening program. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study was performed at a pulmonary nodule and lung cancer screening clinic from October 1, 2012, to September 31, 2019. Referrals were based on chest computed tomography with Lung Imaging Reporting and Data System category 4 finding or an incidental nodule 6 mm or larger. A multidisciplinary team of practitioners from radiology, thoracic surgery, pulmonology, medical oncology, and radiation oncology reviewed all nodules and coordinated workup and treatment as indicated. EXPOSURES Patients referred to the pulmonary nodule and lung cancer screening clinic with an incidental or screen-detected pulmonary nodule. MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of patients undergoing therapeutic intervention with radiation therapy, stratified by the route of detection of their pulmonary nodules (incidental vs screen detected). Secondary outcomes were 2-year local control and metastasis-free survival. RESULTS Among 1150 total patients (median [IQR] age, 66.5 [59.3-73.7] years; 665 [57.8%] female; 1024 [89.0%] non-Hispanic White; 841 [73.1%] current or former smokers), 234 (20.3%) presented with screen-detected nodules and 916 (79.7%) with incidental nodules. For patients with screen-detected nodules requiring treatment, 41 (17.5%) received treatment, with 31 (75.6%) undergoing surgery and 10 (24.4%) receiving radiation therapy. Patients treated with radiation therapy were older (median [IQR] age, 73.8 [67.1 to 82.1] vs 67.6 [61.0 to 72.9] years; P < .001) and more likely to have history of tobacco use (67 [95.7%] vs 128 [76.6%]; P = .001) than those treated with surgery. Fifty-eight patients treated with radiation therapy (82.9%) were considered high risk for biopsy, and treatment recommendations were based on a clinical diagnosis of lung cancer after multidisciplinary review. All screened patients who received radiation therapy had stage I disease and were treated with stereotactic body radiation therapy. For all patients receiving stereotactic body radiation therapy, 2-year local control was 96.3% (95% CI, 91.1%-100%) and metastasis-free survival was 94.2% (95% CI, 87.7%-100%). CONCLUSIONS AND RELEVANCE In this unique prospective cohort, 1 in 4 patients with screen-detected pulmonary nodules requiring intervention were treated with stereotactic body radiation therapy. This finding highlights the role of radiation therapy in a lung cancer screening population and the importance of including radiation oncologists in the multidisciplinary management of pulmonary nodules.
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Affiliation(s)
- Michael G. Milligan
- Harvard Radiation Oncology Program, Boston, Massachusetts
- Department of Radiation Oncology, Massachusetts General Hospital, Boston
| | - Inga T. Lennes
- Department of Medicine, Division of Hematology-Oncology, Massachusetts General Hospital, Boston
| | - Saif Hawari
- Department of Medicine, Division of Hematology-Oncology, Massachusetts General Hospital, Boston
| | - Melin J. Khandekar
- Department of Radiation Oncology, Massachusetts General Hospital, Boston
| | - Yolonda Colson
- Department of Surgery, Massachusetts General Hospital, Boston
| | | | - Angela Frank
- Department of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston
| | - Lecia V. Sequist
- Department of Medicine, Division of Hematology-Oncology, Massachusetts General Hospital, Boston
| | - Henning Willers
- Department of Radiation Oncology, Massachusetts General Hospital, Boston
| | - Florence K. Keane
- Department of Radiation Oncology, Massachusetts General Hospital, Boston
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Milligan MG, Zieminski S, Johnson A, Depauw N, Rosado N, Specht MC, Liao EC, Jimenez RB. Target coverage and cardiopulmonary sparing with the updated ESTRO-ACROP contouring guidelines for postmastectomy radiation therapy after breast reconstruction: a treatment planning study using VMAT and proton PBS techniques. Acta Oncol 2021; 60:1440-1451. [PMID: 34313520 DOI: 10.1080/0284186x.2021.1957499] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The European Society for Therapeutic Radiology and Oncology Advisory Committee in Radiation Oncology Practice (ESTRO-ACROP) recently released new contouring guidelines for postmastectomy radiation therapy (PMRT) after implant-based reconstruction (IBR). As compared to prior ESTRO guidelines, the new guidelines primarily redefined the chest wall (CW) target to exclude the breast prosthesis. In this study, we assessed the impact of these changes on treatment planning and dosimetric outcomes using volumetric-modulated arc therapy (VMAT) and proton pencil-beam scanning (PBS) therapy. METHODS We performed a treatment planning study of 10 women with left-sided breast cancer who underwent PMRT after IBR. All target structures were delineated first using standard (ESTRO) breast contouring guidelines and then separately using the new (ESTRO-ACROP) guidelines. Standard organs-at-risk (OARs) and cardiac substructures were contoured. Four sets of plans were generated: (1) VMAT using standard ESTRO contours, (2) VMAT using new ESTRO-ACROP contours, (3) PBS using standard contours, and (4) PBS using new contours. RESULTS VMAT plans using the new ESTRO-ACROP guidelines resulted in modest sparing of the left anterior descending coronary artery (LAD) (mean dose: 6.99 Gy standard ESTRO vs. 6.08 Gy new ESTRO-ACROP, p = 0.010) and ipsilateral lung (V20: 21.66% vs 19.45%, p = 0.017), but similar exposure to the heart (mean dose: 4.6 Gy vs. 4.3 Gy, p = 0.513), with a trend toward higher contralateral lung (V5: 31.0% vs 35.3%, p = 0.331) and CW doses (V5: 31.9% vs 35.4%, p = 0.599). PBS plans using the new guidelines resulted in further sparing of the heart (mean dose: 1.05 Gy(RBE) vs. 0.54 Gy(RBE), p < 0.001), nearly all cardiac substructures (LAD mean dose: 2.01 Gy(RBE) vs. 0.66 Gy(RBE), p < 0.001), and ipsilateral lung (V20: 16.22% vs 6.02%, p < 0.001). CONCLUSIONS PMRT after IBR using the new ESTRO-ACROP contouring guidelines with both VMAT and PBS therapy is associated with significant changes in exposure to several cardiopulmonary structures.
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Affiliation(s)
- Michael G. Milligan
- Harvard Radiation Oncology Program, Boston, MA, USA
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Stephen Zieminski
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew Johnson
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Nicolas Depauw
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Nikki Rosado
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Michelle C. Specht
- Department of Surgery, Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Eric C. Liao
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Rachel B. Jimenez
- Harvard Radiation Oncology Program, Boston, MA, USA
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
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Franco I, Oladeru OT, Saraf A, Liu KX, Milligan MG, Wo JY, Zietman AL, Nguyen PL, Hirsch AE, Jimenez RB. RISE: An Equity and Inclusion-based Virtual Pipeline Program for Medical Students Underrepresented in Medicine. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.05.149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Liu KX, Everdell E, Pal S, Haas-Kogan DA, Milligan MG. Harnessing Lactate Metabolism for Radiosensitization. Front Oncol 2021; 11:672339. [PMID: 34367959 PMCID: PMC8343095 DOI: 10.3389/fonc.2021.672339] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 07/12/2021] [Indexed: 11/13/2022] Open
Abstract
Cancer cells rewire their metabolism to promote cell proliferation, invasion, and metastasis. Alterations in the lactate pathway have been characterized in diverse cancers, correlate with outcomes, and lead to many downstream effects, including decreasing oxidative stress, promoting an immunosuppressive tumor microenvironment, lipid synthesis, and building chemo- or radio-resistance. Radiotherapy is a key modality of treatment for many cancers and approximately 50% of patients with cancer will receive radiation for cure or palliation; thus, overcoming radio-resistance is important for improving outcomes. Growing research suggests that important molecular controls of the lactate pathway may serve as novel therapeutic targets and in particular, radiosensitizers. In this mini-review, we will provide an overview of lactate metabolism in cancer, discuss three important contributors to lactate metabolism (lactate dehydrogenase, monocarboxylate transporters, and mitochondrial pyruvate carrier), and present data that inhibition of these three pathways can lead to radiosensitization. Future research is needed to further understand critical regulators of lactate metabolism and explore clinical safety and efficacy of inhibitors of lactate dehydrogenase, monocarboxylate transporters, and mitochondrial pyruvate carrier alone and in combination with radiation.
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Affiliation(s)
- Kevin X Liu
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | | | - Sharmistha Pal
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Daphne A Haas-Kogan
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Michael G Milligan
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
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12
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Milligan MG, Cronin AM, Colson Y, Kehl K, Yeboa DN, Schrag D, Chen AB. Overuse of Diagnostic Brain Imaging Among Patients With Stage IA Non-Small Cell Lung Cancer. J Natl Compr Canc Netw 2021; 18:547-554. [PMID: 32380461 DOI: 10.6004/jnccn.2019.7384] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 12/04/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Among patients diagnosed with stage IA non-small cell lung cancer (NSCLC), the incidence of occult brain metastasis is low, and several professional societies recommend against brain imaging for staging purposes. The goal of this study was to characterize the use of brain imaging among Medicare patients diagnosed with stage IA NSCLC. METHODS Using data from linked SEER-Medicare claims, we identified patients diagnosed with AJCC 8th edition stage IA NSCLC in 2004 through 2013. Patients were classified as having received brain imaging if they underwent head CT or brain MRI from 1 month before to 3 months after diagnosis. We identified factors associated with receipt of brain imaging using multivariable logistic regression. RESULTS Among 13,809 patients with stage IA NSCLC, 3,417 (25%) underwent brain imaging at time of diagnosis. The rate of brain imaging increased over time, from 23.5% in 2004 to 28.7% in 2013 (P=.0006). There was significant variation in the use of brain imaging across hospital service areas, with rates ranging from 0% to 64.0%. Factors associated with a greater likelihood of brain imaging included older age (odds ratios [ORs] of 1.16 for 70-74 years, 1.13 for 75-79 years, 1.31 for 80-84 years, and 1.46 for ≥85 years compared with 65-69 years; all P<.05), female sex (OR, 1.09; P<.05), black race (OR 1.23; P<.05), larger tumor size (ORs of 1.23 for 11-20 mm and 1.28 for 21-30 mm tumors vs 1-10 mm tumors; all P<.05), and higher modified Charlson-Deyo comorbidity score (OR, 1.28 for score >1 vs score of 0; P<.05). CONCLUSIONS Roughly 1 in 4 patients with stage IA NSCLC received brain imaging at the time of diagnosis despite national recommendations against the practice. Although several patient factors are associated with receipt of brain imaging, there is significant geographic variation across the United States. Closer adherence to clinical guidelines is likely to result in more cost-effective care.
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Affiliation(s)
| | | | - Yolonda Colson
- Massachusetts General Hospital, Boston, Massachusetts; and
| | | | - Debra N Yeboa
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Aileen B Chen
- The University of Texas MD Anderson Cancer Center, Houston, Texas
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13
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Perni S, Milligan MG, Saraf A, Vivenzio T, Marques A, Baker MA, Kosak T, Bartlett S, Physic MA, Batchelder MR, McBride S, Bredfeldt J, Cail DW, Kearney MC, Whitehouse C, Orio P, Walsh G, Haas‐Kogan DA, Martin NE. Treating the SARS-CoV-2-positive patient with cancer: A proposal for a pragmatic and transparent ethical process. Cancer 2020; 126:3896-3899. [PMID: 32463478 PMCID: PMC7283895 DOI: 10.1002/cncr.32962] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 04/23/2020] [Indexed: 12/30/2022]
Abstract
The treatment of patients with cancer who test positive for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) poses unique challenges. In this commentary, the authors describe the ethical rationale and implementation details for the creation of a novel, multidisciplinary treatment prioritization committee, including physicians, frontline staff, an ethicist, and an infectious disease expert. Organizational obligations to health care workers also are discussed. The treatment prioritization committee sets a threshold of acceptable harm to patients from decreased cancer control that is justified to reduce risk to staff. The creation of an ethical, consistent, and transparent decision‐making process involving such frontline stakeholders is essential as departments across the country are faced with decisions regarding the treatment of SARS‐CoV‐2–positive patients with cancer. This commentary describes the ethical rationale and implementation details for a novel, multidisciplinary, treatment prioritization committee that makes treatment decisions regarding patients with cancer who are positive for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). This consistent, ethical, and transparent process could be adapted to any oncology department in which there is risk disparity between physician decision makers and the frontline staff who are implementing these decisions.
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Affiliation(s)
- Subha Perni
- Harvard Radiation Oncology ProgramHarvard UniversityBostonMassachusettsUSA
- Department of Radiation OncologyBrigham and Women's Hospital, Dana‐Farber Cancer Institute, Harvard Medical School, Harvard UniversityBostonMassachusettsUSA
| | - Michael G. Milligan
- Harvard Radiation Oncology ProgramHarvard UniversityBostonMassachusettsUSA
- Department of Radiation OncologyBrigham and Women's Hospital, Dana‐Farber Cancer Institute, Harvard Medical School, Harvard UniversityBostonMassachusettsUSA
| | - Anurag Saraf
- Harvard Radiation Oncology ProgramHarvard UniversityBostonMassachusettsUSA
- Department of Radiation OncologyBrigham and Women's Hospital, Dana‐Farber Cancer Institute, Harvard Medical School, Harvard UniversityBostonMassachusettsUSA
| | - Todd Vivenzio
- Department of Radiation OncologyBrigham and Women's Hospital, Dana‐Farber Cancer Institute, Harvard Medical School, Harvard UniversityBostonMassachusettsUSA
| | - Amy Marques
- Division of Infectious DiseasesDepartment of MedicineBrigham and Women's HospitalBostonMassachusettsUSA
| | - Meghan A. Baker
- Division of Infectious DiseasesDepartment of MedicineBrigham and Women's HospitalBostonMassachusettsUSA
- Department of Population MedicineHarvard Medical SchoolHarvard Pilgrim Health Care InstituteHarvard UniversityBostonMassachusettsUSA
| | - Tara Kosak
- Department of Radiation OncologyBrigham and Women's Hospital, Dana‐Farber Cancer Institute, Harvard Medical School, Harvard UniversityBostonMassachusettsUSA
| | - Sarah Bartlett
- Department of Radiation OncologyBrigham and Women's Hospital, Dana‐Farber Cancer Institute, Harvard Medical School, Harvard UniversityBostonMassachusettsUSA
| | - Michelle A. Physic
- Department of Radiation OncologyBrigham and Women's Hospital, Dana‐Farber Cancer Institute, Harvard Medical School, Harvard UniversityBostonMassachusettsUSA
| | - Monica R. Batchelder
- Department of Radiation OncologyBrigham and Women's Hospital, Dana‐Farber Cancer Institute, Harvard Medical School, Harvard UniversityBostonMassachusettsUSA
| | - Sean McBride
- Department of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Jeremy Bredfeldt
- Department of Radiation OncologyBrigham and Women's Hospital, Dana‐Farber Cancer Institute, Harvard Medical School, Harvard UniversityBostonMassachusettsUSA
| | - Daniel W. Cail
- Department of Radiation OncologyBrigham and Women's Hospital, Dana‐Farber Cancer Institute, Harvard Medical School, Harvard UniversityBostonMassachusettsUSA
| | - Meghan C. Kearney
- Department of Radiation OncologyBrigham and Women's Hospital, Dana‐Farber Cancer Institute, Harvard Medical School, Harvard UniversityBostonMassachusettsUSA
| | - Colleen Whitehouse
- Department of Radiation OncologyBrigham and Women's Hospital, Dana‐Farber Cancer Institute, Harvard Medical School, Harvard UniversityBostonMassachusettsUSA
| | - Peter Orio
- Department of Radiation OncologyBrigham and Women's Hospital, Dana‐Farber Cancer Institute, Harvard Medical School, Harvard UniversityBostonMassachusettsUSA
| | - Gerard Walsh
- Department of Radiation OncologyBrigham and Women's Hospital, Dana‐Farber Cancer Institute, Harvard Medical School, Harvard UniversityBostonMassachusettsUSA
| | - Daphne A. Haas‐Kogan
- Department of Radiation OncologyBrigham and Women's Hospital, Dana‐Farber Cancer Institute, Harvard Medical School, Harvard UniversityBostonMassachusettsUSA
| | - Neil E. Martin
- Department of Radiation OncologyBrigham and Women's Hospital, Dana‐Farber Cancer Institute, Harvard Medical School, Harvard UniversityBostonMassachusettsUSA
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14
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Milligan MG, Bigger E, Abramson JS, Sohani AR, Zola M, Kayembe MK, Medhin H, Suneja G, Lockman S, Chabner BA, Dryden-Peterson SL. Impact of HIV Infection on the Clinical Presentation and Survival of Non-Hodgkin Lymphoma: A Prospective Observational Study From Botswana. J Glob Oncol 2018; 4:1-11. [PMID: 30241264 PMCID: PMC6223476 DOI: 10.1200/jgo.17.00084] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
PURPOSE Botswana has a high prevalence of HIV infection. Currently, there are few data regarding the sociodemographic factors, clinical characteristics, and outcomes of non-Hodgkin lymphoma (NHL)-an AIDS-defining cancer-in the country. PATIENTS AND METHODS This study used a prospective cancer registry to identify patients with a new diagnosis of NHL reporting for specialty cancer care at three hospitals in Botswana between October 2010 and August 2016. Treatment patterns and clinical outcomes were analyzed. RESULTS One hundred four patients with a new diagnosis of NHL were enrolled in this study, 72% of whom had HIV infection. Compared with patients not infected with HIV, patients infected with HIV were younger (median age, 53.9 v 39.1 years; P = .001) and more likely to present with an aggressive subtype of NHL (65.5% v 84.0%; P = .008). All patients infected with HIV received combined antiretroviral therapy throughout the course of the study, and similar chemotherapeutic regimens were recommended for all patients, regardless of subtype or HIV status (six to eight cycles of cyclophosphamide, doxorubicin, vincristine, and prednisone; or cyclophosphamide, doxorubicin, vincristine, and prednisone plus rituximab). There was no difference in 1-year mortality among patients not infected with HIV and patients infected with HIV (unadjusted analysis, 52.9% v 37.1%; hazard ratio [HR], 0.73; P = .33; adjusted analysis, HR, 0.57; P = .14). However, when compared with a cohort of patients in the United States matched by subtype, stage, age, sex, and race, patients in Botswana fared worse (1-year mortality, 22.8% v 46.3%; HR, 1.89; P = .001). CONCLUSION Among patients with NHL reporting for specialty cancer care in Botswana, there is no association between HIV status and 1-year survival.
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Affiliation(s)
- Michael G. Milligan
- Michael G. Milligan, Jeremy S. Abramson,
Aliyah R. Sohani, Shahin Lockman, Bruce A.
Chabner, and Scott L. Dryden-Peterson, Harvard Medical
School; Elizabeth Bigger, Jeremy S. Abramson, and
Aliyah R. Sohani, Massachusetts General Hospital; Shahin
Lockman and Scott L. Dryden-Peterson, Brigham and
Women’s Hospital and Harvard T.H. Chan School of Public Health, Boston,
MA; Michael G. Milligan, Elizabeth Bigger,
Shahin Lockman, Bruce A. Chabner, and Scott
L. Dryden-Peterson, Botswana Harvard AIDS Institute Partnership;
Musimar Zola, Princess Marina Hospital; Mukendi K.A. Kayembe and
Heluf Medhin, Botswana Ministry of Health, Gaborone, Botswana;
and Gita Suneja, Duke University, Durham, NC
| | - Elizabeth Bigger
- Michael G. Milligan, Jeremy S. Abramson,
Aliyah R. Sohani, Shahin Lockman, Bruce A.
Chabner, and Scott L. Dryden-Peterson, Harvard Medical
School; Elizabeth Bigger, Jeremy S. Abramson, and
Aliyah R. Sohani, Massachusetts General Hospital; Shahin
Lockman and Scott L. Dryden-Peterson, Brigham and
Women’s Hospital and Harvard T.H. Chan School of Public Health, Boston,
MA; Michael G. Milligan, Elizabeth Bigger,
Shahin Lockman, Bruce A. Chabner, and Scott
L. Dryden-Peterson, Botswana Harvard AIDS Institute Partnership;
Musimar Zola, Princess Marina Hospital; Mukendi K.A. Kayembe and
Heluf Medhin, Botswana Ministry of Health, Gaborone, Botswana;
and Gita Suneja, Duke University, Durham, NC
| | - Jeremy S. Abramson
- Michael G. Milligan, Jeremy S. Abramson,
Aliyah R. Sohani, Shahin Lockman, Bruce A.
Chabner, and Scott L. Dryden-Peterson, Harvard Medical
School; Elizabeth Bigger, Jeremy S. Abramson, and
Aliyah R. Sohani, Massachusetts General Hospital; Shahin
Lockman and Scott L. Dryden-Peterson, Brigham and
Women’s Hospital and Harvard T.H. Chan School of Public Health, Boston,
MA; Michael G. Milligan, Elizabeth Bigger,
Shahin Lockman, Bruce A. Chabner, and Scott
L. Dryden-Peterson, Botswana Harvard AIDS Institute Partnership;
Musimar Zola, Princess Marina Hospital; Mukendi K.A. Kayembe and
Heluf Medhin, Botswana Ministry of Health, Gaborone, Botswana;
and Gita Suneja, Duke University, Durham, NC
| | - Aliyah R. Sohani
- Michael G. Milligan, Jeremy S. Abramson,
Aliyah R. Sohani, Shahin Lockman, Bruce A.
Chabner, and Scott L. Dryden-Peterson, Harvard Medical
School; Elizabeth Bigger, Jeremy S. Abramson, and
Aliyah R. Sohani, Massachusetts General Hospital; Shahin
Lockman and Scott L. Dryden-Peterson, Brigham and
Women’s Hospital and Harvard T.H. Chan School of Public Health, Boston,
MA; Michael G. Milligan, Elizabeth Bigger,
Shahin Lockman, Bruce A. Chabner, and Scott
L. Dryden-Peterson, Botswana Harvard AIDS Institute Partnership;
Musimar Zola, Princess Marina Hospital; Mukendi K.A. Kayembe and
Heluf Medhin, Botswana Ministry of Health, Gaborone, Botswana;
and Gita Suneja, Duke University, Durham, NC
| | - Musimar Zola
- Michael G. Milligan, Jeremy S. Abramson,
Aliyah R. Sohani, Shahin Lockman, Bruce A.
Chabner, and Scott L. Dryden-Peterson, Harvard Medical
School; Elizabeth Bigger, Jeremy S. Abramson, and
Aliyah R. Sohani, Massachusetts General Hospital; Shahin
Lockman and Scott L. Dryden-Peterson, Brigham and
Women’s Hospital and Harvard T.H. Chan School of Public Health, Boston,
MA; Michael G. Milligan, Elizabeth Bigger,
Shahin Lockman, Bruce A. Chabner, and Scott
L. Dryden-Peterson, Botswana Harvard AIDS Institute Partnership;
Musimar Zola, Princess Marina Hospital; Mukendi K.A. Kayembe and
Heluf Medhin, Botswana Ministry of Health, Gaborone, Botswana;
and Gita Suneja, Duke University, Durham, NC
| | - Mukendi K.A. Kayembe
- Michael G. Milligan, Jeremy S. Abramson,
Aliyah R. Sohani, Shahin Lockman, Bruce A.
Chabner, and Scott L. Dryden-Peterson, Harvard Medical
School; Elizabeth Bigger, Jeremy S. Abramson, and
Aliyah R. Sohani, Massachusetts General Hospital; Shahin
Lockman and Scott L. Dryden-Peterson, Brigham and
Women’s Hospital and Harvard T.H. Chan School of Public Health, Boston,
MA; Michael G. Milligan, Elizabeth Bigger,
Shahin Lockman, Bruce A. Chabner, and Scott
L. Dryden-Peterson, Botswana Harvard AIDS Institute Partnership;
Musimar Zola, Princess Marina Hospital; Mukendi K.A. Kayembe and
Heluf Medhin, Botswana Ministry of Health, Gaborone, Botswana;
and Gita Suneja, Duke University, Durham, NC
| | - Heluf Medhin
- Michael G. Milligan, Jeremy S. Abramson,
Aliyah R. Sohani, Shahin Lockman, Bruce A.
Chabner, and Scott L. Dryden-Peterson, Harvard Medical
School; Elizabeth Bigger, Jeremy S. Abramson, and
Aliyah R. Sohani, Massachusetts General Hospital; Shahin
Lockman and Scott L. Dryden-Peterson, Brigham and
Women’s Hospital and Harvard T.H. Chan School of Public Health, Boston,
MA; Michael G. Milligan, Elizabeth Bigger,
Shahin Lockman, Bruce A. Chabner, and Scott
L. Dryden-Peterson, Botswana Harvard AIDS Institute Partnership;
Musimar Zola, Princess Marina Hospital; Mukendi K.A. Kayembe and
Heluf Medhin, Botswana Ministry of Health, Gaborone, Botswana;
and Gita Suneja, Duke University, Durham, NC
| | - Gita Suneja
- Michael G. Milligan, Jeremy S. Abramson,
Aliyah R. Sohani, Shahin Lockman, Bruce A.
Chabner, and Scott L. Dryden-Peterson, Harvard Medical
School; Elizabeth Bigger, Jeremy S. Abramson, and
Aliyah R. Sohani, Massachusetts General Hospital; Shahin
Lockman and Scott L. Dryden-Peterson, Brigham and
Women’s Hospital and Harvard T.H. Chan School of Public Health, Boston,
MA; Michael G. Milligan, Elizabeth Bigger,
Shahin Lockman, Bruce A. Chabner, and Scott
L. Dryden-Peterson, Botswana Harvard AIDS Institute Partnership;
Musimar Zola, Princess Marina Hospital; Mukendi K.A. Kayembe and
Heluf Medhin, Botswana Ministry of Health, Gaborone, Botswana;
and Gita Suneja, Duke University, Durham, NC
| | - Shahin Lockman
- Michael G. Milligan, Jeremy S. Abramson,
Aliyah R. Sohani, Shahin Lockman, Bruce A.
Chabner, and Scott L. Dryden-Peterson, Harvard Medical
School; Elizabeth Bigger, Jeremy S. Abramson, and
Aliyah R. Sohani, Massachusetts General Hospital; Shahin
Lockman and Scott L. Dryden-Peterson, Brigham and
Women’s Hospital and Harvard T.H. Chan School of Public Health, Boston,
MA; Michael G. Milligan, Elizabeth Bigger,
Shahin Lockman, Bruce A. Chabner, and Scott
L. Dryden-Peterson, Botswana Harvard AIDS Institute Partnership;
Musimar Zola, Princess Marina Hospital; Mukendi K.A. Kayembe and
Heluf Medhin, Botswana Ministry of Health, Gaborone, Botswana;
and Gita Suneja, Duke University, Durham, NC
| | - Bruce A. Chabner
- Michael G. Milligan, Jeremy S. Abramson,
Aliyah R. Sohani, Shahin Lockman, Bruce A.
Chabner, and Scott L. Dryden-Peterson, Harvard Medical
School; Elizabeth Bigger, Jeremy S. Abramson, and
Aliyah R. Sohani, Massachusetts General Hospital; Shahin
Lockman and Scott L. Dryden-Peterson, Brigham and
Women’s Hospital and Harvard T.H. Chan School of Public Health, Boston,
MA; Michael G. Milligan, Elizabeth Bigger,
Shahin Lockman, Bruce A. Chabner, and Scott
L. Dryden-Peterson, Botswana Harvard AIDS Institute Partnership;
Musimar Zola, Princess Marina Hospital; Mukendi K.A. Kayembe and
Heluf Medhin, Botswana Ministry of Health, Gaborone, Botswana;
and Gita Suneja, Duke University, Durham, NC
| | - Scott L. Dryden-Peterson
- Michael G. Milligan, Jeremy S. Abramson,
Aliyah R. Sohani, Shahin Lockman, Bruce A.
Chabner, and Scott L. Dryden-Peterson, Harvard Medical
School; Elizabeth Bigger, Jeremy S. Abramson, and
Aliyah R. Sohani, Massachusetts General Hospital; Shahin
Lockman and Scott L. Dryden-Peterson, Brigham and
Women’s Hospital and Harvard T.H. Chan School of Public Health, Boston,
MA; Michael G. Milligan, Elizabeth Bigger,
Shahin Lockman, Bruce A. Chabner, and Scott
L. Dryden-Peterson, Botswana Harvard AIDS Institute Partnership;
Musimar Zola, Princess Marina Hospital; Mukendi K.A. Kayembe and
Heluf Medhin, Botswana Ministry of Health, Gaborone, Botswana;
and Gita Suneja, Duke University, Durham, NC
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