Core Outcomes for Colorectal Cancer Surgery: A Consensus Study

BACKGROUND

Colorectal cancer (CRC) is a major cause of worldwide morbidity and mortality. Surgical treatment is common, and there is a great need to improve the delivery of such care. The gold standard for evaluating surgery is within well-designed randomized controlled trials (RCTs); however, the impact of RCTs is diminished by a lack of coordinated outcome measurement and reporting. A solution to these issues is to develop an agreed standard "core" set of outcomes to be measured in all trials to facilitate cross-study comparisons, meta-analysis, and minimize outcome reporting bias. This study defines a core outcome set for CRC surgery.

METHODS AND FINDINGS

The scope of this COS includes clinical effectiveness trials of surgical interventions for colorectal cancer. Excluded were nonsurgical oncological interventions. Potential outcomes of importance to patients and professionals were identified through systematic literature reviews and patient interviews. All outcomes were transcribed verbatim and categorized into domains by two independent researchers. This informed a questionnaire survey that asked stakeholders (patients and professionals) from United Kingdom CRC centers to rate the importance of each domain. Respondents were resurveyed following group feedback (Delphi methods). Outcomes rated as less important were discarded after each survey round according to predefined criteria, and remaining outcomes were considered at three consensus meetings; two involving international professionals and a separate one with patients. A modified nominal group technique was used to gain the final consensus. Data sources identified 1,216 outcomes of CRC surgery that informed a 91 domain questionnaire. First round questionnaires were returned from 63 out of 81 (78%) centers, including 90 professionals, and 97 out of 267 (35%) patients. Second round response rates were high for all stakeholders (>80%). Analysis of responses lead to 45 and 23 outcome domains being retained after the first and second surveys, respectively. Consensus meetings generated agreement on a 12 domain COS. This constituted five perioperative outcome domains (including anastomotic leak), four quality of life outcome domains (including fecal urgency and incontinence), and three oncological outcome domains (including long-term survival).

CONCLUSION

This study used robust consensus methodology to develop a core outcome set for use in colorectal cancer surgical trials. It is now necessary to validate the use of this set in research practice.

Terminology-Based Recording of Clinical Data for Multiple Purposes Within Oncology

INTRODUCTION

Collecting clinical data once for the use in both electronic health record (EHR) and registries requires semantic interoperability. This paper presents the results of a systematic semantic analysis of similarities and differences in clinical documentation across regional EHR and a national oncology registry to assess options for an integration of recording templates.

METHODS

A comparison of current clinical information in EHR and the national registry was carried out, using SNOMED CT as frame of reference to find exact-, similar- and non-match.

RESULTS

Exact match was found for 9 out of 19 items from the registry and EHR, relating to clinical history, observations and findings at the examination and tumor control. Similar match concerned clinical findings of more common side effects to therapy whether present or absent. Both EHR and the registry had information with no compared match.

CONCLUSION

Clinical documentation during a follow-up in head and neck cancer contains a core set of items recorded in both EHR and registry, representing clinical history, observations and more common side effects and tumor evaluation. These core items could be the point of departure for integration or re-design of EHR-systems.

Does Cancer Literature Reflect Multidisciplinary Practice? A Systematic Review of Oncology Studies in the Medical Literature Over a 20-Year Period

PURPOSE

Quality cancer care is best delivered through a multidisciplinary approach requiring awareness of current evidence for all oncologic specialties. The highest impact journals often disseminate such information, so the distribution and characteristics of oncology studies by primary intervention (local therapies, systemic therapies, and targeted agents) were evaluated in 10 high-impact journals over a 20-year period.

METHODS AND MATERIALS

Articles published in 1994, 2004, and 2014 in New England Journal of Medicine, Lancet, Journal of the American Medical Association, Lancet Oncology, Journal of Clinical Oncology, Annals of Oncology, Radiotherapy and Oncology, International Journal of Radiation Oncology, Biology, Physics, Annals of Surgical Oncology, and European Journal of Surgical Oncology were identified. Included studies were prospectively conducted and evaluated a therapeutic intervention.

RESULTS

A total of 960 studies were included: 240 (25%) investigated local therapies, 551 (57.4%) investigated systemic therapies, and 169 (17.6%) investigated targeted therapies. More local therapy trials (n=185 [77.1%]) evaluated definitive, primary treatment than systemic (n=178 [32.3%]) or targeted therapy trials (n=38 [22.5%]; P<.001). Local therapy trials (n=16 [6.7%]) also had significantly lower rates of industry funding than systemic (n=207 [37.6%]) and targeted therapy trials (n=129 [76.3%]; P<.001). Targeted therapy trials represented 5 (2%), 38 (10.2%), and 126 (38%) of those published in 1994, 2004, and 2014, respectively (P<.001), and industry-funded 48 (18.9%), 122 (32.6%), and 182 (54.8%) trials, respectively (P<.001). Compared to publication of systemic therapy trial articles, articles investigating local therapy (odds ratio: 0.025 [95% confidence interval: 0.012-0.048]; P<.001) were less likely to be found in high-impact general medical journals.

CONCLUSIONS

Fewer studies evaluating local therapies, such as surgery and radiation, are published in high-impact oncology and medicine literature. Further research and attention are necessary to guide efforts promoting appropriate representation of all oncology studies in high-impact, broad-readership journals.

Key statistical concepts in cancer research

In this article, we provide a high-level overview of statistical concepts related to study design and data analysis in oncology research. These concepts are discussed for 2 main types of clinical research: (1) observational studies, which focus on biomarker discovery in order to predict disease risk and prognosis, and (2) prospectively designed, well-controlled clinical trials, which are critical for the development of new cancer treatments. Throughout the article, we emphasize the importance of appropriate design and prospectively determined analysis plans. We also hope to promote effective collaboration between oncology investigators and statisticians who center their research on the development of cancer treatments.

Breast cancer specialists' views on and use of risk prediction models in clinical practice: a mixed methods approach

Purpose

Risk prediction models (RPM) in breast cancer quantify survival benefit from adjuvant systemic treatment. These models [e.g. Adjuvant! Online (AO)] are increasingly used during consultations, despite their not being designed for such use. As still little is known about oncologists' views on and use of RPM to communicate prognosis to patients, we investigated if, why, and how they use RPM.

Methods

We disseminated an online questionnaire that was based on the literature and individual and group interviews with oncologists.

Results

Fifty-one oncologists (partially) completed the questionnaire. AO is the best known (95%) and most frequently used RPM (96%). It is used to help oncologists decide whether or not to recommend chemotherapy (> 85%), to inform (86%) and help patients decide about treatment (> 80%), or to persuade them to follow the proposed course of treatment (74%). Most oncologists (74%) believe that using AO helps patients understand their prognosis.

Conclusion

RPM have found a place in daily practice, especially AO. Oncologists think that using AO helps patients understand their prognosis, yet studies suggest that this is not always the case. Our findings highlight the importance of exploring whether patients understand the information that RPM provide.

How well is palliative care integrated into cancer care? A MASCC, ESMO, and EAPC Project

INTRODUCTION

The benefits of integration of palliative care into oncology have become evidence-based. How palliative care is perceived and structured in various settings and countries would be of interest.

METHOD

We used a previously published questionnaire to survey multiple institutions with members in MASCC and ESMO. The survey was made available on the MASCC website for approximately 6 months and repeated requests were made to complete the survey. Comparisons were made between NCI/ESMO designated cancer centers, nondesignated cancer centers, and urban hospitals.

RESULTS

One hundred eighty-three different institutions completed this survey, 28 % of ESMO designated centers. Most institutions had palliative care programs and most programs consisted of an inpatient consult service and outpatient clinics. A minority had inpatient palliative care beds and institution supported hospice services. Barriers to palliative care were largely financial. Integration of palliative care into oncology was highly desirable but only a minority of respondents felt that their institution would financially support expanded services and additional palliative care personnel. Designated centers were more likely to have expanded palliative care services.

DISCUSSION

Our findings are very similar to those previously published. Multiple studies have demonstrated that though palliative care integration into oncology is highly beneficial as measured by patient related outcomes, there is a great concern about reimbursement for services and budget constraints which prevent expansion of services.

CONCLUSION

Palliative care integration into cancer care is largely through consulting services for inpatients and outpatient clinics. Financial concerns limit integration and expansion of palliative care services. Designated cancer centers have more extensive palliative care services relative to nondesignated cancer centers and urban hospitals.

[Mental health in the hospital. Analysis of conditions of risk by department, age and gender, for the creation of best practices for the health of nurses]

BACKGROUND

Nurses mental health is still a major and unachieved goal in many public hospital settings. Hospital work organization analysis shows differences in health professions, hospital units, age and gender.

OBJECTIVES

To analyse work organisation and its effects on nurses mental health in three high risks hospital units (Oncoematology, First Aid, General Medicine) in order to improve good practices for nurses health.

METHODS

The Method of Organizational Congruences (72 hours of observation) has been used to detect organizational constraints and their possible effects on nurses' mental health. General Health Questionnaire (Goldberg D., 12 items) and the Check up Surveys for burnout (Leiter MP and Maslach C.) have been used to evaluate the mental health status of the 80 nurses employed (78% women).

RESULTS

High emotional work load in oncoematology Unit, high monotony and repetitiveness with lower emotional load in first Aid Unit, High mental and physical workload in General Medicine Unit. Burnout was significantly higher in General Medicine Unit, followed by First Aid Unit and oncoematology Unit. Female nurses reported more chronic diseases than males. The GHQ showed high frequency of minor psychiatric disorders (58%) in all units, higher in General Medicine Unit (78%).

CONCLUSION

The overall results show how organizational constraints and mental health conditions differ per hospital units, age groups and gender. Good nursing practices, to prevent mental health problems, should therefore be developed specifically in each hospital unit according to these results.

Comparison of anticipated and actual control group outcomes in randomised trials in paediatric oncology provides evidence that historically controlled studies are biased in favour of the novel treatment

BACKGROUND

Historically controlled studies are commonly undertaken in paediatric oncology, despite their potential biases. Our aim was to compare the outcome of the control group in randomised controlled trials (RCTs) in paediatric oncology with those anticipated in the sample size calculations in the protocols. Our rationale was that, had these RCTs been performed as historical control studies instead, the available outcome data used to calculate the sample size in the RCT would have been used as the historical control outcome data.

METHODS

A systematic search was undertaken for published paediatric oncology RCTs using the Cochrane Central Register of Controlled Trials (CENTRAL) database from its inception up to July 2013. Data on sample size assumptions and observed outcomes (timetoevent and proportions) were extracted to calculate differences between randomised and historical control outcomes, and a one-sample t-test was employed to assess whether the difference between anticipated and observed control groups differed from zero.

RESULTS

Forty-eight randomised questions were included. The median year of publication was 2005, and the range was from 1976 to 2010. There were 31 superiority and 11 equivalence/noninferiority randomised questions with time-to-event outcomes. The median absolute difference between observed and anticipated control outcomes was 5.0% (range: -23 to +34), and the mean difference was 3.8% (95% CI: +0.57 to +7.0; P = 0.022).

CONCLUSIONS

Because the observed control group (that is, standard treatment arm) in RCTs performed better than anticipated, we found that historically controlled studies that used similar assumptions for the standard treatment were likely to overestimate the benefit of new treatments, potentially leading to children with cancer being given ineffective therapy that may have additional toxicity.

A survey of Italian radiation oncologists: job satisfaction and burnout

AIMS AND BACKGROUND

Job satisfaction and burnout can greatly affect the quality of life of professionals involved in the medical field and can also have an impact on many aspects of the work. The aim of the present study was to investigate professional history, professional satisfaction and burnout in Italian radiation oncologists.

METHODS AND STUDY DESIGN

Members of the Italian Association of Radiation Oncology (AIRO) were asked to complete a questionnaire composed of three sections including personal and professional information, the Job Satisfaction Scale (JSS) and the Link Burnout Questionnaire (LBQ).

RESULTS

The 167 participants were prevalently males working in public hospitals. About half of participants were staff physicians, mainly with no other specialty. Concerning the JSS, most respondents were moderately to extremely satisfied with their job. With regard to the LBQ, instead, we found critical results in the four investigated dimensions (psychophysical exhaustion, relation deterioration, professional failure and disillusion).

CONCLUSIONS

This study suggests that Italian radiation oncologists have good medical background and education levels with a deep understanding of working in a clinical discipline. Organizational factors and the work climate are the main determinants of the satisfaction level and burnout is limited to a small percentage of professionals. The identification of specific profiles for professionals with higher levels of burnout or poorer job satisfaction may allow the delivery of targeted prevention or support interventions with the aim of improving workers' quality of life, satisfaction and perception of effectiveness.

Survey of referral patterns and attitudes toward hyperbaric oxygen treatment among Danish oncologists, ear, nose and throat surgeons and oral and maxillofacial surgeons

In head and neck cancer patients with late radiation injury, hyperbaric oxygen (HBO) is used for therapeutic or prophylactic reasons against soft-tissue and osteoradionecrosis (ORN). Twenty-nine departments of oncology, ENT, oral and maxillofacial (OMF) surgery were surveyed using the Enalyzer tool (www.enalyzer.com), of whom 21 responded. Data were incomplete in four returns. Within the previous year, 14 departments had referred at least one patient for hyperbaric oxygen therapy (HBOT). There appears to be a generally positive attitude in Danish OMF, ENT and oncology departments towards referral of patients with ORN for HBOT. However, there is an increasing desire for better evidence for its role in head and neck cancer in the prevention and treatment of soft-tissue injury and osteonecrosis following radiotherapy.

A survey of the practice patterns of gynecologic oncologists dealing with hereditary cancer patients in Japan

Hereditary breast and ovarian cancer syndrome (HBOC) is a significant type of familial ovarian cancer. A survey of gynecologic oncologists was conducted in order to characterize the state of care and awareness of information provision for HBOC in Japan and to identify information necessary to enhance HBOC care. All gynecologic oncologists certified by the Japan Society of Gynecologic Oncology (JSGO) as specialists in the treatment of ovarian cancer were included. They were sent a 44-question questionnaire dealing with the background of the respondent, the facilities at the respondent's medical institution, how the family history interview is conducted, awareness of and practice behavior toward HBOC, performance of genetic testing, and performance of risk-reducing salpingo-oophorectomy (RRSO). The response rate was 50.1 %. About 60 % of respondents stated that "I administer care with HBOC in mind" and "I want to be involved in the care of HBOC." However, only 2 in 3 doctors was able to explain HBOC to patients, fewer than 1 in 5 doctors was able to give counseling to patients, 1 in 10 doctors provided printed information to patients suspected of having a hereditary cancer, and 1 in 7 doctors recommended that patients suspected of having a hereditary cancer visit the department of genetics. The provision of information to patients, recommending that patients visit the department of genetics, and the performance of genetic testing were dependent on whether a department of genetics was present in the respondent's institution. The survey also found that RRSO is not widely performed in Japan.

Health utilities in gynecological oncology and mastology in Germany

BACKGROUND AND AIMS

Cost increases in the healthcare system are leading to a need to distribute financial resources in accordance with the value of each service performed. Health-economic decision-making models can support these decisions. Due to the previous unavailability of health utilities in Germany (scored states of health as a basis for calculating quality-adjusted life-years, QALYs) for women undergoing treatment, international data are often used for such models. However, these may widely deviate from the values for a woman actually living in Germany. It is, therefore, necessary to collect and analyze health utilities in Germany.

MATERIALS AND METHODS

In a questionnaire survey, health utilities were collected, along with data for a healthy control group, for 580 female patients receiving treatment in the fields of mastology and gynecological oncology using a German version of the EuroQol questionnaire (EQ-5D) and a visual analogue scale (VAS). Data were also collected for the patients' medical history, tumor disease, and treatment.

RESULTS

Significant differences with regard to quality of life were measured in relation to the individual tumor entities and in comparison to the controls. Apart from the healthy control group, patients with breast or cervical carcinoma had the best quality of life. In patients with recurrent and metastatic disease, those with breast carcinoma experienced the greatest impairment of their quality of life. According to current treatment, the most important impairment of life quality occurred in patients under radiotherapy and after surgical treatment. There are significant differences from the health utilities recorded for other countries - for example, the state of health declines much more markedly in patients with metastatic disease among American women with breast carcinoma than among German women, in whom recurrent disease and a first diagnosis of metastasis were comparable. Overall, the VAS was able to distinguish more adequately than the EQ-5D questionnaire between the different situations and impairments resulting from diagnosis and therapy.

CONCLUSION

Health utilities are now, for the first time, available for further health-economics analyses in the field of gynecological oncology and mastology for women living in Germany. Important differences in these utilities from those of other countries are evident.

Patient surveillance after initial breast cancer therapy: variation by physician specialty

BACKGROUND

American Society of Clinical Oncology (ASCO) guidelines recommend only office visits and mammograms as the primary modalities for patient surveillance after treatment for breast carcinoma. This study aimed to quantify differences in posttreatment surveillance among medical oncologists, radiation oncologists, and surgeons.

METHODS

We e-mailed a survey to the 3,245 ASCO members who identified themselves as having breast cancer as a major focus of their practices. Questions assessed the frequency of use of 12 specific surveillance modalities for 5 posttreatment years.

RESULTS

Of 1,012 total responses, 846 were evaluable: 5% from radiation oncologists, 70% from medical oncologists, and 10% from surgeons; 15% were unspecified. Marked variation in surveillance practices were noted within each specialty and among specialties.

CONCLUSION

There are notable variations in surveillance intensity. This suggests overuse or underuse or misuse of scarce medical resources.

Physician roles in the cancer-related follow-up care of cancer survivors

BACKGROUND AND OBJECTIVES

Information about primary care physicians' (PCPs) and oncologists' involvement in cancer-related follow-up care, and care coordination practices, is lacking but essential to improving cancer survivors' care. This study assesses PCPs' and oncologists' self-reported roles in providing cancer-related follow-up care for survivors who are within 5 years of completing cancer treatment.

METHODS

In 2009, the National Cancer Institute and the American Cancer Society conducted a nationally representative survey of PCPs (n=1,014) and medical oncologists (n=1,125) (response rate=57.6%, cooperation rate=65.1%). Mailed questionnaires obtained information on physicians' roles in providing cancer-related follow-up care to early-stage breast and colon cancer survivors, personal and practice characteristics, beliefs about and preferences for follow-up care, and care coordination practices.

RESULTS

More than 50% of PCPs reported providing cancer-related follow-up care for survivors, mainly by co-managing with an oncologist. In contrast, more than 70% of oncologists reported fulfilling these roles by providing the care themselves. In adjusted analyses, PCP co-management was associated with specialty, training in late or long-term effects of cancer, higher cancer patient volume, favorable attitudes about PCP care involvement, preference for a shared model of survivorship care, and receipt of treatment summaries from oncologists. Among oncologists, only preference for a shared care model was associated with co-management with PCPs.

CONCLUSIONS

PCPs and oncologists differ in their involvement in cancer-related follow-up care of survivors, with co-management more often reported by PCPs than by oncologists. Given anticipated national shortages of PCPs and oncologists, study results suggest that improved communication and coordination between these providers is needed to ensure optimal delivery of follow-up care to cancer survivors.

Family physicians who have focused practices in oncology: results of a national survey

OBJECTIVE

To characterize the demographic characteristics, practice profile, and current work life of general practitioners in oncology (GPOs) for the first time.

DESIGN

National Web survey performed in March 2011.

SETTING

Canada.

PARTICIPANTS

Members of the national GPO organization. Respondents were asked to forward the survey to non-member colleagues.

MAIN OUTCOME MEASURES

Profile of work as GPOs and in other medical roles, training received, demographic characteristics, and professional satisfaction.

RESULTS

The response rate was 73.3% for members of the Canadian Association of General Practitioners in Oncology; overall, 120 surveys were completed. Respondents worked in similar proportions in small and larger communities. About 60% of them had participated in formal training programs. Most respondents worked part-time as GPOs and also worked in other medical roles, particularly palliative care, primary care practice, teaching, and hospital work. More GPOs from cities with populations of greater than 100 000 worked solely as GPOs than those from smaller communities (P = .0057). General practitioners in oncology played a variety of roles in the cancer care system, particularly in systemic therapy, palliative care, inpatient care, and teaching. As a group, more than half of respondents were involved in the care of each of the 11 common cancer types. Overall, 87.8% of respondents worked in outpatient care, 59.1% provided inpatient care, and 33.0% provided on-call services; 92.8% were satisfied with their work as GPOs.

CONCLUSION

General practitioners in oncology are involved in all cancer care settings and usually combine this work with other roles, particularly with palliative care in rural Canada. Training is inconsistent but initiatives are under way to address this. Job satisfaction is better than that of Canadian FPs in general. As generalists, FPs bring a valuable skill set to their work as GPOs in the cancer care system.

Disparities in use of gynecologic oncologists for women with ovarian cancer in the United States

OBJECTIVE

To examine disparities in utilization of gynecologic oncologists (GOs) across race and other sociodemographic factors for women with ovarian cancer.

DATA SOURCES

Obtained SEER-Medicare linked dataset for 4,233 non-Hispanic White, non-Hispanic African American, Hispanic of any race, and Non-Hispanic Asian women aged ≥ 66 years old diagnosed with ovarian cancer during 2000-2002 from 17 SEER registries. Physician specialty was identified by linking data to the AMA master file using Unique Physician Identification Numbers.

STUDY DESIGN

Retrospective claims data analysis for 1999-2006. Logistic regression models were used to analyze the association between GO utilization and race/ethnicity in the initial, continuing, and final phases of care.

PRINCIPAL FINDINGS

GO use decreased from the initial to final phase of care (51.4-28.8 percent). No racial/ethnic differences were found overall and by phase of cancer care. Women >70 years old and those with unstaged disease were less likely to receive GO care compared to their counterparts. GO use was lower in some SEER registries compared to the Atlanta registry.

CONCLUSIONS

GO use for the initial ovarian cancer treatment or for longer term care was low but not different across racial/ethnic groups. Future research should identify factors that affect GO utilization and understand why use of these specialists remains low.

Physicians' beliefs about breast cancer surveillance testing are consistent with test overuse

BACKGROUND

Overuse of surveillance testing for breast cancer survivors is an important problem but its extent and determinants are incompletely understood. The objectives of this study were to determine the extent to which physicians' breast cancer surveillance testing beliefs are consistent with test overuse, and to identify factors associated with these beliefs.

METHODS

During 2009-2010, a cross-sectional survey of US medical oncologists and primary care physicians (PCPs) was carried out. Physicians responded to a clinical vignette ascertaining beliefs about appropriate breast cancer surveillance testing. Multivariable analyses examined the extent to which test beliefs were consistent with overuse and associated with physician and practice characteristics and physician perceptions, attitudes, and practices.

RESULTS

A total of 1098 medical oncologists and 980 PCPs completed the survey (response rate 57.5%). Eighty-four percent of PCPs [95% confidence interval (CI), 81.4%-86.5%] and 72% of oncologists (95% CI, 69.8%-74.7%) reported beliefs consistent with blood test overuse, whereas 50% of PCPs (95% CI, 47.3%-53.8%) and 27% of oncologists (95% CI, 23.9%-29.3%) reported beliefs consistent with imaging test overuse. Among PCPs, factors associated with these beliefs included smaller practice size, lower patient volume, and practice ownership. Among oncologists, factors included older age, international medical graduate status, lower self-efficacy (confidence in knowledge), and greater perceptions of ambiguity (conflicting expert recommendations) regarding survivorship care.

CONCLUSIONS

Beliefs consistent with breast cancer surveillance test overuse are common, greater for PCPs and blood tests than for oncologists and imaging tests, and associated with practice characteristics and perceived self-efficacy and ambiguity about testing. These results suggest modifiable targets for efforts to reduce surveillance test overuse.

Evaluation of patient enrollment in oncology phase I clinical trials

INTRODUCTION

For anticancer drug development, it is crucial that patients participate in early-phase clinical trials. The main aim of this study was to gain insight into the motivations and other variables influencing patients in their decision to participate in phase I oncology trials.

MATERIALS AND METHODS

Over a period of 25 months, all patients who were informed about (specific) phase I trials in our cancer center were retrospectively included in this study. Data on providing informed consent and final phase I enrollment were collected.

RESULTS

In total, 365 patients, with a median age of 59 years and a median World Health Organization performance status score of 1, were evaluated. The majority of patients (71%) were pretreated with systemic therapy, with a median of two lines. After specific study information had been given, 145 patients (40%) declined informed consent, 54% of them mainly because of low expectations regarding treatment benefits and concerns about potential side effects. Patients who had received previous systemic therapy consented more frequently than others. After initial consent, 61 patients (17%) still did not receive study treatment, mostly because of secondary withdrawal of consent or rapid clinical deterioration prior to first dosing.

DISCUSSION

After specific referral to our hospital for participation in early clinical trials, only 44% of all patients who were informed about a specific phase I trial eventually participated. Reasons for both participation and nonparticipation were diverse. Patient participation rates could be improved by forming an experienced and dedicated study team.