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Doose M, Verhoeven D, Sanchez JI, McGee-Avila JK, Chollette V, Weaver SJ. Clinical Multiteam System Composition and Complexity Among Newly Diagnosed Early-Stage Breast, Colorectal, and Lung Cancer Patients With Multiple Chronic Conditions: A SEER-Medicare Analysis. JCO Oncol Pract 2023; 19:e33-e42. [PMID: 36473151 PMCID: PMC10166428 DOI: 10.1200/op.22.00304] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 09/23/2022] [Accepted: 09/30/2022] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Sixty percent of adults have multiple chronic conditions at cancer diagnosis. These patients may require a multidisciplinary clinical team-of-teams, or a multiteam system (MTS), of high-complexity involving multiple specialists and primary care, who, ideally, coordinate clinical responsibilities, share information, and align clinical decisions to ensure comprehensive care needs are managed. However, insights examining MTS composition and complexity among individuals with cancer and comorbidities at diagnosis using US population-level data are limited. METHODS Using SEER-Medicare data (2006-2016), we identified newly diagnosed patients with breast, colorectal, or lung cancer who had a codiagnosis of cardiopulmonary disease and/or diabetes (n = 75,201). Zaccaro's theory-based classification of MTSs was used to categorize clinical MTS complexity in the 4 months following cancer diagnosis: high-complexity (≥ 4 clinicians from ≥ 2 specialties) and low-complexity (1-3 clinicians from 1-2 specialties). We describe the proportions of patients with different MTS compositions and quantify the incidence of high-complexity MTS care by patient groups. RESULTS The most common MTS composition was oncology with primary care (37%). Half (50.3%) received high-complexity MTS care. The incidence of high-complexity MTS care for non-Hispanic Black and Hispanic patients with cancer was 6.7% (95% CI, -8.0 to -5.3) and 4.7% (95% CI, -6.3 to -3.0) lower than non-Hispanic White patients with cancer; 13.1% (95% CI, -14.1 to -12.2) lower for rural residents compared with urban; 10.4% (95% CI, -11.2 to -9.5) lower for dual Medicaid-Medicare beneficiaries compared with Medicare-only; and 16.6% (95% CI, -17.5 to -15.8) lower for colorectal compared with breast cancer. CONCLUSION Incidence differences of high-complexity MTS care were observed among cancer patients with multiple chronic conditions from underserved populations. The results highlight the need to further understand the effects of and mechanisms through which care team composition, complexity, and functioning affect care quality and outcomes.
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Affiliation(s)
- Michelle Doose
- Division of Clinical and Health Services Research, National Institute on Minority Health and Health Disparities, Bethesda, MD
| | - Dana Verhoeven
- Health Systems and Interventions Research Branch, Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD
| | - Janeth I Sanchez
- Health Systems and Interventions Research Branch, Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD
| | - Jennifer K McGee-Avila
- Health Systems and Interventions Research Branch, Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD
- Infections and Immunoepidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD
| | - Veronica Chollette
- Health Systems and Interventions Research Branch, Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD
| | - Sallie J Weaver
- Health Systems and Interventions Research Branch, Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD
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Sanchez JI, Doose M, Zeruto C, Chollette V, Gasca N, Verhoeven D, Weaver SJ. Multilevel factors associated with inequities in multidisciplinary cancer consultation. Health Serv Res 2022; 57 Suppl 2:222-234. [PMID: 35491756 PMCID: PMC9670237 DOI: 10.1111/1475-6773.13996] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To assess changes in the prevalence of multidisciplinary cancer consultations (MDCc) over the last decade and examine patient, surgeon, hospital, and neighborhood factors associated with receipt of MDCc among individuals diagnosed with cancer. DATA SOURCE Surveillance, Epidemiology and End Results (SEER)-Medicare data from 2006 to 2016. STUDY DESIGN We used time-series analysis to assess change in MDCc prevalence from 2007 to 2015. We also conducted multilevel logistic regression with random surgeon- and hospital-level effects to assess associations between patient, surgeon, neighborhood, and health care organization-level factors and receipt of MDCc during the cancer treatment planning phase, defined as the 2 months following cancer diagnosis. DATA COLLECTION/EXTRACTION METHODS We identified Medicare beneficiaries >65 years of age with surgically resected breast, colorectal (CRC), or non-small cell lung cancer (NSCLC) stages I-III (n = 103,250). PRINCIPAL FINDINGS From 2007 to 2015, the prevalence of MDCc increased from 35.0% to 61.2%. Overall, MDCc was most common among patients with breast cancer compared to CRC and NSCLC. Cancer patients who were Black, had comorbidities, had dual Medicare-Medicaid coverage, were residing in rural areas or in areas with higher Black and Hispanic neighborhood composition were significantly less likely to have received MDCc. Patients receiving surgery at disproportionate payment-sharing or rural-designated hospitals had 2% (95% CI: -3.55, 0.58) and 17.6% (95% CI: -21.45, 13.70), respectively, less probability of receiving MDCc. Surgeon- and hospital-level effects accounted for 15% of the variance in receipt of MDCc. CONCLUSIONS The practice of MDCc has increased over the last decade, but significant geographical and health care organizational barriers continue to impede equitable access to and delivery of quality care across cancer patient populations. Multilevel and multicomponent interventions that target care coordination, health system, and policy changes may enhance equitable access to and receipt of MDCc.
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Affiliation(s)
- Janeth I. Sanchez
- Health Systems and Interventions Branch, Healthcare Delivery Research Program, Division of Cancer Control and Population SciencesNational Cancer InstituteRockvilleMarylandUSA
| | - Michelle Doose
- Division of Clinical and Health Services ResearchNational Institute on Minority Health and Health DisparitiesBethesdaMarylandUSA
| | - Chris Zeruto
- Information Management Services, Inc.CalvertonMarylandUSA
| | - Veronica Chollette
- Health Systems and Interventions Branch, Healthcare Delivery Research Program, Division of Cancer Control and Population SciencesNational Cancer InstituteRockvilleMarylandUSA
| | - Natalie Gasca
- School of Public Health, Department of BiostatisticsUniversity of WashingtonSeattleWashingtonUSA
| | - Dana Verhoeven
- Health Systems and Interventions Branch, Healthcare Delivery Research Program, Division of Cancer Control and Population SciencesNational Cancer InstituteRockvilleMarylandUSA
| | - Sallie J. Weaver
- Health Systems and Interventions Branch, Healthcare Delivery Research Program, Division of Cancer Control and Population SciencesNational Cancer InstituteRockvilleMarylandUSA
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Barrios C, Sánchez-Vanegas G, Villarreal-Garza C, Ossa A, Lombana MA, Monterrosa-Blanco A, Ferrigno AS, Castro CA. Barriers and facilitators to provide multidisciplinary care for breast cancer patients in five Latin American countries: A descriptive-interpretative qualitative study. LANCET REGIONAL HEALTH. AMERICAS 2022; 11:100254. [PMID: 36778924 PMCID: PMC9904076 DOI: 10.1016/j.lana.2022.100254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Background Multidisciplinary care (MDC) remains a cornerstone for breast cancer management as it is associated with improved quality of care and patient outcomes. However, the adoption of MDC practice is heterogeneous and has been poorly explored in Latin America. The objective was to describe barriers and possible facilitators for providing MDC to breast cancer patients in five Latin American countries. Methods A panel of experts with an active clinical practice in Bolivia, Colombia, Ecuador, Mexico, and Uruguay was convened to identify barriers and facilitators to MDC. This study is a qualitative synthesis of a structured discussion regarding the state of MDC in the setting of breast cancer. Findings Experts recognized that most oncology practices in Latin America do not apply a multidisciplinary approach for breast cancer patients. Predominant barriers for MDC are fragmentation of health services, being understaffed, inadequate infrastructure, and geographic disparities. Access to MDC varies widely in the region, with significant heterogeneity documented within countries. MDC practice was described as being more common in the private sector in Ecuador and Uruguay, while it is more widely implemented in public institutions of Colombia and Bolivia. Interpretation Establishing quality MDC remains a challenge for oncology practices in Latin America. Addressing regional issues and identifying specific local needs is warranted to encourage the adoption of an effective multidisciplinary approach and, consequently, improve clinical outcomes. Active involvement of all stakeholders is required to build locally solutions and should involve institutions, health professionals, and patients. Funding Research was funded by Productos Roche S.A.
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Affiliation(s)
- Carlos Barrios
- Oncoclinicas Group, Oncology Research Center, Hospital São Lucas, PUCRS Latin-American Cooperative Oncology Group (LACOG), Rio Grande do Sul, RS, Brazil
| | - Guillermo Sánchez-Vanegas
- Soluciones Integrales Para la Investigación y la Educación en Salud – SIIES Consultores, Cr 45ª #106ª-20, Bogotá, Cundinamarca, Colombia,Fundación Universtiaria de Ciencias de la Salud-FUCS, Bogotá, Colombia.,Corresponding author.
| | - Cynthia Villarreal-Garza
- Breast Cancer Center, Hospital Zambrano Hellion TecSalud, Tecnologico de Monterrey, San Pedro Garza García, Nuevo León, México
| | - Andrés Ossa
- Coordinator Breast Cancer Department Hospital General de Medellín, Medellín, Antioquia, Colombia
| | - Milton A. Lombana
- Scientific Medical Head at Comprehensive Cancer Center, Clinica de Occidente, Cali, Valle del Cauca, Colombia
| | - Angélica Monterrosa-Blanco
- Soluciones Integrales Para la Investigación y la Educación en Salud – SIIES Consultores, Cr 45ª #106ª-20, Bogotá, Cundinamarca, Colombia
| | - Ana S. Ferrigno
- Breast Cancer Center, Hospital Zambrano Hellion TecSalud, Tecnologico de Monterrey, San Pedro Garza García, Nuevo León, México
| | - Carlos Alberto Castro
- Soluciones Integrales Para la Investigación y la Educación en Salud – SIIES Consultores, Cr 45ª #106ª-20, Bogotá, Cundinamarca, Colombia,Fundación Universtiaria de Ciencias de la Salud-FUCS, Bogotá, Colombia
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Bleicher RJ, Moran MS, Ruth K, Edge SB, Dietz JM, Wilke LG, Stearns V, Kurtzman SH, Klein J, Yao KA. The Impact of Radiotherapy Delay in Breast Conservation Patients Not Receiving Chemotherapy and the Rationale for Dichotomizing the Radiation Oncology Time-Dependent Standard into Two Quality Measures. Ann Surg Oncol 2022; 29:469-481. [PMID: 34324114 PMCID: PMC9059503 DOI: 10.1245/s10434-021-10512-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/29/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION The Commission on Cancer/National Quality Forum breast radiotherapy quality measure establishes that for women < 70 years, adjuvant radiotherapy after breast conserving surgery (BCS) should be started < 1 year from diagnosis. This was intended to prevent accidental radiotherapy omission or delay due to a long interval between surgery and chemotherapy completion, when radiation is delivered. However, the impact on patients not receiving chemotherapy, who proceed from surgery directly to radiotherapy, remains unknown. PATIENTS AND METHODS Patients aged 18-69, diagnosed with stage I-III breast cancer as their first and only cancer diagnosis (2004-2016), having BCS, for whom this measure would be applicable, were reviewed from the National Cancer Database. RESULTS Among 308,521 patients, the median age was 57.0 years, and > 99% of all patients were compliant with the measure. The cohort of interest included 186,650 (60.5%) patients not receiving chemotherapy, with a mean age of 57.9 years. Of these, 90.5% received external beam radiotherapy (EBRT) and 9.5% brachytherapy. Among them, 24.9% started radiotherapy > 8 weeks after surgery. In a multivariable model, delay from surgery to radiotherapy increased the hazard ratios for overall survival to 9.0% (EBRT) per month and 3.0% (brachytherapy) per week. CONCLUSION While 99.9% of patients undergoing BCS without chemotherapy remain compliant with the current quality measure, 25% have delays > 8 weeks to start radiation, which is associated with impaired survival. These data suggest that the current quality measure should be dichotomized into two, with or without chemotherapy, in order to impel prompt radiotherapy initiation and maximize outcomes in all patients.
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Affiliation(s)
- Richard J Bleicher
- The Data Working Group of the National Accreditation Program for Breast Centers, Chicago, IL, USA.
- The Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
| | - Meena S Moran
- The Data Working Group of the National Accreditation Program for Breast Centers, Chicago, IL, USA
- The Department of Therapeutic Radiology, Yale University Medical Center, New Haven, CT, USA
| | - Karen Ruth
- The Department of Biostatistics, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Stephen B Edge
- The Data Working Group of the National Accreditation Program for Breast Centers, Chicago, IL, USA
- The Department of Surgical Oncology and Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Jill M Dietz
- The Data Working Group of the National Accreditation Program for Breast Centers, Chicago, IL, USA
- The Department of Surgery, Case Western Reserve University, Cleveland, OH, USA
| | - Lee G Wilke
- The Data Working Group of the National Accreditation Program for Breast Centers, Chicago, IL, USA
- The Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Vered Stearns
- The Data Working Group of the National Accreditation Program for Breast Centers, Chicago, IL, USA
- The Department of Oncology, Johns Hopkins University, Baltimore, MD, USA
| | - Scott H Kurtzman
- The Data Working Group of the National Accreditation Program for Breast Centers, Chicago, IL, USA
- The Department of Surgery, Waterbury Hospital, Waterbury, CT, USA
| | - Jonah Klein
- The Department of Surgery, Lankenau Medical Center, Main Line Health, Wynnewood, PA, USA
| | - Katharine A Yao
- The Data Working Group of the National Accreditation Program for Breast Centers, Chicago, IL, USA
- The Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
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O'Malley DM, Alfano CM, Doose M, Kinney AY, Lee SJC, Nekhlyudov L, Duberstein P, Hudson SV. Cancer prevention, risk reduction, and control: opportunities for the next decade of health care delivery research. Transl Behav Med 2021; 11:1989-1997. [PMID: 34850934 PMCID: PMC8634312 DOI: 10.1093/tbm/ibab109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
In this commentary, we discuss opportunities to optimize cancer care delivery in the next decade building from evidence and advancements in the conceptualization and implementation of multi-level translational behavioral interventions. We summarize critical issues and discoveries describing new directions for translational behavioral research in the coming decade based on the promise of the accelerated application of this evidence within learning health systems. To illustrate these advances, we discuss cancer prevention, risk reduction (particularly precision prevention and early detection), and cancer treatment and survivorship (particularly risk- and need-stratified comprehensive care) and propose opportunities to equitably improve outcomes while addressing clinician shortages and cross-system coordination. We also discuss the impacts of COVID-19 and potential advances of scientific knowledge in the context of existing evidence, the need for adaptation, and potential areas of innovation to meet the needs of converging crises (e.g., fragmented care, workforce shortages, ongoing pandemic) in cancer health care delivery. Finally, we discuss new areas for exploration by applying key lessons gleaned from implementation efforts guided by advances in behavioral health.
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Affiliation(s)
- Denalee M O'Malley
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.,Rutgers Cancer Prevention and Control, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA.,Northwell Health Cancer Institute, New Hyde Park, NY, USA
| | - Catherine M Alfano
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Michelle Doose
- Health Systems and Interventions Research Branch, Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Anita Y Kinney
- Department of Epidemiology and Biostatistics, Rutgers School of Public Health, Piscataway, NJ, USA
| | - Simon J Craddock Lee
- Harold C. Simmons Comprehensive Cancer Center, Department of Population and Data Sciences, UT-Southwestern, Dallas, TX, USA
| | - Larissa Nekhlyudov
- Harvard Medical School, Brigham & Womens' Primary Care Medical Associates, Boston, MA, USA
| | - Paul Duberstein
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.,Rutgers Cancer Prevention and Control, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA.,Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, NJ, USA
| | - Shawna V Hudson
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.,Rutgers Cancer Prevention and Control, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA.,Northwell Health Cancer Institute, New Hyde Park, NY, USA.,Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, NJ, USA
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Su Y, Zheng X, Ouyang Z. The Relationship between Time to Surgery (TTS) and Survival in Breast Cancer: A Systematic Review and Meta-Analysis. IRANIAN JOURNAL OF PUBLIC HEALTH 2021; 50:1773-1782. [PMID: 34722372 PMCID: PMC8542807 DOI: 10.18502/ijph.v50i9.7048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/20/2021] [Indexed: 01/10/2023]
Abstract
Background: Curative operation is the practical and primary therapy for masses of breast cancers. In contrast, the correlation between the time interval from breast cancer diagnosis to curative surgery and survival is still uncertain. Methods: An electronic literature search was conducted on PubMed/Medline and EMBASE (between Jan 2000 and Jan 2020). Primary endpoints were overall survival (OS) or Disease-Free Survival (DFS). The HR with 95% confidence intervals were calculated using a random-effects or fixed-effects model. Results: The combined HR for OS was 1. 10 (95% CI 1. 08–1. 11; P=0. 000) by fixed-effects model, no statistically significant heterogeneity was found (P=1. 000; I2=0%), and this difference was statistically significant (Z=11. 99; P=0. 000). Conclusion: This meta-analysis showed a significant adverse association between more prolonged time to surgery (TTS) and lower overall survival in patients with breast cancer. It is reasonable to minimize that interval between diagnosis and curative surgery.
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Affiliation(s)
- Yongcheng Su
- Department of Breast Surgery, The First Affiliated Hospital of Xiamen University, Xiamen Fujian 361003, China
| | - Xiaogang Zheng
- Department of Breast Surgery, The First Affiliated Hospital of Xiamen University, Xiamen Fujian 361003, China
| | - Zhong Ouyang
- Department of Breast Surgery, The First Affiliated Hospital of Xiamen University, Xiamen Fujian 361003, China
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Doose M, Steinberg MB, Xing CY, Lin Y, Cantor JC, Hong CC, Demissie K, Bandera EV, Tsui J. Comorbidity Management in Black Women Diagnosed with Breast Cancer: the Role of Primary Care in Shared Care. J Gen Intern Med 2021; 36:138-146. [PMID: 32974725 PMCID: PMC7858725 DOI: 10.1007/s11606-020-06234-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 09/10/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Black women are more likely to have comorbidity at breast cancer diagnosis compared with White women, which may account for half of the Black-White survivor disparity. Comprehensive disease management requires a coordinated team of healthcare professionals including primary care practitioners, but few studies have examined shared care in the management of comorbidities during cancer care, especially among racial/ethnic minorities. OBJECTIVE To examine whether the type of medical team composition is associated with optimal clinical care management of comorbidities. DESIGN We used the Women's Circle of Health Follow-up Study, a population-based cohort of Black women diagnosed with breast cancer. The likelihood of receiving optimal comorbidity management after breast cancer diagnosis was compared by type of medical team composition (shared care versus cancer specialists only) using binomial regression. PARTICIPANTS Black women with a co-diagnosis of diabetes and/or hypertension at breast cancer diagnosis between 2012 and 2016 (N = 274). MAIN MEASURES Outcome-optimal clinical care management of diabetes (i.e., A1C test, LDL-C test, and medical attention for nephropathy) and hypertension (i.e., lipid screening and prescription for hypertension medication). Main predictor-shared care, whether the patient received care from both a cancer specialist and a primary care provider and/or a medical specialist within the 12 months following a breast cancer diagnosis. KEY RESULTS Primary care providers were the main providers involved in managing comorbidities and 90% of patients received shared care during breast cancer care. Only 54% had optimal comorbidity management. Patients with shared care were five times (aRR: 4.62; 95% CI: 1.66, 12.84) more likely to have optimal comorbidity management compared with patients who only saw cancer specialists. CONCLUSIONS Suboptimal management of comorbidities during breast cancer care exists for Black women. However, our findings suggest that shared care is more beneficial at achieving optimal clinical care management for diabetes and hypertension than cancer specialists alone.
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Affiliation(s)
- Michelle Doose
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, 3E502, Rockville, MD, 20850, USA.
- Rutgers School of Public Health, Piscataway, NJ, USA.
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA.
| | | | | | - Yong Lin
- Rutgers School of Public Health, Piscataway, NJ, USA
| | - Joel C Cantor
- Rutgers Center for State Health Policy, New Brunswick, NJ, USA
- Rutgers Edward J. Bloustein School of Planning and Public Policy, New Brunswick, NJ, USA
| | - Chi-Chen Hong
- University at Buffalo, Buffalo, NY, USA
- Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Kitaw Demissie
- SUNY Downstate School of Public Health, Brooklyn, NY, USA
| | - Elisa V Bandera
- Rutgers School of Public Health, Piscataway, NJ, USA
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Jennifer Tsui
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Yang X, Huang J, Zhu X, Shen K, Zhu J, Chen X. Compliance with multidisciplinary team recommendations and disease outcomes in early breast cancer patients: An analysis of 4501 consecutive patients. Breast 2020; 52:135-145. [PMID: 32512360 PMCID: PMC7375553 DOI: 10.1016/j.breast.2020.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 05/20/2020] [Accepted: 05/23/2020] [Indexed: 12/24/2022] Open
Abstract
Background Multidisciplinary team (MDT) discussions are widely held to facilitate the diagnosis and treatment of breast cancer, but patient compliance with the MDT recommendations and the impact of compliance on disease outcome are uncertain. Methods We conducted a retrospective review of data from a prospective database of breast cancer patients treated at Shanghai Ruijin Hospital between April 2013 and August 2018. MDT discussions were held for all patients before they started adjuvant therapy. The patients were classified into compliant and non-compliant groups according to whether they received the MDT-recommended regimens. We also analyzed which clinicopathological factors were associated with compliance and prognosis. Results Of 4501 breast cancer patients, 3681 (81.8%) and 820 (18.2%) were included in the compliant and non-compliant groups, respectively. Age >70 years (P < 0.001), invasive ductal carcinoma (P < 0.001), and histological grade III (P = 0.011) were independently associated with higher risk of non-compliance, whereas Ki-67 labeling index ≥14% and history of benign breast disease were independently associated with compliance. Disease-free survival (hazard ratio [HR] 1.813, 95% confidence interval [CI] 1.367–2.405, P < 0.001) and overall survival (HR 2.478, 95% CI 1.431–4.291, P < 0.001) were worse in the non-compliant group. Conclusions Several clinicopathological factors were associated with non-compliance with MDT recommendations for early breast cancer patients. Non-compliance was associated with worse disease outcome. A large consecutive breast cancer cohort with MDT-based treatment recommendation. Factors identified associated with non-compliance with MDT recommendations. A significantly better survival in patients compliant with MDT recommendation.
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Affiliation(s)
- Xingxia Yang
- Department of General Surgery, Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Department of Breast, Jiaxing University Affiliated Women and Children Hospital, Jiaxing, Zhejiang, China
| | - Jiahui Huang
- Department of General Surgery, Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoping Zhu
- Department of Breast, Jiaxing University Affiliated Women and Children Hospital, Jiaxing, Zhejiang, China
| | - Kunwei Shen
- Department of General Surgery, Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Juanying Zhu
- Department of Breast, Jiaxing University Affiliated Women and Children Hospital, Jiaxing, Zhejiang, China.
| | - Xiaosong Chen
- Department of General Surgery, Comprehensive Breast Health Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Retrouvey H, Zhong T, Gagliardi AR, Baxter NN, Webster F. How Ineffective Interprofessional Collaboration Affects Delivery of Breast Reconstruction to Breast Cancer Patients: A Qualitative Study. Ann Surg Oncol 2020; 27:2299-2310. [PMID: 32297084 DOI: 10.1245/s10434-020-08463-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Despite the benefits of breast reconstruction (BR), health care professionals do not consistently integrate it as an option in the treatment of breast cancer patients. Interprofessional collaboration (IPC) amongst professionals may facilitate the elaboration of comprehensive oncological treatment plans. As the application of IPC in the delivery of BR has not yet been studied, we undertook a qualitative study to explore the perceptions of physicians and administrators on IPC in breast cancer care and how these impact BR delivery. METHODS Interviews were conducted with 30 participants (22 physicians and 8 administrators). Physician interviews focused on their personal beliefs and values regarding BR, while administrator interviews explored their institutional treatment regimens as well as the availability of a BR program. Our thematic analysis was informed by the Canadian Interprofessional Health Collaborative (CIHC) competency framework. RESULTS IPC challenges were thought by participants to affect the delivery of BR. At the physician level, a lack of role clarity as well as the absence of an explicitly established leader negatively influence collaboration in BR delivery. In addition, varying views on the usefulness of BR and on the role of plastic surgeons in breast oncological teams discourage positive collaboration, rendering the delivery of BR more difficult. CONCLUSIONS The delivery of BR is overall impaired due to a lack of effective IPC. IPC could be improved through clarifying physician roles, establishing clear leadership, and aligning viewpoints on quality oncological care in collaborative teams; ultimately, this may promote equitable BR delivery for breast cancer patients.
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Affiliation(s)
- Helene Retrouvey
- Division of Plastic and Reconstructive Surgery, Toronto General Hospital, Toronto, ON, Canada.
| | - Toni Zhong
- Division of Plastic and Reconstructive Surgery, Toronto General Hospital, Toronto, ON, Canada
| | | | - Nancy N Baxter
- Department of Surgery and LiKa Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
| | - Fiona Webster
- Labatt Family School of Nursing, Faculty of Health Sciences, Western University, London, Canada
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Mateo AM, Mazor AM, Obeid E, Daly JM, Sigurdson ER, Handorf EA, DeMora L, Aggon AA, Bleicher RJ. Time to Surgery and the Impact of Delay in the Non-Neoadjuvant Setting on Triple-Negative Breast Cancers and Other Phenotypes. Ann Surg Oncol 2019; 27:1679-1692. [PMID: 31712923 DOI: 10.1245/s10434-019-08050-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Characterization of breast cancer phenotypes has improved our ability to predict breast cancer behavior. Triple-negative (TN) breast cancers have higher and earlier rates of distant events. It has been suggested that this behavior necessitates treating TNs faster than others, including use of neoadjuvant chemotherapy (NACT) if time to surgery is not rapid. METHODS A review of women diagnosed with non-inflammatory, invasive breast cancer was conducted using the National Cancer Database for patients not having NACT, diagnosed between 2010 and 2014. Changes in overall survival due to delay were measured by phenotype. RESULTS Overall, 351,087 patients met the inclusion criteria, including 36,505 (10.4%) TNs, 77.9% hormone receptor-positive (HR+) and 11.7% human epidermal growth factor receptor 2 (HER2)-enriched (HER2+). Phenotype, among other factors, was predictive of treatment delays. Adjusted median days from diagnosis to surgery and chemotherapy were 29.9, 31.6 and 31.5 (p< 0.001), and 72.7, 78.0 and 74.4 (p< 0.001) for TNs, HR+ and HER2+ cancers, respectively. After diagnosis, OS declined for all patients per month of preoperative delay (hazard ratio 1.104; p< 0.001). In models separating or combining surgery and chemotherapy, this survival decline did not vary by breast cancer phenotype (p > 0.3). CONCLUSIONS Delays cause small but measurable effects overall, but the effect on survival does not differ among breast cancer phenotypes. Our data suggest that urgency between diagnosis and surgery or chemotherapy is similar for breast cancers of different subtypes. Although NACT is sometimes advocated solely to avoid treatment delays, this study does not suggest a greater surgical urgency for TNs compared with other breast cancer phenotypes.
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Affiliation(s)
- Alina M Mateo
- Department of Surgery, Division of Endocrine and Oncologic Surgery, Pennsylvania Hospital, Philadelphia, PA, USA
| | - Anna M Mazor
- Department of Surgery, Holy Redeemer Hospital, Meadowbrook, PA, USA
| | - Elias Obeid
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - John M Daly
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Elin R Sigurdson
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | | | - Lyudmila DeMora
- Department of Biostatistics, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Allison A Aggon
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Richard J Bleicher
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
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11
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Shao J, Rodrigues M, Corter AL, Baxter NN. Multidisciplinary care of breast cancer patients: a scoping review of multidisciplinary styles, processes, and outcomes. Curr Oncol 2019; 26:e385-e397. [PMID: 31285683 PMCID: PMC6588064 DOI: 10.3747/co.26.4713] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background Clinical practice guidelines recommend a multidisciplinary approach to cancer care that brings together all relevant disciplines to discuss optimal disease management. However, the literature is characterized by heterogeneous definitions and few reviews about the processes and outcomes of multidisciplinary care. The objective of this scoping review was to identify and classify the definitions and characteristics of multidisciplinary care, as well as outcomes and interventions for patients with breast cancer. Methods A systematic search for quantitative and qualitative studies about multidisciplinary care for patients with breast cancer was conducted for January 2001 to December 2017 in the following electronic databases: medline, embase, PsycInfo, and cinahl. Two reviewers independently applied our eligibility criteria at level 1 (title/abstract) and level 2 (full-text) screening. Data were extracted and synthesized descriptively. Results The search yielded 9537 unique results, of which 191 were included in the final analysis. Two main types of multidisciplinary care were identified: conferences and clinics. Most studies focused on outcomes of multidisciplinary care that could be variously grouped at the patient, provider, and system levels. Research into processes tended to focus on processes that facilitate implementation: team-working, meeting logistics, infrastructure, quality audit, and barriers and facilitators. Summary Approaches to multidisciplinary care using conferences and clinics are well described. However, studies vary by design, clinical context, patient population, and study outcome. The heterogeneity of the literature, including the patient populations studied, warrants further specification of multidisciplinary care practice and systematic reviews of the processes or contexts that make the implementation and operation of multidisciplinary care effective.
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Affiliation(s)
- J Shao
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
| | - M Rodrigues
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
| | - A L Corter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
| | - N N Baxter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON
- Department of Surgery, St. Michael's Hospital, Toronto, ON
- Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, ON
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON
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12
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McEvoy MP, Landercasper J, Naik HR, Feldman S. Update of the American Society of Breast Surgeons Toolbox to address the lumpectomy reoperation epidemic. Gland Surg 2018; 7:536-553. [PMID: 30687627 DOI: 10.21037/gs.2018.11.03] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In 2015, the American Society of Breast Surgeons (ASBrS) convened a multidisciplinary consensus conference, the Collaborative Attempt to Lower Lumpectomy Reoperation Rates (CALLER). The CALLER conference endorsed a "toolbox" of multiple processes of care for which there was evidence that they were associated with fewer reoperations. We present an update of the toolbox taking into consideration the latest advances in decreasing re excision rates. In this review, we performed a comprehensive review of the literature from 2015-2018 using search terms for each tool. The original ten tools were updated with the latest evidence from the literature and our strength of recommendation. We added an additional section looking at new tools and techniques that may provide more accurate intraoperative assessment of margins. The updates on the CALLER Toolbox for lumpectomy will help guide surgeons to various resources to aid in the removal of breast cancer, while being aware of cosmesis and decreasing re excision rates.
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Affiliation(s)
- Maureen P McEvoy
- Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, USA
| | - Jeffrey Landercasper
- Gundersen Health System, Norma J. Vinger Center for Breast Cancer, La Crosse, WI, USA
| | - Himani R Naik
- Gundersen Health System, Norma J. Vinger Center for Breast Cancer, La Crosse, WI, USA
| | - Sheldon Feldman
- Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, USA
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13
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Bleicher RJ, Chang C, Wang CE, Goldstein LJ, Kaufmann CS, Moran MS, Pollitt KA, Suss NR, Winchester DP, Tafra L, Yao K. Treatment delays from transfers of care and their impact on breast cancer quality measures. Breast Cancer Res Treat 2018; 173:603-617. [DOI: 10.1007/s10549-018-5046-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 11/08/2018] [Indexed: 11/25/2022]
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14
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Corter AL, Quan ML, Wright FL, Kennedy ED, Simunovic MR, Shao J, Baxter NN. Scoping clinicians' perspectives on pre-treatment multidisciplinary care for young women with breast cancer. J Multidiscip Healthc 2018; 11:547-555. [PMID: 30349286 PMCID: PMC6183552 DOI: 10.2147/jmdh.s173735] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Young women with breast cancer (YWBC) experience worse medical and psychosocial outcomes than their older counterparts. Early input from a multidisciplinary team via pre-treatment multidisciplinary cancer conferences (pMCCs) may be important for addressing the complex needs of YWBC. However, pMCCs are not common. This study has two parts: a survey and workshop aimed at assessing clinicians' perspectives on pMCCs, including the importance of pMCCs in the care of YWBC, as well as barriers to, and strategies for supporting their implementation. METHODS Survey results highlight variability across sites in the delivery of multidisciplinary care in general. However, both survey and workshop results emphasize clinicians' agreement on the importance of pMCCs and suggest that numerous practical and systems levels barriers be addressed before pMCCs can be implemented. CONCLUSIONS pMCCs have the potential to improve surgical treatment and psychosocial outcomes for YWBC. A combined practical and policy approach to their implementation, which sees extension of existing standards to include pMCCs, may support their adoption and subsequent audit practices to assess the effect of pMCCs on outcomes for YWBC.
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Affiliation(s)
- Arden L Corter
- Department of Surgery, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada,
| | - May Lynn Quan
- Department of Surgery and Oncology, University of Calgary, Calgary, Canada
| | | | - Erin D Kennedy
- Division of General Surgery, University Health Network, Mount Sinai Hospital, Toronto, Canada
| | | | - Juliet Shao
- Department of Surgery, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada,
| | - Nancy N Baxter
- Department of Surgery, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada,
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada,
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15
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Abstract
BACKGROUND Even small delays in the treatment of breast cancer are a frequently expressed concern of patients. Knowledge about this subject is important for clinicians to counsel patients appropriately and realistically, while also optimizing care. Although data and quality measures regarding time to chemotherapy and radiotherapy have been present for some time, data regarding surgical care are more recent and no standard exists. This review was written to discuss our current knowledge about the relationship of treatment times to outcomes. METHODS The published medical literature addressing delays and optimal times to treatment was reviewed in the context of our current time-dependent standards for chemotherapy and radiotherapy. The surgical literature and the lack of a time-dependent surgical standard also were discussed, suggesting a possible standard. RESULTS Risk factors for delay are numerous, and tumor doubling times are both difficult to determine and unhelpful to assess the impact of longer treatment times on outcomes. Evaluation components also have a time cost and are inextricable from the patient's workup. Although the published literature has lack of uniformity, optimal times to each modality are strongly suggested by emerging data, supporting the current quality measures. Times to surgery, chemotherapy, and radiotherapy all have a measurable impact on outcomes, including disease-free survival, disease-specific survival, and overall survival. CONCLUSIONS Delays have less of an impact than often thought but have a measurable impact on outcomes. Optimal times from diagnosis are < 90 days for surgery, < 120 days for chemotherapy, and, where chemotherapy is administered, < 365 days for radiotherapy.
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Affiliation(s)
- Richard J Bleicher
- Department of Surgical Oncology, Room C-308, Fox Chase Cancer Center, Philadelphia, PA, USA.
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16
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Esposito AC, Crawford J, Sigurdson ER, Handorf EA, Hayes SB, Boraas M, Bleicher RJ. Omission of radiotherapy after breast conservation surgery in the postneoadjuvant setting. J Surg Res 2017; 221:49-57. [PMID: 29229152 DOI: 10.1016/j.jss.2017.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 06/28/2017] [Accepted: 08/01/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Breast conservation therapy (BCT) consists of breast conservation surgery (BCS) and radiotherapy (RT). Neoadjuvant chemotherapy (NACT) can downstage tumors, broadening BCS eligibility in patients requiring mastectomy. However, tumor downstaging does not obviate need for RT. This study evaluated factors that predict RT omission after NACT and BCS. METHODS The National Cancer Database was queried for women with unilateral, clinical stage II-III breast cancer, treated with NACT and BCS between 2008 and 2012. Patients not receiving RT after NACT and BCS were identified. A subgroup analysis was performed eliminating patients for whom RT was recommended but not received. RESULTS Among 10,220 patients meeting study eligibility, 974 (9.53%) did not receive RT after BCS. Predictors of RT omission included older age, insurance status, facility type, facility region, more recent year of diagnosis, receptor status unknown, human epidermal growth factor receptor 2 status positive or unknown, and positive margins. Factors increasing the likelihood of RT receipt included cN3 disease, receptor positivity, and primary downstaging. Race, Hispanicity, education, income, comorbidities, rural versus urban setting, histology, grade, and nodal stage change were not associated with RT omission. When excluding the 314 patients for whom RT was recommended but not received, age, Medicaid insurance, facility type, facility region, receptor status unknown, human epidermal growth factor receptor 2 status unknown, and positive margins were predictors of RT omission. CONCLUSIONS Race, comorbidities, and socioeconomic status were not predictors of RT omission. It remains unclear whether omission of RT in some cases is due to lack of physician knowledge. Further efforts are needed to ensure that physicians and patients recognize that RT is a vital and required part of BCT, even after NACT.
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Affiliation(s)
- Andrew C Esposito
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania; Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - James Crawford
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Elin R Sigurdson
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania; Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Elizabeth A Handorf
- Department of Biostatistics, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Shelly B Hayes
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania; Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Marcia Boraas
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania; Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Richard J Bleicher
- Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania; Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania.
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