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Makram OM, Nain P, Vasbinder A, Weintraub NL, Guha A. Cardiovascular Risk Assessment and Prevention in Cardio-Oncology: Beyond Traditional Risk Factors. Cardiol Clin 2025; 43:1-11. [PMID: 39551552 DOI: 10.1016/j.ccl.2024.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2024]
Abstract
This review goes beyond traditional approaches in cardio-oncology, highlighting often-neglected factors impacting patient care. Social determinants, environment, health care access, and gut microbiome significantly influence patient outcomes. Powerful tools like multi-omics and wearable technologies offer deeper insights into real-world experiences. The future lies in integrating these advancements with established practices to achieve precision cardio-oncology care. By crafting tailored therapies and continuously updating comprehensive management plans based on real-time data, we can unlock the full potential of personalized care for all patients.
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Affiliation(s)
- Omar M Makram
- Department of Medicine, Medical College of Georgia at Augusta University, Augusta, GA 30912, USA; Department of Medicine, Cardio-Oncology Program, Cardiology Division, Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Priyanshu Nain
- Department of Medicine, Cardio-Oncology Program, Cardiology Division, Medical College of Georgia at Augusta University, Augusta, GA, USA; Division of Cardiology, Department of Medicine, Medical College of Georgia at Augusta University, Augusta, GA 30912, USA
| | - Alexi Vasbinder
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, WA, USA
| | - Neal L Weintraub
- Department of Medicine, Cardio-Oncology Program, Cardiology Division, Medical College of Georgia at Augusta University, Augusta, GA, USA; Division of Cardiology, Department of Medicine, Medical College of Georgia at Augusta University, Augusta, GA 30912, USA
| | - Avirup Guha
- Department of Medicine, Cardio-Oncology Program, Cardiology Division, Medical College of Georgia at Augusta University, Augusta, GA, USA; Division of Cardiology, Department of Medicine, Medical College of Georgia at Augusta University, Augusta, GA 30912, USA.
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Blaes A, Nohria A, Armenian S, Bergom C, Thavendiranathan P, Barac A, Sanchez-Petitto G, Desai S, Zullig LL, Morgans AK, Herrmann J. Cardiovascular Considerations After Cancer Therapy: Gaps in Evidence and JACC: CardioOncology Expert Panel Recommendations. JACC CardioOncol 2025; 7:1-19. [PMID: 39896126 PMCID: PMC11782100 DOI: 10.1016/j.jaccao.2024.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 06/06/2024] [Accepted: 06/19/2024] [Indexed: 02/04/2025] Open
Abstract
Cancer survivors, particularly those treated with anthracyclines and chest radiation, face an elevated risk of cancer therapy-related cardiovascular toxicity. These complications affect not only physical health, but also life expectancy. Risk factors for cancer therapy-related cardiovascular toxicity include age at which cancer treatment was received, the use of (potentially) cardiotoxic cancer therapies, and the presence of concomitant cardiovascular risk factors. Current guidelines provide recommendations for cardiovascular surveillance after cancer therapy, including type and frequency. All cancer survivors are advised to undergo annual clinical screenings and optimization of cardiovascular risk factors. Those at higher risk should undergo additional cardiovascular testing. This document aims to summarize the available evidence, present practical recommendations, and outline existent gaps in the current literature regarding cardiovascular care after cancer therapies.
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Affiliation(s)
- Anne Blaes
- Division of Hematology/Oncology/Transplantation, University of Minnesota, Minneapolis, Minnesota, USA
| | - Anju Nohria
- Cardio-Oncology Program, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Saro Armenian
- Department of Pediatrics, City of Hope, Duarte, California, USA
| | - Carmen Bergom
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Paaladinesh Thavendiranathan
- Ted Rogers Program in Cardiotoxicity Prevention, Division of Cardiology, Peter Munk Cardiac Center, University of Toronto, Toronto, Ontario, Canada
| | - Ana Barac
- Inova Schar Heart and Vascular and Inova Schar Cancer Institute, Falls Church, Virginia, USA
| | | | - Sanjal Desai
- Division of Hematology/Oncology/Transplantation, University of Minnesota, Minneapolis, Minnesota, USA
| | - Leah L. Zullig
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | | | - Joerg Herrmann
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Ng HS, Meng R, Marin TS, Damarell RA, Buckley E, Selvanayagam JB, Koczwara B. Cardiovascular mortality in people with cancer compared to the general population: A systematic review and meta-analysis. Cancer Med 2024; 13:e70057. [PMID: 39096123 PMCID: PMC11297437 DOI: 10.1002/cam4.70057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 07/12/2024] [Accepted: 07/20/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND Cardiovascular disease (CVD) is the leading cause of non-cancer death in cancer survivors, but the risk of CVD varies between cancers. OBJECTIVES To synthesise available evidence on patterns and magnitude of CVD mortality risk. METHODS A systematic search of Medline (OVID), CINAHL and Scopus databases from 01-January-2000 to 16-July-2023 of studies of people with cancer, reporting CVD mortality in cancer population compared with a reference population (e.g. general population) as standardised mortality ratios (SMR). Meta-analysis of SMRs across cancer and CVD types were pooled using a random-effects model to allow for heterogeneity of the true effect size across studies. RESULTS We identified 136 studies from 16 countries. Sample sizes ranged from 157 to 7,529,481. The majority (n = 98; 72%) were conducted in the United States, followed by Europe (n = 22; 16%). The most common cancers studied were gastrointestinal (n = 34 studies), haematological (n = 31) and breast (n = 29). A total of 876 CVD SMRs were extracted across diverse CVD conditions. Of those, the majority (535; 61%) indicated an increased risk of CVD death (SMR >1), 109 (12%) a lower risk of CVD death (SMR <1) and 232 (27%) an equivalent risk (95% CI of SMR included 1) compared to the general population. The meta-analysis of all reported SMRs showed an increased risk of CVD death (SMR = 1.55, 95% CI = 1.40-1.72) in cancer survivors compared with the general population. The SMR varied between CVD conditions and ranged from 1.36 (95% CI = 1.29-1.44) for heart diseases to 1.56 (95% CI = 1.39-1.76) for cerebrovascular diseases. SMR varied across cancer types, ranging from 1.14 (95% CI = 1.04-1.25) for testicular/germ cell tumours to 2.82 (95% CI = 2.20-3.63) for brain/central nervous system tumours. CONCLUSIONS Cancer survivors are at increased risk of premature CVD mortality compared to the general population, but the risk varies by cancer type and CVD. Future research should focus on understanding mechanisms behind the increased CVD risk to develop appropriate interventions.
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Affiliation(s)
- Huah Shin Ng
- Flinders Health and Medical Research Institute, College of Medicine and Public HealthFlinders UniversityAdelaideSouth AustraliaAustralia
- SA Pharmacy, SA HealthAdelaideSouth AustraliaAustralia
| | - Rosie Meng
- Flinders Health and Medical Research Institute, College of Medicine and Public HealthFlinders UniversityAdelaideSouth AustraliaAustralia
| | - Tania S. Marin
- Flinders Health and Medical Research Institute, College of Medicine and Public HealthFlinders UniversityAdelaideSouth AustraliaAustralia
| | - Raechel A. Damarell
- Research Centre for Palliative Care, Death and Dying, College of Nursing and Health SciencesFlinders UniversityAdelaideSouth AustraliaAustralia
| | - Elizabeth Buckley
- Flinders Health and Medical Research Institute, College of Medicine and Public HealthFlinders UniversityAdelaideSouth AustraliaAustralia
| | - Joseph B. Selvanayagam
- Flinders Health and Medical Research Institute, College of Medicine and Public HealthFlinders UniversityAdelaideSouth AustraliaAustralia
- Department of Cardiovascular MedicineFlinders Medical CentreAdelaideSouth AustraliaAustralia
| | - Bogda Koczwara
- Flinders Health and Medical Research Institute, College of Medicine and Public HealthFlinders UniversityAdelaideSouth AustraliaAustralia
- Department of Medical OncologyFlinders Medical CentreAdelaideSouth AustraliaAustralia
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Amsalu E, Zhang Y, Harrison C, Nguyen TV, Nguyen TN. Exploring Frailty in the Intersection of Cardiovascular Disease and Cancer in Older People. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:7105. [PMID: 38063535 PMCID: PMC10706810 DOI: 10.3390/ijerph20237105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/04/2023] [Accepted: 11/21/2023] [Indexed: 12/18/2023]
Abstract
Advances in cardiovascular therapies and cancer treatments have resulted in longer patient survival. The coexistence of cancer and cardiovascular disease has been recognized as a complex clinical scenario. In addition to cardiovascular disease, older people with cancer are at greater risk of experiencing multimorbidity and geriatric syndromes, such as frailty. In older people, the concurrent presence of cancer and cardiovascular disease increases the risk of mortality, and the presence of frailty can exacerbate their conditions and hinder treatment effectiveness. Given the significant intersection among frailty, cardiovascular disease, and cancer in older people, this paper aims to provide an overview of the current research in this field and identifies gaps in the research to understand the burden and impact of frailty in these populations. While many studies have examined the prevalence and impact of frailty on adverse outcomes in patients with cancer or cardiovascular disease, evidence of frailty in individuals with both conditions is lacking. There is no universally accepted definition of frailty, which leads to inconsistencies in identifying and measuring frailty in older adults with cardiovascular disease and cancer. The frailty index seems to be a preferred frailty definition in studies of patients with cancer, while the frailty phenotype seems to be more commonly used in cardiovascular research. However, differences in how the frailty index was categorized and in how patients were classified as 'frail' depending on the cut points may have a negative effect on understanding the impact of frailty in the studied populations. This makes it challenging to compare findings across different studies and limits our understanding of the prevalence and impact of frailty in these populations. Addressing these research gaps will contribute to our understanding of the burden of frailty in older people with cardiovascular disease and cancer, and improve clinical care protocols in this vulnerable population.
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Affiliation(s)
- Erkihun Amsalu
- Westmead Applied Research Centre, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2145, Australia;
| | - Ying Zhang
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2050, Australia; (Y.Z.); (C.H.)
| | - Christopher Harrison
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2050, Australia; (Y.Z.); (C.H.)
| | - Tan Van Nguyen
- Department of Interventional Cardiology, Thong Nhat Hospital, Ho Chi Minh City 70000, Vietnam;
- Department of Geriatrics & Gerontology, University of Medicine and Pharmacy, Ho Chi Minh City 70000, Vietnam
| | - Tu Ngoc Nguyen
- Westmead Applied Research Centre, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2145, Australia;
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Han S, Sohn TJ, Avanceña AL, Park C. Rate, Timing, and Duration of Unplanned Readmissions Due to Cardiovascular Diseases among Hospitalized Patients with Cancer in the United States. Rev Cardiovasc Med 2023; 24:326. [PMID: 39076430 PMCID: PMC11272843 DOI: 10.31083/j.rcm2411326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/13/2023] [Accepted: 07/27/2023] [Indexed: 07/31/2024] Open
Abstract
Background Cardiovascular disease (CVD) can lead to unplanned care in patients with cancer, which may affect their prognosis and survival. We aimed to compare the rates, timing, and length of stay of unplanned CVD readmission in hospitalized patients with and without cancer. Methods This study used the 2017-2018 Nationwide Readmissions Database to identify adult hospitalized patients with and without cancer. The primary outcome was 180-day unplanned CVD readmission rates. CVD was defined based on a composite variable that included atrial fibrillation, coronary artery disease, cardiomegaly, cardiomyopathy, heart failure, peripheral artery disease, and stroke. For patients readmitted due to CVD, the timing between admissions (based on the mean number of days between index hospitalization and readmission) and length of stay were further identified. Results After matching, 300,398 patients were included in the two groups. The composite CVD readmission rates were significantly higher in patients with cancer (5.92% vs 4.10%; odds ratio (OR) 1.47, 95% CI 1.44-1.51, p < 0.001). Patients with cancer were also associated with shorter mean number of days to composite CVD readmission (60.48 days vs 68.32 days, p < 0.001) and longer length of stay of composite CVD readmission (8.21 days vs 7.13 days, p < 0.001). These trends were maintained in analyses of the individual CVD. Conclusions Hospitalized patients with cancer experienced higher rates of unplanned readmission due to CVD, and their CVD readmissions occurred sooner and required longer lengths of stay compared to patients without cancer. Efforts to reduce unplanned CVD readmissions, such as providing optimized chronic post-discharge care, may improve the health outcomes of patients with cancer.
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Affiliation(s)
- Sola Han
- Health Outcomes Division, College of Pharmacy, The University of Texas at
Austin, Austin, TX 78712, USA
| | - Ted J. Sohn
- Health Outcomes Division, College of Pharmacy, The University of Texas at
Austin, Austin, TX 78712, USA
| | - Anton L.V. Avanceña
- Health Outcomes Division, College of Pharmacy, The University of Texas at
Austin, Austin, TX 78712, USA
| | - Chanhyun Park
- Health Outcomes Division, College of Pharmacy, The University of Texas at
Austin, Austin, TX 78712, USA
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Vallakati A, Konda B. Secondary prevention of cardiovascular disease: unrecognized opportunity to improve survival in cancer patients. Eur J Prev Cardiol 2023; 30:1323-1324. [PMID: 37235727 DOI: 10.1093/eurjpc/zwad183] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 05/24/2023] [Indexed: 05/28/2023]
Affiliation(s)
- Ajay Vallakati
- Division of Cardiology, Department of Medicine, Ohio State University, 473 W 12th Avenue, Suite 200, Columbus, OH 43210, USA
| | - Bhavana Konda
- Division of Medical Oncology, Department of Medicine, Ohio State University, 473 W 12th Avenue, Columbus, OH 43210, USA
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Edney LC, Roseleur J, Bright T, Watson DI, Arnolda G, Braithwaite J, Delaney GP, Liauw W, Mitchell R, Karnon J. DAta Linkage to Enhance Cancer Care (DaLECC): Protocol of a Large Australian Data Linkage Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:5987. [PMID: 37297591 PMCID: PMC10252629 DOI: 10.3390/ijerph20115987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 05/17/2023] [Accepted: 05/21/2023] [Indexed: 06/12/2023]
Abstract
Cancer is a leading cause of global morbidity and mortality, accounting for 250 Disability-Adjusted Life Years and 10 million deaths in 2019. Minimising unwarranted variation and ensuring appropriate cost-effective treatment across primary and tertiary care to improve health outcomes is a key health priority. There are few studies that have used linked data to explore healthcare utilisation prior to diagnosis in addition to post-diagnosis patterns of care. This protocol outlines the aims of the DaLECC project and key methodological features of the linked dataset. The primary aim of this project is to explore predictors of variations in pre- and post-cancer diagnosis care, and to explore the economic and health impact of any variation. The cohort of patients includes all South Australian residents diagnosed with cancer between 2011 and 2020, who were recorded on the South Australian Cancer Registry. These cancer registry records are being linked with state and national healthcare databases to capture health service utilisation and costs for a minimum of one-year prior to diagnosis and to a maximum of 10 years post-diagnosis. Healthcare utilisation includes state databases for inpatient separations and emergency department presentations and national databases for Medicare services and pharmaceuticals. Our results will identify barriers to timely receipt of care, estimate the impact of variations in the use of health care, and provide evidence to support interventions to improve health outcomes to inform national and local decisions to enhance the access and uptake of health care services.
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Affiliation(s)
- Laura C. Edney
- Flinders Health and Medical Research Institute, Flinders University, Bedford Park, SA 5042, Australia
| | - Jackie Roseleur
- Flinders Health and Medical Research Institute, Flinders University, Bedford Park, SA 5042, Australia
| | - Tim Bright
- Oesophagogastric Surgery Unit, Flinders Medical Centre, Bedford Park, SA 5042, Australia
- College of Medicine and Public Health, Flinders University, Bedford Park, SA 5042, Australia
| | - David I. Watson
- Flinders Health and Medical Research Institute, Flinders University, Bedford Park, SA 5042, Australia
- Oesophagogastric Surgery Unit, Flinders Medical Centre, Bedford Park, SA 5042, Australia
- College of Medicine and Public Health, Flinders University, Bedford Park, SA 5042, Australia
| | - Gaston Arnolda
- Australian Institute of Health Innovation, Macquarie University, North Ryde, NSW 2109, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, North Ryde, NSW 2109, Australia
| | - Geoffrey P. Delaney
- Liverpool Cancer Therapy Centre, Liverpool, NSW 2170, Australia
- South Western Sydney Clinical School, University of New South Wales, Liverpool, NSW 2170, Australia
- Ingham Institute for Applied Medical Research, Liverpool, NSW 2170, Australia
| | - Winston Liauw
- St. George Cancer Care Centre, St. George Hospital, Kogarah, NSW 2217, Australia
- St. George Hospital Clinical School, University of New South Wales, Sydney, NSW 2217, Australia
| | - Rebecca Mitchell
- Australian Institute of Health Innovation, Macquarie University, North Ryde, NSW 2109, Australia
| | - Jonathan Karnon
- Flinders Health and Medical Research Institute, Flinders University, Bedford Park, SA 5042, Australia
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Wang Z, Fan Z, Yang L, Liu L, Sheng C, Song F, Huang Y, Chen K. Higher risk of cardiovascular mortality than cancer mortality among long-term cancer survivors. Front Cardiovasc Med 2023; 10:1014400. [PMID: 36760569 PMCID: PMC9905625 DOI: 10.3389/fcvm.2023.1014400] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 01/02/2023] [Indexed: 01/26/2023] Open
Abstract
Background Previous studies focused more on the short-term risk of cardiovascular (CV) death due to traumatic psychological stress after a cancer diagnosis and the acute cardiotoxicity of anticancer treatments than on the long-term risk of CV death. Methods Time trends in the proportions of CV death (PCV), cancer death (PCA), and other causes in deaths from all causes were used to show preliminary relationships among the three causes of death in 4,806,064 patients with cancer from the Surveillance, Epidemiology, and End Results (SEER) program. Competing mortality risk curves were used to investigate when the cumulative CV mortality rate (CMRCV) began to outweigh the cumulative cancer mortality rate (CMRCA) for patients with cancer who survived for more than 10 years. Multivariable competing risk models were further used to investigate the potential factors associated with CV death. Results For patients with cancer at all sites, the PCV increased from 22.8% in the 5th year after diagnosis to 31.0% in the 10th year and 35.7% in the 20th year, while the PCA decreased from 57.7% in the 5th year after diagnosis to 41.2 and 29.9% in the 10th year and 20th year, respectively. The PCV outweighed the PCA (34.6% vs. 34.1%) since the 15th year for patients with cancer at all sites, as early as the 9th year for patients with colorectal cancer (37.5% vs. 33.2%) and as late as the 22nd year for patients with breast cancer (33.5% vs. 30.6%). The CMRCV outweighed the CMRCA since the 25th year from diagnosis. Multivariate competing risk models showed that an increased risk of CV death was independently associated with older age at diagnosis [hazard ratio and 95% confidence intervals [HR (95%CI)] of 43.39 (21.33, 88.28) for ≥ 80 vs. ≤ 30 years] and local metastasis [1.07 (1.04, 1.10)] and a decreased risk among women [0.82 (0.76, 0.88)], surgery [0.90 (0.87, 0.94)], and chemotherapy [0.85 (0.81, 0.90)] among patients with cancer who survived for more than 10 years. Further analyses of patients with cancer who survived for more than 20 years and sensitivity analyses by cancer at all sites showed similar results. Conclusion CV death gradually outweighs cancer death as survival time increases for most patients with cancer. Both the cardio-oncologist and cardio-oncology care should be involved to reduce CV deaths in long-term cancer survivors.
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Affiliation(s)
- Zhipeng Wang
- Department of Epidemiology and Biostatistics, Key Laboratory of Molecular Cancer Epidemiology, National Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin Medical University, Tianjin, China
| | - Zeyu Fan
- Department of Epidemiology and Biostatistics, Key Laboratory of Molecular Cancer Epidemiology, National Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin Medical University, Tianjin, China
| | - Lei Yang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Beijing Office for Cancer Prevention and Control, Peking University Cancer Hospital and Institute, Beijing, China
| | - Lifang Liu
- Department of Statistics, European Organization for Research and Treatment of Cancer, Brussels, Belgium
| | - Chao Sheng
- Department of Epidemiology and Biostatistics, Key Laboratory of Molecular Cancer Epidemiology, National Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin Medical University, Tianjin, China
| | - Fengju Song
- Department of Epidemiology and Biostatistics, Key Laboratory of Molecular Cancer Epidemiology, National Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin Medical University, Tianjin, China,Fengju Song,
| | - Yubei Huang
- Department of Epidemiology and Biostatistics, Key Laboratory of Molecular Cancer Epidemiology, National Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin Medical University, Tianjin, China,*Correspondence: Yubei Huang,
| | - Kexin Chen
- Department of Epidemiology and Biostatistics, Key Laboratory of Molecular Cancer Epidemiology, National Clinical Research Center for Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin Medical University, Tianjin, China,Kexin Chen,
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