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Maliko N, Bijker N, Bos MEMM, Wouters MWJM, Vrancken Peeters MJTFD. Patterns of care over 10 years in young breast cancer patients in the Netherlands, a nationwide population-based study. Breast 2022; 66:285-292. [PMID: 36375390 PMCID: PMC9663518 DOI: 10.1016/j.breast.2022.11.002] [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: 09/22/2022] [Revised: 11/06/2022] [Accepted: 11/07/2022] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Each year, around 600 young (<40 years) breast cancer (BC) patients are registered in the national NABON Breast Cancer Audit (NBCA). The aim of this study is to compare patient and treatment characteristics of young and older age BC patients over time with a focus on outcome of quality indicators (QIs). Furthermore, we analysed whether de-escalation trends of treatment can be recognized to the same degree in both patient groups. MATERIAL AND METHODS From October 2011 to October 2020 all patients treated for stage I-III invasive BC were included. Tumour characteristics, treatment variables and outcome of QIs of two age categories young (<40 years) and older patient (≥40 years) were analysed. RESULTS In total 114,700 patients were included: 4.6% young patients and 95.4% older patients. Young patients more often presented with a palpable mass, higher stage, and triple-negative BC. Overall, young patients more often started with neoadjuvant systemic treatment (NST) (54.3% vs. 18.6%) and a greater proportion of the young patients retained their breast contour after surgery (73.5% vs. 69.3%). De-escalation trends such as decrease in axillary lymph node dissections and in the use of boost were observed. The omission of radiation treatment after breast conserving surgery was only observed in older patients. CONCLUSION Although this study shows that young women more often present with unfavourable tumours, therapeutic procedures are performed with a higher adherence to the QIs than for older patients and young women do benefit from some de-escalation trends to the same extend as older patients.
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Affiliation(s)
- Nansi Maliko
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, the Netherlands,Department of Surgical Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Nina Bijker
- Department of Radiation Oncology, AmsterdamUMC, Amsterdam, the Netherlands
| | - Monique EMM. Bos
- Department of Medical Oncology, Erasmus MC Cancer Institute, University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Michel WJM. Wouters
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, the Netherlands,Department of Surgical Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Amsterdam, the Netherlands,Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, the Netherlands
| | - Marie-Jeanne TFD. Vrancken Peeters
- Department of Surgical Oncology, Netherlands Cancer Institute/Antoni van Leeuwenhoek, Amsterdam, the Netherlands,Department of Surgery, AmsterdamUMC, Amsterdam, the Netherlands,Corresponding author. Department of Surgical oncology, Netherlands CancerInstitute/Antoni van Leeuwenhoek Hospital Plesmanlaan 121, 1066CX, Amsterdam, the Netherlands.
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Maliko N, Stam MR, Boersma LJ, Vrancken Peeters MJTFD, Wouters MWJM, KleinJan E, Mulder M, Essers M, Hurkmans CW, Bijker N. Transparency in quality of radiotherapy for breast cancer in the Netherlands: a national registration of radiotherapy-parameters. Radiat Oncol 2022; 17:73. [PMID: 35413924 PMCID: PMC9003170 DOI: 10.1186/s13014-022-02043-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 03/30/2022] [Indexed: 11/29/2022] Open
Abstract
Background Radiotherapy (RT) is part of the curative treatment of approximately 70% of breast cancer (BC) patients. Wide practice variation has been reported in RT dose, fractionation and its treatment planning for BC. To decrease this practice variation, it is essential to first gain insight into the current variation in RT treatment between institutes. This paper describes the development of the NABON Breast Cancer Audit-Radiotherapy (NBCA-R), a structural nationwide registry of BC RT data of all BC patients treated with at least surgery and RT. Methods A working group consisting of representatives of the BC Platform of the Dutch Radiotherapy Society selected a set of dose volume parameters deemed to be surrogate outcome parameters, both for tumour control and toxicity. Two pilot studies were carried out in six RT institutes. In the first pilot study, data were manually entered into a secured web-based system. In the second pilot study, an automatic Digital Imaging and Communications in Medicine (DICOM) RT upload module was created and tested. Results The NBCA-R dataset was created by selecting RT parameters describing given dose, target volumes, coverage and homogeneity, and dose to organs at risk (OAR). Entering the data was made mandatory for all Dutch RT departments. In the first pilot study (N = 1093), quite some variation was already detected. Application of partial breast irradiation varied from 0 to 17% between the 6 institutes and boost to the tumour bed from 26.5 to 70.2%. For patients treated to the left breast or chest wall only, the average mean heart dose (MHD) varied from 0.80 to 1.82 Gy; for patients treated to the breast/chest wall only, the average mean lung dose (MLD) varied from 2.06 to 3.3 Gy. In the second pilot study 6 departments implemented the DICOM-RT upload module in daily practice. Anonymised data will be available for researchers via a FAIR (Findable, Accessible, Interoperable, Reusable) framework. Conclusions We have developed a set of RT parameters and implemented registration for all Dutch BC patients. With the use of an automated upload module registration burden will be minimized. Based on the data in the NBCA-R analyses of the practice variation will be done, with the ultimate aim to improve quality of BC RT. Trial registration Retrospectively registered.
Supplementary Information The online version contains supplementary material available at 10.1186/s13014-022-02043-0.
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Affiliation(s)
- Nansi Maliko
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, The Netherlands.,Department of Surgical Oncology, Netherlands Cancer Institute/Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | | | - Liesbeth J Boersma
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Marie-Jeanne T F D Vrancken Peeters
- Department of Surgical Oncology, Netherlands Cancer Institute/Antoni Van Leeuwenhoek, Amsterdam, The Netherlands.,Department of Surgery, AmsterdamUMC, Amsterdam, the Netherlands
| | - Michel W J M Wouters
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, The Netherlands.,Department of Surgical Oncology, Netherlands Cancer Institute/Antoni Van Leeuwenhoek, Amsterdam, The Netherlands.,Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, The Netherlands
| | - Eline KleinJan
- Trusted Third Party, Medical Research Data Management, Deventer, The Netherlands
| | - Maurice Mulder
- Trusted Third Party, Medical Research Data Management, Deventer, The Netherlands
| | | | - Coen W Hurkmans
- Department of Radiation Oncology, Catharina Hospital, Eindhoven, The Netherlands
| | - Nina Bijker
- Department of Radiation Oncology, AmsterdamUMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Neven A, van Maaren MC, Schreuder K, Kranse R, Struikmans H, Poortmans PM, Bartelink H, Collette L, Liu L, Siesling S. Representativeness of trial participants: linking the EORTC boost-no boost trial to the Netherlands Cancer Registry. J Clin Epidemiol 2022; 148:54-64. [DOI: 10.1016/j.jclinepi.2022.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/23/2022] [Accepted: 04/12/2022] [Indexed: 10/18/2022]
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Fastner G, Krug D, Meattini I, Gruber G, Poortmans P. Expert Discussion: Hypofractionated Radiation Therapy - Standard for All Indications? Breast Care (Basel) 2021; 17:224-231. [PMID: 35707177 PMCID: PMC9149542 DOI: 10.1159/000521552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 12/16/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Gerd Fastner
- Department of Radiotherapy and Radio-Oncology, Paracelsus Medical University, University Hospital Salzburg, Landeskrankenhaus Salzburg, Salzburg, Austria
- *Gerd Fastner,
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig Holstein, Kiel, Germany
| | - Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences ”M. Serio”, University of Florence, Florence, Italy
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Günther Gruber
- Institute of Radiotherapy, Klinik Hirslanden, Zurich, Switzerland
- University of Berne, Berne, Switzerland
| | - Philip Poortmans
- Iridium Netwerk, Wilrijk-Antwerp, Belgium
- University of Antwerp, Wilrijk-Antwerp, Belgium
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Loibl S, Poortmans P, Morrow M, Denkert C, Curigliano G. Breast cancer. Lancet 2021; 397:1750-1769. [PMID: 33812473 DOI: 10.1016/s0140-6736(20)32381-3] [Citation(s) in RCA: 631] [Impact Index Per Article: 210.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 09/29/2020] [Accepted: 11/05/2020] [Indexed: 02/07/2023]
Abstract
Breast cancer is still the most common cancer worldwide. But the way breast cancer is viewed has changed drastically since its molecular hallmarks were extensively characterised, now including immunohistochemical markers (eg, ER, PR, HER2 [ERBB2], and proliferation marker protein Ki-67 [MKI67]), genomic markers (eg, BRCA1, BRCA2, and PIK3CA), and immunomarkers (eg, tumour-infiltrating lymphocytes and PD-L1). New biomarker combinations are the basis for increasingly complex diagnostic algorithms. Neoadjuvant combination therapy, often including targeted agents, is a standard of care (especially in HER2-positive and triple-negative breast cancer), and the basis for de-escalation of surgery in the breast and axilla and for risk-adapted post-neoadjuvant strategies. Radiotherapy remains an important cornerstone of breast cancer therapy, but de-escalation schemes have become the standard of care. ER-positive tumours are treated with 5-10 years of endocrine therapy and chemotherapy, based on an individual risk assessment. For metastatic breast cancer, standard therapy options include targeted approaches such as CDK4 and CDK6 inhibitors, PI3K inhibitors, PARP inhibitors, and anti-PD-L1 immunotherapy, depending on tumour type and molecular profile. This range of treatment options reflects the complexity of breast cancer therapy today.
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Affiliation(s)
- Sibylle Loibl
- German Breast Group, Neu-Isenburg, Germany; Centre for Haematology and Oncology Bethanien, Frankfurt, Germany.
| | - Philip Poortmans
- Department of Radiation Oncology, Iridium Kankernetwerk, Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Antwerp, Belgium
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Carsten Denkert
- German Breast Group, Neu-Isenburg, Germany; Institute of Pathology, Philipps University of Marburg, Marburg, Germany; University Hospital Marburg, Marburg, Germany
| | - Giuseppe Curigliano
- European Institute of Oncology IRCCS, Milan, Italy; University of Milano, Milan, Italy
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Kayali M, Jaoude JA, Ramia P, Assi H, Geara F, Poortmans P, Zeidan YH. Post-lumpectomy radiation therapy boost in breast cancer patients: evidence revisited. Ecancermedicalscience 2021; 15:1194. [PMID: 33889203 PMCID: PMC8043677 DOI: 10.3332/ecancer.2021.1194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Indexed: 12/24/2022] Open
Abstract
Purpose Radiation therapy is an integral part in the management of breast cancer after breast conservative surgery. In selected patients at high risk for local recurrence (LR), a boost radiation dose is commonly applied to the tumour bed. Methods We performed a review of the English literature using PubMed, Medline and Google Scholar for published manuscripts addressing the effect of boost radiation in breast cancer patients, focusing mainly on LR and overall survival (OS). Results A total of seven studies were included in our review. Most studies (6/7, 85.7%) showed a significant improvement in local control independent of age (hazard ratios ranging between 0.34 and 0.73), with the largest absolute benefit in younger patients. None of the studies, however, was able to demonstrate an improvement in OS. Conclusions With lack of sufficient studies addressing the role of boost radiation, individualised treatment decisions are recommended, taking into account the risk factors for LR, including tumour biology. Real-life data are sorely needed to better assess the role of tumour bed boost in the contemporary era.
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Affiliation(s)
- Majd Kayali
- Department of Radiation Oncology, American University of Beirut Medical Center, Beirut, Lebanon.,Co-first authors with equal contribution
| | - Joseph Abi Jaoude
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon.,Co-first authors with equal contribution
| | - Paul Ramia
- Department of Radiation Oncology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hazem Assi
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Fady Geara
- Department of Radiation Oncology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Philip Poortmans
- Department of Radiation Oncology, Institut Curie, Paris Sciences & Lettres, PSL University, Paris, France
| | - Youssef H Zeidan
- Department of Radiation Oncology, American University of Beirut Medical Center, Beirut, Lebanon
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Cardoso F, MacNeill F, Penault-Llorca F, Eniu A, Sardanelli F, Nordström EB, Poortmans P. Why is appropriate healthcare inaccessible for many European breast cancer patients? - The EBCC 12 manifesto. Breast 2021; 55:128-135. [PMID: 33461060 PMCID: PMC7817501 DOI: 10.1016/j.breast.2020.12.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/23/2020] [Accepted: 12/24/2020] [Indexed: 12/12/2022] Open
Abstract
In Europe, inappropriate reimbursement and funding rules and regulations act as disincentives to best breast cancer care or, at worst, hinder best care. This problem was the focus of the 12th European Breast Cancer Conference (EBCC) manifesto, discussed during the virtual conference. As patient involvement is indispensable in driving changes to clinical practice, Europa Donna the European patient advocacy group was closely involved in the 12th manifesto. Reimbursement policies have rarely evolved with advances in breast cancer care such as outpatient (ambulatory) care rather than inpatient admission, use of oral or subcutaneous anti-cancer drugs rather than day-hospital intravenous administration, oncoplastic surgery techniques to minimize mastectomy rates, breast reconstructive surgery, risk-reducing surgery for BRCA mutation carriers, or use of hypo-fractionated breast radiation therapy. Although each European country, region and centre will have to understand how their reimbursement policies may hinder best care and find their own solutions, the problems are similar throughout Europe and some solutions can be broadly applied. This manifesto is not calling for more funding or demanding changes that will result in more expensive care. Reimbursement, if better aligned with guidelines and optimal clinical practice, will deliver more cost-effective healthcare. This will release resources, support more equitable use of finite funding and resources, so allowing more European breast cancer patients to benefit from evidence-based treatment recommended by national and international guidelines.
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Affiliation(s)
- Fatima Cardoso
- Breast Unit, Champalimaud Clinical Centre/ Champalimaud Foundation, Lisbon, Portugal.
| | - Fiona MacNeill
- Royal Marsden Hospital London, Division of Breast Surgery (UEMS), UK.
| | | | - Alexandru Eniu
- Cancer Institute Ion Chiricuta, Department of Breast Tumors, Day Hospital Unit, Cluj-Napoca, Romania; Hopital Riviera-Chablais, Switzerland.
| | - Francesco Sardanelli
- Università Degli Studi di Milano, Department of Biomedical Sciences for Health, Milan, Italy; IRCCS Policlinico San Donato, Department of Radiology, San Donato Milanese, Milan, Italy.
| | | | - Philip Poortmans
- Iridium Kankernetwerk and University of Antwerp, Wilrijk, Antwerp, Belgium.
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Beaton L, Chan EK, Tyldesley S, Gondara L, Speers C, Nichol A. In the Era After the European Organisation for Research and Treatment of Cancer 'Boost' Study, is the Additional Radiotherapy to the Breast Tumour Bed Still Beneficial for Young Women? Clin Oncol (R Coll Radiol) 2020; 32:373-381. [PMID: 32057620 DOI: 10.1016/j.clon.2020.01.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 12/02/2019] [Accepted: 12/04/2019] [Indexed: 12/19/2022]
Abstract
AIMS The European Organisation for Research and Treatment of Cancer (EORTC) 22,881-10,882 trial showed significant benefit of a radiotherapy boost (RTB) in women ≤40 years in a pre-hormone therapy (HT) era. We determined how the use of HT and RTB changed in response to clinical guidelines and whether the benefit of routine RTB was still observed in the HT era. MATERIALS AND METHODS Between 1996 and 2004, a provincial database identified all women ≤40 years with breast cancer who met the inclusion criteria of the EORTC trial. In total, 411 patients were classified into three eras defined by the guidelines: era 1 (discretionary HT, discretionary RTB); era 2 (routine HT, discretionary RTB); era 3 (routine HT, routine RTB). HT use, RTB use and cumulative incidence of local recurrence were calculated and compared across eras. RESULTS HT use increased after the first policy change from 13% to 75% for oestrogen receptor-positive patients (P < 0.01). RTB use also increased from 33% to 76% following the second policy change (P < 0.01). At 10 years, the cumulative incidence of local recurrence was 12% in era 1, 6% in era 2 and 6% in era 3 (era 2 versus era 3, P = 0.92). For patients in the routine HT era (eras 2 and 3 combined) there was no significant difference in local recurrence between RTB and 'no RTB' patients (6% versus 7%, P = 0.81). CONCLUSIONS The routine use of HT and RTB increased significantly after new practice guidelines. Introduction of the HT guideline was associated with a 6% improvement in local recurrence at 10 years. No improvement in local recurrence was associated with the introduction of the RTB guideline in the HT era. The routine use of a boost in unselected young women with negative margins should be re-evaluated in the current HT era.
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Affiliation(s)
- L Beaton
- Department of Radiation Oncology, BC Cancer, Vancouver, British Columbia, Canada
| | - E K Chan
- Department of Radiation Oncology, BC Cancer, Vancouver, British Columbia, Canada
| | - S Tyldesley
- Department of Radiation Oncology, BC Cancer, Vancouver, British Columbia, Canada; Breast Cancer Outcomes Unit, BC Cancer, Vancouver, British Columbia, Canada
| | - L Gondara
- Breast Cancer Outcomes Unit, BC Cancer, Vancouver, British Columbia, Canada
| | - C Speers
- Breast Cancer Outcomes Unit, BC Cancer, Vancouver, British Columbia, Canada
| | - A Nichol
- Department of Radiation Oncology, BC Cancer, Vancouver, British Columbia, Canada; Breast Cancer Outcomes Unit, BC Cancer, Vancouver, British Columbia, Canada.
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Raphael DB, Ter Stege JA, Russell NS, Boersma LJ, van der Weijden T. What do patients and health care professionals view as important attributes in radiotherapy decisions? Input for a breast cancer patient decision aid. Breast 2019; 49:149-156. [PMID: 31812074 PMCID: PMC7375659 DOI: 10.1016/j.breast.2019.11.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 11/04/2019] [Accepted: 11/11/2019] [Indexed: 12/20/2022] Open
Abstract
Background and aim There is increased attention for shared decision making (SDM) when deciding on radiotherapy for selected patients with Stage 0–2 breast cancer. This study aimed to explore patients' and health care professionals’ experiences, decisional attributes and needs as input for the development of a patient decision aid to facilitate SDM. Methods Qualitative semi-structured interviews were held with fifteen breast cancer patients, being confronted with a radiotherapy decision one month to eight years earlier. Another fifteen interviews were held with professionals specialized in breast cancer care. Interviews were transcribed verbatim and independently coded by two researchers, who agreed upon relevant issues. Results Most patients made their decision by weighing the advantages of radiotherapy, i.e. comparing the decrease in recurrence risk with and without radiotherapy, and disadvantages, i.e. possible side effects. Patients and professionals agreed that recurrence risks should be communicated, but not on how to deal with uncertainty. There was wide variation in which, and how, side effects were explained by professionals. The most common side effects mentioned by both patients and professionals were skin toxicity, fatigue and breast deformity. Conclusion Patients and professionals appeared to agree on what type of attributes should be communicated during SDM on radiotherapy, but how this should be done is up for discussion. To ensure the patient's voice these attributes and needs need to be incorporated in the risk communication and value elicitation part of the patient decision aid. The format in which the attributes are communicated should be critically evaluated. Patients and professionals agree on most important attributes. These attributes need to be used in a patient decision aid. There is unwarranted inter doctor variation in informing about side effects. Professionals differ in opinion how to inform patients about epistemic uncertainties.
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Affiliation(s)
- D B Raphael
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, the Netherlands; Department of Family Medicine, CAPHRI School for Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands; Department of Radiotherapy, Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, the Netherlands.
| | - J A Ter Stege
- Department of Psychosocial Research and Epidemiology Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, the Netherlands.
| | - N S Russell
- Department of Radiotherapy, Netherlands Cancer Institute, Antoni van Leeuwenhoek, Amsterdam, the Netherlands.
| | - L J Boersma
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, the Netherlands.
| | - T van der Weijden
- Department of Family Medicine, CAPHRI School for Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands.
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