Electronic patient-reported outcomes monitoring during lung cancer chemotherapy: A nested cohort within the PRO-TECT pragmatic trial (AFT-39)

Comparison of Electronic Surveillance With Routine Monitoring for Patients With Lymphoma at High Risk of Relapse: Prospective Randomized Controlled Phase 3 Trial (Sentinel Lymphoma)

Background

Relapse is a major event in patients with lymphoma. Therefore, early detection may have an impact on quality of life and overall survival. Patient-reported outcome measures have demonstrated clinical benefits for patients with lung cancer; however, evidence is lacking in patients with lymphoma. We evaluated the effect of a web-mediated follow-up application for patients with lymphoma at high risk of relapse.

Objective

This study aims to demonstrate that monitoring patients via a web application enables the detection of at least 30% more significant events occurring between 2 systematic follow-up consultations with the specialist using an electronic questionnaire.

Methods

We conducted a prospective, randomized phase 3 trial comparing the impact of web-based follow-up (experimental arm) with a standard follow-up (control arm). The trial was based on a 2-step triangular test and was designed to have a power of 90% to detect a 30% improvement in the detection of significant events. A significant event was defined as a relapse, progression, or a serious adverse event. The study covered the follow-up period after completion of first-line treatment or relapse (24 months). Eligible patients were aged 18 years and older and had lymphoma at a high risk of relapse. In the experimental arm, patients received a 16-symptom questionnaire by email every 2 weeks. An email alert was sent to the medical team based on a predefined algorithm. The primary objective was assessed after the inclusion of the 40th patient. The study was continued for the duration of the analysis.

Results

A total of 52 patients were included between July 12, 2017, and April 7, 2020, at 11 centers in France, with 27 in the experimental arm and 25 in the control arm. The median follow-up was 21.3 (range 1.3-25.6) months, and 121 events were reported during the study period. Most events occurred in the experimental arm (83/119, 69.7%) compared with 30.2% (36/119) in the control arm. A median number of 3.5 (range 1-8) events per patient occurred in the experimental arm, and 1.8 (range 1-6) occurred in the control arm (P=.01). Progression and infection were the most frequently reported events. Further, 19 patients relapsed during follow-up: 6 in the experimental arm and 13 in the control arm (P<.001), with a median follow-up of 7.7 (range 2.8-20.6) months and 6.7 (range 1.9-16.4) months (P=.94), respectively. Statistical analysis was conducted after including the 40th patient, which showed no superiority of the experimental arm over the control arm. The study was therefore stopped after the 52nd patient was enrolled.

Conclusions

The primary objective was not reached; however, patient-reported outcome measures remain essential for detecting adverse events in patients with cancer, and the electronic monitoring method needs to demonstrate its effectiveness and comply with international safety guidelines.

Influence of symptom burden on social alienation in lung cancer patients receiving chemotherapy: the chain mediating effect of perceived social support and positive psychological capital

BACKGROUND

Social alienation is prevalent among lung cancer (LC) patients undergoing chemotherapy. Although previous research has established an association between social alienation and symptom burden, the mechanisms underlying this relationship remain not fully understood.

METHODS

This cross-sectional study used convenience sampling to select 378 LC patients undergoing chemotherapy from September 2022 to December 2023 at a tertiary care hospital in Guangzhou, China. Data collection was conducted using a proprietary Sociodemographic Information Questionnaire, MD Anderson Symptom Inventory (MDASI), Social Alienation Questionnaire, Perceptions of Social Support (PSS) Questionnaire, and Positive Psychological Capital (PPC) Questionnaire. To analyze chain-mediated effects, the PROCESS v3.3 Model 6 SPSS macro software was employed.

RESULTS

The analysis revealed that the burden of symptoms significantly exacerbates social alienation, as evidenced in the mediation effects model (Bootstrap 95% CI: 0.031, 0.092). Furthermore, the burden of symptoms indirectly diminishes PSS (Bootstrap 95% CI: 0.019, 0.057) and PPC (Bootstrap 95% CI: 0.002, 0.020). It is crucial to note that both PSS and PPC significantly mediate the relationship between symptom burden and social alienation, as evidenced (Bootstrap 95% CI: 0.001, 0.011).

CONCLUSIONS

The impact of symptom burden on social alienation is moderated through PSS and PPC, manifesting both directly and indirectly. Moreover, the influence of PPC tends to mitigate the mediating role of PSS. Clinical interventions aimed at bolstering PSS and augmenting PPC may potentially alleviate social alienation and enhance the quality of life for patients undergoing chemotherapy for LC.

A Qualitative Study of Electronic Patient-Reported Outcome Symptom Monitoring After Thoracic Surgery

INTRODUCTION

Thoracic surgery is a mainstay of therapy for lung cancer and other chronic pulmonary conditions, but recovery is often complicated. Digital health systems can facilitate remote postoperative symptom management yet obstacles persist in their routine clinical adoption. This study aimed to identify patient-perceived barriers and facilitators to using an electronic patient-reported outcome (ePRO) monitoring platform specially designed to detect complications from thoracic surgery postdischarge.

METHODS

Patients (n = 16) who underwent thoracic surgery and participated in an ePRO parent study completed semistructured interviews, which were analyzed using thematic content analysis and iterative team-based coding. Themes were mapped onto the three domains of the Capability, Opportunity, and Motivation Model of behavior framework to inform ePRO design and implementation improvements.

RESULTS

Analysis demonstrated seven dominant themes, including barriers (1. postoperative patient physical and mental health, 2. lack of access to email and poor internet connectivity, 3. lack of clarity on ePRO use in routine clinical care, and 4. symptom item redundancy) as well as facilitators (5. ease of the ePRO assessment completion, 6. engagement with the surgical care team on ePRO use, and 7. increased awareness of symptom experience through ePRO use). Suggested ePRO improvements included offering alternatives to web-based completion, tailoring symptom assessments to individual patients, and the need for patient education on ePROs for perioperative care.

CONCLUSIONS

Addressable barriers and facilitators to implementation of ePRO symptom monitoring in the thoracic surgical patient population postdischarge have been identified. Future work will test the impact of design improvements on implementation outcomes of feasibility and acceptability.

Patient-reported outcomes in lung cancer surgery: A narrative review

Lung cancer is a leading cause of cancer-related mortality worldwide, profoundly affecting patients' quality of life. Patient-reported outcomes (PROs) provide essential insights from the patients' perspective, a crucial aspect often overlooked by traditional clinical outcomes. This review synthesizes research on the role of PROs in lung cancer surgery to enhance patient care and outcomes. We conducted a comprehensive literature search across PubMed, Scopus, and Web of Science up to March 2024, using terms such as "lung cancer," "Patient Reported Outcome," "lobectomy," "segmentectomy," and "lung surgery." The criteria included original studies on lung cancer patients who underwent surgical treatment and reported on PROs. After screening and removing duplicates, reviews, non-English articles, and irrelevant studies, 36 research articles were selected, supported by an additional 53 publications, totaling 89 references. The findings highlight the utility of PROs in assessing post-surgical outcomes, informing clinical decisions, and facilitating patient-centered care. However, challenges in standardization, patient burden, and integration into clinical workflows remain, underscoring the need for further research and methodological refinement. PROs are indispensable for understanding the quality-of-life post-surgery and enhancing communication and decision-making in clinical practice. Their integration into routine care is vital for a holistic approach to lung cancer treatment, promising significant improvements in patient outcomes and quality of care.

Patient motivators of postoperative electronic patient-reported outcome symptom monitoring use in thoracic surgery patients: a qualitative study

BACKGROUND

Electronic patient-reported outcome (ePRO) systems can be used to engage patients in remote symptom monitoring to support postoperative care. We interviewed thoracic surgery patients with ePRO experience to identify factors that influenced use of ePROs to report their symptoms post-discharge.

METHOD

This qualitative study used semi-structured telephone interviews with adults who underwent major thoracic surgery at an academic medical center in North Carolina. Individuals who enrolled in symptom monitoring, completed at least one ePRO survey, and were reachable by phone for the interview were included. The ePRO surveys assessed 10 symptoms, including validated Patient-Reported Outcome Common Terminology Criteria for Adverse Events (PRO-CTCAE) measures and thoracic surgery-specific questions. Surveys, offered via web-based and automated telephone options, were administered for four weeks post-discharge with alerts sent to clinicians for concerning symptoms. The interviews were guided by the Capability, Opportunity, Motivation model for behavior change (COM-B) and examined factors that influenced patients' completion of ePRO surveys post-discharge. Team members independently coded interviews and identified themes, informed by COM-B. We report descriptive statistics (demographics, number of surveys completed) and themes organized by COM-B components.

RESULTS

Of 28 patients invited, 25 (89%) completed interviews from July to October 2022. Participants were a median 58 years, 56% female, 80% White, and 56% had a history of malignancy. They completed 131/150 (87%) possible ePRO surveys. For capability, participants reported building ePROs into their routine and having the skills and knowledge, but lacking physical and emotional energy, to complete ePROs. For opportunity, participants identified the ease and convenience of accessing ePROs and providers' validation of ePROs. Motivators were perceived benefits of a deepening connection to their clinical team, improved symptom management for themselves and others, and self-reflection about their recovery. Factors limiting motivation included lack of clarity about the purpose of ePROs and a disconnect between symptom items and individual recovery experience.

CONCLUSIONS

Patients described being motivated to complete ePROs when reinforced by clinicians and considered ePROs as valuable to their post-discharge experience. Future work should enhance ePRO patient education, improve provider alerts and communications about ePROs, and integrate options to capture patients' complex health journeys.

Longitudinal assessment of real-world patient adherence: a 12-month electronic patient-reported outcomes follow-up of women with early breast cancer undergoing treatment

BACKGROUND

Electronic patient-reported outcomes (ePROs) assess patients' health status and quality of life, improving patient care and treatment effects, yet little is known about their use and adherence in routine patient care.

AIMS

We evaluated the adherence of invasive breast cancer and ductal carcinoma in situ (DCIS) patients to ePROs follow-up and whether specific patient characteristics are related to longitudinal non-adherence.

METHODS

Since November 2016, the Breast Center at Charité - Universitätsmedizin Berlin has implemented an ongoing prospective PRO routine program, requiring patients to complete ePROs assessments and consent to email-based follow-up in the first 12 months after therapy starts. Frequencies and summary statistics are presented. Multiple logistic regression models were performed to determine an association between patient characteristics and non-adherence.

RESULTS

Out of 578 patients, 239 patients (41.3%, 95%CI: 37.3-45.5%) completed baseline assessment and all five ePROs follow-up during the first 12 months after therapy. On average, above 70% of those patients responded to the ePROs follow-up assessment. Adherence to the ePROs follow-up was higher during the COVID-19 pandemic than in the time periods before (47.4% (111/234) vs. 33.6% (71/211)). Factors associated with longitudinal non-adherence were younger age, a higher number of comorbidities, no chemotherapy, and a low physical functioning score in the EORTC QLQ-C30 at baseline.

CONCLUSIONS

The study reveals moderate adherence to 12-month ePROs follow-up assessments in invasive early breast cancer and DCIS patients, with response rates ranging from 60 to 80%. Emphasizing the benefits for young patients and those with high disease burdens might further increase adherence.

Interventions for Concerning Patient-Reported Outcomes in Routine Cancer Care: A Systematic Review

IMPORTANCE

Collecting patient-reported outcomes (PROs) in routine cancer care improves patient-clinician communication, decision making, and overall patient satisfaction. Recommendations exist regarding standardized ways to collect, store, and interpret PRO data. However, evidence on incorporating PROs into cancer process of care, especially the type of HIs that are warranted after observing a concerning PRO and the effectiveness of these HIs are lacking.

OBJECTIVE

This study summarizes HIs triggered after PRO completion and their effectiveness in improving patient outcomes for adults being treated for cancer types that are resource intensive and associated with high symptom burden [i.e., gastrointestinal (GI), lung, and head and neck cancer (HNC)]. Secondary outcomes included factors associated with poor implementation of PROs.

EVIDENCE REVIEW

A literature search of peer-reviewed publications on MEDLINE, CINAHL Plus, APA PsycInfo, Scopus, and Cochrane was conducted following PRISMA guidelines from 1 January 2012, to 31 July 2022. Trial and real-world studies describing HIs after PRO completion for adult patients being treated for GI, lung, and HNC were included. Sixteen studies involving 144,496 patients were included. The Joanna Briggs Institute critical appraisal checklist was used to assess risk of bias.

FINDINGS

Of the 16 included studies, 5 included patients with HNC. Commonly used PRO measurement tools were the PRO-CTCAE and ESAS. Only three studies reported specific HIs delivered in response to concerning PROs and measured their effectiveness on patient outcomes. In all three studies, these HIs significantly improved cancer-related care. The most common HIs undertaken in response to concerning PROs were referrals to other specialists/allied healthcare professionals, medication changes, or self-management advice. Provider-related barriers to PRO measurement and delivery included the overwhelming number of alerts, the time required to address each PRO and the unclear role of healthcare providers in response to these alerts. Patient-related barriers included lower digital literacy and socioeconomic status, older age, rural living, and patients suffering from GI and HNC.

CONCLUSIONS AND RELEVANCE

This review highlights that PRO-triggered HIs are heterogenous and can improve patient quality of life. Further studies are necessary to determine the types of interventions with the greatest impact on patient care and outcomes.

Country-specific reference values for PROMIS® pain, physical function and participation measures compared to US reference values

INTRODUCTION

Patient-Reported Outcomes Measurement Information System (PROMIS^®) is commonly used across medical conditions. To facilitate interpretation of scores across countries, we calculated Dutch reference values for PROMIS Physical Function (PROMIS-PF), Pain Interference (PROMIS-PI), Pain Behavior (PROMIS-PB), Ability to Participate in Social Roles and Activities (PROMIS-APSRA), and Satisfaction with Social Roles and Activities (PROMIS-SSRA), as compared to US reference values.

PATIENTS AND METHODS

A panel completed full PROMIS-PF (n=1310), PROMIS-PI and PROMIS-PB (n=1052), and PROMIS-APSRA and PROMIS-SSRA (n=1002) item banks and reported their level of health per domain (no, mild, moderate, severe limitations). T-scores were calculated by sample and subgroups (age, gender, self-reported level of domain). Distribution-based and anchor-based thresholds for mild, moderate, and severe scores were determined.

RESULTS

Mean T-scores were close to the US mean of 50 for PROMIS-PF (49.8) and PROMIS-APSRA (50.6), lower for PROMIS-SSRA (47.5) and higher for PROMIS-PI (54.9) and PROMIS-PB (52.0). Distribution-based thresholds for mild, moderate, and severe scores were comparable to US recommended cut-off values (except for PROMIS-PI) but participants reported limitations 'earlier' than suggested thresholds.

CONCLUSION

Dutch reference values were close to US reference values for some PROMIS domains but not all. We recommend country-specific reference values to facilitate worldwide PROMIS use.KEY MESSAGESPROMIS offers universally applicable IRT-based efficient and patient-friendly measures to assess commonly relevant patient-reported outcomes across medical conditions.To support the use of PROMIS in daily clinical practice and research across the world, country-specific general population reference values should be obtained.More research is necessary to obtain reliable and valid cut-off values for what constitutes mild, moderate and severe scores from the patients' perspective.

Pain experience of lung cancer patients during home recovery after surgery: A qualitative descriptive study

BACKGROUND

Patients with lung cancer surgery often suffer pain after discharge. However, there is limited evidence to describe the pain experience from the qualitative investigation. This study was designed to describe the pain experience of lung cancer patients during home recovery after surgery and to provide evidence for developing pain management strategies.

METHODS

This qualitative descriptive study recruited 35 patients who had received lung resection and were discharged by purposive sampling from May to July 2022. Mobile phone interviews were conducted to collect views on patients' pain experience after discharge. The interviews were audio-recorded and converted verbatim into standard text, and the data were iteratively thematic analyzed.

RESULTS

A thematic framework was identified for three themes: perception and impact of pain, coping styles for pain, and unmet needs for pain. Whether short or long-term after discharge, patients complain that they suffer from different degrees and types of pain, causing them a "double burden" physically and mentally. The lack of knowledge about pain may lead them to adopt very different coping styles and desire professional continuous pain management.

CONCLUSIONS

This study may help clarify the status of pain problems that patients face after lung cancer surgery and provides multiple dimensions of pain assessment and management objectives for quantitative research. We call on medical staff to pay attention to patients' perspectives and related needs after discharge and formulate targeted management strategies to reduce pain and improve their quality of life.

The Feasibility, Acceptability, and Effectiveness of Electronic Patient-Reported Outcome Symptom Monitoring for Immune Checkpoint Inhibitor Toxicities: A Systematic Review

PURPOSE

Increasing use of immune checkpoint inhibitors (ICIs) in routine cancer care will increase the incidence of immune-related adverse events (irAEs). Systems are needed to support remote monitoring for irAEs. Electronic patient-reported outcome (ePRO) symptom monitoring systems can help monitor and manage symptoms and side effects. We assessed the content and features of ePRO symptom monitoring systems for irAEs, and their feasibility, acceptability, and impact on patient outcomes and health care utilization.

METHODS

A systematic literature search was conducted in May 2022 on MEDLINE, Embase, PsycINFO, and Cochrane Central Register of Controlled Trials. Quantitative and qualitative data relevant to the review questions were extracted and synthesized in tables.

RESULTS

Seven papers describing five ePRO systems were included. All systems collected PROs between clinic visits. Two of five used validated symptom questionnaires, 3/5 provided prompts to complete questionnaires, 4/5 provided reminders to self-report, and 3/5 provided clinician alerts for severe/worsening side effects. Four of five provided coverage of ≥26/30 irAEs in the ASCO irAE guideline. Feasibility and acceptability were demonstrated with consent rates of 54%-100%, 17%-27% of questionnaires generating alerts, and adherence rates of 74%-75%. One paper showed a reduction in grade 3-4 irAEs, treatment discontinuation, clinic visit duration, and emergency department presentations, while another showed no difference in these outcomes or the rate of steroid use.

CONCLUSION

There is preliminary evidence of the feasibility and acceptability of ePRO symptom monitoring for irAEs. However, further studies are needed to confirm the impact on ICI-specific outcomes, such as the frequency of grade 3-4 irAEs and duration of immunosuppression. Suggestions for the content and features of future ePRO systems for irAEs are provided.

Electronic Medical Record-Based Electronic Messaging Among Patients with Breast Cancer: A Systematic Review

BACKGROUND

Electronic medical record (EMR) systems and electronic messages are an increasingly common conduit between physicians and patients. Clear benefits of this type of communication have been established, especially among cancer patients. Studies suggest that patient portals and electronic messaging platforms can help with care coordination between oncology providers and facilitate asynchronous patient-provider communication. Despite the many benefits, there is little research regarding EMR and secure messaging use, particularly among patients with breast cancer.

OBJECTIVES

The objective of this systematic review was to examine the evidence supporting the use of EMR-based messaging systems in patients with breast cancer.

METHODS

A systematic literature search of Ovid MEDLINE, PubMed, Scopus, Web of Science CINAHL, and Cochrane Library was conducted. Studies were required to be published between 2005 and 2022 and report data on demographic information and electronic messaging between patients and providers. Studies were excluded if they reported insufficient data, did not include breast cancer patients, or were not published in English.

RESULTS

This study identified 10 articles that met inclusion criteria. The resulting studies investigated topics such as: patterns of messaging and medication adherence, cancer screening, messaging as a predictor of behavior or outcomes, and symptom management. The literature indicates that electronic messaging with providers was associated with clinical benefits for breast cancer patients and improved screening behaviors.

CONCLUSION

This review uncovered multiple areas to focus future research on, including ideal volume of electronic messages sent and their relation to prescription adherence, studies focusing solely on the breast cancer population, racial disparities in electronic messaging, and provider perceptions of electronic messaging. It is vital that more work be done to understand barriers and gaps in EMR usage to ensure that all individuals can access this increasingly essential medical service while minimizing physician workload and burnout.

Feasibility of perioperative remote monitoring of patient-generated health data in complex surgical oncology

BACKGROUND

The feasibility of remote perioperative telemonitoring of patient-generated physiologic health data and patient-reported outcomes in a high risk complex general and urologic oncology surgery population is evaluated.

METHODS

Complex general surgical/urologic oncology patients wore a pedometer, completed ePROs (electronic patient-reported outcome surveys) and record their vitals (weight, pulse, pulse oximetry, blood pressure, and temperature) via a telehealth app platform. Feasibility (% adherence) was assessed as the primary outcome measure.

RESULTS

Twenty-one patients with a median age 58 (32-82) years were included. The readmission rate was 33% and the incidence of ≥Grade 3a morbidity was 24%. Adherence to vital sign and ePRO measurements was 95% before surgery, 91% at discharge, and 82%, 68%, and 64% at postdischarge d2, 7, 14, and 30, respectively. There was significant worsening of mobility, self-care and usual daily activity at postdischarge d2 compared to preoperative baseline (p < 0.05). Median daily preoperative steps taken by patients with

CONCLUSIONS

Telemonitoring is feasible in a general surgical and urologic oncology setting. Future studies will ascertain optimal patient selection, duration, and extent of perioperative monitoring.

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Key Words

• patient-generated health data
• patient-reported outcomes
• telemonitoring

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MESH Headings

• Humans
• Middle Aged
• Patient Discharge
• Feasibility Studies
• Surgical Oncology
• Aftercare
• Telemedicine

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Grants Collapse

Affiliation(s)

Laleh G Melstrom Department of Surgery City of Hope, Division of Surgical Oncology, Duarte, California, USA
Xiaoke Zhou Department of Population Sciences, City of Hope, Duarte, California, USA
Andreas Kaiser Department of Surgery City of Hope, Division of Colorectal Surgery, Duarte, California, USA
Kevin Chan Department of Surgery City of Hope, Division of Urologic Oncology, Duarte, California, USA
Clayton Lau Department of Surgery City of Hope, Division of Urologic Oncology, Duarte, California, USA
Mustafa Raoof Department of Surgery City of Hope, Division of Surgical Oncology, Duarte, California, USA
Susanne G Warner Department of Surgery Mayo Clinic, Rochester, Minnesota, USA
Ali Zhumkhawala Department of Surgery City of Hope, Division of Urologic Oncology, Duarte, California, USA
Bertram Yuh Department of Surgery City of Hope, Division of Urologic Oncology, Duarte, California, USA
Gagandeep Singh Department of Surgery City of Hope, Division of Surgical Oncology, Duarte, California, USA
Yuman Fong Department of Surgery City of Hope, Division of Surgical Oncology, Duarte, California, USA
Virginia Sun Department of Surgery City of Hope, Division of Surgical Oncology, Duarte, California, USA Department of Population Sciences, City of Hope, Duarte, California, USA

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Feasibility of perioperative remote monitoring of patient-generated health data in complex surgical oncology

BACKGROUND

The feasibility of remote perioperative telemonitoring of patient-generated physiologic health data and patient-reported outcomes in a high risk complex general and urologic oncology surgery population is evaluated.

METHODS

Complex general surgical/urologic oncology patients wore a pedometer, completed ePROs (electronic patient-reported outcome surveys) and record their vitals (weight, pulse, pulse oximetry, blood pressure, and temperature) via a telehealth app platform. Feasibility (% adherence) was assessed as the primary outcome measure.

RESULTS

Twenty-one patients with a median age 58 (32-82) years were included. The readmission rate was 33% and the incidence of ≥Grade 3a morbidity was 24%. Adherence to vital sign and ePRO measurements was 95% before surgery, 91% at discharge, and 82%, 68%, and 64% at postdischarge d2, 7, 14, and 30, respectively. There was significant worsening of mobility, self-care and usual daily activity at postdischarge d2 compared to preoperative baseline (p < 0.05). Median daily preoperative steps taken by patients with

CONCLUSIONS

Telemonitoring is feasible in a general surgical and urologic oncology setting. Future studies will ascertain optimal patient selection, duration, and extent of perioperative monitoring.

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Key Words

• patient-generated health data
• patient-reported outcomes
• telemonitoring

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MESH Headings

• Humans
• Middle Aged
• Patient Discharge
• Feasibility Studies
• Surgical Oncology
• Aftercare
• Telemedicine

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Grants Collapse

Affiliation(s)

Laleh G. Melstrom Department of Surgery City of HopeDivision of Surgical OncologyDuarteCaliforniaUSA
Xiaoke Zhou Department of Population SciencesCity of HopeDuarteCaliforniaUSA
Andreas Kaiser Department of Surgery City of HopeDivision of Colorectal SurgeryDuarteCaliforniaUSA
Kevin Chan Department of Surgery City of HopeDivision of Urologic OncologyDuarteCaliforniaUSA
Clayton Lau Department of Surgery City of HopeDivision of Urologic OncologyDuarteCaliforniaUSA
Mustafa Raoof Department of Surgery City of HopeDivision of Surgical OncologyDuarteCaliforniaUSA
Susanne G. Warner Department of Surgery Mayo ClinicRochesterMinnesotaUSA
Ali Zhumkhawala Department of Surgery City of HopeDivision of Urologic OncologyDuarteCaliforniaUSA
Bertram Yuh Department of Surgery City of HopeDivision of Urologic OncologyDuarteCaliforniaUSA
Gagandeep Singh Department of Surgery City of HopeDivision of Surgical OncologyDuarteCaliforniaUSA
Yuman Fong Department of Surgery City of HopeDivision of Surgical OncologyDuarteCaliforniaUSA
Virginia Sun Department of Surgery City of HopeDivision of Surgical OncologyDuarteCaliforniaUSA Department of Population SciencesCity of HopeDuarteCaliforniaUSA

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