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McKechnie T, Lee Y, Hong D, Dionne J, Doumouras A, Parpia S, Bhandari M, Eskicioglu C. A history of bariatric surgery before surgery for colorectal cancer may improve short-term postoperative outcomes: Analysis of the national inpatient sample 2015-2019. Surgery 2023; 174:1168-1174. [PMID: 37709649 DOI: 10.1016/j.surg.2023.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/11/2023] [Accepted: 08/08/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Bariatric surgery is the most effective and sustainable form of weight loss. Bariatric surgery before elective operations for colorectal pathology may improve postoperative outcomes. To compare patients with and without prior bariatric surgery undergoing surgery for colorectal cancer in terms of postoperative morbidity and health care use. METHODS Adult patients undergoing resection for colorectal cancer from 2015 to 2019 were identified from the National Inpatient Sample. Patients were stratified according to their history of bariatric surgery. Propensity score matching with 4:1 nearest-neighbor matching was performed according to demographic, operative, and hospital characteristics. The primary outcome was postoperative morbidity. Secondary outcomes included system-specific postoperative complications, postoperative mortality, postoperative length of stay, total admission health care cost, and post-discharge disposition. McNemar's test and Wilcoxon matched-pairs signed-rank test were performed. RESULTS After propensity score matching, 1,197 patients without prior bariatric surgery and 376 patients with prior bariatric surgery were included. Patients with prior bariatric surgery had an absolute reduction of 6.5% in overall in-hospital postoperative morbidity (19.1% vs 25.6%, P < .0001), a $5,256 decrease in hospitalization cost ($70,344 vs $75,600, P = .034), and were more likely to be discharged home after their index operation (72.9% vs 63.9%, P < .0001). CONCLUSION Bariatric surgery before surgery for colorectal cancer may be associated with decreased postoperative morbidity and health care use. Bariatric surgery and other forms of rapid and effective weight loss, such as very low-energy diets, should be evaluated further for the optimization of obese patients before nonbariatric abdominal surgery.
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Affiliation(s)
- Tyler McKechnie
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada. https://twitter.com/tylermckechnie
| | - Yung Lee
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA. https://twitter.com/YungLeeMD
| | - Dennis Hong
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Department of Surgery, St. Joseph Healthcare, Hamilton, Ontario, Canada. https://twitter.com/Drbariatricsx
| | - Joanna Dionne
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Aristithes Doumouras
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Surgery, St. Joseph Healthcare, Hamilton, Ontario, Canada. https://twitter.com/Doctor_Doum
| | - Sameer Parpia
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Mohit Bhandari
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Cagla Eskicioglu
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Department of Surgery, St. Joseph Healthcare, Hamilton, Ontario, Canada.
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Justesen TF, Gögenur M, Clausen JSR, Mashkoor M, Rosen AW, Gögenur I. The impact of time to surgery on oncological outcomes in stage I-III dMMR colon cancer - A nationwide cohort study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106887. [PMID: 37002178 DOI: 10.1016/j.ejso.2023.03.223] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 03/22/2023] [Indexed: 03/31/2023]
Abstract
INTRODUCTION One of the considerations when investigating neoadjuvant interventions is the prolonging of time from diagnosis to curative surgery (i.e. the treatment interval [TI]). The aim of this study was to investigate the association between the length of TI and overall survival and disease-free survival in patients with deficient mismatch repair (dMMR) colon cancer. MATERIALS AND METHODS This retrospective propensity score-adjusted study included all patients of ≥18 years of age undergoing elective curative surgery for stage I-III, dMMR colon cancer. Data were extracted from four Danish patient databases. Outcomes were investigated in groups with TIs of ≤14 days versus >14 days. Propensity scores were computed using all demographics, diagnoses and measurements. Matching was done in a 1:1 ratio. RESULTS A total of 4130 patients were included in the study with a mean age of 73.8 years and a median follow-up time of 43.9 months. After matching, 2794 patients were included in the analysis of overall survival. No significant difference in overall survival was seen between patients with TIs of ≤14 days versus >14 days (hazard ratio [HR], 0.97; 95% confidence interval [CI], 0.81-1.17; p = 0.78). In the analysis of disease-free survival, 1798 patients were included after matching. This showed no significant difference between patients with TIs of ≤14 days versus >14 days (HR, 0.85; 95% CI, 0.69-1.06; p = 0.14). CONCLUSION No associations were found between TI and overall survival and disease-free survival in patients with stage I-III, dMMR colon cancer undergoing elective curative surgery.
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Affiliation(s)
| | - Mikail Gögenur
- Center for Surgical Science, Zealand University Hospital, Lykkebækvej 1, 4600, Køge, Denmark.
| | - Johan Stub Rønø Clausen
- Center for Surgical Science, Zealand University Hospital, Lykkebækvej 1, 4600, Køge, Denmark.
| | - Maliha Mashkoor
- Center for Surgical Science, Zealand University Hospital, Lykkebækvej 1, 4600, Køge, Denmark.
| | | | - Ismail Gögenur
- Center for Surgical Science, Zealand University Hospital, Lykkebækvej 1, 4600, Køge, Denmark; Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark.
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Justesen TF, Gögenur I, Tarpgaard LS, Pfeiffer P, Qvortrup C. Evaluating the efficacy and safety of neoadjuvant pembrolizumab in patients with stage I-III MMR-deficient colon cancer: a national, multicentre, prospective, single-arm, phase II study protocol. BMJ Open 2023; 13:e073372. [PMID: 37349100 PMCID: PMC10314641 DOI: 10.1136/bmjopen-2023-073372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 06/08/2023] [Indexed: 06/24/2023] Open
Abstract
INTRODUCTION Within the last two decades, major advances have been made in the surgical approach for patients with colorectal cancer. However, to this day we face considerable challenges in reducing surgery-related complications and improving long-term oncological outcomes. Unprecedented response rates have been achieved in studies investigating immunotherapy in patients with mismatch repair deficient (dMMR) colorectal cancer. This has raised the question of whether neoadjuvant immunotherapy may change the standard of care for localised dMMR colon cancer and pave the way for organ-sparing treatment. METHODS AND ANALYSIS This is an investigator-initiated, multicentre, prospective, single-arm, phase II study in patients with stage I-III dMMR colon cancer scheduled for intended curative surgery. Eighty-five patients will be treated with one dose of pembrolizumab (4 mg/kg) and within 5 weeks will undergo a re-evaluation with an endoscopy and a CT scan-to assess tumour response-before standard resection of the tumour. The primary endpoint is the number of patients with pathological complete response, and secondary endpoints include safety (number and severity of adverse events) and postoperative surgical complications. In addition, we aspire to identify predictive biomarkers that can point out patients that achieve pathological complete response. ETHICS AND DISSEMINATION The Regional Committee for Health Research and Ethics and the Danish Medicines Agency have approved this study. The study will be performed according to the Helsinki II declaration. Written informed consent will be obtained from all participants. The results of the study will be submitted to peer-reviewed journals for publication and presented at international congresses. TRIAL REGISTRATION NUMBER NCT05662527.
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Affiliation(s)
| | - Ismail Gögenur
- Center for Surgical Science, Zealand University Hospital, Koge, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Line Schmidt Tarpgaard
- Department of Oncology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Per Pfeiffer
- Department of Oncology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Molenaar CJL, Minnella EM, Coca-Martinez M, ten Cate DWG, Regis M, Awasthi R, Martínez-Palli G, López-Baamonde M, Sebio-Garcia R, Feo CV, van Rooijen SJ, Schreinemakers JMJ, Bojesen RD, Gögenur I, van den Heuvel ER, Carli F, Slooter GD. Effect of Multimodal Prehabilitation on Reducing Postoperative Complications and Enhancing Functional Capacity Following Colorectal Cancer Surgery: The PREHAB Randomized Clinical Trial. JAMA Surg 2023; 158:572-581. [PMID: 36988937 PMCID: PMC10061316 DOI: 10.1001/jamasurg.2023.0198] [Citation(s) in RCA: 50] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 11/19/2022] [Indexed: 03/30/2023]
Abstract
Importance Colorectal surgery is associated with substantial morbidity rates and a lowered functional capacity. Optimization of the patient's condition in the weeks prior to surgery may attenuate these unfavorable sequelae. Objective To determine whether multimodal prehabilitation before colorectal cancer surgery can reduce postoperative complications and enhance functional recovery. Design, Setting, and Participants The PREHAB randomized clinical trial was an international, multicenter trial conducted in teaching hospitals with implemented enhanced recovery after surgery programs. Adult patients with nonmetastasized colorectal cancer were assessed for eligibility and randomized to either prehabilitation or standard care. Both arms received standard perioperative care. Patients were enrolled from June 2017 to December 2020, and follow-up was completed in December 2021. However, this trial was prematurely stopped due to the COVID-19 pandemic. Interventions The 4-week in-hospital supervised multimodal prehabilitation program consisted of a high-intensity exercise program 3 times per week, a nutritional intervention, psychological support, and a smoking cessation program when needed. Main Outcomes and Measures Comprehensive Complication Index (CCI) score, number of patients with CCI score more than 20, and improved walking capacity expressed as the 6-minute walking distance 4 weeks postoperatively. Results In the intention-to-treat population of 251 participants (median [IQR] age, 69 [60-76] years; 138 [55%] male), 206 (82%) had tumors located in the colon and 234 (93%) underwent laparoscopic- or robotic-assisted surgery. The number of severe complications (CCI score >20) was significantly lower favoring prehabilitation compared with standard care (21 of 123 [17.1%] vs 38 of 128 [29.7%]; odds ratio, 0.47 [95% CI, 0.26-0.87]; P = .02). Participants in prehabilitation encountered fewer medical complications (eg, respiratory) compared with participants receiving standard care (19 of 123 [15.4%] vs 35 of 128 [27.3%]; odds ratio, 0.48 [95% CI, 0.26-0.89]; P = .02). Four weeks after surgery, 6-minute walking distance did not differ significantly between groups when compared with baseline (mean difference prehabilitation vs standard care 15.6 m [95% CI, -1.4 to 32.6]; P = .07). Secondary parameters of functional capacity in the postoperative period generally favored prehabilitation compared with standard care. Conclusions and Relevance This PREHAB trial demonstrates the benefit of a multimodal prehabilitation program before colorectal cancer surgery as reflected by fewer severe and medical complications postoperatively and an optimized postoperative recovery compared with standard care. Trial Registration trialregister.nl Identifier: NTR5947.
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Affiliation(s)
| | - Enrico Maria Minnella
- Department of Anesthesia, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Miquel Coca-Martinez
- Department of Anesthesia, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
- Department of Anesthesia, Hospital Clínic de Barcelona, Barcelona, Spain
| | | | - Marta Regis
- Department of Mathematics and Computer Science, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Rashami Awasthi
- Department of Anesthesia, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | | | | | - Raquel Sebio-Garcia
- Physical Medicine and Rehabilitation Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Carlo Vittorio Feo
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
- Unit of Provincial General Surgery, Azienda Unità Sanitaria Locale Ferrara, Ferrara, Italy
| | | | | | - Rasmus Dahlin Bojesen
- Center for Surgical Science, Zealand University Hospital, Roskilde, Denmark
- Department of Surgery, Slagelse Hospital, Slagelse, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ismail Gögenur
- Center for Surgical Science, Zealand University Hospital, Roskilde, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Surgery, Zealand University Hospital, Køge, Denmark
| | - Edwin R. van den Heuvel
- Department of Mathematics and Computer Science, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Francesco Carli
- Department of Anesthesia, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
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Drosdowsky A, Lamb KE, Bergin RJ, Boyd L, Milley K, IJzerman MJ, Emery JD. A systematic review of methodological considerations in time to diagnosis and treatment in colorectal cancer research. Cancer Epidemiol 2023; 83:102323. [PMID: 36701982 DOI: 10.1016/j.canep.2023.102323] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 01/06/2023] [Accepted: 01/09/2023] [Indexed: 01/26/2023]
Abstract
Research focusing on timely diagnosis and treatment of colorectal cancer is necessary to improve outcomes for people with cancer. Previous attempts to consolidate research on time to diagnosis and treatment have noted varied methodological approaches and quality, limiting the comparability of findings. This systematic review was conducted to comprehensively assess the scope of methodological issues in this field and provide recommendations for future research. Eligible articles had to assess the role of any interval up to treatment, on any outcome in colorectal cancer, in English, with no limits on publication time. Four databases were searched (Ovid Medline, EMBASE, EMCARE and PsycInfo). Papers were screened by two independent reviewers using a two-stage process of title and abstract followed by full text review. In total, 130 papers were included and had data extracted on specific methodological and statistical features. Several methodological problems were identified across the evidence base. Common issues included arbitrary categorisation of intervals (n = 107, 83%), no adjustment for potential confounders (n = 65, 50%), and lack of justification for included covariates where there was adjustment (n = 40 of 65 papers that performed an adjusted analysis, 62%). Many articles introduced epidemiological biases such as immortal time bias (n = 37 of 80 papers that used survival as an outcome, 46%) and confounding by indication (n = 73, 56%), as well as other biases arising from inclusion of factors outside of their temporal sequence. However, determination of the full extent of these problems was hampered by insufficient reporting. Recommendations include avoiding artificial categorisation of intervals, ensuring bias has not been introduced due to out-of-sequence use of key events and increased use of theoretical frameworks to detect and reduce bias. The development of reporting guidelines and domain-specific risk of bias tools may aid in ensuring future research can reliably contribute to recommendations regarding optimal timing and strengthen the evidence base.
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Affiliation(s)
- Allison Drosdowsky
- Department of General Practice and Centre for Cancer Research, The University of Melbourne, Parkville, Australia.
| | - Karen E Lamb
- Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Australia
| | - Rebecca J Bergin
- Department of General Practice and Centre for Cancer Research, The University of Melbourne, Parkville, Australia; Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Australia
| | - Lucy Boyd
- Department of General Practice and Centre for Cancer Research, The University of Melbourne, Parkville, Australia
| | - Kristi Milley
- Department of General Practice and Centre for Cancer Research, The University of Melbourne, Parkville, Australia; Primary Care Collaborative Cancer Clinical Trials Group (PC4), Carlton, Australia
| | - Maarten J IJzerman
- Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Australia
| | - Jon D Emery
- Department of General Practice and Centre for Cancer Research, The University of Melbourne, Parkville, Australia; Primary Care Collaborative Cancer Clinical Trials Group (PC4), Carlton, Australia
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Wu D, Yang Z, Sun L, Quan Y, Min Z. Preoperative prediction of lymphovascular invasion of CRC by artificial neural network. PRECISION MEDICAL SCIENCES 2022. [DOI: 10.1002/prm2.12074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Dejun Wu
- Department of General Surgery, Shanghai Pudong Hospital Fudan University Pudong Medical Center Shanghai China
| | - Zhou Yang
- Department of General Surgery, Shanghai Pudong Hospital Fudan University Pudong Medical Center Shanghai China
| | - Leilei Sun
- Department of Anesthesiology, Shanghai Pudong Hospital Fudan University Pudong Medical Center Shanghai China
| | - Yingjun Quan
- Department of General Surgery, Tongren Hospital Shanghai Jiao Tong University School of Medicine Shanghai China
| | - Zhijun Min
- Department of General Surgery, Shanghai Pudong Hospital Fudan University Pudong Medical Center Shanghai China
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7
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Implementation of prehabilitation in colorectal cancer surgery: qualitative research on how to strengthen facilitators and overcome barriers. Support Care Cancer 2022; 30:7373-7386. [PMID: 35610321 PMCID: PMC9130002 DOI: 10.1007/s00520-022-07144-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 05/11/2022] [Indexed: 11/05/2022]
Abstract
Purpose Prehabilitation is increasingly offered to patients with colorectal cancer (CRC) undergoing surgery as it could prevent complications and facilitate recovery. However, implementation of such a complex multidisciplinary intervention is challenging. This study aims to explore perspectives of professionals involved in prehabilitation to gain understanding of barriers or facilitators to its implementation and to identify strategies to successful operationalization of prehabilitation. Methods In this qualitative study, semi-structured interviews were performed with healthcare professionals involved in prehabilitation for patients with CRC. Prehabilitation was defined as a preoperative program with the aim of improving physical fitness and nutritional status. Parallel with data collection, open coding was applied to the transcribed interviews. The Ottawa Model of Research Use (OMRU) framework, a comprehensive interdisciplinary model guide to promote implementation of research findings into healthcare practice, was used to categorize obtained codes and structure the barriers and facilitators into relevant themes for change. Results Thirteen interviews were conducted. Important barriers were the conflicting scientific evidence on (cost-)effectiveness of prehabilitation, the current inability to offer a personalized prehabilitation program, the complex logistic organization of the program, and the unawareness of (the importance of) a prehabilitation program among healthcare professionals and patients. Relevant facilitators were availability of program coordinators, availability of physician leadership, and involving skeptical colleagues in the implementation process from the start. Conclusions Important barriers to prehabilitation implementation are mainly related to the intervention being complex, relatively unknown and only evaluated in a research setting. Therefore, physicians’ leadership is needed to transform care towards more integration of personalized prehabilitation programs. Implications for cancer survivors By strengthening prehabilitation programs and evidence of their efficacy using these recommendations, it should be possible to enhance both the pre- and postoperative quality of life for colorectal cancer patients during survivorship.
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Franssen RFW, Strous MTA, Bongers BC, Vogelaar FJ, Janssen-Heijnen MLG. The Association Between Treatment Interval and Survival in Patients With Colon or Rectal Cancer: A Systematic Review. World J Surg 2021; 45:2924-2937. [PMID: 34175967 PMCID: PMC8322003 DOI: 10.1007/s00268-021-06188-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Surgery for colon or rectal cancer is associated with a high incidence of complications, especially in patients with a low aerobic fitness. Those patients might benefit from a comprehensive preoperative workup including prehabilitation. However, time between diagnosis and treatment is often limited due to current treatment guidelines. To date, it is unclear whether the treatment interval can be extended without compromising survival. METHODS A systematic review concerning the association between treatment intervals and survival in patients who underwent elective curative surgery for colon or rectal cancer was performed. A search up to December 2020 was conducted in PubMed, Cinahl and Embase. Original research articles were eligible. Quality assessment was performed using the Downs and Black checklist. RESULTS Eleven observational studies were included (897 947 patients). In colon cancer, treatment intervals that were statistically significant associated with reduced overall survival or cancer-specific survival ranged between > 30 and > 84 days. In rectal cancer, only one out of four studies showed that treatment intervals > 49 days was associated with reduced cancer-specific survival. CONCLUSIONS This systematic review identified that studies investigating the association between treatment intervals and survival are heterogeneous with regard to treatment interval definitions, treatment interval time intervals and used outcome measures. These aspects need standardization before a reliable estimate of an optimal treatment interval can be made. In addition, further research should focus on establishing optimal treatment intervals in patients at high risk for postoperative complications, as particularly these patients might benefit from extended diagnosis to treatment intervals permitting comprehensive preoperative preparation.
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Affiliation(s)
- Ruud F W Franssen
- Department of Clinical Physical Therapy, VieCuri Medical Center, Venlo Tegelseweg, Venlo, 210 5912BL, The Netherlands.
- Department of Epidemiology, GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.
| | - Maud T A Strous
- Department of Epidemiology, GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Surgery, VieCuri Medical Center, Venlo, The Netherlands
| | - Bart C Bongers
- Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism (NUTRIM), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - F Jeroen Vogelaar
- Department of Surgery, VieCuri Medical Center, Venlo, The Netherlands
| | - Maryska L G Janssen-Heijnen
- Department of Epidemiology, GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Epidemiology, VieCuri Medical Center, Venlo, The Netherlands
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