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Farah E, Carbonell C, Boyne DJ, Brenner DR, Henning JW, Moldaver D, Shokar S, Cheung WY. Treatment Patterns and Health Outcomes among Patients with HER2 IHC0/-Low Metastatic or Recurrent Breast Cancer. Cancers (Basel) 2024; 16:518. [PMID: 38339269 PMCID: PMC10854846 DOI: 10.3390/cancers16030518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/10/2024] [Accepted: 01/22/2024] [Indexed: 02/12/2024] Open
Abstract
Improved understanding of the biological heterogeneity of breast cancer (BC) has facilitated the development of more effective and personalized approaches to treatment. This study describes real-world evidence on treatment patterns and outcomes for a population-based cohort of patients with human epidermal growth factor receptor (HER2) IHC0 and -low BC with de novo or recurrent disease from Alberta, Canada. Patients 18+ years old diagnosed with HER2 IHC0/-low, de novo/recurrent BC from 2010 to 2019 were identified using Alberta's cancer registry. Analyses of these patients' existing electronic medical records and administrative claims data were conducted to examine patient characteristics, treatment patterns, and survival outcomes. A total of 3413 patients were included in the study, of which 72.10% initiated first line hormonal and non-hormonal systemic therapy. The 1-year overall survival (OS) was 81.09% [95% CI, 79.52-82.69]. Recurrent patients had a higher OS compared to de novo patients: 54.30 months [95% CI, 47.80-61.90] vs. 31.5 months [95% CI, 28.40-35.90], respectively. Median OS was 43.4 months [95% CI, 40.70-47.10] and 35.80 months [95% CI, 29.00-41.70] among patients with HER2-low and HER2 IHC0 cancer, respectively. The study results provide real-world evidence regarding the clinical outcomes of HER2 IHC0/-low and de novo/recurrent disease.
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Affiliation(s)
- Eliya Farah
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Chantelle Carbonell
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Devon J. Boyne
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Darren R. Brenner
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Jan-Willem Henning
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | | | - Simran Shokar
- AstraZeneca Canada Inc., Mississauga, ON L4Y 1M4, Canada
| | - Winson Y. Cheung
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB T2N 1N4, Canada
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Fries AH, Choi E, Wu JT, Lee JH, Ding VY, Huang RJ, Liang SY, Wakelee HA, Wilkens LR, Cheng I, Han SS. Software Application Profile: dynamicLM-a tool for performing dynamic risk prediction using a landmark supermodel for survival data under competing risks. Int J Epidemiol 2023; 52:1984-1989. [PMID: 37670428 PMCID: PMC10749764 DOI: 10.1093/ije/dyad122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 08/24/2023] [Indexed: 09/07/2023] Open
Abstract
MOTIVATION Providing a dynamic assessment of prognosis is essential for improved personalized medicine. The landmark model for survival data provides a potentially powerful solution to the dynamic prediction of disease progression. However, a general framework and a flexible implementation of the model that incorporates various outcomes, such as competing events, have been lacking. We present an R package, dynamicLM, a user-friendly tool for the landmark model for the dynamic prediction of survival data under competing risks, which includes various functions for data preparation, model development, prediction and evaluation of predictive performance. IMPLEMENTATION dynamicLM as an R package. GENERAL FEATURES The package includes options for incorporating time-varying covariates, capturing time-dependent effects of predictors and fitting a cause-specific landmark model for time-to-event data with or without competing risks. Tools for evaluating the prediction performance include time-dependent area under the ROC curve, Brier Score and calibration. AVAILABILITY Available on GitHub [https://github.com/thehanlab/dynamicLM].
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Affiliation(s)
- Anya H Fries
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Eunji Choi
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Julie T Wu
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Justin H Lee
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Victoria Y Ding
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Robert J Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Su-Ying Liang
- Palo Alto Medical Foundation Research Institute, Palo Alto Medical Foundation, Palo Alto, CA, USA
| | - Heather A Wakelee
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cancer Institute, Stanford, CA, USA
| | - Lynne R Wilkens
- Cancer Epidemiology Program, University of Hawaii Cancer Center, Honolulu, HI, USA
| | - Iona Cheng
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Summer S Han
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cancer Institute, Stanford, CA, USA
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA, USA
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
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Plichta JK, Thomas SM, Hayes DF, Chavez-MacGregor M, Allison K, de los Santos J, Fowler AM, Giuliano AE, Sharma P, Smith BD, van Eycken E, Edge SB, Hortobagyi GN. Novel Prognostic Staging System for Patients With De Novo Metastatic Breast Cancer. J Clin Oncol 2023; 41:2546-2560. [PMID: 36944149 PMCID: PMC10414698 DOI: 10.1200/jco.22.02222] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 01/22/2023] [Accepted: 02/13/2023] [Indexed: 03/23/2023] Open
Abstract
PURPOSE Given the heterogeneity and improvement in outcomes for metastatic breast cancer (MBC), we developed a staging system that refines prognostic estimates for patients with metastatic cancer at the time of initial diagnosis, de novo MBC (dnMBC), on the basis of survival outcomes and disease-related variables. METHODS Patients with dnMBC (2010-2016) were selected from the National Cancer Database (NCDB). Recursive partitioning analysis (RPA) was used to group patients with similar overall survival (OS) on the basis of clinical T category, grade, estrogen receptor (ER), progesterone receptor, human epidermal growth factor receptor 2, histology, organ system site of metastases (bone-only, brain-only, visceral), and number of organ systems involved. Three-year OS rates were used to assign a final stage: IVA: >70%, IVB: 50%-70%, IVC: 25 to <50%, and IVD: <25%. Bootstrapping was applied with 1,000 iterations, and final stage assignments were made based on the most commonly occurring assignment. Unadjusted OS was estimated. Validation analyses were conducted using SEER and NCDB. RESULTS At a median follow-up of 52.9 months, the median OS of the original cohort (N = 42,467) was 35.4 months (95% CI, 34.8 to 35.9). RPA stratified patients into 53 groups with 3-year OS rates ranging from 73.5% to 5.7%; these groups were amalgamated into four stage groups: 3-year OS, A = 73.2%, B = 61.9%, C = 40.1%, and D = 17% (log-rank P < .001). After bootstrapping, the survival outcomes for the four stages remained significantly different (log-rank P < .001). This staging system was then validated using SEER data (N = 20,469) and a separate cohort from the NCDB (N = 7,645) (both log-rank P < .001). CONCLUSION Our findings regarding the heterogeneity in outcomes for patients with dnMBC could guide future revisions of the current American Joint Committee on Cancer staging guidelines for patients with newly diagnosed stage IV disease. Our findings should be independently confirmed.
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Affiliation(s)
- Jennifer K. Plichta
- Department of Surgery, Duke University Medical Center, Durham, NC
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC
- Duke Cancer Institute, Durham, NC
| | - Samantha M. Thomas
- Biostatistics Shared Resource, Duke Cancer Institute, Durham, NC
- Duke University, Department of Biostatistics & Bioinformatics, Durham, NC
| | - Daniel F. Hayes
- University of Michigan Rogel Cancer Center, Ann Arbor, MI
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Mariana Chavez-MacGregor
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kimberly Allison
- Department of Pathology, Stanford University School of Medicine, Stanford, CA
| | | | - Amy M. Fowler
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
- Department of Medical Physics, University of Wisconsin School of Medicine and Public Health, Madison, WI
- University of Wisconsin Carbone Cancer Center, Madison, WI
| | - Armando E. Giuliano
- Cedars-Sinai Medical Center, University of California—Los Angeles, Los Angeles, CA
| | - Priyanka Sharma
- Department of Internal Medicine, Division of Medical Oncology, University of Kansas Medical Center, Westwood, KS
| | - Benjamin D. Smith
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Stephen B. Edge
- Department of Surgical Oncology and Cancer Prevention and Control, University at Buffalo, Buffalo, NY
- Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Gabriel N. Hortobagyi
- Department of Breast Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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Dogan I, Aksoy S, Cakar B, Basaran G, Ercelep O, Molinas Mandel N, Korkmaz T, Gokmen E, Sener C, Aydiner A, Saip P, Eralp Y. Demographic and Clinical Features of Patients with Metastatic Breast Cancer: A Retrospective Multicenter Registry Study of the Turkish Oncology Group. Cancers (Basel) 2023; 15:cancers15061667. [PMID: 36980554 PMCID: PMC10046761 DOI: 10.3390/cancers15061667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/04/2023] [Accepted: 03/05/2023] [Indexed: 03/11/2023] Open
Abstract
This multicenter registry study aims to analyze time-related changes in the treatment patterns and outcome of patients with metastatic breast cancer (MBC) over a ten-year period. Correlations between demographic, prognostic variables and survival outcomes were carried out in database aggregates consisting of cohorts based on disease presentation (recurrent vs. de novo) and the diagnosis date of MBC (Cohort I: patient diagnosed between January 2010 and December 2014; and Cohort II: between January 2015 and December 2019). Out of 1382 patients analyzed, 52.3% patients had recurrent disease, with an increased frequency over time (47.9% in Cohort I vs. 56.1% in Cohort II, p < 0.001). In recurrent patients, 38.4% (n = 277) relapsed within two years from initial diagnosis, among which triple-negative BC (TNBC) was the most frequent (51.7%). Median overall survival (OS) was 51.0 (48.0–55.0) months for all patients, which was similar across both cohorts. HER2+ subtype had the highest OS among subgroups (HER2+ vs. HR+ vs. TNBC; 57 vs. 52 vs. 27 months, p < 0.001), and the dnMBC group showed a better outcome than recMBC (53 vs. 47 months, p = 0.013). Despite the lack of CDK inhibitors, luminal A patients receiving endocrine therapy had a favorable outcome (70 months), constituting an appealing approach with limited resources. The only survival improvement during the timeframe was observed in HER2+ dnMBC patients (3-year OS Cohort I: 62% vs. Cohort II: 84.7%, p = 0.009). The incorporation of targeted agents within standard treatment has improved the outcome in HER2+ MBC patients over time. Nevertheless, despite advances in early diagnosis and treatment, the prognosis of patients with TNBC remains poor, highlighting the need for more effective treatment options.
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Affiliation(s)
- Izzet Dogan
- Department of Medical Oncology, Institute of Oncology, Istanbul University, Istanbul 34093, Turkey; (I.D.)
| | - Sercan Aksoy
- Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara 06100, Turkey
| | - Burcu Cakar
- Department of Medical Oncology, Faculty of Medicine, Ege University, Izmir 35100, Turkey
| | - Gul Basaran
- Department of Medical Oncology, Acibadem University, Altunizade Acibadem Hospital, Istanbul 34662, Turkey
| | - Ozlem Ercelep
- Department of Medical Oncology, Faculty of Medicine, Marmara University, Istanbul 34722, Turkey
| | - Nil Molinas Mandel
- Department of Medical Oncology, Koç University Amerikan Hospital, Istanbul 34010, Turkey
| | - Taner Korkmaz
- Department of Medical Oncology, Acibadem University, Maslak Acibadem Hospital, Istanbul 34457, Turkey
| | - Erhan Gokmen
- Department of Medical Oncology, Faculty of Medicine, Ege University, Izmir 35100, Turkey
| | - Cem Sener
- Incidence Medical Research and Biostatistics Consultancy Services, Istanbul 34440, Turkey
| | - Adnan Aydiner
- Department of Medical Oncology, Institute of Oncology, Istanbul University, Istanbul 34093, Turkey; (I.D.)
| | - Pinar Saip
- Department of Medical Oncology, Institute of Oncology, Istanbul University, Istanbul 34093, Turkey; (I.D.)
| | - Yesim Eralp
- Research Institute of Senology, Acıbadem University, Maslak Acıbadem Hospital, Istanbul 34457, Turkey
- Correspondence:
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Barcenas CH, Song J, Murthy RK, Raghavendra AS, Li Y, Hsu L, Carlson RW, Tripathy D, Hortobagyi GN. Reply to A. Pfob and C. Sidey-Gibbons. JCO Clin Cancer Inform 2022; 6:e2100171. [PMID: 35175860 DOI: 10.1200/cci.21.00171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Carlos H Barcenas
- Carlos H. Barcenas, MD, MS, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Juhee Song, PhD, Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX; Rashmi K. Murthy, MD, MBE and Akshara S. Raghavendra, MD, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Yisheng Li, PhD, Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX; Limin Hsu, MS, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Robert W. Carlson, MD, National Comprehensive Cancer Network (NCCN), Plymouth Meeting, PA, Department of Medicine, Division of Medical Oncology, Stanford University Medical Center, Stanford, CA; and Debu Tripathy, MD and Gabriel N. Hortobagyi, MD, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Rashmi K Murthy
- Carlos H. Barcenas, MD, MS, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Juhee Song, PhD, Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX; Rashmi K. Murthy, MD, MBE and Akshara S. Raghavendra, MD, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Yisheng Li, PhD, Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX; Limin Hsu, MS, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Robert W. Carlson, MD, National Comprehensive Cancer Network (NCCN), Plymouth Meeting, PA, Department of Medicine, Division of Medical Oncology, Stanford University Medical Center, Stanford, CA; and Debu Tripathy, MD and Gabriel N. Hortobagyi, MD, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Akshara S Raghavendra
- Carlos H. Barcenas, MD, MS, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Juhee Song, PhD, Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX; Rashmi K. Murthy, MD, MBE and Akshara S. Raghavendra, MD, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Yisheng Li, PhD, Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX; Limin Hsu, MS, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Robert W. Carlson, MD, National Comprehensive Cancer Network (NCCN), Plymouth Meeting, PA, Department of Medicine, Division of Medical Oncology, Stanford University Medical Center, Stanford, CA; and Debu Tripathy, MD and Gabriel N. Hortobagyi, MD, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yisheng Li
- Carlos H. Barcenas, MD, MS, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Juhee Song, PhD, Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX; Rashmi K. Murthy, MD, MBE and Akshara S. Raghavendra, MD, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Yisheng Li, PhD, Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX; Limin Hsu, MS, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Robert W. Carlson, MD, National Comprehensive Cancer Network (NCCN), Plymouth Meeting, PA, Department of Medicine, Division of Medical Oncology, Stanford University Medical Center, Stanford, CA; and Debu Tripathy, MD and Gabriel N. Hortobagyi, MD, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Limin Hsu
- Carlos H. Barcenas, MD, MS, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Juhee Song, PhD, Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX; Rashmi K. Murthy, MD, MBE and Akshara S. Raghavendra, MD, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Yisheng Li, PhD, Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX; Limin Hsu, MS, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Robert W. Carlson, MD, National Comprehensive Cancer Network (NCCN), Plymouth Meeting, PA, Department of Medicine, Division of Medical Oncology, Stanford University Medical Center, Stanford, CA; and Debu Tripathy, MD and Gabriel N. Hortobagyi, MD, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Robert W Carlson
- Carlos H. Barcenas, MD, MS, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Juhee Song, PhD, Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX; Rashmi K. Murthy, MD, MBE and Akshara S. Raghavendra, MD, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Yisheng Li, PhD, Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX; Limin Hsu, MS, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Robert W. Carlson, MD, National Comprehensive Cancer Network (NCCN), Plymouth Meeting, PA, Department of Medicine, Division of Medical Oncology, Stanford University Medical Center, Stanford, CA; and Debu Tripathy, MD and Gabriel N. Hortobagyi, MD, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Debu Tripathy
- Carlos H. Barcenas, MD, MS, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Juhee Song, PhD, Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX; Rashmi K. Murthy, MD, MBE and Akshara S. Raghavendra, MD, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Yisheng Li, PhD, Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX; Limin Hsu, MS, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Robert W. Carlson, MD, National Comprehensive Cancer Network (NCCN), Plymouth Meeting, PA, Department of Medicine, Division of Medical Oncology, Stanford University Medical Center, Stanford, CA; and Debu Tripathy, MD and Gabriel N. Hortobagyi, MD, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gabriel N Hortobagyi
- Carlos H. Barcenas, MD, MS, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Juhee Song, PhD, Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX; Rashmi K. Murthy, MD, MBE and Akshara S. Raghavendra, MD, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Yisheng Li, PhD, Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX; Limin Hsu, MS, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Robert W. Carlson, MD, National Comprehensive Cancer Network (NCCN), Plymouth Meeting, PA, Department of Medicine, Division of Medical Oncology, Stanford University Medical Center, Stanford, CA; and Debu Tripathy, MD and Gabriel N. Hortobagyi, MD, Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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