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Cornford P, Robijn E, Rogers E, Wassersug R, Fleure L. Fatigue in Prostate Cancer: A Roundtable Discussion and Thematic Literature Review. EUR UROL SUPPL 2024; 63:119-125. [PMID: 38596782 PMCID: PMC11001642 DOI: 10.1016/j.euros.2024.03.003] [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] [Accepted: 03/05/2024] [Indexed: 04/11/2024] Open
Abstract
Context Cancer and its treatments cause fatigue in up to 90% of men with advanced prostate cancer. As men with prostate cancer are surviving longer, cancer-related fatigue is becoming increasingly important for clinicians to understand and proactively manage. Objective The aim of this work is to identify knowledge gaps that may support healthcare professionals to recommend personalised fatigue management strategies. Evidence acquisition This manuscript is based on a roundtable discussion held during the European Association of Urology 2022 Annual Symposium, combined with a review of the literature. Five core themes were generated from the roundtable: (1) meaning of fatigue in prostate cancer patients, (2) impact of fatigue, (3) association between fatigue and treatment selection, (4) benefits of managing fatigue, and (5) barriers to exercise. Evidence synthesis Cancer-related fatigue has complex underlying aetiology and is a subjective experience that may be under-reported. Some studies have shown that techniques such as education, cognitive behavioural therapy, guided imagery, and progressive muscle relaxation can result in clinically meaningful improvements in fatigue. However, the largest body of evidence, and a theme echoed in the roundtable discussions, was the benefit of exercise on fatigue. Despite the benefits of exercise, for some men, objective barriers to exercise exist and knowledge of benefits does not automatically translate into implementation and adherence. Conclusions Understanding the specific health needs of individual patients and their desired health outcomes is essential to identify personalised strategies for minimising fatigue. As an outcome of the roundtable meeting, we developed a quick reference guide for healthcare providers. A high-resolution copy can be downloaded from https://patients.uroweb.org/library/fatigue-in-prostate-cancer-patients-guide/. Patient summary This article is based on dialogue between a group of specialists, patients, and caregivers, which took place at a roundtable meeting during the European Association of Urology 2022 Annual Symposium. The group discussed how healthcare providers can best support their patients who experience fatigue. The group subsequently developed a guide to help healthcare providers during appointments.
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Affiliation(s)
- Philip Cornford
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Esther Robijn
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Eamonn Rogers
- European Association of Urology, Arnhem, The Netherlands
| | | | - Louisa Fleure
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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McHugh A, O'Connell E, Gurd B, Rae P, George ES, Kleckner AS, Baguley BJ. Mediterranean-style dietary interventions in adults with cancer: a systematic review of the methodological approaches, feasibility, and preliminary efficacy. Eur J Clin Nutr 2024:10.1038/s41430-024-01426-8. [PMID: 38459161 DOI: 10.1038/s41430-024-01426-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 02/26/2024] [Accepted: 02/28/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Cancer and its treatments can lead to excess body fat, decreases in lean mass, cardiotoxicity, and other side effects. The Mediterranean diet (MED-diet) has the potential to improve clinical and supportive care outcomes. The aim of this systematic review was to evaluate the feasibility, safety, and efficacy of the MED-diet on health outcomes in adults with cancer. METHODS Three databases were searched from inception to February 2023. Eligible studies included randomised controlled trials testing a MED-diet intervention among adults with cancer. Within- and between-group differences for adherence, dietary intake and health outcomes were extracted. RESULTS Fifteen studies describing fourteen interventions were included, and there were considerable differences in study design and implementation of the MED-diet. Studies were predominately in women with a history of breast cancer. The MED-diet was safe with no adverse events reported, and feasible with high adherence and/or increases in MED-diet-compliant foods. The MED-diet when applied with an energy restriction below estimated requirements for weight loss demonstrated reductions in body weight (range: -3.9 kg to -0.7 kg). Interventions that showed significant reductions in body weight also improved quality of life. There is limited evidence to evaluating the MED-diet on cardiovascular and inflammatory markers, and heterogenous MED-diet prescriptions impede definitive conclusions on these health outcomes. CONCLUSION The MED-diet was feasible and safe for adults with cancer. There were reported benefits for weight loss following a MED-diet when an energy restriction was applied, however further evaluation to determine the effects on cardiometabolic biomarkers and other outcomes are required.
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Affiliation(s)
- Aoife McHugh
- School of Exercise and Nutrition Sciences, Deakin University, Burwood, VIC, Australia
| | - Ellie O'Connell
- School of Exercise and Nutrition Sciences, Deakin University, Burwood, VIC, Australia
| | - Bridie Gurd
- School of Exercise and Nutrition Sciences, Deakin University, Burwood, VIC, Australia
| | - Paige Rae
- School of Exercise and Nutrition Sciences, Deakin University, Burwood, VIC, Australia
| | - Elena S George
- School of Exercise and Nutrition Sciences, Deakin University, Burwood, VIC, Australia
- Institute for Physical Activity and Nutrition, Deakin University, Geelong, VIC, Australia
| | - Amber S Kleckner
- Department of Pain and Translational Symptom Science, University of Maryland School of Nursing, Baltimore, MD, USA
| | - Brenton J Baguley
- School of Exercise and Nutrition Sciences, Deakin University, Burwood, VIC, Australia.
- Institute for Physical Activity and Nutrition, Deakin University, Geelong, VIC, Australia.
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Poon DMC, Tan GM, Chan K, Chan MTY, Chan TW, Kan RWM, Lam MHC, Leung CLH, Wong KCW, Kam KKH, Ng CF, Chiu PKF. Addressing the risk and management of cardiometabolic complications in prostate cancer patients on androgen deprivation therapy and androgen receptor axis-targeted therapy: consensus statements from the Hong Kong Urological Association and the Hong Kong Society of Uro-Oncology. Front Oncol 2024; 14:1345322. [PMID: 38357197 PMCID: PMC10864500 DOI: 10.3389/fonc.2024.1345322] [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] [Accepted: 01/15/2024] [Indexed: 02/16/2024] Open
Abstract
Background Androgen deprivation therapy (ADT) is the foundational treatment for metastatic prostate cancer (PCa). Androgen receptor (AR) axis-targeted therapies are a new standard of care for advanced PCa. Although these agents have significantly improved patient survival, the suppression of testosterone is associated with an increased risk of cardiometabolic syndrome. This highlights the urgency of multidisciplinary efforts to address the cardiometabolic risk of anticancer treatment in men with PCa. Methods Two professional organizations invited five urologists, five clinical oncologists, and two cardiologists to form a consensus panel. They reviewed the relevant literature obtained by searching PubMed for the publication period from April 2013 to April 2023, to address three discussion areas: (i) baseline assessment and screening for risk factors in PCa patients before the initiation of ADT and AR axis-targeted therapies; (ii) follow-up and management of cardiometabolic complications; and (iii) selection of ADT agents among high-risk patients. The panel convened four meetings to discuss and draft consensus statements using a modified Delphi method. Each drafted statement was anonymously voted on by every panelist. Results The panel reached a consensus on 18 statements based on recent evidence and expert insights. Conclusion These consensus statements serve as a practical recommendation for clinicians in Hong Kong, and possibly the Asia-Pacific region, in the management of cardiometabolic toxicities of ADT or AR axis-targeted therapies in men with PCa.
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Affiliation(s)
- Darren M. C. Poon
- Department of Clinical Oncology, State Key Laboratory of Translational Oncology, Sir YK Pao Centre for Cancer, Hong Kong Cancer Institute, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
- Comprehensive Oncology Centre, Hong Kong Sanatorium and Hospital, Hong Kong, Hong Kong SAR, China
| | - Guang-Ming Tan
- Division of Cardiology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Kuen Chan
- Department of Clinical Oncology, Pamela Youde Nethersole Eastern Hospital, Hong Kong, Hong Kong SAR, China
| | - Marco T. Y. Chan
- Division of Urology, Department of Surgery, Tuen Mun Hospital, Hong Kong, Hong Kong SAR, China
| | - Tim-Wai Chan
- Department of Clinical Oncology, Queen Elizabeth Hospital, Hong Kong, Hong Kong SAR, China
| | | | - Martin H. C. Lam
- Hong Kong Integrated Oncology Centre, Hong Kong, Hong Kong SAR, China
| | | | - Kenneth C. W. Wong
- Department of Clinical Oncology, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Kevin K. H. Kam
- Division of Cardiology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Chi-Fai Ng
- S.H. Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Peter K. F. Chiu
- S.H. Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
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Yang U, Harikrishna A, Preda V, Chen J. Efficacy of multidisciplinary interventions in preventing metabolic syndrome and improving body composition in prostate cancer patients treated with androgen deprivation therapy: A systematic review and meta-analysis. Clin Nutr ESPEN 2023; 58:27-49. [PMID: 38057016 DOI: 10.1016/j.clnesp.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 09/01/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Exercise is known to reduce adverse side effects of androgen-deprivation therapy (ADT) on quality of life, bone health and fatigue for prostate cancer (PCa) patients. We conducted a systematic review with meta-analysis to evaluate the effect of multidisciplinary interventions on body composition and metabolic syndrome (MetS) in ADT-treated PCa patients. METHODS A systematic review and meta-analysis were conducted based on searches of EMBASE, MEDLINE, CENTRAL and Scopus databases from inception to March 2023. Participants included ADT-treated PCa patients who received multidisciplinary interventions including exercise, diet, nutrition, pharmacotherapy, bariatric surgery, or psychological/behavioural therapy. Primary outcomes were changes in body composition and MetS, with prostate-specific antigen (PSA) as a secondary outcome. After meta-analysis, results were reported in mean difference, 95% confidence interval and p-value, with forest plots. Additionally, we conducted subgroup analyses to compare the effect of different interventions. RESULTS Thirty-three articles met the eligibility criteria out of 1443 articles and 28 studies were included in meta-analysis. Of 33 studies, 17 included exercise-only interventions and 10 included exercise + diet/nutrition interventions, but no studies included diet/nutrition-only interventions. All studies employed multidisciplinary approaches in developing or delivering the interventions. Most studies (85%) had low-moderate risk of bias, thus providing good evidence to this review. Overall, interventions had a positive effect on body composition measures; lean mass (LM):0.82 kg (95% CI:0.47,1.17;p < 0.00001), body fat mass (BFM):-0.68 kg (95% CI:-1.12,-0.24;p = 0.002), fat-free mass:0.75 kg (95% CI:0.14,1.37;p = 0.02) and body fat percentage (BFP):-0.99% (95% CI:-1.29,-0.68;p < 0.00001), as well as on MetS; waist circumference:-1.95 cm (95% CI:-3.10,-0.79;p = 0.0009), systolic blood pressure:-3.43 mmHg (95% CI:-6.36,-0.50;p = 0.02) and diastolic blood pressure:-2.48 mmHg (95% CI:-4.19,-0.76;p = 0.005). Subgroup-analyses showed that a combined approach including exercise + diet/nutrition was most effective in improving BFP, WC, SBP and DBP whereas exercise was more effective in improving LM and BFM. CONCLUSIONS In ADT-treated PCa patients, multidisciplinary interventions, especially those combining exercise and diet/nutrition, can improve body composition and metabolic health.
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Affiliation(s)
- Uhjin Yang
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia.
| | - Athulya Harikrishna
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Veronica Preda
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Juliana Chen
- Discipline of Nutrition and Dietetics, Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia; Charles Perkins Centre, The University of Sydney, Camperdown, NSW, Australia
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Dovey Z, Horowitz A, Waingankar N. The influence of lifestyle changes (diet, exercise and stress reduction) on prostate cancer tumour biology and patient outcomes: A systematic review. BJUI COMPASS 2023; 4:385-416. [PMID: 37334023 PMCID: PMC10268595 DOI: 10.1002/bco2.237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 03/05/2023] [Indexed: 06/20/2023] Open
Abstract
Background The mostly indolent natural history of prostate cancer (PCa) provides an opportunity for men to explore the benefits of lifestyle interventions. Current evidence suggests appropriate changes in lifestyle including diet, physical activity (PA) and stress reduction with or without dietary supplements may improve both disease outcomes and patient's mental health. Objective This article aims to review the current evidence on the benefits of all lifestyle programmes for PCa patients including those aimed at reducing obesity and stress, explore their affect on tumour biology and highlight any biomarkers that have clinical utility. Evidence acquisition Evidence was obtained from PubMed and Web of Science using keywords for each section on the affects of lifestyle interventions on (a) mental health, (b) disease outcomes and (c) biomarkers in PCa patients. PRISMA guidelines were used to gather the evidence for these three sections (15, 44 and 16 publications, respectively). Evidence synthesis For lifestyle studies focused on mental health, 10/15 demonstrated a positive influence, although for those programmes focused on PA it was 7/8. Similarly for oncological outcomes, 26/44 studies demonstrated a positive influence, although when PA was included or the primary focus, it was 11/13. Complete blood count (CBC)-derived inflammatory biomarkers show promise, as do inflammatory cytokines; however, a deeper understanding of their molecular biology in relation to PCa oncogenesis is required (16 studies reviewed). Conclusions Making PCa-specific recommendations on lifestyle interventions is difficult on the current evidence. Nevertheless, notwithstanding the heterogeneity of patient populations and interventions, the evidence that dietary changes and PA may improve both mental health and oncological outcomes is compelling, especially for moderate to vigorous PA. The results for dietary supplements are inconsistent, and although some biomarkers show promise, significantly more research is required before they have clinical utility.
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Affiliation(s)
- Zach Dovey
- Mount Sinai Health System, Department of UrologyIcahn Medical SchoolNew YorkNew YorkUSA
| | - Amir Horowitz
- Icahn School of MedicineThe Mount Sinai HospitalNew YorkNew YorkUSA
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Chang M, Wang J, Hashim HA, Xie S, Malik AA. Effect of high-intensity interval training on aerobic capacity and fatigue among patients with prostate cancer: a meta-analysis. World J Surg Oncol 2022; 20:348. [PMID: 36261844 PMCID: PMC9580114 DOI: 10.1186/s12957-022-02807-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 10/03/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE This study focused on evaluating whether high-intensity interval training (HIIT) had an effect on aerobic capacity and fatigue among patients with prostate cancer (PCa) and exploring its effect on the immune system of PCa patients. METHODS To investigate the potential effect of HIIT on patients with prostate cancer, a meta-analysis was carried out. From January 2012 to August 2022, studies that met predefined criteria were searched in the Scopus, PubMed, Web of Science, and EBSCO databases. Analysis of the standardized mean differences was performed using Review Manager 5.4.1 software with a 95% confidence interval. RESULTS This review examined a total of 6 articles. There were 215 male patients with PCa involved, and the mean age was 64.4 years. According to the results of the meta-analysis, the HIIT group (n = 63) had greater VO2peak (P<0.01) than the control group (CON) (n = 52) (P = 0.30, I2 = 19% in the heterogeneity test; MD, 1.39 [0.50, 2.27]). Moreover, fatigue was significantly different (P<0.01) between the HIIT (n = 62) and CON (n = 61) groups (P = 0.78, I2 = 0% in the heterogeneity test; SMD, -0.52 [-0.88, -0.16]). Furthermore, among PCa patients, HIIT showed higher efficacy (P < 0.01) in decreasing PSA than the CON regimen (P=0.22, I2 = 34% in the heterogeneity test; MD, -1.13 [-1.91, -0.34]). CONCLUSIONS HIIT improves aerobic capacity, fatigue, and PSA levels among PCa patients but does not significantly affect IL-6 or TNF-α content. Therefore, HIIT may be a novel and potent intervention scheme for PCa patients.
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Affiliation(s)
- Ming Chang
- Exercise and Sports Science Programme, School of Health Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, 16150, Malaysia
| | - Junguo Wang
- Department of Orthopaedics, Qingdao Hospital of Traditional Chinese Medicine (Hiser hospital), Qingdao, Shandong, China
| | - Hairul A Hashim
- Exercise and Sports Science Programme, School of Health Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, 16150, Malaysia
| | - Shihao Xie
- Exercise and Sports Science Programme, School of Health Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, 16150, Malaysia
| | - Adam A Malik
- Exercise and Sports Science Programme, School of Health Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, 16150, Malaysia.
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The Beneficial Effect of a Healthy Dietary Pattern on Androgen Deprivation Therapy-Related Metabolic Abnormalities in Patients with Prostate Cancer: A Meta-Analysis Based on Randomized Controlled Trials and Systematic Review. Metabolites 2022; 12:metabo12100969. [PMID: 36295871 PMCID: PMC9611951 DOI: 10.3390/metabo12100969] [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: 09/23/2022] [Revised: 10/10/2022] [Accepted: 10/10/2022] [Indexed: 12/24/2022] Open
Abstract
Metabolic abnormalities as side effects of androgen-deprivation therapy (ADT) can accelerate progression of prostate cancer (PCa) and increase risks of cardiovascular diseases. A healthy dietary pattern (DP) plays an important role in regulating glycolipid metabolism, while evidence about DP on ADT-related metabolic abnormalities is still controversial. To explore the effect of DP on metabolic outcomes in PCa patients with ADT, PubMed, Embase, Cochrane, and CINAHL were searched from inception to 10 September 2022. Risk of biases was evaluated through Cochrane Collaboration’s Tool. If heterogeneity was low, the fixed-effects model was carried out; otherwise, the random-effects model was used. Data were determined by calculating mean difference (MD) or standardized MD (SMD) with 95% confidence intervals (CIs). Nine studies involving 421 patients were included. The results showed that healthy DP significantly improved glycated hemoglobin (MD: −0.13; 95% CI: −0.24, −0.02; p = 0.020), body mass index (MD: −1.02; 95% CI: −1.29, −0.75; p < 0.001), body fat mass (MD: −1.78; 95% CI: −2.58, −0.97; p < 0.001), triglyceride (MD: −0.28; 95% CI: −0.51, −0.04; p = 0.020), systolic blood pressure (MD: −6.30; 95% CI: −11.15, −1.44; p = 0.010), and diastolic blood pressure (MD: −2.94; 95% CI: −5.63, −0.25; p = 0.030), although its beneficial effects on other glycolipid metabolic indicators were not found. Additionally, a healthy DP also lowered the level of PSA (MD: −1.79; 95% CI: −2.25, −1.33; p < 0.001). The meta-analysis demonstrated that a healthy DP could improve ADT-related metabolic abnormalities and be worthy of being recommended for PCa patients with ADT.
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Rubino R, Iuliucci MR, Gatani S, Piscosquito A, D’Ambrosio B, Ingenito C, Scafuri L, Buonerba C, Di Lorenzo G. Mediterranean Diet as a Supportive Intervention in Cancer Patients: Current Evidence and Future Directions. Curr Oncol 2022; 29:7579-7582. [PMID: 36290874 PMCID: PMC9600992 DOI: 10.3390/curroncol29100597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022] Open
Abstract
Cancer currently represents a leading cause of morbidity and mortality, and it can be held responsible for about one in six deaths worldwide [...].
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Affiliation(s)
- Roberta Rubino
- Oncology Unit, “Andrea Tortora” Hospital, ASL Salerno, 84016 Pagani, Italy
- Associazione O.R.A.—Oncology Research Assistance, 80049 Somma Vesuviana, Italy
| | - Michela Rosaria Iuliucci
- Oncology Unit, “Andrea Tortora” Hospital, ASL Salerno, 84016 Pagani, Italy
- Associazione O.R.A.—Oncology Research Assistance, 80049 Somma Vesuviana, Italy
| | - Simona Gatani
- Oncology Unit, “Andrea Tortora” Hospital, ASL Salerno, 84016 Pagani, Italy
- Associazione O.R.A.—Oncology Research Assistance, 80049 Somma Vesuviana, Italy
| | - Arianna Piscosquito
- Oncology Unit, “Andrea Tortora” Hospital, ASL Salerno, 84016 Pagani, Italy
- Associazione O.R.A.—Oncology Research Assistance, 80049 Somma Vesuviana, Italy
| | - Bruno D’Ambrosio
- Oncology Unit, “Andrea Tortora” Hospital, ASL Salerno, 84016 Pagani, Italy
- Associazione O.R.A.—Oncology Research Assistance, 80049 Somma Vesuviana, Italy
| | - Concetta Ingenito
- Oncology Unit, “Andrea Tortora” Hospital, ASL Salerno, 84016 Pagani, Italy
- Associazione O.R.A.—Oncology Research Assistance, 80049 Somma Vesuviana, Italy
| | - Luca Scafuri
- Oncology Unit, “Andrea Tortora” Hospital, ASL Salerno, 84016 Pagani, Italy
- Associazione O.R.A.—Oncology Research Assistance, 80049 Somma Vesuviana, Italy
| | - Carlo Buonerba
- Oncology Unit, “Andrea Tortora” Hospital, ASL Salerno, 84016 Pagani, Italy
- Associazione O.R.A.—Oncology Research Assistance, 80049 Somma Vesuviana, Italy
| | - Giuseppe Di Lorenzo
- Oncology Unit, “Andrea Tortora” Hospital, ASL Salerno, 84016 Pagani, Italy
- Associazione O.R.A.—Oncology Research Assistance, 80049 Somma Vesuviana, Italy
- Department of Medicine and Health Sciences “Vincenzo Tiberio”, University of Molise, 86100 Campobasso, Italy
- Correspondence: ; Tel.: +39-0819-213-111
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