1
|
Joseph K, Balushi MA, Ghosh S, Stenson T, Abraham A, Elangovan A, Warkentin H, Paulson K, Tankel K, Usmani N, Severin D, Schiller D, Wong C, Mulder K, Doll C, King K, Nijjar T. Long-Term Patient-Reported Quality of Life of Anal Cancer Survivors Treated With Intensity Modulated Radiation Therapy and Concurrent Chemotherapy: Results From a Prospective Phase II Trial. Int J Radiat Oncol Biol Phys 2023; 117:434-445. [PMID: 37148982 DOI: 10.1016/j.ijrobp.2023.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/12/2023] [Accepted: 04/18/2023] [Indexed: 05/08/2023]
Abstract
PURPOSE Intensity modulated radiation therapy (IMRT) has confirmed its superiority in improving acute treatment-related toxicities in anal cancer, without compromising tumor control. However, the effect of IMRT on long-term quality of life (QOL) is poorly documented. The study prospectively evaluated the long-term patient-reported QOL after IMRT-based chemoradiation in anal cancer. METHODS AND MATERIALS Fifty-eight patients treated with IMRT and concurrent 5 fluorouracil/mitomycin-C were enrolled in the study. A prespecified secondary endpoint was prospective evaluation of long-term QOL. Fifty-four patients underwent QOL evaluation at baseline, after treatment, and during follow-up until 60 months, with European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30) scales and the Colorectal Cancer-Specific Quality Of Life Questionnaire (QLQ-CR29) scales. The QOL scores at baseline and posttreatment periods were compared. RESULTS For QLQ-C30, at 60 months, the mean scores of global health status, all functional scales, and all symptoms except diarrhea had improved, indicating normalization of QOL. Clinically and statistically significant improvements in the global health status (15.4; P = .003), role functioning (19.3; P = .0017), emotional functioning (18.9; P = .008), and social functioning (29.8; P ≤ .001) were observed. Diarrhea persisted as a concern over the years (P = .172). For European Organization for Research and Treatment of Cancer QLQ-CR29, rectal pain (-38.6; P = .001), mucous or blood discharge per rectum (-22.8; P = .005), and perianal soreness (-37.3; P ≤ .001) were improved both clinically and statistically. Clinically significant fecal leakage was reported by 16% of patients (5.6; P = .421). Volumes receiving 45 and 54 Gy were independent predictors for fecal incontinence. Clinically and statistically significant urinary incontinence occurred in 21% of patients (17.5; P = .014). Deterioration of dyspareunia was clinically significant (26.7; P = .099) at 60 months. CONCLUSIONS Compared with historical data, IMRT is associated with reduced long-term effects on QOL. The majority of patients treated with IMRT experienced clinically significant recovery of function and improvement in QOL over 5 years after completion of treatment. Specific toxicities such as chronic diarrhea, fecal incontinence, and urinary and sexual dysfunction were primarily responsible for deterioration of the long-term QOL. Future research aimed at reducing such toxicities is needed to further improve long-term QOL in anal cancer.
Collapse
Affiliation(s)
- Kurian Joseph
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada.
| | - Mustafa Al Balushi
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Sunita Ghosh
- Division of Medical Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Trevor Stenson
- Alberta Cancer Clinical Trials, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Aswin Abraham
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Arun Elangovan
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Heather Warkentin
- Alberta Cancer Clinical Trials, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Kim Paulson
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Keith Tankel
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Nawaid Usmani
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Diane Severin
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Dan Schiller
- Division of Medical Physics, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Clarence Wong
- Division of General Surgery, Department of Surgery, University of Alberta, Edmonton, Canada; Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Karen Mulder
- Division of Medical Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Corinne Doll
- Division of Radiation Oncology, Department of Oncology, University of Calgary & Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Karen King
- Division of Medical Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Tirath Nijjar
- Division of Radiation Oncology, Department of Oncology, University of Alberta & Cross Cancer Institute, Edmonton, Alberta, Canada
| |
Collapse
|
2
|
Zhou X, Chen XH, Li SH, Li N, Liu F, Wang HM. Effects of surgical treatment modalities on postoperative cognitive function and delirium in elderly patients with extremely unstable hip fractures. World J Psychiatry 2023; 13:533-542. [PMID: 37701542 PMCID: PMC10494770 DOI: 10.5498/wjp.v13.i8.533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 06/15/2023] [Accepted: 07/05/2023] [Indexed: 08/17/2023] Open
Abstract
BACKGROUND As the perioperative risk of elderly patients with extremely unstable hip fractures (EUHFs) is relatively high and therapeutic effect is not satisfactory, new thera-peutic strategies need to be proposed urgently to improve the efficacy and clinical outcomes of such patients. AIM To determine the influence of two surgical treatment modalities on postoperative cognitive function (CF) and delirium in elderly patients with EUHFs. METHODS A total of 60 elderly patients consecutively diagnosed with EUHF between September 2020 and January 2022 in the Chongqing University Three Gorges Hospital were included. Of them, 30 patients received conventional treatment (control group; general consultation + fracture type-guided internal fixation), and the other 30 received novel treatment (research group; perioperative multidisciplinary treatment diagnosis and treatment + individualized surgical plan + risk prediction). Information on hip function [Harris hip score (HHS)], perioperative risk of orthopedic surgery [Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM)], CF [Montreal cognitive assessment scale (MoCA)], postoperative delirium [mini-cognitive (Mini-Cog)], adverse events (AEs; internal fixation failure, infection, nonunion, malunion, and postoperative delirium), and clinical indicators [operation time (OT), postoperative hospital length of stay (HLOS), ambulation time, and intraoperative blood loss (IBL)] were collected from both groups for comparative analyses. RESULTS The HHS scores were similar between both groups. The POSSUM score at 6 mo after surgery was significantly lower in the research group compared with the control group, and MoCA and Mini-Cog scores were statistically higher. In addition, the overall postoperative complication rate was significantly lower in the research than in the control group, including reduced OT, postoperative HLOS, ambulation time, and IBL. CONCLUSION The new treatment modality has more clinical advantages over the conventional treatment, such as less IBL, faster functional recovery, more effectively optimized perioperative quality control, improved postoperative CF, mitigated postoperative delirium, and reduced operation-related AEs.
Collapse
Affiliation(s)
- Xue Zhou
- Department of Operating Room, Chongqing University Three Gorges Hospital, Chongqing 404000, China
| | - Xiao-Hua Chen
- Department of Orthopedics, Chongqing University Three Gorges Hospital, Chongqing 404000, China
- Chongqing Municipality Clinical Research Center for Geriatric Diseases, Chongqing University Three Gorges Hospital, Chongqing 404000, China
| | - Sheng-Hua Li
- Department of Orthopedics, Chongqing University Three Gorges Hospital, Chongqing 404000, China
- Chongqing Municipality Clinical Research Center for Geriatric Diseases, Chongqing University Three Gorges Hospital, Chongqing 404000, China
| | - Nan Li
- Department of Orthopedics, Chongqing University Three Gorges Hospital, Chongqing 404000, China
| | - Feng Liu
- Department of Orthopedics, Chongqing University Three Gorges Hospital, Chongqing 404000, China
| | - Hao-Ming Wang
- Department of Orthopedics, Chongqing University Three Gorges Hospital, Chongqing 404000, China
- Chongqing Municipality Clinical Research Center for Geriatric Diseases, Chongqing University Three Gorges Hospital, Chongqing 404000, China
| |
Collapse
|
3
|
Gondal TA, Chaudhary N, Bajwa H, Rau A, Le D, Ahmed S. Anal Cancer: The Past, Present and Future. Curr Oncol 2023; 30:3232-3250. [PMID: 36975459 PMCID: PMC10047250 DOI: 10.3390/curroncol30030246] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/07/2023] [Accepted: 03/09/2023] [Indexed: 03/14/2023] Open
Abstract
Anal cancer is a rare cancer that accounts for about 2% of all gastrointestinal tract malignancies. Among anal cancer, squamous cell cancer is the most common malignancy. The incidence of all stages of anal squamous cell cancer has been increasing. Human papillomavirus infection and immunosuppression are major risk factors for anal cancer. The management of anal cancer has evolved over the past several decades and continues to do so. Chemoradiation therapy remains the mainstay for treatment for most patients with early-stage disease, whereas systemic therapy is the primary treatment for patients with metastatic disease. Patients with persistent disease or recurrence following chemoradiation therapy are treated with salvage surgery. Access to novel cytotoxic combinations and immunotherapy has improved the outcomes of patients with advanced disease. This review provides an overview of advances in the management of anal cancer over the past two decades. This paper reviews the epidemiology, risk factors, pathology, diagnosis, and management of localized and advanced anal squamous cell cancer, highlights current knowledge gaps in the management of anal cancer, and discusses future directions.
Collapse
|
4
|
Hosni A, Ringash J, Han K, Liu ZA, Brierley JD, Wong RKS, Dawson LA, Cummings BJ, Krzyzanowska MK, Chen EX, Hedley D, Knox JJ, Easson AM, Lindsay P, Craig T, Kim J. Impact of Definitive Chemoradiation on Quality-of-Life Changes for Patients With Anal Cancer: Long-term Results of a Prospective Study. Dis Colon Rectum 2022; 65:642-53. [PMID: 35067501 DOI: 10.1097/DCR.0000000000002385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Maintaining and improving quality of life (QOL) are important goals of anal cancer management. This disease is generally curable, with many long-term survivors. OBJECTIVE Long-term QOL after chemoradiation for patients with anal cancer was evaluated. DESIGN This was a prospective cohort study. SETTINGS This study used data from a prospective study of patients with anal cancer who were treated with chemoradiation between 2008 and 2013. PATIENTS Patients with anal cancer who were treated with image-guided intensity-modulated radiation therapy were included. INTERVENTIONS English-speaking patients completed European Organization for Research and Treatment of Cancer cancer-specific (C30) and site-specific (CR29) QOL questionnaires at baseline, at end of radiation, at 3 and 6 months, and then annually. MAIN OUTCOMES MEASURES Long-term QOL was evaluated clinically (a change in score of ≥10 points was considered clinically significant) and statistically (using repeated-measurement analysis) by comparing the subscale scores at 1, 2, and 3 years with baseline scores. Subanalysis compared patients who received a radiation dose of 45 to 54 Gy versus 63 Gy. RESULTS Ninety-six patients were included (median follow-up of 56.5 months). The symptom and functional scales showed a clinically significant decline at the end of treatment with improvement by 3 months after treatment. There was a long-term statistically significant decline in dyspnea, body image, bowel embarrassment, fecal incontinence, and hair loss, and there was long-term statistically and clinically significant worsening of impotence. Higher radiation dose (63 Gy) was not associated with significantly worse QOL. LIMITATIONS Limitations included single-institution, single-arm study design, and lack of dose reconstruction (ie, analyses were based on prescribed, rather than delivered, dose). CONCLUSIONS Patients with anal cancer treated with chemoradiation reported recovery of overall QOL to baseline levels. Specific symptoms remained bothersome, emphasizing the need to address and manage the chemoradiation-induced symptoms, during treatment and in the long term. See Video Abstract at http://links.lww.com/DCR/B905. IMPACTO DE LA QUIMIORRADIACIN DEFINITIVA EN CAMBIOS EN LA CALIDAD DE VIDA DE LOS PACIENTES CON CNCER ANAL RESULTADOS A LARGO PLAZO DE UN ESTUDIO PROSPECTIVE ANTECEDENTES:Mantener y mejorar la calidad de vida son objetivos importantes del tratamiento del cáncer anal, ya que esta enfermedad generalmente es curable, con muchos sobrevivientes a largo plazo.OBJETIVO:Se evaluó la calidad de vida a largo plazo después de la quimiorradiación en pacientes con cáncer anal.DISEÑO:Este fue un estudio de cohorte prospectivo.ENTORNO CLINICO:Utilizamos datos de un estudio prospectivo en pacientes con cáncer anal tratados con quimiorradiación entre 2008-2013.PACIENTES:Los pacientes con cáncer anal fueron tratados con radioterapia de intensidad modulada guiada por imágenes.INTERVENCIONES:Los pacientes de habla inglesa completaron los cuestionarios de calidad de vida específicos de cáncer (C30) y específicos del sitio (CR29) de la Organización Europea para la Investigación y el Tratamiento del Cáncer al inicio, al final de la radiación, 3 y 6 meses, y luego anualmente.PRINCIPALES MEDIDAS DE RESULTADOS:Se evaluó a largo plazo la calidad de vida clínicamente (un cambio en la puntuación de ≥10 puntos se consideraron clínicamente significativo) y estadísticamente (usando análisis de medición repetida) comparando las subescalas de puntuación al 1, 2, y 3 años. Con puntuaciones de referencia. El subanálisis comparó pacientes que recibieron 45-54 Gy versus 63 Gy.RESULTADOS:Se incluyeron un total de 96 pacientes (mediana de seguimiento: 56,5 meses). La mayoría de las escalas funcionales y de síntomas mostraron una disminución clínicamente significativa al final del tratamiento con una mejoría a los 3 meses posteriores al tratamiento. Hubo una disminución estadísticamente significativa a largo plazo en disnea, imagen corporal, vergüenza intestinal, incontinencia fecal y pérdida de cabello; y hubo un empeoramiento a largo plazo estadística y clínicamente significativo en impotencia. La dosis de radiación más alta (63 Gy) no se asoció con una calidad de vida significativamente peor.LIMITACIONES:Institución única, diseño de estudio de un solo brazo y falta de recomposición de la dosis (es decir, los análisis se basan en la dosis prescrita, en lugar de la administrada).CONCLUSIÓNES:Los pacientes con cáncer anal tratados con quimiorradiación reportaron una recuperación de la QOL en general a los niveles de base. Síntomas específicos siguieron siendo molestos, lo que enfatiza la necesidad de resolver y tartar los síntomas inducidos por la quimiorradiación no solo durante el tratamiento, sino a largo plazo. Consulte Video Resumen en http://links.lww.com/DCR/B905. (Traducción- Dr. Francisco M. Abarca-Rendon).
Collapse
|
5
|
Haas S, Mikkelsen AH, Kronborg C, Oggesen BT, Faaborg PM, Serup-Hansen E, Spindler KLG, Christensen P. Management of late adverse effects after chemoradiation for anal cancer. Acta Oncol 2021; 60:1688-1701. [PMID: 34845967 DOI: 10.1080/0284186x.2021.1983208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND PURPOSE Significant improvements in the treatment of anal cancer have produced a growing population of anal cancer survivors. These patients often experience late adverse effects related to their treatment. Research has revealed substantial unmet needs because of long-term symptoms and functional impairments after treatment that may negatively affect health-related quality of life. The purpose of the present guidelines is to review the scientific evidence for the management of late adverse effects after (chemo)radiotherapy ([C]RT) for anal cancer and to extrapolate knowledge from other pelvic malignancies treated with pelvic (C)RT so that they may guide the clinical management of late adverse effects. MATERIALS AND METHODS Relevant studies were systematically searched in four databases from their inception to June 2020 (no language limitation) and guidelines were searched in 16 databases, focussing on bowel dysfunction, psychosocial aspects, pain, and sexual and urinary dysfunction. The guidelines were developed by a panel of experts using the Oxford Centre for Evidence-based Medicine, levels of evidence, and grades of recommendations. SCIENTIFIC EVIDENCE Late adverse effects after (C)RT for anal cancer are associated with a low overall quality of life among survivors. The most pronounced late adverse effects are bowel dysfunction (present in up to 78%), urinary dysfunction (present in up to 45%), and sexual dysfunction (present in up to 90% of men and up to 100% of women). Only indirect data on adequate treatment options of these late adverse effects for anal cancer are available. CONCLUSION Quality of life and late adverse effects should be monitored systematically following treatment for anal cancer to identify patients who require further specialist evaluation or support. Increased awareness of the extent of the problem may serve to stimulate and facilitate multidisciplinary collaboration, which is often required.
Collapse
Affiliation(s)
- Susanne Haas
- Danish Cancer Society, National Research Centre for Survivorship and Late Adverse Effects following Pelvic Organ Cancer, Department of Surgery, Aarhus University Hospital, Aalborg, Denmark
| | | | - Camilla Kronborg
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | | | - Pia Moeller Faaborg
- Department of Surgery, Vejle Hospital, Danish Colorectal Cancer Centre South, Vejle, Denmark
| | | | | | - Peter Christensen
- Danish Cancer Society, National Research Centre for Survivorship and Late Adverse Effects following Pelvic Organ Cancer, Department of Surgery, Aarhus University Hospital, Aalborg, Denmark
| |
Collapse
|
6
|
Mahmoud Moustafa E, Rashed ER, Rashed RR, Omar NN. Piceatannol promotes hepatic and renal AMPK/SIRT1/PGC-1α mitochondrial pathway in rats exposed to reserpine or gamma-radiation. Int J Immunopathol Pharmacol 2021; 35:20587384211016194. [PMID: 33985371 PMCID: PMC8127740 DOI: 10.1177/20587384211016194] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 04/18/2021] [Indexed: 01/20/2023] Open
Abstract
Human exposure to radio-therapeutic doses of gamma rays can produce late effects, which negatively affect cancer patients' quality of life, work prospects, and general health. This study was performed to explore the role of Piceatannol (PIC) in the process of "mitochondrial biogenesis" signaling pathway as possible management of disturbances induced in stressed animal model(s) either by gamma-irradiation (IR) or administration of reserpine (RES); as a mitochondrial complex-I inhibitor. PIC (10 mg/kg BW/day; orally) were given to rats for 7 days, after exposure to an acute dose of γ-radiation (6 Gy), or after a single reserpine injection (1 g/kg BW; sc). Compared to reserpine or γ-radiation, PIC has attenuated hepatic and renal mitochondrial oxidative stress denoted by the significant reduction in the content of lipid peroxides and NO with significant induction of SOD, CAT, GSH-PX, and GR activities. PIC has also significantly alleviated the increase of the inflammatory markers, TNF-α and IL-6 and apoptotic markers, cytochrome c, and caspase-3. The decrease of oxidative stress, inflammation, and apoptotic responses were linked to a significant amelioration in mitochondrial biogenesis demonstrated by the increased expression and proteins' tissue contents of SIRT1/p38-AMPK, PGC-1α signaling pathway. The results are substantiated by the significant amelioration in mitochondrial function verified by the higher levels of ATP content, and complex I activity, besides the improvement of hepatic and renal functions. Additionally, histopathological examinations of hepatic and renal tissues showed that PIC has modulated tissue architecture after reserpine or gamma-radiation-induced tissue damage. Piceatannol improves mitochondrial functions by regulating the oxidant/antioxidant disequilibrium, the inflammatory and apoptotic responses, suggesting its possible use as adjuvant therapy in radio-therapeutic protocols to attenuate hepatic and renal injuries.
Collapse
Affiliation(s)
- Enas Mahmoud Moustafa
- Radiation Biology Department, National Center for Radiation Research and Technology, Egyptian Atomic Energy Authority, Cairo, Egypt
| | - Engy Refaat Rashed
- Drug Radiation Research Department, National Center for Radiation Research and Technology, Egyptian Atomic Energy Authority, Cairo, Egypt
| | - Rasha Refaat Rashed
- Drug Radiation Research Department, National Center for Radiation Research and Technology, Egyptian Atomic Energy Authority, Cairo, Egypt
| | - Nesreen Nabil Omar
- Biochemistry Department, Faculty of Pharmacy, Modern University for Technology and Information, Cairo, Egypt
| |
Collapse
|
7
|
Abstract
INTRODUCTION Anal cancer is a rare malignancy with increasing incidence, notably in women. This disease is highly associated with HPV infection and its incidence and mortality are currently rising. Most patients present with localized disease which has a high survival after definitive treatment with chemoradiation. For patients who develop metastatic disease or present with this de novo, survival is poor. AREAS COVERED This review provides a summary of current literature on anal cancer. With a focus on women, this includes current epidemiological trends, role of HPV, and the current and future treatment landscape, including HPV vaccination and immunotherapy. Screening currently focusses on HIV-positive men, missing most female cases. In curative disease, trials are investigating treatment de-intensification in good prognostic groups. Immunotherapy is showing early promise in the advanced disease setting. EXPERT OPINION Similar to cervical cancer, anal cancer is strongly associated with HPV, and therefore, broader implementation of screening programs may reduce its incidence. HPV vaccination is expected to reduce the development of (pre)malignant anal lesions. The emergence of biomarkers will assist patient treatment selection, allowing optimal balance of treatment efficacy and morbidity. It is hoped that new treatment approaches, including immunotherapy, will improve outcomes. International collaboration is needed.
Collapse
Affiliation(s)
- Caroline Lum
- Medical Oncology, Monash Medical Centre , Clayton, Australia
| | - Hans Prenen
- Medical Oncology, Monash Medical Centre , Clayton, Australia.,Oncology Department, University Hospital Antwerp , Antwerp, Belgium
| | - Amy Body
- Medical Oncology, Monash Medical Centre , Clayton, Australia
| | - Marissa Lam
- Medical Oncology, Monash Medical Centre , Clayton, Australia
| | - Eva Segelov
- Medical Oncology, Monash Medical Centre , Clayton, Australia.,School of Clinical Sciences, Monash University , Clayton, Australia
| |
Collapse
|