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Jenkins V, Matthews L, Solis-Trapala I, Gage H, May S, Williams P, Bloomfield D, Zammit C, Elwell-Sutton D, Betal D, Finlay J, Nicholson K, Kothari M, Santos R, Stewart E, Bell S, McKinna F, Teoh M. Patients' experiences of a suppoRted self-manAGeMent pAThway In breast Cancer (PRAGMATIC): quality of life and service use results. Support Care Cancer 2023; 31:570. [PMID: 37698629 PMCID: PMC10497681 DOI: 10.1007/s00520-023-08002-z] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 08/16/2023] [Indexed: 09/13/2023]
Abstract
PURPOSE To describe trends and explore factors associated with quality of life (QoL) and psychological morbidity and assess breast cancer (BC) health service use over a 12-month period for patients joining the supported self-management (SSM)/patient-initiated follow-up (PIFU) pathway. METHODS Participants completed questionnaires at baseline, 3, 6, 9 and 12 months that measured QoL (FACT-B, EQ 5D-5L), self-efficacy (GSE), psychological morbidity (GHQ-12), roles and responsibilities (PRRS) and service use (cost diary). RESULTS 99/110 patients completed all timepoints; 32% (35/110) had received chemotherapy. The chemotherapy group had poorer QoL; FACT-B total score mean differences were 8.53 (95% CI: 3.42 to 13.64), 5.38 (95% CI: 0.17 to 10.58) and 8.00 (95% CI: 2.76 to 13.24) at 6, 9 and 12 months, respectively. The odds of psychological morbidity (GHQ12 >4) were 5.5-fold greater for those treated with chemotherapy. Financial and caring burdens (PRRS) were worse for this group (mean difference in change at 9 months 3.25 (95% CI: 0.42 to 6.07)). GSE and GHQ-12 scores impacted FACT-B total scores, indicating QoL decline for those with high baseline psychological morbidity. Chemotherapy patients or those with high psychological morbidity or were unable to carry out normal activities had the highest service costs. Over the 12 months, 68.2% participants phoned/emailed breast care nurses, and 53.3% visited a hospital breast clinician. CONCLUSION The data suggest that chemotherapy patients and/or those with heightened psychological morbidity might benefit from closer monitoring and/or supportive interventions whilst on the SSM/PIFU pathway. Reduced access due to COVID-19 could have affected service use.
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Affiliation(s)
- V Jenkins
- Sussex Health Outcomes Research & Education in Cancer (SHORE-C), Brighton & Sussex Medical School, University of Sussex, Falmer, East Sussex, England, UK.
| | - L Matthews
- Sussex Health Outcomes Research & Education in Cancer (SHORE-C), Brighton & Sussex Medical School, University of Sussex, Falmer, East Sussex, England, UK
| | - I Solis-Trapala
- School of Medicine, Keele University, University Road, Staffordshire, England, UK
| | - H Gage
- Surrey Health Economics Centre/Department of Clinical and Experimental Medicine, Leggett Building, University of Surrey, Guildford, Surrey, England, UK
| | - S May
- Sussex Health Outcomes Research & Education in Cancer (SHORE-C), Brighton & Sussex Medical School, University of Sussex, Falmer, East Sussex, England, UK
| | - P Williams
- Department of Mathematics, University of Surrey, Guildford, Surrey, England, UK
| | - D Bloomfield
- Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, East Sussex, England, UK
- Surrey & Sussex Cancer Alliance, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, England, UK
| | - C Zammit
- Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, East Sussex, England, UK
- Surrey & Sussex Cancer Alliance, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, England, UK
| | - D Elwell-Sutton
- Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, East Sussex, England, UK
| | - D Betal
- Worthing Hospital, University Hospitals Sussex NHS Foundation Trust, Worthing, West Sussex, England, UK
| | - J Finlay
- Worthing Hospital, University Hospitals Sussex NHS Foundation Trust, Worthing, West Sussex, England, UK
| | - K Nicholson
- Worthing Hospital, University Hospitals Sussex NHS Foundation Trust, Worthing, West Sussex, England, UK
| | - M Kothari
- Ashford & St Peter's NHS Foundation Trust, London Road, Ashford, Surrey, England, UK
| | - R Santos
- Ashford & St Peter's NHS Foundation Trust, London Road, Ashford, Surrey, England, UK
| | - E Stewart
- Ashford & St Peter's NHS Foundation Trust, London Road, Ashford, Surrey, England, UK
| | - S Bell
- Surrey & Sussex Cancer Alliance, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, England, UK
| | - F McKinna
- Surrey & Sussex Cancer Alliance, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, England, UK
| | - M Teoh
- Surrey & Sussex Cancer Alliance, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, England, UK
- Ashford & St Peter's NHS Foundation Trust, London Road, Ashford, Surrey, England, UK
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Schmid P, Pinder SE, Bundred N, Wheatley D, Macaskill J, Zammit C, Hu J, Price R, Shia A, Lim L, Parker P, Molinero L, Yu J, O'Brien C, Wilson T, Savage H, Derynck M, Lackner MR, Amler L, Purushotham A, Thompson A, Gendreau S. Abstract P5-13-01: Transcript analysis of PI3K and immune-related genes and gene signatures in the pre- and post-treatment samples from the window of opportunity study of anastrozole and anastrozole with pictilisib (GDC-0941) in patients with HR-positive early breast cancer (OPPORTUNE study). Cancer Res 2016. [DOI: 10.1158/1538-7445.sabcs15-p5-13-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: The OPPORTUNE Study randomized postmenopausal patients (pts) to receive 2-week preoperative treatment with anastrozole (ANA) plus pictilisib ("ANA+PIC" arm) or ANA alone. Patients had newly diagnosed, operable, ER+, HER2- invasive breast cancer of ≥1 cm size. The primary outcome at interim analysis (n=70) revealed that the addition of PIC significantly increased the anti-proliferative response to ANA as measured by reduction in Ki67 immunohistochemistry (IHC). Multivariate analyses suggested benefit of PIC for patients with luminal B disease (Schmid et al. SABCS 2014).
Methods: RNA expression analysis of ∼800 breast cancer-related genes was performed on patients analyzed at the interim analysis, including 14 (ANA) and 20 (ANA+PIC) patients with matched pre- and post- treatment paired tumour samples using the nCounter platform (NanoString). Differential expression of individual genes by arm was assessed using paired and moderated t-tests and statistical significance assessed through false discovery rate (FDR). Ingenuity Pathway Analysis (IPA) of differentially expressed transcripts identified pathways of relevance. Protein expression was analyzed by reverse protein array ( RPPA) in pre- and post-treatment samples.
Results: In an unsupervised analysis, down-regulation of genes associated with ER signaling was observed in patients who received single-agent ANA and ANA+PIC, which included genes that regulate the cell cycle, cell death, survival, growth and proliferation and known ER target genes (e.g., PGR, GREB1). In addition, transcripts related to growth factor signaling pathway appeared to be specifically modulated in the ANA+PIC arm, possibly via the upregulation of the expression of RTK ligands. There were no clear changes in PI3K-related phosphoproteins (e.g., AKT, S6, 4E-BP1) in the post-treatment samples by RPPA. However, known PI3K-regulated genes, IRS2 and PIK3IP1, were upregulated in the post-treatment samples and a composite PI3K gene expression signature score (O'Brien et al. 2010) was reduced in both study arms following treatment. This PI3K signature was associated with pre-treatment luminal B status (n=27) and, consistent with this finding, the baseline PI3K gene signature score in the ANA arm, but not the ANA+PIC arm, was inversely associated with the decrease in post treatment Ki67. The tumor immune microenvironment was analyzed though the use of composite gene sets. In our initial observations, analysis of pre- and post-treatment samples showed that 2-week treatment with ANA resulted in a modest increase in transcripts associated with multiple immune signatures, which was further enhanced by the addition of PIC.
Conclusions: Gene expression analysis of pre- and post-treatment samples in the OPPORTUNE study demonstrates on-target inhibition of ER and PI3K signaling networks. The analysis of additional paired samples is in progress to further assess if 2-weeks of treatment with a regimen containing an AI in patients with early breast cancer impacts the tumor immune microenvironment.
Citation Format: Schmid P, Pinder SE, Bundred N, Wheatley D, Macaskill J, Zammit C, Hu J, Price R, Shia A, Lim L, Parker P, Molinero L, Yu J, O'Brien C, Wilson T, Savage H, Derynck M, Lackner MR, Amler L, Purushotham A, Thompson A, Gendreau S. Transcript analysis of PI3K and immune-related genes and gene signatures in the pre- and post-treatment samples from the window of opportunity study of anastrozole and anastrozole with pictilisib (GDC-0941) in patients with HR-positive early breast cancer (OPPORTUNE study). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-13-01.
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Affiliation(s)
- P Schmid
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - SE Pinder
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - N Bundred
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - D Wheatley
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - J Macaskill
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - C Zammit
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - J Hu
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - R Price
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - A Shia
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - L Lim
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - P Parker
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - L Molinero
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - J Yu
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - C O'Brien
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - T Wilson
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - H Savage
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - M Derynck
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - MR Lackner
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - L Amler
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - A Purushotham
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - A Thompson
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
| | - S Gendreau
- Barts Cancer Institute, Queen Mary University London, London, United Kingdom; Kings College London, London, United Kingdom; Guys and St Thomas NHS Trust, Kings College London, London, United Kingdom; University Hospital of South Manchester, Manchester, United Kingdom; Royal Cornwall Hospital, Truro, United Kingdom; Ninewells Hospital Dundee, Dundee, United Kingdom; Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom; Barts Health NHS Trust, London, United Kingdom; Kings College Hospital, London, United Kingdom; MD Anderson Cancer Centre, Houston, TX; Genentech, South San Francisco, California, South San Francisco, CA
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