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Morrow A, Steinberg J, Chan P, Tiernan G, Kennedy E, Egoroff N, Hilton D, Sankey L, Venchiarutti R, Hayward A, Pearn A, McKay S, Debono D, Hogden E, Taylor N. In person and virtual process mapping experiences to capture and explore variability in clinical practice: application to genetic referral pathways across seven Australian hospital networks. Transl Behav Med 2023; 13:561-570. [PMID: 37036763 PMCID: PMC10415733 DOI: 10.1093/tbm/ibad009] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2023] Open
Abstract
Genetic referral for Lynch syndrome (LS) exemplifies complex clinical pathways. Identifying target behaviours (TBs) for change and associated barriers requires structured group consultation activities with busy clinicians - consolidating implementation activities whilst retaining rigour is crucial. This study aimed to: i) use process mapping to gain in-depth understandings of site-specific LS testing and referral practices in Australian hospitals and support identification of TBs for change, ii) explore if barriers to identified TBs could be identified through process mapping focus-group data, and iii) demonstrate pandemic-induced transition from in-person to virtual group interactive process mapping methods. LS clinical stakeholders attended interactive in-person or virtual focus groups to develop site-specific "process maps" visually representing referral pathways. Content analysis of transcriptions informed site-specific process maps, then clinical audit data was compared to highlight TBs for change. TBs were reviewed in follow-up focus groups. Secondary thematic analysis explored barriers to identified TBs, coded against the Theoretical Domains Framework (TDF). The transition from in-person to pandemic-induced virtual group interactive process mapping methods was documented. Process mapping highlighted six key areas of clinical practice variation across sites and site-specific TBs for change were identified. Key barriers to identified TBs emerged, categorised to seven TDF domains. Process mapping revealed variations in clinical practices surrounding LS referral between sites. Incorporating qualitative perspectives enhances process mapping by facilitating identification of TBs for change and barriers, providing a pathway to developing targeted interventions. Virtual process mapping activities produced detailed data and enabled comprehensive map development.
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Affiliation(s)
- April Morrow
- Implementation to Impact Hub, School of Population Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
| | - Julia Steinberg
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, New South Wales, Australia
| | - Priscilla Chan
- Implementation to Impact Hub, School of Population Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
| | - Gabriella Tiernan
- Implementation to Impact Hub, School of Population Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
| | - Elizabeth Kennedy
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, New South Wales, Australia
| | - Natasha Egoroff
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Desiree Hilton
- Familial Cancer Service, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, NSW, Australia
| | | | - Rebecca Venchiarutti
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Anne Hayward
- The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Amy Pearn
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, New South Wales, Australia
| | - Skye McKay
- Implementation to Impact Hub, School of Population Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
| | - Deborah Debono
- Centre for Health Services Management, School of Public Health, University of Technology Sydney, New South Wales, Australia
| | - Emily Hogden
- Implementation to Impact Hub, School of Population Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
| | - Natalie Taylor
- Implementation to Impact Hub, School of Population Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
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Steinberg J, Chan P, Hogden E, Tiernan G, Morrow A, Kang YJ, He E, Venchiarutti R, Titterton L, Sankey L, Pearn A, Nichols C, McKay S, Hayward A, Egoroff N, Engel A, Gibbs P, Goodwin A, Harris M, Kench JG, Pachter N, Parkinson B, Pockney P, Ragunathan A, Smyth C, Solomon M, Steffens D, Toh JWT, Wallace M, Canfell K, Gill A, Macrae F, Tucker K, Taylor N. Lynch syndrome testing of colorectal cancer patients in a high-income country with universal healthcare: a retrospective study of current practice and gaps in seven australian hospitals. Hered Cancer Clin Pract 2022; 20:18. [PMID: 35509103 PMCID: PMC9066828 DOI: 10.1186/s13053-022-00225-1] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 04/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To inform effective genomic medicine strategies, it is important to examine current approaches and gaps in well-established applications. Lynch syndrome (LS) causes 3-5% of colorectal cancers (CRCs). While guidelines commonly recommend LS tumour testing of all CRC patients, implementation in health systems is known to be highly variable. To provide insights on the heterogeneity in practice and current bottlenecks in a high-income country with universal healthcare, we characterise the approaches and gaps in LS testing and referral in seven Australian hospitals across three states. METHODS We obtained surgery, pathology, and genetics services data for 1,624 patients who underwent CRC resections from 01/01/2017 to 31/12/2018 in the included hospitals. RESULTS Tumour testing approaches differed between hospitals, with 0-19% of patients missing mismatch repair deficiency test results (total 211/1,624 patients). Tumour tests to exclude somatic MLH1 loss were incomplete at five hospitals (42/187 patients). Of 74 patients with tumour tests completed appropriately and indicating high risk of LS, 36 (49%) were missing a record of referral to genetics services for diagnostic testing, with higher missingness for older patients (0% of patients aged ≤ 40 years, 76% of patients aged > 70 years). Of 38 patients with high-risk tumour test results and genetics services referral, diagnostic testing was carried out for 25 (89%) and identified a LS pathogenic/likely pathogenic variant for 11 patients (44% of 25; 0.7% of 1,624 patients). CONCLUSIONS Given the LS testing and referral gaps, further work is needed to identify strategies for successful integration of LS testing into clinical care, and provide a model for hereditary cancers and broader genomic medicine. Standardised reporting may help clinicians interpret tumour test results and initiate further actions.
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Affiliation(s)
- Julia Steinberg
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, NSW, 2011, Woolloomooloo, Australia.
| | - Priscilla Chan
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, NSW, 2011, Woolloomooloo, Australia
| | - Emily Hogden
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, NSW, 2011, Woolloomooloo, Australia
| | - Gabriella Tiernan
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, NSW, 2011, Woolloomooloo, Australia
| | - April Morrow
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, NSW, 2011, Woolloomooloo, Australia
| | - Yoon-Jung Kang
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, NSW, 2011, Woolloomooloo, Australia
| | - Emily He
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, NSW, 2011, Woolloomooloo, Australia
| | - Rebecca Venchiarutti
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Leanna Titterton
- NSW Health, Western Sydney Local Health District, Westmead, NSW, Australia
| | | | - Amy Pearn
- Cancer Council NSW, Sydney, NSW, Australia
| | - Cassandra Nichols
- Genetic Services of Western Australia, King Edward Memorial Hospital, Perth, Western Australia, Australia
| | - Skye McKay
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, NSW, 2011, Woolloomooloo, Australia
| | - Anne Hayward
- The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Natasha Egoroff
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Alexander Engel
- The University of Sydney, Northern Clinical School Royal North Shore Hospital, Sydney, NSW, Australia
| | - Peter Gibbs
- Personalised Oncology Division, Walter and Eliza Hall Institute, Melbourne, Victoria, Australia
| | - Annabel Goodwin
- Cancer Genetics Department, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | | | - James G Kench
- Department of Tissue Pathology & Diagnostic Oncology, NSW Health Pathology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Nicholas Pachter
- Genetic Services of Western Australia, King Edward Memorial Hospital, Perth, Western Australia, Australia
- School of Medicine and Pharmacology, University of Western Australia, Perth, Western, Australia
| | - Bonny Parkinson
- Centre for the Health Economy, Macquarie University, Sydney, NSW, Australia
| | - Peter Pockney
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Abiramy Ragunathan
- Westmead Familial Cancer Services, The Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, NSW, Australia
| | | | - Michael Solomon
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - James Wei Tatt Toh
- Department of Colorectal Surgery, The University of Sydney, Westmead Hospital, Westmead, NSW, Australia
| | - Marina Wallace
- Fiona Stanley Hospital, South Metropolitan Health Service, Murdoch, Western Australia, Australia
| | - Karen Canfell
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, NSW, 2011, Woolloomooloo, Australia
| | - Anthony Gill
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Finlay Macrae
- Colorectal Medicine and Genetics, Department of Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Kathy Tucker
- Hereditary Cancer Clinic, Prince of Wales Hospital, Sydney, NSW, Australia
- Prince of Wales Clinical School, UNSW, Sydney, NSW, Australia
| | - Natalie Taylor
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, 153 Dowling St, NSW, 2011, Woolloomooloo, Australia
- School of Population Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
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Tiernan G, Freeman V, Morrow A, Hogden E, Canfell K, Kang YJ, Taylor N. What would I do? Perspectives on the factors underlying Lynch syndrome genetic testing and results sharing decisions for high-risk colorectal cancer patients. Psychooncology 2021; 31:587-596. [PMID: 34698409 PMCID: PMC9298871 DOI: 10.1002/pon.5840] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 10/06/2021] [Accepted: 10/13/2021] [Indexed: 11/17/2022]
Abstract
Objective Universal tumour testing for Lynch syndrome (LS) in all incident colorectal cancers (CRCs) and sequential diagnostic genetic testing is cost‐effective in Australia. Because of this, our study aimed to understand factors underlying possible decisions faced by tumour test‐positive CRC patients and their at‐risk relatives throughout the LS diagnosis pathway. Methods Semi‐structured telephone interviews were conducted with 23 participants, using four hypothetical scenarios. Vignette‐guided closed‐ and open‐ended questions asked about LS genetic testing uptake, discussing diagnosis with at‐risk relatives, and risk‐reducing interventions. Personal perspectives on genetic testing were collected pre‐post vignette discussion. Inductive thematic analysis was performed on open‐ended questions. Decisional pathway diagrams were developed to convey factors influencing complex decision‐making processes. Results Participant responses incorporated unfolding scenario information, resulting in three decision themes: (1) wanting to know one's LS status; (2) informing family about LS; (3) navigating risk‐reducing interventions. Across all themes, ‘knowledge’ emerged as a facilitator, and ‘negative emotional experience’ as a barrier. Personal supportive views toward genetic testing increased post‐interview. Conclusions When communicating with tumour test‐positive CRC patients or their relatives about LS genetic testing, providing guidance/resources to inform decisions around risk‐reducing interventions and informing family members is critical. Scenario‐driven interviews provide insight into what individuals might do when facing complex healthcare decisions and could aid informed decision‐making. This approach may be applicable in other conditions, particularly with mainstreaming being increasingly introduced into the genetic context.
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Affiliation(s)
- Gabriella Tiernan
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - Victoria Freeman
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - April Morrow
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - Emily Hogden
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - Karen Canfell
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Yoon-Jung Kang
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - Natalie Taylor
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,School of Population Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
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Edge R, Meyers J, Tiernan G, Li Z, Schiavuzzi A, Chan P, Vassallo A, Morrow A, Mazariego C, Wakefield CE, Canfell K, Taylor N. Cancer care disruption and reorganisation during the COVID-19 pandemic in Australia: A patient, carer and healthcare worker perspective. PLoS One 2021; 16:e0257420. [PMID: 34534231 PMCID: PMC8448370 DOI: 10.1371/journal.pone.0257420] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 08/18/2021] [Indexed: 11/19/2022] Open
Abstract
The COVID-19 pandemic has dramatically impacted cancer care worldwide. Disruptions have been seen across all facets of care. While the long-term impact of COVID-19 remains unclear, the immediate impacts on patients, their carers and the healthcare workforce are increasingly evident. This study describes disruptions and reorganisation of cancer services in Australia since the onset of COVID-19, from the perspectives of people affected by cancer and healthcare workers. Two separate online cross-sectional surveys were completed by: a) cancer patients, survivors, carers, family members or friends (n = 852) and b) healthcare workers (n = 150). Descriptive analyses of quantitative survey data were conducted, followed by inductive thematic content analyses of qualitative survey responses relating to cancer care disruption and perceptions of telehealth. Overall, 42% of cancer patients and survivors reported experiencing some level of care disruption. A further 43% of healthcare workers reported atypical delays in delivering cancer care, and 50% agreed that patient access to research and clinical trials had been reduced. Almost three quarters (73%) of patients and carers reported using telehealth following the onset of COVID-19, with high overall satisfaction. However, gaps were identified in provision of psychological support and 20% of participants reported that they were unlikely to use telehealth again. The reorganisation of cancer care increased the psychological and practical burden on carers, with hospital visitation restrictions and appointment changes reducing their ability to provide essential support. COVID-19 has exacerbated a stressful and uncertain time for people affected by cancer and healthcare workers. Service reconfiguration and the adoption of telehealth have been essential adaptations for the pandemic response, offering long-term value. However, our findings highlight the need to better integrate psychosocial support and the important role of carers into evolving pandemic response measures. Learnings from this study could inform service improvements that would benefit patients and carers longer-term.
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Affiliation(s)
- Rhiannon Edge
- Daffodil Centre, The University of Sydney, a joint venture with Cancer Council New South Wales, Sydney, NSW, Australia
| | - Josh Meyers
- Cancer Council NSW, Sydney, NSW, Australia
- * E-mail:
| | - Gabriella Tiernan
- Daffodil Centre, The University of Sydney, a joint venture with Cancer Council New South Wales, Sydney, NSW, Australia
| | - Zhicheng Li
- Daffodil Centre, The University of Sydney, a joint venture with Cancer Council New South Wales, Sydney, NSW, Australia
| | - Alexandra Schiavuzzi
- Daffodil Centre, The University of Sydney, a joint venture with Cancer Council New South Wales, Sydney, NSW, Australia
| | - Priscilla Chan
- Daffodil Centre, The University of Sydney, a joint venture with Cancer Council New South Wales, Sydney, NSW, Australia
| | - Amy Vassallo
- The George Institute for Global Health, UNSW, Sydney, NSW, Australia
| | - April Morrow
- Daffodil Centre, The University of Sydney, a joint venture with Cancer Council New South Wales, Sydney, NSW, Australia
| | - Carolyn Mazariego
- Daffodil Centre, The University of Sydney, a joint venture with Cancer Council New South Wales, Sydney, NSW, Australia
- The University of Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Claire E. Wakefield
- Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children’s Hospital, Sydney, NSW, Australia
- School of Women’s and Children’s Health, UNSW Sydney, Sydney, Australia
| | - Karen Canfell
- Daffodil Centre, The University of Sydney, a joint venture with Cancer Council New South Wales, Sydney, NSW, Australia
- The University of Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Natalie Taylor
- Daffodil Centre, The University of Sydney, a joint venture with Cancer Council New South Wales, Sydney, NSW, Australia
- The University of Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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Morrow A, Chan P, Tiernan G, Steinberg J, Debono D, Wolfenden L, Tucker KM, Hogden E, Taylor N. Building capacity from within: qualitative evaluation of a training program aimed at upskilling healthcare workers in delivering an evidence-based implementation approach. Transl Behav Med 2021; 12:6320108. [PMID: 34255088 PMCID: PMC8765000 DOI: 10.1093/tbm/ibab094] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Translating evidence into complex health systems is an ongoing challenge. Building the capacity of healthcare workers in behavioral and implementation science methods may facilitate the use of evidence-based implementation approaches, leading to sustainable and effective translation. The aim was to describe the development, contents and evaluation of a training workshop aimed at upskilling hospital-embedded staff to deliver an evidence-based implementation approach. The Hide and Seek Project (HaSP) is a cluster randomized controlled trial testing two implementation approaches for improving hereditary cancer referral at eight Australian hospitals. Healthcare workers were recruited as “Implementation Leads” and trained via a one-day workshop—TRAining in evideNce-baSed ImpLementATion for hEalth (TRANSLATE). The purpose of TRANSLATE was to upskill Implementation Leads in the delivery of HaSP, as well as implementation science methods more broadly. Implementation Leads participated in semi-structured evaluation interviews, which were analyzed using inductive thematic analysis. Nine Implementation Leads from various professional backgrounds completed the training. Four key themes were identified: (i) training day reactions, (ii) learning, (iii) implementation barriers and facilitators, and (iv) building health system capacity for implementation. Participants reported high levels of satisfaction, and anticipated that the knowledge and skills may be useful in the future. We describe a novel training program focused on the delivery of evidence-based implementation within health systems. Guided by insights from this study, methods to deliver the training on a larger scale and across different contexts are being explored. The prolonged impact of TRANSLATE will be further evaluated at trial completion. Trial registration: ANZCTR, ACTRN12618001072202. Registered on June 27, 2018
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Affiliation(s)
- April Morrow
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Camperdown New South Wales, Australia
| | - Priscilla Chan
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, New South Wales, Australia
| | - Gabriella Tiernan
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, New South Wales, Australia
| | - Julia Steinberg
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Camperdown New South Wales, Australia
| | - Deborah Debono
- Centre for Health Services Management, School of Public Health, University of Technology Sydney, New South Wales, Australia
| | - Luke Wolfenden
- School of Medicine and Public Health, University of Newcastle, New South Wales, Australia
| | - Katherine M Tucker
- Hereditary Cancer Centre, Prince of Wales Hospital, New South Wales, Australia.,Prince of Wales Clinical School, UNSW Sydney, New South Wales, Australia
| | - Emily Hogden
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, New South Wales, Australia
| | - Natalie Taylor
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Camperdown New South Wales, Australia
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