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Smit KC, Derksen JWG, Beets GLO, Belt EJT, Berbée M, Coene PPLO, van Cruijsen H, Davidis MA, Dekker JWT, van Dodewaard-de Jong JM, Haringhuizen AW, Helgason HH, Hendriks MP, Hoekstra R, de Hingh IHJT, IJzermans JNM, Janssen JJB, Konsten JLM, Los M, Mekenkamp LJM, Nieboer P, Peeters KCMJ, Peters NAJB, Pruijt HJFM, Quarles van Ufford-Mannesse P, Rietbroek RC, Schiphorst AHW, Schouten van der Velden A, Schrauwen RWM, Sie MPS, Sommeijer DW, Sonneveld DJA, Stockmann HBAC, Tent M, Terheggen F, Tjin-A-Ton MLR, Valkenburg-van Iersel L, van der Velden AMT, Vles WJ, van Voorthuizen T, Wegdam JA, de Wilt JHW, Koopman M, May AM. Physical Activity Is Associated with Improved Overall Survival among Patients with Metastatic Colorectal Cancer. Cancers (Basel) 2022; 14:cancers14041001. [PMID: 35205748 PMCID: PMC8870120 DOI: 10.3390/cancers14041001] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/08/2022] [Accepted: 02/14/2022] [Indexed: 02/05/2023] Open
Abstract
Simple Summary Physical activity is linked to longer survival among non-metastasized colorectal cancer patients. It is unclear if physical activity is also beneficial for survival among patients with metastatic colorectal cancer. We researched this question in our study of 293 patients with metastatic colorectal cancer. We found that participants who reported higher levels of physical activity at diagnosis lived longer compared to patients who reported low activity levels. Furthermore, adherence to the physical activity guidelines for cancer survivors was related to prolonged survival. Our findings suggest that patients with metastatic colorectal cancer also benefit from being physically active. Future studies are needed to investigate whether improving exercise levels after diagnosis of metastasis is also beneficial and what kind of exercise interventions are most optimal for possibly improving survival time of patients with metastatic colorectal cancer. Abstract Regular physical activity (PA) is associated with improved overall survival (OS) in stage I–III colorectal cancer (CRC) patients. This association is less defined in patients with metastatic CRC (mCRC). We therefore conducted a study in mCRC patients participating in the Prospective Dutch Colorectal Cancer cohort. PA was assessed with the validated SQUASH questionnaire, filled-in within a maximum of 60 days after diagnosis of mCRC. PA was quantified by calculating Metabolic Equivalent Task (MET) hours per week. American College of Sports and Medicine (ACSM) PA guideline adherence, tertiles of moderate to vigorous PA (MVPA), and sport and leisure time MVPA (MVPA-SL) were assessed as well. Vital status was obtained from the municipal population registry. Cox proportional-hazards models were used to study the association between PA determinants and all-cause mortality adjusted for prognostic patient and treatment-related factors. In total, 293 mCRC patients (mean age 62.9 ± 10.6 years, 67% male) were included in the analysis. Compared to low levels, moderate and high levels of MET-hours were significantly associated with longer OS (fully adjusted hazard ratios: 0.491, (95% CI 0.299–0.807, p value = 0.005) and 0.485 (95% CI 0.303–0.778, p value = 0.003), respectively), as were high levels of MVPA (0.476 (95% CI 0.278–0.816, p value = 0.007)) and MVPA-SL (0.389 (95% CI 0.224–0.677, p value < 0.001)), and adherence to ACSM PA guidelines compared to non-adherence (0.629 (95% CI 0.412–0.961, p value = 0.032)). The present study provides evidence that higher PA levels at diagnosis of mCRC are associated with longer OS.
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Affiliation(s)
- Karel C. Smit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, 3508 GA Utrecht, The Netherlands; (K.C.S.); (J.W.G.D.)
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, 3584 CX Utrecht, The Netherlands;
| | - Jeroen W. G. Derksen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, 3508 GA Utrecht, The Netherlands; (K.C.S.); (J.W.G.D.)
| | - Geerard L. O. Beets
- Department of Surgery, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands;
- GROW School for Oncology and Developmental Biology, Maastricht University, 6200 MD Maastricht, The Netherlands
| | - Eric J. Th. Belt
- Department of Surgery, Albert Schweitzer Hospital, Albert Schweitzerplaats 25, 3318 AT Dordrecht, The Netherlands;
| | - Maaike Berbée
- Department of Radiotherapy, Maastro Clinic, 6202 NA Maastricht, The Netherlands;
| | - Peter Paul L. O. Coene
- Department of Surgery, Maasstad Hospital, Maasstadweg 21, 3079 DZ Rotterdam, The Netherlands;
| | - Hester van Cruijsen
- Department of Medical Oncology, Antonius Hospital, 8600 BA Sneek, The Netherlands;
| | - Marjan A. Davidis
- Department of Medical Oncology, Rivas, Banneweg 57, 4204 AA Gorinchem, The Netherlands;
| | - Jan Willem T. Dekker
- Department of Surgery, Reinier de Graaf Hospital, Reinier de Graafweg 5, 2600 GA Delft, The Netherlands;
| | | | | | - Helgi H. Helgason
- Department of Medical Oncology, Haaglanden Medical Center, 2501 CK Den Haag, The Netherlands;
| | - Mathijs P. Hendriks
- Department of Medical Oncology, Northwest Clinics, 1800 AM Alkmaar, The Netherlands;
| | - Ronald Hoekstra
- Department of Medical Oncology, Ziekenhuisgroep Twente, Zilvermeeuw 1, 7609 PP Hengelo, The Netherlands;
| | - Ignace H. J. T. de Hingh
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands;
| | - Jan N. M. IJzermans
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, 3000 AD Rotterdam, The Netherlands;
| | - Johan J. B. Janssen
- Department of Medical Oncology, Canisius Wilhelmina Hospital, 6500 GS Nijmegen, The Netherlands;
| | - Joop L. M. Konsten
- Department of Surgery, Viecuri Hospital, Tegelseweg 210, 5912 BL Venlo, The Netherlands;
| | - Maartje Los
- Department of Medical Oncology, St. Antonius Hospital, 3430 EM Nieuwegein, The Netherlands;
| | - Leonie J. M. Mekenkamp
- Department of Medical Oncology, Medisch Spectrum Twente, 7500 KA Enschede, The Netherlands;
| | - Peter Nieboer
- Department of Medical Oncology, Wilhelmina Hospital, 9400 RA Assen, The Netherlands;
| | - Koen C. M. J. Peeters
- Department of Surgery, Leiden University Medical Center, University of Leiden, Postzone K6-39 Albinusdreef 2, 2300 RC Leiden, The Netherlands;
| | - Natascha A. J. B. Peters
- Department of Medical Oncology, Sint Jans Hospital, Vogelsbleek 5, 6001 BE Weert, The Netherlands;
| | - Hans J. F. M. Pruijt
- Department of Medical Oncology, Jeroen Bosch Hospital, 5200 ME Den Bosch, The Netherlands;
| | | | - Ron C. Rietbroek
- Department of Medical Oncology, Rode Kruis Hospital, Vondellaan 13, 1942 LE Beverwijk, The Netherlands;
| | - Anandi H. W. Schiphorst
- Department of Surgery, Diakonessenhuis Hospital, Bosboomstraat 1, 3582 KE Utrecht, The Netherlands;
| | | | - Ruud W. M. Schrauwen
- Department of Gastroenterology and Hepatology, Bernhoven Hospital, Nistelrodeseweg 10, 5406 PT Uden, The Netherlands;
| | - Mark P. S. Sie
- Department of Medical Oncology, ZorgSaam Hospital, Wielingenlaan 2, 4535 PA Terneuzen, The Netherlands;
| | - Dirkje W. Sommeijer
- Department of Medical Oncology, Academisch Medisch Centrum, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands;
- Department of Medical Oncology, Flevo Hospital, Hospitaalweg 1, 1315 RA Almere, The Netherlands
| | - Dirk J. A. Sonneveld
- Department of Surgery, Dijklander Hospital, Waterlandlaan 250, 1441 RN Purmerend, The Netherlands;
| | | | - Marleen Tent
- Department of Medical Oncology, Treant Hospital, 7800 RA Emmen, The Netherlands;
| | - Frederiek Terheggen
- Department of Medical Oncology, Bravis Hospital, Boerhaavelaan 25, 4708 AE Roosendaal, The Netherlands;
| | | | | | - Ankie M. T. van der Velden
- Department of Medical Oncology, Tergooi Hospital, Van Riebeeckweg 212, 1213 XZ Hilversum, The Netherlands;
| | - Wouter J. Vles
- Department of Surgery, Ikazia Hospital, Montessoriweg 1, 3083 AN Rotterdam, The Netherlands;
| | - Theo van Voorthuizen
- Department of Medical Oncology, Rijnstate Hospital, Postus 9555, 6800 TA Arnhem, The Netherlands;
| | - Johannes A. Wegdam
- Department of Surgery, Elkerliek Hospital, Wesselmanlaan 25, 5707 HA Helmond, The Netherlands;
| | - Johannes H. W. de Wilt
- Department of Surgery, Radboud University Medical Center, University of Nijmegen, 6500 HB Nijmegen, The Netherlands;
| | - Miriam Koopman
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, 3584 CX Utrecht, The Netherlands;
| | - Anne M. May
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, 3508 GA Utrecht, The Netherlands; (K.C.S.); (J.W.G.D.)
- Correspondence:
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Brinkman-Stoppelenburg A, Vergouwe Y, Booms M, Hendriks MP, Peters LA, Quarles van Ufford-Mannesse P, Terheggen F, Verhage S, van der Vorst MJDL, Willemen I, Polinder S, van der Heide A. The Impact of Palliative Care Team Consultation on Quality of Life of Patients with Advanced Cancer in Dutch Hospitals: An Observational Study. Oncol Res Treat 2020; 43:405-413. [PMID: 32580199 DOI: 10.1159/000508312] [Citation(s) in RCA: 4] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 04/28/2020] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Experimental studies have shown that palliative care team (PCT) involvement can improve quality of life (QoL) and symptom burden of patients with advanced cancer. It is unclear to what extent this effect is sustained in daily practice of hospital care. OBJECTIVE This observational study aims to investigate the effect of PCT consultation on QoL and symptom burden of hospitalized patients with advanced cancer in daily practice. METHODS After admission to 1 of 9 participating hospitals, patients with advanced cancer for whom the attending physician answered "no" to the Surprise Question were invited to complete a questionnaire, including the EORTC QLQ-C15-PAL, at 6 points in time, until 3 months after admission. Outcomes were compared between patients who received PCT consultation and patients who did not, taking into account differences in baseline characteristics. RESULTS A total of 164 patients consented to participate, of whom 32 received PCT consultation. Of these patients, 108 were able to complete a questionnaire at day 14, of whom 19 after receiving PCT consultation. After adjusting for baseline differences, EORTC QLQ-C15-PAL scores for pain, appetite, and emotional functioning at day 14 were more favorable for patients who received a PCT consultation. CONCLUSION PCT consultation decreased patients' symptom burden and tends to have a positive effect on QoL of hospitalized patients with advanced cancer, even if the PCT is consulted late in the patient's disease trajectory.
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Affiliation(s)
| | - Yvonne Vergouwe
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Monique Booms
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Mathijs P Hendriks
- Department of Internal Medicine, Northwest Clinics, Alkmaar, The Netherlands
| | - Liesbeth A Peters
- Department of Pulmonary Diseases, Northwest Clinics, Den Helder, The Netherlands
| | | | - Frederiek Terheggen
- Department of Internal Medicine, Bravis Hospital, Bergen op Zoom, The Netherlands
| | - Sylvia Verhage
- Breast Center, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Maurice J D L van der Vorst
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands.,Department of Internal Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Ingrid Willemen
- Department of Internal Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Engelhardt EG, Pieterse AH, Han PKJ, van Duijn-Bakker N, Cluitmans F, Maartense E, Bos MMEM, Weijl NI, Punt CJA, Quarles van Ufford-Mannesse P, Sleeboom H, Portielje JEA, van der Hoeven KJM, Woei-A-Jin FJS, Kroep JR, de Haes HCJM, Smets EMA, Stiggelbout AM. Disclosing the Uncertainty Associated with Prognostic Estimates in Breast Cancer. Med Decis Making 2016; 37:179-192. [DOI: 10.1177/0272989x16670639] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [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
Background. Treatment decision making is often guided by evidence-based probabilities, which may be presented to patients during consultations. These probabilities are intrinsically imperfect and embody 2 types of uncertainties: aleatory uncertainty arising from the unpredictability of future events and epistemic uncertainty arising from limitations in the reliability and accuracy of probability estimates. Risk communication experts have recommended disclosing uncertainty. We examined whether uncertainty was discussed during cancer consultations and whether and how patients perceived uncertainty. Methods. Consecutive patient consultations with medical oncologists discussing adjuvant treatment in early-stage breast cancer were audiotaped, transcribed, and coded. Patients were interviewed after the consultation to gain insight into their perceptions of uncertainty. Results. In total, 198 patients were included by 27 oncologists. Uncertainty was disclosed in 49% (97/197) of consultations. In those 97 consultations, 23 allusions to epistemic uncertainty were made and 84 allusions to aleatory uncertainty. Overall, the allusions to the precision of the probabilities were somewhat ambiguous. Interviewed patients mainly referred to aleatory uncertainty if not prompted about epistemic uncertainty. Even when specifically asked about epistemic uncertainty, 1 in 4 utterances referred to aleatory uncertainty. When talking about epistemic uncertainty, many patients contradicted themselves. In addition, 1 in 10 patients seemed not to realize that the probabilities communicated during the consultation are imperfect. Conclusions. Uncertainty is conveyed in only half of patient consultations. When uncertainty is communicated, oncologists mainly refer to aleatory uncertainty. This is also the type of uncertainty that most patients perceive and seem comfortable discussing. Given that it is increasingly common for clinicians to discuss outcome probabilities with their patients, guidance on whether and how to best communicate uncertainty is urgently needed.
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Affiliation(s)
- Ellen G. Engelhardt
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands (EGE, AHP, NvD, AMS)
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME (PKJH)
- Department of Oncology, Alrijne Hospital, Leiderdorp, the Netherlands (FC)
- Department of Oncology, Reinier de Graaf Hospital, Delft, the Netherlands (ED, MMEMB)
- Department of Internal Medicine and Oncology, MCH Bronovo Hospital, The Hague, the Netherlands (NIW)
| | - Arwen H. Pieterse
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands (EGE, AHP, NvD, AMS)
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME (PKJH)
- Department of Oncology, Alrijne Hospital, Leiderdorp, the Netherlands (FC)
- Department of Oncology, Reinier de Graaf Hospital, Delft, the Netherlands (ED, MMEMB)
- Department of Internal Medicine and Oncology, MCH Bronovo Hospital, The Hague, the Netherlands (NIW)
| | - Paul K. J. Han
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands (EGE, AHP, NvD, AMS)
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME (PKJH)
- Department of Oncology, Alrijne Hospital, Leiderdorp, the Netherlands (FC)
- Department of Oncology, Reinier de Graaf Hospital, Delft, the Netherlands (ED, MMEMB)
- Department of Internal Medicine and Oncology, MCH Bronovo Hospital, The Hague, the Netherlands (NIW)
| | - Nanny van Duijn-Bakker
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands (EGE, AHP, NvD, AMS)
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME (PKJH)
- Department of Oncology, Alrijne Hospital, Leiderdorp, the Netherlands (FC)
- Department of Oncology, Reinier de Graaf Hospital, Delft, the Netherlands (ED, MMEMB)
- Department of Internal Medicine and Oncology, MCH Bronovo Hospital, The Hague, the Netherlands (NIW)
| | - Frans Cluitmans
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands (EGE, AHP, NvD, AMS)
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME (PKJH)
- Department of Oncology, Alrijne Hospital, Leiderdorp, the Netherlands (FC)
- Department of Oncology, Reinier de Graaf Hospital, Delft, the Netherlands (ED, MMEMB)
- Department of Internal Medicine and Oncology, MCH Bronovo Hospital, The Hague, the Netherlands (NIW)
| | - Ed Maartense
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands (EGE, AHP, NvD, AMS)
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME (PKJH)
- Department of Oncology, Alrijne Hospital, Leiderdorp, the Netherlands (FC)
- Department of Oncology, Reinier de Graaf Hospital, Delft, the Netherlands (ED, MMEMB)
- Department of Internal Medicine and Oncology, MCH Bronovo Hospital, The Hague, the Netherlands (NIW)
| | - Monique M. E. M. Bos
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands (EGE, AHP, NvD, AMS)
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME (PKJH)
- Department of Oncology, Alrijne Hospital, Leiderdorp, the Netherlands (FC)
- Department of Oncology, Reinier de Graaf Hospital, Delft, the Netherlands (ED, MMEMB)
- Department of Internal Medicine and Oncology, MCH Bronovo Hospital, The Hague, the Netherlands (NIW)
| | - Nir I. Weijl
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands (EGE, AHP, NvD, AMS)
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME (PKJH)
- Department of Oncology, Alrijne Hospital, Leiderdorp, the Netherlands (FC)
- Department of Oncology, Reinier de Graaf Hospital, Delft, the Netherlands (ED, MMEMB)
- Department of Internal Medicine and Oncology, MCH Bronovo Hospital, The Hague, the Netherlands (NIW)
| | - Cornelis J. A. Punt
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands (EGE, AHP, NvD, AMS)
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME (PKJH)
- Department of Oncology, Alrijne Hospital, Leiderdorp, the Netherlands (FC)
- Department of Oncology, Reinier de Graaf Hospital, Delft, the Netherlands (ED, MMEMB)
- Department of Internal Medicine and Oncology, MCH Bronovo Hospital, The Hague, the Netherlands (NIW)
| | - Patricia Quarles van Ufford-Mannesse
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands (EGE, AHP, NvD, AMS)
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME (PKJH)
- Department of Oncology, Alrijne Hospital, Leiderdorp, the Netherlands (FC)
- Department of Oncology, Reinier de Graaf Hospital, Delft, the Netherlands (ED, MMEMB)
- Department of Internal Medicine and Oncology, MCH Bronovo Hospital, The Hague, the Netherlands (NIW)
| | - Harm Sleeboom
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands (EGE, AHP, NvD, AMS)
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME (PKJH)
- Department of Oncology, Alrijne Hospital, Leiderdorp, the Netherlands (FC)
- Department of Oncology, Reinier de Graaf Hospital, Delft, the Netherlands (ED, MMEMB)
- Department of Internal Medicine and Oncology, MCH Bronovo Hospital, The Hague, the Netherlands (NIW)
| | - Johanneke E. A. Portielje
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands (EGE, AHP, NvD, AMS)
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME (PKJH)
- Department of Oncology, Alrijne Hospital, Leiderdorp, the Netherlands (FC)
- Department of Oncology, Reinier de Graaf Hospital, Delft, the Netherlands (ED, MMEMB)
- Department of Internal Medicine and Oncology, MCH Bronovo Hospital, The Hague, the Netherlands (NIW)
| | - Koos J. M. van der Hoeven
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands (EGE, AHP, NvD, AMS)
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME (PKJH)
- Department of Oncology, Alrijne Hospital, Leiderdorp, the Netherlands (FC)
- Department of Oncology, Reinier de Graaf Hospital, Delft, the Netherlands (ED, MMEMB)
- Department of Internal Medicine and Oncology, MCH Bronovo Hospital, The Hague, the Netherlands (NIW)
| | - F. J. Sherida Woei-A-Jin
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands (EGE, AHP, NvD, AMS)
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME (PKJH)
- Department of Oncology, Alrijne Hospital, Leiderdorp, the Netherlands (FC)
- Department of Oncology, Reinier de Graaf Hospital, Delft, the Netherlands (ED, MMEMB)
- Department of Internal Medicine and Oncology, MCH Bronovo Hospital, The Hague, the Netherlands (NIW)
| | - Judith R. Kroep
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands (EGE, AHP, NvD, AMS)
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME (PKJH)
- Department of Oncology, Alrijne Hospital, Leiderdorp, the Netherlands (FC)
- Department of Oncology, Reinier de Graaf Hospital, Delft, the Netherlands (ED, MMEMB)
- Department of Internal Medicine and Oncology, MCH Bronovo Hospital, The Hague, the Netherlands (NIW)
| | - Hanneke C. J. M. de Haes
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands (EGE, AHP, NvD, AMS)
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME (PKJH)
- Department of Oncology, Alrijne Hospital, Leiderdorp, the Netherlands (FC)
- Department of Oncology, Reinier de Graaf Hospital, Delft, the Netherlands (ED, MMEMB)
- Department of Internal Medicine and Oncology, MCH Bronovo Hospital, The Hague, the Netherlands (NIW)
| | - Ellen M. A. Smets
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands (EGE, AHP, NvD, AMS)
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME (PKJH)
- Department of Oncology, Alrijne Hospital, Leiderdorp, the Netherlands (FC)
- Department of Oncology, Reinier de Graaf Hospital, Delft, the Netherlands (ED, MMEMB)
- Department of Internal Medicine and Oncology, MCH Bronovo Hospital, The Hague, the Netherlands (NIW)
| | - Anne M. Stiggelbout
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands (EGE, AHP, NvD, AMS)
- Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME (PKJH)
- Department of Oncology, Alrijne Hospital, Leiderdorp, the Netherlands (FC)
- Department of Oncology, Reinier de Graaf Hospital, Delft, the Netherlands (ED, MMEMB)
- Department of Internal Medicine and Oncology, MCH Bronovo Hospital, The Hague, the Netherlands (NIW)
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