Publications by authors named "Catherine Duggan"

119 Publications

Identifying Breast Cancer Care Quality Measures for a Cancer Facility in Rural Sub-Saharan Africa: Results of a Systematic Literature Review and Modified Delphi Process.

JCO Glob Oncol 2020 09;6:1446-1454

Brigham and Women's Hospital, Boston, MA.

Purpose: The burden of cancer is growing in low- and middle-income countries (LMICs), including sub-Saharan Africa. Ensuring the delivery of high-quality cancer care in such regions is a pressing concern. There is a need for strategies to identify meaningful and relevant quality measures that are applicable to and usable for quality measurement and improvement in resource-constrained settings.

Methods: To identify quality measures for breast cancer care at Butaro Cancer Center of Excellence (BCCOE) in Rwanda, we used a modified Delphi process engaging two panels of experts, one with expertise in breast cancer evidence and measures used in high-income countries and one with expertise in cancer care delivery in Rwanda.

Results: Our systematic review of the literature yielded no publications describing breast cancer quality measures developed in a low-income country, but it did provide 40 quality measures, which we adapted for relevance to our setting. After two surveys, one conference call, and one in-person meeting, 17 measures were identified as relevant to pathology, staging and treatment planning, surgery, chemotherapy, endocrine therapy, palliative care, and retention in care. Successes of the process included participation by a diverse set of global experts and engagement of the BCCOE community in quality measurement and improvement. Anticipated challenges include the need to continually refine these measures as resources, protocols, and measurement capacity rapidly evolve in Rwanda.

Conclusion: A modified Delphi process engaging both global and local expertise was a promising strategy to identify quality measures for breast cancer in Rwanda. The process and resulting measures may also be relevant for other LMIC cancer facilities. Next steps include validation of these measures in a retrospective cohort of patients with breast cancer.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1200/GO.20.00186DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7529520PMC
September 2020

Changes in Dietary Inflammatory Index Patterns with Weight Loss in Women: A Randomized Controlled Trial.

Cancer Prev Res (Phila) 2020 Aug 28. Epub 2020 Aug 28.

Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington.

Dietary composition can influence systemic inflammation; higher levels of circulating inflammatory biomarkers are associated with increased risk of breast and other cancers. A total of 438 overweight/obese, healthy, postmenopausal women were randomized to a caloric-restriction diet (goal: 10% weight-loss), aerobic-exercise (225 min/week moderate-to-vigorous activity), combined diet+exercise, or control. Dietary inflammatory index (DII) and energy-adjusted (E-DII) scores were derived from food frequency questionnaires (FFQ) and could be calculated for 365 participants with complete FFQs at baseline and 12 months. Changes from baseline to 12 months in E-DII scores in the intervention arms versus controls were analyzed using generalized estimating equations, adjusted for confounders. We examined associations between changes in previously measured biomarkers and E-DII at 12 months. Participants randomized to diet and diet+exercise arms had greater reductions in E-DII (-104.4% and -84.4%), versus controls (-34.8%, both < 0.001). Weight change had a more marked effect than E-DII change on biomarkers at 12-months; associations between E-DII and biomarker changes were reduced after adjustment by weight change. Changes in E-DII at 12 months, adjusted for weight change, were negatively associated with changes in ghrelin [ = -0.19; = 0.05 (diet), = -0.29; = 0.02 (diet+exercise)], and positively with VEGF [ = 0.22; = 0.03 (diet+exercise)], and red blood cell counts [ = 0.30; = 0.004 (exercise)]. C-reactive protein (CRP) and IL6 levels were not associated with E-DII changes at 12 months. In conclusion, a behavior change of low-calorie, low-fat diet significantly reduces dietary inflammatory potential, modulating biomarkers that are associated with tumorigenesis, such as VEGF, but not CRP or IL6. Diets high in saturated fats and low in fruit and vegetable intake are associated with increased inflammation, which increases cancer risk. This study showed that changes in diet quality had effects on factors associated with cancer; however, the majority of beneficial effects were associated with weight loss rather than diet quality.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1158/1940-6207.CAPR-20-0181DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7914258PMC
August 2020

Situational analysis of breast health care systems: Why context matters.

Cancer 2020 May;126 Suppl 10:2405-2415

Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.

Background: Implementation of evidence-based, resource-appropriate guidelines for breast cancer control should be preceded by a baseline assessment or situational analysis to assess breast health infrastructure, workforce capacity, patient pathways, existing practices, accessibility, and costs.

Methods: To support the assessment of breast health care systems within the broader context in which they exist, the Breast Health Global Initiative (BHGI) developed, tested, and refined a set of situational analysis tools with which to guide the assessment of breast health care capacity, identify the relative strengths and weaknesses of the health system, and support stakeholders in prioritizing actionable items to advance breast cancer care using evidence-based strategies tailored to their setting. The tools address 6 domains of breast health care delivery: 1) breast cancer early detection practices; 2) breast cancer awareness programs; 3) the availability of breast cancer surgery; 4) the availability of pathology; 5) the availability of radiotherapy, and 6) the availability of systemic therapy services. The current study also describes the more comprehensive International Atomic Energy Agency Programme of Action for Cancer Therapy (PACT) integrated missions for PACT (imPACT) review.

Results: As of 2020, 5 formal BHGI situational analyses have been performed in India, Brazil, Panama, Tanzania, and Uganda. As of August 2019, a total of 100 imPACT reviews have been conducted in 91 countries. These assessments can contribute to more informed policymaking.

Conclusions: Situational analyses are a prerequisite for the development of resource-appropriate strategies with which to advance breast cancer control in any setting and should assess services across the entire breast health care continuum as well as the broader structural, sociocultural, personal, and financial contexts within which they operate.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/cncr.32899DOI Listing
May 2020

The Breast Health Global Initiative 2018 Global Summit on Improving Breast Healthcare Through Resource-Stratified Phased Implementation: Methods and overview.

Cancer 2020 May;126 Suppl 10:2339-2352

Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington.

Background: The Breast Health Global Initiative (BHGI) established a series of resource-stratified, evidence-based guidelines to address breast cancer control in the context of available resources. Here, the authors describe methodologies and health system prerequisites to support the translation and implementation of these guidelines into practice.

Methods: In October 2018, the BHGI convened the Sixth Global Summit on Improving Breast Healthcare Through Resource-Stratified Phased Implementation. The purpose of the summit was to define a stepwise methodology (phased implementation) for guiding the translation of resource-appropriate breast cancer control guidelines into real-world practice. Three expert consensus panels developed stepwise, resource-appropriate recommendations for implementing these guidelines in low-income and middle-income countries as well as underserved communities in high-income countries. Each panel focused on 1 of 3 specific aspects of breast cancer care: 1) early detection, 2) treatment, and 3) health system strengthening.

Results: Key findings from the summit and subsequent article preparation included the identification of phased-implementation prerequisites that were explored during consensus debates. These core issues and concepts are key components for implementing breast health care that consider real-world resource constraints. Communication and engagement across all levels of care is vital to any effectively operating health care system, including effective communication with ministries of health and of finance, to demonstrate needs, outcomes, and cost benefits.

Conclusions: Underserved communities at all economic levels require effective strategies to deploy scarce resources to ensure access to timely, effective, and affordable health care. Systematically strategic approaches translating guidelines into practice are needed to build health system capacity to meet the current and anticipated global breast cancer burden.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/cncr.32891DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7482869PMC
May 2020

Breast cancer treatment: A phased approach to implementation.

Cancer 2020 May;126 Suppl 10:2365-2378

Hopital Riviera Chablais, Vaud-Valais, Rennaz, Switzerland.

Optimal treatment outcomes for breast cancer are dependent on a timely diagnosis followed by an organized, multidisciplinary approach to care. However, in many low- and middle-income countries, effective care management pathways can be difficult to follow because of financial constraints, a lack of resources, an insufficiently trained workforce, and/or poor infrastructure. On the basis of prior work by the Breast Health Global Initiative, this article proposes a phased implementation strategy for developing sustainable approaches to enhancing patient care in limited-resource settings by creating roadmaps that are individualized and adapted to the baseline environment. This strategy proposes that, after a situational analysis, implementation phases begin with bolstering palliative care capacity, especially in settings where a late-stage diagnosis is common. This is followed by strengthening the patient pathway, with consideration given to a dynamic balance between centralization of services into centers of excellence to achieve better quality and decentralization of services to increase patient access. The use of resource checklists ensures that comprehensive therapy or palliative care can be delivered safely and effectively. Episodic or continuous monitoring with established process and quality metrics facilitates ongoing assessment, which should drive continual process improvements. A series of case studies provides a snapshot of country experiences with enhancing patient care, including the implementation of national cancer control plans in Kenya, palliative care in Romania, the introduction of a 1-stop clinic for diagnosis in Brazil, the surgical management of breast cancer in India, and the establishment of a women's cancer center in Ghana.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/cncr.32910DOI Listing
May 2020

Breast cancer patient advocacy: A qualitative study of the challenges and opportunities for civil society organizations in low-income and middle-income countries.

Cancer 2020 May;126 Suppl 10:2439-2447

Department of Medicine, University of Washington, Seattle, Washington.

Background: Breast cancer advocacy movements, driven by advocate-led civil society organizations (CSOs), have proven to be a powerful force for the advancement of cancer control in high-income countries (HICs). However, although patient advocacy movements are growing in low-income and middle-income countries (LMICs) in response to an increasing cancer burden, the experiences and needs of advocate-led breast cancer CSOs in LMICs is understudied.

Methods: The authors conducted a qualitative study using in-depth interviews and focus group discussions with 98 participants representing 23 LMICs in Eastern Europe, Central Asia, East and Southern Africa, and Latin America.

Results: Despite geographic, cultural, and socioeconomic differences, the common themes that emerged from the data across the 3 regions are strikingly similar: trust, knowledge gaps, stigma, sharing experiences, and sustainability. The authors identified common facilitators (training/education, relationship building/networking, third-party facilitators, and communication) and barriers (mistrust, stigma, organizational fragility, difficulty translating HIC strategies) to establishing trust, collaboration, and advancing cancer advocacy efforts. To the authors' knowledge, the current study is the first to describe the role that coalitions and regional networks play in advancing breast cancer advocacy in LMICs across multiple regions.

Conclusions: The findings of the current study corroborate the importance of investing in 3-way partnerships between CSOs, political leaders, and health experts. When provided with information that is evidence-based and resource appropriate, as well as opportunities to network, advocates are better equipped to achieve their goals. The authors propose that support for CSOs focuses on building trust through increasing opportunities for engagement, disseminating best practices and evidence-based information, and fostering the creation of platforms for partnerships and networks.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/cncr.32852DOI Listing
May 2020

A phased approach to implementing the Breast Imaging Reporting and Data System (BI-RADS) in low-income and middle-income countries.

Cancer 2020 May;126 Suppl 10:2424-2430

Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington.

Background: Successful breast cancer detection programs rely on standardized reporting and interpreting systems, such as the Breast Imaging Reporting and Data System (BI-RADS), to improve system performance. In low-income and middle-income countries, evolving diagnostic programs have insufficient resources to either fully implement BI-RADS or to periodically evaluate the program's performance, which is a necessary component of BI-RADS. This leads to inconsistent breast ultrasound interpretation and a failure to improve performance.

Methods: The authors applied the Breast Health Global Initiative's phased implementation strategy to implement diagnostic ultrasound and BI-RADS within the context of a limited-resource setting.

Results: The authors recommended starting with triage ultrasound to distinguish suspicious masses from normal breast tissue and benign masses such as cysts because the majority of health workers performing ultrasounds at this level have minimal breast imaging experience. Transitioning to full diagnostic ultrasound with condensed or full BI-RADS should occur after performance and quality metrics have been met.

Conclusions: Transitioning through these phases across facilities likely will occur at different times, particularly in rural versus urban settings.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/cncr.32864DOI Listing
May 2020

Health system strengthening: Integration of breast cancer care for improved outcomes.

Cancer 2020 May;126 Suppl 10:2353-2364

Centre for Global Health Research, St. Michael's Hospital, Toronto, Ontario, Canada.

The adoption of the goal of universal health coverage and the growing burden of cancer in low- and middle-income countries makes it important to consider how to provide cancer care. Specific interventions can strengthen health systems while providing cancer care within a resource-stratified perspective (similar to the World Health Organization-tiered approach). Four specific topics are discussed: essential medicines/essential diagnostics lists; national cancer plans; provision of affordable essential public services (either at no cost to users or through national health insurance); and finally, how a nascent breast cancer program can build on existing programs. A case study of Zambia (a country with a core level of resources for cancer care, using the Breast Health Global Initiative typology) shows how a breast cancer program was built on a cervical cancer program, which in turn had evolved from the HIV/AIDS program. A case study of Brazil (which has enhanced resources for cancer care) describes how access to breast cancer care evolved as universal health coverage expanded. A case study of Uruguay shows how breast cancer outcomes improved as the country shifted from a largely private system to a single-payer national health insurance system in the transition to becoming a country with maximal resources for cancer care. The final case study describes an exciting initiative, the City Cancer Challenge, and how that may lead to improved cancer services.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/cncr.32871DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7197416PMC
May 2020

Breast cancer early detection: A phased approach to implementation.

Cancer 2020 May;126 Suppl 10:2379-2393

Department of Global Health, University of Washington, Seattle, Washington.

When breast cancer is detected and treated early, the chances of survival are very high. However, women in many settings face complex barriers to early detection, including social, economic, geographic, and other interrelated factors, which can limit their access to timely, affordable, and effective breast health care services. Previously, the Breast Health Global Initiative (BHGI) developed resource-stratified guidelines for the early detection and diagnosis of breast cancer. In this consensus article from the sixth BHGI Global Summit held in October 2018, the authors describe phases of early detection program development, beginning with management strategies required for the diagnosis of clinically detectable disease based on awareness education and technical training, history and physical examination, and accurate tissue diagnosis. The core issues address include finance and governance, which pertain to successful planning, implementation, and the iterative process of program improvement and are needed for a breast cancer early detection program to succeed in any resource setting. Examples are presented of implementation, process, and clinical outcome metrics that assist in program implementation monitoring. Country case examples are presented to highlight the challenges and opportunities of implementing successful breast cancer early detection programs, and the complex interplay of barriers and facilitators to achieving early detection for breast cancer in real-world settings are considered.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/cncr.32887DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7237065PMC
May 2020

Breast cancer early detection and diagnostic capacity in Uganda.

Cancer 2020 May;126 Suppl 10:2469-2480

Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.

Background: Greater than 80% of women presenting for breast cancer treatment in Uganda have late-stage disease, which is attributable to a dysfunctional referral system and a lack of recognition of the early signs and symptoms among primary health care providers, and compounded by the poor infrastructure and inadequate human capacity. Improving the breast health care system requires a systemic approach beginning with situational analysis to identify systematic gaps that prevent sustainable improvements in outcome.

Methods: The authors performed a situational analysis of the breast health care system using methods developed by the Breast Health Global Initiative. Based on their findings, they developed a series of recommendations for strengthening the health system for the early diagnosis of breast cancer based on clinical detection, referral, tissue sampling, and diagnosis.

Results: Deficits in the recognition of breast cancer signs and symptoms, the underuse of clinical breast examination as a diagnostic and/or screening tool, the centralization of diagnostic tests (radiology and pathology), reliance on excisional biopsies rather than needle biopsies, and a lack of trained professionals and knowledge of the referral system all contribute to significant health system delays.

Conclusions: To strengthen referral networks and improve the early diagnosis of breast cancer in Uganda, national referral hospitals should provide educational programs to primary health care providers in community health centers (CHCs), at which the majority of women first present with symptoms. At secondary district-level facilities in which imaging and tissue sampling can be performed, the capacity for diagnostic testing could be increased through task shifting of basic interpretation (abnormal vs normal) from specialists to nonspecialists using networking technology to facilitate remote oversight from specialists at the national referral hospitals.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/cncr.32890DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7219536PMC
May 2020

Advancing the workforce to meet the Primary Health Care Agenda: pharmacy's contribution to universal health coverage.

Authors:
Catherine Duggan

Int J Pharm Pract 2020 Apr;28(2):118-120

International Pharmaceutical Federation, The Hague, The Netherlands.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/ijpp.12579DOI Listing
April 2020

Eating behaviors and weight loss outcomes in a 12-month randomized trial of diet and/or exercise intervention in postmenopausal women.

Int J Behav Nutr Phys Act 2019 11 27;16(1):113. Epub 2019 Nov 27.

Public Health Sciences Division, Fred Hutchinson Cancer Research Center, M4-B874, PO Box 19024, Seattle, WA, 98109, USA.

Background: Certain eating behaviors are common among women with obesity. Whether these behaviors influence outcomes in weight loss programs, and whether such programs affect eating behaviors, is unclear.

Methods: Our aim was to examine the effect of baseline eating behaviors on intervention adherence and weight among postmenopausal women with overweight or obesity, and to assess intervention effects on eating behaviors. Four hundred and 39 women (BMI ≥25 kg/m) were randomized to 12 months of: i) dietary weight loss with a 10% weight loss goal ('diet'; n = 118); ii) moderate-to-vigorous intensity aerobic exercise for 225 mins/week ('exercise'; n = 117); iii) combined dietary weight loss and exercise ('diet + exercise'; n = 117); or iv) no-lifestyle change control (n = 87). At baseline and 12 months, restrained eating, uncontrolled eating, emotional eating and binge eating were measured by questionnaire; weight and body composition were assessed. The mean change in eating behavior scores and weight between baseline and 12 months in the diet, exercise, and diet + exercise arms were each compared to controls using the generalized estimating equation (GEE) modification of linear regression adjusted for age, baseline BMI, and race/ethnicity.

Results: Baseline restrained eating was positively associated with change in total calories and calories from fat during the dietary intervention but not with other measures of adherence. Higher baseline restrained eating was associated with greater 12-month reductions in weight, waist circumference, body fat and lean mass. Women randomized to dietary intervention had significant reductions in binge eating (- 23.7%, p = 0.005 vs. control), uncontrolled eating (- 24.3%, p < 0.001 vs. control), and emotional eating (- 31.7%, p < 0.001 vs. control) scores, and a significant increase in restrained eating (+ 60.6%, p < 0.001 vs. control); women randomized to diet + exercise reported less uncontrolled eating (- 26.0%, p < 0.001 vs. control) and emotional eating (- 22.0%, p = 0.004 vs. control), and increased restrained eating (+ 41.4%, p < 0.001 vs. control). Women randomized to exercise alone had no significant change in eating behavior scores compared to controls.

Conclusions: A dietary weight loss intervention helped women modify eating behaviors. Future research should investigate optimal behavioral weight loss interventions for women with both disordered eating and obesity.

Trial Registration: NCT00470119 (https://clinicaltrials.gov). Retrospectively registered May 7, 2007.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12966-019-0887-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6882083PMC
November 2019

Beating non-communicable diseases in primary health care: The contribution of pharmacists and guidance from FIP to support WHO goals.

Res Social Adm Pharm 2020 07 17;16(7):974-977. Epub 2019 Oct 17.

Pharmabrain GmbH, Research and Training Centre, Berlin, Germany.

According to the World Health Organization (WHO), more than 36 million people die annually from non-communicable diseases (NCDs), representing over 60% of deaths worldwide, 15 million of which occur before the age of 70 years. Prevention and control of NCDs and their risk factors require interventions that are therapeutically cost-effective, affordable by the patient and/or health systems and feasible, based upon local resources. This commentary paper sets a basis of global evidence to advocate, nationally and internationally, for an expanded role for pharmacists in NCD management by compiling best practices and examples. It encourages pharmacists around the world to act upon NCDs, from prevention and screening activities, to patient referral when appropriate, and to pharmacist-led, patient-centred NCD management to improve outcomes and quality of life. Priority NCDs fall into four areas: cardiovascular diseases, diabetes, asthma/chronic obstructive pulmonary disease and cancer. Building on the key roles they already play as primary healthcare professionals in the community, pharmacists can provide focused interventions, specialised counselling and care coordination, improving patient engagement to achieve better outcomes in the global fight against NCDs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.sapharm.2019.10.008DOI Listing
July 2020

Advancing cancer care and prevention in the Caribbean: a survey of strategies for the region.

Lancet Oncol 2019 09 5;20(9):e522-e534. Epub 2019 Aug 5.

Jamaica Cancer Care and Research Institute, University of the West Indies, Kingston, Jamaica; Harvard/ MGH Center on Genomics, Vulnerable Populations, and Health Disparities, Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA.

Cancer is now the second leading cause of death in the Caribbean. Despite this growing burden, many Caribbean small island nations have health systems that struggle to provide optimal cancer care for their populations. In this Series paper, we identify several promising strategies to improve cancer prevention and treatment that have emerged across small island nations that are part of the Caribbean Community. These strategies include the establishment of a Caribbean cancer registry hub, the development of resource-appropriate clinical guidelines, innovations in delivering specialty oncology services (eg, paediatric oncology and palliative care), improving access to opioids, and developing regional training capacity in palliative medicine. These developments emphasise the crucial role of public-private partnerships in improving health care for the region and show how fostering strategic collaborations with colleagues and centres in more developed countries, who can contribute specialised expertise and improve regional collaboration, can improve care across the cancer control continuum.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/S1470-2045(19)30516-9DOI Listing
September 2019

The development of a foundation-level pharmacy competency framework: An analysis of country-level applicability of the Global Competency Framework.

Res Social Adm Pharm 2020 03 22;16(3):396-404. Epub 2019 Jun 22.

University College London, School of Pharmacy, 29-39 Brunswick Square, London, WC1N 1AX, United Kingdom. Electronic address:

Background: The importance and usefulness of competency frameworks (CFs) in pharmacy professional development is recognised globally. However, there is no national CF for pharmacists in Japan yet.

Objective: This study was conducted to measure the level of relevance of behavioural statements of the International Pharmaceutical Federation (FIP) Global Competency Framework (GbCF) to Japanese foundation-level pharmacy practice, aiming for developing a national framework for foundation-level pharmacists in Japan.

Methods: A cross-sectional, anonymous, online self-completed survey was conducted during June and July 2018 in Japan. The questionnaire was adopted from the GbCF, translated into Japanese. A snowballing sampling approach was used. The relevance levels of the GbCF items were assessed by using 4-point Likert scales, and analysed by descriptive and inferential methods.

Results: A total 604 useable responses were included in analyses. High levels of relevance levels were found in two clusters ('pharmaceutical public health' and 'pharmaceutical care'), while the other two clusters ('organisation and management' and 'professional/personal') showed significantly low relevance (relevance = 89.6%, 82.5%, 59.6%, and 67.9%, respectively). The study found little engagement of the academic sector with framework, while the industry sector showed relevance to all clusters evenly. Regarding years working in sectors, there was no progression of relevance in 'organisation and management' and 'professional/personal' competencies during foundation years as well as very little professional/personal development.

Conclusions: The study revealed specific competencies and behaviours which require modifications to adapt the GbCF into the Japanese pharmacy practice environment. This is a key step towards the development of a national framework, illustrating current Japanese foundation-level pharmacy practice compared with global standards. The findings will be used as a base for developing a framework for foundation-level pharmacists in Japan and address concerns such as pharmacist preparedness to advance in management roles and limited personal and professional development.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.sapharm.2019.06.007DOI Listing
March 2020

FIP's Commitment to Action on the WHO Astana Declaration: Transforming pharmacy for better health for all.

Res Social Adm Pharm 2020 May 2;16(5):724-726. Epub 2019 Jul 2.

International Pharmaceutical Federation (FIP), Andries Bickerweg 5, The Hague, JP, 2517, the Netherlands.

The attainment of better health for all cannot be achieved without effective primary health care. The WHO Declaration of Astana renewed global commitment to primary health care by all countries and states around the world. With pharmacy and the pharmacy workforce being integral to the delivery of quality primary health care, the International Pharmaceutical Federation (FIP) is leading pharmacy's commitment to the Astana Declaration. Through a series of regional conferences, starting with the Eastern Mediterranean region, FIP is working with its regional partners and members across the world to progress this imperative and consolidate the role of pharmacy in delivering the primary health care agenda. The first pharmacy Commitment to Primary Health Care was made in Amman, Jordan in April 2019, paving the way for transforming pharmacy for better primary health care everywhere. Now, it is time to move from commitment to action.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.sapharm.2019.06.017DOI Listing
May 2020

FIP Perspectives: Realising global patient safety goals requires an integrated approach with pharmacy at the core.

Res Social Adm Pharm 2019 07 23;15(7):815-817. Epub 2019 Feb 23.

International Pharmaceutical Federation (FIP), Andries Bickerweg 5, 2517 JP, The Hague, the Netherlands.

Patient safety is becoming increasingly recognised as a top priority for action that requires a collective and coordinated response. The leading cause of harm or injury in health care systems is medication errors. As medicines experts, the pharmacy workforce plays a key role in minimising medication errors and mitigating the global challenge of patient safety. Pharmacists' involvement in ensuring patient safety is crucial. Pharmacists are charged with the responsibility to ensure that when a patient receives and uses a medicine, it will not cause harm or death. The International Pharmaceutical Federation (FIP) recognises the critical role the pharmacy plays in realising global, regional and national patient safety goals; and works with its partners, stakeholders and members around the world to advocate for the role of pharmacy in achieving this global patient safety agenda and to envision a world of safe access to medicines and care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.sapharm.2019.02.012DOI Listing
July 2019

County of Residence and Screening Practices among Latinas and Non-Latina Whites in Two Rural Communities.

Ethn Dis 2019 17;29(1):31-38. Epub 2019 Jan 17.

Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA.

Objectives: Latinas are less likely than non-Latina Whites (NLW) to utilize mammographic screening and are more likely to be diagnosed with late-stage breast cancer. Here, we examine the effects of county-level factors on guideline-concordant breast-cancer screening behaviors in Latinas and NLWs.

Design: Latinas (N=108) and NLW women (N=132) aged >40 years, residing in two adjacent rural, medically underserved counties in eastern Washington State, completed a baseline questionnaire on mammography utilization and demographics.

Main Outcome Measures: Differences in socioeconomic variables and knowledge of screening practices were examined by ethnicity and county of residence. Predictors of having had a mammogram within the past two years were analyzed using multivariate logistic regression.

Results: Ethnicity was not associated with having a guideline-concordant mammogram; however, age (odds ratio [OR]=1.04, 95%CI:1.01-1.08); having >12 years of education (OR=2.09, 95%CI:1.16-3.79); having a regular clinic for health care (OR=2.22, 95%CI:1.05-4.70); having had a prior clinical breast exam (OR=5.07, 95%CI:1.71-15.02), and county of residence (OR=2.27, 95%CI:1.18-4.37) were all associated with having had a guideline-concordant mammogram.

Conclusions: County of residence and having had a prior CBE were strong predictors of screening utilization. Community-level factors in medically underserved areas may influence screening patterns.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.18865/ed.29.1.31DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6343545PMC
May 2020

Body mass index is negatively associated with telomere length: a collaborative cross-sectional meta-analysis of 87 observational studies.

Am J Clin Nutr 2018 09;108(3):453-475

Department of Epidemiology and Public Health, University College London, London, United Kingdom.

Background: Even before the onset of age-related diseases, obesity might be a contributing factor to the cumulative burden of oxidative stress and chronic inflammation throughout the life course. Obesity may therefore contribute to accelerated shortening of telomeres. Consequently, obese persons are more likely to have shorter telomeres, but the association between body mass index (BMI) and leukocyte telomere length (TL) might differ across the life span and between ethnicities and sexes.

Objective: A collaborative cross-sectional meta-analysis of observational studies was conducted to investigate the associations between BMI and TL across the life span.

Design: Eighty-seven distinct study samples were included in the meta-analysis capturing data from 146,114 individuals. Study-specific age- and sex-adjusted regression coefficients were combined by using a random-effects model in which absolute [base pairs (bp)] and relative telomere to single-copy gene ratio (T/S ratio) TLs were regressed against BMI. Stratified analysis was performed by 3 age categories ("young": 18-60 y; "middle": 61-75 y; and "old": >75 y), sex, and ethnicity.

Results: Each unit increase in BMI corresponded to a -3.99 bp (95% CI: -5.17, -2.81 bp) difference in TL in the total pooled sample; among young adults, each unit increase in BMI corresponded to a -7.67 bp (95% CI: -10.03, -5.31 bp) difference. Each unit increase in BMI corresponded to a -1.58 × 10(-3) unit T/S ratio (0.16% decrease; 95% CI: -2.14 × 10(-3), -1.01 × 10(-3)) difference in age- and sex-adjusted relative TL in the total pooled sample; among young adults, each unit increase in BMI corresponded to a -2.58 × 10(-3) unit T/S ratio (0.26% decrease; 95% CI: -3.92 × 10(-3), -1.25 × 10(-3)). The associations were predominantly for the white pooled population. No sex differences were observed.

Conclusions: A higher BMI is associated with shorter telomeres, especially in younger individuals. The presently observed difference is not negligible. Meta-analyses of longitudinal studies evaluating change in body weight alongside change in TL are warranted.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/ajcn/nqy107DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6454526PMC
September 2018

Long-term weight loss maintenance, sex steroid hormones, and sex hormone-binding globulin.

Menopause 2019 04;26(4):417-422

Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA.

Objective: We tested the effects of weight loss on serum estradiol, estrone, testosterone, and sex hormone-binding globulin (SHBG) in overweight/obese women 18 months after completing a year-long, 4-arm, randomized-controlled dietary weight loss and/or exercise trial.

Methods: From 2005 to 2008, 439 overweight/obese, postmenopausal women (BMI >25 kg/m), 50 to 75 years, were randomized to a year-long intervention: diet (reduced calorie, 10% weight loss, N = 118), exercise (225 min/wk moderate-to-vigorous activity, N = 117), combined diet + exercise (N = 117), or control (N = 87). At 12 months, 399 women provided blood; of these, 156 returned at 30 months and gave a blood sample. Hormones and SHBG were measured by immunoassay. Changes were compared using generalized estimating equations, adjusting for confounders.

Results: At 30 months, participants randomized to the diet + exercise intervention had statistically significant increases in SHBG levels versus controls (P = 0.001). There was no statistically significant change in SHBG in the exercise or diet intervention arms. Hormone levels did not vary by intervention arm from baseline to 30 months. Participants who maintained weight loss at 30 months had statistically significantly greater decreases in free estradiol and free testosterone (Ptrend = 0.02 and Ptrend = 0.04, respectively) and increases in SHBG (Ptrend < 0.0001) versus those who did not have sustained weight loss. Levels of other analytes did not vary by weight loss at 30 months.

Conclusions: Sustained weight loss results in reductions in free estradiol and testosterone and increases in SHBG 18-month post-intervention.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/GME.0000000000001250DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6435415PMC
April 2019

Improving Breast Health Care in the State of Sergipe, Brazil: A Commentary.

J Glob Oncol 2018 08;4:1-3

Catherine Duggan, Allison Dvaladze, and Benjamin O. Anderson, Fred Hutchinson Cancer Research Center, Seattle, WA; Tauane A. Cruz and Anna Cabanes, Susan G. Komen, Dallas, TX; Maisa R.T. Porto, MR Assessoria e Consultoria em Educacao e Saude, Lauro de Freitas, Bahia; and Cristiani L.M.S. Borges, Secretaria Municipal de Saude de Aracaju, Brazil.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1200/JGO.18.00114DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6223498PMC
August 2018

Accuracy of mammography and clinical breast examination in the implementation of breast cancer screening programs in Colombia.

Prev Med 2018 10 6;115:19-25. Epub 2018 Aug 6.

Prevention and Implementation Group, International Agency for Research on Cancer, Lyon, France; Subdirección de Investigaciones y Salud Pública, Instituto Nacional de Cancerología, Bogotá, Colombia. Electronic address:

Most evidence on breast cancer screening accuracy derives from high income countries. We evaluated screening accuracy and factors related to program implementation in Bogota, Colombia. Between 2008 and 2012 participants underwent clinical breast examination (CBE) and mammography. Positive results underwent histological verification. Adherence to screening protocols was analyzed. Sensitivity, specificity, and predictive values were estimated and adjusted by overdiagnosis. Impact of alternative screening algorithms on follow-up was explored, including combined screening tests and modified coding systems for mammography. In total, 7436 women aged 50-69 were enrolled; 400 discontinued and 1003 non-compliant with screening protocols. 23 cancer cases were diagnosed. Mammography sensitivity and specificity were 78.3% (95%CI 77.3-99.3) and 99.4% (95%CI 99.2-99.6). CBE sensitivity was 39.1% (95%CI 37.9-40.3) and specificity 83.4% (95%CI 82.6-84.3). Parallel mammography and CBE showed the highest sensitivity (95.6%) and combined as serial tests the lowest (positive CBE followed by mammography 13.0%). A simplified coding system for mammography (recall/no-recall) had 6.3% of positive results and a minor reduction in specificity compared with standard mammography, but reported the best balance between recall rates and screening protocol compliance. Call-backs had high rates of loss-to-follow-up; thus, alternative screening algorithms might help increase screening compliance and follow-up in low and middle income countries, particularly in populations with poor screening history and low access to health services.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ypmed.2018.08.005DOI Listing
October 2018

A competency framework for clinical pharmacists and heart failure.

Int J Pharm Pract 2019 Oct 20;27(5):424-435. Epub 2018 Jul 20.

City Hospitals Sunderland Foundation Trust, Sunderland, UK.

Objectives: Heart failure is an escalating 'pandemic' with malignant outcomes. Clinical pharmacist heart failure services have been developing for the past two decades. However, little clarity is available on the additional advanced knowledge, skills and experience needed for pharmacists to practice safely and competently. We aimed to provide an expert consensus on the minimum competencies necessary for clinical pharmacists to deliver appropriate care to patients with heart failure.

Methods: There were four methodological parts; (1) establishing a project group from experts in the field; (2) review of the literature, including existing pharmacy competency frameworks in other specialities and previous heart failure curricula from other professions; (3) consensus building, including developing, reviewing and adapting the contents of the framework; and (4) write-up and dissemination to widen the impact of the project.

Key Findings: The final framework defines minimum competencies relevant to heart failure for four different potential levels of specialism: all pharmacists regardless of role (Stage 1); all patient-facing clinical pharmacists (Stage 2); clinical pharmacists with specific planned roles in the care of heart failure patients (Stage 3); and regionally/nationally/internationally recognised expert pharmacists with a direct specialism in heart failure (Stage 4).

Conclusions: The framework delivers the vital first step needed to help standardise care, give pharmacists a blueprint for career progression and continuing professional development and bring clarity to the role of the pharmacist. Future collaboration between professional bodies and training providers is needed to develop structured programmes to align with the framework and facilitate training and resultant accreditation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/ijpp.12465DOI Listing
October 2019

Early detection and treatment strategies for breast cancer in low-income and upper middle-income countries: a modelling study.

Lancet Glob Health 2018 08;6(8):e885-e893

Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Department of Statistics, University of Washington, Seattle, WA, USA. Electronic address:

Background: Poor breast cancer survival in low-income and middle-income countries (LMICs) can be attributed to advanced-stage presentation and poor access to systemic therapy. We aimed to estimate the outcomes of different early detection strategies in combination with systemic chemotherapy and endocrine therapy in LMICs.

Methods: We adapted a microsimulation model to project outcomes of three early detection strategies alone or in combination with three systemic treatment programmes beyond standard of care (programme A): programme B was endocrine therapy for all oestrogen-receptor (ER)-positive cases; programme C was programme B plus chemotherapy for ER-negative cases; programme D was programme C plus chemotherapy for advanced ER-positive cases. The main outcomes were reductions in breast cancer-related mortality and lives saved per 100 000 women relative to the standard of care for women aged 30-49 years in a low-income setting (East Africa; using incidence data and life tables from Uganda and data on tumour characteristics from various East African countries) and for women aged 50-69 years in a middle-income setting (Colombia).

Findings: In the East African setting, relative mortality reductions were 8-41%, corresponding to 23 (95% uncertainty interval -12 to 49) to 114 (80 to 138) lives saved per 100 000 women over 10 years. In Colombia, mortality reductions were 7-25%, corresponding to 32 (-29 to 70) to 105 (61 to 141) lives saved per 100 000 women over 10 years.

Interpretation: The best projected outcomes were in settings where access to both early detection and adjuvant therapy is improved. Even in the absence of mammographic screening, improvements in detection can provide substantial benefit in settings where advanced-stage presentation is common.

Funding: Fred Hutchinson Cancer Research Center/University of Washington Cancer Consortium Cancer Center Support Grant of the US National Institutes of Health.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/S2214-109X(18)30257-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6214657PMC
August 2018

Food availability and food access in rural agricultural communities: use of mixed methods.

BMC Public Health 2018 05 16;18(1):634. Epub 2018 May 16.

Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave. N, M3-B232, Seattle, WA, 98109-1024, USA.

Background: Hispanics bear some of the highest burden of the obesity epidemic and the disparities gap is bigger among Hispanics in rural communities. This mixed methods study examined the objective and subjective assessment of food availability and food access in four rural, agricultural, and predominantly Hispanic communities.

Methods: In this convergent parallel mixed methods study, we used the Nutrition Environment Measures Survey (NEMS) of Food Stores and Restaurants to objectively assess 57 food stores and 69 restaurants in four rural agricultural communities in Washington State. To complement the objective assessment findings, we conducted semi-structured interviews with 32 community residents. The data were collected from 2013 to 2014. Frequencies and means were calculated for quantitative data and content analysis conducted for interview data.

Results: Participants (n = 32) had a mean age of 35.6 (SD 6.2) years, were mostly women, uninsured, low income, and had less than a high school education. Grocery and convenience stores had low NEMS composite scores indicating low overall availability of food items, low quality, and high food prices. Composite scores for sit-down restaurants, fast casual restaurants, and fast-food restaurants were similarly low in all four towns indicating limited availability of healthier options. Semi-structured interviews revealed participants perceived high availability and accessibility of quality fresh produce. Most participants reported eating out regularly several times a week, frequenting restaurant chains that serve buffets or fast foods, and allowing children to make decisions regarding their own food choices.

Conclusions: Community members' perception of food availability and food access may be different from the objective assessment of food environment. This information can be used to inform community-wide interventions to address food environment in these rural communities.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12889-018-5547-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5956971PMC
May 2018

Genetic variation in TNFα, PPARγ, and IRS-1 genes, and their association with breast-cancer survival in the HEAL cohort.

Breast Cancer Res Treat 2018 Apr 18;168(2):567-576. Epub 2017 Dec 18.

Epidemiology Program, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.

Purpose: Tumor necrosis factor-α (TNF-α), peroxisome proliferator-activated receptor-γ (PPARγ), and insulin receptor substrate-1 (IRS-1) are associated with obesity, insulin resistance, and inflammation. Few data exist on associations between polymorphisms in these genes and mortality in breast cancer survivors.

Methods: We investigated associations between TNF-α G > A (rs1800629); PPARγ ProAla (rs1801282); and IRS-1 GlyArg (rs1801278) polymorphisms and anthropometric variables, circulating levels of previously measured biomarkers, and tumor characteristics in 553 women enrolled in the Health, Eating, Activity, and Lifestyle Study, a multiethnic, prospective cohort study of women diagnosed with stage I-IIIA breast cancer between 1995 and 1999 (median follow-up 14.7 years).  Using Cox proportional hazards models adjusted for possible confounders, we evaluated associations between these polymorphisms and mortality.

Results: Carriers of the PPARγ variant allele had statistically significantly lower rates of type 2 diabetes (P = 0.04), lower BMI (P = 0.01), and HOMA scores [P = 0.004; non-Hispanic White (NHWs) only]; carriers of the TNF-α variant A allele had higher serum glucose (P = 0.004, NHW only); and the IRS-1 variant was associated with higher leptin levels (P = 0.003, Hispanics only). There were no associations between any of the polymorphisms and tumor characteristics. Among 141 deaths, 62 were due to breast cancer. Carriers of the TNF-α-variant A allele had a decreased risk of breast-cancer-specific mortality [hazard ratio (HR) 0.30; 95% confidence interval (CI) 0.10-0.83] and all-cause mortality (HR 0.51; 95% CI 0.28-0.91).

Conclusions: Neither the PPARγ nor the IRS-1 polymorphism was associated with mortality outcome. The TNF-α G > A polymorphism was associated with reduced breast-cancer-specific and all-cause mortality.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10549-017-4621-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5839976PMC
April 2018

Long-Term Effects of Weight Loss and Exercise on Biomarkers Associated with Angiogenesis.

Cancer Epidemiol Biomarkers Prev 2017 12 17;26(12):1788-1794. Epub 2017 Oct 17.

Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington.

We tested the effect of weight loss on circulating levels of the angiogenic factors VEGF and pigment epithelium-derived factor (PEDF) in postmenopausal overweight/obese women, 18 months after completing a year-long 4-arm randomized controlled trial of behavioral weight loss and/or exercise versus control (i.e., 30 months postrandomization). The 439 overweight/obese, postmenopausal women, ages 50 to 75 years, were randomized to: diet (goal: 10% weight loss, = 118), exercise (225 min/wk moderate-to-vigorous activity, = 117), diet + exercise ( = 117), or control ( = 87). At 12 months, 399 women gave a blood sample; 156 returned at 30 months. Biomarkers were measured by immunoassay. Changes were compared using generalized estimating equations, adjusting for baseline BMI, age, and race/ethnicity. Participants randomized to diet, exercise, and diet + exercise arms had greater reductions in VEGF at 30 months (-14.1% = 0.02; -19.7% = 0.003; -14.5% = 0.002, respectively) versus controls (-4.5%). There were no statistically significant changes in PEDF in any intervention arm. Participants maintaining ≥10% of baseline weight loss at 30 months had greater reductions in VEGF versus those who gained weight/had no weight change (-22.3% vs. -10.2% respectively, = 0.002). Participants maintaining any weight loss had significantly lower levels of PEDF at 30 months versus those who gained weight/no weight change. Sustained weight loss via diet and/or exercise results in reductions in angiogenic factors, and can be maintained up to 30-month follow-up. Limitations include relatively small numbers, and possible bias toward more successful weight loss among women who returned at 30 months. Maintaining weight loss can achieve long-term reductions in biomarkers of angiogenesis that can persist up to 18 months after completion of a weight loss intervention. .
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1158/1055-9965.EPI-17-0356DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5712238PMC
December 2017

Resource-stratified implementation of a community-based breast cancer management programme in Peru.

Lancet Oncol 2017 10;18(10):e607-e617

Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Department of Global Health, University of Washington, Seattle, WA, USA; Department of Surgery, University of Washington, Seattle, WA, USA. Electronic address:

Breast cancer incidence and mortality rates continue to rise in Peru, with related deaths projected to increase from 1208 in 2012, to 2054 in 2030. Despite improvements in national cancer control plans, various barriers to positive breast cancer outcomes remain. Multiorganisational stakeholder collaboration is needed for the development of functional, sustainable early diagnosis, treatment and supportive care programmes with the potential to achieve measurable outcomes. In 2011, PATH, the Peruvian Ministry of Health, the National Cancer Institute in Lima, and the Regional Cancer Institute in Trujillo collaborated to establish the Community-based Program for Breast Health, the aim of which was to improve breast health-care delivery in Peru. A four-step, resource-stratified implementation strategy was used to establish an effective community-based triage programme and a practical early diagnosis scheme within existing multilevel health-care infrastructure. The phased implementation model was initially developed by the Breast Cancer Initiative 2·5: a group of health and non-governmental organisations who collaborate to improve breast cancer outcomes. To date, the Community-based Program for Breast Health has successfully implemented steps 1, 2, and 3 of the Breast Cancer Initiative 2·5 model in Peru, with reports of increased awareness of breast cancer among women, improved capacity for early diagnosis among health workers, and the creation of stronger and more functional linkages between the primary levels (ie, local or community) and higher levels (ie, district, region, and national) of health care. The Community-based Program for Breast Health is a successful example of stakeholder and collaborator involvement-both internal and external to Peru-in the design and implementation of resource-appropriate interventions to increase breast health-care capacity in a middle-income Latin American country.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/S1470-2045(17)30592-2DOI Listing
October 2017

Resource-Stratified Guidelines for Cancer Management: Correction and Commentary.

J Glob Oncol 2017 Feb 31;3(1):84-88. Epub 2016 Aug 31.

, Fred Hutchinson Cancer Research Center and University of Washington, Seattle, WA; , Fred Hutchinson Cancer Research Center, Seattle, WA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1200/JGO.2016.006213DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5493239PMC
February 2017