Publications by authors named "Richard Sullivan"

283 Publications

Access to cancer medicines deemed essential by oncologists in 82 countries: an international, cross-sectional survey.

Lancet Oncol 2021 Sep 15. Epub 2021 Sep 15.

Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, ON, Canada; Departments of Oncology, Queen's University, Kingston, ON, Canada; Public Health Sciences, Queen's University, Kingston, ON, Canada. Electronic address:

Background: The WHO Essential Medicines List (EML) identifies priority medicines that are most important to public health. Over time, the EML has included an increasing number of cancer medicines. We aimed to investigate whether the cancer medicines in the EML are aligned with the priority medicines of frontline oncologists worldwide, and the extent to which these medicines are accessible in routine clinical practice.

Methods: This international, cross-sectional survey was developed by investigators from a range of clinical practice settings across low-income to high-income countries, including members of the WHO Essential Medicines Cancer Working Group. A 28-question electronic survey was developed and disseminated to a global network of oncologists in 89 countries and regions by use of a hierarchical snowball method; each primary contact distributed the survey through their national and regional oncology associations or personal networks. The survey was open from Oct 15 to Dec 7, 2020. Fully qualified physicians who prescribe systemic anticancer therapy to adults were eligible to participate in the survey. The primary question asked respondents to select the ten cancer medicines that would provide the greatest public health benefit to their country; subsequent questions explored availability and cost of cancer medicines. Descriptive statistics were used to compare access to medicines between low-income and lower-middle-income countries, upper-middle-income countries, and high-income countries.

Findings: 87 country-level contacts and two regional networks were invited to participate in the survey; 46 (52%) accepted the invitation and distributed the survey. 1697 respondents opened the survey link; 423 were excluded as they did not answer the primary study question and 326 were excluded because of ineligibility. 948 eligible oncologists from 82 countries completed the survey (165 [17%] in low-income and lower-middle-income countries, 165 [17%] in upper-middle-income countries, and 618 [65%] in high-income countries). The most commonly selected medicines were doxorubicin (by 499 [53%] of 948 respondents), cisplatin (by 470 [50%]), paclitaxel (by 423 [45%]), pembrolizumab (by 414 [44%]), trastuzumab (by 402 [42%]), carboplatin (by 390 [41%]), and 5-fluorouracil (by 386 [41%]). Of the 20 most frequently selected high-priority cancer medicines, 19 (95%) are currently on the WHO EML; 12 (60%) were cytotoxic agents and 13 (65%) were granted US Food and Drug Administration regulatory approval before 2000. The proportion of respondents indicating universal availability of each top 20 medication was 9-54% in low-income and lower-middle-income countries, 13-90% in upper-middle-income countries, and 68-94% in high-income countries. The risk of catastrophic expenditure (spending >40% of total consumption net of spending on food) was more common in low-income and lower-middle-income countries, with 13-68% of respondents indicating a substantial risk of catastrophic expenditures for each of the top 20 medications in lower-middle-income countries versus 2-41% of respondents in upper-middle-income countries and 0-9% in high-income countries.

Interpretation: These data demonstrate major barriers in access to core cancer medicines worldwide. These findings challenge the feasibility of adding additional expensive cancer medicines to the EML. There is an urgent need for global and country-level policy action to ensure patients with cancer globally have access to high priority medicines.

Funding: None.
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http://dx.doi.org/10.1016/S1470-2045(21)00463-0DOI Listing
September 2021

The UK's contribution to cancer control in low-income and middle-income countries.

Lancet Oncol 2021 09;22(9):e410-e418

UK Global Cancer Network, Manchester, UK; School of Medical Sciences, University of Manchester, Manchester, UK; Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK.

Cancer mortality rates in low-income and middle-income countries (LMICs) are unacceptably high, requiring both collaborative global effort and in-country solutions. Experience has shown that working together in policy, clinical practice, education, training, and research leads to bidirectional benefit for LMICs and high-income countries. For over 60 years, the UK National Health Service has benefited from recruitment from LMICs, providing the UK with a rich diaspora of trained health-care professionals with links to LMICs. A grassroots drive to engage with partners in LMICs within the UK has grown from the National Health Service, UK academia, and other organisations. This drive has generated a model that rests on two structures: London Global Cancer Week and the UK Global Cancer Network, providing a high-value foundation for international discussion and collaboration. Starting with a historical perspective, this Series paper describes the UK landscape and offers a potential plan for the future UK's contribution to global cancer control. We also discuss the opportunities and challenges facing UK partnerships with LMICs in cancer control. The UK should harness the skills, insights, and political will from all partners to make real progress.
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http://dx.doi.org/10.1016/S1470-2045(21)00380-6DOI Listing
September 2021

Risk of COVID-19 death in cancer patients: an analysis from Guy's Cancer Centre and King's College Hospital in London.

Br J Cancer 2021 Aug 16. Epub 2021 Aug 16.

Medical Oncology, Guy's and St Thomas' NHS Foundation Trust (GSTT), London, UK.

Background: Using an updated dataset with more patients and extended follow-up, we further established cancer patient characteristics associated with COVID-19 death.

Methods: Data on all cancer patients with a positive reverse transcription-polymerase chain reaction swab for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) at Guy's Cancer Centre and King's College Hospital between 29 February and 31 July 2020 was used. Cox proportional hazards regression was performed to identify which factors were associated with COVID-19 mortality.

Results: Three hundred and six SARS-CoV-2-positive cancer patients were included. Seventy-one had mild/moderate and 29% had severe COVID-19. Seventy-two patients died of COVID-19 (24%), of whom 35 died <7 days. Male sex [hazard ratio (HR): 1.97 (95% confidence interval (CI): 1.15-3.38)], Asian ethnicity [3.42 (1. 59-7.35)], haematological cancer [2.03 (1.16-3.56)] and a cancer diagnosis for >2-5 years [2.81 (1.41-5.59)] or ≥5 years were associated with an increased mortality. Age >60 years and raised C-reactive protein (CRP) were also associated with COVID-19 death. Haematological cancer, a longer-established cancer diagnosis, dyspnoea at diagnosis and raised CRP were indicative of early COVID-19-related death in cancer patients (<7 days from diagnosis).

Conclusions: Findings further substantiate evidence for increased risk of COVID-19 mortality for male and Asian cancer patients, and those with haematological malignancies or a cancer diagnosis >2 years. These factors should be accounted for when making clinical decisions for cancer patients.
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http://dx.doi.org/10.1038/s41416-021-01500-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8366163PMC
August 2021

Cancer Biomarkers in the era of precision oncology: Addressing the needs of patients and health systems.

Semin Cancer Biol 2021 Aug 10. Epub 2021 Aug 10.

Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, United Kingdom. Electronic address:

Cancer Biomarkers are the key to unlocking the promise of precision oncology, selecting which patients will respond to a more personalised treatment while sparing non-responders the therapy-related toxicity. In this paper, we highlight the primacy of cancer biomarkers, but focus on their importance to patients and to health systems. We also highlight how cancer biomarkers represent value for money. We emphasise the need for cancer biomarkers infrastructure to be embedded into European health systems. We also highlight the need to deploy multiple biomarker testing to deliver the optimal benefit for patients and health systems and consider cancer biomarkers from the perspective of cost, value and regulation. Cancer biomarkers must also be situated in the context of the upcoming In Vitro Diagnostics Regulation, which may pose certain challenges (e.g. non-compliance of laboratory developed tests, leading to cancer biomarker shortages and increased costs) that need to be overcome. Cancer biomarkers must be embedded in the real world of oncology delivery and testing must be implemented across Europe, with the intended aim of narrowing, not widening the inequity gap for patients. Cancer patients must be placed firmly at the centre of a cancer biomarker informed precision oncology care agenda.
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http://dx.doi.org/10.1016/j.semcancer.2021.08.002DOI Listing
August 2021

Real-world outcomes associated with new cancer medicines approved by the Food and Drug Administration and European Medicines Agency: A retrospective cohort study.

Eur J Cancer 2021 Sep 6;155:136-144. Epub 2021 Aug 6.

Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom; Department of Clinical Oncology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Institute of Cancer Policy, King's College London, United Kingdom. Electronic address:

Purpose: Real-World Data (RWD) studies are increasingly used to support regulatory approvals, reimbursement decisions, and changes in clinical practice for novel cancer drugs. However, few studies have systematically appraised their quality or compared outcomes to pivotal trials.

Methods: All RWD studies (2010-2019) for drugs approved by the Food and Drug Administration (FDA) and European Medicines Agency (EMA) from 2010 to 2015 for solid organ tumours in the non-curative setting were identified. Quality assessment was undertaken using the Newcastle Ottawa Scale. Survival differences between each RWD study and the pivotal trial were determined using a related sample Wilcoxon signed-rank test.

Results: 293 RWD studies for 45 of the 57 drug indications approved by the FDA/EMA were identified. The most common tumour types were prostate cancer (29%, n = 86) and melanoma (15%, n = 43). A quarter of the studies had industry funding. No high-quality studies were identified, and 78% were low quality. Comparative survival analysis between RWD and pivotal trials was possible for 224 studies (37 drug indications). Differences in median survival between the RWD studies and their corresponding trial ranged from -32 months to 21 months (IQR -4·2 months to 1·6 months). Low-quality studies were more likely to report superior survival outcomes (23%) compared to higher quality studies (8%) (p = 0.02).

Conclusion: RWD study quality for novel cancer drugs is low and of insufficient rigour to inform reimbursement decisions and clinical practice. RWD studies seeking publication should provide a completed quality assessment tool on submission. Greater investment in properly designed RWD studies is required.
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http://dx.doi.org/10.1016/j.ejca.2021.07.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8442759PMC
September 2021

Veterinary intelligence: integrating zoonotic threats into global health security.

J R Soc Med 2021 Aug 5:1410768211035355. Epub 2021 Aug 5.

Conflict and Health Research Group, King's College London, London WC2R 2LS, UK.

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http://dx.doi.org/10.1177/01410768211035355DOI Listing
August 2021

The economic burden of colorectal cancer across Europe: a population-based cost-of-illness study.

Lancet Gastroenterol Hepatol 2021 09 28;6(9):709-722. Epub 2021 Jul 28.

Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, UK.

Background: Colorectal cancer is one of the leading causes of cancer morbidity and mortality in Europe. We aimed to ascertain the economic burden of colorectal cancer across Europe using a population-based cost-of-illness approach.

Methods: In this population-based cost-of-illness study, we obtained 2015 activity and costing data for colorectal cancer in 33 European countries (EUR-33) from global and national sources. Country-specific aggregate data were acquired for health-care, mortality, morbidity, and informal care costs. We calculated primary, outpatient, emergency, and hospital care, and systemic anti-cancer therapy (SACT) costs, as well as the costs of premature death, temporary and permanent absence from work, and unpaid informal care due to colorectal cancer. Colorectal cancer health-care costs per case were compared with colorectal cancer survival and colorectal cancer personnel, equipment, and resources across EUR-33 using univariable and multivariable regression. We also compared hospital care and SACT costs against 2009 data for the 27 EU countries.

Findings: The economic burden of colorectal cancer across Europe in 2015 was €19·1 billion. The total non-health-care cost of €11·6 billion (60·6% of total economic burden) consisted of loss of productivity due to disability (€6·3 billion [33·0%]), premature death (€3·0 billion [15·9%]), and opportunity costs for informal carers (€2·2 billion [11·6%]). The €7·5 billion (39·4% of total economic burden) of direct health-care costs consisted of hospital care (€3·3 billion [43·4%] of health-care costs), SACT (€1·9 billion [25·6%]), and outpatient care (€1·3 billion [17·7%]), primary care (€0·7 billion [9·3%]), and emergency care (€0·3 billion [3·9%]). The mean cost for managing a patient with colorectal cancer varied widely between countries (€259-36 295). Hospital-care costs as a proportion of health-care costs varied considerably (24·1-84·8%), with a decrease of 21·2% from 2009 to 2015 in the EU. Overall, hospital care was the largest proportion (43·4%) of health-care expenditure, but pharmaceutical expenditure was far higher than hospital-care expenditure in some countries. Countries with similar gross domestic product per capita had widely varying health-care costs. In the EU, overall expenditure on pharmaceuticals increased by 213·7% from 2009 to 2015.

Interpretation: Although the data analysed include non-homogenous sources from some countries and should be interpreted with caution, this study is the most comprehensive analysis to date of the economic burden of colorectal cancer in Europe. Overall spend on health care in some countries did not seem to correspond with patient outcomes. Spending on improving outcomes must be appropriately matched to the challenges in each country, to ensure tangible benefits. Our results have major implications for guiding policy and improving outcomes for this common malignancy.

Funding: Department for Employment and Learning of Northern Ireland, Medical Research Council, Cancer Research UK, Health Data Research UK, and DATA-CAN.
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http://dx.doi.org/10.1016/S2468-1253(21)00147-3DOI Listing
September 2021

A prospective study to determine the cost of illness for oral cancer in India.

Ecancermedicalscience 2021 17;15:1252. Epub 2021 Jun 17.

Tata Memorial Centre and HBNI, Mumbai 400012, India.

India accounts for almost a third of the global burden of oral cancer, a situation worsened by the inability to afford care. When available, aid is often insufficient, and costing is based on informal estimations. This study objectively determines direct healthcare costs of oral cancer in India. The study was performed from a healthcare provider's perspective using a validated bottom-up method. Care pathways were determined by prospectively observing the natural management of 100 oral cancer patients treated between October 2019 and March 2020. Specific costing categories were built across services, and apportioned values for each interaction was averaged. Costs of treatment and service utilisation were obtained using probabilistic sensitivity analyses. The unit cost of treating advanced stages (United States Dollar (USD) 2,717) was found to be 42% greater than early stages (USD1,568). There was an 11% reduction in unit costs with increases in socioeconomic status. Medical equipment accounted for 97.8% of capital costs, with the highest contributor being imaging services. Variable costs for surgery in advanced stages were 1.4 times higher than early stages. Compared to surgery alone, the average cost of treatment increased by 44.6% with adjuvant therapy. These results show that over the next decade, India will incur an economic burden of USD 3 billion towards the direct healthcare of oral cancer. Early detection and prevention strategies leading to 20% reduction in advanced stage disease could save USD 30 million annually. These results are critical to deliver a disease-driven and objective reform for oral cancer care.
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http://dx.doi.org/10.3332/ecancer.2021.1252DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8241452PMC
June 2021

Cancer Registration in the Middle East, North Africa, and Turkey: Scope and Challenges.

JCO Glob Oncol 2021 07;7:1101-1109

Global Health Institute, American University of Beirut, Beirut, Lebanon.

Purpose: National cancer control strategies have been identified as essential tools for reducing and managing the growing burden of cancer in low- and middle-income countries. Cancer registration is an instrumental component of any cancer control strategy, providing the data to inform effective cancer policy. In the Middle East, North Africa, and Turkey (MENAT) region, cancer registration varies immensely and faces multifaceted challenges including protracted conflict. This study investigates and maps out the present capacities and outputs of cancer registration in the MENAT region and identifies thematic barriers facing implementation and utilization of cancer registry data.

Materials And Methods: We used a self-administered online survey with open and close-ended questions targeting national and institutional cancer registry managers in the MENAT countries.

Results: Registry managers from 19 MENAT countries reported the presence of 97 population-based, 48 hospital-based, and 24 pathology-based registries. Most population-based registries were well- or partially developed. Lack of accurate death records, complete medical records, and communication between stakeholders and deficiencies in trained personnel were critical challenges that were more severe in active conflict zones and neighboring conflict-affected regions. Cancer registration challenges included weak health infrastructure, absence of legislation mandating cancer registration, and disruption of cancer registration because of active conflict and loss of funding. Refugee host countries, such as Lebanon, Turkey, and Jordan, also reported conflict-related challenges including refugee mobility and lack of accurate data on forced migrants.

Conclusion: This study provides a much-needed understanding of the current landscape and contextual challenges affecting cancer registration in the MENAT. These data are important for identifying areas on which to focus regional capacity-strengthening initiatives.
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http://dx.doi.org/10.1200/GO.21.00065DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8457856PMC
July 2021

The International Collaboration for Research methods Development in Oncology (CReDO) workshops: shaping the future of global oncology research.

Lancet Oncol 2021 08 30;22(8):e369-e376. Epub 2021 Jun 30.

Departments of Administration and Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India.

Low-income and middle-income countries (LMICs) have a disproportionately high burden of cancer and cancer mortality. The unique barriers to optimum cancer care in these regions necessitate context-specific research. The conduct of research in LMICs has several challenges, not least of which is a paucity of formal training in research methods. Building capacity by training early career researchers is essential to improve research output and cancer outcomes in LMICs. The International Collaboration for Research methods Development in Oncology (CReDO) workshop is an initiative by the Tata Memorial Centre and the National Cancer Grid of India to address gaps in research training and increase capacity in oncology research. Since 2015, there have been five CReDO workshops, which have trained more than 250 oncologists from India and other countries in clinical research methods and protocol development. Participants from all oncology and allied fields were represented at these workshops. Protocols developed included clinical trials, comparative effectiveness studies, health services research, and observational studies, and many of these protocols were particularly relevant to cancer management in LMICs. A follow-up of these participants in 2020 elicited an 88% response rate and showed that 42% of participants had made progress with their CReDO protocols, and 73% had initiated other research protocols and published papers. In this Policy Review, we describe the challenges to research in LMICs, as well as the evolution, structure, and impact of CReDO and other similar workshops on global oncology research.
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http://dx.doi.org/10.1016/S1470-2045(21)00077-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8328959PMC
August 2021

Biomedicine and the soul of medicine: optimising the balance.

Lancet Oncol 2021 07;22(7):907-909

Institute of Cancer Policy, School of Cancer Sciences, King's College London, London, UK.

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http://dx.doi.org/10.1016/S1470-2045(21)00271-0DOI Listing
July 2021

Viral hepatitis in correctional facilities in the Northern Territory of Australia 2003-2017.

BMC Infect Dis 2021 Jun 16;21(1):584. Epub 2021 Jun 16.

Charles Darwin University, Menzies School of Health Research, Casuarina, Northern Territory, Australia.

Background: The demographic of Northern Territory prison population differs than elsewhere in Australia and the prevalence of hepatitis B and hepatitis C may therefore be somewhat different from other jurisdictions. There has been no study which has specifically described the serological results of a large proportion of prisoners in Northern Territory correctional facilities over an extended period of time.

Methods: This retrospective longitudinal study reviewed serological results and testing rates for hepatitis B, and hepatitis C performed in correctional facilities in the Northern Territory of Australia between July 1st, 2003 and June 30th, 2017.

Results: The proportion of positive records over 14 years for hepatitis B surface antigen (HBsAg) was 641/12,066 (5.3, 95% CI 4.9-5.7), for hepatitis B core antibody (anti-HBc) 4937/12,138 (40.1, 95%CI 39.8-41.6), for hepatitis B surface antibody (anti-HBs) 6966/13,303 (52.4, 95% CI 51.5-53.2), and for hepatitis C antibody 569/12,153 (4.7, 95% CI 4.3-5.1). The proportion of prisoners tested for hepatitis B and hepatitis C has decreased since 2015, while a high proportion of prisoners remain non-immune to hepatitis B.

Conclusion: There is a relatively high proportion of positive serological markers of hepatitis B, and a lower proportion of positive hepatitis C serology in the Northern Territory's correctional facilities compared to overall Australian rates. As the proportion of prisoners tested for hepatitis B and C has decreased recently, and a high proportion of prisoners remain non-immune to hepatitis B, there are opportunities to increase testing and vaccination rates in this population.
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http://dx.doi.org/10.1186/s12879-021-06286-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8210364PMC
June 2021

Cost-effectiveness of precision diagnostic testing for precision medicine approaches against non-small-cell lung cancer: A systematic review.

Mol Oncol 2021 Jun 10. Epub 2021 Jun 10.

Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, UK.

Precision diagnostic testing (PDT) employs appropriate biomarkers to identify cancer patients that may optimally respond to precision medicine (PM) approaches, such as treatments with targeted agents and immuno-oncology drugs. To date, there are no published systematic appraisals evaluating the cost-effectiveness of PDT in non-small-cell lung cancer (NSCLC). To address this gap, we conducted Preferred Reporting Items for Systematic Reviews and Meta-Analyses searches for the years 2009-2019. Consolidated Health Economic Evaluation Reporting Standards were employed to screen, assess and extract data. Employing base costs, life years gained or quality-adjusted life years, as well as willingness-to-pay (WTP) threshold for each country, net monetary benefit was calculated to determine cost-effectiveness of each intervention. Thirty-seven studies (50%) were included for analysis; a further 37 (50%) were excluded, having failed population-, intervention-, comparator-, outcomes- and study-design criteria. Within the 37 studies included, we defined 64 scenarios. Eleven scenarios compared PDT-guided PM with non-guided therapy [epidermal growth factor receptor (EGFR), n = 5; programmed death-ligand 1 (PD-L1), n = 6]. Twenty-eight scenarios compared PDT-guided PM with chemotherapy alone (anaplastic lymphoma kinase, n = 3; EGFR, n = 17; PD-L1, n = 8). Twenty-five scenarios compared PDT-guided PM with chemotherapy alone, while varying the PDT approach. Thirty-four scenarios (53%) were cost-effective, 28 (44%) were not cost-effective, and two were marginal, dependent on their country's WTP threshold. When PDT-guided therapy was compared with a therapy-for-all patients approach, all scenarios (100%) proved cost-effective. Seven of 37 studies had been structured appropriately to assess PDT-PM cost-effectiveness. Within these seven studies, all evaluated scenarios were cost-effective. However, 81% of studies had been poorly designed. Our systematic analysis implies that more robust health economic evaluation could help identify additional approaches towards PDT cost-effectiveness, underpinning value-based care and enhanced outcomes for patients with NSCLC.
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http://dx.doi.org/10.1002/1878-0261.13038DOI Listing
June 2021

COVID-19 Risk Factors for Cancer Patients: A First Report with Comparator Data from COVID-19 Negative Cancer Patients.

Cancers (Basel) 2021 May 19;13(10). Epub 2021 May 19.

School of Cancer and Pharmaceutical Sciences, King's College London, London SE1 9RT, UK.

Very few studies investigating COVID-19 in cancer patients have included cancer patients as controls. We aimed to identify factors associated with the risk of testing positive for SARS CoV2 infection in a cohort of cancer patients. We analyzed data from all cancer patients swabbed for COVID-19 between 1 March and 31 July 2020 at Guy's Cancer Centre. We conducted logistic regression analyses to identify which factors were associated with a positive COVID-19 test. Results: Of the 2152 patients tested for COVID-19, 190 (9%) tested positive. Male sex, black ethnicity, and hematological cancer type were positively associated with risk of COVID-19 (OR = 1.85, 95%CI:1.37-2.51; OR = 1.93, 95%CI:1.31-2.84; OR = 2.29, 95%CI:1.45-3.62, respectively) as compared to females, white ethnicity, or solid cancer type, respectively. Male, Asian ethnicity, and hematological cancer type were associated with an increased risk of severe COVID-19 (OR = 3.12, 95%CI:1.58-6.14; OR = 2.97, 95%CI:1.00-8.93; OR = 2.43, 95%CI:1.00-5.90, respectively). This study is one of the first to compare the risk of COVID-19 incidence and severity in cancer patients when including cancer patients as controls. Results from this study have echoed those of previous reports, that patients who are male, of black or Asian ethnicity, or with a hematological malignancy are at an increased risk of COVID-19.
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http://dx.doi.org/10.3390/cancers13102479DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8161328PMC
May 2021

Economic impact of avoidable cancer deaths caused by diagnostic delay during the COVID-19 pandemic: A national population-based modelling study in England, UK.

Eur J Cancer 2021 07 5;152:233-242. Epub 2021 May 5.

Department of Oncology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Institute of Cancer Policy, King's College London, London, United Kingdom; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom. Electronic address:

Introduction: Delays in cancer diagnosis arose from the commencement of non-pharmaceutical interventions (NPI) introduced in the UK in March 2020 in response to the COVID-19 pandemic. Our earlier work predicted this will lead to approximately 3620 avoidable deaths for four major tumour types (breast, bowel, lung, and oesophageal cancer) in the next 5 years. Here, using national population-based modelling, we estimate the health and economic losses resulting from these avoidable cancer deaths. We also compare these with the impact of an equivalent number of COVID-19 deaths to understand the welfare consequences of the different health conditions.

Methods: We estimate health losses using quality-adjusted life years (QALYs) and lost economic productivity using the human capital (HC) approach. The analysis uses linked English National Health Service (NHS) cancer registration and hospital administrative datasets for patients aged 15-84 years, diagnosed with breast, colorectal, and oesophageal cancer between 1st Jan to 31st Dec 2010, with follow-up data until 31st Dec 2014, and diagnosed with lung cancer between 1st Jan to 31st Dec 31 2012, with follow-up data until 31st Dec 2015. Productivity losses are based on the estimation of excess additional deaths due to cancer at 1, 3 and 5 years for the four cancer types, which were derived from a previous analysis using this dataset. A total of 500 random samples drawn from the total number of COVID-19 deaths reported by the Office for National Statistics, stratified by gender, were used to estimate productivity losses for an equivalent number of deaths (n = 3620) due to SARS-CoV-2 infection.

Results: We collected data for 32,583 patients with breast cancer, 24,975 with colorectal cancer, 6744 with oesophageal cancer, and 29,305 with lung cancer. We estimate that across the four site-specific cancers combined in England alone, additional excess cancer deaths would amount to a loss of 32,700 QALYs (95% CI 31,300-34,100) and productivity losses of £103.8million GBP (73.2-132.2) in the next five years. For breast cancer, we estimate a loss of 4100 QALYS (3900-4400) and productivity losses of £23.2 m (18.2-28.6); for colorectal cancer, 15,000 QALYS (14,100-16,000) lost and productivity losses of £35.7 m (22.4-48.7); for lung cancer 10,900 QALYS (9,900-11,700) lost and productivity losses of £38.3 m (14.0-59.9) for lung cancer; and for oesophageal cancer, 2700 QALYS (2300-3,100) lost and productivity losses of £6.6 m (-6 to -17.6). In comparison, the equivalent number of COVID-19 deaths caused approximately 21,450 QALYs lost, as well as productivity losses amounting to £76.4 m (73.5-79.2).

Conclusion: Premature cancer deaths resulting from diagnostic delays during the first wave of the COVID-19 pandemic in the UK will result in significant economic losses. On a per-capita basis, this impact is, in fact, greater than that of deaths directly attributable to COVID-19. These results emphasise the importance of robust evaluation of the trade-offs of the wider health, welfare and economic effects of NPI to support both resource allocation and the prioritisation of time-critical health services directly impacted in a pandemic, such as cancer care.
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http://dx.doi.org/10.1016/j.ejca.2021.04.019DOI Listing
July 2021

Modelling palliative and end-of-life resource requirements during COVID-19: implications for quality care.

BMJ Open 2021 05 25;11(5):e043795. Epub 2021 May 25.

Department of Population Health Sciences, University of Bristol, Bristol, UK.

Objectives: The WHO estimates that the COVID-19 pandemic has led to more than 1.3 million deaths (1 377 395) globally (as of November 2020). This surge in death necessitates identification of resource needs and relies on modelling resource and understanding anticipated surges in demand. Our aim was to develop a generic computer model that could estimate resources required for end-of-life (EoL) care delivery during the pandemic.

Setting: A discrete event simulation model was developed and used to estimate resourcing needs for a geographical area in the South West of England. While our analysis focused on the UK setting, the model is flexible to changes in demand and setting.

Participants: We used the model to estimate resourcing needs for a population of around 1 million people.

Primary And Secondary Outcome Measures: The model predicts the per-day 'staff' and 'stuff' resourcing required to meet a given level of incoming EoL care activity.

Results: A mean of 11.97 hours of additional community nurse time, up to 33 hours of care assistant time and up to 30 hours additional care from care assistant night sits will be required per day as a result of out of hospital COVID-19 deaths based on the model prediction. Specialist palliative care demand is predicted to increase up to 19 hours per day. An additional 286 anticipatory medicine bundles per month will be necessary to alleviate physical symptoms at the EoL care for patients with COVID-19: an average additional 10.21 bundles of anticipatory medication per day. An average additional 9.35 syringe pumps could be needed to be in use per day.

Conclusions: The analysis for a large region in the South West of England shows the significant additional physical and human resource required to relieve suffering at the EoL as part of a pandemic response.
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http://dx.doi.org/10.1136/bmjopen-2020-043795DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8154294PMC
May 2021

Weaponizing water as an instrument of war in Syria: Impact on diarrhoeal disease in Idlib and Aleppo governorates, 2011-2019.

Int J Infect Dis 2021 Jul 16;108:202-208. Epub 2021 May 16.

University of Umea, Sweden.

Objectives: Investigate the weaponization of water during the Syrian conflict and the correlation of attacks on water, sanitation, and hygiene (WASH) infrastructure in Idlib and Aleppo governorates with trends in waterborne diseases reported by Early Warning and Response surveillance systems.

Methods: We reviewed literature and databases to obtain information on attacks on WASH in Aleppo and Idlib governorates between 2011 and 2019. We plotted weekly trends in waterborne diseases from two surveillance systems operational in Aleppo and Idlib governorates between 2015 and early 2020.

Results: The literature review noted several attacks on water and related infrastructure in both governorates, suggesting that WASH infrastructure was weaponized by state and non-state actors. Most interference with WASH in the Aleppo governorate occurred before 2019 and in the Idlib governorate in the summer of 2020. Other acute diarrhea represented >90% of cases of diarrhea; children under 5 years contributed 50% of cases. There was substantial evidence (p < 0.001) of an overall upward trend in cases of diarrheal disease.

Conclusions: Though no direct correlation can be drawn between the weaponization of WASH and the burden of waterborne infections due to multiple confounders, this research introduces important concepts on attacks on WASH and their potential impacts on waterborne diseases.
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http://dx.doi.org/10.1016/j.ijid.2021.05.030DOI Listing
July 2021

Cancer and COVID-19 vaccines: a complex global picture.

Lancet Oncol 2021 06 27;22(6):749-751. Epub 2021 Apr 27.

Institute of Cancer Policy, School of Cancer & Pharmaceutical Sciences, King's College London & Guy's and St Thomas' NHS Trust, London, UK. Electronic address:

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http://dx.doi.org/10.1016/S1470-2045(21)00244-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8078890PMC
June 2021

Mental health disorders research in the countries of the Organisation of Islamic Cooperation (OIC), 2008-17, and the disease burden: Bibliometric study.

PLoS One 2021 23;16(4):e0250414. Epub 2021 Apr 23.

Department of Psychiatry, and Stess Assessment and Research Centre (STAR), Hacettepe University, Ankara, Turkey.

The 57 countries of the Organisation of Islamic Cooperation are suffering from an increasing burden from mental health disorders. We investigated their research outputs during 2008-17 in the Web of Science in order to compare them with the burden from different mental health disorders and in different countries. The papers were identified with a complex filter based on title words and journals. Their addresses were parsed to give fractional country counts, show international collaboration, and also reveal country concentration on individual disorders and types of research. We found 17,920 papers in the decade, with output quadrupling. Foreign contributions accounted for 15% of addresses; they were from Europe (7%), Canada + USA (5%) and elsewhere (3%). They were much greater for Qatar and Uganda (> 60%), but less than 10% for Iran and Turkey. Schizophrenia and bipolar disorder were over-researched, but suicide and self-harm were seriously neglected, relative to their mental health disorder burdens. Although OIC research has been expanding rapidly, some countries have published little on this subject, perhaps because of stigma. Turkey collaborates relatively little internationally and as a result its papers received few citations. Among the large OIC countries, it has almost the highest relative mental health disorders burden, which is also growing rapidly.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0250414PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8064544PMC
April 2021

Silver linings: a qualitative study of desirable changes to cancer care during the COVID-19 pandemic.

Ecancermedicalscience 2021 11;15:1202. Epub 2021 Mar 11.

Division of Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, K7L 3N6, Canada.

Introduction: Public health emergencies and crises such as the current COVID-19 pandemic can accelerate innovation and place renewed focus on the value of health interventions. Capturing important lessons learnt, both positive and negative, is vital. We aimed to document the perceived positive changes (silver linings) in cancer care that emerged during the COVID-19 pandemic and identify challenges that may limit their long-term adoption.

Methods: This study employed a qualitative design. Semi-structured interviews ( = 20) were conducted with key opinion leaders from 14 countries. The participants were predominantly members of the International COVID-19 and Cancer Taskforce, who convened in March 2020 to address delivery of cancer care in the context of the pandemic. The Framework Method was employed to analyse the positive changes of the pandemic with corresponding challenges to their maintenance post-pandemic.

Results: Ten themes of positive changes were identified which included: value in cancer care, digital communication, convenience, inclusivity and cooperation, decentralisation of cancer care, acceleration of policy change, human interactions, hygiene practices, health awareness and promotion and systems improvement. Impediments to the scale-up of these positive changes included resource disparities and variation in legal frameworks across regions. Barriers were largely attributed to behaviours and attitudes of stakeholders.

Conclusion: The COVID-19 pandemic has led to important value-based innovations and changes for better cancer care across different health systems. The challenges to maintaining/implementing these changes vary by setting. Efforts are needed to implement improved elements of care that evolved during the pandemic.
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http://dx.doi.org/10.3332/ecancer.2021.1202DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8043681PMC
March 2021

Changing Mortality and Place of Death in Response to Refugee Influx: A Population-Based Cross-Sectional Study in Jordan, 2005-2016.

J Palliat Med 2021 Apr 7. Epub 2021 Apr 7.

Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, United Kingdom.

Jordan faces complex health care challenges due to refugee influx and an aging population. Palliative care planning and delivery require data to ensure services respond to changing population needs. To determine the trend in mortality and place of death in Jordan. Population-based study. Death registry data of adult decedents ( = 143,215), 2005-2016. Descriptive statistics examined change in demographic and place of death (categorized as hospital and nonhospital). Binomial logistic regression compared the association between hospital deaths and demographic characteristics in 2008-2010, 2011-2013, and 2014-2016, with 2005-2007. The annual number of deaths increased from 6792 in 2005 to 17,018 in 2016 (151% increase). Hospital was the most common place of death (93.7% of all deaths) in Jordan, and percentage of hospital deaths increased for Jordanian (82.6%-98.8%) and non-Jordanian decedents (88.1%-98.7%). There was an increased likelihood of hospital death among Jordanian decedents who died from nonischemic heart disease (odd ratio [OR]: 1.11, 95% confidence interval [CI]: 1.09-1.13,  < 0.001), atherosclerosis (OR: 1.10, 95% CI: 1.08-1.13,  < 0.001), renal failure (OR: 1.05, 95% CI: 1.02-1.08,  < 0.001), hemorrhagic fevers (OR: 1.09, 95% CI: 1.06-1.13,  < 0.001), and injury (OR: 1.18, 95% CI: 1.06-1.33,  < 0.001) in the period 2014-2016, compared with 2005-2007. There were similar increases in the likelihood of hospital death among non-Jordanians in 2014-2016 for the following conditions: malignant neoplasms (except leukemia), nonischemic heart disease, atherosclerosis, injury, and HIV, compared with 2005-2007. Country-level palliative care development must respond to both internal (aging) and external (refugee influx) population trends. Universal Health Coverage requires palliative care to move beyond cancer and meet population-specific needs. Community-based services should be prioritized and expanded to care for the patients with nonischemic heart disease, atherosclerosis, renal failure, hemorrhagic fevers, and injury.
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http://dx.doi.org/10.1089/jpm.2020.0476DOI Listing
April 2021

User Experience With Low-Cost Virtual Reality Cancer Surgery Simulation in an African Setting.

JCO Glob Oncol 2021 03;7:435-442

Department of Obstetrics and Gynecology, UNC School of Medicine, University of North Carolina at Chapel, Chapel Hill, NC.

Purpose: Limited access to adequate cancer surgery training is one of the driving forces behind global inequities in surgical cancer care. Affordable virtual reality (VR) surgical training could enhance surgical skills in low- and middle-income settings, but most VR and augmented reality systems are too expensive and do not teach open surgical techniques commonly practiced in these contexts. New low-cost VR can offer skill development simulations relevant to these settings, but little is known about how knowledge is gained and applied by surgeons training and working in specific resource-constrained settings. This study addresses this gap, exploring gynecologic oncology trainee learning and user experience using a low-cost VR simulator to learn to perform an open radical abdominal hysterectomy in Lusaka, Zambia.

Methods: Eleven surgical trainees rotating through the gynecologic oncology service were sequentially recruited from the University Teaching Hospital in Lusaka to participate in a study evaluating a VR radical abdominal hysterectomy training designed to replicate the experience in a Zambian hospital. Six participated in semi-structured interviews following the training. Interviews were analyzed using open and axial coding, informed by grounded theory.

Results: Simulator participation increased participants' perception of their surgical knowledge, confidence, and skills. Participants believed their skills transferred to other related surgical procedures. Having clear goals and motivation to improve were described as factors that influenced success.

Conclusion: For cancer surgery trainees in lower-resourced settings learning medical and surgical skills, even for those with limited VR experience, low-cost VR simulators may enhance anatomical knowledge and confidence. The VR simulator reinforced anatomical and clinical knowledge acquired through other modalities. VR-enhanced learning may be particularly valuable when mentored learning opportunities are limited.
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http://dx.doi.org/10.1200/GO.20.00510DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8081482PMC
March 2021

The impact of national non-pharmaceutical interventions ('lockdowns') on the presentation of cancer patients.

Ecancermedicalscience 2021 3;15:1180. Epub 2021 Feb 3.

King's College London, WC2R 2LS, UK.

One of the most ignored aspects of the COVID-19 pandemic has been the impact of public health measures by governments on wider health and welfare. From March 2020, hospitals in the UK saw a dramatic reduction in patients with cancer presenting due to multifactorial reasons. The impact of the pandemic on patients with cancer in the South East London Cancer Alliance was studied. The specific aims were (1) to examine the reduction in cancer diagnoses during the first wave of the pandemic and (2) to examine the stage of diagnosis of patients with cancer presenting during the pandemic compared with that of patients presenting before the pandemic. There was an 18.2% reduction in new cancer diagnoses (an estimate of 987 cancers), when compared with 2019. This fall in cancer diagnoses was most marked in patients with prostate (51.4%), gynaecological (29.7%), breast (29.5%) and lung (23.4%) cancers. There was an overall 3.9% increase in advanced stage presentation (Stages 3 and 4), with an overall 6.8% increase in Stage 4 cancers during this period. The greatest shifts were seen in lung (increase of 6.3%, with an 11.2% increase in Stage 4 cancer alone) and colorectal (5.4%) cancers. For prostate cancer, there was an increase in 3.8% in those presenting with Stage 4 disease. For breast cancer, there was an 8% reduction in patients diagnosed with Stage 1 cancer with commensurate increases in the proportion of those with Stage 2 disease. The experiences in cancer are a salient warning that pandemic control measures and policy need to balance all health and welfare. Alternative strategies need to be adopted during further waves of the current and any future pandemic to ensure that patients with cancer are prioritised for diagnosis and treatment to prevent late-stage presentation and an increase in avoidable deaths.
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http://dx.doi.org/10.3332/ecancer.2021.1180DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7987492PMC
February 2021

ECAP-Controlled Closed-Loop Spinal Cord Stimulation Efficacy and Opioid Reduction Over 24-Months: Final Results of the Prospective, Multicenter, Open-Label Avalon Study.

Pain Pract 2021 Jul 2;21(6):680-691. Epub 2021 May 2.

Saluda Medical Pty Ltd, Artarmon, New South Wales, Australia.

Introduction: Chronic pain is a major public health concern, as is the associated use of opioid medications, highlighting the importance of alternative treatments, such as spinal cord stimulation (SCS). Here, we present the final 24-month results of the Avalon study, which investigated the use of the first closed-loop SCS system in patients with chronic pain. The system measures the evoked compound action potentials (ECAPs) elicited by each stimulus pulse and drives a feedback loop to maintain the ECAP amplitude near constant.

Methods: Fifty patients were implanted with the Evoke system (Saluda Medical) and followed over 24-months. Pain, quality of life (QOL), function, sleep, and medication use were collected at baseline and each scheduled visit. ECAP amplitudes and programming adjustments were also monitored.

Results: At 24 months, responder rates (≥ 50% pain reduction) and high responder rates (≥ 80% pain reduction) for overall pain were 89.5% and 68.4%, respectively, the latter up from 42.2% at 3 months. Significant improvements from baseline were observed in QOL, function, and sleep over the 24 months, including ≥ 80% experiencing a minimally important difference in QOL and > 50% experiencing a clinically significant improvement in sleep. At 24 months, 82.8% of patients with baseline opioid use eliminated or reduced their opioid intake. Over the course of the study, reprogramming need fell to an average of less than once a year.

Conclusion: Over a 24-month period, the Evoke closed-loop SCS maintained its therapeutic efficacy despite a marked reduction in opioid use and steady decrease in the need for reprogramming.
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http://dx.doi.org/10.1111/papr.13008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8359972PMC
July 2021

Compounded trauma: A qualitative study of the challenges for refugees living with advanced cancer.

Palliat Med 2021 05 26;35(5):916-926. Epub 2021 Mar 26.

Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK.

Background: Although palliative care is now an essential health service under Universal Health Coverage, ensuring access and appropriate care for refugees is a specific challenge for this large population.

Aim: To identify the needs and experiences of adult refugees in Jordan with advanced cancer and informal caregivers.

Design: A qualitative study using semi-structured interviews.

Setting/participants: Participants were purposively sampled at two Jordanian hospitals to achieve heterogeneity by age, gender, country of origin, and primary diagnosis.

Results: Twenty-nine refugees (22 patients, 7 caregivers) participated, and four themes were generated: (1) Psychological distress and sustaining social support. Refugees often experienced unmet psychosocial needs. However, psychosocial support was reported either absent or limited. (2) Knowledge and uncertainty. Lack of information and poor communication between healthcare providers and patients caused significant distress due to uncertainty. (3) Family anxiety and support roles. Being away from the home country cut patients and caregivers off from their wider social support network, which added increased anxiety and responsibilities to caregivers. (4) Compounded trauma and poverty. Many refugees have experienced trauma related to war that may affect their physical and mental health. They faced serious financial crises caused by the rising cost of medicines and treatment.

Conclusions: This study reveals the impact of fractured families and networks on social support in advanced cancer, and the compounding trauma of the disease for refugees. Detailed person-centred assessment and emphasis on psychosocial support is essential, and home-based care should not presume community support for patients to remain at home.
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http://dx.doi.org/10.1177/02692163211000236DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8114446PMC
May 2021

Blood-borne virus testing in patients diagnosed with non-Hodgkin lymphoma.

Intern Med J 2021 02;51(2):301-302

Department of Infectious Diseases, Prince of Wales Hospital, Sydney, New South Wales, Australia.

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http://dx.doi.org/10.1111/imj.15178DOI Listing
February 2021

Lung cancer research and its citation on clinical practice guidelines.

Lung Cancer 2021 04 5;154:44-50. Epub 2021 Feb 5.

King's College London, Institute of Cancer Policy, Guy's Hospital, Great Maze Pond, London SE1 9RT, UK. Electronic address:

Background: The impact of medical research is usually judged on the basis of citations in the serial literature. A better test of its utility is through its contribution to clinical practice guidelines (CPGs) on how to prevent, diagnose, and treat illness. This study aimed to compare the parameters of lung cancer research papers with those cited as references in lung cancer CPGs from 16 countries, and the Cochrane Collaboration. These comparisons were mainly based on bibliographic data compiled from the Web of Science (WoS).

Methodology: We examined 7357 references (of which 4491 were unique) cited in a total of 77 lung cancer CPGs, and compared them with 73,214 lung cancer papers published in the WoS between 2004 and 2018.

Results: References used by lung CPGs were much more clinical than the overall body of research papers on this cancer, and their authors predominantly came from smaller northern European countries. However, the leading institutions whose papers were cited the most on these CPGs were from the USA, notably the MD Anderson Cancer Center in Texas, the Memorial Sloan Kettering Cancer Center, New York, and the Mayo Clinic in Rochester, Minnesota. The types of research cited by the CPGs were primarily clinical trials, as well as three treatment modalities (chemotherapy, radiotherapy and surgery). Genetics, palliative care and quality of life were largely neglected. The median time gap between papers cited on a lung CPG and its publication was 3.5 years longer than for WoS citations.

Conclusions: Analysis of the references on CPGs allows an alternative means of research evaluation, and one that may be more appropriate for clinical research than citations in academic journals. Own-country references show the direct contribution of research to a country's health care, and other-country references show the esteem in which this research has been held internationally.
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http://dx.doi.org/10.1016/j.lungcan.2021.01.024DOI Listing
April 2021
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