Bio

Bio


I am a medical oncologist focused on breast cancer and cancer survivorship. My career goal is to improve outcomes and experiences of patients and caregivers living with and beyond cancer, and my research and scholarship have contributed to understanding and meeting the needs of the growing population of cancer survivors. My editorial work for the Journal of Clinical Oncology has given me the opportunity to shape the discourse in oncology and as Editor-in-Chief of Cancer.Net I can bring high quality information about cancer to the lay public.

Clinical Focus


  • Medical Oncology
  • Breast Cancer
  • Cancer Survivorship

Academic Appointments


Administrative Appointments


  • Editor-in-Chief Cancer.Net, American Society of Clinical Oncology (2015 - Present)
  • Director Cancer Survivorship Program, Stanford (2016 - Present)

Boards, Advisory Committees, Professional Organizations


  • Chair Psychosocial Oncology Interest Group, Multinational Association of Supportive Care in Cancer (2014 - 2020)
  • Editorial Consultant, Journal of Clinical Oncology (2014 - Present)
  • Editor-in-Chief of Cancer. Net, American Society of Clinical Oncology (2015 - Present)

Professional Education


  • Medical Education: Dartmouth Geisel School of Medicine Office of the Registrar (1982) NH
  • Board Certification: American Board of Internal Medicine, Medical Oncology (1997)
  • Fellowship: Dana Farber Cancer Institute Hematology Oncology Fellowship (1989) MA
  • Board Certification: American Board of Internal Medicine, Internal Medicine (1985)
  • Residency: Beth Israel Deaconess Medical Center (1985) MA

Community and International Work


  • IDEA/Global Mentoring of Oncologists, global

    Topic

    Building Capacity for Cancer Care

    Partnering Organization(s)

    ASCO (American Society of Clinical Oncology)

    Populations Served

    Low and Medium Resource Countries

    Location

    International

    Ongoing Project

    Yes

    Opportunities for Student Involvement

    No

Research & Scholarship

Clinical Trials


  • Leveraging Mindsets to Improve Health and Wellbeing in Patients With Cancer Not Recruiting

    Primary Objectives: Mindsets have been rigorously studied in the domains of development, education, and more recently, in health and disease. However, there are no large-scale longitudinal studies of the mindsets held by cancer patients and how they may affect treatment outcomes, physical health, and psychological well-being. This randomized, single-blind, treatment-as-usual (TAU) control study aims to assess (1) mindsets at four time points spanning from the point of diagnosis to six weeks post-treatment to patients who are newly diagnosed with cancer and undergoing treatment with curative intent, and (2) the impact of a brief but targeted mindset intervention to help instill more useful mindsets about the nature of cancer and the role of the body on patient reported measures of physical and psychological health. This study aims to add to the existing literature on psychosocial interventions for cancer patients and survivors while addressing the substantial time and cost limitations of traditional interventions. It also contributes to the body of research indicating that mindsets play an important role in both health and wellbeing. Secondary Objectives: This study has two secondary objectives. First, we aim to determine the impact of patient mindsets on measures of treatment (treatment efficacy and treatment related adverse events) and psychosocial health (stress, coping, mood, emotions). Second, we aim to understand the relationship between patient mindsets and biomarkers of immune and inflammatory processes in patients undergoing cancer treatment

    Stanford is currently not accepting patients for this trial. For more information, please contact Alia J Crum, PhD, 650-725-2418.

    View full details

Publications

All Publications


  • Response to neoadjuvant chemotherapy and the 21-gene Breast Recurrence Score test in young women with estrogen receptor-positive early breast cancer. Breast cancer research and treatment Sella, T., Gelber, S. I., Poorvu, P. D., Kim, H., Dominici, L., Guzman-Arocho, Y. D., Collins, L., Ruddy, K. J., Tamimi, R. M., Peppercorn, J. M., Schapira, L., Borges, V. F., Come, S. E., Warner, E., Snow, C., Jakubowski, D. M., Russell, C. A., Winer, E. P., Rosenberg, S. M., Partridge, A. H. 2020

    Abstract

    PURPOSE: The 21-gene Breast Recurrence Score test predicts benefit from adjuvant chemotherapy in estrogen receptor-positive, HER2-negative (ER+/HER2-) breast cancer (BC). We examined whether the 21-gene assay predicts response to neoadjuvant chemotherapy (NCT).METHODS: We identified patients with stage I-III ER+/HER2- BC treated with NCT from the Young Women's Breast Cancer Study, a prospective cohort of women diagnosed with BC at age ?40 years. The 21-gene assay was performed on tumor specimens removed prior to NCT either as part of clinical care or retrospectively for research. Pathological complete response (pCR) was defined as ypT0/is ypN0. The relationship between Recurrence Score result and pCR was evaluated using logistic regression modeling.RESULTS: 76 women received NCT for ER+/HER2- BC and were eligible for this analysis. Median age at diagnosis was 37 years (range 24-40). Scores ranged between 5 and 77 with 50% >25 and 5% <11. Median Recurrence Score result was significantly higher among tumors achieving pCR vs. non-pCR response (61.5 vs. 23, pwilcoxon=0.0005). pCR rate in patients with scores >25 was 21% (8/38) vs. 5% in patients with scores <25 (2/38) (p=0.09), with both pCRs in the <25 group in patients with scores between 21 and 25. In multivariable analysis, only Recurrence Score result was significantly associated with pCR (OR: 1.07, 95%CI 1.01-1.12, p=0.01).CONCLUSIONS: In young women with ER+/HER2- BC who received NCT, higher pretreatment Recurrence Score result was associated with an increased likelihood of pCR. Gene expression profile assays may have a role in decision making in young women in need of neoadjuvant therapy.

    View details for DOI 10.1007/s10549-020-05989-5

    View details for PubMedID 33150547

  • Symptom appraisal in uncertainty: a theory-driven thematic analysis with survivors of childhood cancer. Psychology & health Heathcote, L. C., Loecher, N., Simon, P., Spunt, S. L., Jordan, A., Tutelman, P. R., Cunningham, S., Schapira, L., Simons, L. E. 2020: 1?18

    Abstract

    OBJECTIVE: Somatic symptoms capture attention, demand interpretation, and promote health behaviors. Symptom appraisal is particularly impactful within uncertain health contexts such as cancer survivorship. Yet, little is known about how individuals make sense of somatic symptoms within uncertain health contexts, nor how this process guides health behaviors.DESIGN: 25 adolescent and young adult survivors of childhood cancer completed semi-structured interviews regarding how they appraise and respond to changing somatic sensations within the uncertain context of survivorship.MAIN OUTCOME MEASURES: Interviews were transcribed verbatim and subjected to a hybrid deductive-inductive thematic analysis, guided by the Cancer Threat Interpretation model.RESULTS: We constructed three themes. Symptoms as signals of bodily threat (theme 1) captured that participants described commonly interpreting and worrying about everyday sensations as indicating cancer recurrence or new illness. Playing detective with bodily signals (theme 2) captured participants' felt need to employ cognitive and behavioral strategies to determine whether somatic sensations indicated a credible health threat. These two themes are qualified by the final theme, Living with symptom-related uncertainty (theme 3), which captured participants' recognition that post-cancer symptoms are wily and influenced by psychological factors such as anxiety.CONCLUSIONS: These data highlight that making sense of everday somatic sensations can be particularly challenging following an experience of cancer. There is a need for novel symptom management approaches that target how somatic sensations are appraised and responded to as signals of bodily threat.

    View details for DOI 10.1080/08870446.2020.1836180

    View details for PubMedID 33073604

  • Passing those endless hours. The journal of supportive oncology Schapira, L. ; 8 (3): 137?38

    View details for PubMedID 20552928

  • Shared uncertainty. The journal of supportive oncology Schapira, L. ; 2 (1): 14, 18

    View details for PubMedID 15330368

  • Hospice by another name... It's still hard to talk about dying. The journal of supportive oncology Schapira, L. ; 6 (7): 323

    View details for PubMedID 18847076

  • Risk of primary urological and genital cancers following incident breast cancer: a Danish population-based cohort study. Breast cancer research and treatment Sundboll, J., Farkas, D. K., Adelborg, K., Schapira, L., Tamang, S., Norgaard, M., Cullen, M. R., Cronin-Fenton, D., Sorensen, H. T. 2020

    Abstract

    PURPOSE: The prevalence of breast cancer survivors has increased due to dissemination of population-based mammographic screening and improved treatments. Recent changes in anti-hormonal therapies for breast cancer may have modified the risks of subsequent urological and genital cancers. We examine the risk of subsequent primary urological and genital cancers in patients with incident breast cancer compared with risks in the general population.METHODS: Using population-based Danish medical registries, we identified a cohort of women with primary breast cancer (1990-2017). We followed them from one year after their breast cancer diagnosis until any subsequent urological or genital cancer diagnosis. We computed incidence rates and standardized incidence ratios (SIRs) with 95% confidence intervals (CIs) as the observed number of cancers relative to the expected number based on national incidence rates (by sex, age, and calendar year).RESULTS: Among 84,972 patients with breast cancer (median age 61years), we observed 623 urological cancers and 1397 genital cancers during a median follow-up of 7.4years. The incidence rate per 100,000 person-years was stable during follow-up (83 for urological cancers and 176 for genital cancers). The SIR was increased for ovarian cancer (1.37, 95% CI 1.23-1.52) and uterine cancer (1.37, 95% CI 1.25-1.50), but only during the pre-aromatase inhibitor era (before 2007). Moreover, the SIR of kidney cancer was increased (1.52, 95% CI 1.15-1.97), but only during 2007-2017. The SIR for urinary bladder cancer was marginally increased (1.15, 95% CI 1.04-1.28) with no temporal effects. No associations were observed for cervical cancer.CONCLUSION: Breast cancer survivors had higher risks of uterine and ovarian cancer than expected, but only before 2007, and of kidney cancer, but only after 2007. The risk of urinary bladder cancer was moderately increased without temporal effects, and we observed no association with cervical cancer.

    View details for DOI 10.1007/s10549-020-05879-w

    View details for PubMedID 32845432

  • ASCO Voices 2020. Journal of clinical oncology : official journal of the American Society of Clinical Oncology Rayson, D., Bufill, J. A., Close, J., Cyusa, A., Oettel, K., Okolo, O., Parikh, A., Schapira, L. 2020: JCO2001584

    View details for DOI 10.1200/JCO.20.01584

    View details for PubMedID 32772763

  • Utilization of COVID-19 treatments and clinical outcomes among patients with cancer: A COVID-19 and Cancer Consortium (CCC19) cohort study. Cancer discovery Rivera, D. R., Peters, S., Panagiotou, O. A., Shah, D. P., Kuderer, N. M., Hsu, C., Rubinstein, S. M., Lee, B. J., Choueiri, T. K., de Lima Lopes, G., Grivas, P., Painter, C. A., Rini, B. I., Thompson, M. A., Arcobello, J., Bakouny, Z., Doroshow, D. B., Egan, P. C., Farmakiotis, D., Fecher, L. A., Friese, C. R., Galsky, M. D., Goel, S., Gupta, S., Halfdanarson, T. R., Halmos, B., Hawley, J. E., Khaki, A. R., Lemmon, C. A., Mishra, S., Olszewski, A. J., Pennell, N. A., Puc, M. M., Revankar, S. G., Schapira, L., Schmidt, A., Schwartz, G. K., Shah, S. A., Wu, J. T., Xie, Z., Yeh, A. C., Zhu, H., Shyr, Y., Lyman, G. H., Warner, J. L. 2020

    Abstract

    Among 2,186 US adults with invasive cancer and laboratory-confirmed SARS-CoV-2 infection, we examined the association of COVID-19 treatments with 30-day all-cause mortality, and factors associated with treatment. Logistic regression with multiple adjustments (e.g., comorbidities, cancer status, baseline COVID-19 severity) was performed. Hydroxychloroquine with any other drug was associated with increased mortality versus treatment with any COVID-19 treatment other than hydroxychloroquine or untreated controls; this association was not present with hydroxychloroquine alone. Remdesivir had numerically reduced mortality versus untreated controls that did not reach statistical significance. Baseline COVID-19 severity was strongly associated with receipt of any treatment. Black patients were approximately half as likely to receive remdesivir as white patients. While observational studies can be limited by potential unmeasured confounding, our findings add to the emerging understanding of patterns of care for patients with cancer and COVID-19 and support evaluation of emerging treatments through prospective controlled trials inclusive of this population.

    View details for DOI 10.1158/2159-8290.CD-20-0941

    View details for PubMedID 32699031

  • Uncertainty upon uncertainty: supportive Care for Cancer and COVID-19. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer Young, A. M., Ashbury, F. D., Schapira, L., Scotte, F., Ripamonti, C. I., Olver, I. N. 2020

    View details for DOI 10.1007/s00520-020-05604-9

    View details for PubMedID 32613372

  • The Effects of Tai Chi and Qigong on Immune Responses: A Systematic Review and Meta-Analysis. Medicines (Basel, Switzerland) Oh, B., Bae, K., Lamoury, G., Eade, T., Boyle, F., Corless, B., Clarke, S., Yeung, A., Rosenthal, D., Schapira, L., Back, M. 2020; 7 (7)

    Abstract

    Background: Effective preventative health interventions are essential to maintain well-being among healthcare professionals and the public, especially during times of health crises. Several studies have suggested that Tai Chi and Qigong (TQ) have positive impacts on the immune system and its response to inflammation. The aim of this review is to evaluate the current evidence of the effects of TQ on these parameters. Methods: Electronic searches were conducted on databases (Medline, PubMed, Embase and ScienceDirect). Searches were performed using the following keywords: "Tai Chi or Qigong" and "immune system, immune function, immunity, Immun*, inflammation and cytokines". Studies published as full-text randomized controlled trials (RCTs) in English were included. Estimates of change in the levels of immune cells and inflammatory biomarkers were pooled using a random-effects meta-analysis where randomised comparisons were available for TQ versus active controls and TQ versus non-active controls. Results: Nineteen RCTs were selected for review with a total of 1686 participants and a range of 32 to 252 participants within the studies. Overall, a random-effects meta-analysis found that, compared with control conditions, TQ has a significant small effect of increasing the levels of immune cells (SMD, 0.28; 95% CI, 0.13 to 0.43, p = 0.00), I2 = 45%, but not a significant effect on reducing the levels of inflammation (SMD, -0.15; 95% CI, -0.39 to 0.09, p = 0.21), I2 = 85%, as measured by the systemic inflammation biomarker C-reactive protein (CRP) and cell mediated biomarker cytokines. This difference in results is due to the bidirectional regulation of cytokines. An overall risk of bias assessment found three RCTs with a low risk of bias, six RCTs with some concerns of bias, and ten RCTs with a high risk of bias. Conclusions: Current evidence indicates that practising TQ has a physiologic impact on immune system functioning and inflammatory responses. Rigorous studies are needed to guide clinical guidelines and harness the power of TQ to promote health and wellbeing.

    View details for DOI 10.3390/medicines7070039

    View details for PubMedID 32629903

  • Management of cancer and health after the clinic visit: A call to action for self-management in cancer care. Journal of the National Cancer Institute Howell, D., Mayer, D. K., Fielding, R., Eicher, M., Verdonck-de Leeuw, I. M., Johansen, C., Soto-Perez-de-Celis, E., Foster, C., Chan, R., Alfano, C. M., Hudson, S. V., Jefford, M., Lam, W. W., Loerzel, V., Pravettoni, G., Rammant, E., Schapira, L., Stein, K. D., Kocswara, B., Global Partners for Self-Management in Cancer 2020

    Abstract

    Individuals with cancer and their families assume responsibility for management of cancer as an acute and chronic disease. Yet, cancer lags other chronic diseases in its provision of proactive self-management support (SMS) in routine 'everyday' care leaving this population vulnerable to worse health status, long-term disability and poorer survival. Enabling cancer patients to manage the medical, emotional consequences, and lifestyle/work changes due to cancer and treatment is essential to optimizing health and recovery across the continuum of cancer. In this paper, the Global Partners on Self-Management in Cancer (GPS) puts forth six priority areas for action. Action 1: Prepare patients/survivors for active involvement in care. Action 2: Shift the care culture to support patients as partners in co-creating health and embed self-management support in everyday health care provider practices and in care pathways. Action 3: Prepare the workforce in the knowledge and skills necessary to enable patients in effective self-management and reach consensus on core curricula. Action 4: Establish and reach consensus on a patient reported outcome system for measuring the effects of self-management support and performance accountability. Action 5: Advance the evidence and stimulate research on self-management and self-management support in cancer populations. Action 6: Expand reach and access to self-management support programs across care sectors and tailored to diversity of need, and stimulation of research to advance knowledge. It's time for a revolution to better integrate self-management support as part of high quality, person-centered support and precision medicine in cancer care to optimize health outcomes, accelerate recovery and possibly improve survival.

    View details for DOI 10.1093/jnci/djaa083

    View details for PubMedID 32525530

  • Posttraumatic Stress in Breast Cancer Survivors Diagnosed at a Young Age. Psycho-oncology Vazquez, D., Rosenberg, S., Gelber, S., Ruddy, K. J., Morgan, E., Recklitis, C., Come, S., Schapira, L., Partridge, A. H. 2020

    Abstract

    OBJECTIVE: Young breast cancer patients experience greater psychosocial distress compared with older patients, which raises concern for their risk of posttraumatic stress disorder (PTSD). We sought to characterize the prevalence of clinically significant symptoms of PTSD and associated factors among breast cancer survivors diagnosed at a young age.METHODS: The Young Women's Breast Cancer Study, an ongoing prospective cohort study, enrolled 1302 women diagnosed with breast cancer at age?40 between 2006 and 2016. Participants complete serial surveys, and we obtained additional information from medical record review. Socio-demographics, anxiety and depression, social support, and psychiatric co-morbidities and medications were assessed at study baseline (median, 5months post-diagnosis). We defined a participant as having clinically significant posttraumatic stress symptoms (PTSS) by scoring ?50 on the PTSD Checklist-Specific Version, administered on the 30-month survey.RESULTS: Among 700 women with stage 1-3 disease, the prevalence of PTSS was 6.3% (95%CI = 4.5-8.1). In multivariable analyses, PTSS was significantly associated with anxiety (OR 12.43, 95%CI = 5.81-26.59, P <0.0001) and stage 2 vs 1 disease (OR 2.26, 95%CI = 1.04-4.93, P =0.04). PTSS was inversely associated with having a college degree (OR 0.29, 95%CI = 0.13-0.62, P =0.002) and greater social support (OR 0.44, 95%CI = 0.21-0.94, P =0.03).CONCLUSION: We found similar rates of cancer-related PTSS in breast cancer survivors diagnosed at a young age compared with the general breast cancer population despite their well-documented increased risk of overall distress. Nevertheless, factors associated with posttraumatic stress should be considered at diagnosis and in survivorship to identify young patients who may benefit from psychosocial resources.

    View details for DOI 10.1002/pon.5438

    View details for PubMedID 32515073

  • Risk of primary gastrointestinal cancers following incident non-metastatic breast cancer: a Danish population-based cohort study. BMJ open gastroenterology Adelborg, K., Farkas, D. K., Sundboll, J., Schapira, L., Tamang, S., Cullen, M. R., Cronin-Fenton, D., Sorensen, H. T. 2020; 7 (1)

    Abstract

    OBJECTIVE: We examined the risk of primary gastrointestinal cancers in women with breast cancer and compared this risk with that of the general population.DESIGN: Using population-based Danish registries, we conducted a cohort study of women with incident non-metastatic breast cancer (1990-2017). We computed cumulative cancer incidences and standardised incidence ratios (SIRs).RESULTS: Among 84972 patients with breast cancer, we observed 2340 gastrointestinal cancers. After 20 years of follow-up, the cumulative incidence of gastrointestinal cancers was 4%, driven mainly by colon cancers. Only risk of stomach cancer was continually increased beyond 1year following breast cancer. The SIR for colon cancer was neutral during 2-5 years of follow-up and approximately 1.2-fold increased thereafter. For cancer of the oesophagus, the SIR was increased only during 6-10 years. There was a weak association with pancreas cancer beyond 10 years. Between 1990-2006 and 2007-2017, the 1-10 years SIR estimate decreased and reached unity for upper gastrointestinal cancers (oesophagus, stomach, and small intestine). For lower gastrointestinal cancers (colon, rectum, and anal canal), the SIR estimate was increased only after 2007. No temporal effects were observed for the remaining gastrointestinal cancers. Treatment effects were negligible.CONCLUSION: Breast cancer survivors were at increased risk of oesophagus and stomach cancer, but only before 2007. The risk of colon cancer was increased, but only after 2007.

    View details for DOI 10.1136/bmjgast-2020-000413

    View details for PubMedID 32611556

  • Partners of young breast cancer survivors: a cross-sectional evaluation of psychosocial concerns, coping, and mental health. Journal of psychosocial oncology Borstelmann, N. A., Rosenberg, S., Gelber, S., Zheng, Y., Meyer, M., Ruddy, K. J., Schapira, L., Come, S., Borges, V., Cadet, T., Maramaldi, P., Partridge, A. H. 2020: 1?17

    Abstract

    Evaluation of psychosocial concerns, coping style, and mental health in partners of young (diagnosed at ?40?years) survivors of early-stage breast cancer (BC).Cross-sectional; partners participated in a one-time survey.289 participants; most were male, white, working full-time, college educated, with median age of 43?years, parenting children <18?years old.Logistic regression was used to explore associations with anxiety and depression (?8 on Hospital Anxiety and Depression sub-scales).Overall, 41% reported symptoms of anxiety, 18% reported symptoms of depression, and 44% identified maladaptive coping. Multivariable regression analyses revealed: lower social support and poorer quality of life significantly associated with depression (p < .05); maladaptive coping, fulltime employment, poorer caregiver QOL, and less education significantly associated with anxiety.Partners of young BC survivors who use more maladaptive coping strategies, report less social support, work fulltime, and/or who have lower education levels experience negative mental health outcomes.Enhancing constructive coping and ensuring all partners have access to supportive resources may improve partners' emotional adjustment.

    View details for DOI 10.1080/07347332.2020.1823546

    View details for PubMedID 33000705

  • Association of Breast Cancer Surgery With Quality of Life and Psychosocial Well-being in Young Breast Cancer Survivors. JAMA surgery Rosenberg, S. M., Dominici, L. S., Gelber, S., Poorvu, P. D., Ruddy, K. J., Wong, J. S., Tamimi, R. M., Schapira, L., Come, S., Peppercorn, J. M., Borges, V. F., Partridge, A. H. 2020

    Abstract

    Young women with breast cancer are increasingly choosing bilateral mastectomy (BM), yet little is known about short-term and long-term physical and psychosocial well-being following surgery in this population.To evaluate the differential associations of surgery with quality of life (QOL) and psychosocial outcomes from 1 to 5 years following diagnosis.Cohort study.Multicenter, including academic and community hospitals in North America.Women age ?40 when diagnosed with Stage 0-3 with unilateral breast cancer between 2006 and 2016 who had surgery and completed QOL and psychosocial assessments.Primary breast surgery including breast-conserving surgery (BCS), unilateral mastectomy (UM), and BM.Physical functioning, body image, sexual health, anxiety and depressive symptoms were assessed in follow-up.Of 826 women, mean age at diagnosis was 36.1 years; most women were White non-Hispanic (86.7%). Regarding surgery, 45% had BM, 31% BCS, and 24% UM. Of women who had BM/UM, 84% had reconstruction. While physical functioning, sexuality, and body image improved over time, sexuality and body image were consistently worse (higher adjusted mean scores) among women who had BM vs BCS (body image: year 1, 1.32 vs 0.64; P?

    View details for DOI 10.1001/jamasurg.2020.3325

    View details for PubMedID 32936216

  • Perceptions of time spent pursuing cancer care among patients, caregivers, and oncology professionals. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer Hall, E. T., Sridhar, D., Singhal, S., Fardeen, T., Lahijani, S., Trivedi, R., Gray, C., Schapira, L. 2020

    Abstract

    Patients with cancer spend significant time receiving treatment and recovering from side effects. Little is known about how patients and their caregivers perceive time spent receiving cancer treatment and how this impacts health-related quality of life (HRQoL). Our study aims to characterize perceptions of time invested in receiving cancer therapy as experienced by patients, caregivers, and oncology professionals.We conducted semi-structured interviews with patients undergoing treatment for advanced lung cancer and melanoma, their informal caregivers, and oncology professionals (physicians, nurses, social workers, and chaplains). Participants received and provided care at a tertiary cancer center. Interviews were audiorecorded and transcribed verbatim. Transcripts were analyzed qualitatively using predominantly inductive coding to identify themes relating to time perception and cancer care.We interviewed 29 participants (11 patients, 7 informal caregivers, and 11 oncology professionals) and found they consistently differentiated between time remaining in life ("existential time") and time required to manage cancer treatment and symptoms ("chronological time"). Patients and caregivers reported distress around the mechanics of oncologic care that interrupted their daily lives (hobbies, activities). Participants described the impact of time invested in cancer care on dimensions of quality of life, ranging from minimal to substantial negative impact.We found that the time spent undergoing cancer treatment affects well-being and often prevents patients and caregivers from participating in meaningful activities. The investment of personal time undergoing cancer therapy for patients with advanced solid tumors merits further study and can enhance communication between patients, caregivers, and their oncologists.

    View details for DOI 10.1007/s00520-020-05763-9

    View details for PubMedID 32935204

  • Do qualitative interviews cause distress in adolescents and young adults asked to discuss fears of cancer recurrence? Psycho-oncology Heathcote, L. C., Loecher, N., Spunt, S. L., Simon, P., Tutelman, P. R., Wakefield, C. E., Ach, E., Schapira, L. 2020

    Abstract

    This article is protected by copyright. All rights reserved.

    View details for DOI 10.1002/pon.5544

    View details for PubMedID 32909342

  • Clinical impact of COVID-19 on patients with cancer (CCC19): a cohort study. Lancet (London, England) Kuderer, N. M., Choueiri, T. K., Shah, D. P., Shyr, Y., Rubinstein, S. M., Rivera, D. R., Shete, S., Hsu, C. Y., Desai, A., de Lima Lopes, G., Grivas, P., Painter, C. A., Peters, S., Thompson, M. A., Bakouny, Z., Batist, G., Bekaii-Saab, T., Bilen, M. A., Bouganim, N., Larroya, M. B., Castellano, D., Del Prete, S. A., Doroshow, D. B., Egan, P. C., Elkrief, A., Farmakiotis, D., Flora, D., Galsky, M. D., Glover, M. J., Griffiths, E. A., Gulati, A. P., Gupta, S., Hafez, N., Halfdanarson, T. R., Hawley, J. E., Hsu, E., Kasi, A., Khaki, A. R., Lemmon, C. A., Lewis, C., Logan, B., Masters, T., McKay, R. R., Mesa, R. A., Morgans, A. K., Mulcahy, M. F., Panagiotou, O. A., Peddi, P., Pennell, N. A., Reynolds, K., Rosen, L. R., Rosovsky, R., Salazar, M., Schmidt, A., Shah, S. A., Shaya, J. A., Steinharter, J., Stockerl-Goldstein, K. E., Subbiah, S., Vinh, D. C., Wehbe, F. H., Weissmann, L. B., Wu, J. T., Wulff-Burchfield, E., Xie, Z., Yeh, A., Yu, P. P., Zhou, A. Y., Zubiri, L., Mishra, S., Lyman, G. H., Rini, B. I., Warner, J. L. 2020

    Abstract

    Data on patients with COVID-19 who have cancer are lacking. Here we characterise the outcomes of a cohort of patients with cancer and COVID-19 and identify potential prognostic factors for mortality and severe illness.In this cohort study, we collected de-identified data on patients with active or previous malignancy, aged 18 years and older, with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection from the USA, Canada, and Spain from the COVID-19 and Cancer Consortium (CCC19) database for whom baseline data were added between March 17 and April 16, 2020. We collected data on baseline clinical conditions, medications, cancer diagnosis and treatment, and COVID-19 disease course. The primary endpoint was all-cause mortality within 30 days of diagnosis of COVID-19. We assessed the association between the outcome and potential prognostic variables using logistic regression analyses, partially adjusted for age, sex, smoking status, and obesity. This study is registered with ClinicalTrials.gov, NCT04354701, and is ongoing.Of 1035 records entered into the CCC19 database during the study period, 928 patients met inclusion criteria for our analysis. Median age was 66 years (IQR 57-76), 279 (30%) were aged 75 years or older, and 468 (50%) patients were male. The most prevalent malignancies were breast (191 [21%]) and prostate (152 [16%]). 366 (39%) patients were on active anticancer treatment, and 396 (43%) had active (measurable) cancer. At analysis (May 7, 2020), 121 (13%) patients had died. In logistic regression analysis, independent factors associated with increased 30-day mortality, after partial adjustment, were: increased age (per 10 years; partially adjusted odds ratio 184, 95% CI 153-221), male sex (163, 107-248), smoking status (former smoker vs never smoked: 160, 103-247), number of comorbidities (two vs none: 450, 133-1528), Eastern Cooperative Oncology Group performance status of 2 or higher (status of 2 vs 0 or 1: 389, 211-718), active cancer (progressing vs remission: 520, 277-977), and receipt of azithromycin plus hydroxychloroquine (vs treatment with neither: 293, 179-479; confounding by indication cannot be excluded). Compared with residence in the US-Northeast, residence in Canada (024, 007-084) or the US-Midwest (050, 028-090) were associated with decreased 30-day all-cause mortality. Race and ethnicity, obesity status, cancer type, type of anticancer therapy, and recent surgery were not associated with mortality.Among patients with cancer and COVID-19, 30-day all-cause mortality was high and associated with general risk factors and risk factors unique to patients with cancer. Longer follow-up is needed to better understand the effect of COVID-19 on outcomes in patients with cancer, including the ability to continue specific cancer treatments.American Cancer Society, National Institutes of Health, and Hope Foundation for Cancer Research.

    View details for DOI 10.1016/S0140-6736(20)31187-9

    View details for PubMedID 32473681

  • Patterns of social media use and associations with psychosocial outcomes among breast and gynecologic cancer survivors. Journal of cancer survivorship : research and practice Tolby, L. T., Hofmeister, E. N., Fisher, S., Chao, S., Benedict, C., Kurian, A. W., Berek, J. S., Schapira, L., Palesh, O. G. 2020

    Abstract

    We sought to characterize the use of social media (SM) among breast and gynecologic cancer survivors, as well as associations between patterns of SM use and psychosocial outcomes.Two hundred seventy-three breast and gynecologic cancer survivors recruited at the Stanford Women's Cancer Center completed the study. Participants completed questionnaires to measure quality of life (FACT-G), functional social support (Duke-UNC FSSQ), distress (PHQ-4), decision regret (DRS), and SM use.In total, 75.8% of the sample reported using SM. There was no difference in quality of life (QOL), functional social support (FSS), distress, or decision regret between SM users and non-users. SM users indicated using SM for social support (34.3%) and loneliness (24.6%) more than for information-seeking (15.9%), coping (18.8%), or self-disclosure (14%). SM use for coping was associated with lower QOL (p

    View details for DOI 10.1007/s11764-020-00959-8

    View details for PubMedID 33161562

  • Contemporary management of breast cancer during pregnancy and subsequent lactation in a multicenter cohort of young women with breast cancer. The breast journal Lee, G. E., Rosenberg, S. M., Mayer, E. L., Borges, V., Meyer, M. E., Schapira, L., Come, S. E., Partridge, A. H. 2019

    Abstract

    The incidence of breast cancer diagnosed during pregnancy is increasing. We sought to characterize patient, treatment, pregnancy and lactation factors among young women with newly diagnosed breast cancer during pregnancy in a prospective cohort study. We identified all women who were pregnant when diagnosed with invasive breast cancer among those enrolled in the Young Women's Breast Cancer Study (NCT01468246), and collected details on pregnancy, birth and lactation from surveys, and treatment information medical record review. Of 1302 enrolled participants, 976 women with invasive breast cancer completed full baseline surveys, among whom 39 (4.0%) patients reported being pregnant at diagnosis. Median age at diagnosis was 34years (range: 25-40), with stage distribution: I, 28%; II, 44%; III, 23%; and IV, 5%. 74% of patients (29/39) had grade 3 tumors, 59% (23/39) ER-positive, and 31% (12/39) HER2-positive disease. 23 (59%) had surgery during pregnancy, 4 (17%) during the first trimester. Among the women who had surgery during pregnancy, 61% (14/23) underwent lumpectomy, 35% (8/23) unilateral, and 4% (1/23) bilateral mastectomy. All patients who had chemotherapy (51%, 20/39) received it in second and third trimesters, and had ACx4. There were 31 live births, 2 spontaneous, and 5 therapeutic abortions. Among live births, 16 (41%) were before 37weeks of gestation. Three women reported breastfeeding. Within 6months after delivery, comprehensive staging in 13 patients showed upstaging in four patients. In a contemporary cohort of young women with breast cancer, pregnancy at diagnosis is relatively uncommon. Treatment during pregnancy can generally be consistent with standard surgical and chemotherapy approaches, with attention to timing of therapies. Longer-term outcomes including effects of some timing issues including delayed use of anti-HER2 therapy on patient outcomes warrant further research.

    View details for DOI 10.1111/tbj.13431

    View details for PubMedID 31318125

  • Patient-Reported Outcomes for Cancer Patients Receiving Checkpoint Inhibitors: Opportunities for Palliative Care-A Systematic Review JOURNAL OF PAIN AND SYMPTOM MANAGEMENT Hall, E. T., Singhal, S., Dickerson, J., Gabster, B., Wong, H., Aslakson, R. A., Schapira, L., Ast, K., Carroll, T., Dzeng, E., Harrison, K. L., Kaye, E. C., LeBlanc, T. W., Lo, S. S., McKenna, K., Nageswaran, S., Powers, J., Rotella, J., Ullrich, C., Vickey, T., AAHPM Res Comm Writing Grp 2019; 58 (1): 137-+
  • Nonadherent behaviors among young women on adjuvant endocrine therapy for breast cancer. Cancer Wassermann, J., Gelber, S. I., Rosenberg, S. M., Ruddy, K. J., Tamimi, R. M., Schapira, L., Borges, V. F., Come, S. E., Meyer, M. E., Partridge, A. H. 2019

    Abstract

    BACKGROUND: Young age is a known factor associated with suboptimal adherence to endocrine therapy (ET) for adjuvant breast cancer (BC) treatment. This study was aimed at assessing nonadherent behaviors and associated factors among young women with early-stage hormone receptor-positive BC.METHODS: As part of a multicenter, prospective cohort of women with a diagnosis of BC at or under the age of 40years, participants were surveyed 30months after their diagnosis about adherent behaviors. Among those who reported taking ET, adherence was measured with a 3-item Likert-type scale: Do you ever forget to take your ET? If you feel worse when you take your ET, do you stop taking it? Did you take your ET exactly as directed by your doctor over the last 3months? Women reporting at least 1 nonadherent behavior were classified as nonadherers. Variables with a P value<.20 were included in a multivariable logistic model.RESULTS: Among 384 women, 194 (51%) were classified as nonadherers. Univariate factors that retained significance in the multivariable model included educational level (odds ratio [OR], 0.50 for high vs low; P=.04), level of social support according to the Medical Outcome Study Social Support Survey (OR, 0.98 per 1 point; P=.01), and confidence with the decision regarding ET measured on a 0 to 10 numerical scale (OR, 0.63 for high vs low; P=.04).CONCLUSIONS: Findings from this study could help to identify young patients at higher risk for nonadherence. Interventions adapted to the level of education and aimed at reinforcing support and patients' confidence in their decision to take ET could improve adherence and associated outcomes in this population.

    View details for DOI 10.1002/cncr.32192

    View details for PubMedID 31120571

  • Identifying distinct trajectories of change in young breast cancer survivors' sexual functioning PSYCHO-ONCOLOGY von Hippel, C., Rosenberg, S. M., Austin, S., Sprunck-Harrild, K., Ruddy, K. J., Schapira, L., Come, S., Borges, V. F., Partridge, A. H. 2019; 28 (5): 1033?40

    View details for DOI 10.1002/pon.5047

    View details for Web of Science ID 000467279600012

  • Patient reported outcomes for cancer patients receiving immunotherapy: opportunities for palliative care - A Systematic Review. Journal of pain and symptom management Hall, E. T., Singhal, S., Dickerson, J., Gabster, B., Wong, H., Aslakson, R. A., Schapira, L. 2019

    Abstract

    CONTEXT: Immune checkpoint inhibitors (ICIs) are increasingly used to treat a variety of cancers, but comparatively little is known about patient-reported outcomes (PROs) and health-related quality of life (HRQoL) among patients receiving these novel therapies.OBJECTIVES: We performed a systematic review to examine PROs and HRQoL among cancer patients receiving ICIs as compared to other anticancer therapies.METHODS: We systematically searched PubMed, CINAHL, Embase, Web of Science, and Scopus, using search terms representing ICIs, PROs and HRQoL on August 10, 2018. Eligible articles were required to involve cancer patients treated with ICIs and to report PROs and/or HRQoL data.RESULTS: We screened 1,453 references and included 15 publications representing 15 randomized controlled trials in our analysis. Studies included several cancer types (melanoma, lung cancer, genitourinary cancer, and head/neck cancer), utilized four different ICIs (nivolumab, pembrolizumab, atezolizumab, and ipilimumab), and compared ICIs to a wide range of therapies (chemotherapy, targeted therapies, other immunotherapy strategies, and placebo). Studies utilized a total of seven different PROs to measure HRQOL, most commonly the European Organisation for the Research and Treatment of Cancer core quality of life questionnaire (EORTC QLQ-C30) (n = 12, 80%). PRO data were reported in a variety of formats and at a variety of time points throughout treatment which made direct comparison challenging. Some trials (n=11, 73%) reported PROs on specific symptoms. In general, patients receiving ICIs had similar to improved HRQoL and experiences when compared to other therapies.CONCLUSION: Despite the broad clinical trials experience of ICI therapies across cancer types, relatively few randomized studies reported patient PROs and HRQoL data. Available data suggest that ICIs are well-tolerated in terms of HRQoL compared to other anticancer therapies although the conclusions are limited by the heterogeneity of trial designs and outcomes. Currently used instruments may fail to capture important symptomatology unique to ICIs, underscoring a need for PROs designed specifically for ICIs.

    View details for PubMedID 30905677

  • Identifying Distinct Trajectories of Change in Young Breast Cancer Survivors' Sexual Functioning. Psycho-oncology von Hippel, C., Rosenberg, S. M., Austin, S. B., Sprunck-Harrild, K., Ruddy, K. J., Schapira, L., Come, S., Borges, V. F., Partridge, A. H. 2019

    Abstract

    OBJECTIVES: To identify and characterize distinct trajectories of change in young women's sexual functioning over five years following breast cancer diagnosis.METHODS: Group-based trajectory modeling was applied to the sexual functioning of 896 women diagnosed with stage I-IV breast cancer at age ?40 years. The Cancer Rehabilitation Evaluation System was used to evaluate women's symptoms of sexual dysfunction annually for five years.RESULTS: Five distinct trajectories of sexual functioning were identified: one asymptomatic, one minimally symptomatic, two moderately symptomatic, and one severely symptomatic trajectory. 12% of women were asymptomatic throughout follow-up. The plurality of women experienced stable mild symptoms (42%). Amongst those with moderate symptoms, some experienced improvement over time (22%) while others experienced deterioration (13%). 11% experienced stable severe symptoms that did not remit over time. Independent predictors of experiencing a symptomatic rather than asymptomatic trajectory (p<0.05, two-sided) included diagnosis with stage 2 versus 1 disease, ER+ disease treated with oophorectomy or ovarian suppression, being partnered, having anxiety, poorer body image, and greater musculoskeletal pain.CONCLUSIONS: We identified distinct trajectories that describe the reported sexual symptoms in this cohort of young breast cancer survivors. The majority of women reported various degrees of sexual dysfunction that remained stable over the study period. There is, however, potential for improvement of moderate and severe symptoms of sexual dysfunction in early survivorship.

    View details for PubMedID 30817075

  • Family-building decision aid and planning tool for young adult women after cancer treatment: protocol for preliminary testing of a web-based decision support intervention in a single-arm pilot study. BMJ open Benedict, C., Ford, J. S., Schapira, L., Simon, P., Spiegel, D., Diefenbach, M. 2019; 9 (12): e033630

    Abstract

    Many young adult female (YA-F) cancer survivors who received gonadotoxic therapy will experience fertility problems. After cancer, having a child will often require assisted reproductive technology (ART), surrogacy or adoption. However, there are significant informational, psychosocial, financial and logistical barriers to pursuing these options. Survivors report high rates of decision uncertainty and distress related to family-building decisions. The aim of this study is to pilot test a web-based decision aid and planning tool for family-building after cancer.The pilot study will use a single-arm trial design to test the feasibility and acceptability (aim 1) and obtain effect size estimates of the decision support intervention (aim 2). The target sample size is 100. Participants will include YA-F survivors (aged 18-45 years) who are post-treatment and have not completed desired family-building. A longitudinal prepost design will be conducted. Participants will complete three psychosocial assessment surveys over a 3-month time period to track decisional conflict (primary outcome) and cognitive, emotional, and behavioural functioning (secondary outcomes). After completing the baseline survey (T1; pre-intervention), participants will have access to the decision aid website. Postintervention surveys will be administered at 1-month (T2) and 3-month (T3) follow-up time points. Feasibility and acceptability metrics will be analysed. Pairwise t-tests will test mean scores of outcome variables from T1 to T2. Effect size estimates (Cohen's d) will be calculated. Google analytics will evaluate user engagement with the website over the study period. Baseline and follow-up data will examine measures of feasibility, acceptability and intervention effect size.This will be the first test of a supportive intervention to guide YA-F cancer survivors in family-building decisions and early planning. Study findings will inform intervention development. Future directions will include a randomised controlled trial to test intervention efficacy over a longer time period.NCT04059237; Pre-results.

    View details for DOI 10.1136/bmjopen-2019-033630

    View details for PubMedID 31888941

  • Prognostic Impact of the 21-Gene Recurrence Score Assay Among Young Women With Node-Negative and Node-Positive ER-Positive/HER2-Negative Breast Cancer. Journal of clinical oncology : official journal of the American Society of Clinical Oncology Poorvu, P. D., Gelber, S. I., Rosenberg, S. M., Ruddy, K. J., Tamimi, R. M., Collins, L. C., Peppercorn, J., Schapira, L., Borges, V. F., Come, S. E., Warner, E., Jakubowski, D. M., Russell, C., Winer, E. P., Partridge, A. H. 2019: JCO1901959

    Abstract

    The 21-gene recurrence score (RS) assay is prognostic among women with early-stage estrogen receptor-positive (ER+) and human epidermal growth factor receptor 2-negative (HER2-) breast cancer and is used to inform recommendations for chemotherapy. Women ? 40 years of age represent a minority of patients studied using gene expression profiles.The Young Women's Breast Cancer Study is a prospective cohort of women diagnosed with breast cancer at age ? 40 years and enrolled patients between 2006 and 2016 (N = 1,302). We identified patients with stage I-III ER+/HER2- breast cancer. The RS assay was performed on banked specimens for patients who had not been tested clinically. Distant recurrence-free survival (DRFS) was assessed by TAILORx and traditional RS risk groups among patients with axillary node-negative (N0) and limited node-positive (N1) breast cancer.Among eligible women (N = 577), 189 (33%) had undergone RS testing, and 320 (56%) had banked specimens sufficient for testing. Median follow-up was 6.0 years. Median age at diagnosis was 37.2 years; 300 of 509 patients (59%) had N0 breast cancer, of whom 195 (65%) had an RS of 11-25 and fewer than half (86 of 195; 44%) received chemotherapy. Six-year DRFS rates were 94.4% and 92.3% (RS < 11), 96.9% and 85.2% (RS 11-25), and 85.1% and 71.3% (RS ? 26) among women with N0 and N1 disease, respectively.The RS assay is prognostic among young women with node-negative and limited node-positive breast cancer, representing a valuable tool for risk stratification. Disease outcomes with a median follow-up of 6 years among young women with N0 disease and an RS of 0-25, a minority of whom received chemotherapy, and node-positive disease with an RS < 11 were very good, whereas those with N0 disease and an RS ? 26 or N1 disease with an RS ? 11 experienced substantial risk of early distant recurrence.

    View details for DOI 10.1200/JCO.19.01959

    View details for PubMedID 31809240

  • Targeting Mindsets, Not Just Tumors Trends in Cancer Zion, S. R., Schapira, L., Crum, A. J. 2019
  • Employment trends in young women following a breast cancer diagnosis. Breast cancer research and treatment Rosenberg, S. M., Vaz-Luis, I., Gong, J., Rajagopal, P. S., Ruddy, K. J., Tamimi, R. M., Schapira, L., Come, S., Borges, V., de Moor, J. S., Partridge, A. H. 2019

    Abstract

    Little is known about how a breast cancer diagnosis and treatment affects job-related outcomes in young women with breast cancer, who are an integral part of the workforce. We sought to describe employment trends among young breast cancer survivors.911 women with non-metastatic breast cancer were surveyed about employment-related outcomes 1 year post-diagnosis. Participants were enrolled in the Young Women's Breast Cancer Study an ongoing, multi-center cohort of women diagnosed with breast cancer at age ??40.Among 911 women, median age at diagnosis was 36years (range 17-40). Most women (80%, n?=?729) were employed 1 year post-diagnosis. Among the 7% (n?=?62) employed before diagnosis but who reported unemployment at 1 year, approximately half reported they were unemployed for health reasons. Among employed women, 7% said treatment affected their ability to perform their job. Women with stage-three disease (vs. stage 1 disease, odds ratio (OR): 3.73, 95% CI 1.39-9.97) and those who reported having money to pay bills after cutting back or difficulty paying bills at baseline (vs. having enough money for special things, OR 2.70, 95% CI 1.32-5.52) at baseline were more likely to have transitioned out of the workforce.Our results suggest an impact of disease burden and socioeconomic status on employment in young breast cancer survivors. There is a need to ensure young survivors who leave the workforce following diagnosis are sufficiently supported given the potential adverse psychosocial and financial impacts of unemployment on survivors, their families, communities, and society.

    View details for DOI 10.1007/s10549-019-05293-x

    View details for PubMedID 31147983

  • Evaluation of significant genome-wide association studies risk - SNPs in young breast cancer patients. PloS one Rath, M., Li, Q., Li, H., Lindstrom, S., Miron, A., Miron, P., Dowton, A. E., Meyer, M. E., Larson, B. G., Pomerantz, M., Seo, J., Collins, L. C., Vardeh, H., Brachtel, E., Come, S. E., Borges, V., Schapira, L., Tamimi, R. M., Partridge, A. H., Freedman, M., Ruddy, K. J. 2019; 14 (5): e0216997

    Abstract

    PURPOSE: Genome-wide-association studies (GWAS) have identified numerous single nucleotide polymorphisms (SNPs) that are associated with an increased risk of breast cancer. Most of these studies were conducted primarily in postmenopausal breast cancer patients. Therefore, we set out to assess whether or not these breast cancer variants are also associated with an elevated risk of breast cancer in young premenopausal patients.METHODS: In 451 women of European ancestry who had prospectively enrolled in a longitudinal cohort study for women diagnosed with breast cancer at or under age 40, we genotyped 44 SNPs that were previously associated with breast cancer risk. A control group was comprised of 1142 postmenopausal healthy women from the Nurses' Health Study (NHS). We assessed if the frequencies of the adequately genotyped SNPs differed significantly (p?0.05) between the cohort of young breast cancer patients and postmenopausal controls, and then we corrected for multiple testing.RESULTS: Genotyping of the controls or cases was inadequate for comparisons between the groups for seven of the 44 SNPs. 9 of the remaining 37 were associated with breast cancer risk in young women with a p-value <0.05: rs10510102, rs1219648, rs13387042, rs1876206, rs2936870, rs2981579, rs3734805, rs3803662 and rs4973768. The directions of these associations were consistent with those in postmenopausal women. However, after correction for multiple testing (Benjamini Hochberg) none of the results remained statistically significant.CONCLUSION: After correction for multiple testing, none of the alleles for postmenopausal breast cancer were clearly associated with risk of premenopausal breast cancer in this relatively small study.

    View details for DOI 10.1371/journal.pone.0216997

    View details for PubMedID 31125336

  • Online Communities as Sources of Peer Support for People Living With Cancer: A Commentary. Journal of oncology practice Gupta, T., Schapira, L. 2018: JOP1800261

    Abstract

    Online communities are virtual spaces dedicated to hosting conversations between individuals with a common interest. Information can be shared and obtained incrementally, as users can periodically post both questions and responses to other users' questions. Although online communities have been used frequently by patients for a myriad of health issues, much remains to be learned about these resources. In this commentary, we explore the emerging role of online communities as forums for information exchange and sources of support for patients with cancer and caregivers. We discuss selected examples of online communities launched by research institutions, advocacy groups, philanthropic organizations, start-ups, and novel enterprises featuring collaborations between industry, health care professionals, and advocates. We explore the risks and benefits of online communities as perceived by oncology clinicians and provide practical recommendations for improving communication between clinicians and patients about the use of online resources.

    View details for PubMedID 30335558

  • Anxiety and Depression in Young Women With Metastatic Breast Cancer: A Cross-Sectional Study PSYCHOSOMATICS Park, E. M., Gelber, S., Rosenberg, S. M., Seah, D. E., Schapira, L., Come, S. E., Partridge, A. H. 2018; 59 (3): 251?58

    Abstract

    Young adults with cancer experience disruptions in their normal developmental trajectories and commonly experience psychologic distress related to their diagnoses. Young women with metastatic breast cancer (MBC) are at particular risk of adverse mental health outcomes.We sought to determine the prevalence of and factors associated with anxiety and depression symptoms in young women with newly diagnosed de novo MBC.A total of 54 women with newly diagnosed de novo MBC were identified from an ongoing, prospective, multicenter cohort of women diagnosed with breast cancer at age <40. Depression and anxiety symptoms were assessed using the Hospital Anxiety and Depression Scale (HADS). Items assessing socio-demographics, physical symptom burden, social support, and disease and treatment history, with complementary medical record review, were used to assess variables potentially associated with anxiety and depression symptoms.Mean HADS Depression score was 4.4 (standard deviation = 3.7) and mean HADS Anxiety score was 7.9 (standard deviation = 5.0). Eleven (20%) women scored ?8 on the HADS Depression subscale, the suggested threshold for depression/anxiety screening, and 24 (44%) women scored ?8 on the HADS Anxiety subscale. In a multivariable model of anxiety, higher physical symptom scores (odds ratio = 4.41, p = 0.005) was significantly associated with higher anxiety scores. None of the other variables improved the model fit.In this study, a considerable proportion of young women with newly diagnosed MBC experienced anxiety symptoms, although depression was less common. Future strategies focused on distress reduction in young MBC patients should focus on physical symptom management as well as anxiety identification and management.

    View details for PubMedID 29525523

    View details for PubMedCentralID PMC5935568

  • The Power of Trust. JAMA oncology Mou, E., Schapira, L., Kunz, P. 2018

    View details for PubMedID 29710067

  • Management of side effects during and post-treatment in breast cancer survivors BREAST JOURNAL Palesh, O., Scheiber, C., Kesler, S., Mustian, K., Koopman, C., Schapira, L. 2018; 24 (2): 167?75

    Abstract

    Cancer-related fatigue, insomnia, and cancer-related cognitive impairment are commonly experienced symptoms that share psychological and physical manifestations. One or more of these symptoms will affect nearly all patients at some point during their course of treatment or survivorship. These side effects are burdensome and reduce patients' quality of life well beyond their cancer diagnosis and associated care treatments. Cancer-related fatigue, insomnia, and cancer-related cognitive impairment are likely to have multiple etiologies that make it difficult to identify the most effective method to manage them. In this review, we summarized the information on cancer-related fatigue, insomnia, and cancer-related cognitive impairment incidence and prevalence among breast cancer patients and survivors as well as recent research findings on pharmaceutical, psychological, and exercise interventions that have shown effectiveness in the treatment of these side effects. Our review revealed that most current pharmaceutical interventions tend to ameliorate symptoms only temporarily without addressing the underlying causes. Exercise and behavioral interventions are consistently more effective at managing chronic symptoms and possibly address an underlying etiology. Future research is needed to investigate effective interventions that can be delivered directly in clinic to a large portion of patients and survivors.

    View details for PubMedID 28845551

  • Amani's Silence. oncologist Baider, L., Schapira, L. 2017

    View details for DOI 10.1634/theoncologist.2017-0207

    View details for PubMedID 28592623

  • For Our Patients, for Ourselves: The Value of Personal Reflection in Oncology. American Society of Clinical Oncology educational book. American Society of Clinical Oncology. Meeting Schapira, L., Meisel, J. L., Srivastava, R. 2017; 37: 765-770

    Abstract

    Caring for patients with cancer is a great privilege as well as an emotionally and intellectually challenging task. Stress and burnout are prevalent among oncology clinicians, with serious repercussions for the care of patients. Professional societies must provide guidance for trainees and practicing physicians to mitigate the negative consequences of stress on their personal lives and medical practice. Reflection, reading, and writing about personal experiences provide outlets for fortifying personal reserves and promoting resilience to allow us to recognize the joy and meaning of our work and to forge connections with our peers. Herein, we present some of our own reflections on how and why one might take time to write, and about the power of the written word in oncology and medicine.

    View details for DOI 10.14694/EDBK_175520

    View details for PubMedID 28561701

  • Normalization of compression-induced hemodynamics in patients responding to neoadjuvant chemotherapy monitored by dynamic tomographic optical breast imaging (DTOBI). Biomedical optics express Sajjadi, A. Y., Isakoff, S. J., Deng, B., Singh, B., Wanyo, C. M., Fang, Q., Specht, M. C., Schapira, L., Moy, B., Bardia, A., Boas, D. A., Carp, S. A. 2017; 8 (2): 555?69

    Abstract

    We characterize novel breast cancer imaging biomarkers for monitoring neoadjuvant chemotherapy (NACT) and predicting outcome. Specifically, we recruited 30 patients for a pilot study in which NACT patients were imaged using dynamic tomographic optical breast imaging (DTOBI) to quantify the hemodynamic changes due to partial mammographic compression. DTOBI scans were obtained pre-treatment (referred to as day 0), as well as 7 and 30 days into therapy on female patients undergoing NACT. We present data for the 13 patients who participated in both day 0 and 7 measurements and had evaluable data, of which 7 also returned for day 30 measurements. We acquired optical images over 2 minutes following 4-8 lbs (18-36 N) of compression. The timecourses of tissue-volume averaged total hemoglobin (HbT), as well as hemoglobin oxygen saturation (SO2) in the tumor vs. surrounding tissues were compared. Outcome prediction metrics based on the differential behavior in tumor vs. normal areas for responders (>50% reduction in maximum diameter) vs. non-responders were analyzed for statistical significance. At baseline, all patients exhibit an initial decrease followed by delayed recovery in HbT, and SO2 in the tumor area, in contrast to almost immediate recovery in surrounding tissue. At day 7 and 30, this contrast is maintained in non-responders; however, in responders, the contrast in hemodynamic time-courses between tumor and normal tissue starts decreasing at day 7 and substantially disappears at day 30. At day 30 into NACT, responding tumors demonstrate "normalization" of compression induced hemodynamics vs. surrounding normal tissue whereas non-responding tumors did not. This data suggests that DTOBI imaging biomarkers, which are governed by the interplay between tissue biomechanics and oxygen metabolism, may be suitable for guiding NACT by offering early predictions of treatment outcome.

    View details for DOI 10.1364/BOE.8.000555

    View details for PubMedID 28270967

    View details for PubMedCentralID PMC5330555

  • ESMO / ASCO Recommendations for a Global Curriculum in Medical Oncology Edition 2016. ESMO open Dittrich, C., Kosty, M., Jezdic, S., Pyle, D., Berardi, R., Bergh, J., El-Saghir, N., Lotz, J. P., sterlund, P., Pavlidis, N., Purkalne, G., Awada, A., Banerjee, S., Bhatia, S., Bogaerts, J., Buckner, J., Cardoso, F., Casali, P., Chu, E., Close, J. L., Coiffier, B., Connolly, R., Coupland, S., De Petris, L., De Santis, M., de Vries, E. G., Dizon, D. S., Duff, J., Duska, L. R., Eniu, A., Ernstoff, M., Felip, E., Fey, M. F., Gilbert, J., Girard, N., Glaudemans, A. W., Gopalan, P. K., Grothey, A., Hahn, S. M., Hanna, D., Herold, C., Herrstedt, J., Homicsko, K., Jones, D. V., Jost, L., Keilholz, U., Khan, S., Kiss, A., Khne, C. H., Kunstfeld, R., Lenz, H. J., Lichtman, S., Licitra, L., Lion, T., Litire, S., Liu, L., Loehrer, P. J., Markham, M. J., Markman, B., Mayerhoefer, M., Meran, J. G., Michielin, O., Moser, E. C., Mountzios, G., Moynihan, T., Nielsen, T., Ohe, Y., berg, K., Palumbo, A., Peccatori, F. A., Pfeilstcker, M., Raut, C., Remick, S. C., Robson, M., Rutkowski, P., Salgado, R., Schapira, L., Schernhammer, E., Schlumberger, M., Schmoll, H. J., Schnipper, L., Sessa, C., Shapiro, C. L., Steele, J., Sternberg, C. N., Stiefel, F., Strasser, F., Stupp, R., Sullivan, R., Tabernero, J., Travado, L., Verheij, M., Voest, E., Vokes, E., Von Roenn, J., Weber, J. S., Wildiers, H., Yarden, Y. 2016; 1 (5): e000097

    Abstract

    The European Society for Medical Oncology (ESMO) and the American Society of Clinical Oncology (ASCO) are publishing a new edition of the ESMO/ASCO Global Curriculum (GC) thanks to contribution of 64 ESMO-appointed and 32 ASCO-appointed authors. First published in 2004 and updated in 2010, the GC edition 2016 answers to the need for updated recommendations for the training of physicians in medical oncology by defining the standard to be fulfilled to qualify as medical oncologists. At times of internationalisation of healthcare and increased mobility of patients and physicians, the GC aims to provide state-of-the-art cancer care to all patients wherever they live. Recent progress in the field of cancer research has indeed resulted in diagnostic and therapeutic innovations such as targeted therapies as a standard therapeutic approach or personalised cancer medicine apart from the revival of immunotherapy, requiring specialised training for medical oncology trainees. Thus, several new chapters on technical contents such as molecular pathology, translational research or molecular imaging and on conceptual attitudes towards human principles like genetic counselling or survivorship have been integrated in the GC. The GC edition 2016 consists of 12 sections with 17 subsections, 44 chapters and 35 subchapters, respectively. Besides renewal in its contents, the GC underwent a principal formal change taking into consideration modern didactic principles. It is presented in a template-based format that subcategorises the detailed outcome requirements into learning objectives, awareness, knowledge and skills. Consecutive steps will be those of harmonising and implementing teaching and assessment strategies.

    View details for DOI 10.1136/esmoopen-2016-000097

    View details for PubMedID 27843641

    View details for PubMedCentralID PMC5070299

  • Molecular Phenotype of Breast Cancer According to Time Since Last Pregnancy in a Large Cohort of Young Women. The oncologist Collins, L. C., Gelber, S., Marotti, J. D., White, S., Ruddy, K., Brachtel, E. F., Schapira, L., Come, S. E., Borges, V. F., Schedin, P., Warner, E., Wensley, T., Tamimi, R. M., Winer, E. P., Partridge, A. H. 2015; 20 (7): 713?18

    Abstract

    The increase in breast cancer risk during pregnancy and postpartum is well known; however, the molecular phenotype of breast cancers occurring shortly after pregnancy has not been well studied. Given this, we investigated whether nulliparity and the time interval since pregnancy among parous women affects the breast cancer phenotype in young women.We examined molecular phenotype in relation to time since pregnancy in a prospective cohort of 707 young women (aged ?40 years) with breast cancer. Parity was ascertained from study questionnaires. Using tumor histologic grade on central review and biomarker expression, cancers were categorized as luminal A- or B-like, HER2 enriched, and triple negative.Overall, 32% were luminal A-like, 41% were luminal B-like, 9% were HER2 enriched, and 18% were triple negative. Although, numerically, patients diagnosed >5 years after pregnancy had more luminal A-like subtypes than women with shorter intervals since pregnancy, there was no evidence of a relationship between these intervals and molecular subtypes once family history of breast cancer and age at diagnosis were considered.Distribution of breast cancer molecular phenotype did not differ significantly among young women by parity or time interval since parturition when important predictors of tumor phenotype such as age and family history were considered.Distribution of breast cancer molecular phenotype did not differ among parous young women by time interval since pregnancy. The implication of these findings for clinical practice suggests that pregnancy-associated breast cancers may be seen up to 5 years beyond parturition.

    View details for DOI 10.1634/theoncologist.2014-0412

    View details for PubMedID 26025931

    View details for PubMedCentralID PMC4492229

  • Partner support and anxiety in young women with breast cancer. Psycho-oncology Borstelmann, N. A., Rosenberg, S. M., Ruddy, K. J., Tamimi, R. M., Gelber, S., Schapira, L., Come, S., Borges, V., Morgan, E., Partridge, A. H. 2015; 24 (12): 1679?85

    Abstract

    Using a large prospective cohort of women age 40 or younger diagnosed with breast cancer, we examined the relationship between perceived partner support and anxiety.Six hundred seventy-five young women with breast cancer Stages I-III, median age 36, completed a self-report baseline questionnaire. Perceived partner support was assessed using items extracted from the marital subscale of the Cancer Rehabilitation Evaluation System; generalized social support was assessed with the Medical Outcomes Study-Social Support Survey. Anxiety was measured using the anxiety subscale of the Hospital Anxiety and Depression Scale. Multivariable logistic regression analyses evaluated the association between partner support, other sociodemographic factors, and anxiety.Mean age at diagnosis was 35.4 years. Fourteen percent of the women were not partnered, and among those who were partnered or in a significant relationship, 20% were categorized as unsupported. In univariate and multivariable analysis adjusting for sociodemographic factors, women in an unsupported-partnered relationship had higher odds of anxiety symptoms compared with women in a supported-partnered relationship. Young age and being financially insecure were also both independently associated with anxiety.Our findings suggest that partner support may play a key role in a young woman's adjustment to a serious stressor such as breast cancer. In addition, younger age increases vulnerability to anxiety as does struggling with finances. Because supportive efforts of a partner have potential to protect against the impact of stress, interventions to enhance partner support and reduce anxiety might be beneficial to address challenges experienced as a couple in this setting.

    View details for DOI 10.1002/pon.3780

    View details for PubMedID 25765893

  • Treatment-related amenorrhea and sexual functioning in young breast cancer survivors. Cancer Rosenberg, S. M., Tamimi, R. M., Gelber, S., Ruddy, K. J., Bober, S. L., Kereakoglow, S., Borges, V. F., Come, S. E., Schapira, L., Partridge, A. H. 2014; 120 (15): 2264?71

    Abstract

    Sexual dysfunction is a known complication of adjuvant therapy for breast cancer and an important determinant of quality of life. However, few studies have explored how treatment and other factors affect sexual functioning in young breast cancer survivors.Four hundred sixty-one premenopausal women with stage 0 through III breast cancer were surveyed an average of 1 year after diagnosis as part of a prospective cohort study of women who were aged ?40 years at diagnosis. Sexual interest and dysfunction were assessed using the Cancer Rehabilitation Evaluation System (CARES). Mean CARES scores were compared and multiple regression models were fit to assess treatment and a range of menopausal and somatic symptoms in relation to sexual functioning.Mean CARES sexual interest and dysfunction scores were both highest (indicating poorer functioning) among women who received chemotherapy and were amenorrheic from treatment. After accounting for menopausal and somatic symptoms, treatment-associated amenorrhea remained associated with decreased interest but was no longer an independent predictor of dysfunction. In the multivariable analysis, independent predictors of dysfunction included vaginal pain symptoms, poorer body image, and fatigue. Sexual interest was associated with vaginal pain symptoms, body image, and weight problems.Factors associated with decreased sexual functioning in young breast cancer survivors can often be ameliorated. The current findings have implications for premenopausal women with other types of cancer who might be experiencing amenorrhea because of chemotherapy or surgery. Increased awareness and early intervention is essential to help improve sexual functioning and associated quality of life for all young cancer survivors.

    View details for DOI 10.1002/cncr.28738

    View details for PubMedID 24891236

    View details for PubMedCentralID PMC4116329

  • Handling uncertainty. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer Schapira, L. 2014; 22 (3): 859?61

    Abstract

    Uncertainty is triggered by many events during the experience of illness - from hearing bad news to meeting a new doctor. Oncology professionals need to recognize the intense feelings associated with uncertainty and respond empathically to patients. This article describes opportunities to strengthen the therapeutic connection and minimize uncertainty.

    View details for DOI 10.1007/s00520-013-2086-y

    View details for PubMedID 24337763

  • The influence of the patient-clinician relationship on healthcare outcomes: a systematic review and meta-analysis of randomized controlled trials. PloS one Kelley, J. M., Kraft-Todd, G., Schapira, L., Kossowsky, J., Riess, H. 2014; 9 (4): e94207

    Abstract

    To determine whether the patient-clinician relationship has a beneficial effect on either objective or validated subjective healthcare outcomes.Systematic review and meta-analysis.Electronic databases EMBASE and MEDLINE and the reference sections of previous reviews.Included studies were randomized controlled trials (RCTs) in adult patients in which the patient-clinician relationship was systematically manipulated and healthcare outcomes were either objective (e.g., blood pressure) or validated subjective measures (e.g., pain scores). Studies were excluded if the encounter was a routine physical, or a mental health or substance abuse visit; if the outcome was an intermediate outcome such as patient satisfaction or adherence to treatment; if the patient-clinician relationship was manipulated solely by intervening with patients; or if the duration of the clinical encounter was unequal across conditions.Thirteen RCTs met eligibility criteria. Observed effect sizes for the individual studies ranged from d = -.23 to .66. Using a random-effects model, the estimate of the overall effect size was small (d = .11), but statistically significant (p = .02).This systematic review and meta-analysis of RCTs suggests that the patient-clinician relationship has a small, but statistically significant effect on healthcare outcomes. Given that relatively few RCTs met our eligibility criteria, and that the majority of these trials were not specifically designed to test the effect of the patient-clinician relationship on healthcare outcomes, we conclude with a call for more research on this important topic.

    View details for DOI 10.1371/journal.pone.0094207

    View details for PubMedID 24718585

    View details for PubMedCentralID PMC3981763

  • Hemodynamic signature of breast cancer under fractional mammographic compression using a dynamic diffuse optical tomography system. Biomedical optics express Carp, S. A., Sajjadi, A. Y., Wanyo, C. M., Fang, Q., Specht, M. C., Schapira, L., Moy, B., Bardia, A., Boas, D. A., Isakoff, S. J. 2013; 4 (12): 2911?24

    Abstract

    Near infrared dynamic diffuse optical tomography measurements of breast hemodynamics during fractional mammographic compression offer a novel contrast mechanism for detecting breast cancer and monitoring chemotherapy. Tissue viscoelastic relaxation during the compression period leads to a slow reduction in the compression force and reveals biomechanical and metabolic differences between healthy and lesion tissue. We measured both the absolute values and the temporal evolution of hemoglobin concentration during 25-35 N of compression for 22 stage II and III breast cancer patients scheduled to undergo neoadjuvant chemotherapy. 17 patients were included in the group analysis (average tumor size 3.2 cm, range: 1.3-5.7 cm). We observed a statistically significant differential decrease in total and oxy-hemoglobin, as well as in hemoglobin oxygen saturation in tumor areas vs. healthy tissue, as early as 30 seconds into the compression period. The hemodynamic contrast is likely driven by the higher tumor stiffness and different viscoelastic relaxation rate, as well as the higher tumor oxygen metabolism rate.

    View details for DOI 10.1364/BOE.4.002911

    View details for PubMedID 24409390

    View details for PubMedCentralID PMC3862147

  • Body image in recently diagnosed young women with early breast cancer. Psycho-oncology Rosenberg, S. M., Tamimi, R. M., Gelber, S., Ruddy, K. J., Kereakoglow, S., Borges, V. F., Come, S. E., Schapira, L., Winer, E. P., Partridge, A. H. 2013; 22 (8): 1849?55

    Abstract

    To assess body image concerns among young women following a breast cancer diagnosis.A total of 419 women with recently diagnosed stage 0-III breast cancer were surveyed following enrollment as part of a prospective cohort study of women age 40 or younger at diagnosis. Body image was assessed using three items from the psycho-social scale of the Cancer Rehabilitation Evaluation System (CARES). CARES scores range from 0 to 4, with higher scores indicative of greater image concerns. Mean CARES scores were calculated and compared between treatment groups using t-tests and analysis of variance. Multiple linear regression models were fit to evaluate the relationship between physical and psychological factors and body image.Mean time from diagnosis to completion of the baseline survey was 5.2 months. The mean CARES score for all women was 1.28. Mean CARES scores in the mastectomy-only group (1.87) and in the mastectomy with reconstruction group (1.52) were significantly higher (p < 0.0001) compared with the scores in the lumpectomy group (0.85), indicating that radical surgery was associated with more body image concerns. Radiation (p = 0.01), anxiety (p = 0.0001), depression (p < 0.0001), fatigue (p = 0.04), musculoskeletal pain symptoms (p < 0.0001), weight gain (p = 0.01), and weight loss (p = 0.02), in addition to surgery type (p < 0.0001), were all associated with more body image concerns in the multi-variable analysis.This analysis highlights the impact of treatment, along with physical and psychological factors, on body image early in the survivorship period. Our findings provide targets for potential future intervention and may aid young women in the surgical decision-making process.

    View details for DOI 10.1002/pon.3221

    View details for PubMedID 23132765

    View details for PubMedCentralID PMC3594059

  • The impact of intrapersonal, interpersonal, and community factors on the identity formation of young adults with cancer: a qualitative study. Psycho-oncology Kumar, A. R., Schapira, L. 2013; 22 (8): 1753?58

    Abstract

    The purpose of this study was to examine how young adult cancer patients make sense of their experiences with cancer.Semi-structured interviews were conducted with patients at an urban tertiary care centerThe sample for this study included 15 young adult cancer survivors. The ages of the participants ranged from 18 to 30 years. The sample was 67% female (n = 10) and 33% male (n = 5). The sample was 87% Caucasian (n = 13) and 13% Hispanic (n = 2). Fifty-three percent of the participants were between ages 18 and 23 years (n = 8), and 47% of the participants were between ages 24 and 30 years (n = 7). Three themes emerged from the data: intrapersonal change, interpersonal interactions, and role and identity in the hospital and the community. As they inevitably lose control in their lives, young adult patients seek to return to a familiar lifestyle that they consider as 'normal'. The formation of a revised identity and redefined set of norms allows the patients to regain control and express their individualism.This study contributes to our knowledge of the experiences of young adult cancer patients and survivors. The findings serve to inform young adults, caregivers, and health professionals on coping with illness and its aftermath.

    View details for DOI 10.1002/pon.3207

    View details for PubMedID 23080480

  • Engaging referring physicians in the clinical trial process. Journal of oncology practice Baer, A. R., Michaels, M., Good, M. J., Schapira, L. 2012; 8 (1): e8?e10

    Abstract

    By building relationships with referring physicians and educating them about the clinical trial process, oncologists can help increase trial accrual among patients with cancer.

    View details for DOI 10.1200/JOP.2011.000476

    View details for PubMedID 22548019

    View details for PubMedCentralID PMC3266325

  • A new look at informed consent for cancer clinical trials. Journal of oncology practice Baer, A. R., Good, M., Schapira, L. 2011; 7 (4): 267?70

    Abstract

    Informed consent is fundamental to the conduct of clinical trials. Prospective participants need to be adequately informed and given the opportunity to ask questions and consult with relatives or friends without feeling pressured or rushed.

    View details for DOI 10.1200/JOP.2011.000347

    View details for PubMedID 22043194

    View details for PubMedCentralID PMC3140452

  • Patients as real time teachers. Journal of cancer education : the official journal of the American Association for Cancer Education Bandman, B. M., Bandman, C. E., Pennell, N., Schapira, L. 2007; 22 (2): 131?33

    View details for DOI 10.1007/BF03174363

    View details for PubMedID 17605630

  • Palpable right breast mass in a pregnant woman. Nature clinical practice. Oncology Katz, M. S., Schapira, L., Harisinghani, M. G., Hughes, K. S. 2005; 2 (4): 218?21; quiz 1 p following 222

    Abstract

    A 29-year-old female presented with a palpable right breast mass at a 12-week prenatal visit. She had no family history of breast or ovarian cancer. Ultrasound revealed a 3 cm lobulated mass, which was confirmed to be malignant by a core biopsy. Postmastectomy pathology at 15 weeks' gestation demonstrated this mass to be a stage T2N0M0 high-grade invasive ductal carcinoma with 0/20 axillary nodes involved. A staging CT scan postpartum showed an enlarged right internal mammary lymph node, confirmed by MRI as suspicious for malignancy.Physical examination, breast ultrasound, core biopsy, mastectomy, CT scan, MRI.Pregnancy-associated breast carcinoma.Mastectomy, chemotherapy and radiotherapy.

    View details for DOI 10.1038/ncponc0135

    View details for PubMedID 16264937

  • An existential oncologist. Journal of clinical oncology : official journal of the American Society of Clinical Oncology Schapira, L. 2003; 21 (9 Suppl): 77s?78s

    View details for DOI 10.1200/JCO.2003.01.179

    View details for PubMedID 12743202

  • A revisitation of "doc, how much time do I have?". Journal of clinical oncology : official journal of the American Society of Clinical Oncology Schapira, L., Eisenberg, P. D., MacDonald, N., Mumber, M. P., Loprinzi, C. 2003; 21 (9 Suppl): 8s?11s

    View details for DOI 10.1200/JCO.2003.01.156

    View details for PubMedID 12743179

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