Monday, May 07, 2012
JCO: A Way Forward on the Medically Appropriate Use of White Cell Growth Factors (hematopoietic colony-stimulating factors (CSFs))
A Way Forward on the Medically Appropriate Use of White Cell Growth Factors
Discussion points:
- Are Hematopoietic Colony-Stimulating Factors Over- or Underused?
- Table 1. Comparison of Major Guidelines
- How Can These Disparate Conclusions Be Reconciled?
- CSFs for Dose Maintenance in Routine Noncurative Cancer Care
- CSFs Used to Treat FN or Afebrile Neutropenia
- What Is the Harm in Using CSFs?
- Are CSFs a Prudent Use of Societal Resources?
- Why Do Oncologists Prescribe CSFs if There Is Minimal Evidence for Benefit?
- How Did We Arrive at Widespread Use Without Clinical Trial Justification?
- The Way Forward to Evidence-Based Use of CSFs
- Disclosures/REFERENCES
JCO: Financial Hardship: A Consequence of Survivorship? editorial/link to original paper
editorial:
#1: Financial Hardship: A Consequence of Survivorship?
Editorial: Financial Hardship: A Consequence of Survivorship?
referenced:
#2: (paywalled) See accompanying article on page 1608
Risk Factors for Financial Hardship in Patients Receiving Adjuvant Chemotherapy for Colon Cancer: A Population-Based Exploratory Analysis
paywalled: How Radiation Oncologists Would Disclose Errors: Results of a Survey of Radiation Oncologists and Trainees (patient safety)
How Radiation Oncologists Would Disclose Errors: Results of a Survey of Radiation Oncologists and Trainees
Purpose
To analyze error disclosure attitudes of radiation oncologists and to correlate error disclosure beliefs with survey-assessed disclosure behavior.Health News - Targeting ovarian cancer - Dr. Robert Bristow finds disparities in access to the top-quality care that boosts survival
Health News - Targeting ovarian cancer
Dr. Robert Bristow finds disparities in access to the top-quality care that boosts survival
Patients Share Of Expensive Specialty Drugs Is Rising - Kaiser Health News (choices: eating vs insurance costs...)
Patients Share Of Expensive Specialty Drugs Is Rising - Kaiser Health News
"....The coinsurance was killing them. "It was a choice between that and eating," says Gary Ryness.
Working with an insurance consultant, they switched from a preferred provider organization to a health maintenance organization that didn't have coinsurance charges for self-injectable drugs such as Avonex. Now, they pay nothing for the drug...."
".....many patients who rely on specialty drugs are coping with very serious, long-term medical conditions. "Consumerism" - encouraging patients to shop wisely for health care - doesn't really apply when such patients need drugs for which there are few or no alternatives, says Stone.
"With people as sick as the patients we're talking about, I don't think they're going to say, 'Is there a less expensive injectable drug I can take?' " she says. "It's a whole different dynamic."
Next week: Some states seek to require parity on oral cancer drug coverage.
National Guideline Clearinghouse | Epithelial ovarian, fallopian tube, and primary peritoneal cancer - Alberta, Canada
Blogger's Note: note the differences in early stage recommendations per cell type
National Guideline Clearinghouse | Epithelial ovarian, fallopian tube, and primary peritoneal cancer.
Guideline Title
Epithelial ovarian, fallopian tube, and primary peritoneal cancer.
Bibliographic Source(s)
| Alberta Provincial Gynecologic Oncology Tumour Team. Epithelial ovarian, fallopian tube, and primary peritoneal cancer. Edmonton (Alberta): Alberta Health Services, Cancer Care; 2010 Jul. 19 p. (Clinical practice guideline; no. GYNE-005). [104 references] |
Guideline Status
This is the current release of the guideline.
-
|
-
|
Scope
Disease/Condition(s)
- Epithelial ovarian cancer
- Fallopian tube cancer
- Primary peritoneal cancer
Guideline Category
Evaluation
Management
Treatment
Clinical Specialty
Obstetrics and Gynecology
Oncology
Radiation Oncology
Surgery
Intended Users
Physician Assistants
Physicians
Guideline Objective(s)
To outline management decisions for women with epithelial ovarian, fallopian tube, or primary peritoneal cancer
Key Points
Key Points
- Completely staged, early epithelial ovarian, fallopian tube, and primary peritoneal cancers are highly curable. As such, patients should be referred to a gynecologic oncologist for adequate staging, including sampling of para-aortic and pelvic lymph nodes, infracolic omentectomy, possible appendectomy and biopsy of suspicious peritoneal lesions, in addition to a thorough inspection and palpation of all peritoneal surfaces, and peritoneal washings.
- Advanced epithelial ovarian, fallopian tube, and primary peritoneal cancers are best treated with optimal debulking surgery in conjunction with adjuvant therapy. As such, patients should be referred to a gynecologic oncologist
National Guideline Clearinghouse | Palliative radiotherapy.
Blogger's Note: the document reveals only one indication for ovarian cancer and it has been categorized under urogenital bleeding
National Guideline Clearinghouse | Palliative radiotherapy.
Guideline Objective(s)
To provide recommended palliative radiotherapy strategies for adult patients with advanced cancer
Scope
Disease/Condition(s)
Advanced cancer with:
- Brain metastases
- Malignant epidural spinal cord compression
- Malignant superior vena cava obstruction
- Bone metastases
- Upper aero-digestive tract obstruction, compression, or invasion
- Malignancy-associated urogenital or gastrointestinal bleeding, or hemoptysis
Guideline Category
Management
Treatment
Clinical Specialty
Gastroenterology
Neurological Surgery
Obstetrics and Gynecology
Oncology
Pulmonary Medicine
Radiation Oncology
Urology
Bleeding
Recommendations for Urogenital Bleeding
- External beam radiotherapy has been shown to control hematuria in up to 60 percent of patients with advanced bladder cancer; and control rates of 80 percent at six weeks have recently been reported in patients with advanced prostate cancer. In patients with a life expectancy less than six months, external beam radiotherapy treatment with 8 Gy/1 fraction could be considered. Otherwise, a short course multi-fraction schedule could be considered.
- In patients with vaginal bleeding who are unsuitable for radical treatment, radiotherapy is effective in resolving bleeding secondary to endometrial or cervical cancer. There is insufficient evidence to recommend an ideal dose and fractionation schedule. Radiotherapy may also be used to control bleeding and palliate pain and mass effect in advanced ovarian cancer.
paywalled: Clinical implications of pleural effusions in ovarian cancer - Porcel - Respirology - Wiley Online Library
Blogger's Note: note the use of neoadjuvant therapy in this particular subset of ovarian cancer patients
Clinical implications of pleural effusions in ovarian cancer - Porcel - Respirology
Keywords:
- malignant pleural effusion;
- ovarian cancer;
- thoracoscopy;
- pleurodesis
ABSTRACT
The
pleural cavity constitutes the most frequent extra-abdominal metastatic
site in ovarian carcinoma (OC). In patients with OC and pleural
effusions, a positive fluid cytology is required for a stage IV
diagnosis. Unfortunately, about 30% of malignant pleural effusions
exhibit false negative cytological pleural fluid results. In those
circumstances, exploratory video-assisted thoracoscopic surgery (VATS)
serves as a diagnostic, staging and even therapeutic modality. Maximal
(no visible disease) or, at least, optimal (no residual implant greater
than 1 cm) cytoreduction should be the primary surgical goal in stage IV
OC patients. This is due to residual tumor after cytoreductive surgery
being one of the most important factors impacting on survival. Although
malignant pleural effusions do not preclude abdominal surgical
debulking, excision of gross pleural nodules may be necessary to achieve
optimal cytoreduction. VATS quantifies pleural tumor burden and allows
for intrathoracic cytoreduction or, if the latter is not feasible,
ensures that abdominal surgery is not unnecessarily performed on women
in whom gross tumor would still remain in the pleural space afterwards.
Taxane-platinum neoadjuvant chemotherapy should be offered to this
group. Patients with tumor extension into the pleural space have a
median overall survival of 2 years.
Insight: Training immune system to fight cancer comes of age | Reuters
Blogger's Note: not specific to ovarian cancer
Insight: Training immune system to fight cancer comes of age | Reuters
".....While extending life is the gold standard, most cancer drug trials have been deemed successful if tumors shrink or if a treatment can demonstrate a delay in tumor growth or in worsening of the disease, known as progression-free survival (PFS).
But Provenge and Yervoy have extended survival without necessarily impacting PFS or tumor shrinkage in many cases.
"Overall survival is the accurate indicator. Tumors may look bigger because they are filled with immune cells, so they appear worse," said Wolchok. "We've proposed a new set of response criteria to try to incorporate some of this biology.".......
PLoS ONE: Empty Reviews: A Description and Consideration of Cochrane Systematic Reviews with No Included Studies - your opinions?
Blogger's Note/Opinion: gyn cancers - this topic of discussion should be of interest: Cochrane total gyn cancers reviews = #85; empty reviews = #7; because Cochrane synthesizes and analyses systematic reviews, often the results are inadequate (for patients/providers) in that studies included are: poor quality; lacking in data or are not randomized clinical trials; we often see this as 'further research is required'; many 'argue' that the value of systematic reviews in gyn cancers are dated (as discussed in this article) but part of this issue is the nature of, in particular, ovarian cancer research itself; the other 'issue' for this blogger is the number of systematic reviews which continually review reviews; (re: reviews that include Cochrane systematic reviews); there needs to be a streamlining of systematic reviews (randomized clinical trial reviews) nominating or permitting one entity/conglomerate - eg. the philosophy of meaningful use, however, therein lies system wide issues within cancer; observational studies are often not included in the reviews and Cochrane is attempting to address this issue within the parameters of the purpose and philosophy of Cochrane itself, still for quality evidence Cochrane remains the leader; note also that Cochrane has always been one of, if not the leader, in including patients/consumers - your thoughts?
PLoS ONE: Empty Reviews: A Description and Consideration of Cochrane Systematic Reviews with No Included Studies
Introduction
The
Cochrane Library is the largest and perhaps best recognized global
collection of health care evidence, currently hosting more than 4,500
systematic reviews in its Cochrane Database of Systematic Reviews (CDSR).
However, it has been reported that clinicians find Cochrane reviews of
limited relevance to practice decisions. For example, one study found
that while Cochrane reviews are highly regarded for their quality, they
are used less than other sources for clinical decision-making because of
their emphasis on methodology and rigor rather than on clinical
relevance [1].
It is not Cochrane's policy to provide guidelines for practice or policy decisions [2].
Instead, it sees itself as the provider of best quality evidence and
specifically states that guidelines go “beyond a systematic review and
require additional information and informed judgments that are typically
the domain of clinical practice guideline developers.”Systematic reviews that find no studies eligible for inclusion, commonly known as “empty reviews,” may be especially problematic for clinicians and other decision-makers. Little is known about the incidence, prevalence or variation in reporting of such reviews [3]. The little that has been written about them suggests that the reporting of implications for practice may sustain a risk for bias. With no studies meeting criteria for inclusion, these empty reviews may appear to: (1) offer no conclusions, (2) offer conclusions based on referenced excluded studies, (3) offer conclusions based on other evidence, or (4) offer conclusions not based on evidence. Thus, empty reviews may contribute to what appears to be generalized disappointment with The CDSR among some clinicians and policymakers [1], [4]........
Conclusions
The stated purpose of Cochrane reviews is to help healthcare providers, consumers, researchers, and policy makers “make well-informed decisions about health care… by providing a reliable synthesis of the available evidence on a given topic… considering all the evidence on the effect of an intervention” [2]......Sunday, May 06, 2012
www.ccocr.org - Guest Speakers - 6th Canadian Conference on Ovarian Cancer Research (patients/ advocates need not apply)
Blogger's Note: unlike the annual SGO programme ovarian cancer patient advocates need not apply (not welcome); survivor's course available for a fee
www.ccocr.org - Guest Speakers
Epigenetic modification and cancer: mark or stamp? (BRCA/fallopian tube....)
Epigenetic modification and cancer: mark or stamp?
Abstract
Hypotheses are built upon data, but
data require hypotheses before they can be understood. The development
of the ‘two-hit’
hypothesis of carcinogenesis was a key event in
cancer genetics because it provided a testable model of how tumours
develop.
In this commentary on ‘Promoter hypermethylation
patterns in Fallopian tube epithelium of BRCA1 and BRCA2 germline mutation carriers’ by Bijron et al. published in the February 2012 issue of Endocrine-Related Cancer, the need for new grammar and some new hypotheses in epigenetics is discussed. Meanwhile, data suggesting an important role
of epigenetic modification in the cause, progression and treatment of cancer continues to accumulate............
Introduction
In hereditary tumours, the first hit
occurs in the germ line, whereas in non-hereditary tumours, the first
hit occurs in the
cell from which the tumour arises. The second
hits are always somatic, and can inactivate the second allele in various
different
ways. The development of the ‘two-hit’
hypothesis of carcinogenesis was a key event in cancer genetics because
it provided
a testable model of how tumours develop (Knudson 1971, 1978). Although there have been extensions and revisions to the basic model (Tomlinson et al. 2001), the essential elements of the basic hypothesis remain intact, 40 years on. In the original ‘test case’ of RB-1 mutations in retinoblastoma, these events were physical alterations in the structure of the chromosome or gene (Cavenee et al. 1983), and the perception was such that physical changes put a ‘stamp’ on the tumour that could be detected by examination of
genomic DNA.............
continue to read full paper
paywalled: Sleep disturbance, cytokines, and fatigue in women with ovarian cancer.
Sleep disturbance, cytokines, and fatigue in women with ovarian cancer.
Abstract
Pro-inflammatory cytokines, such as interleukin-6 (IL-6), have been implicated in the underlying processes contributing to sleep regulation and fatigue. Despite evidence for sleep difficulties, fatigue, and elevations in IL-6 among women with ovarian cancer, the association between these symptoms and IL-6 has not been investigated. To address this knowledge gap, we examined relationships between sleep disturbance, fatigue, and plasma IL-6 in 136 women with ovarian cancer prior to surgery. These relationships were also examined in 63 of these women who were disease-free and not receiving chemotherapy 1 year post-diagnosis. At both time-points, higher levels of IL-6 were significantly associated with sleep disturbances (p<0.05), controlling for potentially confounding biological and psychosocial covariates. Higher IL-6 was significantly associated with fatigue prior to surgery (p<0.05); however, when sleep disturbance was included in the model, the relationship was no longer significant. IL-6 was not significantly associated with fatigue at 1 year. Changes in sleep over time were significantly associated with percent change in IL-6 from pre-surgery to 1 year, adjusting for covariates (p<0.05). These findings support a direct association of IL-6 with sleep disturbances in this population, whereas the relationship between IL-6 and fatigue prior to surgery may be mediated by poor sleep. As this study is the first to examine cytokine contributions to sleep and fatigue in ovarian cancer, further research is warranted to clarify the role of biological correlates of sleep and fatigue in this population.The Healthcare Blog: Will Regina Holliday Become Health Care’s Rosa Parks?
Blogger's Note: the outcome/s of these issues/activities will have international implications with a direct/indirect application to the 99%/1% movements in the recent past
~~~~~~~~~~~~~~~~~~
Will Regina Holliday Become Health Care’s Rosa Parks?:
By Michael L. Millenson
The protest organized by Regina Holliday over a patient’s right to access their medical information is not quite the same magnitude as agitating for integration in 1950s-era Alabama. Yet there are intriguing similarities between the crusade Rosa Parks launched then and what Holliday is attempting today. Both involve a refusal to accept second-class status and a resolve to push back against entrenched institutions.
Parks’ story is well known. Her refusal to surrender her seat to a white male passenger on a Montgomery city bus in December, 1955, prompted her arrest and a sustained bus boycott by outraged black residents. That boycott’s success propelled a young Martin Luther King, Jr. to the forefront of the fight against segregation. Parks eventually came to be known as the “mother of the modern day civil rights movement.”
Holliday’s protest is seeking media attention – as this is written, it had not taken place – by targeting the American Hospital Association’s annual meeting at a Washington hotel. The rights issue involves how quickly patients are able to see their own electronic medical information after leaving the hospital. The AHA, representing an industry that grew up as “the physician’s workshop,” wants a 30-day grace period to give doctors more time to prepare and review material. Holliday demands immediate access.
What makes this a fight about freedom, and not just fodder for the Federal Register, is its profound potential to affect how each of us takes responsibility for our own health and health care in the digital information age. What is most likely to capture the general public’s interest, however, is the way that general principle finds emotional resonance in Holliday’s personal story.
A widow with two young children, Holliday recalls on her blog how her husband, Fred, died “painfully [from cancer] after suffering for weeks.” She blames inadequate pain management and uncoordinated care due to a chaotic medical record. When they sought access to his electronic medical record, the hospital responded by saying “we must wait 21 days and pay 73 cents per page to see the story of his care. Then they told us we could go home to die.”
Just as Rosa Parks was not a random bus passenger – she and her husband, Raymond, were active members of the NAACP – Holliday is not a random patient protester. An artist, she responded to Fred’s death by becoming a “patients right arts advocate,” producing paintings with titles like “73 Cents,” and “Hubris Hospital” and “Give Us Our Damned Data.”
Also like Parks, Holliday is part of a larger community that shares a similar outrage over being relegated to the back seat, even if in the doctor- and hospital-dominated world of health care, the “back of the bus” is symbolic rather than literal. Her protest drew expressions of support from the National Partnership for Women & Families, the Center for Democracy and Technology and others. But the key to whether this protest is a turning point may lie in a phrase used in a letter supporting immediate access from the Society for Participatory Medicine, to which Holliday belongs. (Disclosure: I’m a Society board member and a friend of Holliday’s, but did not draft the comments.)
The Society wrote: “The overarching principle with respect to patient access to electronic health record data…should be: ‘Nothing about me, without me.’”
That phrase comes from a health care conference held in Salzburg, Austria in the late 1990s. It echoes the slogan, “Nothing about us without us” popularized by disability activists in South Africa and then adopted by activists in this country. It is a powerful statement about equality, engagement and control of one’s own destiny even when those who do not want to share control do so with the best of intentions, whether seeking to help the disabled or trying to implement electronic medical records in hospitals.
The problem, as The Silent World of Doctor and Patient defined it so insightfully more than a quarter-century ago, is that many providers genuinely believe it is their duty to act as “rational agents” on the patient’s behalf without asking the patient’s opinion. In contrast, “nothing about me without me” is the patient’s demand for freedom and, yes, the responsibility that comes with it.
That demand is not unprecedented. I’ve written how new moms were given strict baby feeding schedules by pediatricians until Dr. Benjamin Spock declared that mothers deciding when to feed their babies was “was used by the entire human race until the turn of the century.” How the first American Medical Association code of ethics required patients to obey their doctors, and how it required repeated lawsuits by patients before doctors had to tell patients in clear language the risks as well as benefits of a procedure. And how the AHA, facing the threat of legislation, adopted a Patient Bill of Rights that included such privileges as being told the names of all the doctors treating you.
What distinguishes Holliday’s effort is the power of information access in the digital age. “Give us our damned data” means possessing the raw clinical material that lets us partner with our own doctors or choose other clinicians who better meet our needs. We can go “off the grid,” perhaps “crowdsourcing” questions to others, or we can apply that digitized information to treatment recommendations and outcome prediction algorithms based on the same evidence our doctor uses.
Demanding access to our digitized information immediately, rather than when it is convenient for the doctor and hospital to give it to us, is a stark declaration that it is our health and our lives that are immediately at stake: “Nothing about me without me” from our first cry for food on the day we are born and then every day after.
This dispute may soon be forgotten as a kerfuffle over criteria for “Stage 2 meaningful use” subsidies from the Department of Health and Human Services. But if it can ignite an understanding about what takes for us to be true equals in health and health care decisions, it could be the start of a mass movement that would make Rosa Parks proud.
Michael Millenson is a Highland Park, IL-based consultant, a visiting scholar at the Kellogg School of Management and the author of “Demanding Medical Excellence: Doctors and Accountability in the Information Age.
Survey: doctoral thesis - Personal Health Record System Survey (international survey/anonymous)
Blogger's Note: although many patients/consumers may agree/disagree with the use of the term 'chronic' as it applies to cancer, it is one way to voice your opinions should you choose to do so
~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Survey
PERSONAL HEALTH RECORD SYSTEM SURVEY
The following pages contain an anonymous questionnaire, which we invite you to complete.
This questionnaire was developed as part of a doctoral thesis at HEC Montréal on the following topic: "The role of personal health records in the improvement of healthcare services for individuals with chronic diseases".
Not only will your participation be greatly appreciated, but it may also be beneficial for improving healthcare services for individuals with chronic diseases.
Please answer the questions included in this questionnaire without hesitation, because generally, your first impressions best reflect your true opinions. There is no time limit for completing the questionnaire, although we have estimated that it should take about 30 to 45 minutes.
The information gathered is anonymous and shall remain strictly confidential. It will be used only to advance knowledge and for the dissemination of the overall results at academic or professional forums and thought publications. The information collected for this research project can be utilized in further studies about personal health records and chronic care.
You are completely free to refuse to participate in this project and you may decide to stop answering the questions at any time. If you do not want to answer to a particular question, simply stop answering this questionnaire, which will put an end to your participation to this study. Completing this questionnaire will be considered as your consent to participate in our research project.
If you have any questions about this research, please contact the senior researcher, Dr. Chekli, at the telephone number or email address indicated below.
The research ethics committee of HEC Montréal has determined that the collection of data linked to the present study meets the ethics standards for research involving human subjects. If you have any questions related to ethics, please contact the committee secretary at 1-514-340-7182 or at cer@hec.ca
Thank you very much for your participation.
Mohamed Chekli, MD, MSc eng.
Ph. D. Candidate - Administration
HEC Montréal
1-514-739-2502
mohamed.chekli@hec.ca
Albert Lejeune, PhD
Titular Professor
Université du Québec à Montréal
1-514-987-3000 (#4844)
lejeune.albert@uqam.ca
Francois Bellavance, PhD
Titular Professor
HEC Montréal
1-514-340-6485
francois.bellavance@hec.ca
Forbes: (U.S.) Hospital Association "Declares War" on Patient Empowerment
Blogger's Note: click on the pdf link for letter from AHA (as below):
"A firestorm has been triggered by the American Hospital Association’s (AHA) 68 page letter (PDF) commenting on the Stage 2 Meaningful Use proposed requirements."
"Our members are particularly concerned with the proposed objective to provide patients with the ability to view, download and transmit large volumes of protected health information via the Internet (a “patient portal”). The AHA believes that this objective is not feasible as proposed, raises significant security issues, and goes well beyond current technical capacity. We also believe that CMS should not include this objective because the Office of Civil Rights, and not CMS, regulates how health care providers and other covered entities fulfill their obligations under the Health Insurance Portability and Accountability Act (HIPAA), including the obligation to give patients access to their health records. Please see our detailed comments for more
recommendations on changes to specific objectives and measures."
~~~~~~~~~~~~~~~~~~~~~~~~~~
Hospital Association "Declares War" on Patient Empowerment:
A firestorm has been triggered by the American Hospital Association’s (AHA) 68 page letter (PDF) commenting on the Stage 2 Meaningful Use proposed requirements. The reaction has been swift from various individuals and organizations focused on patient rights and empowerment.
Consumer Rights and Patient Empowerment Organizations also weighed in.
- The Center for Democracy & Technology picked apart the legal “hail mary” that the AHA was using in their response. See Hospital Association Fights Digital Data Access for Patients for more.
- The Society for Participatory Medicine stated the following. “Patient engagement is the cornerstone of a successful, cost effective, and high-quality health care system,” said Daniel Z. Sands, MD, the Society’s president and a practicing internist. “Those goals cannot be achieved unless we give patients access to their own health information and encourage them to use it.”
Saturday, May 05, 2012
paywalled: Ovarian Low-Grade Serous Carcinoma: A Comprehensive Update
Ovarian Low-Grade Serous Carcinoma: A Comprehe... [Gynecol Oncol. 2012] - PubMed - NCBI
Ovarian Low-Grade Serous Carcinoma: A Comprehensive Update
Abstract
Ovarian low-grade serous ovarian carcinoma (OvLGSCa) comprises a minority within the heterogeneous group of ovarian carcinomas. Despite biological differences with their high-grade serous counterparts, current treatment guidelines do not distinguish between these two entities. OvLGSCas are characterized by an indolent clinical course. They usually develop from serous tumors of low malignant potential, although they can also arise de novo. When compared with patients with ovarian high grade serous carcinoma (OvHGSCa) patients with OvLGSCa are younger and have better survival outcomes. Current clinical and treatment data available for OvLGSCa come from retrospective studies, suggesting that optimal cytoreductive surgery remains the cornerstone in treatment, whereas chemotherapy has a limited role. Molecular studies have revealed the preponderance of the RAS/RAF/MAPK signalling pathway in the pathogenesis of OvLGSCa, thereby representing an attractive therapeutic target for patients affected by this disease. Improved clinical trial designs and international collaboration are required to optimally address the unmet medical treatment needs of patients affected by this disease.open access: Reproductive Technologies and the Risk of Birth Defects — NEJM
Blogger's Note: this is not cancer-specific/related but may be of interest to young cancer survivors
Reproductive Technologies and the Risk of Birth Defects — NEJM
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