Hepatic adenoma among adult survivors of childhood cancer.

2016 ◽  
Vol 34 (3_suppl) ◽  
pp. 117-117
Author(s):  
Emily S. Tonorezos ◽  
Dana Barnea ◽  
Ghassan K. Abou-Alfa ◽  
Jacqueline Bromberg ◽  
Michael Ian D'Angelica ◽  
...  
Keyword(s):  
Young Adult ◽  
Hormone Therapy ◽  
Malignant Transformation ◽  
Cancer Diagnosis ◽  
Adult Survivors ◽  
Myelogenous Leukemia ◽  
Hepatic Adenoma ◽  
Increased Risk ◽  
History Of ◽  
Young Adult Cancer

117 Background: Hepatic adenoma is a rare and poorly understood benign epithelial neoplasm. Because of the potential for spontaneous hemorrhage, rupture, or malignant transformation; hepatic adenoma over 5 cm require resection. In the general population, the prevalence of hepatic adenoma is estimated at 1 in 100,000 and identified predominantly in obese females on oral contraceptives. An increased risk for hepatic adenoma among adult survivors of childhood and young adult cancer has not been previously reported Methods: Cancer diagnosis and treatment, as well as demographic factors, medications, and comorbidities, were collected from the medical chart among patients with pathological confirmation of hepatic adenoma. All cases were patients diagnosed with a non-hepatic cancer before the age of 40 and seen at Memorial Sloan Kettering Cancer Center. Results: Twelve cases of hepatic adenoma were pathologically confirmed; seven patients (58%) had more than one adenoma. Eleven (92%) cases were female. The most common preceding cancer diagnosis was leukemia (N = 4; 33%). Five (42%) had undergone allogeneic hematopoietic cell transplant with total body irradiation (TBI) as part of their preconditioning regimen. Cases were not as a rule obese; median body mass index was 22.2 kg/m2 (range, 17.6-31.0 kg/m2). All eleven females had a history of current or prior hormone therapy with estrogen and progesterone; the single male case was hypogonadal as a result of radiation therapy to the testes during treatment for acute myelogenous leukemia (AML) and was receiving testosterone therapy at the time of chart review. Eight patients (67%) had hypothyroidism and two (17%) were taking anti-epileptic drugs. Only two patients (17%) were monitored radiographically following biopsy; seven patients (58%) underwent hepatic resection and three (25%) underwent embolization. No patient had significant blood loss or has been observed to undergo malignant transformation, although follow-up is ongoing. Conclusions: Adult survivors of childhood and young adult cancer, particularly females with a history of current or prior hormone therapy, may be at increased risk for hepatic adenoma. Further investigation of this potentially morbid condition is warranted.

scholarly journals Chronic Comorbidities Among Survivors of Adolescent and Young Adult Cancer

2020 ◽  
Vol 38 (27) ◽  
pp. 3161-3174 ◽  
Author(s):  
Chun Chao ◽  
Smita Bhatia ◽  
Lanfang Xu ◽  
Kimberly L. Cannavale ◽  
F. Lennie Wong ◽  
...  
Keyword(s):  
Radiation Therapy ◽  
Young Adult ◽  
Adolescent And Young Adult ◽  
Cumulative Exposure ◽  
Kaiser Permanente ◽  
Increased Risk ◽  
History Of ◽  
Survivorship Care Planning ◽  
Young Adult Cancer ◽  
Chronic Comorbidities

PURPOSE To describe the incidence, relative risk, and risk factors for chronic comorbidities in survivors of adolescent and young adult (AYA) cancer. METHODS This retrospective cohort study included 2-year survivors of AYA cancer diagnosed between age 15 and 39 years at Kaiser Permanente Southern California from 2000 to 2012. A comparison cohort without cancer was individually matched (13:1) to survivors of cancer on age, sex, and calendar year. Using electronic medical records, all participants were followed through December 31, 2014, for chronic comorbidity diagnoses. Poisson regression was used to evaluate the association between cancer survivor status and risk of developing each comorbidity. The associations between cumulative exposure to chemotherapy and radiation therapy and selected comorbidities were examined for survivors of cancer. RESULTS The cohort included 6,778 survivors of AYA cancer and 87,737 persons without a history of cancer. The incidence rate ratio (IRR) for survivors of cancer was significantly increased for nearly all comorbidities examined. IRR ranged from 1.3 (95% CI, 1.2 to 1.4) for dyslipidemia to 8.3 (95% CI, 4.6 to 14.9) for avascular necrosis. Survivors of AYA cancer had a 2- to 3-fold increased risk for cardiomyopathy, stroke, premature ovarian failure, chronic liver disease, and renal failure. Among survivors of cancer, significant associations between chemotherapy and radiation therapy exposures and late effects of cardiomyopathy, hearing loss, stroke, thyroid disorders, and diabetes were observed from the multivariable analyses. Forty percent of survivors of AYA cancer had multiple (≥ 2) comorbidities at 10 years after index date, compared with 20% of those without cancer. CONCLUSION Risk of developing comorbidities is increased in survivors of AYA cancer compared with the general population. Specific cancer treatment exposures were associated with risk of developing different comorbidities. These findings have important implications for survivorship care planning and patient education.

scholarly journals Survivors’ Dilemma: Young Adult Cancer Survivors’ Perspectives of Work-Related Goals

2021 ◽  
pp. 216507992110126
Author(s):  
Lauren Victoria Ghazal ◽  
John Merriman ◽  
Sheila Judge Santacroce ◽  
Victoria Vaughan Dickson
Keyword(s):  
Content Analysis ◽  
Young Adult ◽  
Cancer Survivors ◽  
Cancer Diagnosis ◽  
Financial Toxicity ◽  
Self Identity ◽  
Work Related ◽  
Young Adult Cancer Survivors ◽  
Adult Cancer Survivors ◽  
Young Adult Cancer

Background: Young adult cancer survivors have significant work-related challenges, including interruptions to education and employment milestones, which may affect work-related goals (WRGs). The study purpose was to explore posttreatment perspectives of WRGs in a sample of young adult hematologic cancer survivors. Methods: This qualitative descriptive study used social media to recruit eligible cancer survivors (young adults working or in school at the time of cancer diagnosis). Data were collected through telephone semi-structured interviews and analyzed using directed content analysis, followed by thematic content analysis to identify themes. Findings: The sample ( N = 40) were mostly female (63.5%), White (75%), and diagnosed with Hodgkin lymphoma (57.5%); most worked in professional (40%) or health care (23%) roles. The overarching theme, “Survivors’ Dilemma,” highlights a changed perspective on work-related fulfillment and financial obligations, capturing survivors’ decision-making process regarding work. Three subthemes illustrated questions that participants contemplated as they examined how their WRGs had changed: (a) Self-identity: Do I want to do this work? (b) Perceived health and work ability: Can I do this work? and (c) Financial toxicity: Can I afford to/not to do this work? Conclusions/Application to Practice: Participants experienced a state of dilemma around their WRGs, weighing areas around self-identity, perceived health and work ability, and financial toxicity. Findings suggest occupational health nurses should be aware of challenges surrounding WRGs, including how goals may change following a cancer diagnosis and treatment, and the potential stressors involved in the Survivors’ Dilemma. Occupational health nurses should assess for these issues and refer young survivors to employee and financial assistance programs, as necessary.

scholarly journals Young Adult Cancer Survivorship: Recommendations for Patient Follow-up, Exercise Therapy, and Research

2020 ◽  
Author(s):  
Scott C Adams ◽  
Jennifer Herman ◽  
Iliana C Lega ◽  
Laura Mitchell ◽  
David Hodgson ◽  
...  
Keyword(s):  
Young Adult ◽  
Late Effects ◽  
Adolescent And Young Adult ◽  
Future Research ◽  
Evidence Based ◽  
Pediatric Cancer Survivors ◽  
Increased Risk ◽  
Care Guidelines ◽  
Young Adult Cancer ◽  
Evidence Based Guidelines

Abstract Survivors of adolescent and young adult cancers (AYAs) often live 50 to 60 years beyond their diagnosis. This rapidly growing cohort is at increased risk for cancer- and treatment-related late effects that persist for decades into survivorship. Recognition of similar issues in pediatric cancer survivors has prompted the development of evidence-based guidelines for late effects screening and care. However, corresponding evidence-based guidelines for AYAs have not been developed. We hosted an AYA survivorship symposium for a large group of multidisciplinary AYA stakeholders (approximately 200 were in attendance) at Princess Margaret Cancer Centre (Toronto, ON) to begin addressing this disparity. The following overview briefly summarizes and discusses the symposium’s stakeholder-identified high-priority targets for late effects screening and care, and highlights knowledge gaps to direct future research in the field of AYA survivorship. This overview, while not exhaustive, is intended to stimulate clinicians to consider these high-priority screening and care targets when seeing survivors in clinical settings and, ultimately, support the development of evidence-based ‘late effects’ screening and care guidelines for AYAs.

scholarly journals Meaningful Use of an Electronic Personal Health Record (ePHR) among Pediatric Cancer Survivors

2017 ◽  
Vol 26 (01) ◽  
pp. 250-264 ◽  
Author(s):  
Rebecca S Williamson ◽  
Brooke O Cherven ◽  
Jordan Gilleland Marchak ◽  
Paula Edwards ◽  
Michael Palgon ◽  
...  
Keyword(s):  
Young Adult ◽  
Personal Health Record ◽  
Adult Survivors ◽  
Personal Health ◽  
Adult Care ◽  
Adolescent Cancer ◽  
Increased Risk ◽  
Electronic Personal Health Records ◽  
Young Adult Survivors ◽  
To Receive

Summary Background and Objectivs: Survivors of pediatric and adolescent cancer are at an increased risk of chronic and debilitating health conditions and require life-long specialized care. Stand-alone electronic personal health records (ePHRs) may aid their self-management. This analysis characterizes young adult survivors and parents who meaningfully use an ePHR, Cancer SurvivorLinkTM, designed for survivors of pediatric and adolescent cancer. Methods: This was a retrospective observational study of patients seen at a pediatric survivor clinic for annual survivor care. Young adult survivors and/or parent proxies for survivors <18 years old who completed ePHR registration prior to their appointment or within 90 days were classified as registrants. Registrants who uploaded or downloaded a document and/or shared their record were classified as meaningful users. Results: Overall, 23.7% (148/624) of survivors/parents registered and 38% of registrants used SurvivorLink meaningfully. Young adult registrants who transferred to adult care during the study period were more likely to be meaningful users (aOR: 2.6 (95% CI: 1.1, 6.1)) and used the ePHR twice as frequently as those who continued to receive care in our institution’s pediatric survivor clinic. Among survivors who continued to receive care at our institution, being a registrant was associated with having an annual follow-up visit (aOR: 2.6 (95% CI: 1.2, 5.8)). Conclusions: While ePHRs may not be utilized by all survivors, SurvivorLink is a resource for a subset and may serve as an important bridge for patients who transfer their care. Using SurvivorLink was also associated with receiving recommended annual survivor care.

scholarly journals Incidence of VTE Among Patients with a Cancer Diagnosis in Oklahoma County

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 3463-3463
Author(s):  
Micah Denay McCumber ◽  
Aaron Mark Wendelboe ◽  
Janis Campbell ◽  
Kai Ding ◽  
Michele G Beckman ◽  
...  
Keyword(s):  
Native Americans ◽  
Cancer Diagnosis ◽  
Incidence Rates ◽  
Cancer Type ◽  
Surveillance Period ◽  
Increased Risk ◽  
History Of ◽  
Race Ethnicity ◽  
History Of Cancer ◽  
Active Cancer

Background: Patients with cancer are at elevated risk for venous thromboembolism (VTE). Active cancer contributes a 4-7 fold increased risk for VTE; however, the incidence of VTE stratified by subpopulations of patients diagnosed with cancer, especially race/ethnicity, is uncertain. Objective: Describe the incidence of VTE among adult patients (age ≥ 18 years) with a cancer diagnosis in Oklahoma County, OK according to age, gender, race, and cancer type. Methods: In collaboration with the Centers for Disease Control and Prevention, we established a population-based surveillance system for VTE in Oklahoma County, OK between April 1, 2012-March 31, 2014 to estimate the incidences of first-time and recurrent VTE events. The Commissioner of Health made VTE a reportable condition and delegated surveillance-related responsibilities to the University of Oklahoma, College of Public Health. Active surveillance involved reviewing imaging studies (e.g., chest computed tomography and compression ultrasounds of the extremities) from all inpatient and outpatient facilities in the county and collecting demographic, treatment and risk factor data on all VTE case-patients. Patients were linked to the Oklahoma Central Cancer Registry. Any patient with a cancer diagnosis since 1997, excluding basal or squamous cell carcinoma, were included in the population-at-risk. Active cancer was defined as metastatic or a diagnosis ≤6 months before their VTE diagnosis. Poisson regression was used to estimate incidence rates (IRs) and 95% confidence intervals (CIs), which are reported per 1,000 person years (PY). Estimates with &lt;10 events were suppressed. Results: Among all patients aged ≥18 years with a cancer diagnosis since 1997, 1.5% (n = 881) had a VTE event during the 2-year surveillance period. The overall annual age-adjusted incidence of VTE among those with cancer was 6.8 per 1,000 PY (95% CI: 5.81, 7.95). The demographic-specific incidence rates are summarized in Table 1. The VTE incidence did not significantly differ by sex. When stratified by age, annual VTE incidence was similar among those aged 18-39 years (6.1/1,000 PY, 95% CI: 4.35, 8.61), 40-59 years (6.2/1,000 PY, 95% CI: 5.4, 7.14), and 60-79 years (7.2/1,000 PY, 95% CI: 6.55, 7.90), however, the incidence was significantly higher (p&lt;0.05) in those aged 80+ years (10.1/1,000 PY, 95% CI: 8.77, 11.61). When patients with a cancer diagnosis were stratified by race/ethnicity, non-Hispanic blacks had the highest VTE incidence (11.7/1,000 PY, 95% CI: 10.00, 13.59), followed by Hispanics (8.0/1,000 PY, 95% CI: 5.66, 11.44), non-Hispanic whites (6.9/1,000 PY, 95% CI: 6.41, 7.48), other non-Hispanic/unknown (5.8/1,000 PY, 95% CI: 3.45, 9.85), and non-Hispanic Native Americans (2.6/1,000 PY, 95% CI: 1.39, 4.79). VTE incidence was highest among those with active cancer or a history of cancer within the past three years, after which it appeared to decrease. When stratified by primary cancer type, VTE incidence was highest among those with brain cancer (16.6/1,000 PY, 95% CI: 11.06, 25.04) and lowest among those with prostate cancer (5.2/1,000 PY, 95% CI: 4.20, 6.44). As shown in Table 2, when stratified by cancer type, the incidence of VTE was higher (non-overlapping CIs) among those with active cancer compared to those with a history of cancer &gt;6 months for several tumor types. Discussion: The incidence of VTE among those with cancer differs by race/ethnicity, with non-Hispanic blacks bearing the highest burden of disease. The risk of VTE persists and is particularly elevated up to three years after a cancer diagnosis. Disclosures Raskob: Eli Lilly: Consultancy; Pfizer: Consultancy, Honoraria; Portola: Consultancy; Novartis: Consultancy; BMS: Consultancy, Honoraria; Janssen R&D, LLC: Consultancy, Honoraria; Tetherex: Consultancy; Daiichi Sankyo: Consultancy, Honoraria; Anthos: Consultancy; Bayer Healthcare: Consultancy, Honoraria; Boehringer Ingelheim: Consultancy.

scholarly journals A Retrospective Evaluation of Risk of Peripartum Cardiac Dysfunction in Survivors of Childhood, Adolescent and Young Adult Malignancies

Cancers ◽  
2019 ◽  
Vol 11 (8) ◽  
pp. 1046
Author(s):  
Chait-Rubinek ◽  
Mariani ◽  
Goroncy ◽  
Herschtal ◽  
Wheeler ◽  
...  
Keyword(s):  
At Risk ◽  
Young Adult ◽  
Cancer Diagnosis ◽  
Cardiac Dysfunction ◽  
Adolescent And Young Adult ◽  
Cardiac Events ◽  
Increased Risk ◽  
Cardiac Assessment ◽  
Long Term Survivors

Long-term survivors of childhood, adolescent and young adult (AYA) malignancies with past exposure to potentially cardiotoxic treatments are at risk of peripartum cardiac dysfunction. Incidence and risk factors for peripartum cardiac dysfunction and maternal cardiac outcomes in this population were investigated. Eligible long-term survivors were aged <30 years at cancer diagnosis, with ≥1 pregnancy occurring ≥5 years after diagnosis. “Peripartum” cardiac events were defined as occurring within pregnancy or ≤5months after delivery. Cardiac events were classified “symptomatic” or “subclinical”. “Peripartum cardiomyopathy” (PPCM) was defined as symptomatic dysfunction without prior cardiac dysfunction. Of 64 eligible women, 5 (7.8%) had peripartum cardiac events: 3 symptomatic, 2 subclinical. Of 110 live births, 2 (1.8%, 95% CI 0.2–6.4) were defined as PPCM: Significantly greater than the published general population incidence of 1:3000 (p < 0.001), representing a 55-fold (95% CI 6.6–192.0) increased risk. Risk factor analyses were hypothesis-generating, revealing younger age at cancer diagnosis and higher anthracycline dose. Postpartum, cardiac function of 4 women (80%) failed to return to baseline. In conclusion, peripartum cardiac dysfunction is an uncommon but potentially serious complication in long-term survivors of paediatric and AYA malignancies previously treated with cardiotoxic therapies. Peripartum cardiac assessment is strongly recommended for at-risk patients.

scholarly journals Recommendations for Premature Ovarian Insufficiency Surveillance for Female Survivors of Childhood, Adolescent, and Young Adult Cancer: A Report From the International Late Effects of Childhood Cancer Guideline Harmonization Group in Collaboration With the PanCareSurFup Consortium

2016 ◽  
Vol 34 (28) ◽  
pp. 3440-3450 ◽  
Author(s):  
Wendy van Dorp ◽  
Renée L. Mulder ◽  
Leontien C.M. Kremer ◽  
Melissa M. Hudson ◽  
Marry M. van den Heuvel-Eibrink ◽  
...  
Keyword(s):  
Young Adult ◽  
Late Effects ◽  
Alkylating Agents ◽  
Adolescent And Young Adult ◽  
Premature Ovarian Insufficiency ◽  
Ovarian Insufficiency ◽  
Female Survivors ◽  
Increased Risk ◽  
Long Term Follow Up ◽  
Young Adult Cancer

Purpose Female survivors of childhood, adolescent, and young adult (CAYA) cancer who were treated with alkylating agents and/or radiation, with potential exposure of the ovaries, have an increased risk of premature ovarian insufficiency (POI). Clinical practice guidelines can facilitate these survivors’ access to optimal treatment of late effects that may improve health and quality of survival; however, surveillance recommendations vary among the existing long-term follow-up guidelines, which impedes the implementation of screening. Patients and Methods The present guideline was developed by using an evidence-based approach and summarizes harmonized POI surveillance recommendations for female survivors of CAYA cancer who were diagnosed at age < 25 years. The recommendations were formulated by an international multidisciplinary panel and graded according to the strength of the evidence and the potential benefit gained from early detection and intervention. The harmonized POI surveillance recommendations were developed by using a transparent process and are intended to facilitate care for survivors of CAYA cancer. Results and Conclusion The harmonized set of POI surveillance recommendations is intended to be scientifically rigorous, to positively influence health outcomes, and to facilitate the care for female survivors of CAYA cancer.

Risk Of Acute and Chronic Leukemias Following Radiation Treatment For Locoregional Prostate Cancer In The United States Over 35-Years

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 2652-2652
Author(s):  
Sudipto Mukherjee ◽  
Chandana A. Reddy ◽  
Jay P. Ciezki ◽  
Ramon V. Tiu ◽  
Anjali S. Advani ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
Cancer Diagnosis ◽  
Radiation Treatment ◽  
The United States ◽  
Myelogenous Leukemia ◽  
Acute Leukemias ◽  
Prostate Cancer Diagnosis ◽  
Increased Risk ◽  
Secondary Leukemias

Abstract Background Prostate cancer is the most common cancer diagnosis in men, and one of the leading indications for radiation therapy. The risk of resultant secondary leukemias has not been consistently established. We investigated the risk of all leukemias in a population-based cohort of patients (pts) with locoregional prostate cancer definitively treated with radiotherapy. Methods We queried the Surveillance, Epidemiology, and End Results (SEER) 17 registries to identify a cohort of men >20 years old (n = 183,268) with locoregional prostate adenocarcinoma newly diagnosed between January 1973 and December 2008. Pts who underwent initial treatment with radical prostatectomy (RP) were compared to pts receiving RP with external beam radiotherapy (RP w/EBRT) to investigate the risk of radiation-induced leukemias. These cohorts tend to be well matched regarding age, medical comorbidities and disease characteristics. All new leukemias occurring as a second primary cancer at least one year after the first diagnosis of prostate cancer were identified in SEER using the International Classification of Diseases for Oncology, Third Edition (ICD-O-3) morphology codes. Secondary leukemias included acute myeloid leukemia (AML); chronic myelogenous leukemia (CML); acute and chronic lymphocytic leukemia (ALL & CLL) and other categories as reported in SEER. Pts were observed from date of prostate cancer diagnosis until leukemia occurrence, death, or last date of follow-up. Univariate and multivariate analyses were performed using the Fine and Gray competing risk regression analysis with leukemia as a time-dependent endpoint and death from any cause or the diagnosis of any other second cancer as competing events. RP w/ EBRT group was compared with the RP cohort as the reference group, controlling for age. Hazard ratios (HR) with 95% confidence intervals (CIs) are reported. Results Median age was 67 years (yrs, range 22 – 105) at prostate cancer diagnosis: 67 yrs in RP and 68 yrs in RP w/ EBRT pts (p<0.0001); 158,913 (86.7%) were treated with RP and 24,355 (13.3%) with RP w/EBRT. Median follow-up was 7.6 yrs [(range, 1 – 35.5): 7.5 yrs in the RP group and 8.3 yrs in the RP w/ EBRT group, (p<0.0001)]. In total, 949 (0.5%) leukemia cases were identified: 336 (0.2%) acute leukemias [266 (0.2%) in the RP group and 70 (0.3%) in the RP w/ EBRT]; 538 (0.3%) chronic leukemias [462 (0.3%) in the RP group and 76 (0.3%) in the RP w/ EBRT] and 75 (0.04%) of unspecified histology. Histologic subtypes (per ICD-O-3 codes) were: AML (n=249), acute monocytic leukemia (n=18), ALL (n=24), other acute leukemias (n=45), other myeloid/monocytic/lymphocytic leukemias (n=48), aleukemic/subleukemic/NOS (n=27), CML (n=131) and CLL (n=407). Median age at acute leukemia diagnosis was 77 yrs [(range, 50 – 101): 78 yrs in the RP group and 76 yrs in RP w/EBRT pts, (p=0.0271)] and for chronic leukemias was 76 yrs [(range, 47 – 101): 76 yrs in the RP group and 77 yrs in the RP w/EBRT pts, (p=0.50)].The median time to develop acute leukemias was 6.0 yrs [(range, 1 – 28.2): 6.1 yrs in the RP group and 5.7 yrs in the RP w/EBRT pts, (p=0.20)] and chronic leukemias was 6.9 yrs [(range, 1 – 29.8): 6.7 yrs in the RP group and 8.6 yrs in the RP w/EBRT pts, (p=0.0020)]. The cumulative incidence rate (CIR) at 20 years for acute leukemias was 0.24% for the RP pts vs. 0.32% for the RP w/EBRT pts (p=0.0196). The CIR at 20 years for chronic leukemias was 0.47% for the RP pts vs. 0.36% for the RP w/EBRT pts (p=0.10). In univariate analyses, age >70 yrs (HR=1.40; CI, 1.13 – 1.74; p=0.0023), and those who received RP w/ EBRT (HR=1.49; CI, 1.14 – 1.94; p=0.0033) were significantly more likely to develop acute leukemias. In multivariate analysis, both advanced age (HR=1.40; CI, 1.13 – 1.74; p = 0.0023) and RP w/ EBRT (HR=1.49; CI, 1.14 – 1.94; p=0.0032), remained significantly associated with increased risk of acute leukemias. Radiation treatment was not significantly associated with the risk of developing chronic leukemias among pts treated with RP w/EBRT vs. RP [HR=0.91; CI, 0.72 – 1.16; p=0.45). Conclusions Among the best matched prostate cancer treatment cohorts, those who underwent EBRT following RP had a 49% increased risk of subsequent acute leukemias, although the absolute number of cases was low. Risk assessment in this cohort spans a time frame where radiation technologies have rapidly advanced and hence treatment period effects need to be considered in interpretation of results Disclosures: No relevant conflicts of interest to declare.

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