Does a treatment delay affect the survival of octogenarian patient population?

2017 ◽  
Vol 35 (8_suppl) ◽  
pp. 149-149
Author(s):  
Ali Mehmood Raufi ◽  
Hassaan Jafri ◽  
Todd W. Gress
Keyword(s):  
Cancer Treatment ◽  
Cancer Patients ◽  
Patient Population ◽  
Gynecological Cancer ◽  
Eastern Cooperative Oncology Group ◽  
Treatment Delay ◽  
Comprehensive Cancer Center ◽  
Cancer Center ◽  
Cancer Management ◽  
The Impact

149 Background: The cancer management of the elderly patient is an increasingly important and challenging issue. The aim of this retrospective analysis is to evaluate the impact of treatment delay on survival outcome of cancer in octogenarian patients. Methods: From 2006 to 2015, established cancer patients age 80 and above who received treatment at our comprehensive cancer center were retrospectively reviewed. We evaluated the relationship between a delay in cancer treatment of more than 30 days in the octogenarian patient and survival using Kaplan-Meier survival and Cox proportional hazards models. Results: There were 235 octogenarian cancer patients available for evaluation and 115 of these had a delay in initiation of cancer treatment ( > 30 days). Mean age was 83.7 years the treatment delay (TD) group and 83.9 in the no treatment delay (NTD) group (p = 0.70) Eastern Cooperative Oncology Group (ECOG) score of 2 or more was present in 22.6% of the TD group and 18.3% of the NTD group (p = 0.42). Metastatic disease was higher in the NTD group (22.5% vs. 11.3% TD group; p = 0.051). There were more breast (36.5% TD vs. 12.5% NTD group) and lung cancer (26.9% TD vs. 18.3% NTD group) in the TD group, and more genitourinary (20.8% NTD vs. 9.6% TD group) and gynecological cancer (20.8% NTD vs. 15.6% TD group) in the NTD group (p < 0.001 for overall comparison). Median overall survival was higher in the TD group (50 vs. 24 months NTD group; p = 0.001). Treatment delay was still associated with improved survival even after adjusting for age, gender, ECOG, stage of disease, and type of tumor (HR 0.64, CI 0.44-0.92). Conclusions: We found that a delay in cancer treatment in the octogenarian patient was associated with better overall survivial. Bias in regards to the reasons for the treatment delay may exist and could have affected our results. We attempted to minimize this bias by adjusting for characteristics that influence treatment between our two study groups. Nevertheless, our findings suggest that a delay in cancer treatment at minimum did not adversely affect mortality in this older patient population.

scholarly journals The impact of COVID 19 pandemic on pattern of cancer mortality in Najran, Saudi Arabia: a single-cancer center experience

2021 ◽  
Author(s):  
Ahmed M Badheeb ◽  
Mohamed A Badheeb ◽  
Hamdi A Alhakimi
Keyword(s):  
Hepatocellular Carcinoma ◽  
Saudi Arabia ◽  
Cancer Treatment ◽  
Cancer Patients ◽  
Cancer Mortality ◽  
Cancer Center ◽  
Anti Cancer ◽  
Before And After ◽  
The Difference ◽  
The Impact

Abstract Background: The aim of this paper is to compare the patterns and determinants of cancer mortality in Najran region before and after the COVID-19 epidemics. The association between cancer mortality and each of age, sex, site of cancer, stage, and the 30-days survival rate after the last dose of chemotherapy were assessed.Materials & Methods: Adult cancer patients who died of cancer in King Khalid Hospital in Najran Saudi Arabia, were included in this retrospective observational study. We compared mortality patterns in a period of 6 months in 2020 (March to August) with the corresponding period of 2019.Results: 50 dead adult cancer patients were included, 24 in 2019 and 26 in 2020. Among them, 21% vs 42% were younger than 65 years of age; 61% vs 62% were males, for the years 2019 & 2020 respectively. The top three killers in 2019 were colorectal, gastro-esophageal cancers, and hepatocellular carcinoma, while in 2020 were colorectal, hepatocellular carcinoma, and lymphomas. About 16.7% of patients died within 30 days of receiving anti-cancer treatment in 2019 in comparison with 7.7% in 2020. The difference in the 30-days mortality after receiving anti-cancer treatment was not statistically significant between 2019 and 2020 (p = 0.329).Conclusion: The Year 2020, the time of the COVID-19pandemic, was not associated with a significant increase in short-term mortality among patients with malignancy in Najran, Saudi Arabia. Our results generally reflect the crucial role of strict preventive national measures in saving lives and warrants further exploration.

scholarly journals Parenting while living with advanced cancer: A qualitative study

2016 ◽  
Vol 31 (3) ◽  
pp. 231-238 ◽  
Author(s):  
Eliza M Park ◽  
Devon K Check ◽  
Mi-Kyung Song ◽  
Katherine E Reeder-Hayes ◽  
Laura C Hanson ◽  
...  
Keyword(s):  
Decision Making ◽  
Qualitative Study ◽  
Functional Status ◽  
Advanced Cancer ◽  
Metastatic Cancer ◽  
Eastern Cooperative Oncology Group ◽  
Comprehensive Cancer Center ◽  
Cancer Center ◽  
Parental Concerns ◽  
The Impact

Background: Patients with advanced cancer who have dependent children are an important population with a life-limiting illness and high levels of psychological distress. Few studies have addressed the experience of being a parent with advanced cancer and their potential palliative needs. Aim: To describe the experience of living with advanced cancer as a parent, including illness experience, parental concerns, and treatment decision making and to explore whether these experiences differ by their functional status. Design: We conducted a cross-sectional, qualitative study using in-depth, semi-structured interviews. Data were analyzed using thematic content analysis. Setting and participants: A total of 42 participants with metastatic cancer and with at least one child under the age of 18 years were recruited from a comprehensive cancer center. 25 participants were rated as having high functional status (the Eastern Cooperative Oncology Group (ECOG) Performance Status Scale = 0–1) and 17 with low functional status (ECOG=2–4). Results: We identified four themes regarding the experience of being a parent with advanced cancer: (1) parental concerns about the impact of their illness and death on their children, (2) “missing out” and losses of parental role and responsibilities, (3) maintaining parental responsibilities despite life-limiting illness, and (4) parental identity influencing decision making about treatment. Parental functional status influenced not only physical responsibilities but also intensified parenting psychological concerns. Conclusion: Parents with metastatic cancer may have unique palliative care needs as they experience parenting concerns while managing the psychological and physical demands of advanced cancer.

Patient attitudes toward oncofertility care in male cancer patients receiving targeted and immune therapies.

2017 ◽  
Vol 35 (15_suppl) ◽  
pp. e21593-e21593
Author(s):  
Katy K. Tsai ◽  
Puneet Kamal ◽  
Joris Ramstein ◽  
Alain Patrick Algazi ◽  
Adil Daud ◽  
...  
Keyword(s):  
Cancer Patients ◽  
Checkpoint Inhibitors ◽  
Comprehensive Cancer Center ◽  
Cancer Center ◽  
Patient Attitudes ◽  
Durable Response ◽  
Care Plans ◽  
Future Fertility ◽  
Long Term Treatment ◽  
The Impact

e21593 Background: Tyrosine kinase inhibitors (TKI) and immune checkpoint inhibitors (ICI) have resulted in durable response for many cancer patients. The impact of these agents on future fertility are not well described, and patients are often committed to long-term treatment without adequate oncofertility counseling. We sought to better characterize patient attitudes toward oncofertility and challenges faced by male cancer patients undergoing treatment with TKI or ICI. Methods: Men receiving TKI/ICI at the UCSF Helen Diller Family Comprehensive Cancer Center were retrospectively identified. Eligible men had received at least one dose of TKI/ICI. Detailed questionnaires addressing cancer history, possible effects of treatment on fertility, and obstacles to fertility preservation were completed. Results: Between January 2013 to September 2016, 51 men with a mean age of 46 years (SD 12, range 21-72), 65% white, completed questionnaires. Most (61%) were CML patients, with 12% RCC, 10% GIST, 6% melanoma, and NET, oligodendroglioma, and HCC comprising remaining histologies. 96% were treated with TKI, and 4% with ICI. At the time of diagnosis, 35% of patients indicated a desire to father future children, and 53% believed that cancer treatment might affect their fertility. Despite this, 45% were not asked whether having children was important to them, and 47% did not receive information from any provider on their oncology care team about the possible risks of TKI/ICI to future fertility. The majority of patients felt there was inadequate discussion of how treatment might affect testosterone levels (73%) and their ability to father a child (53%), yet only 14% recalled adequate referrals to a fertility specialist. Conclusions: These data demonstrate that male cancer patients perceive treatment-related infertility risks as important, yet have few opportunities to discuss these concerns with providers. Care plans to address oncofertility needs, especially as TKI/ICI are increasingly used in multiple cancer types, are needed as part of the diagnosis, treatment, and follow up of these patients. Larger retrospective and prospective studies are ongoing to further characterize this patient cohort.

Pastoral care of cancer patients: Defining utilization of services at a comprehensive cancer center.

2020 ◽  
Vol 38 (15_suppl) ◽  
pp. e24171-e24171
Author(s):  
Elizabeth Palmer ◽  
Anghela Paredes ◽  
Madison Hyer ◽  
Timothy M. Pawlik
Keyword(s):  
Pastoral Care ◽  
Cancer Treatment ◽  
Cancer Patients ◽  
Spiritual Care ◽  
Cancer Care ◽  
Comprehensive Cancer Center ◽  
Cancer Center ◽  
Spiritual Needs ◽  
Active Listening ◽  
Patients With Cancer

e24171 Background: Addressing the religious/spiritual needs of patients is an important component of comprehensive cancer care. Patients often report that providers infrequently engage them about their needs during treatment. In addition, providers cite inadequate training as a significant barrier to providing spiritual care. While patients may benefit from the presence of a spiritual care specialist during cancer treatment, the utilization and content of these services are not well defined. We sought to characterize utilization of pastoral care (PC) services, as well as delineate differences in PC utilization among patients with cancer. Methods: Data on patients being treated for cancer at a Comprehensive Cancer Center between 2015-2018 were obtained from the electronic medical record. Overall utilization, type of PC services utilized, as well as factors associated with use of PC were assessed. Analyses included descriptive statistics and logistic regression. Results: Among 14,322 cancer patients, roughly one-third (n = 5166, 36.1%) had at least one PC encounter during their cancer treatment. Interventions most frequently provided by PC included supportive presence (93.5%) and active listening (86.6%), while the most frequently explored topics were treatment expectations (59.8%), issues with faith/beliefs (42.9%), and available coping mechanisms (35.4%). Patients diagnosed with colorectal (OR:1.42, 95%CI:1.07-1.89), liver (OR:2.41, 95%CI:1.80-3.24), or pancreatic cancer (OR:1.43, 95%CI:1.02-2.00) were more likely to utilize PC services compared with other cancers. Patients that identified as Catholic (OR:1.47, 95%CI:1.17-1.84) or Christian (OR:1.73, 95%CI:1.39-2.15) were more likely to request PC services (both p < 0.001) than individuals who had no religious preference/affiliation. Among surgical patients (n = 1,174), the majority of encounters with PC services were in the postoperative setting (n = 801, 70.6%). Patients most often reported that PC helped with verbalization of their feelings (93.6%) and helped reduce stress (76.9%). Conclusions: Over one-third of patients with cancer interacted with PC and received services that often addressed both psychosocial and spiritual concerns. Overall PC utilization and types of PC services rendered varied relative to demographic and religious factors. Providers should be aware of varying patient religious/spiritual needs so as to optimize the entire cancer care experience for patients.

The impact of FDG-PET/CT on the management of gynecologic cancers: A retrospective study.

2013 ◽  
Vol 31 (15_suppl) ◽  
pp. e16500-e16500
Author(s):  
Ramiz Ahmad Abu-Hijlih ◽  
Akram Al-Ibraheem ◽  
Yazan Asad Abuodeh ◽  
Imada A. Jaradat
Keyword(s):  
Ct Scan ◽  
Treatment Response ◽  
Cancer Patients ◽  
Fdg Pet ◽  
Gynecological Cancer ◽  
Pet Scan ◽  
Cancer Center ◽  
Pet Ct ◽  
Fdg Pet Ct ◽  
The Impact

e16500 Background: Fluoro-Deoxyglucose (FDG-PET) coupled with Magnetic Resonance Imaging (MRI) and Computerized Tomography (CT) provides valuable information in primary staging and evaluation of therapeutic response in gynecological cancer patients. The aim of this study is to investigate the additional value of PET/CT to MRI and CT scan, in patients recently diagnosed with a gynecological tumor or for evaluation of treatment response. Methods: Between January 2010 and June 2012, forty patients with gynecologic tumors (23 cervical, 8 endometrial and 9 ovarian) were evaluated at King Hussein Cancer Center. These patients were divided into two groups: (1) PET scan at presentation for initial staging workup (15 patients) and (2)PET scan at follow up for treatment response evaluation (25 patients). Results: The FDG-PET/CT scan yielded the following additional information: upstaging in 7.5% (3 in 40 patients) and down staging in 32.5% (13 in 40 patients). As a result, treatment strategy was changed from curative to palliative in one patient, and additional curative therapy was implemented following exclusion of distant metastasis in eight patients. Moreover, the discrepancy in nodal status found with FDG-PET/CT compared with anatomical imaging was detected in 8 patients (20%), which led to modifications in radiotherapy field and customizing the radiation dose with minimizing treatment-related toxicity. Conclusions: This study has demonstrated the effectiveness of FDG-PET/CT in the management of gynecological cancer patients. It is a highly valuable utility that raised the accuracy of patients’ stratification to curative or palliative treatments. Furthermore it helped radiotherapy to be more precisely targeted towards the malignant process. However, further prospective studies are still required to identify the group of patients who would benefit the most from this procedure.

Frequency of unsafe storage, use, and disposal practices of opioids among cancer patients presenting to the emergency department

2016 ◽  
Vol 15 (6) ◽  
pp. 638-643 ◽  
Author(s):  
Julio Silvestre ◽  
Akhila Reddy ◽  
Maxine de la Cruz ◽  
Jimin Wu ◽  
Diane Liu ◽  
...  
Keyword(s):  
Emergency Department ◽  
Patient Education ◽  
Cancer Patients ◽  
Comprehensive Cancer Center ◽  
Cancer Center ◽  
Prescription Opioid ◽  
Opioid Use ◽  
Pain Medications ◽  
The Impact ◽  
At Home

AbstractObjective:Approximately 75% of prescription opioid abusers obtain the drug from an acquaintance, which may be a consequence of improper opioid storage, use, disposal, and lack of patient education. We aimed to determine the opioid storage, use, and disposal patterns in patients presenting to the emergency department (ED) of a comprehensive cancer center.Method:We surveyed 113 patients receiving opioids for at least 2 months upon presenting to the ED and collected information regarding opioid use, storage, and disposal. Unsafe storage was defined as storing opioids in plain sight, and unsafe use was defined as sharing or losing opioids.Results:The median age was 53 years, 55% were female, 64% were white, and 86% had advanced cancer. Of those surveyed, 36% stored opioids in plain sight, 53% kept them hidden but unlocked, and only 15% locked their opioids. However, 73% agreed that they would use a lockbox if given one. Patients who reported that others had asked them for their pain medications (p = 0.004) and those who would use a lockbox if given one (p = 0.019) were more likely to keep them locked. Some 13 patients (12%) used opioids unsafely by either sharing (5%) or losing (8%) them. Patients who reported being prescribed more pain pills than required (p = 0.032) were more likely to practice unsafe use. Most (78%) were unaware of proper opioid disposal methods, 6% believed they were prescribed more medication than required, and 67% had unused opioids at home. Only 13% previously received education about safe disposal of opioids. Overall, 77% (87) of patients reported unsafe storage, unsafe use, or possessed unused opioids at home.Significance of Results:Many cancer patients presenting to the ED improperly and unsafely store, use, or dispose of opioids, thus highlighting a need to investigate the impact of patient education on such practices.

scholarly journals Care as Usual: An Acceptable Strategy to Apply During the COVID-19 Pandemic in a French Tertiary Gynecologic Oncology Department

2021 ◽  
Vol 11 ◽  
Author(s):  
Guillaume Blache ◽  
Houssein El Hajj ◽  
Camille Jauffret ◽  
Gilles Houvenaeghel ◽  
Laura Sabiani ◽  
...  
Keyword(s):  
Gynecological Cancer ◽  
Gynecologic Oncology ◽  
Surgical Patients ◽  
Oncologic Outcomes ◽  
Comprehensive Cancer Center ◽  
Surgical Approaches ◽  
Cancer Center ◽  
Complication Rates ◽  
Oncological Treatment ◽  
The Impact

We describe and analyze a “care as usual” strategy of a French Comprehensive Cancer Center during the COVID-19 pandemic to manage surgical patients with gynecological cancer. We conducted a retrospective analysis evaluating the surgical activity in our gynecologic oncology department between January 21 and May 12, 2020. We compared the surgical activity and surgical and oncologic outcomes during the pre-lockdown period and the pandemic period. The main objective was to evaluate the impact of the COVID-19 pandemic on surgical activity. The secondary objectives were to analyze the surgical and the oncologic outcomes. We compared the surgical activity during the 8 weeks after the national lockdown (85 procedures) to the surgical activity in the 8 weeks preceding the lockdown (127 procedures). We observed a 33% decrease in activity between the two periods. The clinical and epidemiologic characteristics were similar between the two periods. There were no differences between the surgical approaches (p = 0.592), the surgical complexity (p = 0.323), the length of stay (p = 0.85), and even for the complex procedure (p = 0.96) and the perioperative (p = 0.791) and postoperative complication rates (p = 0.102). We observed a significant decrease in the time of return to intended oncological treatment (RIOT) during the lockdown period with an average of 31.9 days compared to 46.9 days in the pre-lockdown period (p = 0.003). During the COVID-19 pandemic, “care as usual” represents an acceptable strategy without impairing the oncologic outcome in a Comprehensive Cancer Center with a patient-centered clinical pathway for gynecologic oncologic surgical patients.

Assessing the impact of the COVID-19 pandemic on patients with genitourinary malignancies.

2021 ◽  
Vol 39 (6_suppl) ◽  
pp. 38-38
Author(s):  
Hala Borno ◽  
Sylvia Zhang ◽  
Scarlett Lin Gomez ◽  
Celia Kaplan ◽  
Christine Miaskowski ◽  
...  
Keyword(s):  
Cancer Treatment ◽  
Household Income ◽  
Negative Impact ◽  
Survey Study ◽  
Comprehensive Cancer Center ◽  
Cancer Center ◽  
Cross Sectional Survey ◽  
Annual Household Income ◽  
Ongoing Research ◽  
The Impact

38 Background: The COVID-19 pandemic has vast implications on the health system. Patients with a cancer diagnosis may face greater challenges in the context of the current COVID-19 pandemic. Methods: We sought to assess the impact of the COVID-19 pandemic among patients with genitourinary malignancies. We performed a cross-sectional survey study at a Comprehensive Cancer Center during the current pandemic. Results: A total of 86 participants were recruited to the study to date, 72.1% had prostate, 19.8% had kidney, and 12.8% had bladder cancer. A subset (n = 5) had more than one primary tumor. The mean time from diagnosis was 6.47 years (std dev 6.01, range from 0 to 27 years). Overall, 73% reported having metastatic disease and prior treatment with surgery (62%), radiation (71%), or systemic therapy (68%), with 68.6% currently receiving cancer treatment. In the study, 78.9% of patients were >65 years of age and 88.2% were White. The majority of participants had a bachelor’s degree or higher level of education (74.4%), were legally married (82.6%), were homeowners (91.9%), and reported an annual household income of >$100,000 (56.0%). Among respondents, 7% reported loss/change of health insurance and 30% reported a decrease in household income. Among patients with reduced household income, 23% reported a reduction of more than 50%. In this study, 28% of patients reported that the pandemic impacted their cancer treatment. Overall 7% reported decrease in frequency of labs, 11% reported a delay in obtaining a scan, 5% reported treatment delays, and 96% reported use of telemedicine (video or telephone) visit. Overall, 59% reported fear of hospitalization, 23% reported delays in seeking medical care, and 16% reported missing required medications. Conclusions: The negative impact of the COVID-19 pandemic on patients with genitourinary malignancies is extensive. Ongoing research is evaluating the impact across socio-demographically groups and examine clinical outcomes associated with delays in care and medication non-adherence.

Practice of venous thromboembolism (VTE) prophylaxis in hospitalized cancer patients at a comprehensive cancer center.

2014 ◽  
Vol 32 (30_suppl) ◽  
pp. 149-149
Author(s):  
M.Alma Rodriguez ◽  
Alma Yvette DeJesus ◽  
Lee Cheng ◽  
Michael Kroll
Keyword(s):  
Risk Assessment ◽  
Cancer Patients ◽  
Comprehensive Cancer Center ◽  
Categorical Variables ◽  
Cancer Center ◽  
Moderate Risk ◽  
Pharmacological Prophylaxis ◽  
Vte Prophylaxis ◽  
National Quality ◽  
The Impact

149 Background: VTE prophylaxis measures are endorsed by the National Quality Forum in alignment with quality indicators from the Centers for Medicare & Medicaid Services. Accordingly, documentation of VTE risk, prophylaxis measures, and contraindications are recommended for hospitalized patients. To standardize practice we embedded a VTE risk assessment and prophylaxis module into admission and post-surgical order sets (OS), starting August 15, 2011. Methods: A retrospective study of 9,065 cancer patients (≥18 years) admitted to The University of Texas MD Anderson Cancer Center between June 01, 2013 through September 30, 2013. Pharmacological prophylaxis was executed with low-molecular-weight heparin or unfractionated heparin. Mechanical prophylaxis was executed with graduated compression stockings and/or sequential compression devices. Chi-square testing was used to determine the association between categorical variables. All statistically significant levels were determined with P values < 0.05. Results: 7,366 (81%) of all hospital admissions had documented VTE risk assessment and prophylaxis through the standardized VTE module. Before implementation of the new OS, only 40% of eligible patients received an order for VTE prophylaxis. The majority of patients were designated high or moderate risk (91.1%). Patients with high risk were more likely to receive pharmacological prophylaxis than those with moderate risk (74.1% vs. 38.2%, P<0.01). The most frequent contraindications to pharmacological prophylaxis were major surgery with risk of bleeding and thrombocytopenia (Table). Conclusions: Most patients received VTE prophylaxis based on VTE risk levels presented in a standardized OS. There is is limited information in the clinical literature about the impact of VTE prophylaxis on outcomes among cancer patients, we plan to assess anticoagulation-related outcomes in this cohort of patients. [Table: see text]

scholarly journals Impacts of COVID-19 on Liver Cancers: During and after the Pandemic

Liver Cancer ◽  
2020 ◽  
Vol 9 (5) ◽  
pp. 491-502 ◽  
Author(s):  
Stephen Lam Chan ◽  
Masatoshi Kudo
Keyword(s):  
Cancer Treatment ◽  
Cancer Patients ◽  
Hepatic Injury ◽  
Healthcare Services ◽  
Current Data ◽  
Mitigation Measures ◽  
Medical Illness ◽  
Cancer Management ◽  
Liver Cancers ◽  
The Impact

Background: The pandemic of coronavirus disease 2019 (COVID-19) has diverted resources from healthcare services for patients with chronic medical illness such as cancer. COVID-19 also causes organ dysfunction, complicating cancer treatment. In most countries with an outbreak of COVID-19, modifications of cancer management have been adopted to accommodate the crisis and minimize the exposure of cancer patients to the infection. In countries where COVID-19 numbers are subsiding, medical teams should also be prepared to resume normal practices gradually. Here, we aim to review the literature on the impact of COVID-19 on patients with hepatocellular carcinoma (HCC) as well as discuss modifications to the management of HCC during and after recovery from the pandemic. Summary: Based on current data, 10–40% of patients with COVID-19 have hepatic injury characterized by an elevation of transaminases and/or hyperbilirubinemia. Multiple mechanisms contribute to the hepatic injury, including direct viral entry to hepatocytes/cholangiocytes, immune-mediated hepatitis, hypoxia, and drug-related hepatotoxicity. In patients with HCC, COVID-19 may exacerbate existing chronic liver disease and complicate the management of cancer. Cancer patients generally have a higher risk of infection and worse outcome, especially those who have recently undergone cancer treatment. Although HCC is under-represented in COVID-19 series, mitigation measures should be implemented to minimize the exposure of patients to the virus. A decision on the treatment of HCC should be balanced with consideration of the availability of medical resources, the level of infection risk of COVID-19, and the risk-benefit ratio of the individual patient. In areas where the COVID-19 outbreak is subsiding, clinicians should be prepared to manage a surge of HCC patients with higher disease burdens and complications. Key Messages: Mitigation measures to protect at-risk patients, such as those with cancers, from SARS-CoV-2 infection should be exercised and the impact of COVID-19 on this group of patients should be thoroughly studied.

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