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Patient and Survivor Care
May 01, 2017

Addressing the Survivorship Care Needs of Patients Receiving Extended Cancer Treatment

Publication: American Society of Clinical Oncology Educational Book
The number of cancer survivors (i.e., people living with diagnoses of cancer) continues to grow and is expected to reach 18 million individuals in the United States by 2022.1 The growth in the number of survivors has, in part, stimulated the development of a field known as cancer survivorship. Although definitions vary, cancer survivorship care and research is widely viewed as focusing on the health and life of a person with cancer beyond the acute diagnosis and treatment phase. According to the National Cancer Institute’s Office of Cancer Survivorship, research in this area seeks to “prevent and control adverse cancer diagnosis and treatment-related outcomes…, to provide a knowledge base regarding optimal follow-up care and surveillance of cancers, and to optimize health after cancer treatment.”2
Although the focus of cancer survivorship has been on the period following acute diagnosis and treatment, work in this area has acknowledged the challenges inherent in identifying the end of the acute or primary phase for many forms of cancer treatment.3 Indeed, attempts to summarize cancer survivorship research often refer to studies of individuals who have completed curative treatment or have transitioned to maintenance or prophylactic therapy.4 Inherent in this expanded definition is recognition that for many individuals, cancer will be a chronic disease requiring extended treatment over many years.5
With growing acceptance of the need to expand the scope of cancer survivorship care and research to include patients on extended treatment, we offer an in-depth examination of three distinct patient populations. In each instance, we identify major survivorship issues related to receiving extended treatment and the current status of efforts to understand and address these issues. First, we discuss the patient population receiving extended treatment to prevent disease recurrence or progression. Issues encountered by early-stage patients receiving hormonal therapy for breast and prostate cancer are used to illustrate the survivorship care needs of this patient population. Second, we focus on the population receiving extended treatment to control disease. Issues encountered by patients receiving targeted therapy for chronic myelogenous leukemia (CML) are used to illustrate the survivorship care needs of this patient population.
Third, we discuss the population with advanced or metastatic disease receiving extended treatment to slow disease progression, control symptoms, and maintain quality of life (QOL). Issues encountered by patients receiving novel therapies for advanced or metastatic cancers are used to illustrate the survivorship care needs of this patient population. A concluding section identifies cross-cutting themes and directions for future research.

Extended Adjuvant Endocrine Therapy

Adjuvant therapy for cancer is prescribed for patients in whom all known disease has been treated with either primary surgery or radiation therapy. With control of the local disease completed, the focus of adjuvant therapy is to eliminate occult metastatic cancer that may have disseminated in the months and years before the primary tumor was discovered. In this setting, the treatments are directed against preventing a recurrence (local or distant) of disease. Cytotoxic chemotherapy or radiation therapy are usually time limited in duration (6–12 months); however, endocrine therapies can extend over many years. Indications for the use of adjuvant therapy are related to the risk for recurrence, and this is usually dictated by the size of the tumor, its local extent, and other histologic and biologic features (e.g., grade, hormone receptors, gene expression profile). Breast and prostate cancers represent two very common adult cancers in which extended hormonal (endocrine) therapies are applied, and for which excellent data from large randomized trials support the value of targeting the hormonal milieu of the patient’s body as a means of preventing recurrent disease from manifesting itself. Endocrine therapies may be given as the sole adjuvant therapy in both breast and prostate cancer or may follow chemotherapy and radiation. For both patients with breast cancer and those with prostate cancer, there may be untoward side effects from antagonizing the normal hormonal environment, and these may limit the ability to maintain adherence to these treatments over a long period of time.

Breast Cancer Adjuvant Endocrine Therapy

All women with nonmetastatic primary breast cancer, whose tumor expresses estrogen and/or progesterone receptor, are considered appropriate candidates for adjuvant endocrine therapy. This also includes women with stage 0, noninvasive, intraductal cancers for whom the primary indication is breast cancer prevention in the ipsilateral or contralateral breast.6 This approach to management evolved over many years of randomized trials, in which initially only women with relatively high absolute risks for recurrence were exposed to adjuvant endocrine therapy. However, over the past 30 years, and as supported in a National Institutes of Health consensus conference in 2000, all women with hormone receptor positive tumors larger than 1 cm were deemed to benefit from 5 years of adjuvant tamoxifen.7 Subsequently, additional studies supported the use of aromatase inhibitors as an alternative for 5 years in postmenopausal women, and further studies identified settings in which adjuvant endocrine therapy should be continued for up to 10 years.8 Although the specific choice of endocrine therapy may differ according to the woman’s menopausal status, all of the current approaches to endocrine therapy require daily oral therapy for a minimum of 5 years.
From the earliest clinical use of adjuvant tamoxifen, adherence to ongoing therapy was recognized as an issue.9 In this report from Partridge et al,9 up to 50% of women were nonadherent to tamoxifen therapy by 4 years, and this was most common among younger, older, and nonwhite women. Even in clinical trials of adjuvant tamoxifen therapy, diminished adherence rates at 5 years were noted in highly motivated patients; for both tamoxifen and placebo, only 23% of women were taking their study medications at 5 years in the NSABP B-14 trial.10 In the recently reported NSABP B-35 trial comparing anastrozole with tamoxifen in patients with ductal carcinoma in situ,6 only 64% of participants completed the study medications at 5 years, with no difference between the two endocrine therapies. Finally, in a large observational study within an integrated health system, adherence to clinically prescribed endocrine therapy11 was reduced, with the finding of early discontinuation (in the first year of therapy) among younger and older women and poor persistence into the fifth year of treatment. An additional report from this same cohort showed increased mortality among women who were nonadherent.12
What are the barriers to initiation and adherence among women who are prescribed adjuvant endocrine therapy? In Sidebar 1, we list the most common issues identified in the literature13-17 and in clinical experience. Interventions to enhance adherence should focus on these common issues, with an important focus on effective communication about the clinical value and magnitude of treatment benefit, with the assurance that potential side effects will be addressed. These are issues that should be addressed as part of initial treatment discussions and decisions. Furthermore, ongoing follow-up should be conducted by a member of the clinical team to assess any challenges to continued adherence, especially addressing ongoing complaints and any financial concerns that may make continued persistence with treatment an issue.
SIDEBAR 1. Common Barriers to Adherence to Endocrine Therapy in Patients With Breast Cancer
Lack of knowledge about the role and benefits of endocrine therapy
Uncontrolled treatment-associated symptoms (vasomotor symptoms, arthralgia, vaginal symptoms)
Concerns about rare but serious toxicities (e.g., blood clots, stroke, endometrial cancer, fracture)
Cost of the medications
Distrust of health system and poor communication with medical staff
Lack of perceived risk for recurrence

Prostate Cancer Endocrine Therapy

Unlike the setting of breast cancer, endocrine therapy of prostate cancer is often limited to neoadjuvant use before radiation therapy or short-term adjuvant therapy after radiation. This is usually provided only to patients with high-risk local disease. However, there is another larger group of patients, who have undergone prostatectomy or radiation therapy for local disease, in whom endocrine therapy is initiated for a rising prostate-specific antigen level without evidence of definitive metastatic disease. These patients are likely to be on long-term endocrine therapy, without evidence of clinically symptomatic disease, for which long-term adherence is an issue. Of course, men with metastatic prostate cancer are also on long-term endocrine therapy, and this situation is more comparable to patients with CML described in the next section.
Similar to breast cancer, endocrine therapy for prostate cancer manipulates a man’s hormonal environment and focuses on androgen deprivation as a first maneuver. This can be accomplished either with orchiectomy or regular injection of a gonadotropin-releasing hormone analog. Sometimes this is combined with an oral anti-androgen agent (e.g., bicalutamide), but more often antiandrogen therapies are added at the time of prostate-specific antigen level progression or for locally recurrent disease. The patient is said to have “castrate-resistant prostate cancer,” and a variety of other androgen-targeted oral therapies are added. All of these therapies are associated with a variety of symptoms associated with low testosterone, including hot flashes, breast enlargement or tenderness, weight gain, decreased libido, and impotence. In addition, there may be body image and mood changes.
Although the symptoms of androgen therapies have been described in clinical trials and observational studies, relatively little is known about how these symptoms affect adherence to endocrine therapy. In a recent study, Jung et al18 found that many men did not have adequate information about their treatments and that their reports of symptoms to their physicians were not addressed. Many of the findings in this survey study were similar to what has been reported about women with breast cancer. However, we could find no other reports in the literature on this topic, and thus this is an important gap. In addition, the newer antiandrogen therapies are very expensive, with monthly costs for enzalutamide and abiraterone estimated to be in excess of $8,000.19 This is certainly another major barrier to long-term adherence.

Extended Targeted Treatment to Control Disease

Targeted cancer therapies represent a new generation of drugs designed to treat cancer by interfering with molecular targets that play a critical role in growth, progression, and spread of the disease. One of the first and most successful examples of how targeted therapies can improve outcomes occurred in the treatment of CML. With approximately 8,000 new diagnoses annually in the United States,20 CML accounts for 20% of new adult leukemias. On the basis of research showing the cause to be formation of the BCR-ABL oncogene that produces a constitutively active tyrosine kinase,21 the oral medication imatinib was evaluated because it is a potent inhibitor of this enzyme.22 Clinical trials confirmed its efficacy23,24 and demonstrated clinically important differences in QOL favoring imatinib25 over the existing regimen of interferon and cytarabine. Eight-year survival rates for patients with CML have since improved from less than 20% historically to 87% in the imatinib era.26 The success of imatinib is widely considered a model for the development of other targeted cancer therapies.27 Several second-generation tyrosine kinase inhibitors (TKIs) have since been approved for use against CML,27 and other oral medications targeting tyrosine kinase pathways have been or are being developed for many other forms of cancer.28 Treatment of CML typically requires daily oral administration of a TKI over an extended period of time. Discontinuation of medication is generally not recommended unless patients achieve a deep molecular response.29 Among those patients who do achieve a deep molecular response, studies suggest that only 40% will stay in remission after stopping first-line treatment.29

Adherence Issues

The necessity of taking an oral medication for an extended period, combined with the potential for missed doses that can result in impaired cytogenetic and molecular responses,30,31 points to the importance of understanding and promoting medication adherence in patients with CML prescribed TKIs. A recent meta-analysis of 40 studies concluded that, depending on the assessment method, 25% to 33% of patients with CML are not adhering to their prescribed regimens.32 Research on predictors of adherence in this patient population is more limited. A systematic review of this literature identified drug-related adverse events and forgetfulness as common reasons for intentional and unintentional nonadherence, respectively.33 These findings suggest that efforts to maintain adherence should include reminders to take medication as well as effective management of medication side effects.

Side Effects and Symptoms

Although imatinib and similar TKIs are better tolerated than many of the regimens they replaced,25 evidence suggests they are not without side effects. Common side effects of imatinib, dasatinib, and nilotinib observed in clinical trials include pain, diarrhea, nausea, and fatigue.34 On the basis of the National Cancer Institute’s Common Toxicity Criteria, adverse event rates for any grade for these symptoms among patients taking imatinib were found to be 43.7% (nausea), 36.5% (pain), 34.5% (fatigue), and 32.8% (diarrhea).24 Similar adverse rates for these symptoms have been observed for nilotinib and dasatinib.27 These toxicities were generally low grade, but even low-grade toxicities that persist for months or years in patients on chronic therapy have the potential to greatly impair function and overall QOL and contribute to nonadherence.
It should be noted that Common Toxicity Criteria adverse event reports are based on clinician ratings and may represent underestimates of symptoms for which assessment through patient self-report represents the “gold standard” (e.g., fatigue).35 More recent studies using patient self-report measures suggest that fatigue is among the most common and problematic symptoms experienced by patients with CML.36-40 One study in particular speaks to the clinical importance of fatigue in patients with CML. Efficace et al37 evaluated the relationship of symptoms, clinical features, and demographics to QOL. Fatigue (as measured by the Functional Assessment of Chronic Illness Therapy Fatigue Scale41) was independently associated with worse QOL on all scales of the SF-3642 and had the highest inclusion frequency of all variables examined. The presence of fatigue was also associated with greater symptom burden, a factor related to poorer TKI adherence in patients with CML.31 These findings led the investigators to conclude that fatigue is the main factor limiting QOL in patients with CML who receive long-term TKI therapy.37

Interventions to Promote Adherence and Manage Symptoms in Patients With CML Prescribed TKIs

Despite its importance, we are aware of only one published randomized controlled trial evaluating an intervention designed to promote oral medication adherence in patients with CML.43 In this study, 86 patients with CML who had been on TKIs for at least 6 months were randomized to an intervention group or a usual-care control group. The intervention combined a nurse-conducted medication counseling session with supporting educational materials and access to daily text message reminders to take medication. At 9-month follow-up, self-reported medication adherence had increased significantly more often in the intervention group than in the control group (60% vs. 33%, respectively). Seventy percent or more of patients rated the counseling and educational materials as useful. In contrast, only one-third of patients chose to receive text message reminders, and only 27% of them perceived them as useful.
Despite the high prevalence of treatment-related symptoms, we could identify no published randomized controlled trials evaluating symptom management interventions for patients with CML on TKI therapy. Given research suggesting its clinical importance, the development of interventions to address fatigue should be viewed as a high priority. In the absence of an understanding of the pathophysiology of TKI-related fatigue,37 clinical practice guidelines for addressing fatigue in cancer survivors44 may suggest promising strategies. Although evidence was viewed as insufficient to recommend pharmacologic therapies, evidence was sufficient to recommend physical activity interventions and cognitive behavioral therapy.44 An example of the latter is an intervention demonstrated to be effective against severe fatigue in disease-free survivors following completion of cancer treatment.45 This intervention addresses six possible contributory factors (insufficient coping with cancer, fear of disease recurrence, dysfunctional fatigue-related cognitions, sleep dysregulation, activity dysregulation, and low social support or negative social interactions) and is delivered in a series of face-to-face sessions by a trained therapist. A recent publication describes the successful adaptation of this intervention for use in patients with TKI-related fatigue and for internet delivery to improve patient access.46 A small-scale randomized controlled trial of this adapted intervention is currently under way.47

Summary of Survivorship Care Needs of Patients With CML on Extended Therapy

Patients with CML are in the vanguard in that they are one of the first cancer populations for whom disease control is typically achieved exclusively with the use a targeted therapy agent prescribed over an extended period of time. Although much less toxic than earlier regimens, TKIs for CML have been found to commonly produce side effects that adversely affect QOL and contribute to intentional nonadherence to daily oral dosing. Accordingly, survivorship care needs of this patient population include effective management of common treatment-related symptoms (e.g., fatigue) and assistance in maintaining high levels of medication adherence. Development of interventions to effectively meet the needs of this population is still at a very early stage.

Extended Treatment of Patients with Advanced or Metastatic Disease

Patients with advanced or metastatic cancer often receive treatments with the goal of slowing disease progression, controlling symptoms, and maintaining QOL. Historically, treatment of many patients with advanced cancers rarely extended life beyond 1 year.48-54 However, the expected survival of numerous patients with advanced cancer has improved significantly in recent years, following the advent of novel genotype-directed therapies55-60 and immune checkpoint–targeting agents.61-66 Thus, as the paradigm has shifted toward more effective treatment of patients with advanced cancer, so too have the supportive care needs of this unique group of cancer survivors.

Supportive Care Needs of Survivors With Advanced Cancer

Patients with advanced cancer often experience multiple symptoms, both physical and psychological, as well as issues related to prognostic uncertainty, financial distress, and the need for caregiving support from family and friends. Notably, patients with advanced cancer who receive extended treatments and survive for prolonged periods likely experience issues similar to all patients with advanced cancer, but limited research has focused on the unique survivorship needs of this population (Sidebar 2).
SIDEBAR 2. Unique Supportive Care Needs of Survivors With Advanced Cancer
Physical and psychological symptoms
Maintaining quality of life
Prognostic uncertainty
Making informed treatment decisions
Financial burden
Family caregiving demands

Symptoms Experienced by Patients With Advanced Cancer

Patients with advanced cancer frequently experience numerous physical and psychological symptoms that are often under-recognized by their clinicians.67-70 Symptoms such as pain, dyspnea, fatigue, nausea, and lack of appetite can lead to poor QOL and psychological distress for patients and their family members.71-73 However, research demonstrates that clinicians often fail to reliably detect their patients’ symptoms and frequently underestimate their severity.74-77 In addition, studies suggest that patients may underreport their symptoms to their clinicians, often resulting in worse symptom management.70,78-80 Thus, there is a critical need to recognize and address symptoms in patients with advanced cancer. Moreover, research is needed to better understand the symptom support needs of patients with advanced cancer who receive extended treatments and survive for prolonged periods.
Patients’ symptoms represent a modifiable target for interventions aimed at improving patient outcomes.81-83 A randomized trial of an intervention in which patients in the outpatient setting completed electronic self-reports of their symptoms and had their symptom reports delivered to their clinicians demonstrated better symptom control for those receiving the intervention compared with usual care.82 More recently, a web-based patient-reported symptom monitoring intervention with automated reporting to clinicians for severe or worsening symptoms was compared with usual care in 766 patients with cancer in the outpatient setting.81 Patients who received the intervention reported better QOL and experienced fewer hospitalizations. These studies highlight the importance of symptom monitoring interventions, and future work should further investigate the efficacy of these interventions among long-term survivors living with advanced cancer.

Prognostic Uncertainty

Patients with advanced cancer often misunderstand their prognosis and the goals of their treatment.84,85 Recent advancements in cancer therapies have further complicated oncologists’ ability to effectively communicate an accurate assessment of their patient’s prognosis.86 However, little research exists regarding the increasing challenge of how clinicians should communicate with patients about their prognosis in the modern era of targeted anticancer therapies. This is important, because patients with accurate perceptions of their prognosis are more empowered to make informed treatment decisions and plan for their future.87-90 Moreover, research has shown that patients with advanced cancer prefer their oncologists to provide honest and accurate prognostic disclosure early in the disease course.91 Consistent with these preferences, expert groups have recommended that clinicians initiate communication about prognosis at the time of diagnosis and that these discussions continue longitudinally, throughout the cancer trajectory.92,93 By initiating these discussions early, and incorporating new information as it becomes available, clinicians can help patients better understand their prognosis and make more effective decisions about their care.

The Financial Burden Experienced by Cancer Survivors

Increasingly, studies have shown that patients with cancer experience substantial financial burden related to the disease and its treatment, yet financial burden among cancer survivors remains understudied.94-98 Prior work demonstrates that patients with histories of cancer experience financial issues such as job loss, missed work, and trouble obtaining affordable health insurance.99-102 Notably, cancer survivors often need long-term health care for years after their initial diagnosis, and the high out-of-pocket medical costs coupled with the loss of income can further compound their economic hardship.103-105 This financial burden can negatively affect their health outcomes, including poorer QOL, increased symptom burden, and potentially higher mortality.98,106,107 Importantly, in the modern era of cancer therapeutics, with patients living longer and drug prices increasing exponentially increasing, patients with advanced cancers are particularly vulnerable to the adverse financial consequences of their cancer.103,108 Survivors’ financial burden may influence their decision to forgo needed care or to not properly adhere to prescribed therapies in an effort to defray costs109-111 and thereby jeopardize their health.12,112,113 Thus, the financial burden experienced by cancer survivors is an important issue with the potential to impact the quality of their survivorship care.

Family Caregivers of Patients With Cancer

Patients with advanced cancer often require assistance from friends and family as they navigate their cancer course.114,115 Unfortunately, family caregivers are often neglected when considering the unique supportive care needs of patients with advanced cancer. Family caregivers often experience a substantial symptom burden, including fatigue, sleep disturbance, depression, and anxiety.116-118 Caregiving demands can negatively affect family caregivers’ QOL and affect their ability to effectively care for their loved ones.119,120 As novel cancer therapies continue to change the survival trajectory for patients with advanced cancer, efforts are needed to understand how best to support family caregivers throughout the patient’s course.

Summary of Survivorship Care Needs of Patients With Advanced Cancer Receiving Extended Therapies

Patients with advanced cancer often experience issues related to symptoms, prognostic uncertainty, financial distress, and caregiving. Importantly, numerous studies have demonstrated the efficacy of palliative care interventions to address the unique supportive care needs of these patients.121-126 On the basis of ample evidence, ASCO guidelines recommend dedicated palliative care services for patients with advanced cancer early in the disease course, concurrent with active treatment.127 However, minimal data exist to determine the role of palliative care interventions for patients with advanced cancer who receive extended treatments and survive for prolonged periods. Future studies are needed that focus on the unique survivorship needs of this population to develop effective ways to support these patients throughout their cancer trajectory.

Conclusion and Future Directions

For many people with cancer, their care will involve extended treatment over considerable periods of time. This reality challenges the paradigm that has defined survivorship care and research as focusing on the period after patients complete a relatively brief period of active treatment. Organizations such as ASCO have already acknowledged that survivorship care and research should also include patients receiving maintenance or prophylactic therapy for cancer.
As described above, patient populations receiving extended treatment include individuals receiving hormonal therapy for breast and prostate cancer, as well as individuals receiving targeted therapy such as TKIs for CML. A major survivorship issue for these patients is the need to identify and address factors that contribute to difficulties in maintaining high levels of adherence to prescribed therapies over extended periods of time. This situation is especially challenging, because patients control when they take their medicine. A key driver of nonadherence with these agents is adverse side effects that impair QOL (e.g., arthralgia and fatigue). This situation underscores the importance of achieving adequate symptom control among patients receiving extended treatment. Unfortunately, there has been relatively little research addressing issues of adherence and symptom management with oral anticancer agents. Recognizing this gap, the National Cancer Institute recently released a funding opportunity announcement designed to encourage research on oral anticancer medication utilization, delivery, and adherence.128
The other population described above includes patients with advanced or metastatic cancer who are receiving novel therapies that can extend life for prolonged periods of time. This population has a number of survivorship needs, including effective symptom management, help in dealing with prognostic uncertainty and financial distress, and family caregiver support. None of these issues has been systematically studied, despite the growing numbers of patients with advanced or metastatic disease experiencing longer survival with novel therapies. An immediate and important research goal is to evaluate the potential benefits of palliative care services for these individuals, given ample evidence regarding the efficacy of these services for patients who are newly diagnosed with advanced disease.

Authors' Disclosures of Potential Conflicts of Interest

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to

Paul B. Jacobsen

No relationship to disclose

Ryan D. Nipp

No relationship to disclose

Patricia A. Ganz

Leadership: Intrinsic LifeSciences (I)
Stock and Other Ownership Interests: Abbott Laboratories, GlaxoSmithKline, Intrinsic LifeSciences (I), Johnson & Johnson, Merck, Novartis, Pfizer, Silarus Therapeutics (I), Teva, xenon pharma (I)
Honoraria: Biogen (I)
Consulting or Advisory Role: Gilead Sciences (I), InformedDNA, Keryx (I), La Jolla Pharma (I), Lilly, Silarus Therapeutics (I), Vifor Pharma (I)
Research Funding: Keryx (I)
Patents, Royalties, Other Intellectual Property: #related to iron metabolism and the anemia of chronic disease (I), #Up-to-Date royalties for section editor on survivorship
Travel, Accommodations, Expenses: Intrinsic LifeSciences (I), Keryx (I)


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American Society of Clinical Oncology Educational Book
Pages: 674 - 683
PubMed: 28561717


Published online: October 29, 2018


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Paul B. Jacobsen, PhD [email protected]
From the Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD; Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA; Jonsson Comprehensive Cancer Center, Fielding School of Public Health and the David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.
Ryan D. Nipp, MD
From the Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD; Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA; Jonsson Comprehensive Cancer Center, Fielding School of Public Health and the David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.
Patricia A. Ganz, MD
From the Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD; Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA; Jonsson Comprehensive Cancer Center, Fielding School of Public Health and the David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA.


Corresponding author: Paul B. Jacobsen, PhD, Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Dr., Bethesda, MD 20892; email: [email protected].
Disclosures of potential conflicts of interest provided by the authors are available with the online article at

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American Society of Clinical Oncology Educational Book 2017 :37, 674-683

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