Aug 18
32m 21s
An estimated 85k adolescents and young adults (AYAs) between the ages of 15 to 39 will be diagnosed with cancer in the United States this year. AYAs with advanced cancer face care gaps for psychosocial support and communication. A recent paper published in JCO OP titled “Promoting Resilience in Stress Management: A Randomized Controlled Trial of a Novel Psychosocial Intervention for Adolescents and Young Adults With Advanced Cancer” detailed the findings of a clinical trial testing a skills-based coaching program with the goal of decreasing psychological distress and improving quality of life.
TRANSCRIPT
Dr. Fumiko Chino: Hello, and welcome to Put into Practice, the podcast from the JCO Oncology Practice. I'm Dr. Fumiko Chino, an Assistant Professor in Radiation Oncology at MD Anderson Cancer Center, with a research focus on access, affordability, and equity.
An estimated 85,000 adolescents and young adults (AYAs) between the age of 15 and 39 will be diagnosed with cancer in the United States this year. Although this accounts for less than 5% of all cancers, AYA cancers have been rising over the past decade, and AYA survivors have unique survivorship needs, including physical, emotional, social, and spiritual communication.
A recent paper published in JCO OP titled "Promoting Resilience and Stress Management: A Randomized Control Trial of a Novel Psychosocial Intervention for Adolescents and Young Adults With Advanced Cancer" detailed the findings of a clinical trial testing a skills-based coaching program with the goal of decreasing psychological distress and improving quality of life.
I'm excited to welcome two guests to the podcast today to discuss optimal care for the AYA population. Dr. Abby Rosenberg, MD, MS, MA, is the Chief of Pediatric Palliative Care at the Dana-Farber Cancer Institute, Director of Pediatric Palliative Care, Boston Children's Hospital, and an Associate Professor of Pediatrics, Harvard Medical School. She is also the current designated pediatric oncologist at the ASCO Board of Directors. Both Dr. Rosenberg's clinical approach and her research focus on helping patients facing critical illness live their best lives and for as long as possible. Specifically, she and her team develop programs that help patients and families build resilience and optimize quality of life. She is the first author of the published trial we will be discussing today.
Dr. Lauren Ghazal, PhD, FNP-BC, is an Assistant Professor and researcher at the University of Rochester School of Nursing. As an AYA cancer survivor herself and a family nurse practitioner with a background in economics, she brings a unique perspective to cancer care delivery research. Dr. Ghazal completed a postdoctoral research fellowship at the University of Michigan on an NCI T32 in cancer care delivery after earning her PhD at NYU, where her dissertation focused on work-related challenges and financial toxicity in AYAs.
Our full disclosures are available in the transcript of this episode, and we've already agreed to go by our first names for the podcast today.
Abby and Lauren, it's wonderful to speak to you.
Dr. Abby Rosenberg: Thanks for having us. We're so happy to be here.
Dr. Lauren Ghazal: Yes, thank you for having us.
Dr. Fumiko Chino: Our specific topic today is: improving outcomes for the AYA population. Abby, do you mind starting us off by sharing some background on this trial and giving us a brief overview of the study and your findings?
Dr. Abby Rosenberg: Yeah, I'm happy to. And thanks again for having us.
You mentioned, Fumiko, the prevalence and problems that adolescents and young adults with cancer often have. One of the things that I like to point out is we know that if you're diagnosed with cancer as an adolescent or a young adult, you have higher risks of poor psychosocial outcomes forevermore compared to younger pediatric or older adult counterparts. With that in mind, we have been thinking for a long time about: how do you promote well-being and resilience in this particular population?
One of the things that we also know is that adolescents and young adults with advanced cancers, those that have recurred or progressed through initial treatment, not only tend to be less engaged with a lot of the really important conversations that we have in healthcare, but later on, especially if their time becomes short, they tend to regret that disengagement. And so what we had done in our previous research is we had created this program called PRISM, and that stands for Promoting Resilience in Stress Management. And PRISM was a peer-to-peer–based coaching program designed by our team in partnership with AYAs for AYAs, specifically to help them navigate these stressors. And what it does is it leverages simple, reproducible, evidence-based what we call ‘resilience skills’. And these are things like skills in stress management, setting goals, cognitive reframing - that's how you appraise a situation - and then benefit-finding or meaning-making. And our prior randomized trial suggested that PRISM compared to usual care amongst adolescents and young adults with early-diagnosed cancers improved their resilience and their hope and their quality of life, and it reduced their psychological distress.
In those studies, teens and young adults who had advanced cancers said, "Hey, you know what? These skills really helped me navigate this first experience, and now that my cancer has come back, what I really need help with is applying these skills to these really hard conversations I'm having with my medical team and with my family." So the current study that you are talking about today really tried to ask the question of: could we combine our previous PRISM projects with some integrated advanced care planning communication skills for AYAs with advanced cancer? And if we did that, could we improve some of these important outcomes?
And so what we did was we randomly assigned 144 adolescents and young adults with advanced cancer to either PRISM or usual care. In this study, PRISM included those same four skills - stress management, goal setting, cognitive reframing, and benefit-finding - plus an optional component where they could engage in formal advanced care planning skills. And then we saw what we got at 3, 6, 9, and 12 months. Amongst the 144 people who enrolled, their average age was about 16 and a half years, and they were half-half male and female.
Within the first 3 months, the people who got usual care, not PRISM, did better with their quality of life. It's not what you want to see as an investigator. But the people who got PRISM did better with their hope and their resilience skills. And then I think what was more important is over time, the improvements in the usual care arm, they weren't sustained. And in fact, the people who got usual care instead of PRISM tended to kind of bounce all over the place with their psychosocial well-being. There was really no predictability, and on average, they did worse over time. But on the other hand, people who got PRISM not only immediately improved that resilience and hope at 3 months, but then they had sustained and continuous improvements in quality of life and distress. They were more engaged in things like advanced care planning and conversations with their doctors and nurses over time. And the overall suggestion of those data is that building skills and resilience and hope early on can lead to lasting improvements in overall well-being.
Dr. Fumiko Chino: That is a fantastic overview of the trial, and again, I love this concept of building from within, you know, what started with a peer-to-peer type program and realizing that these skills are so helpful to people going through any kind of critical illness.
Now, Lauren, I'd love your take on why this type of study is important, why interventions in the AYA space can be so challenging to develop and test. So, for example, in this trial, one-third of the intervention group discontinued sessions because they were either too busy or too sick.
Dr. Lauren Ghazal: Yes. And thanks again, Fumiko, for the introduction and for having me here. As you mentioned in my introduction, I'm an AYA. I was diagnosed at 26 with stage 2 Hodgkin lymphoma. And as many of us AYAs in the advocacy space, as you know, at the time of diagnosis, I was doing far more important things in my life than wanting to worry about and deal with cancer. And so when cancer came very dramatically into my life, I had to tackle it with whatever, as Abby said, resiliency skills and resilient skills that I had built up to that point. I was 26, so 10 years over the median age of Abby's study, but that's what I was left with at the time to deal with my diagnosis and my survivorship. So I was also working as a family nurse practitioner in primary care, and I was also in my first year of a PhD program in nursing research. So I had caught that nursing bug to be a researcher really early on in my clinical training. And I remember seeing this paper come across my inbox a few months back, and I was so excited to read this publication. As an AYA, I'm always like selfishly so grateful to see work being done in studying resiliency and stress management and overall quality of life because I feel like I'm constantly kind of suffering with that and really trying to understand kind of how do I separate my AYA advocacy role and my personal experience in this work, and then also as a researcher in the AYA world.
And so, yes, very excited to see this study. And we all know AYAs face these unique challenges, challenges that include high symptom burden, developmental transitions, these competing life demands that can make participation in research particularly complex. I know firsthand how overwhelming having a cancer diagnosis can be during this life stage that's already filled with so much uncertainty. And so when you're straddling again this independence-dependence as an AYA, for me again, just beginning graduate training and trying to make sense of who I was, who I was becoming, all of these competing demands that can complicate not only how we experience care, but how we also engage with research.
So I think when I think about Abby's study too and something that you had mentioned in the overview is really like the time investment of putting up this hard work up front of building the resilient skills that maybe you didn't see it within the first 3 months compared to usual care, but later on in the 6- and 12-month time point, that's so critical to promoting resilience and sustaining that resilience not only throughout the rest of your survivorship and navigating, you know, your healthcare engagement, but also your overall life skills too.
And so I don't think you even know this, Fumiko, for as well as you know me, that I actually participated in another clinical trial on resilience and stress management. And this was 5 years ago now. And I actually pulled out the toolkit that we were given really early on this year when there was a lot of other stressor trigger points in my life, and I did one of the activities, and it was really just on targeting the trigger points, the stress points, and then trying to kind of address what I had control over in that moment, right, what was out of my control. And so that's 5 years. We know that we have not a lot of funding available that we can study AYAs for 5 years in these clinical trials, but they’re skills that are really that you're using for the rest of your life. And so being able to capture that, I think is just so important. That was one thing I wanted to take home here was that I used those skills that I learned 6, 7 years out from that trial.
Dr. Fumiko Chino: I was going to ask you a follow-up question to see if anyone had ever actually tried to develop coping skills for you as part of your standard of care, and it sounds like as part of a clinical trial, actually, you did get some of those, that development of those skills, and they're still paying off for you 5 years later, which is phenomenal. And I think we'll see potentially people on Abby's trial still benefiting in survivorship, be that as it may, in years if they get to that point, which is, you know, again, the whole goal of trying to think about resilience and building hope and sustainable interventions.
Now, this study was really focused on patients in the early adolescent and young adult ages 12 to 24 on the trial and was recruited from the children's hospital pediatric cancer departments. Abby, as part of your clinical experience as a pediatrician, what are the potential differences in the cares and needs of the younger versus the older AYA population? From my own experience, I can give you an example. I remember when my husband was diagnosed with cancer in his 20s, one of his team members referred to him as, quote unquote, "basically a pediatric case." It kind of hit me sideways at the time, but in hindsight, I can actually understand how being treated in the pediatrics department could have had some unique advantages, especially with wrap-around services at the end of life.
Dr. Abby Rosenberg: I so appreciate that question, Fumiko, and I feel like I first want to apologize on behalf of all oncologists for the way that your husband received or heard those words because I think the beauty of AYA oncology is that we really want to find the right place for people. And the way we balance it, before I answer your question, is I think there's two domains that people think about. One is what kind of cancer does this person have? Because there are a lot of, quote, “pediatric” types of tumors, and those types of biologies, those types of cancers are things that adult medical oncologists just may be less familiar with and we pediatric oncologists know how to treat really well and vice versa. So like if a young woman came into my clinic with breast cancer, I would be like, “Yeah, we don't do that in peds, you need to go across the street to the medical oncologists.” If the goal is, we need the best oncologist to treat and hopefully cure you of your disease, then that's decision point number one. Decision point two is: what is the developmental and psychosocial place that you are in in your life? And so similarly, you know, AYAs are defined by the National Cancer Institute from people between the ages of 15 and 39, and that is an enormous developmental age spectrum. And my 15-year-old patients are really different than the 35-year-olds across the street. And so what we think about in this sort of triaging of where people should go is are you still living with your parents? Who are your decision-makers? In pediatrics, we are inherently family-centered. Like, we do not ever make decisions in isolation with patients, at least I should say very rarely. It's always understanding that they are in a dynamic of relationships and other caregivers and loved ones. And that's somewhat different in adult cancer centers where the patient can have a lot of private conversations with or without their caregivers.
The other thing we think about a lot in pediatrics is people are still developing in their autonomy, their identity, many people are still on their parents' insurance, many people need caregiving support full-time, and it's different from if you're an independent young adult. And so we sort of think about how do we provide all of the services that you need.
You mentioned wrap-around services. So now I get to stand on my ‘pediatrics is better’ soapbox. We in pediatrics practice these holistic ways of approaching healthcare in general. So in most pediatric places, every person with cancer has an assigned social worker. They often have access to things like psychology and child life and music therapy and art therapy and school rehab, and there's schools embedded within the children's hospitals and all the things that you can think of to try to maintain your life track as best we can while you're going through all the stressors of cancer. As you said, I'm a pediatrician, I'm a pediatric oncologist. My focus has been in AYA oncology, but in the pediatric space, and we thought about, should we also enroll people who are in the adult medical oncology centers, and we realized that that quote “usual care” would be so different between groups depending on where people were receiving their oncology care that we just decided for the rigor of the science to focus on pediatric centers. And I think what's kind of cool about that is if you imagine usual care in pediatrics is pretty high bar, like you get a lot. If PRISM is still better, that says something about what we are missing even in pediatric oncology care, let alone what the rest of the oncology treatment centers might be missing too.
Dr. Fumiko Chino: Absolutely, absolutely. And again, not to dog on adult cancer services or to speak the benefits of pediatrics, but I definitely see that gap certainly in my own clinic and from my own lived experience.
Now, Lauren, I have certainly heard from other AYA survivors in their 20s and 30s that they felt that sort of they were between worlds during their cancer treatment and just survivorship. Many have to maybe even move back home or they might need family caregivers during their treatment, and this can cause really a disconnect in identity that can also add to stress and anxiety. In your opinion, how can we be supporting AYA survivors' psychosocial needs better?
Dr. Lauren Ghazal: Yeah, that's the million-dollar question. And I want to preface this by saying that it's so difficult to speak on behalf of all AYAs, and I can never do that. And I say this a lot, but we know this, the NCI, ACS knows, the one-size-fits-all for survivorship model does not work, especially for AYAs, and Abby alluded to this very wide age range that we see in AYA cancer survivorship. I think that there are really great programs across the nation that standardize AYA formal programs that are being designed, that are being implemented across the many different areas of AYA survivorship that Abby had mentioned including financial navigation, getting financial services, psychosocial support, embedding psych and mental health therapy into those survivorship programs as well because those are the biggest barriers for AYAs is being able to access mental health providers that are trained in seeing AYA patients. And for many AYAs, I've been hearing more and more from friends of mine that they had to transition to a new mental health provider, which we know is so difficult during that period of diagnosis.
I would also say too that there's a lot of research being done at UNC in their, the University of North Carolina Chapel Hill, in their AYA program in implementing their AYA Needs Assessment or their Bridge that Dr. Emily Haines has developed, and I know they're undergoing a bit more testing too in shortening that. But when I look at that too and I see all of the different areas that AYAs endorse as these top unmet needs and then really being able to screen and identify in one place that, "Okay, there's more support needed here." That's when then there can be tailoring done. But to actually centrally funnel in through a standardized assessment that can be implemented, and then also recognizing that not every cancer program and AYA program across the nation has every answer and every resource available. And so being able to say, "Okay, we have these formal connections not only with a local AYA organization but also nationally through incredible organizations like Triage Cancer and Cancer and Careers or through the Cancer Support Network." Those have been areas that I've, you know, have really tried to push for is really strengthening referrals to address the health-related social needs of AYAs more formally through community-based organizations and then also streamlining a needs assessment for AYAs.
Dr. Fumiko Chino: I often think about the challenge for someone who potentially could travel or maybe should travel to receive specialty care at these large centers that have so many resources versus staying closer to home where they have more support, where it is a lower cost, right? And trying to figure out what's really worth it. And I think you brought up a really good point, which is that there are national community-based services that are available to everyone. You don't have to go to an MD Anderson or a Dana-Farber to receive them necessarily as long as people are properly plugged into those services.
Now, this trial enrolled AYA patients with advanced cancer. I know Abby, you already spoke to this a little bit, but one of the goals was to increase AYA engagement in goals of care and formal advanced care planning. And I was saddened but not shocked to see that less than 10% of patients in either arm had formal documentation of advance directives in their chart. This certainly aligns with my own experience, not to make this all about me, but, you know, I had a very traumatic conversation in a hallway outside of an ICU about intubation for my husband. And this paper really puts it quite eloquently, stating that even though the intervention may have, quote unquote, “enabled AYAs to engage”, it did not help oncologists do the same necessarily. Abby, I would appreciate your insight into the barriers that oncologists may have about starting some of these hard conversations, particularly with younger patients.
Dr. Abby Rosenberg: First of all, again, I'm going to apologize on behalf of all healthcare providers for the non-ideal ways that you guys were hearing serious news. Now I'm going to put on my oncologist hat and say, there's a couple things that I think explain these data. The first is, we oncologists love our patients. We want to fix this problem. We want to cure the cancer. We have the same hopes and prayers that so many of our patients and families do, and so I think there is this real sense of failure when we see the beginnings of treatment not working, and I think oncologists and patients will align together to keep fighting as long as they can.
What we found in this study, we measured engagement in a lot of different ways and we saw that AYAs who received the PRISM program were more likely to directly engage in conversations that we would extract from like medical records, like sort of text notes about what conversations were happening in the room. They were more likely to ask direct questions and respond directly to palliative care consultation when palliative care teams were having sort of really hard conversations about prognosis and goals of care and what matters to you given what is happening. But the next step, as you're describing, is the formal documentation of something like an advance directive and the formal documentation of, “What would I want if I can't speak for myself?”
So there's a couple sort of last things that I'll say that I think explain why we didn't see any difference in uptake of those advance directives in our study. One is, we had younger people. So 16 and a half, those young folks don't complete their own advance directives. They can complete a document called “Voicing My CHOiCES” which talks about what they would hypothetically want, but that is another sort of formal documentation that I think a lot of people might have felt like, "I'm not going to engage in that," or the oncologist wouldn't have offered it because they were talking to the parents or it was too scary or too hard for these young people who were still not of the age of majority making their own decisions, number one.
And number two is, I think we really try to avoid, not for the right reasons, but I think oncologists in general with well intentions try to avoid those hard conversations because they worry that we will cause harm, we will cause pain, we will, quote, “take away hope”. And this is where I and probably many other folks in palliative and supportive oncology struggle because we know that patients and families have those things on their minds. We know that inviting the conversation doesn't in fact take away their hope, it helps them really make more precise the things that they are hoping for and enable them to achieve the goals that they can realistically achieve, especially if time is short. And I think in this study, maybe the first obstacle was: will AYAs engage? We found the answer is ‘yes’. And so now the second obstacle is, how do we enable the oncologists to reciprocate and to ask the hard questions? And maybe it's partnering with psychosocial clinicians and palliative care. Maybe it's just a little bit of risk-taking on the part of the oncologists to be curious and say, "Hey, what's on your mind? Many people like you think about these things. I'm happy to talk about them with you too. What do you think?" And then if an AYA says, "Hell no, I don't want to talk about that," fine, we can be like, “Great.” But at least we're providing a doorway for them to walk through if they want.
Dr. Fumiko Chino: It reminds me of what Dr. Tarlise Townsend- she gave this profound speech at ASCO Quality from a couple of years ago, and she said she had to kind of do her own death work to kind of come to terms with these issues and really think for herself what she was kind of willing to put up with and for what kind of end point.
Lauren, do you have anything to add?
Dr. Lauren Ghazal: Oh yeah, I just had a follow-up question for Abby too in that you mentioned, you know, you were able to answer, "Will they, will AYAs engage?" and ‘yes’. Were you able to kind of decipher if they can engage with other healthcare professionals or other healthcare team members? Is there more of that engagement happening, let's say, with the infusion nurse or with the nurse practitioner?
Dr. Abby Rosenberg: Great question. Just based on the way we measured this, we did not pick that up, and that's one of the limitations of the project is that we didn't expressly ask people, “Who is your person, who are you talking to about this?” Because what we were trying to do is sort of see organically if it came up without prompting. But I think you're right, Lauren, what we know about the experiences of folks with advanced cancers, and this is true certainly in pediatric and AYA oncology, is that it's not necessarily the oncologist who is the trusted person. It could be the infusion nurse. Often, it's the bedside nurse when folks are in the hospital for long periods of time. It could be the chaplain. It could be a whole host of people, the social workers.
And I think what is really important is recognizing two things. One is, we need to honor the interprofessional team and recognize who needs to be in the room for this young person to engage in these really hard conversations And then secondly: how do we still empower the oncologists? And I say that not because I'm elevating the oncologist's role as much as I'm saying the oncologists are the ones who are offering treatment choices and guiding the care plan, and if they aren't part of the conversation, if they aren't hearing an AYA say, "You know what, actually what's most important to me is to be home," then we oncologists are potentially misguiding people. And so how we find that balance, we have to figure out how to integrate all of the players and important people into the room.
Dr. Fumiko Chino: That dovetails so nicely to my next question for Lauren because I know that you had written in The Cancer Letter a couple of years ago that - and this is a direct quote - "Our current status quo is not working. It leaves patients without the resources or the knowledge to be fully engaged. We need more research directed at effective provider-patient communication and tailored interventions that engage the full care team to address each patient's unique needs and experiences." Now, having said that, what would you like to see next in the context of either research or practice to advance this very necessary communication and patient-centered care?
Dr. Lauren Ghazal: Yes, and I had an incredible co-author for that piece as well. It was Fumiko, Abby.
Dr. Fumiko Chino: That's awesome.
Dr. Lauren Ghazal: So she's set me up very well for this. Thank you for referencing that piece again, Fumiko. You know, it's really great that Abby had touched on and everything that she's said so far is kind of what I had jotted down and brainstormed in preparation for this and what I'd like to see next, I think coming from an AYA in really this shift from like just simply documenting communication or communication breakdowns to actively building, testing, implementing solutions and that we know that will center AYAs and their care partners, whomever it is, throughout their experience with cancer. And really taking the time too to note that it's especially important for marginalized and underrepresented groups like queer and LGBTQ AYAs with cancer who we know face additional challenges throughout cancer survivorship.
And so, I'm speaking to the choir here, but we trained as a nurse and as a nurse practitioner, communication in our training, you know, is treated as a soft skill rather than like a clinical competency that really we know has direct implications for outcomes for AYAs that include adherence, that include quality of life, include trust with our healthcare providers and in our healthcare system. And so I always advocate for more interventions that are co-designed with AYAs and their care partners and their communities that really account for structural barriers, identity-based barriers to communication, and that can extend beyond this dyad of just provider and patient but to include our broader healthcare team that include navigators, social workers, nurses, child life specialists even.
And I had another piece that I had written around trauma-informed care for LGBTQ cancer survivors, but we know that embedding even tailored communication strategies into routine care improves care and care delivery, like trauma-informed care practices. And so I also always advocate for proactive conversations around the taboo topics of AYA care that we know things like fertility and family-building, finances, and employment, as you know so well, Fumiko, things about cost-of-care conversations, but all areas where AYAs can see, can often feel unseen or silenced or that it's not important right now because their goal is just to survive throughout this. Yeah, so that's a little bit about kind of my take on communication.
Dr. Abby Rosenberg: Can I just jump in and say, I mean, I think, Lauren, the other thing to amplify from what you just said is if we don't model that it's okay to talk about these subjects, most patients in particular follow the lead of the clinical team. And so if it's not brought up, then the patient will appropriately assume that's not what I'm supposed to talk to my healthcare team about. But if we introduce all these topics and normalize them as part of a holistic care approach, then we're more likely to have these full, rich conversations that need to happen.
Dr. Fumiko Chino: Absolutely, communication is not a soft skill. It is an essential skill for patient care. And again, this idea that the oncologist is the end-all be-all for communication is also, I think, deeply flawed, and thinking about the full team as being a team that actually envelops the patient in care is also essential.
All right. Well, wrapping up, do you have any last thoughts today, anything that we missed, anything that you want to highlight again in terms of opportunities to reinforce for our listeners from Lauren or Abby?
Dr. Abby Rosenberg: When I think about this whole horizon of research and clinical care, to me, I guess I'm taking away two things. One is to really be unafraid, those of us who are at the bedside, in whatever role, to open the door to these pathways of communication about all sorts of scary topics because then we can provide better care. And then the second, I think now, as a resilience researcher, is we can expect and normalize that some of these coping skills can be learned, and the investing in them in an evidence-based way can have these durable impacts in overall patient and family well-being, and so it's worth the investment.
Dr. Fumiko Chino: We're worth it. Our patients are worth it. I was just thinking about as a caregiver, how much I wish resilience training and coping skills had been directed at me, selfishly again, I'm sorry, I'm again, this is all about me, apparently. But I do think that that might be one of the next frontiers as well because the caregivers really are part of that team unit that helps envelop the patient in love and care and support.
Dr. Abby Rosenberg: Well said.
Dr. Lauren Ghazal: I'm snapping for you, Fumiko.
Dr. Fumiko Chino: Well, on the exit of the snaps, then, I want to thank you both so much for this wonderful conversation. Many thanks to both Dr. Rosenberg and Dr. Ghazal as well as our listeners for your time. You will find the links to the papers that we discussed in the transcript of this episode. If you value the insights that you hear from the JCO OP Put into Practice podcast, please take a moment to rate, review, and subscribe wherever you get your podcasts.
I hope that you will join us next month for another Put into Practice episode, and until then, I hope you are staying safe.
Dr. Abby Rosenberg: Thanks, everybody.
Dr. Lauren Ghazal: Thank you.
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Fumiko Chino
Employment
Company: MD Anderson Cancer Center
Consulting or Advisory Role
Company: Institute for Value Based Medicine
Research Funding
Company: Merck
Abby R. Rosenberg
No Relationships to Disclose
Lauren Victoria Ghazal
No Relationships to Disclose