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Wednesday, July 30, 2014

BY JEFFREY M. HARTOG, DMD, MD

 

In my experience over the years, radiation therapy as part of the overall treatment of breast cancer has notably decreased the risk of recurrence and improved overall survival for advanced breast cancer in women undergoing mastectomies. There is also some evidence that it may be beneficial in less advanced cases, as well. In addition, more and more frequently, patients are choosing breast-sparing surgery for breast cancer treatment, and radiation therapy is an essential component of this approach.

 

Although radiation therapy may be beneficial in terms of the treatment of the cancer itself, we in the medical profession should consider the problems it can create for women seeking breast reconstruction – for example, increased complications, complete failure of breast reconstruction with either implants or tissue flaps, and poor aesthetic outcomes. The radiation may also increase the deformity of the breast in women undergoing lumpectomies due to scarring and contraction of the tissues.

 

In most cases, women who have undergone lumpectomies followed by radiation are not offered reconstruction at all, despite the fact that they are frequently left with moderate or severe breast deformities and significant breast asymmetry as it relates to the other, untreated breast. Despite the effectiveness in treating breast cancer, radiation therapy results in increasing fibrosis of the tissues and adversely affects the body’s ability to heal itself in the radiated areas.

 

Fortunately, we now have an effective way to reverse the deleterious effects of radiation therapy, improve outcomes and decrease complications in women undergoing breast reconstruction. Furthermore, women with lumpectomies now have a viable option to reconstruct their breasts and improve symmetry with the opposite side. I have found fat transfer, or fat grafting, to be an effective method to restore the vitality of radiated tissue, facilitate breast reconstruction, and reconstruct breasts treated with lumpectomies followed by radiation.

 

Technique

The fat transfer technique is simple, involves no incisions, and is a 100-percent outpatient procedure. The fat is harvested with a standard gentle liposuction procedure, and then simply injected into the radiated areas using meticulous micrografting techniques. Usually, more than one procedure is required to restore the tissue quality and the breast defect, but now we can simplify the procedure by banking fat harvested with a single liposuction procedure, making subsequent micrografting injection procedures much easier.

 

Fat grafting works in two ways to restore radiation-damaged tissue. The first and most obvious way is that the fat replaces the scarred and fibrotic tissue and restores the tissue quality and volume. The second, more subtle manner is due to the stem and regenerative cells contained in the fat, which improve the ability of the tissue to heal itself. There is strong evidence that one of the effects of radiation is to destroy and deplete the stem and regenerative cells that normally exist in tissues, and this is one of the factors promoting increased scarring and contraction of radiated tissues. It’s also a possible mechanism of the increased complication rate when breast reconstruction is attempted, particularly with implants.

 

Depending on the situation, we can use fat transfer alone, as in most lumpectomy patients, or we can use it in combination with implants, as in mastectomy patients. The procedure can also salvage failed or compromised breast reconstructions with flap procedures.

 

Fat transfer is an essential component in reconstruction of breasts treated with radiation and can make the difference between success or failure. In certain situations, even mastectomy patients who have been heavily radiated may not be considered as candidates for breast reconstruction at all. Frequently, fat transfer can provide a method for reconstruction even for these patients, who have been told that reconstruction is not an option by most plastic surgeons.

 

Of course, fat transfer is also an option for women who choose not to have reconstruction with artificial implants or tissue flaps requiring major invasive procedures to harvest the flaps from other parts of their bodies.

 

Because breast reconstruction with fat transfer can be tedious and requires meticulous specialized techniques as well as some patience on the part of the patient, who may need two or more fat transfer procedures, many plastic surgeons do not even offer this procedure to their patients. However, to me, it is unacceptable to expect women to walk away after such life-changing procedures without being offered the option of breast reconstruction.

 

Women should know they don’t have to live with deformed breasts after radiation. Oncologists should present breast reconstruction options to their patients, including the natural fat transfer procedure.

 

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JEFFREY M. HARTOG, DMD, MD, Director of the Bougainvillea Clinique in Winter Park, Florida, specializes in fat transfer to the breast and presents nationally and internationally on the subject.


Tuesday, July 29, 2014

by Scott D. Siegel, PhD; and Darcy Burbage, RN, MSN, AOCN, CBCN

 

In the July 10 issue, the article “Deadline for Survivorship Care Plan Compliance Being Rethought” notes that the Commission on Cancer (CoC) is “revisiting the [survivorship care plan] requirement since many institutions have been having trouble complying.” Respectfully, in loyal opposition, we say it’s about time the CoC is giving this standard second thought. The OT piece highlighted the feasibility question: is it even possible to meet the requirements of this standard? As we will review below, it was foreseeable from the outset that this was an unattainable standard. But more important than the question of “Can we?” is the question of “Should we?” That is, even putting aside the very real challenges this standard imposes on cancer programs, do treatment summaries and care plans actually offer any real value? The evidence challenges the assumption that if we could just find a way to implement this standard, it would improve care for survivors.

 

First, to the feasibility question: how does a cancer program go about providing a “comprehensive care summary and follow-up plan” to all cancer patients completing treatment? The simple answer is to hire someone (or several people, depending on the number of patients being treated) to complete these documents and then review them with cancer survivors. This is typically too time-consuming a task to ask existing staff to handle. To put this in perspective, at our program we have a very experienced Advanced Oncology Certified Nurse in the role of “survivorship nurse navigator,”  and it takes her (DB) on average 45 minutes to an hour to just complete a treatment summary/care plan for one patient (not reimbursable). Then it takes another 30 minutes to review the summary/care plan with the patient.

 

If our survivorship navigator only completed and reviewed summaries/care plans with our survivors, never taking a day off or even a break, never offering any other survivorship service, she could reach about 1,400 survivors per year. Our cancer program sees over 3,000 new cancer cases per year. While we are very fortunate to have a full-time position devoted to survivorship issues, something many other community programs are not able to fund, we are certainly not in a position to hire multiple survivorship navigators.

 

To get around the time and labor issues, some have suggested that cancer programs can rely on software to prepopulate treatment summary fields with data from the tumor registry or the electronic health record (EHR).  Unfortunately tumor registries are often several months behind. But even if the tumor registry was “real-time,” it tracks things like whether a patient received chemotherapy (yes or no) and not the specific types of chemotherapy a patient received, thus falling short of the CoC standard requirements. Using software to pull data from EHRs is also not as straightforward as it might seem. Most cancer care in this country is delivered in the community setting where there is often a hybrid model of employed and private physician offices, typically with multiple EHRs. It is unusual for EHRs to talk well with one another, and treatment summary software has yet to overcome most of these hurdles. Because the software either does not exist or the computer programming necessary to make it all work would be prohibitively expensive, for most sites, treatment summaries/care plans must be completed manually—hence the compliance concerns.

 

Next let’s turn to the question of whether we should attempt to meet this standard, feasibility issues aside. The theory goes that treatment summaries/care plans will help bridge the gap between oncology and primary care.  Oncologists cannot follow their patients forever; at some point survivors need to transition back to their PCP. If survivors just had this document, with all the treatments they received, and handed it to their other physicians, no one would be “lost in transition” anymore, to borrow from the Institute of Medicine (IOM) report.1

 

The flaw in this theory is that it sounds so intuitive no one really bothered to test it before mandating treatment summaries for all survivors. As it turns out, even with this document in hand, survey research has revealed that PCPs do not feel adequately trained to manage cancer survivors.2-4 The research also shows that medical oncologists don’t trust PCPs to follow their patients, which is why medical oncologists are so reluctant to discharge. And the survivors, too, say they would rather be followed by their medical oncologist.

 

A single document, no matter how comprehensive, does not make up for the fact that most PCPs did not receive training on survivorship care when they attended medical school. And to the concern that we don’t have enough medical oncologists to follow the ever-growing population of cancer survivors, we don’t have enough PCPs either.5 This is a serious problem, certainly, but not one that treatment summaries/care plans fix.

 

The other argument frequently offered in support of treatment summaries/care plans is that it “empowers” survivors. With treatment summaries, survivors will have more knowledge, and with knowledge comes power. In our practice, despite making it as pleasant as possible an experience for our survivors to review their treatment summary (we coordinate with other appointments, do not bill, and the survivorship navigator offers to discuss the treatment summary only after establishing a good rapport), two-thirds of our survivors decline the service.6

 

Far from feeling empowered, the feedback we typically receive is: “That’s too much right now,” “I have other worries,” “Can’t my doctors just talk about this with each other?” And to the point of having other worries, when we survey our survivors – and the research again supports our findings7,8 – they ask for help with things like returning to work, managing long-term side effects -- and perhaps most of all, managing their fear of recurrence. These are the very kinds of concerns our program seeks to address with our survivors, but our reach is limited by the time and resources we must devote to treatment summaries/care plans. 

 

Somewhere along the way survivorship care became synonymous with treatment summaries/care plans. We find this unfortunate. And this is not what the IOM report recommended, by the way. Treatment summaries were but a small part of the overall approach to survivorship care the IOM report was advocating (and something that should be reimbursable at that, which currently is not).  The other IOM recommendations included a greater focus on symptom and side-effect management and developing and testing new models of care for survivors. 

 

The real harm is that by focusing exclusively on treatment summaries we divert precious resources away from the kinds of services survivors actually want and need so that we can complete a document that sounds good in theory.  This is hardly evidence-based care. This is hardly survivor-centered care. And as people who consider themselves strong advocates for cancer survivors, we say it’s about time we rethought things. 

 

References

1.  Hewitt M, Greenfield S, Stovall E. (2005). From cancer patient to cancer survivor: Lost in transition. Washington, DC; National Academies Press.  

2.  Grunfield E, Julian J, Pond G, et al. (2011). Evaluating survivorship care plans: Results of a randomized, clinical trial of patients with breast cancer. Journal of Clinical Oncology 29:4755-4762.

3.   McCabe M, Bhatia S, Oeffinger K, et al. (2013). American Society of Clinical Oncology statement:  Achieving high-quality cancer survivorship care. Journal of Clinical Oncology 31, 631-640. doi: 10.1200/JCO.2012.46.6854.

4.  Grunfield E, Earle C. (2010). The interface between primary and oncology specialty care: Treatment through survivorship. Journal of the National Cancer Institute Monographs 40, 25-30.  

5.   Klabunde C, Han P, Earle C, et al. (2013). Physician roles in the cancer related follow-up care of cancer survivors. Family Medicine 45, 463-474.

6.   Burbage D, Siegel S (in review). Implementing the role of a survivorship nurse navigator in a community cancer center.

7.   Miller L (2012). Sources of uncertainty in cancer survivorship. Journal of Cancer Survivorship 6, 431-440.

8.   Ness S, Kokal J, Fee-Schroeder K, et al (2013). Concerns across the survivorship trajectory: Results from a survey of cancer survivors. Oncology Nursing Forum 40, 35-42.

 

 

Scott D. Siegel, PhD, a licensed psychologist, is Director of Psychosocial Oncology & Survivorship at the Helen F. Graham Cancer Center & Research Institute in the Christiana Care Health System. Darcy Burbage, RN, MSN, AOCN, CBCN, is Survivorship Nurse Navigator at the Helen F. Graham Cancer Center and Research Institute.


Tuesday, July 22, 2014

                                                              ROBERT C. YOUNG, MD

 

There seems to be an intense public fascination with emergency room medicine. Television shows like Scrubs, and ER presented humorous or sanitized versions of the subject. A documentary series on Vancouver General Hospital on the Knowledge Network (Emergency Room: Life and Death at VGH) won several awards this year. Books abound: Emergency! True from the Nation's ERs by Mark Brown, MD; Angels in the ER: Inspiring True Stories from an Emergency Room Doctor by Robert Lesslie, MD; and Something for the Pain: Compassion and Burnout in the ER by Paul Austin, MD, all present a more distilled and abridged version of the reality experienced in the trenches.

 

This is not so with On the Edge of Life. Mikkael Sekeres, MD, MS, rotated through the ER of Mass General where a journal had been started by Theodore Stern, MD, allowing house staff to jot down their thoughts about the experience. Now, 20 years later, the journal has grown to seven volumes of unabridged observations recorded in real time. The editors have used these thoughts and distilled them into separate chapters on humor, life and death, patients and families, and doctors.

 

The result is a candid, realistic, no-holds-barred, even at times harsh, collection, which will unfortunately ring true to all who have rotated through an MICU. It must be said that the information is also disturbing and in many ways disheartening. As one house officer said, “I’m scared, sad, incompetent, weak, pressured, lonely, isolated, bitter, dumb, inefficient, and nobody else could feel as I do.”

 

House staff are plunged into this fray and have to act immediately to care for the sickest of the sick. One house officer captured the feeling of inadequacy perfectly: “I wrote my first order as a physician (to give the patient potassium). Actually the nurse told me the patient needed potassium, taught me how to write the order, what to give, where and when. But I was able to write my name without any help!”

 

Humor somewhat paradoxically is a common part of the MICU experience. Dr. Stern emphasizes that “Humor bonds staff. Sleep, food, and shared laughter are powerful medicines and great pacifiers. Displays of humor insulate staff from the misery around them. To outsiders, the gallows humor may seem inappropriate, sophomoric, and ill timed. It probably is. Humor can facilitate coping but it comes at a price. Doctors use humor because at times it is easier to laugh than to cry.”

 

Female physicians struggle with career building and child-bearing during training years. This makes for some unique physician-related humorous circumstances. Consider this interaction: “JAR [junior assistant resident] on the .road to matrimony plans for the future. Let’s see, if I get pregnant right now, I wouldn’t have the baby until August.” SAR [senior assistant resident]: “It would make rounds a little uncomfortable for the rest of us.”

 

Humor often comes from patients who misunderstand our “medspeak.” Here is an example: Patient who had an inferior wall MI while walking his pit bull. SAR: He needs bypass surgery. Patient: Can’t I just get rid of the dog and take it easy?

 

One of the grimmest messages in the book is the struggle doctors have to come to grips with the realities of desperately ill patients. Twenty-five percent of patients will not leave the MICU alive, and even fewer will leave the hospital and return to functional lives. The ideal candidate for the MICU is a patient with a short-term serious curable illness. Yet the editors point out that “most [MICU patients] are frail, elderly, and destined to die of chronic disease but are kept alive by the use of advanced technology.” As one house officer explains;” Plenty of people have come through the MICU this month. Yet it strikes me that in the saves column, after 59 admissions and only 12 deaths, we have only two.” As another house officer wrote; “just because we have the capacity to prolong life in elderly people doesn’t mean we have to, but we do; everyday in this place we prolong suffering at little benefit.”

 

The editors explain; “We manage to learn a great deal about the mechanics of medical care for desperately sick patients, but caring for patients in the ICU raises issues about aggressive and expensive health care; it is often ambivalent and disturbing. A lack of definitive answers, guidance, and policies contributes to the distress experienced by house officers.”

 

Because these unvarnished thoughts from these young physicians are all too familiar to most doctors, it’s hard to know whether re-reading these first-hand experiences will be of sufficient interest to a broad spectrum of doctors or oncologists. It certainly left me with the view that many of the serious and stressful issues of complex care of the chronically ill in MICU’s have not been addressed since I was a house officer.

 

Unfortunately, patients and lay readers will likely be confused by the medical jargon and probably frightened by the candid expressions of ambivalence toward end-stage medical care expressed in such blunt fashion.

 

However, progress in making the MICU a more inviting and compassionate place is being made. In the June 26 issue of the New England Journal of Medicine (NEJM 2014;370:2506-2514), a review article, “Dying with Dignity in the Intensive Care Unit” by Deborah Cook, MD, and Graeme Rocker, MD, explores in detail the coexistence of palliative care and critical care in the MICU. They discuss the need for palliative care, the importance of eliciting the values of patients, the critical need for communication about patients’ perceptions about what matters most for high-quality end-of-life care. They call for providing clear prognostic information, recommendations to forgo the use of life- support technology, and the need to provide holistic care. They advocate for patient and family-centered decision making, communication, continuity of care; emotional, spiritual, and practical support; symptom management; and importantly, organizational support for ICU clinicians. The article is a comprehensive and encouraging blueprint for improving MICU care. However, it will be a challenge to accomplish in this era of restricted health care budgets, manpower shortages, and clinicians’ time constraints.

 

In the same issue of the journal, a Perspective article, “Where We Die” by David Rothman, MD (2014;370:2457-2470), notes that throughout history until the mid-20th century, the appropriate place to die was at home surrounded by family and friends. Now in the 21st, we are returning to more deaths at home and fewer in hospitals, but greater ICU use.

 

The test for the future will be to create an ICU culture that utilizes increasingly complex treatments but also helps patients and their families make wise decisions about managing the end of life.    

 


Monday, May 19, 2014

BY MIKKAEL A. SEKERES, MD, MS

 

We followed the highway, its boundaries occasionally buttressed by cement walls to block sniper fire, past checkpoints in and out of Area C of the West Bank until we arrived finally in Jerusalem. The four of us--an Italian, a Brit, a South African, and an American--specialists in lymphoid and myeloid malignancies, packed tightly behind our 84-year-old tour guide like ducklings following their mother as we left the safety of our small shuttle for the Old City.

After traveling thousands of miles to attend the annual hematology conference organized by Aaron Polliack in Israel, we would have one day to explore this ancient town.

 

We passed through the Zion Gate, the walls forming the arched entrance pocked with bullet holes from the most recent attempt to overtake this conflicted area. Inside, more walls--this time surrounding the Armenian church, a barrier thwarting those who would try to complete their genocide. We stopped after walking a few hundred meters as our tour guide described life in the different quarters--Jewish, Muslim, Armenian, and Christian. As he talked, we noticed that in one small view we could see the remains of an ancient Roman thoroughfare, a Chabad temple, and a Mosque, and we heard the call to prayer.

 

Hawkers in stalls selling textiles, menorahs, hookahs, jewelry, rugs, scenes of Christ and the apostles. “I give you a good price!” We heard over and over as people jostled into one another through the narrow, crowded path. We stopped for lunch, falafels and chicken shwarma, the table and chairs appearing as if out of nowhere. Nearby sat some Chassidic Jews, with black hats and long beards; a tour group of Christians from Holland, we guessed; Jordanians smoking cigarettes. We finished and pressed on.

Throngs of people were entering and leaving the Church of the Holy Sepulchre. Inside, we followed the flow upstairs, to Calvary where Christ is believed to have been crucified. People dropped to their knees almost helplessly to pray. Scenes from the old and new testament on the walls, originally depicted to instruct illiterate parishioners. Downstairs, people pressing hats, scarves, shirts to the Stone of Anointing, where Christ was laid before being transferred to his burial tomb, which was itself encased in a wooden supporting structure donated by England, which in turn was encased by more crowds waiting to enter. A group from Thailand kneeled in an enclave, praying. We heard another tour guide speaking in German. about the multiple iterations of the church’s destruction and construction. “Babylonian stone…Greeks erected a wall dividing the church…Crusades came through and killed everyone…” Their distinct crosses etched in the stone.

 

Through metal detectors as we ended at the Wailing Wall. Our small group splintered now as we walked to the men’s or women’s sides. The Wall was almost blinding as the mid-afternoon sun reflected off of it, but soft to the touch from generations of people wearing its surface down in prayer. A man quietly davined next to me, scraps of paper with prayers written on them stuffed into the Wall’s crevices. As we left, we walked past kids newly enlisted into the Israeli Army, not yet assigned to a unit, still carrying their guns awkwardly. Our shuttle was waiting, and we said goodbye to each other, until ASCO, or ASH.

 

I can’t pretend to even start to understand the history, politics, and religions of the Middle East, the conflicts that have arisen there, or their resolutions. It seemed to me, though, that there are lessons we can take away in how we approach cancer research and treatment.

 

We frequently do research in isolation, trying to develop theories within our narrow disease focus, when those theories may already have been tested and expanded elsewhere. We’d learn a lot more, faster, if we packed a group of people from different disciplines in a shuttle, or at adjoining tables over lunch, and forced them to spend a day together.

 

Too often, we compete against each other, and spend an inordinate amount of time trying to tear down each other’s research in favor of our own. It would be an interesting exercise to assess how many letters to the editor in academic journals are truly about open public debate to test scientific rigor, as opposed to needless self-aggrandizement. We should spend more time building, less time destroying.

 

Oncologists across the world often will not change their practice until trials have been replicated in their own country. There are examples in every cancer. As is the case with many religions, where much of the fundamental moral structure is similar, our fundamental motivation is the same: We want to cure cancer, and we want to treat our patients with the best available drugs. We should trust each other more, and be quicker to adopt the findings of well-done clinical trials conducted elsewhere, so we can improve what we consider standard therapy for our patients, and move more quickly to the next clinical question.

 

Finally, we shouldn’t give our hematology/oncology fellows their “guns” too soon. In other words, we need to devote real time to teaching clinical skills, sound research principles, critical appraisal, and writing tools, and to developing communication prowess before we nudge them out of the nest to enter their own practices, and conduct their own research.

 

Anyway, that’s my religion.

 

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MIKKAEL A. SEKERES, MD, MS,

OT’S Clinical Advisory Editor for Hematology/Oncology and a member of the FDA's Oncologic Drugs Advisory Committee, is Director of the Leukemia Program at the Cleveland Clinic Taussig Cancer Institute and Chair of the Hematology/Oncology Pharmacy & Therapeutics Committee. He is a staff member in the Department of Hematologic Oncology and Blood Disorders and holds a joint appointment in the Departments of Translational Hematology and Oncology Research.

 


Sunday, April 27, 2014

BY LARRY MAXWELL, MD

Department Chair of Obstetrics and Gynecology

Inova Fairfax Hospital

Advisory Board Chair, Globe-athon

 

As doctors, we have an incredible ability to touch patients’ lives, often when they are going through the most vulnerable moments. In the safety of our offices, we provide consultation and facts to help with a patient’s short- and long-term outcomes. However, as soon as patients walk out of our doors, they are bombarded with myriad messages from non-medical sources about their conditions, some that are true and some that are false, but few we have control over.

 

It is also our responsibility to help engage patients in the dialogue regarding cancer education outside of the office to help dispel myths and keep them focused on potential treatment outcomes. Some cancer campaigns to date have been unifying, increasing public awareness and adding fundraising dollars to cancer research. But there is more we need to do as physicians.

 

From a health care perspective, there is a great need for educational efforts, especially for lesser-known cancers. Lack of information causes significant problems in prevention and early detection, especially in the case of gynecological (GYN) cancers. Research from the American Cancer Society reveals that only 15 percent of ovarian cancer cases are caught before the cancer has spread. Due to late diagnosis, GYN cancers are harder and more expensive to treat and the survival rates are lower. Yet, ACS research also shows that when ovarian cancer is detected and treated early, the five-year survival rate is 92 percent.

 

Physicians and other medical professionals have an opportunity to share their expertise with individuals so that they can be aware of the prevention and early-detection measures they can take every day. For this to occur, physicians need to use their expertise to support initiatives that help disseminate the right information and bring awareness to the issues.

 

Patients, survivors and caregivers are having the conversations at home and online, and we need to continue to support these conversations to ensure information accuracy and awareness.

 

Movement for One Dedicated Mission

In the case of GYN cancers, there are five primary cancers -- cervical, ovarian, uterine, vaginal, and vulvar -- and multiple education and advocacy organizations involved in a variety of complementary, yet separate, initiatives. Only those diagnosed know to turn to these organizations for support.

To help unify and use our collective voice, GYN cancer organizations across the globe are organizing around one goal – ending women’s below-the-belt cancers. While each organization has its own mission and goals, we all agree that awareness is the most important component of our efforts. Globe-athon to End Women’s Cancers is a global movement to raise awareness about GYN cancers, while also serving as a catalyst for unprecedented bridge building and collaboration beyond regional and international borders.

 

As part of the effort last year, more than 60 countries and 130 cities hosted events to raise awareness and encourage participation in Globe-athon. During the second annual effort this year, Globe-athon will occur during four weeks in September with hundreds of events and educational seminars throughout the world to raise awareness for, and ultimately increase, early detection and prevention of GYN cancers.

 

With Globe-athon we are working to create a global communications grid through our multi-lingual website (globeathon.com) and social media platforms, including Facebook and Twitter, to facilitate dissemination of information to patients and the general public, foster discussion amongst survivors around the world, and ultimately enable retrieval of survivor information to support research efforts.

 

The real impact, over the long run, is a global network talking about the issue and sharing solutions. With this kind of attention on below-the-belt cancers, we have the opportunity to save a generation of women.

 

National and international health initiatives like Globe-athon are opportunities to raise awareness about major health issues like GYN cancers in a way that help improve doctor-patient conversations, and call attention to the need for more education and research. The vast health information available is daunting for many people who are trying to take charge of their health.

 

When physicians and other medical professionals team up for specific health initiatives, it is a unique opportunity that brings credible and trusted resources together for one dedicated mission. Oncologists have the credible voice to inspire and inform educational campaigns to raise awareness, increase detection, and pursue prevention. Now is the time to lend your voice to the organizations and movements that need it most.