Introduction
‘Cancer occurs in one in four of the population with over a quarter of a million people in the UK diagnosed each year (excluding non-melanoma skin cancer). A diagnosis of cancer can be emotionally challenging’ (Galway, 2012).
All individuals should have the right to access support services for emotional problems and for psychological support. Psychosocial and psychological stress is becoming more established as a risk factor for people getting treated for cancer of any form; ‘people who have cancer may find the physical, emotional, and social effects of the disease to be stressful. Those who attempt to manage their stress with risky behaviors such as smoking or drinking alcohol or who become more sedentary may have a poorer quality of life after cancer treatment.’ (National Cancer Institute, 2016) Cancer is one of the world’s most known and studied diseases, therefore it is becoming easier and easier to treat without an actual cure being discovered yet. However, cancer has many side effects, before, during and after treatment, which can harm ones psychological and psychosocial wellbeing such as how they feel act and are treated by others because of cancer. This literature review was conducted to any evidence that suggests psychological and psychosocial wellbeing can have an effect on a patient’s recovery from a cancer diagnosis.
Search Strategy
A thorough, systematic search of online databases was accomplished in CINAHL, Psychology and Behavioural Sciences Collection, Academic Search Complete and Google Scholar for published literature. Hardimans Library was the online library used for methodical information. The search terms that the researcher used included, Psychological, Cancer, Psychosocial, Relationships, Quality of Life, Stress, Wellbeing, Cancer Patients and Caregivers. The terms were carefully thought out and put into the search engine; different terms and combinations of terms were used to ensure a more comprehensive search. The time frame was set from 2003 to 2015 and all search engines were to be in the English language.
Psychological Effect of Cancer:
Under this heading of the literature review, the psychological aspects of cancer patients will be discussed and analysed. A total of eight research studies will be utilised to inform this theme.
An American, cross-sectional, multi-institutional study was carried out by Kadan’Lottick, et al (2005). The aim of this research was to determine the occurrence of diagnosable psychiatric illness amongst cancer patients and describe the mental health services used by the patients with advanced cancer. For an accurate study to be carried out, a suitable group of advanced cancer patients were gathered. The study consisted of 251 patients. Eligibility included, distant metastases, primary therapy failure, nonpaid caregivers, aged over 20 years, stamina for the interview, English or Spanish-speaking, and adequate cognitive ability. All potentially eligible patients were then approached by trained research staff and offered participation in the study. Interested patients and caregivers were contacted by telephone or a hospital room visit within the week to obtain informed consent. Caregivers were included because these are the people taking care of the patients and if they are not mentally healthy, how can a cancer patient become healthy with negative vibes surrounding them? The data collection tool was collected via structured interviews and a detailed questionnaire was administered by trained interviewers, however, no information was provided on reliability and/or validity of the data collection tool. Descriptive statistics were used to characterize the demographics of the study sample. The researchers found that overall, 12% met criteria for a psychiatric condition and 28% had accessed a mental health intervention after their cancer diagnosis. The research also found that 17% of the cancer patients had been to see a mental health professional and 90% were willing to receive treatment for emotional issues. Even though patients visit mental health professionals, so too do caregivers. In 2005, a quantitative study by Vanderwerker et al aimed to examine the occurrence of psychiatric disorders and mental health service use among caregivers. Since caregivers are providing a service for those receiving cancer treatments, caregivers must be in good health to provide a safe service. If caregivers are attending mental health services, this can benefit the cancer patient because if the caregivers are mentally healthy then they can provide better care and even educate patients on the importance of taking care of their mental health. The data collection tool consisted of interviews and an assessment of mental health service users. The reliability of this method of data collection was not mentioned. 200 caregivers of advanced cancer patients were interviewed and administered the Structured Clinical Interview of the Diagnostic and Statistical Manual of Mental Disorders 4th Edition and an assessment of mental health service use by trained interviewers. The method of analysis was not detailed; however, it would appear to have been a quantitative data analysis. The key findings in this research were, 13% of caregivers met criteria for a psychiatric disorder and 25% accessed treatment for mental health concerns since the patient’s cancer diagnosis. Among caregivers with a current psychiatric disorder, 81% discussed mental health concerns with a health professional before the patient’s cancer diagnosis compared with 46% after the diagnosis. Only 46% of caregivers with a current psychiatric disorder accessed mental health services.
The relationship between patient and caregiver will always be about cancer and the treatment of cancer, however, the relationship between couples where one has been diagnosed with cancer can be difficult to cope with. An American study carried out by Hagedoorn, et al (2008) whose aim was to measure how couples cope with a cancer diagnosis, the research calculated both the cancer patient and their partner to gather an accurate result. This research is relevant to this topic since the psychological impact of the partner also affects the cancer patient and the relationship they share. These couples react as an emotional system rather than as individuals. The research was conducted using meta-analysis and narrative critical appraisal. Those who took part in the research were in a couple, the couples consisted of a male and female relationship. Individual levels of distress were determined more by gender than by the role of being the person with cancer versus that person’s partner. Overall, it was women who were reported to have consistently more distress than men regardless of their role. The association between patient and partner distress within couples was only moderate, nevertheless, it is important to clarify that couples react as an ’emotional system’ and not as individuals.
Br”nstr”m (2011) conducted a study which aimed to report the effects of a mindfulness stress reduction training programme among patients who are being treated for cancer on perceived stress, depression, anxiety, post-traumatic stress symptoms, positive state of mind, coping self-efficacy, and mindfulness. The method of recruiting these patients was through adverts and e-mail list announcements through cancer patient organisations; the patients were then recruited and randomized into an intervention group or a waiting list control group. The time frame of this study was eight weeks. Data was gathered through questionnaires which were sent out to each patient after their course of treatment for cancer was completed. Compared to participants who were in the control group, the intervention group showed a larger increase in mindfulness at the six month follow-up. However, there were no differences on any of the other outcomes between the intervention and control groups. Continued meditation practice was associated with a reduction in post-traumatic stress symptoms of avoidance. This study highlights the need for mindfulness training as many people will require an intervention about the importance of a healthy mind and the benefits a healthy mind can bring. The study draws attention to the need to better understand the work behind the effect of mindfulness training and to potential modification of mindfulness interventions to promote sustained benefits over time.
An observational cohort study carried out by Burgess, et al (2005) aimed to examine the prevalence of and the ultimate risk factors for depression and anxiety in women with early breast cancer in the five years after diagnosis or recurrence. This study was conducted in Guys Hospital, London, where the researchers invited 222 women with breast cancer to take part in the study, of that 222, 170 women completed the interview data up to either five years after diagnosis or recurrence. Quantitative data analysis was conducted. The findings show that almost 50% of the women had depression, anxiety, or both in the year after diagnosis, 25% in the second, third, and fourth years, and 15% in the fifth year. Point prevalence was 33% at diagnosis, falling to 15% after one year of the diagnosis. The study showed that 45% of those with recurrence experienced depression, anxiety, or both within three months of their diagnosis. Previous psychological treatment predicted depression, anxiety, or both in the period around diagnosis (one month before diagnosis to four months after diagnosis). Longer term depression and anxiety were shown to be associated with previous psychological treatment, lack of an intimate confiding relationship, younger age, and severely stressful non-cancer life experiences. However, interestingly, clinical factors were not associated with depression and anxiety, at any time. Lack of intimate confiding support also predicted more protracted episodes of depression and anxiety for the women. A study carried out by Mykletun, et al (2005) aimed to examine the disparity in the long-term quality of life in testicular cancer survivors in relation to testicular cancer treatment modality, side effects, and testicular cancer related stress in a large population. The data collection tool deployed was a thoroughly structured questionnaire at a mean of 11 years of follow-up in 1,409 testicular cancer survivors treated from 1980 to 1994. The reliability of this tool was not presented. Norm data was obtained from 2,678 males who were representative of the general population. Quality of life was measured with the Short Form-36 and testicular cancer related stress was measured with the Impact of Event Scale. Descriptive statistical analysis was conducted during this research. The results show that there were no clinically relevant differences in quality of life between testicular cancer survivors and age-adjusted norm data. Variation of the quality of life in testicular cancer survivors was related to self-reported side effects and testicular cancer related stress but not to the treatment modality. Testicular cancer survivors do not suffer long term from reduced quality of life, and only minor differences in their quality of life were found between different treatment modalities. Testicular cancer survivors who report more side effects or testicular cancer related stress have increased risk for reduced quality of life, but these associations are not explained by cancer treatment modalities.
An American study carried out by Carlson, et al (2003) aimed to investigate the relationship between a mindfulness-based stress reduction mediation programme and quality of life, mood states, stress symptoms and lymphocyte counts production. This research design involved 49 patients with breast cancer and 10 with prostate cancer. There was an 8’week programme that involved meditation, gentle yoga, relaxation, and daily home practice. Once the patients were accrued on the waiting list using the recruitment strategy, they were scheduled for an individual interview with the principal investigator. 49 and 42 patients were assessed pre’ and post-intervention, respectively. Symptoms of stress, and sleep quality had seen an improvement. Significant improvements were seen in the overall quality of life. There were no significant changes in the number of lymphocytes or cell separation, which strengthened the likelihood of stress contributing to cancer formation.
A study carried out by Bower, et al (2005) sought this study to evaluate Cortisol (stress hormone) responses to an experimental psychological stressor in fatigued and non-fatigued survivors of breast cancer. The study attracted 27 breast cancer survivors through social media to participate in the research; of these 27, 11 of which were fatigued and 16 were non-fatigued; all of which had completed cancer treatment at least 3 years previously and were currently healthy with no evidence of recurrence. The type of sampling was not mentioned, however it can be presumed it was that of a volunteer sampling strategy. A laboratory stressor and the Trier Social Stress Test (a test to provoke stress levels in someone) occurred over a 90-minute session. After every fifteen minutes during the session, saliva samples and autonomic measures (heart rate, blood pressure) were collected. The results showed that fatigued survivors had a significantly high Cortisol response to the stressor whereas; the non-fatigued participants had a lower Cortisol response. There were no differences in the autonomic (the autonomic system directs all internal functions such as blood pressure, blood flow, and sweating, University of Chicago, 2016) measures that could be observed.
From the evidence suggested, psychological factors can be related to the augmentation of cancer cells. In some cases, stress can be the cause of a person drinking overeating and/or smoking, as a coping mechanism; this can then in turn lead to the growth of cancer. Nevertheless, a cancer patient may suffer from depression, stress, anxiety etc. from having a possible physical impairment. Psychologically, cancer can affect one’s life as they may not be able to do the things they once saw as a norm. From the evidence specified above, it is clear more mental health treatment should be provided for a cancer patient before, during and after their treatment.
Psychosocial Effects of Cancer:
Under this heading of the literature review, the psychosocial factors and how it effects a cancer patient will be discussed and analysed. According to the Oxford English Dictonary, (2016) psychosocial is a term which relates ‘to the interrelation of social factors and individual thought and behaviour’. There will be eight studies will be utilised to inform this theme.
A qualitative, exploratory study carried out by H”rtl et al. (2010) sought to investigate the changes in the quality of life and body image among breast cancer patients. This study was carried out over a 2 year period and aimed to examine different predictive factors for quality of life 2 years after the primary operation. The sampling of this study was generated by a total of 203 women with a diagnosis of breast cancer. The sampling of this study was conducted through a breast cancer specific quality of life questionnaire, a questionnaire about stress ex-perienced by a cancer patient, a Freibury personality test and a life orientation test. They completed the questionnaires 2 weeks and another 6, 12, 18, and 24 months after surgery. Data were collected through questionnaires and a Freiburg Personality Inventory and a Life Orientation Test. No information was provided on the validity and/or reliability of the data collection. The results illustrated that over the two year period, the quality of life had im-proved. However, even though QOL improved, cognitive functioning, body image, and the three symptom scales of insomnia, constipation, and diarrhoea did not change. Age was only capable of predicting physical functioning, whereas tumour size, axillary surgery, and adju-vant chemotherapy were not predictive of the long-term quality of life. Initial distress was the most potent predictive factor for long-term quality of life. Higher scores for neuroticism were associated with a poorer quality of life. However, optimism was not capable of predicting the quality of life 2 years later. Hoeck et al (2015) executed a structured qualitative study which aimed to summarize the existing knowledge of the need for psychosocial rehabilitation for patients with lung or gynaecological cancer and their relatives, and to specifically address firstly, how psychosocial rehabilitation was experienced by those patients and their relatives and secondly, how their relatives were involved in psychosocial rehabilitation. A narrative review procedure was chosen as a total of 16 studies were included in the review. The studies were divided into two main categories: (1) studies focusing on needs for psychosocial support; and (2) studies focusing on interventions. Five interventions comprising various forms of support that were purely supportive and were carried out by healthcare professionals were identified. Qualitative description served as the inspirational platform for the analysis of data. There were overlaps between the needs of the patient and the relative, but there were also distinctive characteristics of the needs in the two groups. The needs varied during the cancer trajectory, and it was therefore recommend that support be offered continuously. It was also evident that the relatives should be involved in the patients’ care and that the involvement was beneficial for both the patient and the relative. Of the 16 studies, seven studies were about patients with gynaecological cancer and four studies were about patients with lung cancer, whereas two were about the patient’s relatives. Five studies included pa-tients with lung cancer and/ or gynaecological cancer and patients with other cancer diagno-ses. A similar study to this was carried out by Telepak et al (2014) which sought to study the psychosocial factors that have previously been linked with survival and mortality in cancer populations. The study utilized a non-experimental, longitudinal design. This study examined the relationship between several psychosocial factors prior to surgical resection and the risk of all causes of mortality in women with endometrial cancer. The participants were 87 women who were diagnosed with endometrial cancer and had surgery following this. Participants provided psychosocial data immediately prior to surgery. Survival statuses were 4’5 years post-diagnoses, abstracted via medical record review. Cox regression was employed for the survival analysis. Of the 87 women in this sample, 21 women died during the 4 to 5 year follow-up. Adjusting for age, presence of regional disease and medical comorbidity severity greater use of an active coping style prior to surgery was significantly associated with a lower probability of all-cause mortality. Life stress, depressive symptoms, use of self-distraction coping, receipt of emotional support and endometrial cancer quality of life prior to surgery were not significantly associated with all-cause mortality 4’5 years following diagnosis. A study carried out by Singh (2015) which is a non-interventional, cross sectional, self reported based psychological investigation analysis that was carried out at the outpatient clinic of the Oncology Department at GGS Medical College, Faridkot; aimed to analyse and compare de-pression, stress and anxiety levels and their impacting factors in homogenous surviving cancer patients receiving chemotherapy as compared to normal control. The observational study included a total of 600 study subjects which were evaluated for research, these included 300 cancer patients and 300 matched controls. No information is given on the reliability or the validity of this research. All 600 eligible study subjects participated in the study with 300 cancer patients and 300 matched controls. Out of the total subjects, 56% had shown to be illiterate and majority was (33.33%) housewife by occupation. Out of our 300 cancer patients, 28% were suffering from head and neck thorax cancer followed by gastrointestinal tract and breast (20%). Family history was seen only in 10%, in which no significant hereditary corre-lation was observed. As per the chemotherapy session’s progress, they divided the patients in three subgroups; the first group had 108 patients and received one to two chemotherapy cy-cles, the second group had 114 patients to which they received three to four chemotherapy cycles, and the third group had 78 patients receiving more than five chemotherapy cycles. Anxiety mean scoring showed a statistical significant difference in groups (according to che-motherapy cycles given and duration of disease). The study showed that stress was more ob-served in breast cancer patients. A Korean study carried out by Hong (2015) aimed to inves-tigate health conditions and health-related quality of life of community-dwelling populations with cancer, stroke, and cardiovascular disease based on standardized data. The study sub-jects numbered 422 in total: 179 patients had cancer, 128 were stroke patients, and 115 were cardiovascular disease patients. This study collected data during health interviews carried out as part of the sixth Korean National Health and Nutrition Examination Survey. Face-to-face health interviews were conducted by trained surveyors who visited households during 2013. The contents of the interviews included data on demographic factors, physical condition, psy-chological condition, and their health relating to quality of life. Stress perceptions related to health condition differed significantly across the populations of cancer. Individuals’ physical conditions did not differ significantly across the populations of cancer patients. Stress percep-tions relating to psychological condition differed significantly. However, no significant dif-ference was found between populations regarding the relationship between sleeping and the three diseases. Everyday activities such as self-care, usual activities, and anxiety/depression differed significantly across the populations of cancer patients. A study carried out by Hwang et al (2015) which sought to determine the functional deflects and the quality of life amongst cancer survivors. The study consisted of 68 participants who had undergone and completed cancer treatment; these participants completed the Post Cancer Outcome Survey developed for this study. In this cross-sectional descriptive study the researchers used a developed in-strument to collect data on functional deficits, psychosocial burdens, and quality of life re-called by cancer survivors. These participants were gathered by convenience and snowball sampling methods through professional and social networks and also, by support groups for cancer survivors, which also included the online support forums. The participants, who were aged between 18 and 64 years of age, were diagnosed with cancer of any type and at any stage; they had completed cancer treatment such as chemotherapy, radiation or surgery. The results indicated modest to moderate degrees of functional deficits in 28 of the 70 items measuring areas of occupation, performance skills, body functions, and psychosocial well-being within the first year after cancer treatment; significantly lower perceived quality of life during the first year of survivorship compared with that before diagnosis. Functional difficul-ties and compromised quality of life identified in this study indicates the need for occupa-tional therapy among cancer survivors. Increasing clients’ awareness of occupational therapy for post cancer care is also suggested as it would be beneficial to the overall psychosocial wellbeing of the individual. Another Korean study carried out by Kim and Park (2014) sought to identify the relationship between the degree of support from the spouse and the de-gree of health promoting behaviour among the patients with a mastectomy or both mastecto-mies. The study used a descriptive research design. There were 224 patients with a mastec-tomy or both mastectomies. Data was collected through a structured questionnaire. The measurements that were used were Support of Spouse and The Health Promoting Life Profile II. The data was analysed using descriptive statistics, t-test, ANOVA, and Pearson’s correla-tion coefficients. There was no information given on neither the reliability nor the validity of this study. The results conveyed that the mean support of spouse and health promoting behav-iour by perception of patients with mastectomy were moderate. The degree of support from the spouse was positively related to five health promoting behaviours; spiritual growth, stress management, health responsibility, interpersonal relations, nutrition, except physical activity. From the study, one can conclude that it is necessary to educate those patients and their spouses about health management of the patient after mastectomy to overcome any long-term treatment and to improve the quality of life for both the patient and their spouse. Phillips and Lewis (2015) conducted a study which aimed to look at parental cancer as it can be a stressful experience for young people, constituting a potential threat to physical and mental health and normative development. The overall aim of this study was to address the adolescent’s per-spective on the impact of their parent’s advanced cancer on their lives. This qualitative study involved single-occasion, semi-structured elicitation interviews with adolescents whose par-ents were diagnosed with advanced stage cancer. The study consisted of seven adolescents from six families, five females and two males ranging in age from 11 to 15 years. The ill par-ents consisted of four females and two males diagnosed with Stage IV cancer. The core con-struct that organized study results was Weaving a Normal Life with Cancer which involved five major domains: feeling the weight of the world on my shoulders; cancer changes every-thing; confronting or getting away from the cancer; talking about it; and cancer was a positive for me ‘ it taught me. The study shed light on how adolescents self-manage their parent’s advanced cancer and work to delimit the illness even as they are aware of its constant pres-ence. Future research and intervention studies are needed to support and add to the adoles-cents’ self-management strategies to weave a normal life for themselves while in the throes of the cancer’s uncertainty and challenges with family communication.
Conclusion:
The overall aim of this literature review was to investigate the changes a cancer patient goes through in regards their psychological and psychosocial health. With all the support a cancer patient receives with regard to their treatment of the cancer diagnosis, it is also necessary to receive the correct care for their psychological and psychosocial health. With regard to this literature review, it can be concluded that many patients who have been treated with cancer, also need to be educated about their psychological and psychosocial wellbeing. Many people after being diagnosed with cancer developed a mental illness of some kind, depression, anxiety, etc. Therefore, the supportive care that family members, friends and caregivers can give a patient on their mental and physical wellbeing can be crucial to their recovery.
Recommendations for Practice:
From completion of this literature review, it seems caregivers are quite educated in the significance of mental health. However, it is fundamental that caregivers get treated for mental health problems as well as their patients, to be healthy enough to encourage those with mental health issues to a healthy recovery.
Recommendations for Research:
During the construction of this literature review, the reviewer has concluded that cancer is a vastly researched topic. Psychological and psychosocial aspects are both research topics that seem to be quite popular; however, I would recommend that this topic be researched more in adolescents and young adults. It can be a very difficult time for this group of people growing up with new challenges to face each day, normally, it would be interesting to observe how they cope with cancer in their lives also.
Reference List:
Bower, J.E., Ganz, P.A. and Aziz, N., 2005. Altered cortisol response to psychologic stress in breast cancer survivors with persistent fatigue. Psychosomatic Medicine, 67(2), p.277-280.
Br”nstr”m, R., Kvillemo, P. and Moskowitz, J.T., 2012. A randomized study of the effects of mindfulness training on psychological well-being and symptoms of stress in patients treated for cancer at 6-month follow-up. International journal of behavioral medicine, 19(4), pp.535-542.
Burgess, C., Cornelius, V., Love, S., Graham, J., Richards, M. and Ramirez, A., 2005. De-pression and anxiety in women with early breast cancer: five year observational cohort study. Bmj, 330(7493), p.702.
Carlson, L.E., Speca, M., Patel, K.D. and Goodey, E., 2003. Mindfulness’based stress reduc-tion in relation to quality of life, mood, symptoms of stress, and immune parameters in breast and prostate cancer outpatients. Psychosomatic medicine, 65(4), p.571-581.
Fang, P., Tan, K.S., Grover, S., McFadien, M.K., Troxel, A.B. and Lin, L., 2015. Psychoso-cial encounters correlates with higher patient-reported functional quality of life in gyneco-logical cancer patients receiving radiotherapy. Radiation Oncology, 10(1), p.34.
Galway, K., Black, A., Cantwell, M., Cardwell, C.R., Mills, M. and Donnelly, M., (2012). Psychosocial interventions to improve quality of life and emotional wellbeing for recently diagnosed cancer patients. The Cochrane Library.
Hagedoorn, M., Sanderman, R., Bolks, H.N., Tuinstra, J. and Coyne, J.C., 2008. Distress in couples coping with cancer: a meta-analysis and critical review of role and gender effects. Psychological bulletin, 134(1), p.1.
Hoeck, B., Ledderer, L. and Hansen, H.P., 2015. Involvement of patients with lung and gynecological cancer and their relatives in psychosocial cancer rehabilitation: A narrative review. The Patient-Patient-Centered Outcomes Research, 8(2), p.127-143.
Hong, E., 2015. Health-related quality of life and health condition of community-dwelling populations with cancer, stroke, and cardiovascular disease. Journal of physical therapy sci-ence, 27(8), p.2521-2524.
Hwang, E.J., Lokietz, N.C., Lozano, R.L. and Parke, M.A., 2015. Functional Deficits and Quality of Life Among Cancer Survivors: Implications for Occupational Therapy in Cancer Survivorship Care. American Journal of Occupational Therapy, 69(6), p.1-9
Kadan’Lottick, N.S., Vanderwerker, L.C., Block, S.D., Zhang, B. and Prigerson, H.G., 2005. Psychiatric disorders and mental health service use in patients with advanced cancer. Cancer, 104(12), p.2872-2881.
Kim, Y.M. and Park, H.S., 2014. Relationship between Perceived Spouse Support and Health Promoting Behavior in the Breast Cancer Patient with Mastectomy. Asian Oncology Nursing, 14(4), p.203-211.
Mykletun, A., Dahl, A.A., Haaland, C.F., Bremnes, R., Dahl, O., Klepp, O., Wist, E. and Foss”, S.D., 2005. Side effects and cancer-related stress determine quality of life in long-term survivors of testicular cancer. Journal of Clinical Oncology, 23(13), p.3061-3068.
Phillips, F. and Lewis, F.M., 2015. The adolescent’s experience when a parent has advanced cancer: A qualitative inquiry. Palliative medicine, 29(9): p.851-858.
Singh, R.P.B., Singh, H., Singh, C.J. and Kaur, K.T., 2015. Screening of psychological dis-tress in cancer patients during chemotherapy: A cross-sectional study. Indian journal of pal-liative care, 21(3), p.305 -310.
Telepak, L.C., Jensen, S.E., Dodd, S.M., Morgan, L.S. and Pereira, D.B., 2014. Psychosocial factors and mortality in women with early stage endometrial cancer. British journal of health psychology, 19(4), p.737-750.
Vanderwerker, L.C., Laff, R.E., Kadan-Lottick, N.S., McColl, S. and Prigerson, H.G., 2005. Psychiatric disorders and mental health service use among caregivers of advanced cancer pa-tients. Journal of Clinical Oncology, 23(28), p.6899-6907.
essay-2016-07-20-000BPB