Abstract
The Knowledge Summaries for Comprehensive Breast Cancer Control (KSBCs) are a series of 14 publications aligned with World Health Organization guidance on evidence-based breast cancer control and accepted frameworks for action. To study utilization of the KSBCs in the development of locally relevant breast cancer control policies and programs in limited resource settings, the National Cancer Institute Center for Global Health, the University of Washington and the Fred Hutchinson Cancer Research Center developed the Project ECHO® for KSBCs (KSBC ECHO). Project ECHO is an online model which employs case-based learning, while promoting multi-directional learning and network-building. The program was evaluated using a pre-post study design to assess if this online collaborative learning platform can be an effective model for dissemination and utilization of the KSBCs to inform breast cancer control programs and policy advocacy in limited resource settings.
A total of 28 KSBC ECHO participants (57%) responded to the baseline and endpoint program evaluation surveys. Across all 28 respondents, analysis of the data indicates that knowledge increase was statistically significant overall: average knowledge gain was 0.77, 95% CI [0.44 – 1.08] and p value < 0.0001. A majority of responding team leads reported that the core ECHO components (case/didactic presentations, discussion) contributed to a great extent to strengthening their project proposal/goals.
Program evaluation survey responses indicate that utilization of this online platform provided an opportunity for individual knowledge gain, multi-directional information exchange, network-building, and strengthening of the proposed breast cancer control projects based in limited resource settings.
Keywords: Breast cancer, Cancer policy, Cancer control, Global health, Limited resource setting, Advocacy, Network building, Web-based learning, Video technology, Online education
Background
Breast cancer is the most common cancer in women worldwide, with more than 2 million new cases diagnosed, and over 600,000 deaths in 20181. The global incidence of breast cancer is projected to increase to over three million new cases and one million deaths annually by 2040. Much of this increase is expected to occur in countries with a low or middle Human Development Index (HDI) given changing lifestyle factors, increased life expectancy3, and increased awareness and diagnosis4. To address this growing burden, global health experts have advised that countries should strengthen their health care systems, allocate additional resources and develop and implement effective, evidence-based and resource appropriate strategies5.
The Knowledge Summaries for Comprehensive Breast Cancer Control (KSBCs) are a series of 14 publications distilled from evidence-based, resource-stratified guidelines aligned with World Health Organization (WHO) guidance on breast cancer control and accepted frameworks for action. The KSBCs were developed through a collaboration led by the Union for International Cancer Control, Breast Health Global Initiative, Pan American Health Organization, and Center for Global Health of the US National Cancer Institute (NCI/CGH). The KSBCs provide a common platform for policymakers, administrators, clinicians, and advocates to engage in evidence-based decision making that is appropriate to their local setting and advances implementation of an integrated approach to comprehensive breast cancer control6.
The KSBCs have been disseminated through the Breast Health Global Initiative7 partners and the Women’s Empowerment Cancer Advocacy Network8, and are freely available online at the Breast Cancer Initiative 2.59 website. According to a 2017 NCI/CGH-supported study conducted in Kenya10, respondents reported that the KSBCs are useful educational and planning tools. The study, however, did not assess utilization of the evidence-based recommendations within the KSBCs for developing breast cancer policy or program proposals. To further study utilization of the KSBCs by stakeholders in a variety of settings, NCI/CGH, the University of Washington (UW) and the Fred Hutchinson Cancer Research Center (FHCRC) developed the Project ECHO® for KSBCs (KSBC ECHO). Project ECHO is a web-based collaborative learning platform developed in 2003 by Dr. Sanjeev Arora to build clinical capacity for the treatment of Hepatitis C in rural New Mexico, United States11. Project ECHO employs case-based learning strategies to mentor groups on best practices, while promoting multi-directional learning and networkbuilding16. NCI/CGH has utilized Project ECHO to scale existing communities of practice around global cancer research and control, and participants have reported an increase in cancer control knowledge, expanded networks, and opportunities to address planning challenges through ECHO participation15. The objective of the KSBC ECHO was to utilize this collaborative learning model to convene breast cancer project teams from a variety of settings to facilitate utilization of the KSBCs in the development of locally relevant breast cancer control policies and programs. The program was evaluated to assess if this web-based collaborative learning platform can be an effective model for dissemination of KSBC content to inform the development of evidence-based programs and policy advocacy in limited resource settings.
Methods
The KSBC ECHO was convened by an ECHO hub team from NCI/CGH and UW/FHCRC and was advertised via global cancer control-related email lists, social media, existing ECHOs and at multiple international meetings in 2018. Applications were submitted by self-identified breast cancer project team leads, describing their proposed project or policy proposal related to breast cancer control. All applications were reviewed by the ECHO hub team. The ECHO hub team identified moderators and didactic presenters based on their technical knowledge and expertise in comprehensive breast cancer control in low resource settings.
The KSBC ECHO was conducted as a series of bi-weekly sessions via the Zoom® videoconferencing platform, which is made available to ECHO hubs at no cost. Following the ECHO model, each session included a case presentation by one of the participating project teams, a didactic presentation by a technical expert, and group feedback and discussion13. Two additional ‘check-in’ discussion sessions were also included.
The 14 KSBCs covering breast cancer prevention, diagnosis, treatment, and supportive care served as the foundational text for the course. The policy boxes within each KSBC identify cross-cutting planning considerations, which were used to design the KSBC ECHO curriculum:
Preplanning:
Is a change needed? Identifying data needs/sources, leadership, key stakeholders
Planning Step 1:
Where are we now? Assessing the need, access and gaps to services, and health system capacity
Planning Step 2:
Where do we want to be? Defining target population, implementation barriers, objectives, and feasibility
Planning Step 3:
How do we get there? Establishing partnerships, financing, plans for implementation, and evaluation
Each planning step was broken down into a series of ECHO sessions, accompanied by planning step worksheets to encourage participants to engage with the KSBC content ahead of each session. An additional worksheet was dedicated to refining project proposals and developing SMART objectives17. In addition, participants were tasked with identifying a project mentor in their community familiar with the local health system and landscape to foster new relationships and increase local engagement.
Evaluation
The KSBC ECHO was evaluated to assess achievement of program objectives using a pre-post study design18. NCI/CGH developed a set of baseline and endpoint surveys specific to project team leads and project team members. All survey respondents (team leads and team members) were asked about their level of knowledge acquisition based on exposure to the components of the KSBC planning steps outlined above. Project team leads were asked additional questions on learning goals and the impact of ECHO participation and the KSBCs’ scientific content on their project design. Baseline and endpoint surveys were conducted using an online platform. Statistical analysis of the responses was conducted using a paired T-test analysis. Responses to qualitative questions about learning goals, challenges, and impact on project design were coded into repeated concepts using thematic analysis19.
In addition to the baseline and endpoint surveys, four KSBC ECHO participants shared key takeaways, barriers, and recommended solutions based on their participation in the KSBC ECHO. These participants had attended the majority of the ECHO sessions and represented different world regions and types of projects.
Results
Sixteen breast cancer project teams submitted applications, all were accepted upon review, and one of the 16 did not confirm participation in the ECHO. The remaining 15 teams confirmed participation, with a total of 64 participants (15 team leads and 49 team members), from 11 countries. Table 1 highlights the country, lead institution, original project title, and focus area of the 15 participating teams. Three projects focused on breast cancer awareness; six on early detection; and, two each on supportive care, palliative care, and survivorship care. Sixteen technical experts from academic institutions and global breast cancer organizations participated as one-time or ongoing technical experts for the ECHO. The ECHO hub team included two technical leads, one lead coordinator, one operations coordinator, and one evaluation specialist.
Table 1.
Participating KSBC ECHO Project Teams by Country, Lead Institution, Title, Project Focus Area
| Country/Team | Institution | Project Title | Project Focus |
|---|---|---|---|
| Cameroon | Clinique Medical Camassistance; University Hospital Center | Strengthen our pilot program on palliative care for Cameroonian women with metastatic breast cancer | Palliative Care |
| Caribbean | Hope Institute Hospital; Jamaica Cancer Care & Research Institute | Pilot project to provide public sector community based palliative care for women with breast cancer | Palliative Care |
| Indonesia | Dharmais National Cancer Center | Strengthening clinical breast examination referral system in West Jakarta to support early detection program | Early Detection |
| Kenya-1 | Breast Cancer Kenya | Survivorship aspects after mastectomy in Kenya | Supportive Care |
| Kenya-2 | Oasis of Life | Breast cancer awareness among the rural community in Embu, Kenya | Awareness |
| Malaysia-1 | University of Malaya | Exploration of needs of patients and health systems in implementing a breast cancer survivorship care plan in Malaysia | Survivorship Care |
| Malaysia-2 | University of Malaya | Identifying the unmet needs of breast cancer survivors in Malaysia | Survivorship Care |
| Myanmar | Myanmar Oncology Society | To determine the reasons for late stage presentation using a Knowledge, Attitudes and Practice (KAP) Tool | Early Detection |
| Nigeria-2 | Breast Cancer Association of Nigeria (Abuja) | Breast cancer patient navigation system in Nigeria | Supportive Care |
| Nigeria-3 | Breast Cancer Association of Nigeria (Ondo State) | Increasing community health workers’ knowledge on breast cancer detection and prompt referral in Ondo State | Early Detection |
| Nigeria-4 | Breast Cancer Association of Nigeria (Oyo State) | Making breast health awareness a PHC priority | Awareness |
| Nigeria-5 | University of Nigeria Teaching Hospital, Enugu | Promote early detection and prompt treatment of breast cancer in a comprehensive cancer center in Nigeria | Early Detection |
| Rwanda | Partners in Health-Rwanda | Promoting early detection of breast cancer in rural Rwanda: Scaling-up within the national health care system | Early Detection |
| Tanzania | Tanzania Breast Cancer Foundation | STOP Breast Cancer: A project to improve breast cancer health outcomes through promoting linkages in Tanzania | Early Detection |
| Zambia | Zambian Cancer Society | Zambia Cancer Society Project | Awareness |
A total of 14 bi-weekly ECHO sessions were held from January to July 2019. At least one team member from each of the 15 participating teams attended one of the 14 ECHO sessions, for a team participation rate of 100% overall. 47% of participants (30 team leads and team members) participated in at least four of the 14 ECHO sessions. The rate of participation for team leads was 47.6% for the 14 sessions. The rate of participation for team members was 31% for the 14 sessions. On average, 27 people joined each ECHO session, including participants, technical experts, and the hub team. Eight out of 15 project teams (53%) gave a case presentation on their project during the ECHO. A total of ten worksheets and a SMART Goal Worksheet were assigned over the course of the ECHO. Three teams (20%) completed and submitted at least half (5) of the worksheets, and six teams (40%) submitted a completed SMART Goal Worksheet.
Evaluation Results
All participants were invited to complete the baseline and endpoint surveys. Response rate for the baseline survey was (14/15, 93%) for team leads and (29/49, 59%) for team members. Response rate for the endpoint survey was (11/15, 73%) for team leads and (17/49, 35%) for team members. In order to be included in the analysis, respondents had to attend at least one session and complete both the baseline and endpoint survey. Therefore, the analysis includes responses from 11/15 of the leads and 17/34 of the participants, for a total of 28/49, 57%.
53.6% of respondents had never heard of the KSBCs prior to enrolling in the ECHO; 21.4% had heard of but not used the KSBCs; and 21.4% had read at least one before the launch of the ECHO program.
Self-reported knowledge of the KSBC planning steps were assessed at baseline and endpoint using a Likert scale ranging from 0 (No Knowledge) to 4 (Expert Knowledge). Across all 28 respondents, analysis of the data indicates that knowledge increase was statistically significant overall: average knowledge gain was 0.77, 95% CI [0.44 – 1.08] and p value < 0.0001. Average overall knowledge was 1.90 at baseline and 2.67 at endpoint (Figure 1A). Across the 11 responding team leads, knowledge increase was not statistically significant: average knowledge gain was 0.42, 95% CI [−0.07, 0.91] and p value = 0.06. Average baseline for leads was 2.08, endpoint was 2.5 (see Figure 1B). Across the 17 responding team members, knowledge increase was statistically significant: average knowledge gain was 0.99, 95% CI [0.57, 1.41] and p value = 0.0001. Average baseline for participants was 1.78, endpoint was 2.78 (see Figure 1C). Knowledge gain was also significant across the individual planning steps.
Figure 1. KSBC Planning Steps Knowledge Acquisition in All Participants (1A), Team Leads (1B), and Team Participants (1C).
Program participants scored their knowledge of the KSBC planning steps at baseline and endpoint using a Likert scale ranging from 0 (No Knowledge) to 4 (Expert Knowledge). Across all 28 respondents, average overall knowledge was 1.90 at baseline and 2.67 at endpoint. Average knowledge gain was 0.77, 95% CI [0.44 – 1.08] and was statistically significant (p value < 0.0001) (see Figure 1A). Across the 11 responding team leads, average baseline for leads was 2.08 and endpoint was 2.5. Knowledge gain was 0.42, 95% CI [−0.07, 0.91] and was not statistically significant (p value = 0.06) (see Figure 1B). Across the 17 responding team members, average baseline for participants was 1.78 and endpoint was 2.78. Average knowledge gain was 0.99, 95% CI [0.57, 1.41] and was statistically significant (p value = 0.0001).
All of the responding team leads stated that the scientific content of the KSBCs was useful for strengthening their project or policy proposal. The planning steps were cited most often as being useful for improving project scope (by 6 of 11 team lead respondents), followed by other areas including identifying key data sources, developing implementation strategies, identifying partners, and knowledge sharing. Additionally, team leads reported that the KSBCs increase technical expertise (epidemiology, project development), and provide evidence-based strategies.
Regarding aspects of the ECHO program, team leads and team members reported that the core ECHO components (case/didactic presentations, discussion) were most helpful in strengthening their project proposal/goals (see Table 2). Of the responding team leads, 81.8% stated that the ECHO sessions were either moderately or very helpful in reaching their learning goals. In addition, 53.6% of respondents reported that working with a mentor impacted their projects to a great extent.
Table 2.
Extent to Which Components of the KSBC ECHO Were Helpful in Strengthening Project Proposals/Goals.
| Most Helpful | Leads | Participants | All |
|---|---|---|---|
Most Helpful
|
Case presentation (Self) | Didactic presentations | Didactic presentations |
| Didactic presentations* | Case presentations (Others) | Case presentation (Self) | |
| Case presentations (Others) | Case presentation (Self) | Case presentations (Others) | |
| Group discussions* | Group discussions* | Group discussions | |
| Least Helpful | Inter-session assignments | Inter-session assignments | Inter-session assignments |
Same rank as previous KSBC ECHO component.
Team leads reported modifications to project design/goals as a result of participation in the ECHO. Almost half of responding team leads reported that project scope and aims became more focused while project evaluation metrics expanded. Two teams (18.2%) reported a complete change in their target audience (see Table 3); modifying their project aims and scope.
Table 3.
Aspects of Project Design/Objectives that Changed Through Participation in the KSBC ECHO
| Focused/Narrowed | Expanded | No Change | Complete Change | |
|---|---|---|---|---|
| Project aims/goals | 63.6% | 0% | 18.2% | 9.1% |
| Project scope | 45.5% | 9.1% | 27.3% | 9.1% |
| Measures of project success | 27.3% | 45.5% | 18.2% | 9.1% |
| Target audience | 18.2% | 18.2% | 45.5% | 18.2% |
| Stakeholders involved | 9.1% | 36.4% | 36.4% | 18.2% |
Team leads were asked to report the main challenges to strengthening their project goals. Self-reported challenges include determining priorities, lack of data for methods and evaluation, and time and financial constraints. Self-reported strategies to combat these challenges include utilizing stakeholder support, identifying new sources of data, adjusting project aim/scope, putting extra hours into the project, and use of knowledge gained from ECHO sessions.
According to all respondents (team leads and team members), the most valuable aspects of the program were the opportunities to network, learn from others, and share knowledge (13, 46%). Respondents also reported the following to be valuable: didactic presentations, technical support, group discussions and receiving feedback (7, 25%). The SMART goal development process and mentor engagement were least reported as valuable aspects at (3, 11%) and (2, 7%) respectively.
Survey respondents reported that the most challenging aspects of ECHO program participation overall included: competing obligations (12, 43%), connectivity (3, 11%), session times (3, 11%), volume of ECHO work (3, 11%) and difficulties with the content (3, 11%).
Responses from the four KSBC ECHO participants on questions about the key takeaways gained from the KSBC ECHO, barriers to the ECHO learning platform, and recommended solutions, are highlighted in Table 4.
Table 4.
Summary of Responses from Four KSBC ECHO Participant Co-Authors about Key Program Takeaways, Barriers, and Solutions
| What is the most important takeaway you gained from your participation in the KSBC ECHO? | |
|
Technical skill-building, access to experts, application of ECHO in other networks:
“With this ECHO design curriculum, we learn how to use SMART goals and objectives to describe the project document more complete. By this learning technic, we can get so many things from the experts and friends. This kind of technic very suitable for us to keep networking with other cancer unit in 14 provinces from Sumatera Island until Papua.” Learning from different backgrounds and settings: “Tanzania Team managed to learn how different approach can be applied in breast cancer control by having access to various presented projects by participants who are coming from different level of academic professional, [and] learn[ing] what is going on in the other side of the world related with cancer control through the presented program from multidisciplinary participants.” Project strengthening and access to relevant resources: “This KSBC ECHO project has helped us in narrowing down the scope of the study and making our objective more realistic. It also provided reference KAP (Knowledge, Attitudes, Practice) tools for us to prepare a questionnaire that will suit our target population to a T.” Understanding about shared challenges and novel solutions: “I also realized that our challenges were not peculiar to my community and participating in the didactic sessions and shared experiences from other participants enabled us to think of innovative strategies to move us forward.” | |
| What do you perceive as barriers to this learning platform to your local setting? What would you do differently? | |
| Barriers | Recommended Solutions |
| 1. Frequency of sessions and amount of assignments given competing obligations | 1. Ensure participants are aware of time commitment and effort required at the start of the program; |
| 2. Willingness of participants to regularly participate given competing priorities | 2. Encourage intra-team communications so that team members are looped in if they are unable to attend a session. |
| 3. Limited geographic and multi-disciplinary diversity in team representation | 3. Set strategic targets for inviting representation from multiple geographic and institutional backgrounds. |
| 4. Challenge to participation given on-going workload issues. | 4. Ask team members to confirm personal commitment and institutional support for participation before the start of the program. |
| 5. Lack of buy-in from decision-makers for project execution because of competing health priorities and limited resources. | 5. Take a step-by-step approach to building the case for action in breast cancer control over time. |
| 6. Local challenges around internet connectivity, language barriers. | 6. Develop additional locally relevant content and communication channels as a team to supplement the multi-setting ECHO interactions. |
| 7. Lack of engagement with stakeholders from diverse backgrounds. | 7. Build in regular check-ins as a team to reassess and prioritize stakeholder engagement from various disciplines (including finance, education, etc.). |
Discussion
Our aim in this project was to determine whether web-based collaborative learning could be an effective platform for utilization of a program/policy advocacy toolkit for evidence-based breast cancer program development in limited resource settings. The overall evaluation results support the hypothesis that the ECHO platform can be used for this purpose. The focus of the KSBC ECHO sessions was to introduce cross-cutting concepts around developing and implementing a project or policy in comprehensive breast cancer control, and not primarily the scientific content of each KSBC. Therefore, having participants at different levels of familiarity with the KSBCs did not detract from the level of discourse (50% of respondents had not heard of the KSBC prior to applying). Team member survey respondents reported a higher level of knowledge acquisition than the team leads as a result of participation in the ECHO. Team leads started with a higher baseline level of knowledge of breast cancer control as well as project design and management, which may account for that difference. Since the scientific content of the KSBCs was new information for some of the participants, it is difficult to decipher whether knowledge acquisition came from the scientific content of the KSBCs, the experience of participating in the KSBC ECHO sessions, or a combination of both aspects. This aspect could be explored in the future.
Although the team leads’ knowledge acquisition did not reach statistical significance, team leads reported that participation in the ECHO had substantive impact on their projects. Almost half of the team lead survey respondents reported that their project aims became more focused. The ECHO hub team technical co-leads noted that many projects as described in the initial application were too broad and somewhat unrealistic. Therefore, the ECHO sessions were successful in helping the teams narrow the scope of their projects to be more realistic in nature. This was underscored in the takeaways shared by the four team lead co-authors. The fact that there were some project teams who made complete changes to aspects of their projects indicates that the ECHO sessions were successful in promoting applied learning to their project design.
The team leads and team member survey respondents reported that the core aspects of the ECHO session model (case, didactic, discussion) were useful, and it is interesting to note that team member respondents found case presentations by other groups to be more useful than their own. This aligns with the observation that team members gained more knowledge overall, and hearing others’ case presentations about challenges and lessons learned contributes to that knowledge gain. The fact that didactic presentations ranked high by both types of respondents indicates that learning from technical experts via the ECHO model is beneficial. Respondents found value in the key principles underscored by the ECHO model – learning from one another, exchanging knowledge, building networks. This finding was also reflected in the takeaways shared by the team lead co-authors. In addition, the barriers shared by the co-authors were not about the core ECHO components; more so, they focused on time commitment issues, and diversity of team and stakeholder representation, for which viable solutions were proposed.
A unique feature of the KSBC ECHO was the decision to include inter-session worksheet assignments to support application of the learning to the actual breast cancer projects being designed/implemented by project teams. On the one hand, the assignments ranked as being the least useful components of the program, and contributed to the reported challenge of volume of work. Future planning should take into consideration the burden of additional worksheets in addition to the rigorous timeline of bi-weekly sessions. On the other hand, team leads reported anecdotally that the process of developing worksheet and SMART Goal responses assisted in refining and providing specificity to project goals and targets. Future incorporation of additional assignments may be beneficial with time allotted and explained up front, as recommended by the team lead co-authors.
While the KSBC ECHO program initially enrolled a total of 64 participants (team leads and team members), there was a drop off in attendance, and in the end just under 50% (47%) attended at least four sessions. However, after the initial drop off in attendance, the remaining number of participants remained consistent. The fact that there was an average of 27 attendees for each session, including technical expert partners and participants, created enough diversity to contribute to the richness of the dialogue and the bi-directional learning. The reported barriers to participation were largely due to time constraints or session scheduling, and not to the content or relevance of the sessions themselves. Therefore, implementing the recommended solutions identified by the team lead co-authors may support more consistent participation.
There were several limitations to using the pre-post evaluation survey design for the KSBC ECHO. The drop-off in participation from the start of the KSBC ECHO led to a limited survey response rate for analysis purposes. Knowledge acquisition is self-reported and therefore potentially subject to personal bias. And finally, the evaluation only captures points in time at the start and end of the KSBC ECHO program. A longer-term evaluation would provide additional information about the utilization of learning and built networks to inform project development, implementation, and impact.
Conclusion
Despite the limitations stated above, the survey responses and co-authors’ self-reported takeaways indicate that the KSBC ECHO provided an opportunity for individual knowledge gain, multi-directional information exchange, network-building, and strengthening of the proposed breast cancer control projects based in limited resource settings. By instituting the recommended solutions by the team lead co-authors, this program can be adapted elsewhere to encourage dissemination and utilization of evidence-based strategies to develop policies and design locally relevant programs to address the disproportionate cancer burden in low resource settings.
Highlights.
Knowledge Summaries for Breast Cancer Control inform evidence-based policy planning
Structured engagement with the KSBC strengthens program and policy development
Virtual platforms support dissemination of evidence-based cancer control strategies
Acknowledgments
We would like to acknowledge the incredible commitment of time and hard work demonstrated by the individual KSBC ECHO team members and team leads in this KSBC ECHO Program, and their participation in the program evaluation that contributed to this publication. The KSBC ECHO would not have been possible without the contributions and partnership of the invited technical experts from across the U.S. National Cancer Institute and the following institutions: Duke University (U.S.), Harvard Medical School/Brigham and Women’s Hospital (U.S.), Instituto Nacional de Cancerologia (Mexico), International Atomic Energy Agency (Austria), New York University (U.S.), Strategic Health Concepts (U.S.), Susan G. Komen Foundation (U.S.), University of Miami (U.S.), Union for International Cancer Control (Switzerland), and University of Washington (U.S.). Lastly, we are grateful to the authors of the Knowledge Summaries for Comprehensive Breast Cancer Control, and their support for this opportunity to further disseminate and demonstrate utilization of these useful decision-making tools: The Union for International Cancer Control, Pan American Health Organization, World Health Organization, Fred Hutchinson Cancer Research Center, Breast Cancer Initiative 2.5, Breast Health Global Initiative, US National Cancer Institute Center for Global Health, Benjamin O. Anderson, Allison Dvaladze, Julie Gralow, André Ilbawi, Silvana Luciani, Isabel Otero, Lisa Stevens, Julie Torode, and Jo Anne Zujewski.
Funding Disclosure:
This project has been funded in whole or in part with federal funds from the National Cancer Institute, National Institutes of Health, under Contract No. 75N9109D00024, Task Order No. 75N91019F00129. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government.
Footnotes
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