Considerations for using potential surrogate endpoints in cancer screening trials.

The requirement of large-scale expensive cancer screening trials spanning decades creates considerable barriers to the development, commercialisation, and implementation of novel screening tests. One way to address these problems is to use surrogate endpoints for the ultimate endpoint of interest, cancer mortality, at an earlier timepoint. This Review aims to highlight the issues underlying the choice and use of surrogate endpoints for cancer screening trials, to propose criteria for when and how we might use such endpoints, and to suggest possible candidates. We present the current landscape and challenges, and discuss lessons and shortcomings from the therapeutic trial setting. It is hugely challenging to validate a surrogate endpoint, even with carefully designed clinical studies. Nevertheless, we consider whether there are candidates that might satisfy the requirements defined by research and regulatory bodies.

Impact of Basic Needs Fulfillment on the Health, Well-being, and Academic Engagement of Occupational Therapy Students.

The basic needs of students may serve as unknown factors in academic engagement and well-being. Challenges in meeting these needs disproportionately impact underrepresented minority and first-generation students. The purpose of this pilot study was to explore the perceived presence and impact of basic needs on health, well-being, and academic engagement in occupational therapy students. A 43-item survey was distributed to 231 students and focused on questions addressing basic needs in physiology, safety, and belonging. Respondents reported worry over or the need to work to pay bills, no support from family/friends, and limited access to food in the past 30 days and related this to feeling stressed, not being able to do homework, not participating in class, and loss of leisure time. Ninety-four percent used student health services frequently. Recommendations to address gaps in basic needs include flexible policies, inclusive learning environments, supportive and intentional actions, and providing resources.

Air Pollution and Lung Cancer: A Review by International Association for the Study of Lung Cancer Early Detection and Screening Committee.

INTRODUCTION: The second leading cause of lung cancer is air pollution. Air pollution and smoking are synergistic. Air pollution can worsen lung cancer survival. METHODS: The Early Detection and Screening Committee of the International Association for the Study of Lung Cancer formed a working group to better understand issues in air pollution and lung cancer. These included identification of air pollutants, their measurement, and proposed mechanisms of carcinogenesis. The burden of disease and the underlying epidemiologic evidence linking air pollution to lung cancer in individuals who never and ever smoked were summarized to quantify the problem, assess risk prediction models, and develop recommended actions. RESULTS: The number of estimated attributable lung cancer deaths has increased by nearly 30% since 2007 as smoking has decreased and air pollution has increased. In 2013, the International Agency for Research on Cancer classified outdoor air pollution and particulate matter with aerodynamic diameter less than 2.5 microns in outdoor air pollution as carcinogenic to humans (International Agency for Research on Cancer group 1) and as a cause of lung cancer. Lung cancer risk models reviewed do not include air pollution. Estimation of cumulative exposure to air pollution exposure is complex which poses major challenges with accurately collecting long-term exposure to ambient air pollution for incorporation into risk prediction models in clinical practice. CONCLUSIONS: Worldwide air pollution levels vary widely, and the exposed populations also differ. Advocacy to lower sources of exposure is important. Health care can lower its environmental footprint, becoming more sustainable and resilient. The International Association for the Study of Lung Cancer community can engage broadly on this topic.

Design and methodological considerations for biomarker discovery and validation in the Integrative Analysis of Lung Cancer Etiology and Risk (INTEGRAL) Program.

The Integrative Analysis of Lung Cancer Etiology and Risk (INTEGRAL) program is an NCI-funded initiative with an objective to develop tools to optimize low-dose CT (LDCT) lung cancer screening. Here, we describe the rationale and design for the Risk Biomarker and Nodule Malignancy projects within INTEGRAL. The overarching goal of these projects is to systematically investigate circulating protein markers to include on a panel for use (i) pre-LDCT, to identify people likely to benefit from screening, and (ii) post-LDCT, to differentiate benign versus malignant nodules. To identify informative proteins, the Risk Biomarker project measured 1161 proteins in a nested-case control study within 2 prospective cohorts (n = 252 lung cancer cases and 252 controls) and replicated associations for a subset of proteins in 4 cohorts (n = 479 cases and 479 controls). Eligible participants had a current or former history of smoking and cases were diagnosed up to 3 years following blood draw. The Nodule Malignancy project measured 1078 proteins among participants with a heavy smoking history within four LDCT screening studies (n = 425 cases diagnosed up to 5 years following blood draw, 430 benign-nodule controls, and 398 nodule-free controls). The INTEGRAL panel will enable absolute quantification of 21 proteins. We will evaluate its performance in the Risk Biomarker project using a case-cohort study including 14 cohorts (n = 1696 cases and 2926 subcohort representatives), and in the Nodule Malignancy project within five LDCT screening studies (n = 675 cases, 680 benign-nodule controls, and 648 nodule-free controls). Future progress to advance lung cancer early detection biomarkers will require carefully designed validation, translational, and comparative studies.

Scoping Review of Critical Thinking Literature in Healthcare Education.

Critical thinking is the process of analyzing and evaluating thinking to make decisions. Critical thinking exposes assumptions, biases, and beliefs that influence clinical reasoning. This scoping review sought to explore instructional approaches for advancing students' critical thinking in healthcare education. Through analysis of 15 articles, no common definition of critical thinking emerged, nor consensus found on measurement or instructional methods. Some alternative instructional methods such as case-based learning, reflective guided questions, and multiple case exposures, when compared to lecture, did significantly impact learner critical thinking. To determine if critical thinking is an instructional method that would impact implicit biases and healthcare outcomes, five author recommendations are offered from gaps in the existing literature to provide a pathway for future research. To effectively prepare students for clinical practice, long term outcomes are necessary to assess if critical thinking skills can be taught and become part of a professional growth mindset.

Initial Validation of the Weekly Calendar Planning Activity With Adolescents With ABI.

The purpose of this study was to assess the validity of the Weekly Calendar Planning Activity Middle/High School (WCPA) in adolescents with acquired brain injuries (ABI). We recruited neurotypical controls (n = 27) and adolescents with ABI (n = 14) to complete a 90-min battery of cognitive tests. Adolescents with ABI were further divided into mild and severe groups by Glasgow Coma Scale Score and compared with controls. Mann-Whitney U tests revealed significant differences (p = .05) on the WCPA between groups in total time to complete and rules followed. Between the controls and severe group, a significant difference (p = .05) was found for total time spent, errors, rules followed, strategies used, and accurate appointments (p = .01). Moderate correlations were found between the WCPA and neuropsychological tests (ρ = .31-.45). The WCPA is a valid performance-based assessment of functional cognition that can be used to detect deficits in adolescents with severe ABI.

Climate Change and Oncology Nursing: A Call to Action.

Climate change is a public health crisis that amplifies exposure to known carcinogens, leading to increased cases of cancer and other diseases. This clear link is a powerful reason for all oncology nurses concerned with cancer prevention and treatment to be involved in climate change solutions. The purpose of this review is to bring awareness to the consequences climate change has on the incidence and mortality of cancer, how it affects people living with cancer, and how oncology nurses can help mitigate these suboptimal outcomes. .

Management of Lung Cancer Screening Results Based on Individual Prediction of Current and Future Lung Cancer Risks.

OBJECTIVES: We propose a risk-tailored approach for management of lung cancer screening results. This approach incorporates individual risk factors and low-dose computed tomography (LDCT) image features into calculations of immediate and next-screen (1-y) risks of lung cancer detection, which in turn can recommend short-interval imaging or 1-year or 2-year screening intervals. METHODS: We first extended the "LCRAT+CT" individualized risk calculator to predict lung cancer risk after either a negative or abnormal LDCT screen result. To develop the abnormal screen portion, we analyzed 18,129 abnormal LDCT results in the National Lung Screening Trial (NLST), including lung cancers detected immediately (n = 649) or at the next screen (n = 235). We estimated the potential impact of this approach among NLST participants with any screen result (negative or abnormal). RESULTS: Applying the draft National Health Service (NHS) England protocol for lung screening to NLST participants referred 76% of participants to a 2-year interval, but delayed diagnosis for 40% of detectable cancers. The Lung Cancer Risk Assessment Tool+Computed Tomography (LCRAT+CT) risk model, with a threshold of less than 0.95% cumulative lung cancer risk, would also refer 76% of participants to a 2-year interval, but would delay diagnosis for only 30% of cancers, a 25% reduction versus the NHS protocol. Alternatively, LCRAT+CT, with a threshold of less than 1.7% cumulative lung cancer risk, would also delay diagnosis for 40% of cancers, but would refer 85% of participants for a 2-year interval, a 38% further reduction in the number of required 1-year screens beyond the NHS protocol. CONCLUSIONS: Using individualized risk models to determine management in lung cancer screening could substantially reduce the number of screens or increase early detection.

USPSTF2013 versus PLCOm2012 lung cancer screening eligibility criteria (International Lung Screening Trial): interim analysis of a prospective cohort study.

BACKGROUND: Lung cancer is a major health problem. CT lung screening can reduce lung cancer mortality through early diagnosis by at least 20%. Screening high-risk individuals is most effective. Retrospective analyses suggest that identifying individuals for screening by accurate prediction models is more efficient than using categorical age-smoking criteria, such as the US Preventive Services Task Force (USPSTF) criteria. This study prospectively compared the effectiveness of the USPSTF2013 and PLCOm2012 model eligibility criteria. METHODS: In this prospective cohort study, participants from the International Lung Screening Trial (ILST), aged 55-80 years, who were current or former smokers (ie, had ≥30 pack-years smoking history or ≤15 quit-years since last permanently quitting), and who met USPSTF2013 criteria or a PLCOm2012 risk threshold of at least 1·51% within 6 years of screening, were recruited from nine screening sites in Canada, Australia, Hong Kong, and the UK. After enrolment, patients were assessed with the USPSTF2013 criteria and the PLCOm2012 risk model with a threshold of at least 1·70% at 6 years. Data were collected locally and centralised. Main outcomes were the comparison of lung cancer detection rates and cumulative life expectancies in patients with lung cancer between USPSTF2013 criteria and the PLCOm2012 model. In this Article, we present data from an interim analysis. To estimate the incidence of lung cancers in individuals who were USPSTF2013-negative and had PLCOm2012 of less than 1·51% at 6 years, ever-smokers in the Prostate Lung Colorectal and Ovarian Cancer Screening Trial (PLCO) who met these criteria and their lung cancer incidence were applied to the ILST sample size for the mean follow-up occurring in the ILST. This trial is registered at ClinicalTrials.gov, NCT02871856. Study enrolment is almost complete. FINDINGS: Between June 17, 2015, and Dec 29, 2020, 5819 participants from the International Lung Screening Trial (ILST) were enrolled on the basis of meeting USPSTF2013 criteria or the PLCOm2012 risk threshold of at least 1·51% at 6 years. The same number of individuals was selected for the PLCOm2012 model as for the USPSTF2013 criteria (4540 [78%] of 5819). After a mean follow-up of 2·3 years (SD 1·0), 135 lung cancers occurred in 4540 USPSTF2013-positive participants and 162 in 4540 participants included in the PLCOm2012 of at least 1·70% at 6 years group (cancer sensitivity difference 15·8%, 95% CI 10·7-22·1%; absolute odds ratio 4·00, 95% CI 1·89-9·44; p<0·0001). Compared to USPSTF2013-positive individuals, PLCOm2012-selected participants were older (mean age 65·7 years [SD 5·9] vs 63·3 years [5·7]; p<0·0001), had more comorbidities (median 2 [IQR 1-3] vs 1 [1-2]; p<0·0001), and shorter life expectancy (13·9 years [95% CI 12·8-14·9] vs 14·8 [13·6-16·0] years). Model-based difference in cumulative life expectancies for those diagnosed with lung cancer were higher in those who had PLCOm2012 risk of at least 1·70% at 6 years than individuals who were USPSTF2013-positive (2248·6 years [95% CI 2089·6-2425·9] vs 2000·7 years [1841·2-2160·3]; difference 247·9 years, p=0·015). INTERPRETATION: PLCOm2012 appears to be more efficient than the USPSTF2013 criteria for selecting individuals to enrol into lung cancer screening programmes and should be used for identifying high-risk individuals who benefit from the inclusion in these programmes. FUNDING: Terry Fox Research Institute, The UBC-VGH Hospital Foundation and the BC Cancer Foundation, the Alberta Cancer Foundation, the Australian National Health and Medical Research Council, Cancer Research UK and a consortium of funders, and the Roy Castle Lung Cancer Foundation for the UK Lung Screen Uptake Trial.

Using Prediction Models to Reduce Persistent Racial and Ethnic Disparities in the Draft 2020 USPSTF Lung Cancer Screening Guidelines.

We examined whether draft 2020 United States Preventive Services Task Force (USPSTF) lung cancer screening recommendations "partially ameliorate racial disparities in screening eligibility" compared with the 2013 guidelines, as claimed. Using data from the 2015 National Health Interview Survey, USPSTF-2020 increased eligibility by similar proportions for minorities (97.1%) and Whites (78.3%). Contrary to the intent of USPSTF-2020, the relative disparity (differences in percentages of model-estimated gainable life-years from National Lung Screening Trial-like screening by eligible Whites vs minorities) actually increased from USPSTF-2013 to USPSTF-2020 (African Americans: 48.3%-33.4% = 15.0% to 64.5%-48.5% = 16.0%; Asian Americans: 48.3%-35.6% = 12.7% to 64.5%-45.2% = 19.3%; Hispanic Americans: 48.3%-24.8% = 23.5% to 64.5%-37.0% = 27.5%). However, augmenting USPSTF-2020 with high-benefit individuals selected by the Life-Years From Screening with Computed Tomography (LYFS-CT) model nearly eliminated disparities for African Americans (76.8%-75.5% = 1.2%) and improved screening efficiency for Asian and Hispanic Americans, although disparities were reduced only slightly (Hispanic Americans) or unchanged (Asian Americans). The draft USPSTF-2020 guidelines increased the number of eligible minorities vs USPSTF-2013 but may inadvertently increase racial and ethnic disparities. LYFS-CT could reduce disparities in screening eligibility by identifying ineligible people with high predicted benefit regardless of race and ethnicity.

Modeled Reductions in Late-stage Cancer with a Multi-Cancer Early Detection Test.

BACKGROUND: Cancer is the second leading cause of death globally, with many cases detected at a late stage when prognosis is poor. New technologies enabling multi-cancer early detection (MCED) may make "universal cancer screening" possible. We extend single-cancer models to understand the potential public health effects of adding a MCED test to usual care. METHODS: We obtained data on stage-specific incidence and survival of all invasive cancers diagnosed in persons aged 50-79 between 2006 and 2015 from the US Surveillance, Epidemiology, and End Results (SEER) program, and combined this with published performance of a MCED test in a state transition model (interception model) to predict diagnostic yield, stage shift, and potential mortality reductions. We model long-term (incident) performance, accou.

Statistical approaches using longitudinal biomarkers for disease early detection: A comparison of methodologies.

Early detection of clinical outcomes such as cancer may be predicted using longitudinal biomarker measurements. Tracking longitudinal biomarkers as a way to identify early disease onset may help to reduce mortality from diseases like ovarian cancer that are more treatable if detected early. Two disease risk prediction frameworks, the shared random effects model (SREM) and the pattern mixture model (PMM) could be used to assess longitudinal biomarkers on disease early detection. In this article, we studied the discrimination and calibration performances of SREM and PMM on disease early detection through an application to ovarian cancer, where early detection using the risk of ovarian cancer algorithm (ROCA) has been evaluated. Comparisons of the above three approaches were performed via analyses of the ovarian cancer data from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial. Discrimination was evaluated by the time-dependent receiver operating characteristic curve and its area, while calibration was assessed using calibration plot and the ratio of observed to expected number of diseased subjects. The out-of-sample performances were calculated via using leave-one-out cross-validation, aiming to minimize potential model overfitting. A careful analysis of using the biomarker cancer antigen 125 for ovarian cancer early detection showed significantly improved discrimination performance of PMM as compared with SREM and ROCA, nevertheless all approaches were generally well calibrated. Robustness of all approaches was further investigated in extensive simulation studies. The improved performance of PMM relative to ROCA is in part due to the fact that the biomarker measurements were taken at a yearly interval, which is not frequent enough to reliably estimate the changepoint or the slope after changepoint in cases under ROCA.

Applicability of two violence risk assessment tools in a psychiatric prison hospital population.

The risk of violent behavior is known to be higher for patients who suffer from a severe mental disorder. However, specific prediction tools for clinical work in prison psychiatry are lacking. In this single-center study, two violence risk assessment tools (Forensic Psychiatry and Violence Tool, "FoVOx," and Mental Illness and Violence Tool, "OxMIV") were applied to a prison hospital population with a primary psychotic or bipolar disorder and subsequently compared. The required information on all items of both tools was obtained retrospectively for a total of 339 patients by evaluation of available patient files. We obtained the median and inter-quartile range for both FoVOx and OxMIV, and their rank correlation coefficient along with 95% confidence intervals (CIs)-for the full cohort, as well as for cohort subgroups. The two risk assessment tools were strongly positively correlated (Spearman correlation = 0.83; 95% CI = 0.80-0.86). Such a high correlation was independent of nationality, country of origin, type of detention, schizophrenia-spectrum disorder, previous violent crime and alcohol use disorder, where correlations were above 0.8. A lower correlation was seen with patients who were 30 years old or more, married, with affective disorder and with self-harm behavior, and also in patients without aggressive behavior and without drug use disorder. Both risk assessment tools are applicable as an adjunct to clinical decision making in prison psychiatry.

Protocol and Rationale for the International Lung Screening Trial.

Rationale: The NLST (National Lung Screening Trial) reported a 20% reduction in lung cancer mortality with low-dose computed tomography screening; however, important questions on how to optimize screening remain, including which selection criteria are most accurate at detecting lung cancers and what nodule management protocol is most efficient. The PLCOm2012 (Prostate, Lung, Colorectal and Ovarian) Cancer Screening Trial 6-year and PanCan (Pan-Canadian Early Detection of Lung Cancer) nodule malignancy risk models are two of the better validated risk prediction models for screenee selection and nodule management, respectively. Combined use of these models for participant selection and nodule management could significantly improve screening efficiency.Objectives: The ILST (International Lung Screening Trial) is a prospective cohort study with two primary aims: 1) Compare the accuracy of the PLCOm2012 model against U.S. Preventive Services Task Force (USPSTF) criteria for detecting lung cancers and 2) evaluate nodule management efficiency using the PanCan nodule probability calculator-based protocol versus Lung-RADS.Methods: ILST will recruit 4,500 participants who meet USPSTF and/or PLCOm2012 risk ≥1.51%/6-year selection criteria. Participants will undergo baseline and 2-year low-dose computed tomography screening. Baseline nodules are managed according to PanCan probability score. Participants will be followed up for a minimum of 5 years. Primary outcomes for aim 1 are the proportion of individuals selected for screening, proportion of lung cancers detected, and positive predictive values of either selection criteria, and outcomes for aim 2 include comparing distributions of individuals and the proportion of lung cancers in each of three management groups: next surveillance scan, early recall scan, or diagnostic evaluation recommended. Statistical powers to detect differences in the four components of primary study aims were ≥82%.Conclusions: ILST will prospectively evaluate the comparative accuracy and effectiveness of two promising multivariable risk models for screenee selection and nodule management in lung cancer screening.Clinical trial registered with www.clinicaltrials.gov (NCT02871856).

Risk of Prostate Cancer-related Death Following a Low PSA Level in the PLCO Trial.

Longer-than-annual screening intervals have been suggested to improve the balance of benefits and harms in prostate cancer screening. Many researchers, societies, and guideline committees have suggested that screening intervals could depend on the prostate-specific antigen (PSA) result. We analyzed data from men (N = 33,897) ages 55-74 years with a baseline PSA test in the intervention arm of the Prostate, Lung, Colorectal and Ovarian Cancer Screening trial (United States, 1993-2001). We estimated 5- and 10-year risks of aggressive cancer (Gleason ≥8 and/or stage III/IV) and 15-year risks of prostate cancer-related mortality for men with baseline PSA ≤ 0.5 ng/mL (N = 4,862), ≤1 ng/mL (N = 15,110), and 1.01-2.5 ng/mL (N = 12,422). A total of 217 men died from prostate cancer through 15 years, although no men with PSA ≤ 1 ng/mL died from prostate cancer within 5 years [95% confidence interval (CI), 0.00%-0.03%]. The 5-year incidence of aggressive disease was low (0.08%; 95% CI, 0.03%-0.12%) for men with PSA ≤ 1 ng/mL, and higher for men with baseline PSA 1.01-2.5 ng/mL (0.51%; 95% CI, 0.38%-0.74%). No men aged ≥65 years with PSA ≤ 0.5 ng/mL died from prostate cancer within 15 years (95% CI, 0.00%-0.32%), and their 10-year incidence of aggressive disease was low (0.25%; 95% CI, 0.00%-0.53%). Compared with white men, black men with PSA ≤ 1 ng/mL had higher 10-year rates of aggressive disease (1.6% vs. 0.4%; P < 0.01). Five-year screening intervals may be appropriate for the 45% of men with PSA ≤ 1 ng/mL. Men ages ≥65 years with PSA ≤ 0.5 ng/mL could consider stopping screening. Substantial risk disparities suggest appropriate screening intervals could depend on race/ethnicity.

Pragmatic randomised clinical trial of proton versus photon therapy for patients with non-metastatic breast cancer: the Radiotherapy Comparative Effectiveness (RadComp) Consortium trial protocol.

INTRODUCTION: A broad range of stakeholders have called for randomised evidence on the potential clinical benefits and harms of proton therapy, a type of radiation therapy, for patients with breast cancer. Radiation therapy is an important component of curative treatment, reducing cancer recurrence and extending survival. Compared with photon therapy, the international treatment standard, proton therapy reduces incidental radiation to the heart. Our overall objective is to evaluate whether the differences between proton and photon therapy cardiac radiation dose distributions lead to meaningful reductions in cardiac morbidity and mortality after treatment for breast cancer. METHODS: We are conducting a large scale, multicentre pragmatic randomised clinical trial for patients with breast cancer who will be followed longitudinally for cardiovascular morbidity and mortality, health-related quality of life and cancer control outcomes. A total of 1278 patients with non-metastatic breast cancer will be randomly allocated to receive either photon or proton therapy. The primary outcomes are major cardiovascular events, defined as myocardial infarction, coronary revascularisation, cardiovascular death or hospitalisation for unstable angina, heart failure, valvular disease, arrhythmia or pericardial disease. Secondary endpoints are urgent or unanticipated outpatient or emergency room visits for heart failure, arrhythmia, valvular disease or pericardial disease. The Radiotherapy Comparative Effectiveness (RadComp) Clinical Events Centre will conduct centralised, blinded adjudication of primary outcome events. ETHICS AND DISSEMINATION: The RadComp trial has been approved by the institutional review boards of all participating sites. Recruitment began in February 2016. Current version of the protocol is A3, dated 08 November 2018. Dissemination plans include presentations at scientific conferences, scientific publications, stakeholder engagement efforts and presentation to the public via lay media outlets. TRIAL REGISTRATION NUMBER: NCT02603341.

Life-Gained-Based Versus Risk-Based Selection of Smokers for Lung Cancer Screening.

Background: Although risk-based selection of ever-smokers for screening could prevent more lung cancer deaths than screening according to the U.S. Preventive Services Task Force (USPSTF) guidelines, it preferentially selects older ever-smokers with shorter life expectancies due to comorbidities. Objective: To compare selection of ever-smokers for screening based on gains in life expectancy versus lung cancer risk. Design: Cohort analyses and model-based projections. Setting: U.S. population of ever-smokers aged 40 to 84 years. Participants: 130 964 National Health Interview Survey participants, representing about 60 million U.S. ever-smokers during 1997 to 2015. Intervention: Annual computed tomography (CT) screening for 3 years versus no screening. Measurements: Estimated number of lung cancer deaths averted and life-years gained after development of a mortality model. Results: Using the calibrated and validated mortality model in U.S. ever-smokers aged 40 to 84 years and selecting 8.3 million ever-smokers to match the number selected by the USPSTF criteria in 2013 to 2015, the analysis estimated that life-gained-based selection would increase the total life expectancy from CT screening (633 400 vs. 607 800 years) but prevent fewer lung cancer deaths (52 600 vs. 55 000) compared with risk-based selection. The 1.56 million persons selected by the life-gained-based strategy but not the risk-based strategy were younger (mean age, 59 vs. 75 years) and had fewer comorbidities (mean, 0.75 vs. 3.7). Limitation: Estimates are model-based and assume implementation of lung cancer screening with short-term effectiveness similar to that from trials. Conclusion: Life-gained-based selection could maximize the benefits of lung cancer screening in the U.S. population by including ever-smokers who have both high lung cancer risk and long life expectancy. Primary Funding Source: Intramural Research Program of the National Cancer Institute, National Institutes of Health.