Abstract
Purpose
“Patient-centred care” is widely promoted as an ideal goal of health care systems, but is often difficult to achieve in practice. This article has three aims: to develop an original set of generalisable patient-centred care principles (PCCPs); to identify barriers to the implementation of these principles in a real-world setting, using breast reconstruction (BR) services in Australia as a case study; and to document examples of successful patient-centred care in relation to BR.
Methods
Semi-structured interviews (n = 90) were conducted with 31 breast and plastic reconstructive surgeons, 37 breast cancer health professionals and 22 women who underwent mastectomy as part of their breast cancer treatment and were dissatisfied with their BR experiences.
Results
Ten broad PCCPs were derived from our participant interviews. These principles comprised the following: maximising patient choice, access to services, patient and family support and appropriateness of information; minimising patient costs and physical and psychosocial morbidity; and facilitating informed decision-making, interdisciplinary patient management and evidence-informed practice. While the major barriers to the implementation of these PCCPs in relation to BR were resource driven, surgeon-related factors were also identified.
Conclusions
These PCCPs highlight areas of need but also provide examples of high quality patient-centred care. They may help to guide a national discussion about minimum standards of BR practice, while allowing for some necessary regional and cultural variation. They also have the potential to be applied more widely to the provision of a range of health services within Australia or internationally.
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Background
Defining patient-centred care
“Patient-centred care” is widely promoted as an ideal goal of health care systems, but is often difficult to achieve in practice [1]. This is because it requires an integrated health system that is flexible enough to make the patient’s individual needs paramount. One of the earlier definitions from The US Institute of Medicine defined patient-centred care as “Providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions” [2]. Research conducted by the Picker Institute, an international charity, and Harvard Medical School led to the development of Picker’s Eight Principles of Patient-Centred Care in 1987. These have been updated over the years (see Box 1) and since 2002 the Picker Institute has worked with the National Health Service (NHS) in the UK to design patient experience surveys [5].
1987 version [3] | 2018 version [4] |
Respect for patient’s preferences | Involvement in decisions and respect for preferences |
Coordination and integration of care | Effective treatment delivered by trusted professionals |
Information and education | Clear information, communication and support for self-care |
Physical comfort | Attention to physical and environmental needs |
Emotional support | Emotional support, empathy and respect |
Involvement of family and friends | Involvement of, and support for, family and carers |
Continuity and transition | Continuity of care and smooth transitions |
Access to care | Fast access to reliable health advice |
Patient-centred care principles related to breast reconstruction in Australia
Traditionally, disease-specific “best practice” recommendations were embodied in clinical guidelines, and most countries have their own breast cancer management guidelines [6,7,8]. The latest complete set of published Australian clinical guidelines for early breast cancer dates back to 2001 [9] and is currently being updated. In the meantime, topic-specific guidelines have been produced to reflect the latest evidence in specific areas [10]. Cancer Australia has also published a Statement titled Influencing best practice in breast cancer [11]. This Statement is intended to complement the nationally endorsed Optimal care pathway for women with breast cancer [12], by highlighting what “ought to be done” in breast cancer care to “maximise clinical benefit, minimise harm and deliver patient-centred care” [11].
Number 11 of the 12 practices covered by the Cancer Australia Statement declares that it is “Not appropriate to perform a mastectomy without first discussing with the patient the options of immediate or delayed breast reconstruction” [11]. The Optimal care pathway document notes that patient-centred care is one of the “key principles” that underpin this pathway [12]. It defines patient-centred care as “healthcare that is respectful of, and responsive to, the preferences, needs and values of patients and consumers” and notes that it is “increasingly being recognised as a dimension of high-quality healthcare in its own right” [12]. These two publications [11, 12] have highlighted the growing importance of patient-centred care, at least at a rhetorical level. Previous research has documented significant variation in breast reconstruction (BR) uptake between different states and territories and between hospitals situated within metropolitan and non-metropolitan areas [13]. Much of this variation is related to hospital-based factors such as where individual surgeons work and what type of BR, if any, they offer [13, Feng et al., 2019, Patterns of immediate breast reconstruction in NSW Australia: a population-based study, In Press, ANZ J Surg]. These findings confirm that barriers to affordable and timely access to BR are multifactorial and require a combination of responses to address them. Further information about BR in the Australian setting is provided in Appendix 1.
Clinical practice guidelines and optimal care pathways are important tools to support evidence-based best practice treatment and management of a particular disease. Although these tools discuss the importance of patient-centred care, more specific principles are required to guide the implementation of patient-centred care in practice. This article has three aims: to develop an original set of generalisable patient-centred care principles (PCCPs); to identify barriers to the implementation of these principles in a real-world setting, using BR services in Australia as a case study; and to document examples of successful patient-centred care in relation to BR, in order to identify favourable conditions for the implementation of patient-centred care in practice.
Methods
This article reports on findings from the Improving Breast Reconstruction Equity of Access through Stakeholder consultation and Translation into policy and practice (I-BREAST) study.
Participants
One hundred and two participants were invited to take part in a single face-to-face or telephone interview with KF, an experienced qualitative health researcher. Twelve invitees (four surgeons and eight breast care nurses (BCNs)) declined to participate in the study, giving a response rate of 88%. Interviewees included 31 breast and plastic reconstructive surgeons and 37 breast cancer health professionals with primary appointments at 42 hospitals across mainland Australia. In addition, women who underwent mastectomy as part of their breast cancer treatment were purposively sampled to obtain the views of women who self-identified as being dissatisfied with their BR experiences (n = 22). While we realise that many women will be satisfied with their BR experiences, the reason for focusing on women who had negative experiences was to identify if there were specific problems that need to be addressed.
Selection criteria comprised the following:
Surgeons who either performed both mastectomy and BR themselves or in combination with plastic surgeons (convenience sample of 22 breast/oncoplastic and 9 plastic reconstructive surgeons).
Health professionals who worked with women undergoing mastectomy for breast cancer in centres that did and did not offer BR (purposive sample of 37 health professionals, mostly BCNs with selection informed by an earlier survey of BR practice in their local area).
Women who had undergone mastectomy for breast cancer, were interested in BR, and self-identified as being dissatisfied with their BR experience (purposive sample of 22 women).
Recruitment
Surgeons were identified through personal contacts, recommendations by other surgeons and comments by BCNs about particular issues in their local areas. Surgeons who did not perform BR were not invited to participate.
Health professionals (mainly BCNs) were initially identified via a Human Research Ethics Committee [HREC]-approved survey sent to BCNs in January 2016 via the membership lists of the McGrath Foundation, the NSW Breast Cancer Interest Group and the Breast Cancer Network Australia. This same survey was posted on the Reclaim Your Curves (RYC) website in May/June 2016, resulting in further BCNs volunteering to participate.
Women were recruited from a variety of sources including suggestions from surgeons and BCNs, as well as an invitation to participate in the study posted on the BR advocacy RYC website[14].
Recruitment of participants ceased when the study authors agreed they had reached a satisfactory level of data saturation (i.e. the same issues were being identified in subsequent interviews). The role of interview respondents by jurisdiction is provided in Appendix 2.
Interview processes
Interviews were conducted between May 2015 and May 2017 with written informed consent obtained from all participants. Face-to-face interviews took place at a convenient location for the respondent, with KF interviewing in seven capital cities and four regional centres. Telephone interviews were conducted with patients and health professionals in an additional 18 locations across mainland Australia. Interview duration ranged from 9 to 103 min (mean = 43; median = 41).
Data management
Interviews were digitally recorded and de-identified. They were uploaded and transcribed verbatim for data analysis by an independent transcription company that had signed a confidentiality agreement. Each participant was assigned a sequential reference number, with a prefix of W for women, HP for health professional and S for surgeon to ensure confidentiality. Responses from interviewees were grouped into broad topic-based categories, agreed on by all authors, to reflect the range of views on particular issues. Where data was relevant to more than one topic, it was included in all relevant categories. Appendix 3 provides the topics discussed by each group of respondents. This article is based on participant responses to the “Models of care”, “Support”, “Information”, “Cultural differences”, “Waiting times” and “Patient choice” categories.
Data analysis
The interview data provided evidence of situations where patient-centred care was non-existent or severely compromised. It also provided examples of high quality patient-centred care in certain locations. Through our evaluation of the variation in standards across different locations in Australia, the authors derived ten PCCPs that could be used to guide ideal provision of BR services. We then grouped participant quotes that demonstrated practical barriers to the implementation of each of the ten principles (Table 1). Finally, we grouped examples from the interview data of high quality patient-centred care under each of the principles to demonstrate that these ideal practices are possible within the Australian health system where resources are available and clinicians are willing to optimise patient-centred care (Table 2).
Ethics approval
Ethics approval for the I-BREAST study was granted by the Human Research Ethics Committee of St Vincent’s Health Network Sydney (18/099).
Results
Box 2 presents the ten PCCPs the authors derived from their overall evaluation of the interview data.
Principle 1: Facilitate informed/shared decision-making Principle 2: Maximise patient choice Principle 3: Maximise equity of access to services Principle 4: Maximise support for patients and their families Principle 5: Maximise use of appropriate communication techniques and information materials Principle 6: Minimise patient costs Principle 7: Minimise short and long-term physical and psychosocial morbidity Principle 8: Foster interdisciplinary patient management Principle 9: Promote communication between care providers Principle 10: Encourage evidence-informed practice |
Table 1 presents the ten PCCPs and the practical barriers identified by our participants to the implementation of each of these principles, while Table 2 provides examples of successful implementation of the ten PCCPs in relation to BR.
Discussion
Interviews revealed examples of high quality patient-centred care in several metropolitan and regional hospitals, including public hospitals. However, challenges were also identified. Barriers to patient-centred care included problems of inadequate levels of staffing and resources, even in metropolitan and regional areas that could be reasonably expected to be well staffed and well resourced. However, the majority of the 42 hospitals represented in these interviews did not provide services that met all 10 ideal principles for patient-centred care and some of them would struggle to meet any.
It is not possible to discuss all the barriers that were revealed through these interviews, but we will mention a few items that, if implemented more widely, are likely to make a significant difference to the care women receive. Firstly, BCNs are clearly vital for the delivery of patient-centred care as evidenced by the poorer quality care patients received when BCNs were not available.
Secondly, the provision of specialist BR nurses is still a rarity in Australia, but the extra services they offer have the potential to add tremendous value to patients, surgeons and BCNs, as our findings and those from the UK have shown [15]. Specialist BR nurses have the knowledge to offer fully informed discussion, provide referrals as necessary and perform a range of practical tasks such as seroma drainage, inflation of expanders and nipple tattooing in a continuous care model of support. Specialist BR nurses can also collect, collate and analyse patient-reported outcome measures as a means of quality assurance and to inform clinicians of areas that could be improved, as well as to lobby for improved services. One particular benefit of having specialist BCNs is the potential for nurse-led survivorship clinics, which care for the patients once the active treatment phase has ceased.
Pre-operative MDT meetings are also scarce in Australia, with the majority of hospitals discussing their patients’ adjuvant treatment post-operatively. If women have opted to have IBR, then it has already been performed prior to any MDT discussion, with the surgeon being responsible for this decision. The exception is for women considering neo-adjuvant treatment, but in these cases, discussion often involves more informal talks between relevant multidisciplinary team members in order to fast-track chemotherapy treatment and BR is often not discussed in the MDT setting. Some hospitals do hold regular pre-operative MDT meetings which allow for a wider discussion of BR possibilities among clinicians prior to mastectomy. Where breast, oncoplastic and plastic surgeons attend, this could facilitate a more collegial approach to BR discussion, especially if it is open to other local surgeons as a mentoring tool for decision-making. Such cooperation can only benefit patients.
In addition to resource-based barriers to patient-centred care, this research has identified surgeon-based issues. Clinicians need to learn to be better communicators and listeners. Patient-centred care cannot exist in situations where the views of patients and their supporters are not valued. The use of a prompt list to guide BR discussion between surgeons and their patients is likely to be useful, as a reminder against omitting items that are important to the patient, or assuming they understand those issues [16]. Surgeons also need to be prepared to work collaboratively and in the patient’s best interests, even in situations where this may potentially disadvantage them financially. They should be prepared to engage with more junior surgeons to help develop their skills so that future patients will benefit from the time they have committed to mentoring. Surgeons also need to recognise the potential negative impact demarcation between surgical sub-specialties can have on patient care (Flitcroft et al., “On the frontiers of change”: breast surgeons’ views on demarcation between surgical sub-specialties in Australia, under review).
Finally, it is vital that clinicians keep up to date with the latest advances in breast cancer treatments in order to offer their patients treatment options tailored to their specific needs. Patient-centred care must be based on the best and latest evidence, requiring surgeons to keep up to date with clinical trials and relevant publications in order to provide their patients with the latest information. One example is the growing evidence that radiotherapy after implant or autologous reconstruction is oncologically safe, even for older women, does not delay treatment and provides cosmetic outcomes that women are largely satisfied with [17,19,20,21,22]. Furthermore, there is growing evidence of the benefits of neo-adjuvant radiotherapy (NART) in the setting of immediate autologous reconstruction. Tansley et al. [23] predicted superior outcomes from their resequencing of adjuvant radiotherapy in 2013, and their own and subsequent studies appear to confirm it is oncologically safe with a low side effect profile even during BR [24]. NART has also been reported to achieve significant downstaging in some patients with high risk, locally advanced breast cancer regardless of tumour phenotype [25]. Hughes and Neoh noted this treatment sequence allows patients to have an immediate gold standard reconstruction without an increase in surgical morbidity: “It affords the benefits of IBR without concern in delaying adjuvant therapy and appears to be safe from an oncological perspective” [26].
Limitations
The semi-structured questionnaires used in this research are not validated QoL assessment instruments. However, to our knowledge, there are no validated questionnaires available to capture women’s or health clinicians’ views on BR in their local area. It is also possible that some practices may have changed since 2015 when the first interviews were conducted.
Conclusion
We have compiled a list of 10 patient-centred principles that we believe, if implemented, would facilitate the delivery of high quality patient-centred care for women requiring or choosing mastectomy and interested in BR. We realise that achieving some of the ideal BR practices nominated here will not be feasible for many breast cancer services, at least in the short term. However, we believe it is important to identify what an ideal system would look like, so that with time, the care of these patients will improve and become more attuned to patient preferences. These patient-centred principles may form the basis for a national discussion about minimal standards of BR practice, while allowing for some necessary regional and cultural variation. Arguably, women living in rural and remote areas of Australia have different and more difficult access issues to deal with. Further research exploring specific BR models of care for these women is underway.
Policy implications
We have discussed the usefulness of these ten generic PCCPs in identifying barriers to and exemplars of patient-centred care in relation to BR. Their strength lies in their potential as a helpful framework to guide analysis of unmet needs in a range of other health care services. For example, these generalisable principles could be used to benchmark the patient-centredness of existing programs in areas of chronic disease such as other cancers, cardiac disease, diabetes or lung disease.
References
Spotlight on patient centred care (2015). [A series of articles related to patient centred care] BMJ. https://www.bmj.com/patient-spotlight Accessed 30 October 2018
Institute of Medicine (2001) Crossing the quality chasm: a new health system for the 21st century. Institute of Medicine Committee on Quality of Health Care in America. National Academies Press, Washington (DC)
Oneview (2015). Eight Principles of Patient-Centered Care. https://www.oneviewhealthcare.com/the-eight-principles-of-patient-centered-care/ Accessed 30 October 2018
The Picker Institute (2018). Picker Principles of Person Centred Care https://www.picker.org/about-us/picker-principles-of-person-centred-care/ Accessed 30 October 2018
National Health Service (2018). NHS Surveys. Focused on patients’ experiences. http://www.nhssurveys.org/ Accessed 30 October 2018
Cancer Australia (2019) Cancer Australia guidelines. https://canceraustralia.gov.au/publications-and-resources/clinical-practice-guidelines. Accessed 12 Jul 2019
National Comprehensive Cancer Network (2018). NCCN Guidelines. https://www.nccn.org/professionals/physician_gls/default.aspx#site Accessed 18 December 2018 [need to register with NCCN for access]
National Institute for Health and Care Excellence (NICE) Guidelines (2018). Early and locally advanced breast cancer: diagnosis and management. NICE guideline [NG101] July. 8. https://www.nice.org.uk/guidance/ng101 Accessed 18 December 2018
National Breast Cancer Centre, Clinical Practice Guidelines. Management of Early Breast Cancer, NHMRC 2001 https://canceraustralia.gov.au/sites/default/files/publications/cpg-clinical-practice-guidelines-management-early-breast-cancer_504af03111a52.pdf
Cancer Australia. Cancer Australia Guidelines https://canceraustralia.gov.au/publications-and-resources/clinical-practice-guidelines [various years. accessed 16 April 2019]
Cancer Australia (2017). Influencing best practice in breast cancer. https://thestatement.canceraustralia.gov.au/ [accessed 18 Oct 2018]
National Cancer Expert Reference Group (NCERG). (2016) Optimal care pathway for women with breast cancer. https://www.cancer.org.au/content/ocp/health/optimal-care-pathway-for-women-with-breast-cancer-june-2016.pdf#_ga=2.2908403.252905305.1555384912-523466786.1472513159 [accessed 16 April 2019]
Flitcroft K, Brennan M, Costa D, Spillane A (2017) Regional variation in immediate breast reconstruction rates in Australia. BJS Open 1:114–121
Reclaim Your Curves [website]. https://www.reclaimyourcurves.org.au/ [accessed 16 April 2019]
Potter S, Mills N, Cawthorn S, Wilson S, Blazeby J (2013) Exploring inequalities in access to care and the provision of choice to women seeking breast reconstruction surgery: a qualitative study. Br J Cancer 109:1181–1191. https://doi.org/10.1038/bjc.2013.461
Flitcroft KL, Brennan ME, Spillane AJ (2019) The impact on Australian women of lack of choice of breast reconstruction options: a qualitative study. Psycho-Oncology 28(3):547–552
Jethwa KR, Kahila MM, Whitaker TJ, Harmsen WS, Corbin KS, Park SS, Yan ES, Lemaine V, Boughey JC, Mutter RW (2017) Immediate tissue expander or implant-based breast reconstruction does not compromise the oncologic delivery of post-mastectomy radiotherapy (PMRT). Breast Cancer Res Treat 164(1):237–244
Steele KH, Macmillan RD, Ball GR, Akerlund M, McCulley SJ (2018) Multicentre study of patient-reported and clinical outcomes following immediate and delayed autologous breast reconstruction and radiotherapy (ABRAR study). J Plast Reconstr Aesthet Surg 71(2):185–193
Boulva K, Shahvary N, Meloche-Dumas L, Mathieu D, Cote N, Al Khaldi M, Fortin I, Younan R, Patocskai E (2018) Immediate breast reconstruction and post-mastectomy radiation therapy: two safe and complementary entities. Ann Surg Oncol 25(1):S93 [Abstract]
Nogi H, Tomita S, Kamio M, Shioya H, Toriumi Y, Takeyama H (2018) Impact of immediate breast reconstruction after mastectomy on the outcome of patients receiving neoadjuvant chemotherapy. Cancer Res 78(Suppl 4) [Abstract P4-13-16]
Brennan ME, Flitcroft K, Warrier S, Snook K, Spillane AJ (2016) Immediate expander/implant breast reconstruction followed by post-mastectomy radiotherapy for breast cancer: aesthetic, surgical, satisfaction and quality of life outcomes in women with high-risk breast cancer. Breast 30:59–65
Oh D, Flitcroft K, Brennan ME, Spillane AJ (2016) Patterns and outcomes of breast reconstruction in older women—a systematic review of the literature. Eur J Surg Oncol 42:604–615. https://doi.org/10.1016/j.ejso.2016.02.010
Tansley P, Ramsey K, Wong S, Guerrieri M, Pitcher M, Grinsell D (2013) New treatment sequence protocol to reconstruct locally advanced breast cancer. ANZ J Surg 83(9):630–635
Ahmed M, Douek M (2018) A systematic review of neo-adjuvant radiotherapy in the treatment of breast cancer. Eur J Surg Oncol 44(S26) Abstract
Chao M, Foroudi F, Jassal S, Hyett A, Neoh D, Bevington E (2018) Tumor down staging in high risk or locally advanced breast cancer patients undergoing neoadjuvant radiotherapy prior to definitive surgery and autologous breast reconstruction. Eur J Cancer 92:S57–S58 Abstract
Hughes K, Neoh D (2018) Neoadjuvant radiotherapy: changing the treatment sequence to allow immediate free autologous breast reconstruction. J Reconstr Microsurg 34(8):624–631
Australian Institute of Health and Welfare (2016). Australia’s health 2016. Australia’s health series no. 15. Cat. no. AUS 199. Canberra: AIHW. https://www.aihw.gov.au/getmedia/9844cefb-7745-4dd8-9ee2-f4d1c3d6a727/19787-AH16.pdf.aspx?inline=true Accessed 21 Sept 2018.
Parliament of Australia. Biggs A. (2008) Hospital waiting lists explained. https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/BN/0708/Hospitalwaitinglists Accessed 21 Sept 2018.
Breast Cancer Network Australia (2018). State of the Nation Report. BCNA. https://www.bcna.org.au/media/6656/sotn-report-lowres.pdfAccessed 21 Sept 2018.
Breast Cancer Network of Australia (2018a). Ministers respond to BCNA’s State of the Nation report. BCNA News. https://www.bcna.org.au/news/2018/06/ministers-respond-to-bcnas-state-of-the-nation-report/ Accessed 21 Sept 2018.
Acknowledgements
We are grateful for the assistance of the Consumer Advisory Panel (CAP) who advised on the interview component of this study. CAP members provided input into draft questionnaires and participant information to be sent to women with breast cancer, breast care nurses (BCNs) and breast surgeons. We also thank the interview participants.
Funding
KF’s and AS’s academic positions are generously funded by the Friends of the Mater Foundation, North Sydney.
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All authors declare they have no conflicts of interest. KF has full control of all primary data. This data has not been deposited into a public repository to protect the anonymity of interview respondents. The journal may review de-identified data if requested.
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Appendices
Appendix 1. Issues concerning access to breast reconstruction in the Australian setting
Breast reconstruction (BR) is available in public and private hospitals in metropolitan and regional areas of Australia. Medicare Australia offers treatment as a public patient in a public hospital without cost to the patient, so BR performed by a surgeon appointed by the hospital is free of charge [27]. Medicare also covers 75% of the Medicare Benefits Schedule (MBS) fee for services and procedures for private patients in a public or private hospital [27], although the majority of surgeons will charge more than the schedule fee for BR (the “gap”) due to a lack of reasonable indexation of Medicare and health fund rebates over a number of decades.
Waiting times for delayed BR (DBR) are longer in public hospitals due mainly to limited availability of operating theatre time for these procedures, which are classified as Category 3 (non-urgent) surgery. National surgical waiting time guidelines state that Category 3 surgery “is desirable” within 12 months of being placed on a hospital waiting list [28], but wait times of up to 3–5 years are not uncommon [16]. If a woman has immediate BR (IBR) in a public hospital, then she can fast-track the initial reconstruction which, when performed at the same time as the mastectomy, should be completed within 30 days of the initial surgeon’s visit (Category 1).
In June 2015, 47% of the Australian population had some form of private patient hospital cover [27], but over 70% of BR is undertaken in private hospitals [13]. Waiting times for BR in private hospitals is minimal; however, significant out-of-pocket costs are associated with this surgery as the fees the surgeons charge are not regulated and even women with the top level of private health insurance face substantial additional costs for the surgeon, assistant surgeon and anaesthetist. The Breast Cancer Network of Australia (BCNA) has recently reported on out-of-pocket costs associated with breast cancer treatment [29]. The Minister for Health has responded by promising to introduce a more transparent system so that consumers can compare costs for common breast cancer tests and treatments against Medicare rebates before their surgery, as well as offering a guarantee that a Coalition government will provide full Medicare rebates for any breast cancer tests and treatments that are recommended by the Medical Services Advisory Committee [30].
Box 3 describes the two main models of surgeon involvement in BR in Australia.
Appendix 2
Appendix 3
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Flitcroft, K., Brennan, M. & Spillane, A. Principles of patient-centred care and barriers to their implementation: a case study of breast reconstruction in Australia. Support Care Cancer 28, 1963–1981 (2020). https://doi.org/10.1007/s00520-019-04978-9
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DOI: https://doi.org/10.1007/s00520-019-04978-9