Bibliografie vrouwelijke arts en borstkanker Periode 1990 – 2011 (29 juni)* Inleiding In deze bibliografie is de centrale vraag: komt borstkanker meer voor bij vrouwelijke artsen vergeleken met de gewone bevolking? Er werden zoekacties uitgevoerd in de volgende databanken: PubMed, Embase, en PsycINFO. Als tijdsperiode werd gekozen: 1990 – 29 juni 2011. Als talen werden gekozen: Duits, Engels, Frans en Nederlands. De zoekactie leverde ongeveer 1050, veelal irrelevante, referenties (tijdschriftartikelen) op. PubMed leverde 16 relevante referenties op. Embase en PsycINFO leverden ieder 1 aanvullende relevante referentie op. In Scopus werd nog gezocht naar recentere of oudere relevante literatuur op basis van de citaties en referenties behorend bij 10 relevante publicaties uit PubMed. Via Scopus werden zo nog 3 relevante publicaties gevonden. In totaal leverde dit 21 relevante publicaties op.
Incidentie / prevalentie In een Zweeds onderzoek naar beroepen waar Zweedse vrouwen het hoogste risico lopen op borstkanker werden er overmatige risico’s gevonden bij, onder andere, vrouwen die in 1960 en 1970 als arts werkzaam waren (Pollan). Uit onderzoek in Estland, waarin artsen (man en vrouw) werden vergeleken met de gewone bevolking, blijkt dat vrouwelijke artsen een verhoogd risico hebben op borstkanker (Standardized Incidence Ratio 2,03; 95% CI 1,62-2,51) (Innos). Uit onderzoek onder Deens personeel in de gezondheidszorg blijkt dat er een verhoogd risico is op borstkanker onder vrouwelijke tandartsen, ziekenhuisartsen en verpleegkundigen (Rix). In een Fins onderzoek werd gekeken naar bijzondere omstandigheden waarin incidentie van kanker bij artsen die met straling werken werd vergeleken met artsen die niet aan straling werden blootgesteld. Er werd een licht verhoogd risico op borstkanker vastgesteld bij vrouwelijke artsen die met straling werken in vergelijking tot de andere artsen (rate ratio 1,7; 95% CI 1,0-3,1) (Jartti).
Zelfonderzoek Uit Turks onderzoek naar gezondheidsmotivatie en borstkanker screening gedrag onder vrouwelijke artsen, verpleegkundigen en verloskundigen, met een gemiddelde leeftijd van 31,3 jaar, blijkt dat 21,9% van hen regelmatig zelfonderzoek van de borsten uitvoert, en dat 12,5% van hen een mammografie had laten maken. Motivatie rond gezondheid en doelmatigheid van zelfonderzoek van de borsten zijn sterker aanwezig bij artsen dan bij verpleegkundigen en vroedvrouwen (Canbulat). Uit een ander Turks onderzoek naar zelfonderzoek van de borsten door vrouwelijke verpleegkundigen en artsen blijkt dat bijna alle vrouwelijke artsen en verpleegkundigen weten hoe ze dit onderzoek moeten uitvoeren, maar geven ze er geen prioriteit aan om dit uit te voeren. Met andere woorden, zij besteden onvoldoende zorg aan de juiste timing van zelfonderzoek van de borsten (d.w.z. dag 5 tot dag 7 na de menstruatie met de eerste dag van de menstruatie als dag 1) ondanks hun kennis hiervan (Cavdar). Uit Amerikaans onderzoek onder vrouwelijke artsen blijkt dat 21% van hen ten minste één keer per maand zelfonderzoek van de borsten uitvoert. Ongeveer tweederde van hen had een borstonderzoek ondergaan door een arts in het afgelopen jaar en 85% had er een ondergaan in de afgelopen twee jaar. *
Aanwezig in VALUE Databank. Bibliografie afgerond op 28 september 2011
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Van de vrouwelijke artsen die jonger waren dan 40 jaar had 14% een mammografie laten maken in het afgelopen jaar, evenals 42% van hen tussen de 40-49 jaar, en 59% van hen tussen 50-70 jaar (Frank). Uit nationaal Noors onderzoek naar zelfonderzoek van de borsten door vrouwelijk artsen tussen 24-67 jaar blijkt dat 30,6% van hen dit onderzoek tenminste één keer per maand uitvoert. 19,2% van de artsen voerde dit onderzoek nooit uit, omdat ze het vergaten te doen, of omdat ze deel uitmaakten van een lage risicogroep of geen symptomen van een ziekte hadden. Overigens ligt het percentage van de vrouwen die minstens één keer per maand zelfonderzoek van de borsten uitvoert significant hoger bij vrouwelijke artsen dan bij andere universitair geschoolde vrouwen (Rosvold).
Screening Uit Turks onderzoek naar gezondheidsmotivatie en borstkanker screening gedrag onder vrouwelijke artsen, verpleegkundigen en verloskundigen, met een gemiddelde leeftijd van 31,3 jaar, blijkt dat 21,9% van hen regelmatig zelfonderzoek van de borsten uitvoert, en dat 12,5% van hen een mammografie had laten maken. Motivatie rond gezondheid en doelmatigheid van zelfonderzoek van de borsten zijn sterker aanwezig bij artsen dan bij verpleegkundigen en vroedvrouwen (Canbulat). Uit Amerikaans onderzoek onder vrouwelijke artsen blijkt dat 21% van hen ten minste één keer per maand zelfonderzoek van de borsten uitvoert. Ongeveer tweederde van hen had een borstonderzoek ondergaan door een arts in het afgelopen jaar en 85% had er een ondergaan in de afgelopen twee jaar. Van de vrouwelijke artsen die jonger waren dan 40 jaar had 14% een mammografie laten maken in het afgelopen jaar, evenals 42% van hen tussen de 40-49 jaar, en 59% van hen tussen 50-70 jaar (Frank). In een Frans onderzoek onder vrouwelijke gynaecologen werd gevraagd naar hun mening omtrent hun bereidheid om een onderzoek te ondergaan naar een mutatie van BRCA1 als ze zelf een familiair risico hadden op borstkanker. Van alle respondenten had 24% een familielid in de eerste graad met borstkanker. De meeste respondenten (87,4%; IC 95%: 81-93,8) zouden vragen om een onderzoek naar een mutatie van BRCA1. Het percentage vrouwen dat de test zou accepteren is kleiner onder de vrouwen die een familielid in de eerste graad hebben met borstkanker (72,0% vs 92,3%; P = 0,02) (Vennin).
Behandeling Wat zouden chirurgen doen als ze zelf worden geconfronteerd met een 2 cm groot invasief mammacarcinoom? Uit een in 2010 gepubliceerd onderzoek onder 107 vrouwelijke plastische en reconstructieve chirurgen blijkt dat 75% van hen eerder zou opteren voor mastectomie dan voor borstsparende chirurgie en bestraling (21%). De meeste (95% ) van hen die voor mastectomie kiezen zouden dan voor reconstructie kiezen. Wat de keuzes rondom reconstructie betreft: 50% zou kiezen voor borstreconstructie met eigen buikweefsel; 26% zou kiezen voor een implantaat; en 19% zou kiezen voor een latissimus dorsi flap. Van degene die voor een implantaat kiezen, zou 64% een siliconenimplantaat kiezen; 9% zou kiezen voor een implantaat met zoutoplossing; en 27% vindt dat beide soorten implantaten even goed zijn. (Al-Benna). Uit onderzoek onder 26 mannelijke en 14 vrouwelijke chirurgen naar welke behandeling zij zouden kiezen als ze zelf of hun partner borstkanker zouden hebben dat nog in een vroeg stadium verkeerde, blijkt dat de helft zou kiezen voor borstsparende chirurgie; de andere helft zou kiezen voor mastectomie. Er was geen verschil tussen de beide sexen (Collins).
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Incidentie / prevalentie 1. Innos, K. et al., "Cancer incidence and cause-specific mortality in male and female physicians: a cohort study in Estonia," Scandinavian Journal of Public Health 30 (2): 133-140 (2002). Abstract: AIMS: To evaluate whether the presumed knowledge of physicians about healthier lifestyle decreases their risk of cancer and mortality, a retrospective cohort study of male and female physicians was conducted in Estonia. METHODS: The cancer incidence and causespecific mortality of 3,673 physicians (870 M, 2,803 F) in Estonia was compared with the rates of the general population. Information on cancer cases and deaths in the cohort between 1983 and 1998 was obtained from the Estonian Cancer Registry and the mortality database of Estonia. RESULTS: The standardized incidence ratio (SIR) for all cancers was 1.32 (95% confidence interval (CI) 1.15-1.48) in women and 0.92 (95% CI 0.73-1.13) in men. Female physicians had an elevated risk for breast cancer (SIR 2.03, 95% CI 1.62-2.51) and myeloid leukaemia (SIR 3.69, 95% CI 1.35-8.02). Male physicians had an excess of skin melanoma (SIR 4.88, 95% CI 1.58-11.38). A large deficit of lung cancer was observed (SIR 0.24, 95% CI 0.110.48). The very low all-cause mortality in the cohort (standardized mortality ratio 0.55, 95% CI 0.50-0.61) was mainly due to large deficits in deaths from lung cancer, cardiovascular diseases and external causes. The suicide rate in the cohort was lower than in the general population. CONCLUSIONS: No health risks were observed in the cohort that could be linked to the occupational exposures of physicians. The pattern of cancer incidence and mortality seen in physicians in Estonia is similar to the pattern seen among professional classes in other countries.
2. Jartti, P. et al., "Cancer incidence among physicians occupationally exposed to ionizing radiation in Finland," Scandinavian Journal of Work, Environment & Health 32 (5): 368-373 (2006). Abstract: OBJECTIVES: Occupational radiation exposure was estimated, and the cancer incidence among physicians working with radiation was compared to that of unexposed physicians. METHODS: A cohort of 1312 physicians was identified from the Finnish occupational radiation exposure registry. Radiation exposure data were obtained from 1970 to 2001 on the basis of individual dosimeters. Never-monitored Finnish physicians (N=15 821) were used as a reference group, identified from census data of Statistics Finland. Incident cancer cases were identified by record linkage with the Finnish Cancer Registry. RESULTS: The cumulative radiation dose exceeded the recording level (0.3-3.0 mSv during a 3-month period for 1029 radiation-exposed physicians (59.8%). Six percent of the radiologists had received a cumulative dose of 50 mSv or more. Altogether there were 41 cancers observed among the radiation-exposed physicians and 998 cases found in the never-monitored group. Standardized incidence ratios (SIR) for all cancers were comparable with those of the general population. among physicians monitored for radiation [SIR 1.0, 95% confidence interval (95% CI) 0.7-1.4] and other physicians (SIR 1.0, 95% CI 1.0-1.1). For specific cancer sites, a slightly elevated risk of female breast cancer was found among monitored physicians when compared with other physicians (rate ratio 1.7, 95% CI 1.0-3.1). No obvious dose-response relationship was found for the overall cancer incidence. CONCLUSIONS: According to the results from a nationwide cohort, occupational exposure to medical radiation is not a strong risk factor for cancer among physicians. Possible excess risk could not be reliably demonstrated even after the follow-up of a nationwide cohort for up to 30 years.
3. Pollan, M. and P. Gustavsson, "High-risk occupations for breast cancer in the Swedish female working population," American Journal of Public Health 89 (6): 875-881 (1999). 3
Abstract: OBJECTIVES: The purpose of this study was to estimate, for the period 1971 through 1989, occupation-specific risks of breast cancer among Swedish women employed in 1970. METHODS: Age-period standardized incidence ratios were computed. Log-linear Poisson models were fitted, with geographical area and town size taken into account. Risks were further adjusted for major occupational group, used as a proxy for socioeconomic status. Risk estimators were also calculated for women reporting the same occupation in 1960 and 1970. RESULTS: Most elevated risks among professionals, managers, and clerks were reduced when intragroup comparisons were carried out, indicating the confounding effect of socioeconomic status. Excess risks were found for pharmacists, teachers of theoretical subjects, schoolmasters, systems analysts and programmers, telephone operators, telegraph and radio operators, metal platers and coaters, and hairdressers and beauticians, as well as for women working in 1960 and 1970 as physicians, religious workers, social workers, bank tellers, cost accountants, and telephonists. CONCLUSIONS: While the high risks observed among professional, administrative, and clerical workers might be related to lower birth rates and increased case detection, excess risks found for telephone workers and for hairdressers and beauticians deserve further attention.
4. Rix, B. A. and E. Lynge, "Cancer incidence in Danish health care workers," Scandinavian Journal of Social Medicine 24 (2): 114-120 (1996). Abstract: Health care workers are exposed to various occupational hazards. In a register linkage study we investigated cancer incidence in health care personnel in Denmark. The overall cancer incidence was elevated in female general and dental practitioners. Male doctors had a risk of brain cancer twice as high as expected. Male dental practitioners, female hospital doctors and nurses had significantly high risks of melanomas of the skin. The breast cancer risk was elevated among female salaried dentists, hospital doctors, and nurses. Female cleaners had a significantly elevated risk of leukemia (31 cases, SIR 1.54). The lung cancer risk was low in several occupational groups. This indicates a change in risk behavior related to tobacco smoking. A high risk of skin melanomas may indicate that behaviour related to sunlight exposure has not changed.
Zelfonderzoek 1. Canbulat, N. and O. Uzun, "Health beliefs and breast cancer screening behaviors among female health workers in Turkey," European .Journal of Oncology Nursing 12 (2): 148-156 (2008). Abstract: The purpose of this study was to evaluate health beliefs and breast cancer screening behaviors in female health workers in Turkey. This descriptive study was conducted in various health centers located in Erzurum, Turkey. The sample consisted of 268 female health workers (physicians, n=51; nurses, n=169; and midwives, n=48). Data were collected by using a selfadministered questionnaire and the Turkish version of Champion's Health Belief Model Scales (CHBMS). The mean age of participants was 31.31 (S.D.=6.89), and 49.9% of them were married. It was found that only 21.9% of the female health workers performed breast selfexamination (BSE) regularly, and 12.5% of them had a mammogram. Physicians' health motivation and BSE self-efficacy perceptions were higher than the nurses and midwives. Susceptibility, health motivation to BSE, BSE benefits, BSE self-efficacy perceptions of female health workers who performed BSE were significantly higher than those who did not, and a result indicating that positive health beliefs are effective in stimulating performance of BSE of female health workers. Among the variables related with mammography, only susceptibility
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perceptions of female health workers who had a mammogram was significantly higher than those who had not had a mammogram.
2. Cavdar, Y. et al., "Determining female physicians' and nurses' practices and attitudes toward breast self-examination in Istanbul, Turkey," Oncology Nursing Forum 34 (6): 1218-1221 (2007). Abstract: PURPOSE/OBJECTIVES: To determine female physicians' and nurses' practices and attitudes toward breast self-examination (BSE). DESIGN: Descriptive, cross-sectional. SETTING: Two large, bed-capacity university hospitals and 11 smaller, bed-capacity public hospitals. SAMPLE: 201 female nurses and 149 female physicians who work day shift on medical and surgical wards. METHODS: Data were collected on a questionnaire form that was prepared based on information in the literature. The questionnaire had three sections: sociodemographic characteristics, health characteristics, and attitudes and practices related to BSE. Data were analyzed using t tests and chi-square tests. MAIN RESEARCH VARIABLES: Attitudes and practices related to BSE, clinical breast examination, and mammography. FINDINGS: Almost all of the female physicians and nurses knew how to conduct BSE but did not prioritize practicing it. CONCLUSIONS: Female physicians and nurses in Istanbul, Turkey, did not take enough care in the proper timing of BSE (i.e., day 5 to day 7 after menstruation with the first day of menstruation being day 1) despite their knowledge about it. IMPLICATIONS FOR NURSING: Female physicians and nurses need to improve their knowledge and sensitivity concerning breast cancer and BSE if they are to improve and maintain their own well-being as well as carry out their professional roles.
3. Frank, E. et al., "U.S. Women Physicians' personal and clinical breast cancer screening practices," Journal of Women’s Health & Gender-based Medicine 9 (7): 791-801 (2000). Abstract: Little is known about predictors of physicians' personal or clinical compliance with breast cancer screening recommendations. We explored this in 4501 respondents to the Women Physicians' Health Study, a questionnaire-based study of a representative sample of U.S. women M. D.s. Overall, 21% of women physicians performed breast self-examination (BSE) at least monthly, about two thirds had received a clinical breast examination (CBE) within the last year, and 85% had received one within the last 2 years. Of those <40 years old, 14% had received a mammogram in the past year, as had 42% of those 40-49 and 59% of those 50-70 years old. Being a primary care practitioners or obstetrician/gynecologist was a significant predictor of counseling or screening for CBE and mammography. Only 46% of all women physicians reported discussing or performing mammograms at least once a year for those >/=50-
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4. Rosvold, E. O. et al., "Breast self-examination and cervical cancer testing among Norwegian female physicians. A nation-wide comparative study," Social Science & Medicine 52 (2): 249258 (2001). Abstract: Practice of breast self-examination (BSE) and cervical cancer testing (Pap smear tests) was studied in a nation-wide Norwegian representative sample of 284 female physicians aged 24-67. BSE was performed at least once a month in 30.6% of the cases, and 54.6% had a Pap smear test once every third year at least. BSE was never practised among 19.2% of the physicians, the main reasons being that they forgot it, or that they stated that they were in a low risk group or had no symptoms of disease. 16.2% had never had routine Pap smears, and these physicians claimed that they were in a low risk group or had no symptoms of disease, that they had a problem in finding a physician to attend, or that they forgot to take the test. A subgroup of 135 physicians aged 35-49 years was compared with 738 women with higher university education included from a nation-wide representative sample of the general population of Norway. A significantly higher percentage of physicians practised BSE monthly or more often compared with other university educated women. However, a significantly lower percentage of the physicians had Pap smear tests every third year or more frequently. The positive association between being a physician and practising BSE, and the negative association between being a physician and having Pap smear tests, remained after controlling for potential confounders in multivariate analyses.
Screening 1. Canbulat, N. and O. Uzun, "Health beliefs and breast cancer screening behaviors among female health workers in Turkey," European .Journal of Oncology Nursing 12 (2): 148-156 (2008). Abstract: The purpose of this study was to evaluate health beliefs and breast cancer screening behaviors in female health workers in Turkey. This descriptive study was conducted in various health centers located in Erzurum, Turkey. The sample consisted of 268 female health workers (physicians, n=51; nurses, n=169; and midwives, n=48). Data were collected by using a selfadministered questionnaire and the Turkish version of Champion's Health Belief Model Scales (CHBMS). The mean age of participants was 31.31 (S.D.=6.89), and 49.9% of them were married. It was found that only 21.9% of the female health workers performed breast selfexamination (BSE) regularly, and 12.5% of them had a mammogram. Physicians' health motivation and BSE self-efficacy perceptions were higher than the nurses and midwives. Susceptibility, health motivation to BSE, BSE benefits, BSE self-efficacy perceptions of female health workers who performed BSE were significantly higher than those who did not, and a result indicating that positive health beliefs are effective in stimulating performance of BSE of female health workers. Among the variables related with mammography, only susceptibility perceptions of female health workers who had a mammogram was significantly higher than those who had not had a mammogram.
2. Frank, E. et al., "U.S. Women Physicians' personal and clinical breast cancer screening practices," Journal of Women’s Health & Gender-based Medicine 9 (7): 791-801 (2000). Abstract: Little is known about predictors of physicians' personal or clinical compliance with breast cancer screening recommendations. We explored this in 4501 respondents to the Women Physicians' Health Study, a questionnaire-based study of a representative sample of U.S. women M. D.s. Overall, 21% of women physicians performed breast self-examination (BSE) at least monthly, about two thirds had received a clinical breast examination (CBE) within the last year, 6
and 85% had received one within the last 2 years. Of those <40 years old, 14% had received a mammogram in the past year, as had 42% of those 40-49 and 59% of those 50-70 years old. Being a primary care practitioners or obstetrician/gynecologist was a significant predictor of counseling or screening for CBE and mammography. Only 46% of all women physicians reported discussing or performing mammograms at least once a year for those >/=50-
3. Vennin, P. et al., "[Attitudes towards screening and prevention of breast and ovarian cancers with hereditary predisposition. Survey by female gynecologists in the north of France]," Bulletin du Cancer 83 (9): 697-702 (1996). Abstract: Search for mutations of BRCA1 in women at hereditary risk for cancer is now possible. We asked the female gynaecologists of our county (north of France) their opinion about the search of a mutation of BRCA1 if they had a familial risk of breast cancer. Our aim was to obtain the opinion of informed women about their willingness to do the test for themselves and about the consequences they should accept. One hundred and eighty-three women received a questionnaire by post. The response rate was 56.3%. Twenty-four percent of the responders had a first degree relative with breast cancer. Most of the responders (87.4%; IC 95%: 81-93.8) would ask for the search of a mutation of BRCA1. The percentage of women who would accept the test is smaller for the women who have a first degree relative with breast cancer (72.0% vs 92.3%; P = 0.02). The reasons given to do the test were a better screening or prevention (69.7%) and the knowledge of a personal risk (49.4%). For breast cancer, 93.2% (95% CI: 88.4-98) would accept a screening protocol, 30.1% (CI: 21.3-38.9) would accept a prophylactic bilateral mastectomy. For ovarian cancer, 93.2% (CI: 88.4-98) would accept the screening, 52.4% (CI: 42.8-62) would accept a prophylactic ovariectomy. In conclusion, most of the informed women would ask for the test and the surgical options for reducing the risk of cancer are not absolutely rejected. Of course, only future studies will state precisely the choice of truly implicated women.
Behandeling 1. Al-Benna, S., "Female plastic and reconstructive surgeons' personal decision making for breast cancer treatment and reconstruction," Archives of gynecology and obstetrics (2010). Abstract: INTRODUCTION: No original articles have been published exploring female surgeons' preferences for breast cancer treatment and reconstruction if they were to be diagnosed with breast cancer. MATERIALS AND METHODS: 107 female breast plastic and reconstructive surgeons were surveyed as to the methods of breast cancer treatment and reconstruction they would opt for if they were diagnosed with a 2 cm invasive breast carcinoma. RESULTS: 75% stated that they would opt for mastectomy rather than undergo breast conserving surgery and radiation (21%). Most (95%) of those choosing a mastectomy would opt for reconstruction. For reconstruction choices, 50% of those surveyed would have autologous 7
breast reconstruction with abdominal tissue (38% deep inferior epigastric perforator flap; 12% transverse rectus abdominis muscle flap). 26% would choose tissue expansion with implant and 19% would opt for a latissimus dorsi flap. For those choosing tissue expansion with implant reconstruction 64% would choose a silicone implant, 9% would choose a saline implant and 27% felt either type of implant would be acceptable. For those choosing latissimus dorsi flap with implant reconstruction, 69% would choose a silicone implant, 13% would choose a saline implant and 19% felt either type of implant would be acceptable. DISCUSSION: Female surgeons offer an exclusive insight into surgical outcomes following breast cancer therapy and reconstruction. This study suggests that due to their clinical experiences they have knowledge as to outcomes and consequences of breast cancer treatment and reconstruction and their choices do not always adhere to current guidelines.
2. Collins, E. D., C. L. Kerrigan, and P. Anglade, "Surgical treatment of early breast cancer: what would surgeons choose for themselves?," Effective Clinical Practice : ECP 2 (4): 149-151 (1999). Abstract: CONTEXT: Although breast-conserving surgery (BCS) is less invasive than mastectomy and results in similar survival, many women eligible for BCS continue to undergo mastectomy. Whether the persistent use of mastectomy means that women do not understand their options or reflects an informed preference is unknown. OBJECTIVE: To learn which treatment surgeons would choose when asked to imagine that they themselves had early-stage breast cancer. DESIGN: Cross-sectional survey. SAMPLE: Convenience sample of 40 staff and resident surgeons attending surgical grand rounds at Dartmouth-Hitchcock Medical Center in 1998. MAIN OUTCOME MEASURE: Choice of BCS or mastectomy for the treatment of stage I breast cancer. RESULTS: Twenty-six male and 14 female surgeons participated in the survey. Half chose BCS and half chose mastectomy for treatment of their hypothetical early-stage breast cancer. Results did not differ by the sex of the surgeon. CONCLUSION: Even after being reminded of the equivalent 10-year survival statistics, half of the surgeons surveyed said that they would choose mastectomy over BCS for themselves. The assumption that BCS is the "right" choice for early-stage breast cancer may be unwarranted because many patients may have an informed preference for mastectomy.
Persoonlijke verhalen 1. Bemman, K. et al., "Tales from the front: when the doctor gets breast cancer," Journal of the American Medical Women’s Association. 47 (5): 210-212 (1992). 2. Boiron, C. E. M. and C. Boiron, "The experiences of a cancer specialist. [French]," PsychoOncologie .3 (3) (2009). 3. Filipovic, S., "An oncologist's perspective on having breast cancer," Advances in Breast Cancer 6 (2): 7-8 (2009). 4. Hugi, M., "Surviving breast cancer. An emergency physician faces the fight of her life," CMAJ. 156 (3): 397-399 (1997). 5. Kaelin, C., "When a breast cancer expert gets breast cancer. An interview with Harvard breast cancer surgeon Dr. Carolyn Kaelin," Harvard Women’s Health Watch 12 (8): 4-6 (2005).
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6. Mariano, N. A., "I thought I understood breast cancer," Medical Economics 81 (7): 47-49 (2004). 7. Milroy, M. J., "A doctor's story," South Dakota Medicine 59 (1): 22 (2006). 8. Poulson, J., "The days that will still be mine," CMAJ. 158 (12): 1633-1636 (1998). 9. Taylor, P. F., "A physician perspective: belonging to that "special club"," The West Virginia Medical Journal 105 Spec No: 40-41 (2009). 10. Thomas, H., "On living with cancer," The Health Service Journal 116 (6011): 29 (2006).
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