ORIGINAL ARTICLE
High level of unmet needs and anxiety are associated with delayed
initiation of adjuvant chemotherapy for colorectal cancer patients
Li Zhu
1
& Yi Xin Tong
1
& Xiang Shang Xu
1
& Ai Tang Xiao
1
& Yu Jie Zhang
1
& Sheng Zhang
1
Received: 22 October 2019 / Accepted: 28 January 2020
#
The Author(s) 2020
Abstract
Aims Adjuvant chemotherapy is recommended for patients with curatively resected colorectal cancer. The aim of this study is to
evaluate the impact of unmet supportive care needs and anxiety on the initiation of postoperative adjuvant chemotherapy in
colorectal cancer patients.
Methods This is a retrospective study from a single tertiary referral hospital. Patients diagnosed with colorectal cancer who met
the inclusion criteria were included. The Hospital Anxiety and Depression Scale (HADS) and modified 34-item Supportive Care
Needs Survey (SCNS-SF34) were applied to assess patients anxiety level and unmet needs. The time intervals between initiation
of adjuvant chemotherapy and operation were recorded. Factors associated with delayed initiation of chemotherapy were
investigated in univariate and multivariate analysis.
Results A total of 135 patients with colorectal cancer were included. In total, 16.3% (22/135) and 5.2% (7/135) reported
symptoms of anxiety and depression. In multivariate analysis, low to moderate income status, postoperative complications,
anxiety, and high level of unmet needs are independent risk factors for late initiation of chemotherapy.
Conclusions Our findings showed that psychological problems such as anxiety and high unmet supportive needs are correlated
with delayed initiation of adjuvant chemotherapy in colorectal cancer patients.
Keywords Colorectal cancer
.
Adjuvant chemotherapy
.
Delay initiation of chemot herapy
.
Patientsneeds
.
Anxiety
.
Depression
.
SCNS-SF34
Introduction
Colorectal cancer (CRC) is the third most common cancer and
the fourth leading cause of c ancer death in the world [1].
Surgery together with adjuvant chemotherapy (AC) remains
the standard treatment for stage III colorectal cancer patients
and selected stag e II patients [ 2 4]. The recently updated
National Comprehensive Cancer Network (NCCN) guidelines
suggested that the optimal timing to initiate postoperative ad-
juvant chemotherapies should be in/between 4 and 8 weeks
after operations [5]. A systematic and meta-analysis involving
15,410 colorectal patients demonstrated that a 4-week incre-
ment in time to adjuvant chemotherapy was associated with a
14% decrease in both overall survival (OS) and disease-free
survival (DFS) [6]. Another two large-scale retrospective
studies from the US and Netherlands National Cancer
Database also showed that a delay of 68 weeks between
surgery and adjuvant therapy would reduce survival in stage
II and III colorectal cancer patients [7, 8].
Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s00520-020-05333-z) contains supplementary
material, which is available to authorized users.
* Sheng Zhang
szhang5@tulane.edu
Li Zhu
125683844@qq.com
Yi Xin Tong
yx_tong@126.com
Xiang Shang Xu
xsxu@tjh.tjmu.edu.cn
Ai T ang Xiao
pekjean@126.com
Yu Jie Zhang
1179204979@qq.com
1
Department of Gastrointestinal Surgery, Tongji Hospital, Tongji
Medical College, Huazhong University of Science and Technology,
Jie Fang Ave, No, Wuhan 1095, China
Supportive Care in Cancer
https://doi.org/10.1007/s00520-020-05333-z
Multiple factors including patient demographics, advanced
clinical stage, surgical techniques, and postoperative compli-
cations may correlate with the delay initiation of adjuvant
chemotherapy [9, 10]. The lack of relevant knowledge may
lead to patients distress and decease compliance to postoper-
ative chemotherapy [11]. Many reports indicated that individ-
ualized cancer patients suffer from emotional disorders includ-
ing anxiety and depression, which may compromise the effect
of treatments [12]. Meanwhile, high level of unmet supportive
care needs is prevalent among cancer survivors which may
have a negative impact on clinical management [13].
The impact of patients psychological status and level of
unmet needs on the start time of adjuvant chemotherapy has
not been studied. This study focuses on exploring clinical and
psychological factors associated with delayed initiation of ad-
juvant chemotherapy. We hypothesize that high level of anx-
iety and unmet supportive needs may lead to a delayed com-
mencement of postoperative adjuvant chemotherapy in colo-
rectal cancer patients.
Method
Study design and participants
In a single tertiary referral hospital, data from patients with
colorectal cancer who underwent adjuvant chemotherapy be-
tween April 2017 and November 2018 were retrospectively
collected and analyzed. Patients aged over 18 years who met
the following inclusion criteria were recruited in the study: (1)
histopathologically confirmed diagnosis of colorectal cancer
(sites of the original were classified as colon and rectum); (2)
are aware they will receive adjuvant chemotherapy and can
communicate with our medical professional team. The exclu-
sion criteria were (1) diagnosis of other malignancies; (2) pa-
tients already received neoadjuvant therapy; (3) plan to re-
ceive adjuvant chemotherapy in other hospitals; (4) with con-
current psychiatric disorder or other mental problems and fail
to communicate with our team members. Ethical approval for
the study was obtained from the institutional medical ethics
committee. Informed consent was signed by all participants.
Data collection
The following information was collected for analysis: (1) de-
mographic characteristics such as age, gender, education sta-
tus, socioeconomic status, patients performance status (ac-
cording to classification of the Eastern Cooperative
Oncology group) [14], and site of origin; (2) clinical or labo-
ratory characteristics such as neutrophil to lymphocyte ratio
(NLR), serum tumor markers as carcinoembryonic antigen
(CEA) and carbohydrate antigen 19-9 (CA19-9), tumor size,
differentiation, invasion depth (T), presence of lymph node
metastases (N), presence of distant metastases (M), treatment,
and surgical approach; (3) postoperative information such as
postoperative complication (according to the Clavien-Dindo
criteria [15]), length of stay, readmission, types of adjuvant
chemotherapy, and initiation timing of chemotherapy.
Anxiety/depression and supportive needs
measurement
Hospital Anxiety and Depression Scale (HADS) was applied
to assess self-reported symptoms of anxiety and depression.
The HADS consists of 14 items: 7 for anxiety and 7 for de-
pression. Participants answered the questions on a 4-point
Likert scale. The total score for each scale ranges from 0 to
21. The cut-off value for definite cases of anxiety and depres-
sion is a score 11 [16, 17]. Supportive care needs for cancer
patients were measured by the modified 34-item Supportive
Care Needs Survey (SCNS-SF34). The modified version was
adapted from the validated mandarin version of SCNS-SF34
with questions chosen from item 214, 17, 2026, 28, and 29
[18]. We add 12 items specifically concerning relevant needs
for chemotherapy to the modified version of SCNS-SF34. The
modified SCNS-SF34 assesses cancer patients needs in five
domains: physical and daily living (4 items), psychological
(10 items), patient care and support (6 items), health systems
and information (7 items), and chemotherapy (7 items)
(Supplemental Table 1). Participants will indicate their level
of need for the help for each item on a 5-point Likert scale: 1 =
no need, not applicable; 2 = no need, satisfied; 3 = low need;
4 = moderate need; 5 = high need. A standardized Likert-
summated score for each item ranging from 0 to 100 was
calculated, with higher scores representing higher levels of
need for help [18].
The Chinese version of HADS and modified SCNS-SF34
questionnair es were distributed to recruited participants in
48 h after administration. Two colorectal surgeons conducted
the communication and explanation for patients with difficul-
ties in understanding the items in each questionnaire. We col-
lected all the questionnaires before discharge of the patients.
Outcomes and follow-up
The primary endpoint of this study was the starting time of
postoperative adjuvant chemotherapy. The secondary end-
point was the completion time and rate of adjuvant chemo-
therapy. We also evaluated the factors associated with delayed
initiation of AC using multivariable analysis. We defined ear-
ly initiation as the initiation of AC < 4 weeks and delayed
initiation as the initiation of AC 8 weeks. The total follow-
up period is 12 months. This study was approved by the ethics
committees of Tongji hospital. The purpose and content of the
study were explained to t he participants. All participants
signed the informed consent and confidentiality was assured.
Support Care Cancer
Statistical analyses
All continuous variables were presented as medians
(range) and analyzed with the chi-square test or Mann-
Whitney U test. Categorical variables were reported as
whole numb ers an d per cent ages. The receiv er ope ration
curve (ROC curve) method w as used to det ermine the
cut-off value of modified SCNS-SF34 score as low need
and high need. The Kaplan-Meier method was used to
evaluate potential predictive factors for delayed initiation
of adjuvant chemotherapy. Only factors with p value < 0.1
in univariate analysis were included in the final multivar-
iate analysis model. M ultivariate Cox regression was
employed to identify indepe ndent predic tive fac tors for
delayed initiation of chemotherapy. All statistical tests
were performed in the SPSS version 21 (IBM, Armonk,
NY, USA) with a significance level of p va l ue < 0.05 .
Results
Patient baseline and clinicopathological
characteristics
One hundred fifty-three patients were recruited and consid-
ered eligible for this study. After screening based on inclu-
sion and exclusion criteria, 135 patients were successfully
followed up and included i n final study. The median age of
included patients was 55.00 ± 9.73 and most patients were
men (100/135, 74.1%). A total of 73.3% (99/135) patients
were dia gnosed with rec tum cancer an d 26.7% (36 /135)
were colon cancer. All patients underwent laparoscopic
operati on a nd 1 3. 3% ( 18/ 1 35 ) of t hem w er e co n ver te d to
open operation. In total, 4.4% (6/135) patients suffered
from grade 3 postoperative complications and the median
hospital stay is 16 ± 4.7 days. The median time between
adjuvant chemotherapy and operation was 28 ± 14.9 days.
The proportions of patients receiving AC within 4 weeks
and 8 weeks were 59.3% (80/135) and 94.1% (127/135),
respectively. A total of 73.3% (99/135) completed full cy-
cles of adjuvant chemotherapy. Other information was
summarized in Table 1.
Prevalence of anxiety, depression, and supportive
care needs
Among 135 c olorectal cancer patie nts, 16.3% (22/135)
and 5.2% (7/135) reported symptoms of anxiety and de-
pression (HADS-anxiety or HADS-depression score 11)
(Table 2). The average SCNS-SF34 standardized score of
the patients was 54.2 ± 7.3. Half of the top 10 needs items
were from the chemotherapy-related domain, two were
from the patient care and support domain, and other three
Table 1 The demographic and clinicopathological characteristics of
patient
Variable Total (n =135)
Baseline characteristics
Age, median (IQR), year 55.00 ± 9.73
Gender
Male
Female
74.1% (100/135)
25.9% (35/135)
ECOG status
0
1
8.1% (11/135)
91.9% (124/135)
Education
Illiterate/primary school
High school/undergraduate
26.7% (36/135)
73.3% (99/135)
Socioeconomic status
Low to moderate income
High income
78.5% (106/135)
21.5% (29/135)
Smoking
Yes
No
30.4% (41/135)
69.6% (94/135)
Alcohol
Yes
No
25.9% (35/135)
74.1% (100/135)
Clinicopathological parameters
Location
Colon
Rectum
26.7% (36/135)
73.3% (99/135)
T stage (pT)
T1
T2
T3
T4
0.7% (1/135)
15.6% (21/135)
55.6% (75/135)
28.1% (38/135)
N stage (pN)
N0
N1
N2
55.6% (75/135)
29.6% (40/135)
14.8% (20/135)
Tumor size (IQR) cm 3.80 ± 1.30
Differentiation
Well
Medium
Poor
9.6% (13/135)
63.7% (86/135)
26.7% (36/135)
Blood NLR (IQR) 2.41 ± 1.75
Serum CEA
Normal
Elevated
73.3% (99/135)
26.7% (36/135)
Serum CA19-9
Normal
Elevated
84.4% (114/135)
15.6% (21/135)
Operation
Laparoscopic
Conversion to laparotomy
86.7% (117/135)
13.3% (18/135)
Postoperative parameters
Complication
No
Grades 1 and 2
86.7% (117/135)
8.9% (12/135)
Support Care Cancer
are of physical and daily living, psychological and health
system, and information domain, respectively. The t en
most frequently reported common unmet needs were
listed in Table 3. Compared with patients with low unm et
needs, patients with higher unmet needs showed signifi-
cant lower percentage of early initiation of AC < 4 w eeks
(25.9% vs 81.5%) and higher percentage of delayed initi-
ation of AC 8weeks(14.8%vs0%).
Factors associated with the timing to adjuvant
chemotherapy
Risk factors identified f rom univariate analysis were
showninTables4 and 5. Kaplan-Meier analysis showed
that socioeconomic status, serum CEA, postoperative
complications, HADS-anxiety status, HADS-depression
status, and SCNS-SF34 score were significantly associat-
ed with early initiation (< 4 weeks) and delayed initiation
( 8 weeks) of adjuvant chemotherapy.
In the multivariate analysis, socioeconomic status, postop-
erative complications, HADS-anxiety status, and high unmet
supportive needs were identified as independent prognostic
factors associated with early initiation and delayed initiation
of adjuvant chemotherapy. For early initiation of chemother-
apy, high income (p = 0.012), no anxiety (p =0.009),andlow
unmet needs (p < 0.001) were significantly associated with
early initiation of AC. For delayed chemotherapy 8weeks,
low to moderate income (HR = 2.159, p = 0.001), presence of
postoperative complications (HR = 2.263, p = 0.006), and
high unmet needs (HR = 2.905, p < 0.001) were independent
risk factors. The details of multivariate analysis were listed in
Tables 4 and 5.
Conclusions
Discussion of the results
A retrospective study was performed to evaluate clinical char-
acteristics as well as psychological factors related to early and
delayed initiation of adjuvant chemotherapy in colorectal can-
cer patients. Our results demonstrated that low unmet needs
status is significantly correlated with early initiation of AC
(HR = 4.162) while high unmet supportive needs is an inde-
pendent risk factor for delayed initiation AC (HR = 2.905). In
addition, high-income status (HR = 1.880) and no anxiety sta-
tus (HR = 3.881) are correlated with early initiation of AC. A
low to moderate income status (HR = 2.159) and presence of
postoperative complication (HR = 2.263) are independent risk
factors for delayed initiation of AC.
The initiation of chemotherapy treatment may have impact
on patients psychological and physical states. Smooth transi-
tion to postoperative adjuvant chemotherapy is critical in co-
lorectal cancer treatment. Although currently there is no con-
sensus on the exact time to initiate adjuvant chemotherapy, it
is generally agreed that the start time of chemotherapy should
be no later than 8 weeks after operation [59]. The potential
reasons for the delay of chemotherapy generally lie in the
following aspects: patient-related factors such as lower socio-
economic status, female gender, and older age; treatment-
related factors such as postoperative complications, surgical
approach (open vs laparoscopic), and chemotherapy reagents;
Table 2 The prevalence of anxiety and depression and supportive needs
of patient
Variable Total (n =135)
Anxiety and depression
HADS-anxiety score
<8
810
11
61.5% (83/135)
22.2% (30/135)
16.3% (22/135)
HADS-depression score
<8
810
11
72.6% (98/135)
22.2% (30/135)
5.2% (7/135)
SCNS-SF34 standardized score 54.2 ± 7.3
Low need (SCNS-SF34 score < 56)
High need (SCNS-SF34 score 56)
60.0% (81/135)
40.0% (54/135)
HADS, Hospital Anxiety and Depression Scale; SCNS-SF34, 34-item
Supportive Care Needs Survey
Table 1 (continued)
Variable Total (n =135)
Grade 3 4.4% (6/135)
Hospital stay, median, days 16 ± 4.7
Time between AC and operation, median, days 28 ± 14.9
AC within 4 weeks
Yes
No
59.3% (80/135)
40.7% (55/135)
AC within 8 weeks
Yes
No
94.1% (127/135)
5.9% (8/135)
AC regimen
CapeOX
SOX
Capecitabine/S-1
FOLFOX6
Other
83.0% (112/135)
8.1% (11/135)
3.7% (5/135)
3.0% (4/135)
2.2% (3/135)
AC complete rate
Yes
No
73.3% (99/135)
26.7% (36/135)
CI, confidence interval; IQR, interquartile range; EC OG,Eastern
Cooperative Oncology group; CEA, carcinoembryonic antigen; CA19-9,
carbohydrate antigen; NLR, neutrophil to lymphocyte ratio; AC, adjuvant
chemotherapy
Support Care Cancer
Table 3 Ten most frequently reported unmet needs (modified SCNS 34)
Rank Modified SCNS-SF34 item Domain Average score N (%) of unmet
needs
1 Item 29, being informed the reason to receive chemotherapy after surgery
and common side effects
Chemotherapy 73.6 ± 23.8 113/135 (85.7%)
2 Item 31, the common side effects of chemotherapy and how to handle them Chemotherapy 73.4 ± 25.0 105/135 (77.8%)
3 Item 8, fears about the cancer spreading Psychological 70.2 ± 25.6 104/135 (77.0%)
4 Item 28, being informed about the foods for recovery and foods to avoid Chemotherapy 68.8 ± 23. 2 104/135 (77.0%)
5 Item 27, being informed about things you can do to help yourself to get well Health system and
information
68.2 ± 26.8 96/135 (71.1%)
6 Item 30, the time to start chemotherapy and how many cycles to receive Chemotherapy 68.2 ± 27.4 96/135 (71.1%)
7 Item 20, cost of surgery and chemotherapy Patient care and support 67.8 ± 27.2 98/135 (72.6%)
8 Item 18, financial support and insurance coverage for my disease and treatment Patient care and support 66.6 ± 27.8 96/135 (71.1%)
9 Item 4, not being able to do the things you used to do Physical and daily living 64.8 ± 26.6 95/135 (70.4%)
10 Item 32, emotional scared of chemotherapy Chemotherapy 64.8 ± 27.8 94/135 (69.6%)
SCNS-SF34, 34-item Supportive Care Needs Survey
Table 4 Univariate and
multivariate analysis for factors
effecting early initiation (<
4 weeks) of AC
Variables Univariate HR p value Multivariate HR p value
Age
75
<75
1(Ref)
1.176 0.625
NS
Socioeconomic status
Low to moderate income
High income
1(Ref)
2.389 < 0.001
1(Ref)
1.880 0.012
Education
Illiterate/primary school High school/undergraduate 1 (Ref)
1.318 0.294
NS
Cancer TYPE
Rectal
Colon
1(Ref)
1.332 0.236
NS
Serum CEA
Elevated
Normal
1(Ref)
1.475 0.156
NS
Serum NLR
2.4
<2.4
1(Ref)
1.366 0.221
NS
Complication
Yes
No
1(Ref)
3.807 0.009
NS
HADS-anxiety
Yes ( 11)
No (< 11)
1(Ref)
5.081 0.020
1(Ref)
3.881 0.009
HADS-depression
Yes ( 11)
No (< 11)
1(Ref)
5.866 0.079
NS
SCNS-SF34 score
High need
Low need
1(Ref)
4.577 < 0.001
1(Ref)
4.162 < 0.001
HR, hazard ratio; CEA, carcinoembryonic antigen; AC, adjuvant chemotherapy; NLR, neutrophil to lymphocyte
ratio; NS, not significant
Support Care Cancer
social and psychological factors such as lack of insurance,
lack of social support, and insufficient knowledge on chemo-
therapy [10, 1922]. In our study, we found that low income
status and postoperative complications negatively correlated
with the initiation of chemotherapy in colorectal cancer pa-
tients, whi ch is in accordance wi th the present reports. In
addition, we for the first time explored and demonstrated that
anxiety status and high unmet needs may also correlate with
the initiation time of chemotherapy.
Studies have also shown t hat most cancer patients ex-
perience certain level of emotional distress such as anxi-
ety and d e pr es si on [23]. It has been reported that the psy-
chological problems such as anxiety and depression may
lead to negative outcome in cancer perioperative treatment
such as decreased adherence to oral chemotherapy [24].
Meanwhile, cancer patients suffered from various physical
and psychological needs when they started chemotherapy
[25]. Advanced stage, higher levels of distress, younger
age, and woman gender are some predictors for higher
level of supportive needs [26]. In our study, we found that
colorectal cancer patients experience certain level of anx-
iety (16.3%) and depression (5.2%). Patients without anx-
iety tend to start AC w ithin 4 we eks (HR = 3.881) . It
could be reasonable that patients suffered from anxiety
may be afraid of postoperative chemotherapy and l ead to
the early delayed initiation. In addition, we also explored
the prevalence of unmet supportive needs of colorectal
cancer patients with modified SCNS-SF34 (simplified
Chinese version) [18]. Our results supported our hypoth-
esis that higher u nmet needs status is a risk fac tor for
delayed initiation of postoperative chemotherapy.
Although previous studies showed t hat the perceived un-
met needs of cancer patients are associated with poor psy-
chological status and lower quality of life [27], our study
for the first time showed that higher unmet needs post-
poned the initiation of postoperative chemotherapy.
Table 5 Univariate and
multivariate analysis for factors
effecting delayed initiation (
8 weeks) of AC
Variables Univariate HR p value Multivariate HR p value
Age
<75
75
1(Ref)
0.932 0.798
NS
Socioeconomic status
High income
Low to moderate income
1(Ref)
1.979 0.002
1(Ref)
2.159 0.001
Education
High school/undergraduate
Illiterate/primary school
1(Ref)
1.136 0.526
NS
Cancer type
Colon
Rectal
1(Ref)
1.014 0.944
NS
Serum CEA
Normal
Elevated
1(Ref)
1.376 0.118
NS
Serum NLR
<2.4
2.4
1(Ref)
1.131 0.527
NS
Complication
No
Yes
1(Ref)
2.451 0.002
1(Ref)
2.263 0.006
HADS-anxiety
No (< 11)
Yes ( 11)
1(Ref)
2.046 0.004
NS
HADS-depression
No (< 11)
Yes ( 11)
1(Ref)
2.984 0.017
NS
SCNS-SF34 score
Low need
High need
1(Ref)
3.182 < 0.001
1(Ref)
2.905 < 0.001
HR, hazard ratio; CEA, carcinoembryonic antigen; AC, adjuvant chemotherapy; NLR, neutrophil to lymphocyte
ratio; NS, not significant
Support Care Cancer
It has been estimated that up to 50% of patients may expe-
rience a variety of physical and psychological disorders after
diagnosis of cancer and during chemotherapy [28, 29]. Our
results indicated that cancer patients experienced high level of
unmet needs and may need support and practical help in the
management of chemotherapy. Adjuvant chemotherapy is the
standard treatment for stage III colorectal cancer patients after
curative operation. There are few reports that have studied the
techniques for improvement of chemotherapy adherence in
patients with colorectal cancer. Furthermore, previous studies
failed to prove the effectiveness of interventions in reducing
the unmet needs in cancer patients [30]. In our study, there are
a rather large proportion of patients with low education
(26.7% illiterate/primary school) that might have certain bias
in the questionnaires and might impede future educational
intervention. Literatures reported that the proportion of low
educational level (illiterate/primary school) of cancer patients
in China varies from 20 to 50% [3134], which is in accor-
dance with our study. The educational level of cancer patients
in China is generally in low level compared with that in de-
veloped countries. Therefore, personalized education and
family member support program may be beneficial for colo-
rectal cancer patients to a better management and adherence of
adjuvant chemotherapy.
Limitations
The present study has several limitations that should be taken
into consideration. First, a relatively small number of patients
were included in this study. Second, due to the retrospective
setting, our study might inevitably have selection bias and
some data might be missing. Third, we need further verifica-
tion of the reliability of the modified SCNS-SF34 scale. In
addition, information of outcome measurements, such as qual-
ity of life, patients satisfaction, and patient-reported adher-
ence, were not evaluated in our study. Therefore, further per-
spective study with a larger sample size and more outcome
measurements are needed to validate the finding of our study
and further explore the effectiveness of individualized patient
education program.
Conclusion and clinical implications
Despite the limitations mentioned above, there are still
many valuable implications of this retrospective study.
First, to the best of our knowledge, our study f or the first
time indicated that high level of unmet needs and anxiety
contributed to delayed initiation of adjuvant chemotherapy
in pati ents with col orectal cancer. Second, our findings
suggested that individualized education program to relieve
patients anxiety and improve unmet needs might be effec-
tive in improving chemotherapy initiation and adherence.
Based on our results and limitations, we hypothesized that
cancer patients unmet need would have negative impact
on chemotherapy adherence. Furthermore, we will further
confirm the conclusion in a future w ell-designed random-
ized controlled trial and investigate various interventi ons
to enhance patients adherence in chemotherapy.
Acknowledgments The authors thank Ms. Cheng Chen for English
grammatical correction of this manuscript.
Author contributions All authors participated in the study design. All
authors have agreed on the final version and meet the major criteria
recommended by the ICMJE (http://www.icmje.org/). In detail, Li Zhu
conceptually designed the study and wrote the draft. Yi Xin Tong and
Xiang Shang Xu collected the relevant data and followed up the patients.
Ai Tang Xiao and Yu Jie Zhang performed stati stical analysis and
interpretation of the data. Sheng Zhang revised the manuscript and final
approval.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval This study was approved by the ethics committee of
Tongji Hospital, Tongji Medical College, Huazhong University of
Science and Technology.
Open Access This article is licensed under a Creative Commons
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