Exercise Recommendation for People With Bone Metastases: Expert Consensus for Health Care Providers and Exercise Professionals.

INTRODUCTION

People living with advanced or incurable cancers are treated with sequential cancer therapies to improve survival and quality of life, but treatment burden can be high, including fatigue, reduced physical function, and psychosocial morbidity. 1 In this context, people with advanced or incurable cancer highlight that maintaining functional independence and managing symptom burden are top priorities. 2 , 3

Exercise (ie, planned and structured physical activity aimed to improve health) has been shown to improve fatigue, physical function, and psychosocial morbidity in people with early-stage cancers. 4 In the advanced or incurable cancer setting, the presence of bone metastases complicates prescribing exercise and promoting physical activity because of concerns about potential skeletal complications such as pathologic fracture, hypercalcemia, or spinal cord compression. 5 Although people with bone metastases regularly express an interest in information on exercise, 6 - 8 health care professionals report uncertainties regarding risk management. 9 - 11 Recent systematic reviews in advanced or incurable cancer generally show exercise to be safe, feasible, and beneficial for quality of life, physical function, and fatigue. 12 - 18 However, these systematic reviews have not focused specifically on the safety or efficacy of exercise for people with bone metastases.

The International Bone Metastases Exercise Working Group (IBMEWG) was formed on the basis of the recognition that people with bone metastases could potentially benefit from exercise and are not receiving direction from the health care team, as they may be reticent because of lack of guidance in the literature or clinical practice. This group aimed to develop best practice recommendations on the basis of existing research evidence, clinical experience, and expert opinion.

METHODS

The IBMEWG is a multidisciplinary, international panel of physicians, physical therapists, clinical exercise physiologists, and researchers. Sequential steps (Fig 1 ) were taken to inform the recommendations: (1) modified Delphi survey to ascertain the practical considerations of implementing exercise for people with bone metastases in the outpatient oncology setting 19 (all participants provided informed consent, Research Ethics Board approval, University of British Columbia; H19-00379); (2) systematic review to assess the safety, feasibility, and efficacy of exercise in controlled trials that included people with bone metastases (International Prospective Register of Systematic Reviews: CRD42019121958) 20 ; (3) cross-sectional survey to physicians and nurse practitioners to understand the attitudes toward exercise for people with bone metastases and components required to promote exercise referral 21 (all participants provided informed consent, Research Ethics Board approval, University of British Columbia; H19-00379); (4) in-person meeting of IBMEWG to review evidence from steps 1-3 to develop recommendations; and (5) stakeholder engagement , first with people with bone metastases (draft recommendations) and second with clinician peers (penultimate recommendations).

RESULTS

Recommendation 1

Before exercise testing or training, perform a risk assessment to inform the likelihood of a skeletal complication from exercise.

The Delphi identified consensus on information that respondents deemed key to determine exercise suitability (Table 1 ). However, reliance on an individual's self-reported bone lesion details did not reach consensus. The systematic review showed that randomized controlled trials of exercise involving people with bone metastases commonly exclude people deemed to have structurally unstable bone lesion(s) or pain associated with bone lesion(s). 20 Determination of lesion stability was either undefined 22 , 23 or two randomized controlled trials used Taneichi's subtype A-C scoring for osteolytic thoracic and lumbar spine lesions, with computed tomography or magnetic resonance imaging assessed independently by a radiologist and orthopedic surgeon. 24 , 25 In the survey, most respondents agreed that exercise for people with bone metastases was safe (82%) and these individuals look to their health care providers to provide exercise referral and recommendations (74%). To facilitate respondents providing an exercise recommendation to individuals, the most frequently cited resource identified was a set of clinical guidelines for exercise in this population (25%), an easy-to-use screening scale (20%), and a consult with a qualified exercise professional (13%). 21

The IBMEWG acknowledged that in the absence of literature, all people with bone metastases can be at risk of an exercise-related skeletal complication, but this should not preclude prescribing exercise. Identification of individuals who are potentially at higher risk of exercise-related skeletal complication is a complex interplay of these factors: (1) lesion-related, (2) cancer and cancer treatment–related, and (3) person-related (Table 2 ). Furthermore, it was acknowledged that bone scan reports may not consistently provide information on lesion volume and that a computed tomography and magnetic resonance imaging may be more reliable for structural qualities of the bone and preferable for people deemed higher risk. Finally, more research is required to confirm the utility of pre-exercise skeletal assessment scales to guide risk assessment. Stakeholders with bone metastases reported that they were keen to exercise but fearful, lacking in confidence for self-guidance, and uncertain where to look for exercise advice. They confirmed that discussion with the health care team on how to manage risk was of key interest to people with bone metastases.

Recommendation 2

Consultation with the medical team is strongly encouraged before an exercise professional provides structured exercise for a person with bone metastases, to obtain key medical information and establish bidirectional communication for initial assessment and exercise training throughout care.

The primary reason reported by exercise professionals to seek medical clearance or guidance was to obtain key medical information, such as results of bone scan reports to guide exercise prescription and to establish two-way communication (ie, to allow for information sharing with the goal of better safety and overall care). When asked if a primary reason for seeking medical clearance or guidance was a requirement for professional liability (ie, signed approval by a physician), only 39% of exercise professionals strongly agreed or agreed (Table 1 ). In the systematic review, 24% of trials required medical clearance by a physician. For the remainder, exclusion criteria specific to lesion characteristics of bone metastases were used, such as excluding people with unstable bone metastases (24%) or pain associated with the bone lesion (41%). 20 Most survey respondents agreed that people with bone metastases expected their physician to provide physical activity recommendations (74%), and these recommendations would be well received (66%) and followed (58%). However, less than half of the physicians and nurse practitioners (43%) felt confident to recommend exercise to people with bone metastases. 21

The IBMEWG agreed that the term medical consultation versus clearance was the most appropriate term for communication between the exercise professional and health care provider. The goal of such medical consultation is to establish two-way communication to assess the cost to benefit-risk of an exercise prescription, as it can be difficult for health care providers to feel that they have enough understanding of exercise to provide medical clearance and for exercise professionals to obtain or interpret all the desired clinical information to assess risk, especially without access to the medical chart (Appendix Table A 1 , online only).

Recommendation 3

Exercise professionals best suited to prescribe exercise to people with bone metastases are physical therapists and clinical exercise physiologists (or equivalent), who have additional cancer exercise training and appropriate experience in working with people with a cancer diagnosis.

The Delphi showed consensus that the exercise professionals best suited to prescribe exercise to people with bone metastases were university qualified with clinical expertise, namely, physical therapists (95% agree) and clinical exercise physiologists (85% agree), provided that each has additional cancer exercise education and training (Table 1 ). In the systematic review, exercise supervision was provided predominantly by university-trained exercise professionals, including physical therapists and clinical exercise physiologists. All but one trial included at least one session of in-person supervised exercise instruction (ie, individualized demonstration and practice). 20

The IBMEWG recommended that all people are assessed by a physical therapist or clinical exercise physiologist, with additional cancer exercise education and ideally experience in working with people who have bone metastases (Appendix Table A 1 ). This may necessitate that exercise professionals initially are advised or supervised by a more experienced colleague, and these recommendations may need to be adapted in different jurisdictions and clinical settings. Stakeholders with bone metastases endorsed the importance of members of the health care team being able to guide people to qualified professionals. The IBMEWG highlighted that considerable work is needed to establish a referral pathway to improve equitable access to qualified exercise professionals. Each exercise professional must consider their own training and experience, as well as the setting in which they work, to determine if it is appropriate to work with that client or to refer. Finally, the results of the systematic review suggest that an element of supervised exercise instruction should be initially included before the addition of unsupervised exercise for individuals with bone metastases. Although this supports the potential feasibility of delivering supervised virtual exercise programs in light of the COVID-19 pandemic, research is needed to determine the overall safety profile of virtual exercise for individuals with bone metastases. 26

Recommendation 4

Professional judgment should be used to consider if exercise testing at baseline and follow-up is necessary by weighing the risks and benefits of including the test or if the testing protocols may need to be modified.

In the Delphi, for lower and higher risk examples, the statement that “exercise testing was recommended but there were some tests that were contraindicated” met consensus. Specific to strength testing, there was consensus to avoid tests or use caution with a test that places stress on a lesion site (Table 1 ). In the systematic review, few studies provided sufficient details on which participants completed the tests outlined in the methods and why a test may or may not be used for select participants. For the four studies exclusively in people with bone metastases, all outlined specific adjustments to the testing protocol. 20 For example, Galvao et al 27 excluded people with metastatic bone lesion(s) in the proximal femur from completing the 1-RM leg press and 400-m walk tests, and people with lesions in ribs, thoracic spine, or humerus were excluded from completing the 1-RM chest press and 1-RM seated row.

The IBMEWG assessed that there was insufficient evidence to guide specific recommendations on a standardized approach for safe exercise testing. To provide additional expert guidance, the recommendation is to focus on the goal of exercise testing and to follow the testing guidance in the International Exercise Guidelines for Cancer Survivors 4 until further evidence is available to update this approach (Appendix Table A 1 ). In addition, exercise practitioners should use professional judgment to consider if a test is necessary and consistent with the person's goals, while providing written justification for inclusion of the test as part of the treatment plan in an appropriate charting location.

Recommendation 5

Exercise prescription should follow the standard exercise recommendations as outlined by the International Exercise Guidelines for Cancer Survivors, with greater emphasis on postural alignment, controlled movement, and proper technique, as well as consideration given to the location and presentation of the bone lesion(s). Formal monitoring of exercise response and adjustment of exercise prescription should be ongoing.

The Delphi shows a 91% consensus that education and advice on safe movement patterns for activities of daily living is important for all people with bone metastases (Table 1 ). Specific to prescribing an exercise that could directly place stress on the lesion site, most respondents agreed that the correct approach was to use caution. Respondents defined this as “start with active movement and no load or weight and progress slowly, provided there is no exacerbation of pain or adverse symptoms” (47%) or “start with low loads and progress slowly, provided there is no exacerbation of pain or adverse symptoms (28%).” This is a notable departure from approaches outlined originally by Cormie et al 28 and Galvao et al, 27 in which exercise involving the affected bone region was avoided altogether. In the systematic review, exercise prescription modifications specific to the presence of bone metastases were included in 41% of trials, whereas the remainder of trials did not report exercise modifications specific to bone metastases. How a participant's response to exercise was monitored and the related adjustments made to the exercise prescription were not uniformly reported. 20

The IBMEWG discussed the available literature that could be used to inform specific guidance around exercise prescription approaches. Exercise prescription for resistance exercises that prevent direct stress on the site of bone lesions has been published by IBMEWG members (P.C., N.H.H., and R.U.N.). 27 , 28 It was acknowledged that these previously published approaches were conservative and provided a starting point, while evidence regarding safety continued to emerge. The challenge in applying these generic prescription approaches is that individuals with widespread metastatic disease may be recommended to engage in limited exercise options that do not target the overall function or the goals of the individual. The approved movements can also be more restrictive than many activities of daily living that place considerable load on the body, including sites of bone metastases, such as descending stairs.

The IBMEWG recommendation aims to move beyond the initial and restrictive approaches to exercise testing and prescription with the goal better informing the development of efficacious exercise prescriptions for people with bone metastases in the clinical setting. The standard approach to exercise prescription for people living with and beyond cancer as outlined by the International Exercise Guidelines for Cancer Survivors from the American College of Sports Medicine 4 should be used, with ongoing monitoring of individual response to adjust the exercise prescription or to send the person for further review. It was also deemed important to take additional guidance from exercise literature in osteoporosis that has sought to reduce the risk of skeletal-related complications, especially in vertebral bodies and hip. 29 , 30 This includes an emphasis on correct technique and postural alignment with all exercises; avoidance of rapid or loaded end-range movements, such as rotation, flexion, or extension movements that involve the area of the lesions; consideration of impact loading of an exercise along with the type of movement (ie, concentric, eccentric, and plyometric) in the area of the bone lesion(s); and education and precautions to minimize the risk of falls. An additional consideration is that people with bone metastases may be deconditioned, because of treatment or higher symptom burden, and exercise volume should be adjusted accordingly.

Overarching Recommendation

Regular exercise has the potential to maintain or improve physical function and health-related quality of life in people with bone metastases, and the perceived risk of skeletal complication should be weighed against the potential health benefits.

On the basis of the review of available evidence and expert consensus, the IBMEWG has concluded that people with bone metastases should be supported and encouraged to engage in physical activity, including structured exercise, to obtain the well-established general health benefits, as a strategy to manage side effects related to cancer and treatments. 4 Overall, the perceived risk of skeletal complications should be weighed against the potential health benefits of regular physical activity, including prevention of further loss of functional capacity. Exercise professionals should communicate with the health care team to minimize participant risk while providing sufficient exercise stimulus to improve or maintain function or to slow decline, while prioritizing the goals of the person. The IBMWG also identified research priorities to allow for the continuous evolution of evidence-based guidelines (Table 1 ).

This recommendation was strongly endorsed by our stakeholders, both people with bone metastases and clinician peers, who felt it essential for members of the health care team to initiate a conversation about exercise, explain why exercise is important for people with bone metastases, and frame exercise as a range of activities, spanning from activities of daily living to sports. Stakeholders with bone metastases also highlighted the need to increase the availability of exercise services led by qualified exercise professionals and the provision of more information on how to access services.

DISCUSSION

These recommendations aim to provide a framework for improved integration of exercise programming into the care of people with bone metastases. The overarching recommendation is that routine exercise has the potential to improve or maintain physical function and quality of life and reduce treatment side effects, while also potentially increasing resilience for future treatments. To achieve provision of exercise programming, a collaborative relationship between the health care team and qualified exercise professionals is optimal. This approach is intended to improve the health care team's confidence in encouraging people with bone metastases to engage in regular exercise and provide navigation on how to access qualified exercise professionals who can develop appropriate and individualized exercise programming.

Determining the ideal approaches to pre-exercise screening, exercise testing, and exercise programming related to safety and skeletal-related events (SREs) remains a challenge. The IBMEWG recommends that exercise programming for people with bone metastases is administered by qualified exercise professionals, namely, physical therapists and clinical exercise physiologists, who have additional training and experience in working with people with a cancer diagnosis. These exercise professionals have university-level training (or equivalent) in most countries and a scope of practice that includes working with individuals with complex medical conditions.

A specific risk stratification tool to evaluate the appropriateness of exercise participation for an individual is desired by the health care team, exercise professionals, and people with bone metastases. However, the utility to apply existing screening tools used to predict the risk of fracture or guide decisions on prophylactic surgical fixation (ie, Taneichi, Mirels, and Spinal Instability Neoplastic Score 31 ) within the exercise screening process for people with bone metastases is unknown. These have not been trialed extensively as part of the pre-exercise screening process to date and cannot be scored independently by an exercise professional. More research into the practical use of such a screening tool or newly developed tool is needed to determine if a standardized approach is feasible. Confounding this issue, the initial detection of bone metastasis is evolving with the advent of new imaging modalities. Unlike soft tissue tumors where Response Evaluation Criteria in Solid Tumors are clear, the response of bone metastasis to cancer treatment remains poorly understood. 32 A recently proposed algorithm for the investigation of bone metastasis was proposed by the European Society for Medical Oncology in 2020, and this could be considered for future exercise studies. 32

The impact of cancer therapy and bone-modifying agents (BMA) on bone remodeling remains an area of intense study. With respect to BMA, zoledronic acid remains to date the only bisphosphonate to show broad efficacy in reducing SREs in people with bone metastases from almost all malignancies (including lung carcinoma and other solid tumor types: prostate, breast, thyroid, head and neck, thyroid, and renal cell). 32 Data also show decreased SREs with the use of RANK ligand inhibitors (denosumab) for cancers of the prostate, breast, and renal cell, non–small-cell lung cancer, and multiple myeloma. 32 In the future, the use of BMA should be clearly documented in exercise studies to develop a better understanding of their potential influence on bone remodeling. Furthermore, future studies should explore the use of bone biomarkers and imaging, especially positron emission tomography in exploring potential risk indicators and treatment response of exercise interventions.

A key strength of the IBMEWG was the process to merge a systematic understanding of the current literature with a formalized Delphi process and stakeholder input. The IBMEWG recommendations are consistent with two existing publications. Sheill et al 33 published a narrative review of considerations for exercise prescription for people with bone metastases, and the support organization Macmillan Cancer Support in the United Kingdom developed a user-friendly guidance document for health care professionals. 34 The IBMEWG aimed to address gaps in these documents by documenting the specific information gathering and decision-making processes used to generate the recommendations.

A fundamental limitation is a lack of definitive literature on standardized approaches to safety screening, exercise testing and prescription, and safety reporting of minor or major complications with exercise, including between exercise sessions (ie, pain, disability, and need for analgesia). In addition, there is a paucity of data on specific individuals that may be at increased risk of fracture with exercise (ie, elderly individuals with multiple myeloma).

In conclusion, these recommendations provide a framework and starting point for exercise professionals and members of the health care team to improved integration of physical activity into the care of individuals with bone metastases. It is anticipated that the recommendations provided here will continue to evolve as more literature is available.

ACKNOWLEDGMENT

We would like to thank our stakeholders with bone metastases for their participation and peers external to the working group who provided feedback before submission (Alysa Fairchild, David Langelier, Grainne Sheill, Martijn Stuiver, and Shelley Kay).

This work was endorsed by the Oncology Division of the Canadian Physiotherapy Association (CPA), the Canadian Society for Exercise Physiology (CSEP), and the International Physical Therapists for HIV/AIDS, Oncology, Hospice and Palliative Care World Physiotherapy Subgroup (IPT-HOPE).

APPENDIX

Kristin L. Campbell

Honoraria: Astellas Pharma

Prue Cormie

Stock and Other Ownership Interests: Exercise Oncology EDU Pty Ltd

Other Relationship: EX-MED Cancer Ltd

Sarah Weller

Research Funding: Astellas Pharma

Shabbir M. H. Alibhai

Stock and Other Ownership Interests: ResMed

Honoraria: Astellas Scientific and Medical Affairs Inc

Kate A. Bolam

Stock and Other Ownership Interests: Novo Nordisk

Celestia S. Higano

Employment: CTI BioPharma Corp (I)

Stock and Other Ownership Interests: CTI BioPharma Corp (I)

Honoraria: Astellas Pharma

Consulting or Advisory Role: Bayer, Ferring, Clovis Oncology, Blue Earth Diagnostics, Janssen, Hinova Pharmaceuticals, Pfizer, AstraZeneca, Carrick Therapeutics, Novartis, Merck Sharp & Dohme, Astellas Pharma, Myovant Sciences, Genentech, Menarini

Research Funding: Aragon Pharmaceuticals (Inst), AstraZeneca (Inst), Medivation (Inst), Emergent BioSolutions (Inst), Bayer (Inst), Pfizer (Inst), Roche (Inst), Astellas Pharma (Inst), Clovis Oncology (Inst), Ferring (Inst), eFFECTOR Therapeutics (Inst)

Travel, Accommodations, Expenses: Pfizer, Janssen Oncology, Novartis, Merck Sharp & Dohme, Carrick Therapeutics

Kirstin Lane

Stock and Other Ownership Interests: Moderna Therapeutics

Travel, Accommodations, Expenses: Astellas Pharma

Robert U. Newton

Honoraria: GenesisCare

Research Funding: Ipsen

Travel, Accommodations, Expenses: Genesis Cancer Care

Morten Quist

Employment: Zealand Pharmaceuticals (I)

Honoraria: AstraZeneca

Jennifer Rauw

Honoraria: AstraZeneca

Speakers' Bureau: GlaxoSmithKline

Travel, Accommodations, Expenses: AstraZeneca

Friederike Rosenberger

Stock and Other Ownership Interests: BioNTech, Bristol Myers Squibb, AstraZeneca

Honoraria: Bristol Myers Squibb, Hexal

Kathryn H. Schmitz

Patents, Royalties, Other Intellectual Property: Fees from the educational program I developed that are now offered through Klose Training and Consulting

Joachim Wiskemann

Honoraria: Pfizer, Lilly, Novartis

Jennifer Goulart

Research Funding: Astellas Pharma (Inst)

No other potential conflicts of interest were reported.

PRIOR PRESENTATION

Presented in part orally at annual meeting of the American College of Sports Medicine, June 4, 2021 and the International Conference of Physical Therapy in Oncology, May 4, 2021.

SUPPORT

Funded through Astellas Pharma Canada Inc.

AUTHOR CONTRIBUTIONS

Conception and design: Kristin L. Campbell, Prue Cormie, Sarah Weller, Shabbir M. H. Alibhai, Anna Campbell, Andrea L. Cheville, Nicolas H. Hart, Celestia S. Higano, Margaret L. McNeely, Robert U. Newton, Jennifer Rauw, Kerri M. Winters-Stone, Jennifer Goulart

Financial support: Jennifer Goulart

Administrative support: Jennifer Goulart

Provision of study materials or patients: Jennifer Rauw, Jennifer Goulart

Collection and assembly of data: Kristin L. Campbell, Prue Cormie, Sarah Weller, Kate A. Bolam, Mary-Ann Dalzell, Nicolas H. Hart, Celestia S. Higano, Kirstin Lane, Sami Mansfield, Robert U. Newton, Morten Quist, Jennifer Rauw, Daniel Santa Mina, Jennifer Goulart

Data analysis and interpretation: Kristin L. Campbell, Prue Cormie, Sarah Weller, Shabbir M. H. Alibhai, Kate A. Bolam, Andrea L. Cheville, Mary-Ann Dalzell, Nicolas H. Hart, Celestia S. Higano, Kirstin Lane, Robert U. Newton, Friederike Rosenberger, Daniel Santa Mina, Kathryn H. Schmitz, Kerri M. Winters-Stone, Joachim Wiskemann, Jennifer Goulart

Manuscript writing: All authors

Final approval of manuscript: All authors

Accountable for all aspects of the work: All authors

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Exercise Recommendation for People With Bone Metastases: Expert Consensus for Health Care Providers and Exercise Professionals

The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/op/authors/author-center .

Open Payments is a public database containing information reported by companies about payments made to US-licensed physicians ( Open Payments ).

Kristin L. Campbell

Honoraria: Astellas Pharma

Prue Cormie

Stock and Other Ownership Interests: Exercise Oncology EDU Pty Ltd

Other Relationship: EX-MED Cancer Ltd

Sarah Weller

Research Funding: Astellas Pharma

Shabbir M. H. Alibhai

Stock and Other Ownership Interests: ResMed

Honoraria: Astellas Scientific and Medical Affairs Inc

Kate A. Bolam

Stock and Other Ownership Interests: Novo Nordisk

Celestia S. Higano

Employment: CTI BioPharma Corp (I)

Stock and Other Ownership Interests: CTI BioPharma Corp (I)

Honoraria: Astellas Pharma

Consulting or Advisory Role: Bayer, Ferring, Clovis Oncology, Blue Earth Diagnostics, Janssen, Hinova Pharmaceuticals, Pfizer, AstraZeneca, Carrick Therapeutics, Novartis, Merck Sharp & Dohme, Astellas Pharma, Myovant Sciences, Genentech, Menarini

Research Funding: Aragon Pharmaceuticals (Inst), AstraZeneca (Inst), Medivation (Inst), Emergent BioSolutions (Inst), Bayer (Inst), Pfizer (Inst), Roche (Inst), Astellas Pharma (Inst), Clovis Oncology (Inst), Ferring (Inst), eFFECTOR Therapeutics (Inst)

Travel, Accommodations, Expenses: Pfizer, Janssen Oncology, Novartis, Merck Sharp & Dohme, Carrick Therapeutics

Kirstin Lane

Stock and Other Ownership Interests: Moderna Therapeutics

Travel, Accommodations, Expenses: Astellas Pharma

Robert U. Newton

Honoraria: GenesisCare

Research Funding: Ipsen

Travel, Accommodations, Expenses: Genesis Cancer Care

Morten Quist

Employment: Zealand Pharmaceuticals (I)

Honoraria: AstraZeneca

Jennifer Rauw

Honoraria: AstraZeneca

Speakers' Bureau: GlaxoSmithKline

Travel, Accommodations, Expenses: AstraZeneca

Friederike Rosenberger

Stock and Other Ownership Interests: BioNTech, Bristol Myers Squibb, AstraZeneca

Honoraria: Bristol Myers Squibb, Hexal

Kathryn H. Schmitz

Patents, Royalties, Other Intellectual Property: Fees from the educational program I developed that are now offered through Klose Training and Consulting

Joachim Wiskemann

Honoraria: Pfizer, Lilly, Novartis

Jennifer Goulart

Research Funding: Astellas Pharma (Inst)

No other potential conflicts of interest were reported.

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