How do Body Practices Affect the Psychological Aspects of Survivors Women Undergoing Treatment for Breast Cancer? Systematic Literature Review
Como as Práticas Corporais Afetam os Aspectos Psicológicos de Mulheres Sobreviventes e em Tratamento para o Câncer de Mama? Revisão Sistemática da Literatura
¿Cómo Inciden las Prácticas Corporales en los Aspectos Psicológicos de las Mujeres Sobrevivientes y en Tratamiento por Cáncer de Mama? Revisión Sistemática de la Literatura
Juliana da Silveira1; Danielly Yani Fausto2; Patrícia Severo dos Santos Saraiva3; Leonessa Boing4; Vanessa Bellani Lyra5; Anke Bergmann6; Adriana Coutinho de Azevedo Guimarães7
1,2,3,4,7Universidade do Estado de Santa Catarina. Florianópolis (SC), Brazil. E-mails: firstname.lastname@example.org; email@example.com; patrícia.firstname.lastname@example.org; email@example.com; firstname.lastname@example.org. Orcid iD: https://orcid.org/0000-0003-2821-8717; Orcid iD: https://orcid.org/0000-0001-5382-7878; Orcid iD: https://orcid.org/0000-0001-6122-9667; Orcid iD: https://orcid.org/0000-0003-4978-9703; Orcid iD: https://orcid.org/0000-0001-5167-2921
5Faculdade Estácio de Sá, Departamento de Educação Física. São José (SC), Brazil. E-mail: email@example.com. Orcid iD: https://orcid.org/0000-0001-9653-2930
6Instituto Nacional de Câncer (INCA), Divisão de Pesquisa Clínica e Desenvolvimento Tecnológico. Rio de Janeiro (RJ), Brazil. E-mail: firstname.lastname@example.org. Orcid iD: https://orcid.org/0000-0002-1972-8777
Corresponding author: Juliana da Silveira. Rua Pascoal Simone, 358 – Coqueiros. Florianópolis (SC), Brazil. CEP 88080-350. E-mail: email@example.com
Introduction: Body practices can bring physical, psychological benefits and social rehabilitation and may be an alternative treatment for breast cancer. Objective: To analyze the evidence of the results of body practices over the psychological aspects of survivors women undergoing treatment for breast cancer. Method: Systematic blind and independent review from September to December 2021 following the PRISMA guidelines, carried out in the databases: Embase Elsevier; PubMed Central; ScienceDirect; Scopus Elsevier and Web of Science – Core Collection. Results: Of 1,372 studies identified, 22 were included in this systematic review. Among the practices that stood out are meditation and Yoga, with anxiety being the most investigated variable by the studies. It is clear that body practices are options for non-pharmacological clinical treatments utilized in clinical practice by different health professionals in women who have survived breast cancer. Conclusion: Body practices proved to be beneficial in the treatment and psychological health of women who survived breast cancer. This evidence may help to implement body practices as a therapeutic resource to be used in the clinical practice of health professionals. However, more randomized clinical trials that follow study protocols more rigorously are suggested, so that the effectiveness of this approach can be evaluated in different clinical outcomes.
Key words: breast neoplasms/psychology; complementary therapies; adaptation, psychological; musculoskeletal manipulations; women's health.
Introdução: As práticas corporais podem trazer benefícios na área de reabilitação física, psicológica e social e ser uma alternativa de tratamento para o câncer de mama. Objetivo: Analisar as evidências dos resultados das práticas corporais nos aspectos psicológicos de mulheres que sobreviveram e estavam em tratamento para câncer de mama. Método: Revisão sistemática desenvolvida de forma cega e independente, de setembro a dezembro de 2021, seguindo as diretrizes PRISMA, realizada nas bases de dados: Embase Elsevier; PubMed Central; ScienceDirect; Scopus Elsevier e Web of Science – Core Collection. Resultados: Dos 1.372 estudos identificados, 22 foram incluídos nesta revisão sistemática. Entre as práticas que mais se destacaram, estão a meditação e a Yoga, sendo a ansiedade a variável mais investigada pelos estudos. Fica claro que as práticas corporais são opções de tratamentos clínicos não farmacológicos utilizados na prática clínica por diferentes profissionais de saúde em mulheres que sobreviveram ao câncer de mama. Conclusão: As práticas corporais mostraram-se benéficas no tratamento e na saúde psicológica de mulheres que sobreviveram ao câncer de mama. Essas evidências podem auxiliar na implementação das práticas corporais como recurso terapêutico a ser utilizado na prática clínica dos profissionais de saúde. No entanto, são sugeridos mais ensaios clínicos randomizados que sigam os protocolos de estudo com mais rigor, para que a eficácia dessa abordagem possa ser avaliada em diferentes desfechos clínicos.
Palavras-chave: neoplasias da mama/psicologia; terapias complementares; adaptação psicológica; manipulações musculoesqueléticas; saúde da mulher.
Introducción: Las prácticas corporales pueden traer beneficios en el área de rehabilitación física, psicológica y social y ser una alternativa de tratamiento para el cáncer de mama. Objetivo: Analizar las evidencias de los resultados de prácticas corporales en los aspectos psicológicos de mujeres sobrevivientes y en tratamiento por cáncer de mama. Método: Revisión sistemática desarrollada de forma ciega e independiente, de septiembre a diciembre de 2021 siguiendo los lineamientos PRISMA, realizada en las bases de datos: Embase Elsevier; PubMed Central; ScienceDirect; Scopus Elsevier e Web of Science – Core Collection. Resultados: De 1.372 estudios identificados, 22 se incluyeron en esta revisión sistemática. Entre las prácticas que más se destacaron están la meditación y el Yoga, siendo la ansiedad la variable más investigada entre los estudios. Es claro que las prácticas corporales son opciones de tratamientos clínicos no farmacológicos, utilizados en la práctica clínica por diferentes profesionales de la salud en mujeres que han sobrevivido al cáncer de mama. Conclusión: Las prácticas corporales demostraron ser beneficiosas en el tratamiento y la salud psicológica de las mujeres que sobrevivieron al cáncer de mama. Esta evidencia puede ayudar en la implementación de las prácticas corporales como recurso terapéutico para ser utilizado en la práctica clínica de los profesionales de la salud. Sin embargo, se sugieren más ensayos clínicos aleatorizados que sigan los protocolos de estudio de manera más rigurosa, de modo que la efectividad de este enfoque pueda evaluarse en diferentes resultados clínicos.
Palabras clave: neoplasias de la mama/psicología; terapias complementarias; adaptación psicológica; manipulaciones musculoesqueléticas; salud de la mujer.
Body practices can be seen as an important element in some health sectors1, bringing physical, psychological benefits and social rehabilitation, because they affect mood, feelings of ability, autonomy and self-confidence2. Thus, body practices interventions are adopted as non-pharmacological therapy options since they can be alternative treatments3 for menopausal women4,5, Parkinson's disease6,7 and in all stages of breast cancer treatment8,9.
The study by Targ and Levine10 was the first randomized clinical trial addressing body practices in women with breast cancer published in 2002, it concluded that the practice of meditation contributed to reduce depression and anxiety. In 2004 and 2005, studies by Mustian et al.11 and Sandel et al.12 concluded that body practices improved the self-esteem and perceptions of body image. Currently, other studies indicate that body practice interventions for breast cancer survivors helped substantially to reduce depressive symptoms3,13,14, fear of disease recurrence13 and anxiety14,15.
Therefore, body practices are cost-effective, low-cost options with important psychosocial effects16, and treatments with these therapies have been increasingly adopted by health professionals as a complement to standard treatment16,17. Thus, it is important to develop strategies to reduce clinical and psychological symptoms in breast cancer survivors18 and in that line, non-pharmacological interventions are able to improve psychological aspects for different types of cancer17.
In this context, a systematic review addressing the benefits of various body practices in psychological aspects (depression, anxiety, stress, body image, self-esteem, mood, quality of life, sleep disorders, fatigue and pain) will meet the methodological trend widely used in different areas of health1, and can identify directions for clinical practice and future research. The objective of this review is to analyze the evidence of the results of body practices in the psychological aspects of survivors women in treatment of breast cancer.
This systematic review of randomized clinical trials follows the guidelines of the Preferred reporting items for Systematic Reviews and Meta-analysis (PRISMA)19 and was registered in International Prospective Register of Systematic Reviews (PROSPERO)20, CRD: 42022302090, exempted from Institutional Review Board (IRB) approval because there is no involvement of human beings. The research question followed the acronym PICOS: What is the evidence of interventions of body practices on the psychological aspects of survivors women undergoing treatment for breast cancer?
The search was carried out electronically using the descriptors selected in five databases, namely: Embase Elsevier; PubMed Central; ScienceDirect; Scopus Elsevier e Web of Science – Core Collection. All titles and abstracts found in the electronic search were analyzed using the Rayyan application developed by the Qatar Computing Research Institute21, by three investigators, blindly and independently, from 09/03/2021 to 10/20/2021. Reference lists of all significant articles were analyzed to identify other eligible studies.
Three investigators, members of the Laboratory for Research in Leisure and Physical Activity (LAPLAF)/CNPq, carried out the searches during the period from 09/03/2021 to 20/10/2021 according to the eligibility criteria. Disagreements were resolved by a fourth author.
The eligibility criteria were defined according to the PICOS criterion. Eligible studies for this review were: a) randomized clinical trials; b) adult women (≥18 years); c) in treatment or after treatment of breast cancer; d) published in English; e) published from 2011 to 2021; f) investigating results of body practices in psychological outcomes, specifically, depression, anxiety, stress, body image, self-esteem, mood, quality of life, sleep disorders, fatigue and pain; g) open access studies, with abstract and full text. When it was not possible to access the full article and duplicate articles in the databases were excluded.
Figure 1 shows the flowchart of the selection process carried out by the investigators and reasons of non-eligibility. After searching the databases, the titles and abstracts were read (excluding the articles that did not meet the inclusion criteria) followed by full reading of the articles to complete the selection process.
Studies that addressed the effects of interventions through body practices (stretching, flexibility, dance, Yoga, Tai Chi, Lian Gong, Qigong, meditation and acupuncture) on psychological aspects (depression, anxiety, stress, body image, self-esteem, mood, quality of life, sleep disorders, fatigue and pain) in survivors women undergoing treatment for breast cancer were included, given that the diagnosis of breast cancer can arouse different emotional reactions22, due to the acceptance of the diagnosis, treatment, possible mutilation of the breast and fear of death23. Feelings as anguish, sadness, nervousness, lack of interest in things are considered common in women diagnosed with breast cancer24, directly interfering in their social life25.
Body practices that can be used as a natural mechanism of health recovery when related to the diagnosis of breast cancer were considered as an intervention13 and alleviating the symptoms caused by the treatment15.
Body practices of dance, stretching, flexibility, Yoga, Tai Chi, Lian Gong, Qigong, meditation and acupuncture will be analyzed.
Data were independently extracted by two investigators in a structured and predefined model, constructed with the following information: (a) details of the journal (author(s), year and type of study, impact factor and country) where the study was carried out, number of citations according to Web of Science as of November 10, 2021; (b) study title and objectives; (c) sample size, intervention group, duration, frequency, time, intensity of body practices; (d) comparison group; (e) outcomes and instruments used; (e) level of evidence and (f) in the search period (09/03/2021 to 09/27/2021), following the 27-itens PRISMA checklist (yes or no).
Three investigators evaluated independently the methodological quality of the studies following the Cochrane Collaboration Scale26, and by a fourth author who was called in to resolve any discrepancy in accordance with the criteria: (1) random sequence generation, (2) concealment of the allocation sequence, (3) masking of participants and researchers, (4) masking of the outcome assessment, (5) incomplete results and (6) selective reports. The PEDro scale was also used to assist in the evaluation of the eligibility criteria of the studies27.
1,372 articles were found in the first database search, 138 in Embase (Elsevier), 286 in Web of Science – Core Collection, 451 in Scopus, 270 in ScienceDirect and 227 in PubMed. 342 articles were excluded because they were cross-references. After reading titles and abstracts, 939 articles were excluded for not meeting the inclusion criteria. Upon full reading, 22 articles were eligible for this review28-49 (Figure 1).
Charts 1 and 2 present the characteristics of the studies.
Figure 1. Flowchart of the study selection strategy, according to the PRISMA 2020 model
A total of 3,135 women were included, 1,148 in the intervention groups and 1,717 in the control groups. Women considered survivors were included because they had already completed the prescribed cancer treatment and were disease-free29,33,40,44-46,48, after diagnosis of breast cancer42, before radiotherapy cycle43, during radiotherapy38,47, undergoing chemotherapy32,35,39,41,49, in hormone therapy30, undergoing surgery and scheduled to receive radiotherapy31, during radiotherapy, chemotherapy, or mastectomy treatment36, before mastectomy37, and two studies did not present the duration of the treatment during the interventions28,34.
The participants were in stages 0 to III31,38,40,43,46,48, from I to III28,32-34,39,41,44-46, I to IV35, I and II36, and four studies did not provide this information29,30,37,42.
The age of the participants varied according to the inclusion criteria: over 18 years old31,32,41-43,47, over 20 years old38, over 21 years old40, 18 to 65 years35,46, 18 to 75 years33, 19 to 65 years39, 20 to 60 years37, 20 to 65 years34, 25 to 80 years44, 40 to 75 years48, 41 to 76 years49, 42 to 83 years29, 52 to 77 years30; three studies presented only the average age of the participants that ranged from 53 to 59 years old28,36,45.
The oldest studies included are those by Molassiotis et al.44, Monti et al.30 e Henderson et al.34 and the most recent is Araújo et al.35.
The impact factor of journals ranged from 0.02032 and 44.54429,44, two articles were published in journals without impact factor36,37. Of the twenty-two articles found, nineteen were cited in the Web of Science, with 5 citations39,42 to 14144 checked out on November 10, 2021.
The studies were carried out in North America28,29,30,32,34,40-43,48,49, in South America35, in Europe33,36,44,45 and in Asia31,37-39,46,47.
Eight studies were registered in the clinical trials databases: Clinical Trials33,40,44,45,49, University of Hong Kong Clinical Trials Center47, Brazilian Registry of Clinical Trials35 and Iranian Clinical Trials Registry37. The other studies did not provide information on the registration28,29,30-32,34,36,38,39,41-43,46,48.
Sixteen studies declared that there were no conflict of interest28,31-33,35-45,48, five studies did not provide this information29,30,34,46,47, and a study claimed potential conflict of interest due to support from pharmaceutical companies49.
Sixteen studies included control group, ten receiving usual and standard clinical care31,32,33,40,42-49, in one study, there was no formal intervention, and the participants were able to participate in other than meditation activities34, a study with educational activities on breast cancer35, one study received placebo ear pressure39 and three studies did not provide information about control group30,38,49.
Interventions in the control group were therapy to increase emotional expressiveness28, cognitive therapy with stimulus control and relaxation29, stretching program41,43, diaphragmatic breathing program42, Qigong Sham48, self-acupuncture45, aerobic exercises46, simulated acupuncture49, nutrition education34, swimming and Pilates36 and rhythmic breathing37.
The interventions were namely, Mindfulness (meditation techniques)28,30,33,34,38,40, Tai Chi (control over physical function and arousal, with meditative movements)29, Tibetan Yoga program41, meditation with a focus on breathing42, Yoga32,36,43, Qigong e Tai Chi48, acupuncture44,45, Qigong31,46, electroacupuncture49, dance movement therapy program47, Raja Yoga35, Benson relaxation37 and auriculotherapy39.
The period of interventions ranged from a single session42 up to 12 months28,36, one study reported 8 intervention sessions and a religious retreat33. A single study did not present the duration of the intervention37.
The frequency of the interventions varied from single session42, 4 sessions41, 6 weekly sessions44, 8 weekly sessions28, once a week35,45,46, twice a week38,47,48, 3 times a week34,36,43, 6 times a week39, twice a week and once a week49 and eight studies did not present the frequency of the interventions28-33,37,40.
The duration of each session in most studies was up to 60 minutes31,35-38,42-45,48 and in three studies this information was missing30,39,49.
Only three studies reported the intensity of interventions, which were low48 and low to moderate36,46.
Therapists28,29,44, meditation instructors28,35, psychologist trained in meditation33,40, Tibetan Yoga instructor41, Yoga instructor32,43, physical therapist36,41,43, exercise physiologist41,48, body-mind specialist42, nurse48, trained acupuncture therapists45,49, dance instructor46, dance therapist movement therapy47, oriental medicine instructor and Qigong master31, clinical mental health instructors and registered meditation practitioners and nutritionists34, ear therapist39 and in three studies this information was missing30,37,38.
The interventions occurred at the University41,47, biopsy room42, hospital32,35,47 and in seventeen studies this information was missing28-31,33,34,36-39,40,43-46,48,49.
All studies aimed to assess participants at baseline and post-intervention. Some studies have included mid-intervention assessments30,31,36,39,47,49 and follow-up, ranging from 1 month to 24 months after the intervention29,31-34,40,41,43,45,46,48,49.
The psychological outcomes found were sleep disturbance in 9 studies28,29,31,39-41,43,47,48, stress, 4 studies28,32,40,47, quality of life, 9 studies28,31,38,40,43-47, fatigue, 10 studies29,31,38,40,41,44-48, depressive symptoms, 14 studies29,31-36,38,40,43-46,48, anxiety, 13 studies30,32-38,40,42,44-47, pain, with 3 studies40,42,47, anguish, 1 study33 and self-esteem, 1 study34.
The assessment of the quality of the studies is shown in Chart 3. It is noted that the studies had a higher risk of bias in relation to “blinding of participants and staff” and “blinding in the outcome assessment”, as most of them were classified as high or uncertain because they do not provide enough data for the assessment. Also, that the category that presented low risk of bias was “random sequence generation”, considered low in most studies, corresponding to the method utilized to generate the sequence of participants randomly.
Sixteen studies were of moderate to high quality (scores greater than 6 points) on the PEDro scale, which shows that the studies followed the eligibility criteria, such as randomization, blinding and description of losses at follow-up.
Chart 1. Characteristics of the studies included in the systematic review
Chart 2. Details of the studies selected
Captions: POMS = Profile Of Moods State; C-SOSI = Calgary Symptoms of Stress Inventory; FACT-B = The Functional Assessment of Cancer Therapy – Breast; PSQI = Pittsburgh Sleep Quality Index; DSM-IV-TR = DSM-IV-TR Evaluation; AIS = Athens Insomnia Severity Scale; MFI = The Multidimensional Fatigue Inventory; ESS = Epworth Sleepiness Scale; YALE = Physical Activity Survey; STAI = The State-Trait Anxiety Inventory; PSS = Perceived Stress Scale; MDASI = The MD Anderson Symptom Inventory; BPI = Brief Pain Inventory; BFI = Brief Fatigue Inventory; BDI = Beck Depression Inventory; BDI-II= Beck Depression Inventory II; ECog = Everyday Cognition; SF-36 = Medical Outcomes Short-form Health Survey; VAS = Visual Analogue Scale; CES-D = Center for Epidemiologic Studies-Depression Scale; IES = Impact of Scale; BFQ = The Benefit Finding Questionnaire; FSI = Symptom Inventory; HADS = Hospital Anxiety and Depression Scale; FACT-G = The Functional Assessment of Cancer Therapy – General; FACT-F = The Functional Assessment of Cancer Therapy – Fatigue; DASS-21 = Depression Anxiety and Stress Scale; SCL-90-R = Symptom Checklist -90-revised; EVE = Stressful Life Events; MOS = Medical Outcomes Study; BAI = Beck Anxiety Inventory; RSS = Rosenberg Self-Esteem Scale; CSAQ = Cognitive-Somatic Anxiety Questionnaire; PFS = Piper Fatigue Scale; EORTC-QLQ-C30 = European Organization for Research and Treatment of Cancer Quality of Life Questionnaire – Breast Cancer; STAI-Y= State-Trait Anxiety Inventory.
Chart 3. Summary of methodological quality: authors' assessment of the scale items for each study included
Meditation28,30,33-35,37,38,40,42 and Yoga32,36,41,43 were the most frequent interventions, it is a popular practice with simple methods, with no need of specific materials. This predominance seems to suggest the authors' option for body movement conservative activities in relation to technique, volume and intensity, which may indicate a certain insecurity in prescribing more demanding exercises to the group studied.
Meditation interventions were still characterized by being mostly carried out in groups lasting approximately 20 to 60 minutes, along with psychoeducation activities, in addition to retreats for experiences sharing and religion-centered, but the intensities in these cases were not addressed, as well as the weekly frequency, which probably did not change the results of the studies.
There are scarce data on dose response, such as frequency, intensity of interventions in Yoga activities, and duration, since the level of intensity is not clearly defined in the studies, as well as the sessions frequency. It is pointed out in the studies of El-Hashimi and Gorey17 and O’Neill et al.50, that the intensity of Yoga interventions needs to be light, given the high levels of fatigue in breast cancer patients. As it is suggested to carry out the interventions with a frequency of one to three times a week, with sessions of 60 to 90 minutes17, which was not presented in most of the studies included, there is paucity of details on the dose response, leaving margin for further studies with Yoga in patients with breast cancer.
Among the studies of interventions with acupuncture44,45,49, the results concur with the study by Zhang et al.14, where they showed improvement in fatigue, anxiety, quality of life, reduction in pain and sleep disturbances. This can be seen as a safe and effective intervention51,52, since it is a complementary therapy to conventional medical treatments that must be applied by a skilled technical professional in this practice.
Only one study addressed dance interventions47, as well as auriculotherapy39. Dance intervention improved stress and pain, but there are scarce studies specifically involving women with breast cancer; overall, only systematic reviews whose sample consists in individuals with cancer exist, showing that dance can be beneficial over the quality-of-life of patients with cancer53, which once again offers the possibility of new studies with this theme because it is easy to apply and pleasant for those engaged. The findings of this review about auriculotherapy intervention demonstrated beneficial results in sleep quality in concurrence with the study by Yoon and Park39 who investigated women during chemotherapy. New studies are being developed on the effects of auriculotherapy on depression in women with breast cancer, with the recent publication of a systematic review protocol54.
Three studies with the practice of Qigong31,46,48 were included, as the findings corroborate the systematic review and meta-analysis by Meng et al.15, where, in addition to improving quality-of-life and decreasing depression, there was an improvement in anxiety symptoms. Only one study addressing Tai Chi was selected29, its findings are related to the improvement of sleep quality. There are findings in other systematic reviews and meta-analyses on the improvement in quality-of-life, fatigue, self-esteem and depression of the practice of Tai Chi in women with breast cancer52,55.
Despite the lack of accurate information on the total duration of the interventions, the duration of the sessions and the missing information on the frequency and intensity of most interventions, an improvement of the psychological aspects was found. However, without essential information as pointed out to determine the effectiveness of an intervention, it is difficult to evaluate the influence these interventions had on psychological variables, as well as on their future replication56.
There was a variety of instruments used to measure the psychological aspects, and there is no standardization to assess these elements, when it comes to interventions through body practices. The variable sleep quality is the only one following a standard, specifically the Pittsburg Sleep Quality Index (PSQI), a simple, well accepted by the patients and widely applied questionnaire57.
Most studies brought information about the professionals who applied the interventions, showing the importance of supervising the safe and effective performance of these body practices56 by the patients. However, the place where these interventions were carried out was missing in most of the studies, which impedes an adequate assessment of the extent of the influence on the results because the place can improve the performance of the activities.
Regarding the methodological quality of the studies, the categories involving masking of participants and professionals and masking the evaluation of the outcome, presented high risk of bias, and uncertain bias, most likely suggesting that the study participants were aware of the type of intervention received, similar to the professionals who were also cognizant of the assignment of the participants to the interventions. However, it is known that a few body practices cannot be blinded, because the participants need to know what activities are being developed.
The age of the participants ranged from 18 to 83 years old. The body practices varied widely because the studies were developed in culturally different continents as North America, South America, Europe and Asia, possibly suggesting that non-pharmacologic interventions can be applied in any country, population and age.
The studies are strong in terms of methodology, and most of them were monitored by professionals, with a wide cultural and age range.
The use of different questionnaires and different protocols addressing the duration, time, frequency and intensity of interventions is an important limitation, as it impedes comparisons between studies.
Another limitation of this systematic review was the different understandings of what body practices are in different languages and cultures, as well as the heterogeneity of the evaluated outcomes. Some studies had methodological limitations, which makes comparisons between other studies difficult.
The body practices analyzed are safe options for patients at different stages of breast cancer. Randomized clinical trials with more methodological rigor focused on body practices should be encouraged to find more evidences since safety and effectiveness are already a strong aspect of these practices, being potentially an adjuvant treatment for breast cancer.
More protocols addressing body practices and clear standards of performance are necessary.
This review brings contributions to health investigators, as well as doctors, nurses, physiotherapists and physical education professionals who seek to promote better conditions and alternative treatments for women who survive and are undergoing breast cancer treatment.
Juliana da Silveira contributed to the study conception, methodology, analysis, wording, review and administration of the project; Danielly Yani Fausto contributed to the methodology, analysis, wording, review and editing; Patricia Severo dos Santos Saraiva contributed to the methodology, analysis, wording review and editing; Leonessa Boing contributed to the wording, review and editing; Vanessa Bellani Lyra: Writing contributed to the review and editing; Anke Bergmann contributed to wording, review and editing; Adriana Coutinho de Azevedo Guimarães contributed to the study concept, wording, review and editing, supervision and administration of the project.
DECLARATION OF CONFLICT OF INTERESTS
The author Anke Bergmann declares potential conflict of interests because she is the scientific-editor of INCA’s Revista Brasileira de Cancerologia. The other authors have no conflict of interests to declare.
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Recebido em 21/7/2022
Aprovado em 17/10/2022
Executive-Editor: Letícia Casado. Orcid iD: https://orcid.org/0000-0001-5962-8765
Este é um artigo publicado em acesso aberto (Open Access) sob a licença Creative Commons Attribution, que permite uso, distribuição e reprodução em qualquer meio, sem restrições, desde que o trabalho original seja corretamente citado.
©2019 Revista Brasileira de Cancerologia | Instituto Nacional de Câncer | Ministério da Saúde