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Poverty and palliative care in the US: issues facing the urban poor.

Poverty is a significant public health and social problem in the US. The urban poor living with life-limiting illnesses are a particularly vulnerable population. The literature related to the experiences of the urban poor at the end of life is sparse. Most relates to the experiences of patients with cancer. The purpose of this literature review is to describe the problem of poverty in the US, to identify challenges in providing palliative care to the urban poor, and lastly, to articulate implications for nursing practice and nursing research.

Health Services Accessibility↗

Psychological distress in couples dealing with colorectal cancer: gender and role differences and intracouple correspondence.

OBJECTIVES: This longitudinal study examined patterns of psychological distress in couples facing colorectal cancer within 6 months after surgery. In addition, correspondence in psychological distress was investigated between patients and their spouses, taking into account the gender of the patient. METHOD: The study had a longitudinal design, involving three assessment points; (T1) within 2 weeks after surgery, (T2) 3 months after baseline and (T3) 6 months after baseline. At T1, respondents were asked to indicate how they felt during the week prior to surgery. At T2 and T3, respondents reported their feelings during the preceding week. Psychological distress was measured using the 20-item Center for Epidemiologic Studies Depression Scale (CES-D) in 137 couples. RESULTS: Concerning the week prior to surgery, females reported more distress being a patient, whereas males reported more distress being a spouse. In comparison with a reference group, females as well as males, regardless of their role, showed increased levels of psychological distress prior to surgery. At 3 and 6 months following surgery, increased levels of distress continued to exist in females, whereas males' distress returned to normal levels. Neither within female-patient couples, nor within male-patient couples, were associations between patients' and spouses' distress found. CONCLUSION: We demonstrated a considerable impact of the cancer diagnosis on both female and male patients and their spouses before and 3 months after surgery. Six months after surgery, females, in particular, appear to be vulnerable to distress.

Colorectal Neoplasms↗

Effect of the trichothecene mycotoxin diacetoxyscirpenol on nitrosamine-induced oesophageal cancer and on relevant enzymes in oesophagus and liver.

To test the concept that human oesophageal cancer is initiated by nitrosamines and potentiated by consumption of food contaminated by mycotoxins produced by Fusaria, the effect of the trichothecene mycotoxin diacetoxyscirpenol (DS), alone and in combination with N-nitroso-N-methylbenzylamine (NMBzA), on rat oesophagus was studied. Chronic treatment with DS induced oesophageal hyperplasia, but simultaneous treatment with NMBzA tended to inhibit rather than to enhance carcinogenesis. The mycotoxin did not inhibit O6-alkylguanine-DNA alkyltransferase in oesophagus and produced a marked induction of repair protein in liver. Depletion of the repair protein in oesophagus brought about by injection of NMBzA was not inhibited by the mycotoxin, and its reappearance was not delayed. Intubation of DS reduced DNA synthesis in the oesophagus, while dietary treatment resulted in an increase after nine weeks. The results suggest that, while simultaneous treatment with DS reduces cancer induced by NMBzA, if there is first exposure to mycotoxin and induction of hyperplasia, and then exposure to nitrosamine, so that the carcinogen acts on a vulnerable oesophagus in which there is an increased rate of cell proliferation, the mycotoxin could well enhance carcinogenesis.

Animals↗

Promoting health and physical function among cancer survivors: potential for prevention and questions that remain.

Cancer survivors are at increased risk, not only for progressive and recurrent disease, but also other cancers, cardiovascular disease, diabetes, osteoporosis, and functional decline. Lifestyle interventions to improve dietary and physical activity behaviors, and smoking cessation, have the potential to improve the overall health and quality of life of this vulnerable population. Studies on overall health and physical function from 1966 and beyond regarding the impact of behavioral interventions that used randomized and controlled designs were identified through MEDLINE and PubMed searches. Published reports currently exist for 22 exercise interventions, 11 diet-related interventions (excluding those limited to dietary supplements or single nutrients), two diet and exercise interventions, and 10 behavioral-based smoking cessation interventions. Although many interventions have been successful in promoting behavioral change and have resulted in improvements in various health-related outcomes, more research is needed to determine the key components of interventions that are able to produce the greatest behavioral change and the most favorable health-related benefits. The oncology care provider can play a pivotal role in improving the long-term health of cancer survivors by (1) being aware of opportunities to encourage healthful behaviors (ie, smoking cessation, weight control, and increased physical activity); (2) vigilantly tracking long-term effects among cancer survivors and exploring whether they are amenable to intervention; (3) staying abreast of current health behavior guidelines for cancer survivors and existing resources for professional and patient education; and (4) supporting and contributing to efforts aimed at primary and tertiary prevention research.

Aftercare↗

Berberine shows potential in mitigating PM2.5-induced breast cancer progression by inducing DNA damage and inhibiting error-prone DNA repair pathways.

Breast cancer remains the most common cancer among women, with 2.3 million new cases reported globally in 2022. Alongside established risk factors such as age, family history, genetics, obesity, smoking, and alcohol, exposure to fine particulate matter (PM2.5) has recently emerged as an environmental contributor. This risk is especially concerning for low- and middle-income countries (LMICs), where both PM2.5 exposure and cancer burden are disproportionately high; however, mechanistic studies from these regions remain limited. To address this gap and develop mitigation strategies, we investigated the oncogenic potential of water-soluble PM2.5 collected from ambient air on breast cancer and evaluated the potential role of nutraceuticals in mitigating these effects. PM2.5 exposure increased proliferation, migration, and ROS generation, while promoting the formation of multinucleated giant cells, leading to genomic instability. Berberine, a natural alkaloid, countered these effects by increasing DNA damage and exploiting tumor-specific genomic vulnerabilities through disruption of DNA damage response and repair networks, thereby promoting programmed cell death. Transcriptomic profiling of Delhi PM2.5-treated MCF7 cells revealed a Delhi PM2.5-associated carcinogenic gene signature enriched in MAPK signalling, reactive oxygen species, metabolic, lysosomal, and ribosomal pathways. We also found that several genes, including BIRC5, WSB1, and RCC1, within this PM2.5-induced gene signature were dysregulated in breast cancer patients and were inversely regulated by berberine treatment, suggesting that berberine counteracts the transcriptional effects of PM2.5. Our findings highlight ambient PM2.5 exposure as a driver of breast cancer progression and identify berberine as a promising candidate in mitigating PM2.5 effects; however, thorough preclinical and clinical validations are warranted.

Berberine↗

Cytokines and depression: the need for a new paradigm.

Considerable clinical and experimental data support the existence of a relationship between cytokines and depression. At the experimental level, proinflammatory cytokines have been found to induce alterations in brain function analogous to the behavioral and biological abnormalities occurring in depressed patients, including social withdrawal, cognitive impairment, anhedonia, increased activity of the hypothalamus-pituitary-adrenal axis, altered neurotransmission, and cross-sensitization with stressors. At the clinical level, the evidence in favor of innate immune system activation in depressed patients is still controversial, despite accumulating evidence for an increased risk of depressive disorders in patients receiving recombinant cytokines for the treatment of cancer and viral infection. This last issue has received significant attention recently, given that the administration of therapeutic cytokines provides a quasi-experimental model for studying the mechanisms which underlie the effects of cytokines on mood, cognition, and neurovegetative functions. Although the vulnerability factors that account for the risk of depression have yet to be identified, tryptophan depletion, likely related to the induction of indoleamine 2,3-dioxygenase enzyme, may represent an important mediator for the development of depressed mood in cytokine-treated patients. This paper discusses ways in which these emerging data may lead to advances in the recognition and management of non-specific neurobehavioral symptoms associated with the development and progression of cancer.

Cytokines↗

'Coming down the line'-- patients' understanding of their family history of common chronic disease.

PURPOSE: The family history is becoming an increasingly important feature of health promotion and early detection of common chronic diseases in primary care. Previous studies of patients from genetics clinics suggest a divergence between how persons with a family history perceive and understand their risk and the risk information provided by health professionals. This interview study aimed to explore how patients in primary care understand and come to terms with their family history of cancer, heart disease, or diabetes and how family history might affect consultations about disease risk and management. METHODS: Thirty semistructured interviews were conducted with general practice patients who had a family history of cancer, heart disease, or diabetes. The transcript data underwent a qualitative constant comparative analysis. RESULTS: What exactly constitutes having a family history of an illness varied among participants. The development of a personal sense of vulnerability to the illness in the family depended not only on the biomedical approach of counting affected relatives but also on a sophisticated interplay of other factors. The emotional impact of witnessing the illness in the family, particularly if the illness was sudden, premature, or fatal, and the nature of personal relationships within a family that determine a sense of emotional closeness and personal likeness with the affected relative, all contributed to the perception of disease risk. Different beliefs about the contributions of nature and nurture to disease can affect patients' views on the degree of control they can exert over their risk. CONCLUSION: This study highlights potential differences between the way patients and medical professionals assess and understand familial risk of cancer, heart disease, and diabetes. Our previous systematic review findings are enhanced by showing that personal experience of disease and the emotional impact can also influence familial risk perceptions. Eliciting the patient's perspective when discussing risk of chronic disease, particularly in the context of a family history, could inform a more patient-centered approach to risk assessment and communication and support patients to make informed decisions about the management of their disease risk.

Attitude to Health↗

Epigenetic Repression of TP53 Transcription Underlies Cancer Cell Persistence for Carboplatin Resistance in Non-Small Cell Lung Cancer.

While chemoresistance in non-small cell lung cancer (NSCLC) cells has historically been attributed to permanent genetic mutations, emerging evidence highlights the role of nongenetic transcriptional plasticity and 'drug-tolerant persister' cells. To systematically map these epigenetic vulnerabilities, we utilized a genome-wide CRISPR interference library to screen wild-type TP53 NSCLC (A549) cells under carboplatin selection. Using the DrugZ algorithm and subsequent pathway enrichment analyses, this screen revealed that transcriptional suppression of interstrand crosslink DNA repair networks, including the Fanconi anemia pathway, markedly sensitized cells to carboplatin. Unexpectedly, transcriptional silencing of TP53 and its downstream target CDKN1A emerged as the strongest drivers of resistance, enabling cells to bypass therapy-induced senescence and maintain their proliferative potential later. To validate these findings in a clinically relevant context, we established a chronic carboplatin-resistant cell model (A549CarboR cells). A549CarboR exhibited a reduction in TP53 transcripts, along with decreased H3K27 acetylation and increased DNA hypermethylation on its promoter. Epigenetic remodeling using the DNA methyltransferase inhibitor (DNMTi) was associated with unblocking TP53 transcription, restored p53 signaling, and resensitization of resistant cells to carboplatin. Conversely, histone deacetylase inhibitors induced CDKN1A transcription to bypass TP53, indicating distinct epigenetic circuits. Collectively, the results demonstrate for the first time that TP53 expression is dynamically regulated at the transcriptional level through promoter methylation related to the drug tolerance. These insights emphasize that epigenetic silencing, rather than exclusive genetic loss-of-function, contribute to platinum resistance and underscore the therapeutic potential of pairing platinum regimens with DNMTi to target the transcriptomic plasticity of persistent cancer cell populations.

CRISPR interference screening↗

Perceptions of threat, benefits, and barriers in breast self-examination amongst young asymptomatic women.

AIM: Young age at diagnosis of breast cancer is a negative prognostic factor, but early detection of breast pathology may improve prognosis. The present study examined the role of health perceptions (Health Belief Model; HBM) in young women's breast self-examination (BSE). It was hypothesized that cues to action, health motivation, and perceptions of threat (vulnerability, severity), benefits, and barriers, will predict BSE, but that threat perceptions will be more powerful predictors than benefits and barriers. METHOD: Questionnaire data from 178 asymptomatic women (aged 18-35 years) living in the northwestern region of England were analysed. RESULTS: Using hierarchical logistic regression controlling for demographic factors, only severity and barriers emerged as important predictors; lower perceived seriousness of breast cancer and fewer perceived obstacles to practising BSE predicted performance of BSE. For every unit increment on the severity and barrier scales, the odds of a respondent performing BSE decreased by approximately 8 and 20%, respectively. CONCLUSIONS: The results provide qualified support for the HBM. Perceived barriers was the most powerful predictor, although respondents assessed breast-cancer severity based on early detection through BSE. Implications for clinical interventions are considered.

Journal Article↗

Children's health and the environment--the first Herbert L. Needleman Award Lecture.

Children today are exposed extensively to toxins in the environment. Prominent among these are exposures to over 70,000 synthetic chemicals, all newly developed in the past 50 years and largely untested for their hazards to children's health. Children are uniquely vulnerable to toxins, and with increasing incidence they are developing chronic, disabling, life-threatening diseases known or suspected to be of environmental origin-asthma, endocrine disruption, cancer, and the diseases caused by tobacco. Pediatricians need to consider toxic etiologies in the differential diagnosis of childhood illness.

Asthma↗

Mitochondrial DNA mutations in primary leukemia cells after chemotherapy: clinical significance and therapeutic implications.

Mitochondrial DNA (mtDNA) codes for 13 respiratory chain subunits and is more vulnerable to damage than nuclear DNA due, in part, to a lack of histone protection and a weak repair capacity. While mtDNA alterations have been observed in human cancer, their roles in oncogenesis and chemosensitivity remain unclear. We investigated the relationship between mtDNA mutations, reactive oxygen species (ROS) generation, and clinical outcomes in chronic lymphocytic leukemia (CLL) patients. An analysis of mtDNA from 20 CLL patients revealed that primary CLL cells from patients with prior chemotherapy had a significantly higher frequency of heteroplasmic mutations than did those from untreated patients. Overall, mtDNA mutations appeared to be associated with increased ROS generation. Patients refractory to conventional therapeutic agents tended to have higher mutation rates than patients who responded to treatment. Analysis of paired blood samples from the same patient led to the identification of a heteroplasmic mutation in the cytochrome c oxidase II gene several months after chemotherapy. The mutation was associated with increased ROS generation. Our results suggest for the first time that chemotherapy with DNA-damaging agents may cause mtDNA mutations in primary leukemia cells, which often exist in heteroplasmy, and are associated with increased ROS generation.

Adult↗

Circadian rhythms, oxidative stress, and antioxidative defense mechanisms.

Endogenous circadian and exogenously driven daily rhythms of antioxidative enzyme activities and of low molecular weight antioxidants (LMWAs) are described in various phylogenetically distant organisms. Substantial amplitudes are detected in several cases, suggesting the significance of rhythmicity in avoiding excessive oxidative stress. Mammalian and/or avian glutathione peroxidase and, as a consequence, glutathione reductase activities follow the rhythm of melatonin. Another hint for an involvement of melatonin in the control of redox processes is seen in its high-affinity binding to cytosolic quinone reductase 2, previously believed to be a melatonin receptor. Although antioxidative protection by pharmacological doses of melatonin is repeatedly reported, explanations of these findings are still insufficient and their physiological and chronobiological relevance is not yet settled. Recent data indicate a role of melatonin in the avoidance of mitochondrial radical formation, a function which may prevail over direct scavenging. Rhythmic changes in oxidative damage of protein and lipid molecules are also reported. Enhanced oxidative protein modification accompanied by a marked increase in the circadian amplitude of this parameter is detected in the Drosophila mutant rosy, which is deficient in the LMWA urate. Preliminary evidence for the significance of circadian rhythmicity in diminishing oxidative stress comes from clock mutants. In Drosophila, moderately enhanced protein damage is described for the arrhythmic and melatonin null mutant per0, but even more elevated, periodic damage is found in the short-period mutant per(s), synchronized to LD 12:12. Remarkably large increases in oxidative protein damage, along with impairment of tissue integrity and--obviously insufficient--compensatory elevations in protective enzymes are observed in a particularly vulnerable organ, the Harderian gland, of another short-period mutant tau, in the Syrian hamster. Mice deficient in the per2 gene homolog are reported to be cancer-prone, a finding which might also relate to oxidative stress. In the dinoflagellate Lingulodinium polyedrum [Gonyaulax polyedra], various treatments that cause oxidative stress result in strong suppressions of melatonin and its metabolite 5-methoxytryptamine (5-MT) and to secondary effects on overt rhythmicity. The glow maximum, depending on the presence of elevated 5-MT at the end of subjective night, decreases in a dose-dependent manner already under moderate, non-lethal oxidative stress, but is restored by replenishing melatonin. Therefore, a general effect of oxidative stress may consist in declines of easily oxidizable signaling molecules such as melatonin, and this can have consequences on the circadian intraorganismal organization and expression of overt rhythms. Recent findings on a redox-sensitive input into the core oscillator via modulation of NPAS2/BMAL1 or CLK/BMAL1 heterodimer binding to DNA indicate a direct influence of cellular redox balance, including oxidative stress, on the circadian clock.

Animals↗

Communicating prostate cancer risk: what should we be telling our patients?

Until definitive evidence of the effectiveness of prostate cancer screening is available, most guidelines advocate that men make their own decisions about testing, after being fully informed. A man's perception of his personal risk is a key element in the decision-making process. In this decision-making, the current routine use of population risk estimates may be misleading. Risk estimates need to be relevant to the man making the choice. In particular, they should be age-specific and, where possible, include adjustments for known risk factors such as family history. As an example, although the population risk of lung cancer mortality is twice that of prostate cancer, for a non-smoking man with a family history of prostate cancer the direction of this comparison would be reversed. A man aged 50 diagnosed with prostate cancer has a greater likelihood (60%) of dying prematurely (before 80 years) from prostate cancer than a man diagnosed when aged 70 (38%). This can be attributed to the longer time available for the prostate cancer to progress, and the increased effect of competing causes of death among older men. This suggests that the oft-used statement "men are more likely to die with prostate cancer than from prostate cancer" is misleading, particularly for men diagnosed in their 50s or 60s. Decisions need to be made by men based on the best possible understanding of their personal vulnerability, and the individualisation of risk provides a more realistic appraisal of potential threat posed by the disease.

Adult↗

Patterns of childhood solid tumor incidence in northern Israel, 1973-1990.

A retrospective analysis of 515 pediatric cancer cases diagnosed over 18 years, 1973-1990, showed an annual incidence of pediatric solid tumors in northern Israel of 77.1 per million, somewhat lower than previously reported. Lymphomas predominated over central nervous system (CNS) neoplasms, suggesting an Afro-Asian rather than a Western pattern. Jewish and non-Jewish children were at approximately equal risk (1:07:1.0) for the nonleukemic cancer. However, there was a notably higher frequency in males than females (1:42:1.0) and in Ashkenasi Jews as compared to either Sephardi Jews (1.25:1.00) or non-Jews (1.23:1.0). Ethnic, age, and sex predispositions for particular types of malignancy were also noted. Non-Jews tended to have lymphomas or retinoblastomas and Sephardi Jews were predisposed to soft tissue sarcomas. Ashkenasi Jews tended to manifest CNS tumors, retinoblastoma, and osteosarcoma. Children under 5 years showed Burkitt's lymphoma and neuroblastoma, whereas the older group tended to have Hodgkin's lymphoma. Boys were more vulnerable to non-Hodgkin's lymphoma, medulloblastoma, neuroblastoma, and rhabdomyosarcoma, and girls were subject to higher incidences of bone, gonadal, germ cell, and epithelial tumors, as well as to astrocytoma. The implications for genetic or environmental contributions to several cancers are considered in conjunction with ethnic or gender predisposition to those cancers.

Adolescent↗

Prediction of health behaviors in pediatric cancer survivors.

BACKGROUND: It is important to understand the factors that motivate survivors of childhood cancer to engage in healthy behaviors. This is because of their susceptibility to adverse late effects from their malignancy and its treatment. We specifically examined sociodemographic and health perception variables as predictors of health-protective behaviors in pediatric cancer survivors. PROCEDURE: Forty-six patients, ages 10--18 years, who were previously treated for cancer and were 1--4 years off-therapy, were assessed using a battery of testing instruments. RESULTS: Preadolescent and adolescent cancer survivors reported moderately frequent practice of a variety of health-protective behaviors. The prevalence of risky health behaviors, as indicated by alcohol and tobacco use, was low. Regression analyses indicated that the practice of health-protective behaviors was best predicted by patient's age and socioeconomic status (SES); younger adolescents and patients from higher SES more frequently engaged in healthy behaviors. Health perception variables were not significantly related to health-protective behaviors. This was true despite findings that survivors perceived themselves to be vulnerable to health problems, identified a need to protect their health, and perceived their health outcomes to be largely determined by their own behaviors. CONCLUSIONS: Sociodemographic factors should be kept in mind when designing interventions to promote continuing good health for young cancer survivors. Also to be included is the assessment of specific health risks secondary to the cancer therapies given. Risk counseling that recognizes and builds on these variables will be most effective in helping this patient population observe sound health habits.

Adolescent↗

Robust prioritization of genomic features with stability selection.

MOTIVATION: The heterogeneity of complex diseases including cancer leads to heavy-tailed distributions in the disease traits. In such settings, non-robust variable selection methods are inherently susceptible to data contamination and can yield unstable or misleading results. This vulnerability becomes more severe for recently proposed approaches that introduce pseudo-features as negative controls, as these methods further amplify the curse of dimensionality by expanding the genotype matrix in the presence of outliers and high-dimensional genomic features. RESULTS: We develop a robust variable selection framework with stability selection to prioritize genomic features in the presence of contamination. In contrast to existing approaches that rely on pseudo-features for error control, the proposed method achieves double robustness. First, it adopts least absolute deviation (LAD) LASSO to ensure robustness against outliers and heavy-tailed errors in disease traits. Second, it avoids augmenting the genotype matrix with pseudo-features, thereby mitigating the curse of dimensionality that is particularly problematic in high-dimensional genomic data. The proposed method has been extensively evaluated in simulation studies to demonstrate its effectiveness over multiple competing methods for variable selection. In addition, we have applied the proposed method and competing approaches to two real-data case studies: the The Cancer Genome Atlas (TCGA) Skin Cutaneous Melanoma (SKCM) dataset and an eQTL dataset. The results demonstrate that the proposed method achieves superior performance by identifying genomic features with higher reproducibility. AVAILABILITY AND IMPLEMENTATION: The source code for implementing the proposed methods is publicly available at https://github.com/cenwu/RSS with an archival DOI https://doi.org/10.6084/m9.figshare.32306883.

Genomics↗

Copper uptake is required for pyrrolidine dithiocarbamate-mediated oxidation and protein level increase of p53 in cells.

The p53 tumour-suppressor protein is a transcription factor that activates the expression of genes involved in cell cycle arrest, apoptosis and DNA repair. The p53 protein is vulnerable to oxidation at cysteine thiol groups. The metal-chelating dithiocarbamates, pyrrolidine dithiocarbamate (PDTC), diethyldithiocarbamate, ethylene(bis)dithiocarbamate and H(2)O(2) were tested for their oxidative effects on p53 in cultured human breast cancer cells. Only PDTC oxidized p53, although all oxidants tested increased the p53 level. Inductively coupled plasma MS analysis indicated that the addition of 60 microM PDTC increased the cellular copper concentration by 4-fold, which was the highest level of copper accumulated amongst all the oxidants tested. Bathocuproinedisulphonic acid, a membrane-impermeable Cu(I) chelator inhibited the PDTC-mediated copper accumulation. Bathocuproinedisulphonic acid as well as the hydroxyl radical scavenger d-mannitol inhibited the PDTC-dependent increase in p53 protein and oxidation. Our results show that a low level of copper accumulation in the range of 25-40 microg/g of cellular protein increases the steady-state levels of p53. At copper accumulation levels higher than 60 microg/g of cellular protein, p53 is oxidized. These results suggest that p53 is vulnerable to free radical-mediated oxidation at cysteine residues.

Animals↗

Out-of-pocket expenditures of outpatients receiving chemotherapy.

PURPOSE/OBJECTIVES: To examine the magnitude of out-of-pocket expenditures for patients undergoing chemotherapy in an outpatient clinic. DESIGN: Cross-sectional survey. SETTING: An urban outpatient chemotherapy clinic. SAMPLE: Convenience sample of 20 adult patients with cancer. METHODS: Birenbaum's Cost Interview Schedule was administered to patients as they awaited treatment in the chemotherapy clinic; demographic data were collected from patients' charts. MAIN RESEARCH VARIABLE: Out-of-pocket expenditures incurred during a one-month period of chemotherapy treatment. FINDINGS: Estimated out-of-pocket expenses, excluding lost income, ranged widely from $12-$3,130. CONCLUSIONS: Out-of-pocket expenses come from multiple sources over time and can be more costly than previously recognized. Extent of out-of-pocket expenditures may depend on treatment protocol, ease of symptom management, functional status, and nonclinical elements such as socioeconomic factors. Additional investigation can identify which patients are most vulnerable to excessive out-of-pocket expenses and who may be at risk for treatment delay or withdrawal because of difficulties in meeting expenses. IMPLICATIONS FOR NURSING PRACTICE: Recognition of the hidden costs incurred by patients with cancer as they undergo treatment enables nurses to anticipate the financial burden of illness, make necessary referrals, address quality-of-life issues because of financial distress, and avert critical delays in treatment related to overwhelming healthcare costs.

Adult↗