Sep 23, 2021
Dr. Scout and Dr. Charles Kamen discuss the findings of a key survey by the National LGBT Cancer Network of LGBTQI cancer survivors and strategies to improve cancer care for sexual and gender minority patients and survivors. Dr. Scout is the executive director of the National LGBT Cancer Network. Dr. Kamen is a clinical psychologist, assistant professor in the Department of Surgery at the University of Rochester Medical Center, and assistant director for community outreach and engagement at the Wilmot Cancer Institute.
ASCO Daily News: Welcome to the ASCO Daily News podcast. I'm Geraldine Carroll, a reporter for the ASCO Daily News. The National LGBT Cancer Network has released the findings of a key survey of LGBTQI cancer survivors about their cancer treatment experience. To discuss the survey's findings and strategies to improve care for sexual and gender minority patients, I'm joined by Dr. Scout, executive director of the National LGBT Cancer Network, and Dr. Charles Kamen, a clinical psychologist and assistant professor in the Department of Surgery at the University of Rochester Medical Center and assistant director for Community Outreach and Engagement at the Wilmot Cancer Institute. Dr. Kamen also leads the University of Rochester's health equity research for the NCI Community Oncology Research Program.
My guests report no conflicts of interest relating to our discussion today. Their full disclosures and those relating to all episodes of the podcast are available on our transcripts at asco.org/podcasts.
Dr. Scout and Dr. Kamen, welcome to the ASCO Daily News podcast.
Dr. Scout: Thanks. We're really happy to be here.
Dr. Charles Kamen: Thanks so much for having us.
ASCO Daily News: Dr. Scout, the survey captured the experience of over 2,700 individuals. And I think it's important to let our listeners know that approximately 100,000 LGBTQI people are diagnosed with cancer in the United States every year. So although the survey represents just a fraction of this total patient population, these data are important and shed light on the many challenges facing these patients and survivors from diverse communities across the country.
What are the major themes that emerged from these data? And can you give us some specific examples from the survey.
Dr. Scout: Yeah, absolutely. And first of all, I just want to say I'm happy that ASCO is paying attention to this. It's something that we're really proud of having done with the help of about 150 community partners. So, it was really kind of a community-wide effort. And we're really delighted to have this much information about a topic that is so important.
The main takeaway is--we have really kind of four overarching themes we really think about a lot related to the survey. One of them--and this is nice, because we did a survey about 11 years ago, and this is actually pretty different--and that's that many people were able to report that they were able to get welcoming care. So, that we can't directly compare. But we do think that that is kind of a sign of changing times, a sign of the fact that a lot of providers really are trying to do a better job in this arena.
But, unfortunately, there's a few big caveats to that. One is that people often had to go through a much longer journey to get to welcoming care, whether that be physical distance or trying several doctors, different things like that. No one needs that when they're under the duress of a cancer diagnosis. Second of all, if you were any underserved or underrepresented population within the queer communities, like trans or a person of color, your chance of getting that welcome care, of course, dropped.
And then the second big theme is that our families, our chosen families, not only are they a real source of resilience for us, but our support teams are different, usually, than general population support teams. It might be an ex, a best friend, and one cousin kind of thing. But if they're really our chosen family, we need to do a better job of having hospitals acknowledge and recognize and treat them as the people who are our key support teams. Not as much work is being done on that as we'd really like to think is the case.
The third big theme is that a lot of us, we're really looking for tailored resources about all sorts of things, including cancer prevention strategies, even right down to we wanted LGBTQ-tailored resources for physical-activity strategies. And we were almost uniformly unable to get those resources. So there is, especially these days, in a time when you can tailor things down to lots of different subpopulations, we still have a pretty big miss related to what's happening with the queer population on that.
And then the fourth thing--and this we can only really kind of hypothesize--but people were talking about some kind of brutal statements that their doctors were making to them, people who were being told they have cancer in a very rough way, things like that. And we don't wonder if this could be the phenomena of the microaggressions emerging through standard care. And that's something that concerns us and, I think, something to watch.
Dr. Charles Kamen: It's amazing to me, Scout, that the themes from this survey are so similar to the previous survey that you conducted back in, what was that, 2011?
Dr. Scout: Yeah.
Dr. Charles Kamen: So it's been 10 years, and still the same themes are coming up for this population.
Dr. Scout: It is the case. Geraldine, you may not even know this, but Charlie is the other human who is the best expert in the world on what our last survey was, because he worked with us to do a bunch of publications off of it. And yeah, I would say it's distressing. We might have had, potentially, a reduction in some of the phenomena. But we had action steps, coming out of the last survey, that we've been training and we've been going around talking to everybody about for obviously over a decade now. And unfortunately the news is still the same.
ASCO Daily News: Well, Dr. Scout, I'd like to follow up on a point you made about the importance of welcoming care. Certainly the environment in which people receive care can have a significant impact on their experience. Only 12% of respondents in the survey felt that they had received care in a welcoming environment where they saw, for example, a rainbow flag, they saw affirmative messages, and so forth. This is a very significant takeaway for oncologists in community practice and elsewhere.
So, Dr. Scout, do you have any tips for providers about how to make LGBTQI individuals feel welcome, in a safe space, whether they are face to face with their oncologist, or getting blood work done, or even a biopsy?
Dr. Scout: Yeah, we absolutely do. If you think about it, there is a history of bias and discrimination against this set of communities. And unfortunately, right now, if you're not doing something to distinguish yourself from that history, we can't tell. You know, we can't tell that you're not part of the problem.
So, what we say and all the cultural competency trainers say to providers would be, show us. Do something. Don't just think to yourself, well, I support Pride or something like that. But, do something so we can tell as the patients.
So, there's a whole bunch of strategies that are very simple. Put the Rainbow Pride flag up in your office. Partner with a local queer organization to do some outreach. Make sure that you have tailored materials on your website. If I go on your website and search the word, bisexual, and find nothing, not even a non-discrimination statement, then how in the world am I supposed to understand that I might potentially be welcomed there?
And in addition, one of the ways you can do it in a regular, routine, everyday interaction, people often ask, well, what about if I'm [doing this]--work on the systems at your organization, work on the media, work on what's in your waiting room, but then what do you do in that face-to-face interaction? Simplest thing is--it's a beautiful new thing--introduce yourself with your pronouns. So just say, hi, my name is Scout. My pronouns are he/him. So, I'd like to get to know you. If you can tell me your name and your pronouns. And go from there.
It doesn't say that you're queer, it simply says that you acknowledge one aspect of the difficulties experienced by the queer communities and that you're open and trying to be welcoming so that people, if they have unexpected pronouns or even if they have expected pronouns, they still get that little bit of a message that you're welcoming.
ASCO Daily News: Dr. Kamen, do you have any thoughts on approaches that oncologists should be taking? And do you have a sense that these tips are being heard?
Dr. Charles Kamen: I think that extra level to everything that Scout said, which I 100% agree with, is don't put the rainbow sticker on the door unless your staff are competent to treat LGBTQ patients. So, before you have the visible sign of being affirming and welcoming, make sure that you're doing some training of the staff. Make it mandatory if you can. And think about how you are identifying and reaching out to your LGBTQI patients in your practice so that their identities are acknowledged and that they're referred to appropriate services after their cancer care ends or even during their cancer care.
Dr. Scout: You know, I will also just say, related to that--and I completely agree--lots of providers, when you refer anybody out to another provider, if you're welcoming, you want to refer them to a welcoming provider. And unfortunately the strategy for figuring that out right now is still usually a provider calling another provider and figuring out how welcoming they are, and then doing follow-up with the patient.
So, kind of even above and beyond that, remember, especially as an oncologist, your patient is going to now have to experience a bunch of other people. What have you done to make sure that you're able to refer them to welcoming providers instead of just having your own office be welcoming?
Dr. Charles Kamen: And how are you working within the community to be sure that about resources that are outside the walls of your institution, but that may be very LGBTQ-affirming? You may not have an LGBTQI support group in your cancer center, but there may be a great one in town that you could refer patients to. So, I think it is both acknowledging visibly that you are an ally, but putting action to that by looking around for resources to send people to.
Dr. Scout: And if not, we have new national ones you can refer people.
Dr. Charles Kamen: Yes.
ASCO Daily News: Thank you both for making those great points. Dr. Kamen, you've done [so] much research on the experience of LGBTQI individuals in cancer care and have stressed the need for research that is specific to the needs of this population. Can you tell us about the role that identity plays among LGBTQI individuals in determining levels of distress?
Dr. Charles Kamen: If I can dip back into history for just one second, people probably know that, up until 1973, homosexuality was listed by the American Psychiatric Association as a mental illness. And there's still, to this day, discussion around diagnoses like, quote unquote, "transsexualism," or gender identity disorder, or gender dysphoria as sources of psychological distress.
So, there's been a longstanding recognition that LGBTQI identities carry with them a burden of distress. But it wasn't really until the early 2000s that researchers like Vickie Mays or Susan Cochran and Ilan Meyer started to recognize that issue wasn't the LGBTQI identities themselves, the issue was living in a society where LGBTQI individuals were exposed to constant stigma and discrimination. And this led to the development of the Minority Stress Model which many researchers still use today as a way to understand why LGBTQI people experience higher levels of distress and have higher rates of diagnoses like anxiety and depression than heterosexual and cisgender people.
I won't go into an incredible description of Minority Stress, but just the basic premise of it is that LGBTQI individuals walk around the world every day with a stigmatized identity. They could be directly exposed to discrimination as a result of this identity, or they could see people in their community being discriminated against, or anticipate discrimination going into a new environment or situation.
So, all of this can cause chronic underlying stress. There was some very cool pioneering work by Mark Hatzenbuehler and his team that showed that really it's the process of ruminating about these experiences that causes physiologic changes like inflammation. And that has a cascade effect, downstream, on having high rates of distress among LGBTQI people.
And I think, in cancer, we can see this whole process playing out very clearly. We were talking before about the survey that was done in 2011 that I worked on with Scout. And I always talk about this one participant in that study who said, "My oncologist knew about me."--she was a lesbian patient--"My oncologist knew I was a lesbian." But every time I had to encounter a new person, whether for an X-ray or a blood draw, I had all the anxiety of that cancer procedure plus the possibility of homophobia and having to watch out for myself.
Cancer is stressful for everybody. But then, if you have to constantly negotiate whether and how to come out to your providers, you have to brace yourself for discrimination if you do come out. And then, if you don't come out, you have to worry, well, does my provider really know me as a human being if they don't know this important part of myself? All of that can exponentially magnify the stress that LGBTQ people with cancer experience. And so that's really, I think, at least the theoretical framework for understanding these rates of distress.
Dr. Scout: Hey, Charlie, you may not know this, but did I ever tell you that I was diagnosed as a homosexual in 1984?
Dr. Charles Kamen: I wasn't sure how much to go into it. Yeah, I mean, it was still floating around in the Diagnostic and Statistical Manual until 1987, I believe, you could be diagnosed.
Dr. Scout: Also, just really bring home what Charlie is talking about on the other end of it, you know, here I am, the executive director of the National LGBT Cancer Network. And trust me, my partner had to push me to go to the dermatologist to get something checked out, which ultimately was cancer. You know, it's fully treatable.
But there's this real difference between those of us who are kind of like, stiffly this is what we should do, you know? And then when you face the fact of standing naked in front of a provider who you think could be cruel to you, it's a very daunting possibility. So, there's a million ways you can find something else that's going to be your priority that day other than take care of your health needs.
Dr. Charles Kamen: Absolutely. And it also causes people to not want to disclose. But then we had another person from the survey who said there's a part of the cancer experience that never gets shared with providers if they don't know who you really are as an LGBTQI person. So, it's really a catch-22.
ASCO Daily News: So, what is the absolute best practice, in your opinion, to get an assessment of sexual orientation or gender identity that doesn't rely on the patient's disclosure? How should this ideally be done? You've discussed it before, earlier, in our conversation. But is there a best practice that our listeners can take away with them today?
Dr. Charles Kamen: I mean, just based on the minority stress model, it's definitely incumbent on the practices to assess Sexual Orientation and Gender Identity, or SOGI, in a way that's comfortable and affirming for patients. And most of the time, as we're saying, right now, the onus is on the patient to disclose, which is super unfair.
Usually it happens organically. A patient will come in, an LGBT patient will come up with the same-sex partner, and introduce their partner to the provider. And then it is just kind of known that they are a sexual minority person, or based on a med list, or pronouns, or name on an insurance card, a transgender status is known.
But sometimes it doesn't happen that way. It doesn't happen organically. And there's a real breakdown in communication then. And beyond that, a patient's dealing with a million things at the beginning of a cancer journey anyway. So, having them be the ones to figure out how to talk about this is very unfair.
I think the best research we have on this topic is from the EQUALITY study which was done a couple of years ago now by researchers from Harvard and Johns Hopkins. And it focused specifically on the emergency medicine context. But they surveyed a ton of people and providers and found that the overwhelming majority of patients were willing to disclose SOGI, but that they preferred to do it non-verbally, so through a form or a survey or a patient portal, and not verbally, face to face with a provider. That felt less stigmatizing and intense to the respondents in this survey.
Dr. Scout: The other key piece about that is that an overwhelming number of providers thought that they shouldn't know that information because it was too invasive. So, we really need to close that gap.
Dr. Charles Kamen: I forget the exact percentages, but it was something like--
Dr. Scout: It was 90% were willing to disclose, but 80% of providers thought that they shouldn't know.
Dr. Charles Kamen: Yes, yes, thought that patients would not disclose. And there was some variation by the LGBTQI identity, with heterosexual patients being a little lower, like 84%, and lesbian respondents, like 98% of them were like, yes, ask us, we want to tell you.
So, there is that mismatch. And I think the takeaway message, though, is patients are comfortable providing this data if it's asked of them in a respectful and affirming way.
Dr. Scout: And I was going to say, just kind of bringing this down to just real-life experience, I had an experience at a health center recently that I think really is--it was certainly the best practice I'd ever had. And that's that I walked into a waiting room. And in the waiting room, I could see three different cues that they were LGBTQ welcoming. There was a big banner sign saying, "We welcome everybody." There was some stuff up about their Pride activities even though it wasn't Pride Month. And then there was a rainbow sticker on the window or something like that.
By the time I saw those three signs, the fourth thing was they asked me my sexual orientation and gender identity on my intake form. And by then I was like, absolutely, no question, I'm absolutely going to give it.
And I will say they even had a fifth thing. I then went through the patient--and it was like a dental procedure--I went through the procedure, and afterwards something happened that literally made my hair stand up on my neck because I realized how far away we are from this. Someone called me and said, "I'm from the health center. This is Thundermist"--our local federally-qualified health center. "I saw that you marked down that you were trans. I just wanted to welcome you. I'm the trans outreach coordinator. And I wanted to talk to you about some different trans support activities that we have going on across the health center, like swim night, game night, yoga night, things like that."
So, I mean, really it made the hair stand up on my head. I'm like, wow, I'm not just tolerated here, I'm valued. And it was the first time I think that I had ever considered or thought that in a health interaction in my life.
Dr. Charles Kamen: That's incredible. And I think that's the real next step we have to take as organizations, health care organizations, and as a society. If we're going to collect these data, why? What is it being used for?
Dr. Scout: What are we giving back? Yeah.
Dr. Charles Kamen: Yeah. How are we referring people to things like a trans yoga night? Make sure there's action behind collecting the data.
Dr. Scout: But even before that, before we collect, are we showing them it's safe before we ask them to disclose? So, basically are we going out on a little bit of--not even a limb, first, but are we putting our cards on the table before we ask them to put their cards on the table?
Dr. Charles Kamen: Yeah, don't go in cold. Let them know it's a safe place to have this disclosure.
Dr. Scout: Yes.
Dr. Charles Kamen: I will add in, too, we in the ASCO Sexual and Gender Minority Task Force recently conducted a survey with the support of ASCO's Center for Research and Assessment. And we found, by polling over 200 ASCO members, that the two main factors that predicted whether a practice would collect SOGI data was leadership support, which makes sense--if the top is saying, this is important to do, we need to collect SOGI data, it's going to happen across multiple levels of the institution--but also having resources. And I think that's resources both for collecting the data itself, like IT resources or even knowing what questions to ask, but also resources like Scout's saying, to have banners and stickers and training and activities and support. All of that together makes the practice able to do this in a holistic and affirming way.
Dr. Scout: You know, I will say, with the IT support, though, everybody has it in their software package these days. It's just a question of flipping the switch. There's built-in, pre-baked questions. They're not the best in the universe, but they're perfectly functional. So, I hope people realize that that's already there.
Dr. Charles Kamen: Yeah. As of 2018, every electronic medical record has to, by federal law, have a SOGI data collection element within it. And then I think the resource may as much be knowing how to do it as the time and effort to turn those modules on.
ASCO Daily News: Absolutely. So, here's a scenario. We have an LGBTQI individual who is receiving cancer care. And that person comes to the appointment with their caregiver. How should the clinician acknowledge the relationship of a patient or survivor and their partner? This is a very important aspect of care. Dr. Scout, what are your thoughts on this?
Dr. Scout: Well, I presume this isn't the only set of people you're going to see where it may not be husband or wife. The concept of husband and wife have been expanding these days. So, I hope that the oncologist is asking who the person is who's with them. Is this your primary support person? Is this your partner? I just want to make sure, because, of course, having the right support and the best support is going to be important to you doing the best job getting through this whole health event.
So, I would hope that the oncologist is introducing themself with their own pronouns, again, and then asking who all the people at the table are and how they relate to the patient. Because I think we know by now that all those other people are really going to be providing them with a lot of health care support in all those hours when the oncologist is not in front of that patient.
Dr. Charles Kamen: I agree with that. And I think there are lots of examples of this process not going well, the question not being asked, and then the caregiver not being acknowledged for the relationship they have to the patient. And the real problem there is you don't get to offer the caregiver resources then. And a lot of LGBTQ patients and their caregivers report that the caregivers experience as much stress or more stress than the patient does.
So, by getting at this relationship, by asking a simple question like, "Who do we have with us today?" you can then refer that caregiver to a support group or resources as needed.
ASCO Daily News: Of course. I'd like to focus on mental health for a moment. Mental health is a huge concern. And 70% of respondents of the National LGBT Cancer Network survey reported that they never received resources related to mental health developed for LGBTQI individuals.
I'd like to read a quote from one respondent, who wrote, "With respect to mental health in particular, it seems that, locally, there are no criteria for what constitutes LGBTQI care. Mental health providers state that they are, quote unquote, 'friendly,' and have no means of describing what that means. Some are not at all aware of their own biases and subtle homophobia." Dr. Scout, what is your reaction to this statement?
Dr. Scout: I think it's all too true. I've had a lot of challenges with the mental health system myself, as has probably most of the people that I know. So, it's yet again an area where I think the fix is not that complicated. I hope, by now, mental health providers understand [that] they do not see a homogeneous group of people.
And I think, especially these days, since most people are going to the internet for their resources, this really begs the question of, you know, we don't have to wait for the National LGBT Cancer Network to create a bunch of resources. Because trust me, we're not that well funded. But if anybody makes a resource, send it to us. We'll put it on our resource library. And it can be available for anybody around the country.
So, this really is going to take a village of providers to fix some of these issues. I'm not going to ask any one provider or provider group to fix all of them. But if everybody can do a little something, we'll pull all those together and make it available to everybody else. And that will really help build a basis of information. Also, just FYI, in cultural competency, there's a bunch of standards about to be released related to cultural competency. And we do provide trainings, as do other organizations.
So, as with all of these things, take some steps. Inaction is hurting us.
ASCO Daily News: Dr. Kamen, do you have any thoughts on this?
Dr. Charles Kamen: Definitely. I agree with everything that Scout just said. And I think the one maybe silver lining to living through the COVID-19 pandemic has been that we are way more facile now at navigating telehealth services than we were pre-pandemic. I know, in our cancer center, our psycho-oncology service has had more business during the pandemic than before because they're offering virtual visits to patients.
Even if an LGBTQI patient doesn't find a provider within their health care facility that they feel is competent or welcoming, you can go on the internet, as Scout is saying, and you can find really excellent queer-focused and affirming therapists that you can see virtually. So, that's, I guess, one benefit and one thing I hope that we continue to innovate on as we move through 2021.
Dr. Scout: The one thing I would say about that is a lot of that's being threatened by these licensing issues. Because a lot of that is only being provided under licensing exceptions for COVID-19. Likewise our support groups are living under a licensing exception for COVID-19.
So, there has been increasing pressure at a lot of places. I was literally just talking to the White House about it 2 days ago--no, that would be over the weekend--right before the weekend, about how telehealth really is a huge concern for our communities. And continuing these exemptions for all rare and underserved and discriminated-against populations and rural populations that just don't have a big provider base around them, is going to be really, really critical.
So, I hope that there's going to be action on this telehealth front to make these licensing exceptions stick and not just be a little bright light that goes away once we've decided COVID-19's done.
Dr. Charles Kamen: Absolutely agree. And I think that's at the federal level and the state level too. We need advocacy to make sure that these telehealth expansions remain in practice long term.
ASCO Daily News: Dr. Kamen, you cited some interesting research earlier in the conversation. Is there any other research that is specific to the needs of the LGBTQI population that you'd like the oncology community to be aware of?
Dr. Charles Kamen: Oh my gosh, I feel like there's so much good stuff going on now. And it's an amazing change from 2011, when I first started working with Scout on that survey, which was really the only survey of its type anywhere.
Now there is more of a groundswell of interest and effort around LGBTQI cancer care. I'll just highlight three of the projects that are happening with members of the ASCO SGM Task Force. So, I've been working with the Fenway Institute in Boston, which has pioneered a lot of LGBTQI cultural competency training. And we're trying to bring that training and SOGI data collection elements to community oncology. And that's part of the NCI Community Oncology Research Program research base that I work with. So, that's one thing.
Mandi Chapman, another member of the ASCO SGM Task Force, has a beautiful, very comprehensive training that's called the Together Equitable Accessible Meaningful, or TEAM, training. And she's tailored this to SGM-specific care and is testing it with multiple cohorts of health care providers. I think there'll be a publication coming out about that sooner rather than later so keep an eye out for that. And also I believe she is recruiting additional cohorts. So, keep an eye out for that as well.
And then Ash Alpert, another member of the ASCO SGM Task Force, got a Young investigator Award from the Conquer Cancer, [the ASCO Foundation]. And they are developing patient-centered, non-stigmatizing gender identity data collection methods that can be implemented across oncology settings. And they're also looking at connections between violence and cancer risk for the transgender population.
Really, I think this work is incredibly timely. Because people may know or may not know that right now the National Academies of Sciences, Engineering, and Medicine, they're working on a consensus document that's really trying to summarize how best to collect SOGI data across settings. So, Dr. Alpert's work to get a trans-community perspective on this topic is super critical.
Of course, I would be remiss if I didn't mention the National LGBT Cancer Network and their training that they're doing as well, which I believe is still in existence and can be accessed, though Scout, you can correct me if I'm wrong on that.
Dr. Scout: We're actually also doing a partnership right now, with Society for Gynecologic Oncology, to convert it to an online enduring training so it can scale wider. And we actually expect that to be debuting at the beginning of next year.
Dr. Charles Kamen: Yeah, it's so great that there are so many of these efforts happening, because it means that multiple groups can access the training through different channels. And we can end up, hopefully, with a much better pipeline of LGBTQI-competent and trained providers.
The last thing I'll mention is that the ASCO SGM Task Force had done that survey to look at the factors that predict SOGI data collection. And we're now doing a phase II follow-up where we're going to be doing qualitative, in-depth interviews and focus groups with member organizations to try to understand what the factors are on the ground that predict people collecting SOGI or not. So, we'll definitely be looking for organizations to participate in that study, probably in the next couple of months.
Dr. Scout: And I would say you're hearing us talk a lot about data collection because that really is the biggest next horizon related to advancements in SOGI care. Because just to be clear, we can't tell you what our cancer rates are because we don't have any data in any of the registries because that's all abstracted from health records. So, until we get these questions asked as you go into a health care environment, we won't be able to tell you what our disproportionate COVID-19 impact is, we won't be able to tell you our cancer rates. And of course, without a lot of that hard data, we also can't even apply for more research or do interventions to try and fix it.
So, that's why one of the things we really try and encourage providers to look at is when are you going be able to flip that switch and actually do that data collection. If you're really committed to being inclusive for our population, that's a key step.
ASCO Daily News: Absolutely. Well, we will share a link to the National LGBT Cancer Network survey in the transcript of this episode, along with all of the other research and resources that you discussed today.
Thank you so much, Dr. Kamen and Dr. Scout, for being on the podcast today and shining a spotlight on a very important topic in cancer care. Thanks so much.
Dr. Scout: Absolutely. Thank you.
ASCO Daily News: And thank you to our listeners for your time today. If you enjoyed this episode, please take a moment to rate, review, and subscribe wherever you get your podcasts.
Dr. Charles Kamen: None disclosed
Research Funding (institution): Bristol Myers Squibb
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