Management Options For Cancer Research Articles

The impact of adding cost information to a conversation aid to support shared decision making about low-risk prostate cancer treatment: Results of a stepped-wedge cluster randomised trial.

Decision aids help patients consider the benefits and drawbacks of care options but rarely include cost information. We assessed the impact of a conversation-based decision aid containing information about low-risk prostate cancer management options and their relative costs. We conducted a stepped-wedge cluster randomised trial in outpatient urology practices within a US-based academic medical center. We randomised five clinicians to four intervention sequences and enroled patients newly diagnosed with low-risk prostate cancer. Primary patient-reported outcomes collected postvisit included the frequency of cost conversations and referrals to address costs. Other patient-reported outcomes included: decisional conflict postvisit and at 3 months, decision regret at 3 months, shared decision-making postvisit, financial toxicity postvisit and at 3 months. Clinicians reported their attitudes about shared decision-making pre- and poststudy, and the intervention's feasibility and acceptability. We used hierarchical regression analysis to assess patient outcomes. The clinician was included as a random effect; fixed effects included education, employment, telehealth versus in-person visit, visit date, and enrolment period. Between April 2020 and March 2022, we screened 513 patients, contacted 217 eligible patients, and enroled 117/217 (54%) (51 in usual care, 66 in the intervention group). In adjusted analyses, the intervention was not associated with cost conversations (β = .82, p = .27), referrals to cost-related resources (β = -0.36, p = .81), shared decision-making (β = -0.79, p = .32), decisional conflict postvisit (β = -0.34, p= .70), or at follow-up (β = -2.19, p = .16), decision regret at follow-up (β = -9.76, p = .11), or financial toxicity postvisit (β = -1.32, p = .63) or at follow-up (β = -2.41, p = .23). Most clinicians and patients had positive attitudes about the intervention and shared decision-making. In exploratory unadjusted analyses, patients in the intervention group experienced more transient indecision (p < .02) suggesting increased deliberation between visit and follow-up. Despite enthusiasm from clinicians, the intervention was not significantly associated with hypothesised outcomes, though we were unable to robustly test outcomes due to recruitment challenges. Recruitment at the start of the COVID-19 pandemic impacted eligibility, sample size/power, study procedures, and increased telehealth visits and financial worry, independent of the intervention. Future work should explore ways to support shared decision-making, cost conversations, and choice deliberation with a larger sample. Such work could involve additional members of the care team, and consider the detail, quality, and timing of addressing these issues. Patients and clinicians were engaged as stakeholder advisors meeting monthly throughout the duration of the project to advise on the study design, measures selected, data interpretation, and dissemination of study findings.

Can Natural Products Targeting EMT Serve as the Future Anticancer Therapeutics?

Cancer is the leading cause of death and has remained a big challenge for the scientific community. Because of the growing concerns, new therapeutic regimens are highly demanded to decrease the global burden. Despite advancements in chemotherapy, drug resistance is still a major hurdle to successful treatment. The primary challenge should be identifying and developing appropriate therapeutics for cancer patients to improve their survival. Multiple pathways are dysregulated in cancers, including disturbance in cellular metabolism, cell cycle, apoptosis, or epigenetic alterations. Over the last two decades, natural products have been a major research interest due to their therapeutic potential in various ailments. Natural compounds seem to be an alternative option for cancer management. Natural substances derived from plants and marine sources have been shown to have anti-cancer activity in preclinical settings. They might be proved as a sword to kill cancerous cells. The present review attempted to consolidate the available information on natural compounds derived from plants and marine sources and their anti-cancer potential underlying EMT mechanisms.

Innovative Translation Strategies in the Emergence of Next-Generation Drugs in Precision Cancer Medicine

There has been a conscientious momentum to evolve more efficacious and potent chemotherapeutics that could cure advanced cancers. Although, the conventional cancer therapeutics can cause dramatic tumor regressions in some patients, many patients inexplicably reveal no benefit. This is a unique characteristic of tumor recurrence in human cancers, linked with several resistance mechanisms. Recent past years witnessed enormous ground-breaking advancements in genomic medicine symbolizing a culmination of patients' genomic, proteomic, metabolomic, including cellular profiles which have significantly transformed understanding and therapeutic options for cancer management. Furthermore, the ability of combination chemotherapy to cure advanced cancers, immensely facilitated the prospects of adjuvant chemotherapy. Many global pharmaceuticals have accelerated translational research strategies on proteomics and genomic technologies paving the way to emerge next-generation drugs to strengthen personalized cancer medicine. Numerous forthcoming cancer therapies are at most vital phase in their innovation and development for the unfulfilled clinical need to turn into futuristic cancer treatment strategies. There is a growing optimism about the innovative strategies on emergence of the new generation of immunotherapy, targeted therapies, and Oligonucleotide therapy to improve patient outcomes, and to make real dream of accomplishing personalized cancer therapy.

Clinical Management of Prostate Cancer in High-Risk Genetic Mutation Carriers.

Simple SummaryMen with certain genetic differences are at much higher risks of developing metastatic and lethal prostate cancer. With the recent introduction of a new class of medications specifically targeted to these gene repair pathways (PARP inhibitors), it is critical to review the state of the literature surrounding the management of men with prostate cancer who have these genetic differences. We review the existing literature to address common clinical questions pertaining to this population. There is an urgent need for further research regarding clinical management in these scenarios as patients are increasingly seeking out genetic testing and consulting healthcare professionals for guidance.Background: Prostate cancer is a leading cause of death. Approximately one in eight men who are diagnosed with prostate cancer will die of it. Since there is a large difference in mortality between low- and high-risk prostate cancers, it is critical to identify individuals who are at high-risk for disease progression and death. Germline genetic differences are increasingly recognized as contributing to risk of lethal prostate cancer. The objective of this paper is to review prostate cancer management options for men with high-risk germline mutations. Methods: We performed a review of the literature to identify articles regarding management of prostate cancer in individuals with high-risk germline genetic mutations. Results: We identified numerous publications regarding the management of prostate cancer among high-risk germline carriers, but the overall quality of the evidence is low. Conclusions: We performed a review of the literature and compiled clinical considerations for the management of individuals with high-risk germline mutations when they develop prostate cancer. The quality of the evidence is low, and there is an immediate need for further research and the development of consensus guidelines to guide clinical practice for these individuals.

Discovery of SIRT7 Inhibitor as New Therapeutic Options Against Liver Cancer.

Optimal therapeutic strategies for liver cancer patients remain challenging due to the high recurrence rate after surgical resection and chemotherapy resistance. Emerging evidence has shown that epigenetic factor SIRT7 is involved in various aspects of cancer biology, while inactive SIRT7 reverses human cancer phenotype and suppresses tumor growth. In the present study, we predicted the SIRT7 structure by using the fold recognition (or threading) method and performed structure-based virtual screening to develop specific SIRT7 inhibitor by docking 939319 structurally diverse compounds with SIRT proteins. Compounds with high affinities to SIRT7 but low affinities to other SIRT proteins were chosen as candidates of specific SIRT7 inhibitor. Our leading compounds 2800Z and 40569Z showed strong interaction with SIRT7 protein, and specifically inhibited SIRT7 deacetylation activity in vitro. Our docking results also revealed that ARG-120, TRP-126, and HIS-187 were critical sites responsible for interaction of SIRT7 with small molecules. Mutations in the aforementioned sites significantly abolished interaction and inhibitory effects of compounds to SIRT7. In addition, in vivo data indicated that compounds 2800Z and 40569Z were able to induce apoptosis and increase chemosensitivity to sorafenib in human liver cancer. Our findings demonstrated targeting SIRT7 may offer novel therapeutic options for cancer management, and the value of compounds 2800Z and 40569Z as chemical probes for the study of SIRT7 biological functions as well as starting leads for the development of new therapeutic options against liver cancer.

Cost talk: protocol for a stepped-wedge cluster randomized trial of an intervention helping patients and urologic surgeons discuss costs of care for slow-growing prostate cancer during shared decision-making

BackgroundCosts of care are important to patients making cancer treatment decisions, but clinicians often do not feel prepared to discuss treatment costs. We aim to (1) assess the impact of a conversation-based decision aid (Option Grid) containing cost information about slow-growing prostate cancer management options, combined with urologic surgeon training, on the frequency and quality of patient-urologic surgeon cost conversations, and (2) examine the impact of the decision aid and surgeon training on decision quality.MethodsWe will conduct a stepped-wedge cluster randomized trial in outpatient urology practices affiliated with a large academic medical center in the USA. We will randomize five urologic surgeons to four intervention sequences and enroll their patients with a first-time diagnosis of slow-growing prostate cancer independently at each period. Primary outcomes include frequency of cost conversations, initiator of cost conversations, and whether or not a referral is made to address costs. These outcomes will be collected by patient report (post-visit survey) and by observation (audio-recorded clinic visits) with consent. Other outcomes include the following: patient-reported decisional conflict post-visit and at 3-month follow-up, decision regret at 3-month follow-up, shared decision-making post-visit, communication post-visit, and financial toxicity post-visit and at 3-month follow-up; clinician-reported attitudes about shared decision-making before and after the study, and feasibility of sustained intervention use. We will use hierarchical regression analysis to assess patient-level outcomes, including urologic surgeon as a random effect to account for clustering of patient participants.DiscussionThis study evaluates a two-part intervention to improve cost discussions between urologic surgeons and patients when deciding how to manage slow-growing prostate cancer. Establishing the effectiveness of the strategy under study will allow for its replication in other clinical decision contexts.Trial registrationClinicalTrials.govNCT04397016. Registered on 21 May 2020

Clinical and genomic characteristics of metabolic syndrome in colorectal cancer.

Metabolic syndrome (MetS) is characterized by a group of metabolic disturbances which leads to the enhanced risk of cancer development. Elucidating the mechanisms between these two pathologies is essential to identify the potential therapeutic molecular targets for colorectal cancer (CRC). 716 colorectal patients from the First and Second Affiliated Hospital of Wenzhou Medical University were involved in our study and metabolic disorders were proven to increase the risk of CRC. The prognostic value of the MetS factors was analyzed using the Cox regression model and a clinical MetS-based nomogram was established. Then by using multi-omics techniques, the distinct molecular mechanism of MetS genes in CRC was firstly systematically characterized. Strikingly, MetS genes were found to be highly correlated with the effectiveness of targeted chemotherapy administration, especially for mTOR and VEGFR pathways. Our results further demonstrated that overexpression of MetS core gene IL6 would promote the malignancy of CRC, which was highly dependent on mTOR-S6K signaling. In conclusion, we comprehensively explored the clinical value and molecular mechanism of MetS in the progression of CRC, which may serve as a candidate option for cancer management and therapy in the future.

In silico identification of small molecule modulators for disruption of Hsp90–Cdc37 protein–protein interaction interface for cancer therapeutic application

The protein–protein interactions (PPIs) in the biological systems are important to maintain a number of cellular processes. Several disorders including cancer may be developed due to dysfunction in the assembly of PPI networks. Hence, targeting intracellular PPIs can be considered as a crucial drug target for cancer therapy. Among the enormous and diverse group of cancer-enabling PPIs, the Hsp90–Cdc37 is prominent for cancer therapeutic development. The successful inhibition of Hsp90–Cdc37 PPI interface can be an important therapeutic option for cancer management. In the current study, a set of more than sixty thousand compounds belong to four databases were screened through a multi-steps molecular docking study in Glide against the Hsp90–Cdc37 interaction interface. The Glide-score and Prime-MM-GBSA based binding free energy of DCZ3112, standard Hsp90–Cdc37 inhibitor were found to be −6.96 and −40.46 kcal/mol, respectively. The above two parameters were used as cut-off score to reduce the chemical space from all successfully docked molecules. Furthermore, the in-silico pharmacokinetics parameters, common-feature pharmacophore analyses and the molecular binding interactions were used to wipe out the inactive molecules. Finally, four molecules were found to be important to modulate the Hsp90–Cdc37 interface. The potentiality of the final four molecules was checked through several drug-likeness characteristics. The molecular dynamics (MD) simulation study explained that all four molecules retained inside the interface of Hsp90–Cdc37. The binding free energy of each molecule obtained from the MD simulation trajectory was clearly explained the strong affection towards the Hsp90–Cdc37. Hence, the proposed molecule might be crucial for successful inhibition of the Hsp90–Cdc37 interface. Communicated by Ramaswamy H. Sarma

Regulation of Autophagy by Non-Steroidal Anti-Inflammatory Drugs in Cancer.

Cancer is the leading cause of death, placing a substantial global health burden. The development of the most effective treatment regimen is the unmet clinical need for cancer. Inflammation plays a role in tumorigenesis and progression, and anti-inflammation may be a promising option for cancer management and prevention. Emerging studies have shown that non-steroidal anti-inflammatory drugs (NSAIDs) display anticarcinogenic and chemopreventive properties through the regulation of autophagy in certain types of cancer. In this review, we summarize the pharmacological functions and side effects of NSAIDs as chemotherapeutic agents, and focus on its mode of action on autophagy regulation, which increases our knowledge of NSAIDs and cancer-related inflammation, and contributes to a putative addition of NSAIDs in the chemoprevention and treatment of cancer.

Cost-Effectiveness of Active Surveillance, Radical Prostatectomy and External Beam Radiotherapy for Localized Prostate Cancer: An Analysis of the ProtecT Trial

Despite increasing emphasis on value based care, to our knowledge the cost-effectiveness of prostate cancer management options has not been compared using prospective clinical trial data. The ProtecT (Prostate Testing for Cancer and Treatment) trial demonstrated no difference in survival in patients randomized to active surveillance, external beam radiotherapy or radical prostatectomy. We compared cost-effectiveness among the arms of ProtecT. Using a Markov model we compared the cost-effectiveness of active surveillance, radical prostatectomy and external beam radiotherapy based on ProtecT outcomes, specifically 6-year quality of life data and 10-year oncologic data. Costs were based on 2017 Medicare reimbursement while utility values were assigned using the literature. Univariable and multivariable sensitivity analyses were performed. Six years after randomization the mean costs per patient were $12,143 for active surveillance, $17,781 for radical prostatectomy and $29,238 for external beam radiotherapy. The incremental cost-effectiveness ratio relative to active surveillance was $127,752/QALY for radical prostatectomy and $381,894/QALY for external beam radiotherapy. Ten years after randomization radical prostatectomy ($5,627/QALY) and external beam radiotherapy ($78,291/QALY) were more cost-effective than active surveillance. The model was sensitive to the metastasis rate on active surveillance with a threshold of 2.4% at 10 years, below which active surveillance was more cost-effective than radical prostatectomy. On multivariable sensitivity analysis at 10 years using a willingness to pay threshold of $100,000/QALY the most cost-effective strategy was radical prostatectomy in 45% of model microsimulations, external beam radiotherapy in 30% and active surveillance in 25%. Although active surveillance represents a cost-effective strategy to manage localized prostate cancer during the initial several years after diagnosis, the relative cost-effectiveness of treatment emerges with extended followup.

The Multifaceted Roles of Pyroptotic Cell Death Pathways in Cancer

Cancer is a category of diseases involving abnormal cell growth with the potential to invade other parts of the body. Chemotherapy is the most widely used first-line treatment for multiple forms of cancer. Chemotherapeutic agents act via targeting the cellular apoptotic pathway. However, cancer cells usually acquire chemoresistance, leading to poor outcomes in cancer patients. For that reason, it is imperative to discover other cell death pathways for improved cancer intervention. Pyroptosis is a new form of programmed cell death that commonly occurs upon pathogen invasion. Pyroptosis is marked by cell swelling and plasma membrane rupture, which results in the release of cytosolic contents into the extracellular space. Currently, pyroptosis is proposed to be an alternative mode of cell death in cancer treatment. Accumulating evidence shows that the key components of pyroptotic cell death pathways, including inflammasomes, gasdermins and pro-inflammatory cytokines, are involved in the initiation and progression of cancer. Interfering with pyroptotic cell death pathways may represent a promising therapeutic option for cancer management. In this review, we describe the current knowledge regarding the biological significance of pyroptotic cell death pathways in cancer pathogenesis and also discuss their potential therapeutic utility.

Tumor Board Conferences for Multidisciplinary Skin Cancer Management: A Survey of US Cancer Centers.

Background: Tumor board conferences (TBCs) are used by oncologic specialists to review patient cases, exchange knowledge, and discuss options for cancer management. These multidisciplinary meetings are often a cornerstone of treatment at leading cancer centers and are required for accreditation by certain groups, such as the American College of Surgeons' Commission on Cancer. Little is known regarding skin cancer TBCs. The objective of this study was to characterize the structure, function, and impact of existing skin cancer TBCs in the United States. Methods: A cross-sectional online survey was administered to physician leaders of skin cancer TBCs at NCI-designated Comprehensive and Clinical Cancer Centers. Results: Of the 59 centers successfully contacted, 14 (24%) reported not having a conference where skin cancer cases were discussed, and 45 (76%) identified 53 physician leaders. A total of 38 physicians (72%) completed the survey. Half of the meeting leaders were medical and/or surgical oncologists, and dermatologists led one-third of meetings. TBCs had a moderate to significant impact on patient care according to 97% of respondents. All respondents indicated that the meetings enhanced communication among physicians and provided an opportunity for involved specialists and professionals to discuss cases. The most frequently cited barrier to organizing TBCs was determining a common available date and time for attendees (62%). The most common suggestion for improvement was to increase attendance, specialists, and/or motivation. Conclusions: Results showed overall consistency in meeting structure but variability in function, which may be a reflection of institutional resources and investment in the conference. Future directions include defining metrics to evaluate changes in diagnosis or management plan after tumor board discussion, attendance, clinical trial enrollment, and cost analysis. Results of this survey may aid other institutions striving to develop and refine skin cancer TBCs.

Attitude towards active surveillance: a cross-sectional survey among patients with uroandrological disorders

ObjectivesWe looked at subjective attitude towards active surveillance (AS) as the first option for cancer management in a cohort of patients seeking first medical help for uroandrological disorders prior to...

Role of Basti (Medicated Enema) as a therapeutic option in the management of Cancer

BACKGROUND: Cancer is one such disease which is having multi-factorial and diverse kind of etiopathogenesis. Global incidence and prevalence as well as the newer verities of cancers are up surging tremendously across the globe. In such scenario Ayurveda treatment principles are looking promising considering the diversity of treatments under one head as body purification procedures, popularly known as Panchakarma among which Basti or medicated enema is considered as the best treatment available and having capability to arrest multiple disease pathology. AIM: To review and analyse the role of Basti Chikitsa as an therapeutic option in management of Cancer. MATERIALS & METHODS: Review of classical textual data was gathered from Charaka Samhita and texts of contemporary sciences with related articles published was done to analyse the benefit of Basti on Cancer. RESULTS: Irrespective of developing or developed nation, increase in cancer cases is alarmingly high since last few decades and supposed to be highest in upcoming few decades. Basti is safe among many cancer patients even in terminal stages of cancers and practiced by many Indian Ayurveda physician with good efficacy and safety. Basti have the potential to counteract the cancer pathogenesis in all aspects including symptomatic relief, prevention of complication and recurrence too. CONCLUSION: The efficacy and potency of Basti Chikitsa to deal with cancer based on its action can be demonstrated by the analysis of various classical and modern references.

Information Seeking and Satisfaction with Information Sources Among Spouses of Men with Newly Diagnosed Local-Stage Prostate Cancer.

Information sources about prostate cancer treatment and outcomes are typically designed for patients. Little is known about the availability and utility of information for partners. The objectives of our study were to evaluate information sources used by partners to understand prostate cancer management options, their perceived usefulness, and the relationship between sources used and satisfaction with treatment experience. A longitudinal survey of female partners of men newly diagnosed with local-stage prostate cancer was conducted in three different geographic regions. Partners and associated patients were surveyed at baseline (after patient diagnosis but prior to receiving therapy) and at 12months following diagnosis. Information sources included provider, literature, friends or family members, Internet websites, books, traditional media, and support groups. Utility of an information source was defined as whether the partner would recommend it to caregivers of other patients with local-stage prostate cancer. Our study cohort included 179 partner-patient pairs. At diagnosis, partners consulted an average of 4.6 information sources. Non-Hispanic white partners were more likely than others to use friends and family as an information source (OR=2.44, 95% CI (1.04, 5.56)). More educated partners were less likely to use support groups (OR=0.31, 95% CI (0.14, 0.71)). At 12-month follow-up, partners were less likely to recommend books (OR=0.23, 95% CI (0.11, 0.49)) compared to baseline. Partners consulted a large number of information sources in researching treatment options for local-stage prostate cancer and the types of sources accessed varied by race/ethnicity and educational attainment. Additional resources to promote selection of high-quality non-provider information sources are warranted to enable partners to better aid patients in their treatment decision-making process.

Radiation therapy and cancer control in developing countries: Can we save more lives?

Globally, morbidity and mortality due to cancer are predicted to increase in both men and women in the coming decades. Furthermore, it is estimated that two thirds of these cancer-related deaths will occur in low-and middle-income countries (LMIC). In addition to morbidity and mortality, cancer also causes an enormous economic burden, especially in developing countries. There are several treatment and management options for cancer including chemotherapy, radiation therapy, surgery, and palliative care. Radiotherapy or radiation therapy (RT) can be an effective treatment, especially for localized or solid cancers; about half of cancer patients receive radiation as a curative or palliative treatment. Because of its low cost, for patients from LMIC with inoperable tumors, RT may be the only option. With the overall increase in the number of cancer patients especially in resource-starved LMIC, the need for more RT facilities further affects the economic growth of those countries. Therefore, an advanced molecular-targeted and more integrated approach involving either RT alone or with surgery and improved cancer drug access worldwide are urgent needs for cancer care.

Factors that influence patient preferences for prostate cancer management options: A systematic review.

PurposeWe performed a systematic review to evaluate evidence regarding factors that influence patient preferences for management options for localized prostate cancer.MethodsWe followed a prespecified search protocol (PROSPERO identifier CRD42014009173) to identify studies that evaluated patient preferences for prostate cancer management options for localized prostate cancer. We queried PubMed, the Cochrane Database of Systematic Reviews, Embase, Cumulative Index to Nursing & Allied Health Literature (CINAHL) Plus, and Econ-Lit databases. Two separate reviewers completed the article selection process and review, including coding of study characteristics. Study quality was scored according to the PREFS checklist, which consists of five criteria: Purpose, Respondents, Explanation, Findings, and Significance. Reviewers summarized the primary findings of each article included in the analysis.ResultsOf the 606 citations identified in the literature search, there were a total of 21 articles that met all selection criteria, reporting results for a total of 4,131 subjects. Themes identified in the studies included: the importance of patient perceptions of treatment efficacy and side effects; the influence of physician recommendations on patient decision-making; and the prioritization of concerns regarding treatment side effects among those men who prefer radiation therapy or active surveillance. The articles had an average PREFS score of 3.4 (standard deviation [SD] 1.0), which is similar to a recent study for breast cancer treatment preferences.ConclusionThis systematic review of factors that influence patient preferences for prostate cancer management options identified a small, but high quality, group of articles that satisfied the selection criteria. The available evidence suggests that interventions aimed at informing patients regarding the comparative effectiveness of prostate cancer management alternatives should include the influence of physician recommendations and family members’ desires on patient decision-making.

Optically modulated cancer therapeutic delivery: past, present and future.

Chemotherapeutic regimens are often restricted by dose-limiting toxicities that arise from drug exposure to off-site tissues. Nanoparticle drug carriers that specifically deliver therapeutics to the site of malignant tissue are being actively researched today. One strategy is to utilize materials that are light-responsive, such that the carrier can be triggered to release its drug payload at the distinct time and location of light exposure. This review discusses recent advances in the development of such light-responsive drug carriers. With continued optimization and in vivo validation, these approaches may offer novel treatment options for cancer management.

BMI1 promotes the progression of laryngeal squamous cell carcinoma

BMI1 is highly expressed in several malignant tumors, and its expression level is associated with tumor progression, proliferation, and prognosis. However, no published studies have examined the role of BMI1 in laryngeal squamous cell carcinoma (SCC). Expression of BMI1 in primary tumors was analyzed by immunofluorescence staining, real-time PCR, and Western blotting. BMI1 was knocked down, and proliferation, apoptosis, and cell cycle assays were performed. Sensitivity to radiochemotherapy was evaluated, and tumorigenicity assays were performed in vivo. BMI1 was highly expressed in laryngeal SCCs. BMI1 promoted cell proliferation and tumor progression, and inhibited apoptosis due to influences on the cell cycle. More importantly, BMI1 suppressed the sensitization of laryngeal Hep2 cells to radiochemotherapy. BMI1 is essential to maintain the proliferation and progression of laryngeal SCCs. Therefore, depletion of BMI1 may be a potential therapeutic option for cancer management.

Editorial Comment on: Laparoscopic Retroperitoneal Lymph Node Dissection: Does It Still Have a Role in the Management of Clinical Stage I Nonseminomatous Testis Cancer? A European Perspective

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