Alfred I Neugut

New York Presbyterian Hospital, New York, New York, United States

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Publications (572)3891.14 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Although axillary lymph node evaluation is standard of care in the surgical management of invasive breast cancer, a benefit has not been demonstrated in ductal carcinoma in situ (DCIS). Despite uncertainty regarding the efficacy, axillary evaluation is often performed in women with DCIS. To determine the incidence of axillary evaluation in women with DCIS and identify clinical, hospital, and surgeon-related factors associated with axillary evaluation. Cross-sectional analysis conducted from January 2006 through December 2012 of medical records contained in the Perspective database for women with DCIS who underwent breast-conserving surgery (BCS) or mastectomy. A total of 35 591 women aged 18 to 90 years were included in the analysis. Receipt or nonreceipt of surgical axillary evaluation, categorized as sentinel lymph node biopsy (SLNB), axillary lymph node dissection (ALND), or none. Analyses were stratified by surgery type, and multivariable regression analysis was used to identify factors associated with axillary evaluation. Of women identified with DCIS, 26 580 (74.7%) underwent BCS while 9011 (25.3%) underwent mastectomy; 17.7% undergoing BCS and 63.0% undergoing mastectomy had an axillary evaluation. Rates of axillary evaluation increased over time with mastectomy (2006, 56.6%; 2012, 67.4%) and were relatively stable with BCS (2006, 18.5%; 2012, 16.2%). Rates of ALND decreased in women undergoing mastectomy (2006, 20.0%; 2012, 10.7%) and BCS (2006, 1.2%; 2012, 0.3%), with increasing use of SLNB. In a multivariable analysis, hospital factors including nonteaching hospital (risk ratio [RR], 1.17; 95% CI, 1.05-1.30) and urban location (RR, 1.15; 95% CI, 1.03-1.29) influenced axillary evaluation with mastectomy. Surgeon volume was the most significant predictor of axillary evaluation among women undergoing BCS (mid vs low volume: RR, 0.87; 95% CI, 0.70-0.94; high vs low volume: RR, 0.54; 95% CI, 0.44-0.65). Despite guidelines recommending against axillary lymph node evaluation in women with DCIS undergoing BCS and uncertainty regarding its use with mastectomy, SLNB or ALND is performed frequently. Given the additional morbidity and cost of these procedures, alternative surgical approaches or prospective evaluation of the clinical benefit of axillary evaluation in women with DCIS is needed.
    06/2015; 1(3). DOI:10.1001/jamaoncol.2015.0389
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    ABSTRACT: Breast cancer, the leading cancer diagnosis among American women, is positively associated with postmenopausal obesity and little or no recreational physical activity (RPA). However, the underlying mechanisms of these associations remain unresolved. Aberrant changes in DNA methylation may represent an early event in carcinogenesis, but few studies have investigated associations between obesity/RPA and gene methylation, particularly in postmenopausal breast tumors where these lifestyle factors are most relevant. We used case-case unconditional logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CI) for the associations between body mass index (BMI=weight [kg]/height [m(2)]) in the year prior to diagnosis, or RPA (average hours/week), and methylation status (methylated vs. unmethylated) of 13 breast cancer-related genes in 532 postmenopausal breast tumor samples from the Long Island Breast Cancer Study Project. We also explored whether the association between BMI/RPA and estrogen/progesterone-receptor status (ER+PR+ vs. all others) was differential with respect to gene methylation status. Methylation-specific PCR and the MethyLight assay were used to assess gene methylation. BMI 25-29.9kg/m(2), and perhaps BMI≥30kg/m(2), was associated with methylated HIN1 in breast tumor tissue. Cases with BMI≥30kg/m(2) were more likely to have ER+PR+ breast tumors in the presence of unmethylated ESR1 (OR=2.63, 95% CI 1.32-5.25) and women with high RPA were more likely to have ER+PR+ breast tumors with methylated GSTP1 (OR=2.33, 95% CI 0.79-6.84). While biologically plausible, our findings that BMI is associated with methylated HIN1 and BMI/RPA are associated with ER+PR+ breast tumors in the presence of unmethylated ESR1 and methylated GSTP1, respectively, warrant further investigation. Future studies would benefit from enrolling greater numbers of postmenopausal women and examining a larger panel of breast cancer-related genes.
    05/2015; 2(1).
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    ABSTRACT: Polycyclic aromatic hydrocarbons (PAHs) are widespread environmental pollutants, known human lung carcinogens, and potent mammary carcinogens in laboratory animals. However, the association between PAHs and breast cancer in women is unclear. Vehicular traffic is a major ambient source of PAH exposure. Our study aim was to evaluate the association between residential exposure to vehicular traffic and breast cancer incidence. Residential histories of 1,508 breast cancer cases and 1,556 controls were assessed in a population-based investigation conducted in 1996-1997. Traffic exposure estimates of benzo[a]pyrene (B[a]P), as a proxy for traffic-related PAHs, for the years 1960-1995 were reconstructed using a model previously shown to generate estimates that are consistent with measured soil PAHs, PAH-DNA adducts, and CO readings. Associations between vehicular traffic exposure estimates and breast cancer incidence were evaluated using unconditional logistic regression. The odds ratio (95% CI) was modestly elevated by 1.44 (0.78, 2.68) for the association between breast cancer and long-term 1960-1990 vehicular traffic estimates in the top 5%, compared with below the median. The association with recent 1995 traffic exposure was elevated by 1.14 (0.80, 1.64) for the top 5%, compared with below the median, which was stronger among women with low fruit/vegetable intake (1.46 (0.89, 2.40), but not among those with high intake (0.92 (0.53, 1.60)). Among the subset of women with information regarding traffic exposure and tumor hormone receptor subtype, the traffic-breast cancer association was higher for those with estrogen/progesterone-negative tumors (1.67 (0.91, 3.05) relative to controls), but lower among all other tumor subtypes (0.80 (0.50, 1.27) compared with controls). In our population-based study, we observed positive associations between vehicular traffic-related B[a]P exposure and breast cancer incidence among women with comparatively high long-term traffic B[a]P exposures, although effect estimates were imprecise.
    Environmental Health Perspectives 05/2015; DOI:10.1289/ehp.1307736 · 7.98 Impact Factor
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    ABSTRACT: Data from single institution studies suggest that perioperative complication rates following stereotactic needle brain biopsies range from 6-12%, with permanent morbidity and mortality ranging from 3.1-6.4% and 0-1.7%, respectively. However, no population-level data are available. We conducted a population-based analysis to study complications following needle brain biopsy. We analyzed patients recorded in the Nationwide Inpatient Sample who underwent stereotactic needle brain biopsy for neoplastic lesions between 2006 and 2012. A multivariate logistic model was used to identify factors associated with complications. We identified 7514 patients who underwent biopsy for various intracranial pathologies, including primary malignant neoplasm (52.3%), unspecified neoplasm (17.9%), metastasis (9.7%), meningioma (1.5%), radiation necrosis (0.8%), lymphoma (0.5%), and pineal region neoplasm (0.3%). Intracranial hemorrhage was the most frequent complication (5.8%). Other complications, including operative infection (0.1%) and wound breakdown (0.2%), were rare. Multivariate logistic regression analysis revealed that hemorrhage is associated with older age (ref <40yrs; 40-59yrs OR=2.26, 95% CI 1.51-3.38; ≥60yrs OR=1.90, 95% CI 1.22-2.97), hydrocephalus (OR=3.02, 95% CI 2.20-4.14) and cerebral edema (OR=2.16, 95% CI 1.72-2.72). Hemorrhage is less likely when biopsying a primary malignant neoplasm (OR=0.73, 95% CI 0.59-0.90). Overall inpatient mortality following biopsy was 2.8%. Patients with intracranial hemorrhage were significantly more likely than patients without hemorrhage to expire in the hospital (12.8% vs. 2.2%, P<0.001) or be discharged to a rehabilitation/nursing facility (45.2% vs. 23.1%, P<0.001). Intracranial hemorrhage is the most frequent complication associated with needle brain biopsy and is associated with inpatient mortality and hospital disposition. Other complications are rare. Copyright © 2015 Elsevier Inc. All rights reserved.
    World Neurosurgery 05/2015; 84(4). DOI:10.1016/j.wneu.2015.05.025 · 2.88 Impact Factor
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    ABSTRACT: Little is known about how modifiable lifestyle factors interact with the epigenome to influence disease. Body mass index (BMI, weight kg/height m2) and physical activity are associated with postmenopausal breast cancer, but the mechanisms are not well-understood. We hypothesized that BMI or physical activity may modify the association between markers of global DNA methylation and postmenopausal breast cancer risk. Resources from a population-based case-control study (~1300 postmenopausal women) were used to construct logistic regression models. We explored whether the association between breast cancer and global methylation, assessed using the luminometric methylation assay (LUMA) and long interspersed elements-1 (LINE-1) methylation in white blood cell DNA, was modified by BMI or recreational physical activity (RPA). The LUMA-breast cancer association was modified by BMI (multiplicative p=0.03) and RPA (p=0.004). Non-obese women in the highest quartile of LUMA experienced a greater than two-fold increased risk of postmenopausal breast cancer (BMI<25kg/m2: OR=2.16; 95% CI=1.35, 3.57 and BMI 25-29.9kg/m2: OR=2.96; 95% CI=1.69, 5.19) compared to women in the lowest LUMA quartile. Similar increases in the LUMA-breast cancer association were observed among women who were physically active (moderate RPA: OR=2.62; 95% CI=1.44, 4.75 and high RPA: OR=2.62; 95% CI=1.53, 4.49). Estimates among obese and inactive women were less pronounced and imprecise. Although we observed statistical interactions (p<0.05) between BMI and RPA with LINE-1, we were unable to discern any clear associations with breast cancer. The association between LUMA and postmenopausal breast cancer risk may be modified by postmenopausal body size and physical activity.
    Journal of Cancer 05/2015; 6(6):548-54. DOI:10.7150/jca.11359 · 3.27 Impact Factor
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    ABSTRACT: Cytoreduction for ovarian cancer is associated with substantial morbidity. We examined the outcome of patients undergoing surgery for ovarian cancer to determine if there are sub-groups of patients who may benefit from alternative treatments. The National Surgical Quality Improvement Program database was used to identify women who underwent surgery for ovarian cancer from 2005-2012. Multivariable logistic regression models were used to examine the effect of age, race, functional status, ASA class, preoperative albumin and performance of extended cytoreductive procedures on morbidity, mortality and resource utilization. A total of 2870 women were identified. The perioperative complication rate increased from 9.5% in women <50 years, to 13.4% in those age 60-69 years, and 14.6% in women ≥70 years (P<0.0001). Similarly, complications rose from 7.3% in those who did not require any extended procedures to 12.9% after 1 procedure, 28.4% for those who had 2, and 30.0% in women who underwent ≥3 extended procedures (P<0.0001). In a series of multivariable models, the number of extended cytoreductive procedures performed and preoperative albumin were the factors most consistently associated with morbidity. Using a series of model fit statistics, compared to chance alone, the ability to predict any complication increased by 27.4% when procedure score was analyzed, 22.0% with preoperative albumin, 11% with age, and 4% with functional status. While preoperative clinical and demographic factors may help predict the risk of adverse outcomes for women undergoing surgery for ovarian cancer, performance of extended cytoreductive procedures is the strongest risk factor for complications. Copyright © 2015. Published by Elsevier Inc.
    Gynecologic Oncology 05/2015; 138(1). DOI:10.1016/j.ygyno.2015.04.037 · 3.77 Impact Factor
  • Grace Clarke Hillyer · Alfred I. Neugut ·
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    ABSTRACT: Although colonoscopy is predominant among the selection of colorectal cancer screening tests, stool testing (particularly fecal immunochemical testing) has also carved out an important niche for itself. Its simplicity and low cost make it ideal for mass population screening both in the United States and abroad, and it is an alternative choice for those reluctant to undergo endoscopy.
    Cancer 05/2015; 121(18). DOI:10.1002/cncr.29459 · 4.89 Impact Factor

  • Cancer Research 05/2015; 75(9 Supplement):P1-11-09-P1-11-09. DOI:10.1158/1538-7445.SABCS14-P1-11-09 · 9.33 Impact Factor
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    ABSTRACT: To examine relative survival (a metric that incorporates changes in survival within a population) in women with ovarian cancer from 1975 to 2011. Women diagnosed with ovarian cancer from 1975 to 2011 and recorded in the National Cancer Institute's Surveillance, Epidemiology, and End Results database were examined. Relative survival, estimated as the ratio of the observed survival of cancer patients (all-cause mortality) to the expected survival of a comparable group from the general population, was matched to the patients with the main factors that are considered to affect patient survival such as age, calendar time, and race. Hazard ratios were adjusted for age, race, year of diagnosis, time since diagnosis, and the interaction of age and years since diagnosis (except for stage II). A total of 49,932 women were identified. For stage I ovarian cancer, the adjusted excess hazard ratio for death in 2006 was 0.51 (95% confidence interval [CI] 0.41-0.63) compared with those diagnosed in 1975. The reduction in excess mortality remained significant when compared with 1980 and 1985. For women with stage III-IV tumors, the excess hazard of mortality was lower in 2006 compared with all other years of study ranging from 0.49 (95% CI 0.44-0.55) compared with 1975 to 0.93 (95% CI 0.87-0.99) relative to 2000. For women aged 50-59 years, 10-year relative survival was 0.85 (99% CI 0.61-0.95) for stage I disease and 0.18 (99% CI 0.10-0.27) for stage III-IV tumors. For women aged 60-69 years, the corresponding 10-year relative survival estimates were 0.89 (99% CI 0.58-0.98) and 0.15 (99% CI 0.09-0.21). Relative survival has improved for all stages of ovarian cancer from 1975 to 2011. II.
    Obstetrics and Gynecology 05/2015; 125(6):1. DOI:10.1097/AOG.0000000000000854 · 5.18 Impact Factor

  • Gastrointestinal Endoscopy 05/2015; 81(5):AB414-AB415. DOI:10.1016/j.gie.2015.03.1588 · 5.37 Impact Factor

  • Cancer Research 05/2015; 75(9 Supplement):P4-14-03-P4-14-03. DOI:10.1158/1538-7445.SABCS14-P4-14-03 · 9.33 Impact Factor

  • 04/2015; 2(2):127-128. DOI:10.17294/2330-0698.1166
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    ABSTRACT: This randomized controlled trial assessed different educational approaches for increasing colorectal cancer screening uptake in a sample of primarily non-US born urban minority individuals, over aged 50, with health insurance, and out of compliance with screening guidelines. In one group, participants were mailed printed educational material (n = 180); in a second, participants' primary care physicians received academic detailing to improve screening referral and follow-up practices (n = 185); in a third, physicians received academic detailing and participants received tailored telephone education (n = 199). Overall, 21.5 % of participants (n = 121) received appropriate screening within one year of randomization. There were no statistically significant pairwise differences between groups in screening rate. Among those 60 years of age or older, however, the detailing plus telephone education group had a higher screening rate than the print group (27.3 vs. 7.7 %, p = .02). Different kinds of interventions will be required to increase colorectal cancer screening among the increasingly small population segment that remains unscreened. Identifier: NCT02392143.
    Journal of Community Health 04/2015; 40(5). DOI:10.1007/s10900-015-0021-5 · 1.28 Impact Factor
  • Hannah M Simonds · Alfred I Neugut · Judith S Jacobson ·
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    ABSTRACT: Women infected with the human immunodeficiency virus (HIV) have a higher risk of developing cervix carcinoma than do other women who are thought to be more vulnerable to acute toxicities during chemoradiation. We compared HIV-positive/HIV-negative patients with cervix carcinoma at a single institution with respect to cancer treatment toxicities. Among patients with stage Ib1-IIIb invasive cervical carcinoma who received radiation or chemoradiation with curative intent, we evaluated demographic and clinical characteristics of HIV-positive and HIV-negative patients. Treatment regimens were documented and toxicities scored as per Radiation Therapy Oncology Group guidelines. We developed logistic regression models for the associations of grade 3/4 toxicities with HIV status. Complete data were available on 213 patients, including 36 (16.8%) who were HIV positive. More than 85% of both HIV-positive and HIV-negative patients received a minimum of 68-Gy equivalent dose in 2-Gy-fraction external beam and high-dose-rate brachytherapy. More HIV-positive than HIV-negative patients were prescribed radiation alone (38.9% vs 24.29%, P = 0.01), experienced at least 1 grade 3/4 toxicity (38.9% vs 26.6%), or developed grade 3/4 leucopenia (30.6% vs 10.2%, P = 0.003).In a multivariable model, patients who developed a grade 3/4 toxicity were 4 times as likely to have received chemotherapy (odds ratio, 4.41 [95% confidence interval, 1.76-11.1]; P = 0.023) and twice as likely to be HIV positive (odds ratio 2.16 [95% confidence interval, 0.98-4.8]; P = 0.05) as women who did not experience such toxicities. HIV-positive patients with cervical carcinoma received adequate radiotherapy but were less likely than HIV-negative patients to complete chemotherapy. Few HIV-positive or HIV-negative patients who received radiotherapy without chemotherapy experienced grade 3/4 toxicity. However, among patients who received chemotherapy, those who were HIV positive were more likely than others to experience hematologic toxicity.
    International Journal of Gynecological Cancer 04/2015; 25(5). DOI:10.1097/IGC.0000000000000441 · 1.95 Impact Factor
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    ABSTRACT: Frailty is the loss of physical or mental reserve that impairs function, often in the absence of a defined comorbidity. Our aim was to determine whether a modified frailty index (mFI) correlates with morbidity and mortality in patients undergoing hysterectomy. Retrospective cohort study. Hospitals across the USA participating in the National Surgical Quality Improvement Program (NSQIP). Patients who underwent hysterectomy from 2008 to 2012. An mFI was calculated using 11 variables in NSQIP. The associations between mFI and morbidity and mortality were assessed. Model fit statistics (c-statistics) were utilised to evaluate the ability of mFI to distinguish outcomes. Wound infection, severe complications and mortality. A total of 66 105 patients were identified. Wound complications increased from 2.4% in patients with an mFI of zero to 4.8% in those with mFI ≥ 0.5 (P < 0.0001). Similarly, severe complications increased from 0.98% to 7.3% (P < 0.0001), overall complications rose from 3.7% to 14.5% (P < 0.0001) and mortality increased from 0.06% to 3.2% (P < 0.0001) for patients with a frailty index of zero compared with those with an index of ≥0.5. Versus chance, the goodness-of-fit c-statistics suggested that mFI increases the ability to detect wound complications by 11.4%, severe complications by 22.0% and overall complications by 11.0%. The mFI is easily reproducible from routinely collected clinical data and predictive of outcomes in patients undergoing hysterectomy. Frailty may be useful in the preoperative risk assessment of women undergoing gynaecological surgery. Frailty may be useful in the preoperative risk assessment of women undergoing gynaecological surgery. © 2015 Royal College of Obstetricians and Gynaecologists.
    Gynecologic Oncology 04/2015; 137. DOI:10.1016/j.ygyno.2015.01.121 · 3.77 Impact Factor
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    ABSTRACT: Myomectomy, the excision of uterine leiomyoma, is now commonly performed via minimally invasive surgery. Electric power morcellation, or fragmentation of the leiomyoma with a mechanical device, may be used to facilitate extraction of the leiomyoma. To analyze the prevalence of underlying cancer and precancerous changes in women who underwent myomectomy with and without electric power uterine morcellation. We used a US nationwide database to retrospectively analyze women who underwent myomectomy at 496 hospitals from January 2006 to December 2012. Use of electric power morcellation at the time of myomectomy was investigated. The prevalence of uterine cancer, uterine neoplasms of uncertain malignant potential, and endometrial hyperplasia were estimated. Multivariable mixed-effects regression models were developed to examine predictors of use of electric power morcellation and factors associated with adverse pathologic outcomes. Use of electric power morcellation at the time of myomectomy was examined. The occurrence of uterine cancer and precancerous uterine lesions was determined. The cohort consisted of 41 777 women who underwent myomectomy at 496 hospitals and included 3220 (7.7%) who had electric power morcellation. Uterine cancer was identified in 73 (1 in 528) women who underwent myomectomy without electric power morcellation (0.19%; 95% CI, 0.15%-0.23%) and in 3 (1 in 1073) women who underwent electric power morcellation (0.09%; 95% CI, 0.02%-0.27%). The corresponding rates of any pathologic finding (cancer, tumors of uncertain malignant potential, or endometrial hyperplasia) were 0.67% (n = 257) (95% CI, 0.59%-0.75%) (1 in 150) and 0.43% (n = 14) (95% CI, 0.21%-0.66%) (1 in 230), respectively. Advanced age was the strongest risk factor for uterine cancer. The prevalence of cancers and precancerous abnormalities of the uterus in women who undergo myomectomy with or without electric power morcellation is low overall, but risk increases with age. Electric power morcellation should be used with caution in older women undergoing myomectomy.
    04/2015; 1(1). DOI:10.1001/jamaoncol.2014.206

  • Gynecologic Oncology 04/2015; 137. DOI:10.1016/j.ygyno.2015.01.232 · 3.77 Impact Factor

  • Gynecologic Oncology 04/2015; 137. DOI:10.1016/j.ygyno.2015.01.066 · 3.77 Impact Factor

  • Gynecologic Oncology 04/2015; 137:112. DOI:10.1016/j.ygyno.2015.01.278 · 3.77 Impact Factor
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    ABSTRACT: In laboratory experiments, ω-3 polyunsaturated fatty acids (PUFAs) have been found to reduce inflammatory eicosanoids resulting from ω-6 PUFA metabolism via competitive inhibition, and the ω-3-induced cytotoxic environment increases apoptosis and reduces cell growth in breast cancer cells. To the authors' knowledge, epidemiologic investigations regarding whether dietary ω-3 PUFA intake benefits survival after breast cancer are limited and inconsistent. The authors used resources from a population-based follow-up study conducted on Long Island, New York, among 1463 women newly diagnosed with first primary breast cancer who were interviewed an average of approximately 3 months after diagnosis to assess risk and prognostic factors, including dietary intake (using a food frequency questionnaire). Vital status was determined through 2011, yielding a median follow-up of 14.7 years and 485 deaths. Adjusted hazard ratios (HRs) and 95% confidence intervals (95% CIs) were estimated using Cox proportional hazards regression. All-cause mortality was reduced among women with breast cancer reporting the highest quartile of intake (compared with never) for tuna (HR, 0.71; 95% CI, 0.55-0.92), other baked/broiled fish (HR, 0.75; 95% CI, 0.58-0.97), and the dietary long-chain ω-3 PUFAs docosahexaenoic acid (HR, 0.71; 95% CI, 0.55-0.92) and eicosapentaenoic acid (HR, 0.75; 95% CI, 0.58-0.97). All-cause mortality was reduced by 16% to 34% among women with breast cancer who reported a high intake of fish and long-chain ω-3 PUFAs. Long-chain ω-3 PUFA intake from fish and other dietary sources may provide a potential strategy to improve survival after breast cancer. Cancer 2015. © 2015 American Cancer Society. © 2015 American Cancer Society.
    Cancer 03/2015; 121(13). DOI:10.1002/cncr.29329 · 4.89 Impact Factor

Publication Stats

17k Citations
3,891.14 Total Impact Points


  • 1995-2015
    • New York Presbyterian Hospital
      • Department of Pain Medicine
      New York, New York, United States
    • Technion - Israel Institute of Technology
      • Rambam Medical Center
      H̱efa, Haifa District, Israel
    • Icahn School of Medicine at Mount Sinai
      Manhattan, New York, United States
  • 1988-2015
    • Columbia University
      • • Department of Epidemiology
      • • Herbert Irving Comprehensive Cancer Center
      • • College of Physicians and Surgeons
      • • Mailman School of Public Health
      • • Department of Medicine
      New York, New York, United States
  • 1978-2015
    • CUNY Graduate Center
      New York, New York, United States
  • 2014
    • Kaiser Permanente
      Oakland, California, United States
  • 2012
    • Comprehensive Cancer Centers of Nevada
      Las Vegas, Nevada, United States
  • 2010
    • Weill Cornell Medical College
      • Division of Radiation Oncology
      New York, New York, United States
  • 2004
    • Long Island University
      • Department of Psychology (Post)
      New York City, NY, United States
    • University of North Carolina at Chapel Hill
      • Department of Epidemiology
      Chapel Hill, NC, United States
  • 2003
    • Stony Brook University
      • Department of Medicine
      스토니브룩, New York, United States
  • 2002
    • Queen Elizabeth Dental Services Inc.
      Montréal, Quebec, Canada
    • New York Medical College
      • Department of Medicine
      New York, New York, United States
  • 1992-2002
    • Gracie Square Hospital, New York, NY
      New York, New York, United States
  • 2001
    • Yeshiva University
      New York, New York, United States
  • 1996
    • Mid-Columbia Medical Center
      DLS, Oregon, United States
    • Harvard University
      Cambridge, Massachusetts, United States
    • Dana-Farber Cancer Institute
      Boston, Massachusetts, United States
  • 1993
    • New York State
      New York City, New York, United States
  • 1988-1993
    • Rambam Medical Center
      • Department of Oncology
      H̱efa, Haifa District, Israel