Magnitude of Treatment Abandonment in Childhood Cancer
Publication Date
September 30, 2015
Journal
PLOS ONE
Authors
Paola Friedrich, Catherine G. Lam, Elena Itriago, Rafael Perez, et al
Volume
10
Issue
9
Pages
e0135230
DOI
https://dx.plos.org/10.1371/journal.pone.0135230
Publisher URL
http://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0135230
PubMed
http://www.ncbi.nlm.nih.gov/pubmed/26422208
PubMed Central
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4589240
Europe PMC
http://europepmc.org/abstract/MED/26422208
Web of Science
000362175700003
Scopus
84947786129
Mendeley
http://www.mendeley.com/research/magnitude-treatment-abandonment-childhood-cancer
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Mendeley | Further Information

{"title"=>"Magnitude of treatment abandonment in childhood cancer", "type"=>"journal", "authors"=>[{"first_name"=>"Paola", "last_name"=>"Friedrich", "scopus_author_id"=>"53663445600"}, {"first_name"=>"Catherine G.", "last_name"=>"Lam", "scopus_author_id"=>"7402990811"}, {"first_name"=>"Elena", "last_name"=>"Itriago", "scopus_author_id"=>"56971607400"}, {"first_name"=>"Rafael", "last_name"=>"Perez", "scopus_author_id"=>"57198820693"}, {"first_name"=>"Raul C.", "last_name"=>"Ribeiro", "scopus_author_id"=>"7202534592"}, {"first_name"=>"Ramandeep S.", "last_name"=>"Arora", "scopus_author_id"=>"8445328800"}, {"first_name"=>"Ji Hyun", "last_name"=>"Lee", "scopus_author_id"=>"56824594800"}], "year"=>2015, "source"=>"PLoS ONE", "identifiers"=>{"pmid"=>"26422208", "doi"=>"10.1371/journal.pone.0135230", "sgr"=>"84947786129", "scopus"=>"2-s2.0-84947786129", "issn"=>"19326203", "pui"=>"606955666"}, "id"=>"002698ca-22c9-37ec-8583-0f506fd71f8b", "abstract"=>"BACKGROUND: Treatment abandonment (TxA) is recognized as a leading cause of treatment failure for children with cancer in low-and-middle-income countries (LMC). However, its global frequency and burden have remained elusive due to lack of global data. This study aimed to obtain an estimate using survey and population data.\\n\\nMETHODS: Childhood cancer clinicians (medical oncologists, surgeons, and radiation therapists), nurses, social workers, and psychologists involved in care of children with cancer were approached through an online survey February-May 2012. Incidence and population data were obtained from public sources. Descriptive, univariable, and multivariable analyses were conducted.\\n\\nRESULTS: 602 responses from 101 countries were obtained from physicians (84%), practicing pediatric hematology/oncology (83%) in general or children's hospitals (79%). Results suggested, 23,854 (15%) of 155,088 children <15 years old newly diagnosed with cancer annually in the countries analyzed, abandon therapy. Importantly, 83% of new childhood cancer cases and 99% of TxA were attributable to LMC. The annual number of cases of TxA expected in LMC worldwide (26,166) was nearly equivalent to the annual number of cancer cases in children <15 years expected in HIC (26,368). Approximately two thirds of LMC had median TxA ≥ 6%, but TxA ≥ 6% was reported in high- (9%), upper-middle- (41%), lower-middle- (80%), and low-income countries (90%, p<0.001). Most LMC centers reporting TxA > 6% were outside the capital. Lower national income category, higher reliance on out-of-pocket payments, and high prevalence of economic hardship at the center were independent contextual predictors for TxA ≥ 6% (p<0.001). Global survival data available for more developed and less developed regions suggests TxA may account for at least a third of the survival gap between HIC and LMC.\\n\\nCONCLUSION: Results show TxA is prevalent (compromising cancer survival for 1 in 7 children globally), confirm the suspected high burden of TxA in LMC, and illustrate the negative impact of poverty on its occurrence. The present estimates may appear small compared to the global burden of child death from malnutrition and infection (measured in millions). However, absolute numbers suggest the burden of TxA in LMC is nearly equivalent to annually losing all kids diagnosed with cancer in HIC just to TxA, without even considering deaths from disease progression, relapse or toxicity-the main causes of childhood cancer mortality in HIC. Results document the importance of monitoring and addressing TxA as part of childhood cancer outcomes in at-risk settings.", "link"=>"http://www.mendeley.com/research/magnitude-treatment-abandonment-childhood-cancer", "reader_count"=>45, "reader_count_by_academic_status"=>{"Professor > Associate Professor"=>1, "Librarian"=>1, "Student > Doctoral Student"=>5, "Researcher"=>10, "Student > Ph. D. Student"=>3, "Student > Postgraduate"=>3, "Student > Master"=>7, "Other"=>3, "Student > Bachelor"=>9, "Lecturer"=>2, "Professor"=>1}, "reader_count_by_user_role"=>{"Professor > Associate Professor"=>1, "Librarian"=>1, "Student > Doctoral Student"=>5, "Researcher"=>10, "Student > Ph. D. Student"=>3, "Student > Postgraduate"=>3, "Student > Master"=>7, "Other"=>3, "Student > Bachelor"=>9, "Lecturer"=>2, "Professor"=>1}, "reader_count_by_subject_area"=>{"Unspecified"=>3, "Nursing and Health Professions"=>10, "Biochemistry, Genetics and Molecular Biology"=>1, "Medicine and Dentistry"=>22, "Agricultural and Biological Sciences"=>2, "Pharmacology, Toxicology and Pharmaceutical Science"=>1, "Psychology"=>3, "Chemistry"=>1, "Social Sciences"=>1, "Computer Science"=>1}, "reader_count_by_subdiscipline"=>{"Medicine and Dentistry"=>{"Medicine and Dentistry"=>22}, "Chemistry"=>{"Chemistry"=>1}, "Social Sciences"=>{"Social Sciences"=>1}, "Psychology"=>{"Psychology"=>3}, "Agricultural and Biological Sciences"=>{"Agricultural and Biological Sciences"=>2}, "Computer Science"=>{"Computer Science"=>1}, "Nursing and Health Professions"=>{"Nursing and Health Professions"=>10}, "Biochemistry, Genetics and Molecular Biology"=>{"Biochemistry, Genetics and Molecular Biology"=>1}, "Unspecified"=>{"Unspecified"=>3}, "Pharmacology, Toxicology and Pharmaceutical Science"=>{"Pharmacology, Toxicology and Pharmaceutical Science"=>1}}, "group_count"=>3}

Scopus | Further Information

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Figshare

  • {"files"=>["https://ndownloader.figshare.com/files/2293577"], "description"=>"<p>Country names listed are as they appear in World Bank. HIC, high-income countries; UMIC, upper-middle-income countries; LMIC, lower-middle-income countries; LIC, low-income countries. Some countries (such as Chile and Russian Federation) have a higher income group and some countries (such as Libya) have lower income group classification as of 2015, but are illustrated and were kept in the economic bracket assigned through 2010 data in all analyses.</p>", "links"=>[], "tags"=>["child death", "contextual predictors", "population data", "hic", "survival gap", "Results document", "101 countries", "conducted.Results 602 responses", "childhood cancer cases", "LMC.ConclusionResults show TxA", "childhood cancer mortality", "7 children", "Childhood Cancer BackgroundTreatment abandonment", "childhood cancer outcomes", "population data.MethodsChildhood cancer clinicians", "income category", "cancer cases", "Multivariable analyses", "treatment failure", "LMC centers", "disease progression", "cancer survival", "Treatment Abandonment"], "article_id"=>1560177, "categories"=>["Uncategorised"], "users"=>["Paola Friedrich", "Catherine G. Lam", "Elena Itriago", "Rafael Perez", "Raul C. Ribeiro", "Ramandeep S. Arora"], "doi"=>"https://dx.doi.org/10.1371/journal.pone.0135230.g001", "stats"=>{"downloads"=>3, "page_views"=>16, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Countries_included_in_the_study_by_World_Bank_income_group_classification_in_2010_and_geographical_region_/1560177", "title"=>"Countries included in the study by World Bank income group classification in 2010 and geographical region.", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2015-09-30 02:53:05"}
  • {"files"=>["https://ndownloader.figshare.com/files/2293579"], "description"=>"<p>Econ., economic; HIC,high-income countries; H/O, hematology/oncology; LIC, low-income countries; LMIC, lower-middle-income countries; NGO, non-governmental organization; UMIC, upper-middle-income countries. Percentages and further details of other provider and center characteristics are provided in <a href=\"http://www.plosone.org/article/info:doi/10.1371/journal.pone.0135230#pone.0135230.s003\" target=\"_blank\">S3 Table</a>.</p>", "links"=>[], "tags"=>["child death", "contextual predictors", "population data", "hic", "survival gap", "Results document", "101 countries", "conducted.Results 602 responses", "childhood cancer cases", "LMC.ConclusionResults show TxA", "childhood cancer mortality", "7 children", "Childhood Cancer BackgroundTreatment abandonment", "childhood cancer outcomes", "population data.MethodsChildhood cancer clinicians", "income category", "cancer cases", "Multivariable analyses", "treatment failure", "LMC centers", "disease progression", "cancer survival", "Treatment Abandonment"], "article_id"=>1560179, "categories"=>["Uncategorised"], "users"=>["Paola Friedrich", "Catherine G. Lam", "Elena Itriago", "Rafael Perez", "Raul C. Ribeiro", "Ramandeep S. Arora"], "doi"=>"https://dx.doi.org/10.1371/journal.pone.0135230.g002", "stats"=>{"downloads"=>5, "page_views"=>9, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Provider_A_and_center_B_demographics_/1560179", "title"=>"Provider (A) and center (B) demographics.", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2015-09-30 02:53:05"}
  • {"files"=>["https://ndownloader.figshare.com/files/2293580"], "description"=>"<p>Reported median frequency of treatment abandonment (TxA) by country.</p>", "links"=>[], "tags"=>["child death", "contextual predictors", "population data", "hic", "survival gap", "Results document", "101 countries", "conducted.Results 602 responses", "childhood cancer cases", "LMC.ConclusionResults show TxA", "childhood cancer mortality", "7 children", "Childhood Cancer BackgroundTreatment abandonment", "childhood cancer outcomes", "population data.MethodsChildhood cancer clinicians", "income category", "cancer cases", "Multivariable analyses", "treatment failure", "LMC centers", "disease progression", "cancer survival", "Treatment Abandonment"], "article_id"=>1560180, "categories"=>["Uncategorised"], "users"=>["Paola Friedrich", "Catherine G. Lam", "Elena Itriago", "Rafael Perez", "Raul C. Ribeiro", "Ramandeep S. Arora"], "doi"=>"https://dx.doi.org/10.1371/journal.pone.0135230.g003", "stats"=>{"downloads"=>7, "page_views"=>5, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Reported_median_frequency_of_treatment_abandonment_TxA_by_country_/1560180", "title"=>"Reported median frequency of treatment abandonment (TxA) by country.", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2015-09-30 02:53:05"}
  • {"files"=>["https://ndownloader.figshare.com/files/2293582"], "description"=>"<p>Geographical distribution of treatment abandonment (TxA) rates by city in countries with high in-country variability: China (A), Mexico (B), Philippines (C), Colombia (D), Venezuela (E), and India (F).</p>", "links"=>[], "tags"=>["child death", "contextual predictors", "population data", "hic", "survival gap", "Results document", "101 countries", "conducted.Results 602 responses", "childhood cancer cases", "LMC.ConclusionResults show TxA", "childhood cancer mortality", "7 children", "Childhood Cancer BackgroundTreatment abandonment", "childhood cancer outcomes", "population data.MethodsChildhood cancer clinicians", "income category", "cancer cases", "Multivariable analyses", "treatment failure", "LMC centers", "disease progression", "cancer survival", "Treatment Abandonment"], "article_id"=>1560182, "categories"=>["Uncategorised"], "users"=>["Paola Friedrich", "Catherine G. Lam", "Elena Itriago", "Rafael Perez", "Raul C. Ribeiro", "Ramandeep S. Arora"], "doi"=>"https://dx.doi.org/10.1371/journal.pone.0135230.g004", "stats"=>{"downloads"=>7, "page_views"=>24, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Geographical_distribution_of_treatment_abandonment_TxA_rates_by_city_in_countries_with_high_in_country_variability_China_A_Mexico_B_Philippines_C_Colombia_D_Venezuela_E_and_India_F_/1560182", "title"=>"Geographical distribution of treatment abandonment (TxA) rates by city in countries with high in-country variability: China (A), Mexico (B), Philippines (C), Colombia (D), Venezuela (E), and India (F).", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2015-09-30 02:53:05"}
  • {"files"=>["https://ndownloader.figshare.com/files/2293583"], "description"=>"<p><b>Population under 15 years of age (A), burden of childhood cancer cases (B), burden of TxA (C), median reported TxA by country income group (D), and summary of disparities identified (E).</b> TxA, Treatment abandonment; LMC, Low-and-middle income countries; HIC, high-income countries; UMIC, upper-middle-income countries; LMIC, lower-middle-income countries; LIC, low-income countries.</p>", "links"=>[], "tags"=>["child death", "contextual predictors", "population data", "hic", "survival gap", "Results document", "101 countries", "conducted.Results 602 responses", "childhood cancer cases", "LMC.ConclusionResults show TxA", "childhood cancer mortality", "7 children", "Childhood Cancer BackgroundTreatment abandonment", "childhood cancer outcomes", "population data.MethodsChildhood cancer clinicians", "income category", "cancer cases", "Multivariable analyses", "treatment failure", "LMC centers", "disease progression", "cancer survival", "Treatment Abandonment"], "article_id"=>1560183, "categories"=>["Uncategorised"], "users"=>["Paola Friedrich", "Catherine G. Lam", "Elena Itriago", "Rafael Perez", "Raul C. Ribeiro", "Ramandeep S. Arora"], "doi"=>"https://dx.doi.org/10.1371/journal.pone.0135230.g005", "stats"=>{"downloads"=>5, "page_views"=>12, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Summary_of_cancer_disparities_identified_/1560183", "title"=>"Summary of cancer disparities identified.", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2015-09-30 02:53:05"}
  • {"files"=>["https://ndownloader.figshare.com/files/2293584"], "description"=>"<p><sup>1</sup> Incidence and mortality cases for the 0–14 year old age group, including both sexes, were obtained directly from Globocan 2012 for “more developed regions” and “less developed regions”. Available at: <a href=\"http://globocan.iarc.fr/Pages/age-specific_table_sel.aspx\" target=\"_blank\">http://globocan.iarc.fr/Pages/age-specific_table_sel.aspx</a>. Data retrieved December 29, 2014.</p><p>Estimated childhood cancer survival by development.</p>", "links"=>[], "tags"=>["child death", "contextual predictors", "population data", "hic", "survival gap", "Results document", "101 countries", "conducted.Results 602 responses", "childhood cancer cases", "LMC.ConclusionResults show TxA", "childhood cancer mortality", "7 children", "Childhood Cancer BackgroundTreatment abandonment", "childhood cancer outcomes", "population data.MethodsChildhood cancer clinicians", "income category", "cancer cases", "Multivariable analyses", "treatment failure", "LMC centers", "disease progression", "cancer survival", "Treatment Abandonment"], "article_id"=>1560184, "categories"=>["Uncategorised"], "users"=>["Paola Friedrich", "Catherine G. Lam", "Elena Itriago", "Rafael Perez", "Raul C. Ribeiro", "Ramandeep S. Arora"], "doi"=>"https://dx.doi.org/10.1371/journal.pone.0135230.t001", "stats"=>{"downloads"=>1, "page_views"=>12, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Estimated_childhood_cancer_survival_by_development_/1560184", "title"=>"Estimated childhood cancer survival by development.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2015-09-30 02:53:05"}
  • {"files"=>["https://ndownloader.figshare.com/files/2293585"], "description"=>"<p><sup><b>1</b></sup> Total sample size is restricted to those who provided a TxA estimate (602); therefore individual samples are smaller than in demographics section (Supplement A3, total sample n = 667).</p><p><sup><b>2</b></sup> p = value obtained through likelihood estimates.</p><p><sup><b>3</b></sup> HIC = High-income countries, UMIC = upper-middle-income countries, LMIC = lower-middle-income countries, LIC = low-income countries.</p><p><sup><b>4</b></sup> Center volume was evaluated as ordinal, source of funding as out-of-pocket vs. others, and economic hardship as continuous variable in multivariable analysis in order to preserve power.</p><p>Univariable and multivariable analysis: Predictors of reported TxA ≥6%.</p>", "links"=>[], "tags"=>["child death", "contextual predictors", "population data", "hic", "survival gap", "Results document", "101 countries", "conducted.Results 602 responses", "childhood cancer cases", "LMC.ConclusionResults show TxA", "childhood cancer mortality", "7 children", "Childhood Cancer BackgroundTreatment abandonment", "childhood cancer outcomes", "population data.MethodsChildhood cancer clinicians", "income category", "cancer cases", "Multivariable analyses", "treatment failure", "LMC centers", "disease progression", "cancer survival", "Treatment Abandonment"], "article_id"=>1560185, "categories"=>["Uncategorised"], "users"=>["Paola Friedrich", "Catherine G. Lam", "Elena Itriago", "Rafael Perez", "Raul C. Ribeiro", "Ramandeep S. Arora"], "doi"=>"https://dx.doi.org/10.1371/journal.pone.0135230.t002", "stats"=>{"downloads"=>9, "page_views"=>11, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Univariable_and_multivariable_analysis_Predictors_of_reported_TxA_8805_6_/1560185", "title"=>"Univariable and multivariable analysis: Predictors of reported TxA ≥6%.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2015-09-30 02:53:05"}
  • {"files"=>["https://ndownloader.figshare.com/files/2293587", "https://ndownloader.figshare.com/files/2293588", "https://ndownloader.figshare.com/files/2293589", "https://ndownloader.figshare.com/files/2293590", "https://ndownloader.figshare.com/files/2293591"], "description"=>"<div><p>Background</p><p>Treatment abandonment (TxA) is recognized as a leading cause of treatment failure for children with cancer in low-and-middle-income countries (LMC). However, its global frequency and burden have remained elusive due to lack of global data. This study aimed to obtain an estimate using survey and population data.</p><p>Methods</p><p>Childhood cancer clinicians (medical oncologists, surgeons, and radiation therapists), nurses, social workers, and psychologists involved in care of children with cancer were approached through an online survey February-May 2012. Incidence and population data were obtained from public sources. Descriptive, univariable, and multivariable analyses were conducted.</p><p>Results</p><p>602 responses from 101 countries were obtained from physicians (84%), practicing pediatric hematology/oncology (83%) in general or children’s hospitals (79%). Results suggested, 23,854 (15%) of 155,088 children <15 years old newly diagnosed with cancer annually in the countries analyzed, abandon therapy. Importantly, 83% of new childhood cancer cases and 99% of TxA were attributable to LMC. The annual number of cases of TxA expected in LMC worldwide (26,166) was nearly equivalent to the annual number of cancer cases in children <15 years expected in HIC (26,368). Approximately two thirds of LMC had median TxA≥6%, but TxA ≥6% was reported in high- (9%), upper-middle- (41%), lower-middle- (80%), and low-income countries (90%, p<0.001). Most LMC centers reporting TxA>6% were outside the capital. Lower national income category, higher reliance on out-of-pocket payments, and high prevalence of economic hardship at the center were independent contextual predictors for TxA ≥6% (p<0.001). Global survival data available for more developed and less developed regions suggests TxA may account for at least a third of the survival gap between HIC and LMC.</p><p>Conclusion</p><p>Results show TxA is prevalent (compromising cancer survival for 1 in 7 children globally), confirm the suspected high burden of TxA in LMC, and illustrate the negative impact of poverty on its occurrence. The present estimates may appear small compared to the global burden of child death from malnutrition and infection (measured in millions). However, absolute numbers suggest the burden of TxA in LMC is nearly equivalent to annually losing all kids diagnosed with cancer in HIC just to TxA, without even considering deaths from disease progression, relapse or toxicity–the main causes of childhood cancer mortality in HIC. Results document the importance of monitoring and addressing TxA as part of childhood cancer outcomes in at-risk settings.</p></div>", "links"=>[], "tags"=>["child death", "contextual predictors", "population data", "hic", "survival gap", "Results document", "101 countries", "conducted.Results 602 responses", "childhood cancer cases", "LMC.ConclusionResults show TxA", "childhood cancer mortality", "7 children", "Childhood Cancer BackgroundTreatment abandonment", "childhood cancer outcomes", "population data.MethodsChildhood cancer clinicians", "income category", "cancer cases", "Multivariable analyses", "treatment failure", "LMC centers", "disease progression", "cancer survival", "Treatment Abandonment"], "article_id"=>1560187, "categories"=>["Uncategorised"], "users"=>["Paola Friedrich", "Catherine G. Lam", "Elena Itriago", "Rafael Perez", "Raul C. Ribeiro", "Ramandeep S. Arora"], "doi"=>["https://dx.doi.org/10.1371/journal.pone.0135230.s001", "https://dx.doi.org/10.1371/journal.pone.0135230.s002", "https://dx.doi.org/10.1371/journal.pone.0135230.s003", "https://dx.doi.org/10.1371/journal.pone.0135230.s004", "https://dx.doi.org/10.1371/journal.pone.0135230.s005"], "stats"=>{"downloads"=>22, "page_views"=>6, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Magnitude_of_Treatment_Abandonment_in_Childhood_Cancer_/1560187", "title"=>"Magnitude of Treatment Abandonment in Childhood Cancer", "pos_in_sequence"=>0, "defined_type"=>4, "published_date"=>"2015-09-30 02:53:05"}

PMC Usage Stats | Further Information

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  • {"unique-ip"=>"22", "full-text"=>"13", "pdf"=>"16", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"2", "supp-data"=>"2", "cited-by"=>"0", "year"=>"2016", "month"=>"1"}
  • {"unique-ip"=>"21", "full-text"=>"28", "pdf"=>"10", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"3", "supp-data"=>"2", "cited-by"=>"0", "year"=>"2016", "month"=>"3"}
  • {"unique-ip"=>"18", "full-text"=>"21", "pdf"=>"7", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"11", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2016", "month"=>"4"}
  • {"unique-ip"=>"16", "full-text"=>"17", "pdf"=>"7", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"1", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2016", "month"=>"5"}
  • {"unique-ip"=>"30", "full-text"=>"33", "pdf"=>"12", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"5", "supp-data"=>"1", "cited-by"=>"0", "year"=>"2016", "month"=>"6"}
  • {"unique-ip"=>"29", "full-text"=>"28", "pdf"=>"12", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"5", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2016", "month"=>"7"}
  • {"unique-ip"=>"38", "full-text"=>"41", "pdf"=>"15", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"3", "supp-data"=>"1", "cited-by"=>"0", "year"=>"2016", "month"=>"8"}
  • {"unique-ip"=>"22", "full-text"=>"25", "pdf"=>"3", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"4", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2016", "month"=>"9"}
  • {"unique-ip"=>"24", "full-text"=>"26", "pdf"=>"8", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"1", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2016", "month"=>"10"}
  • {"unique-ip"=>"10", "full-text"=>"12", "pdf"=>"9", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"5", "cited-by"=>"0", "year"=>"2016", "month"=>"11"}
  • {"unique-ip"=>"12", "full-text"=>"12", "pdf"=>"6", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"2", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2016", "month"=>"12"}
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  • {"unique-ip"=>"17", "full-text"=>"24", "pdf"=>"9", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"1", "cited-by"=>"0", "year"=>"2017", "month"=>"3"}
  • {"unique-ip"=>"21", "full-text"=>"23", "pdf"=>"15", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2017", "month"=>"4"}
  • {"unique-ip"=>"16", "full-text"=>"24", "pdf"=>"14", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"2", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2017", "month"=>"5"}
  • {"unique-ip"=>"11", "full-text"=>"12", "pdf"=>"6", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2017", "month"=>"6"}
  • {"unique-ip"=>"7", "full-text"=>"7", "pdf"=>"3", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"3", "cited-by"=>"0", "year"=>"2017", "month"=>"7"}
  • {"unique-ip"=>"20", "full-text"=>"24", "pdf"=>"9", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"1", "supp-data"=>"2", "cited-by"=>"1", "year"=>"2017", "month"=>"8"}
  • {"unique-ip"=>"25", "full-text"=>"26", "pdf"=>"7", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"2", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2017", "month"=>"9"}
  • {"unique-ip"=>"29", "full-text"=>"32", "pdf"=>"12", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"1", "supp-data"=>"1", "cited-by"=>"1", "year"=>"2017", "month"=>"10"}
  • {"unique-ip"=>"19", "full-text"=>"23", "pdf"=>"9", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2017", "month"=>"11"}
  • {"unique-ip"=>"14", "full-text"=>"20", "pdf"=>"4", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"2", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2017", "month"=>"12"}
  • {"unique-ip"=>"5", "full-text"=>"5", "pdf"=>"3", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"1", "cited-by"=>"0", "year"=>"2018", "month"=>"1"}
  • {"unique-ip"=>"1", "full-text"=>"1", "pdf"=>"1", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2018", "month"=>"2"}
  • {"unique-ip"=>"18", "full-text"=>"15", "pdf"=>"6", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2018", "month"=>"3"}
  • {"unique-ip"=>"17", "full-text"=>"16", "pdf"=>"3", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"1", "cited-by"=>"0", "year"=>"2019", "month"=>"1"}
  • {"unique-ip"=>"8", "full-text"=>"8", "pdf"=>"4", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"7", "cited-by"=>"0", "year"=>"2018", "month"=>"11"}
  • {"unique-ip"=>"16", "full-text"=>"20", "pdf"=>"7", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"1", "cited-by"=>"1", "year"=>"2018", "month"=>"9"}
  • {"unique-ip"=>"20", "full-text"=>"26", "pdf"=>"7", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"1", "supp-data"=>"10", "cited-by"=>"3", "year"=>"2018", "month"=>"4"}
  • {"unique-ip"=>"21", "full-text"=>"23", "pdf"=>"6", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"13", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2018", "month"=>"5"}
  • {"unique-ip"=>"9", "full-text"=>"8", "pdf"=>"2", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"2", "cited-by"=>"0", "year"=>"2018", "month"=>"6"}
  • {"unique-ip"=>"17", "full-text"=>"17", "pdf"=>"6", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"7", "cited-by"=>"0", "year"=>"2018", "month"=>"7"}
  • {"unique-ip"=>"15", "full-text"=>"15", "pdf"=>"4", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2018", "month"=>"10"}
  • {"unique-ip"=>"10", "full-text"=>"13", "pdf"=>"2", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"2", "cited-by"=>"0", "year"=>"2018", "month"=>"8"}
  • {"unique-ip"=>"17", "full-text"=>"18", "pdf"=>"8", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"2", "supp-data"=>"2", "cited-by"=>"0", "year"=>"2018", "month"=>"12"}
  • {"unique-ip"=>"12", "full-text"=>"10", "pdf"=>"3", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"1", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2019", "month"=>"2"}
  • {"unique-ip"=>"18", "full-text"=>"19", "pdf"=>"3", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"3", "cited-by"=>"0", "year"=>"2019", "month"=>"3"}
  • {"unique-ip"=>"20", "full-text"=>"22", "pdf"=>"6", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"5", "cited-by"=>"0", "year"=>"2019", "month"=>"4"}
  • {"unique-ip"=>"15", "full-text"=>"11", "pdf"=>"5", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"5", "cited-by"=>"0", "year"=>"2019", "month"=>"5"}
  • {"unique-ip"=>"20", "full-text"=>"34", "pdf"=>"5", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2019", "month"=>"8"}
  • {"unique-ip"=>"16", "full-text"=>"26", "pdf"=>"3", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2019", "month"=>"9"}
  • {"unique-ip"=>"13", "full-text"=>"14", "pdf"=>"2", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"4", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2019", "month"=>"10"}
  • {"unique-ip"=>"11", "full-text"=>"9", "pdf"=>"5", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"3", "cited-by"=>"0", "year"=>"2019", "month"=>"12"}
  • {"unique-ip"=>"17", "full-text"=>"17", "pdf"=>"4", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2020", "month"=>"2"}
  • {"unique-ip"=>"21", "full-text"=>"28", "pdf"=>"7", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"1", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2020", "month"=>"3"}
  • {"unique-ip"=>"20", "full-text"=>"27", "pdf"=>"6", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2020", "month"=>"4"}
  • {"unique-ip"=>"16", "full-text"=>"16", "pdf"=>"8", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2020", "month"=>"5"}
  • {"unique-ip"=>"16", "full-text"=>"19", "pdf"=>"4", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2020", "month"=>"6"}
  • {"unique-ip"=>"17", "full-text"=>"17", "pdf"=>"6", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"5", "cited-by"=>"0", "year"=>"2020", "month"=>"7"}
  • {"unique-ip"=>"16", "full-text"=>"18", "pdf"=>"7", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2020", "month"=>"8"}
  • {"unique-ip"=>"15", "full-text"=>"8", "pdf"=>"4", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"5", "cited-by"=>"0", "year"=>"2020", "month"=>"9"}
  • {"unique-ip"=>"6", "full-text"=>"6", "pdf"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2020", "month"=>"10"}
  • {"unique-ip"=>"4", "full-text"=>"4", "pdf"=>"1", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2020", "month"=>"11"}
  • {"unique-ip"=>"9", "full-text"=>"7", "pdf"=>"7", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2020", "month"=>"12"}
  • {"unique-ip"=>"10", "full-text"=>"10", "pdf"=>"2", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"5", "supp-data"=>"3", "cited-by"=>"0", "year"=>"2021", "month"=>"1"}

Relative Metric

{"start_date"=>"2015-01-01T00:00:00Z", "end_date"=>"2015-12-31T00:00:00Z", "subject_areas"=>[]}
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