The meaning that patients with cancer attribute to life influences their expectations and their attitudes to the disease and its treatment. Over the centuries, religion has commonly been the answer encoded by the social setting when it came to matters of life and death. The present article analyzes the historical grounds for forms of cooperation between the scientific disciplines that focus on mental health and the approach of religion, centered on the Italian situation. Such cooperation was hard to imagine in the past, but the situation has changed considerably and cooperation is not only possible but extremely desirable. Acknowledgment of their spiritual needs helps patients to battle with their disease. The care of patients should include catering for their spiritual needs by ensuring the constant presence of a chaplain on hospital wards.
Post author correction
Article Type: EDITORIAL
AuthorsTullio Proserpio, Andrea Ferrari, Laura Veneroni, Carmine Arice, Maura Massimino, Carlo Alfredo Clerici
- • Accepted on 03/07/2017
- • Available online on 07/09/2017
This article is available as full text PDF.
After the diagnosis of cancer, patients are obliged to face the change in their expectations and their attitude to life. Their psychological and spiritual inner world is influenced by the meaning that they attribute to their disease and its treatment, their suffering, and the risk of death (1-2-3). Spirituality is a fundamental aspect of cancer patients, and this may be particularly critical for the most fragile ones, such as young people (4-5-6).
Over the centuries, religion was commonly the answer encoded by the social setting when it came to spirituality and matters of life and death. Even today, for most human beings religions provide answers to their questions about the sense of human life, albeit with important, radical differences vis-à-vis the past. There has clearly been a process of secularization in recent times, and this has brought about a gradual decline in the relevance of religion for society. The great materialist ideologies have battled against the transcendent view offered by religions, while medicine and science have been cast in an important role in the panorama of existential theories. Driven by huge advances in the fight against disease achieved during the 20th century, society has turned to medicine as a reference to life and health, not just the treatment of disease. For some observers, a medical science that attempts to give an answer to existential risks (rather than only clinical questions) becomes a sort of new, surrogate religion, no longer the science of disease but a science of existence (7), which promises a life without fatigue or pain that it is sadly unable to fulfill.
People affected by severe disease like cancer, as well as their families, are thus left with the same fundamental questions: Who are we? Where are we going? What is the meaning of our lives? People ask themselves such profound questions particularly in times of suffering and illness: for them, spiritual well-being and hope become fundamental needs that correlate with their quality of life (8). Hope, like other subjective personal feelings that escape every attempt to measure them objectively, cannot be included in an organizational domain of health care, which can only focus on practical matters (9-10-11-12-13). There are, however, various ways to help people who are suffering, by providing social and psychological support in cooperation with the providers of clinical care. To this end, it is fundamentally important for such support to be provided in a globally caring atmosphere. Attention must be paid to the subjectivity of individual patients in an institutional setting where providing support for the whole sphere of an individual’s relations, affections and values is considered an important aspect of patient care. In other words, modern hospitals need to safeguard patients’ rights in the broadest possible sense, which means meeting also their spiritual needs (and not only in the religious sense) as a part of the support services made available to patients. All the various religious faiths can offer valuable examples of action that can be taken to help a human being who is suffering, each according to their own confessional approaches but all designed to sustain individuals traveling along an arduous personal path. In Western culture, the spiritual counselor is represented by the hospital chaplain. This figure, in the internationally accepted sense of this role, i.e., an appropriately trained professional, is beginning to be called on by hospital staff to serve in an increasingly active role to meet the spiritual needs of patients, to the point of being considered in some cases part of the multidisciplinary team at the patient’s bedside alongside the medical, nursing and other staff members (13, 14). This involvement of a pastoral care provider might pose a major challenge, however, necessitating the sharing of different types of knowledge and different types of approach to a patient’s problems. In fact, obstacles to the full implementation of these principles are sometimes encountered. In some cases, pastoral care is still provided according to a traditional mentality that is difficult to align with the patient care practices of a modern hospital (15). On the other hand, some medical personnel, psychologists and psychiatrists take a negative attitude to the provision of religious support to hospital patients (16).
The real feasibility of integrating the mental health sciences (psychology and psychiatry) with religious practices is a complex question that still suffers from the historically entrenched communication difficulties experienced by the parties concerned.
The development of consultation liaison psychiatry and clinical psychology in Italy during the 20th century: stop points and steps forward in the integration with medicine
A historical perspective of the essential stages in the development of the mental health sciences in Italy is given in
The essential historical stages in the development of the mental health sciences in Italy and their relationship with religion in Italy
|Early 20th century||Based on a law of 1904 (“Provisions on mental hospitals and their inmates”), mental hospitals were developed out of general hospitals for isolating individuals who were considered dangerous|
|Early post-First World War years||Psychology was not recognized as a science||The religious view did not encourage any studies on psychopathology (attributing it to the sphere of sin and evil)|
|1923||The Gentile Reform of the country’s education system, under Mussolini’s first government, abolished psychology as an academic subject||Father Agostino Gemelli in Rome continued to work in the sphere of psychology during Italy’s 20 years under fascist rule|
|1930s||Political obstacles interfered with the diffusion of psychoanalysis that had begun in these years because some of its pioneers were Jews (Edoardo Weiss, Emilio Servadio) or antifascist socialists (Cesare Musatti, Nicola Perrotti)|
|1950s||There were no specific major courses of study on psychiatry at faculties of medicine (there were only complementary lectures)||The term “clinical psychology” appeared for the first time at a conference organized by Father Agostino Gemelli Few university schools of specialization in clinical psychology were established||Pius XII against psychoanalysis (in particular, Freud’s pansexualism and denial of man’s otherworldly destiny was condemned) Pope’s speeches towards accepting psychology and psychotherapy|
|1961-1962||A professorship in psychiatry alone was established (1962)||Members of religious orders were not permitted to undergo psychoanalysis unless they obtained explicit authorization (Holy Office 1961)|
|1963||The Milan Polyclinic Hospital opened its psychiatric ward (called “Guardia II”), which was the first to be established in an Italian general hospital. It took until 1976 before psychiatry was separated from neurology||Establishing a dialogue between psychoanalysis and Catholic thought with the publication of the text
||The College of Bishops took various actions in favor of the psychological sciences|
|1965||The Second Vatican Council (1962-1965) acknowledged in the
|1967||In the encyclical
|1970-1971||The first degree courses in psychology were started in Padua (1970)||Foundation of the Institute of Psychology at the Pontifical Gregorian University (thanks to the contribution of Luigi Maria Rulla, Franco Imoda and Joyce Ridick) (1971)|
|1975||Paul VI acknowledged the possible role of psychologists in the assistance of priests, the therapeutic contributions somatic care can make to the patient’s spirit, and the contribution of psychology to the training of candidates for the priesthood|
|1978||The Law 180 (or Basaglia’s law) reformed psychiatric care: psychiatric services for patient diagnosis and treatment were opened in general hospitals. Psychiatrists began to develop forms of cooperation with other hospital departments|
|1984||Publication of Pope John Paul II’s apostolic letter
|1985||The Italian Society of Psychooncology (
||Publication of the
|1986-1987||The Italian Society of Medical Psychology (
||The creation of the
|1989||A law established the Professional Association of Psychologists, defining the professional figure of the psychologist|
|1992||Institution of the World Day for the Sick by John Paul II|
|2008||The contribution of psychology in the training of candidates for the priesthood (Congregation for Catholic Education)|
The study of psychiatry and psychology is a relatively new entry in the history of Italy’s hospitals and, though there is some degree of affinity in their subject matter, the 2 specialties have been evolving in very different ways. One shared feature, however, is that they were not born in the general hospital setting, nor did they develop and evolve within Italy’s hospital walls for quite a lengthy period of time.
In the early 20th century, psychiatric wards were used more often for purposes of social containment than treatment. Mental hospitals were separated from general hospitals and sometimes located out of town with the aim of isolating individuals who were dangerous to themselves and others or a cause of public scandal (18). Psychiatrists rarely had the opportunity of cooperation and integration with the rest of the world of medicine, and with psychologists in particular. By contrast, elsewhere in Europe consultation-liaison psychiatry (also called medical psychology, or psychological medicine) came into being with the creation of psychiatric wards inside general hospitals. The development of this approach was patchy, mainly due to local schemes, and was more advanced in some countries than others (19).
The first psychiatric ward in a general hospital was established in 1963 in Milan, but only in 1978 was new legislation passed to reform psychiatric care in order to open psychiatric services for patient diagnosis and treatment in general hospitals. Various psychiatrists began to develop forms of cooperation with other hospital departments, exchanging patient consultations and taking part in studies on methods for relieving the psychological discomfort of patients with organic diseases. Psychiatric liaison services were established at the psychiatric departments of the main Italian universities. As the doors of hospital wards were being opened to psychiatry and consultation activities became more common, psychiatrists’ treatment practices were also shifting increasingly in favor of psychopharmacological solutions (20). However, this carried the risk of the contribution that psychiatry had to offer being restricted to psychopharmacological expertise alone – even in the liaison setting – neglecting its psychological and social aspects in favor of a biological model.
The various stages in the Italian life of psychology were, if possible, even more tormented than those of psychiatry. The dominant culture in the early post-war years did not acknowledge psychology as a science, since it took an exclusively rational and spiritual view of the human being that left no space for any debate on irrationality. The spread of psychoanalysis in Italy was hindered also by political matters and religious views. In the years after the Second World War, the development of psychology in Italy was only gradual and late in coming. The term “clinical psychology” appeared for the first time in 1952, at a conference organized by Father Agostino Gemelli (21), whereas elsewhere in Europe psychotherapy and psychoanalysis had been at the service of psychiatric clinical medicine for years, becoming integrated with psychodynamic knowledge. It was a very long time before clinical psychology was granted an academic identity in Italy, and it was only taught at a handful of university schools of specialization in the 1950s. Degree courses in psychology were established much later, in 1970, and even later, in 1989, came the definition of the professional figure of the psychologist.
Such slow progress in the acknowledgement of psychology also limited its involvement in the hospital care setting, which has taken place with some difficulty and been restricted mainly to very advanced health care institutions. In particular, it is only in a few rare cases, and not systematically, that students of psychiatry and clinical psychology are trained to pay attention to the spiritual dimension of their patients – and the training provided to students in medical degree courses is equally lacking in this area. The idea of some degree of integration between these domains remains theoretical and has never been thoroughly elucidated, although there have been some authoritative declarations of support in principle, such as the requirements for the accreditation of public health services established by the Joint Commission for the Accreditation of Hospital Organizations, which include the need to pay attention to patients’ spiritual needs (22).
The evolution of the relationship between the Catholic Church and human sciences
The Church was sometimes accused of interfering with the development of approaches to mental health by associating psychopathological phenomena and emotional suffering with a broader, more generic idea of sin and evil (23). The relation between the Catholic Church and psychological sciences was always complicated. During his papacy, Pius XII condemned Freudian psychoanalysis (24), though more open stances were declared towards psychology and psychotherapy, and their various approaches developed over the years (25). Psychotherapy has nothing
A key event was the Second Vatican Council in 1965, where the idea of psychology cooperating with the Church was pursued (27), particularly in certain specific areas such as the theological investigation of the contribution of the secular sciences, the preparation of candidates for the priesthood, and the pastoral training (28). Times were changing. Paul VI acknowledged the possible role of psychologists in the assistance of priests (29) as well as the therapeutic contributions that somatic care can make to the patient’s spirit (30), and recognized the contribution of psychology in the training of candidates for the priesthood, which was validated years later, in the 2008 Congregation for Catholic Education (31).
In parallel with this evolution, efforts were being made in the ecclesiastical world to devise working methods in clinical psychology and psychotherapy in harmony with the Catholic view, especially with the training of Catholic psychologists, who acknowledged the transcendent view of man as a fundamental element of their work (18). It is also important to mention the Institute of Psychology at the Pontifical Gregorian University, founded in 1971 for the purpose of training specialists in psychology capable of integrating the spiritual and the psychological dimensions in the apostolic and educational activities for which they were responsible as spiritual directors of seminaries, or vocational and other educators.
Other important contributions towards multidisciplinary cooperation in pastoral care for the sick came from the creation of the
Stances in favor of cooperation between the providers of pastoral care and mental health services were systematized in 2016 in the New Charter for Health Care Workers prepared by the Pontifical Council for Pastoral Assistance to Health Care Workers (
Statements from the
|Psychology and psychotherapy|
|No. 131. There is already ample evidence that all bodily illness has a psychological component, either as a co-efficient or as an after-effect. This is what “psychosomatic medicine” is concerned with, where the therapeutic value depends on the doctor-patient relationship (
|Health care workers should seek to relate to the patient in such a way that their humanitarian attitude reinforces their professionalism and their competence is more effective through their ability to understand the patient. A human and loving approach to the patient, required by an integrally human view of illness and strengthened by faith, is the key to this therapeutic effectiveness of the doctor-patient relationship [
|No. 132. Psychological disorders and illnesses can be dealt with and treated through psychotherapy. This includes a variety of methods by which someone can help another to be cured or at least to improve. Psychotherapy is essentially a growing process, that is, a path of liberation from childhood problems, or from the past, in any case, which enables the individual to assume his identity, role and responsibilities.|
|No. 133. “Psychotherapy is morally acceptable as a medical treatment.” But it must respect the person of the patient, who allows access into his inner world. This respect prohibits the psychotherapist from violating the privacy of the other without his consent and obliges him to work within these limits. “Just as it is unlawful to appropriate the goods of another or invade his corporal integrity without his permission, so it is not permissible to enter the inner world of another person against his wishes, whatever be the techniques and methods employed.”|
|The same respect prohibits the influencing or forcing of the patient’s will. “The psychologist whose only desire is the good of the patient will be all the more careful to respect the limits to his action set down by the moral code in that – in a manner of speaking – he holds in his hands the psychological faculties of a person, his ability to act freely, to achieve the noblest ideals which his personal destiny and his social calling imply.” [
|No. 134. From the moral standpoint, logotherapy and counseling are privileged forms of psychotherapy. But they are all acceptable, provided that they are practiced by psychotherapists who are guided by a profound ethical sense.|
|No. 135. Pastoral care of the sick consists in spiritual and religious assistance. This is a fundamental right of the patient and a duty of the Church (
|This is the essential and specific, though not exclusive, task of the health care pastoral worker. Because of the necessary interaction between the physical, psychological and spiritual dimension of the person, and the duty of giving witness to their own faith, all health care workers are bound to create the conditions by which religious assistance is assured to anyone who asks for it, either expressly or implicitly [
A multidisciplinary approach to the sick, with chaplains and mental health specialists working together: a model from a pediatric oncology unit
The forms of cooperation between chaplains and mental health specialists in hospitals have generally not been adopted systematically and they are not usually founded on encoded working or training practices. Where they have been implemented, they have proved capable of making a valuable contribution to the response to patients’ needs.
The 2 activities have numerous features in common that make such a cooperation desirable. For a start, the mental health specialist can support the chaplain’s pastoral work. Taking a modern view of pastoral care, it has been recognized that people can be strongly influenced in the free expression of their faith (a topic of interest from a religious perspective) by biological and psychopathological issues. More importantly, from a modern clinical perspective it has become increasingly clear what effects severe diseases and their treatments can have on a patient’s mental functioning. For instance, a person suffering from physical pain may be incapable of praying, hoping or believing. Excessively intense suffering is believed to be capable of limiting or preventing an individual’s control over their spirit. It is therefore legitimate and – beyond certain thresholds of supportability – the duty of health care providers to prevent, ease or remove pain. The principle of bringing pain under human control has been confirmed several times by the Catholic Church (33). In particular in the terminal stages of severe disease such as cancer, it has been emphasized that suffering can aggravate “the state of weakness and physical exhaustion, check the ardor of soul and sap the moral powers instead of sustaining them. On the other hand, the suppression of pain removes any tension in body and mind, renders prayer easy, and makes possible a more generous gift of self” (35).
Exactly the same problem can arise when the biological effects on the brain caused directly by a disease, or the effects of treatments on the mental functions come to influence patients’ mental state, interfering with their freedom to believe and their ability to hope. That is why help models based exclusively on an optimistic perspective may fail. In such conditions, pastoral work can therefore be facilitated, or even enabled, if patients receive help for their mental conditions.
A modern neuroscientific approach also acknowledges that efforts to improve a patient’s mental health can be usefully integrated with spiritual support work. Neuroscientists attribute great importance to the opportunity to lend meaning to potentially traumatic experiences (17). For patients to be able to make sense of a severe illness as part of their own individual story is not just a matter of explaining the biological aspects of their condition; it also involves a spiritual interpretation of the meaning of life, the significance of what is happening, and transcendent aspects – matters that do not strictly come within the sphere of the psychological sciences. From a Christian perspective, human beings yearn for infinity, and at the same time they are deeply rooted in worldly things. This is particularly true in hospital and in the case of severe physical illness, when disease may influence an individual’s thinking mechanisms, but patients may also have ideas that go beyond their mere biological and material problems.
The aims of a multidisciplinary effort to support the sick, taking a genuinely integrated approach, include
serving as a guarantee of suffering human beings’ subjectivity when they are being treated within a health care system that nowadays may focus more on economic goals than on caring
bearing witness to the irreducible complexity of the personal dimension of individuals
helping to sustain hope, which can relate to numerous aspects, concerning the medical sphere and the hope that the treatments will be successful, as well as religious faith and/or the spiritual domain (the idea of being “saved”, going to heaven, being rejoined with family and friends who have died, giving a sense to life); another type of hope may concern, however, patients’ relationships and affections (e.g., their need to feel acknowledged as important, loved and accepted, not a burden to others), but also the relationship with care providers (13).
In addition to a better understanding of the historical processes that made it difficult in the past for the disciplines to interact, the genuine cooperation and integration of in-hospital psychological and pastoral care also demands that more attention be paid to how the operators involved are trained. In particular, medical personnel and mental health specialists need to receive appropriate training so that they can acknowledge their patients’ spiritual needs and the added value of working in cooperation with pastoral care providers; hospital chaplains, for their part, need to be trained to understand the opportunities deriving from cooperating with medical science and the mental health disciplines in the hospital.
In various international scenarios, hospital chaplains are specialists in spiritual care for the sick and are specifically trained to provide it (36). The name by which these operators are known may vary from one faith to another, from one denomination to another, from one tradition to another, or from one country to another. Standards for health care chaplaincy in Europe (37) were published in June 2002 to guarantee a satisfactory response to patients’ spiritual needs in health care services. They are intended as a reference, a guideline for all faiths and denominations on what shape spiritual support services should take in the world of public health.
The specific training of hospital chaplains should include theological and pastoral education and reflection, awareness of the problems in the world of public health, practical/clinical supervision, and spiritual accompaniment. In the United States, acknowledgment as a hospital chaplain by the Association of Professional Chaplains relies on the successful completion of 4 years of college studies, 3 years at a faculty of theology, and 1 to 2 years of practice in clinical pastoral care, which entails more than 1,600 hours of supervision in counseling for the sick, as well as written and oral examinations. The training also includes a full-time practical placement under supervision for a year (36). Moreover, in the United States the integration of psychological-clinical practice and spiritual assistance is by now a structural feature (38), and spiritual consultation is offered to patients as part of the overall care by the medical team. Psychiatrists and mental health professionals working in hospitals receive training in the spiritual field, and participation in courses related to the spiritual and pastoral dimension is scheduled in the professional training.
In Italy, the people who provide spiritual support in hospitals are generally ministers who work at the hospital on the basis of various regional agreements or conventions drawn up by the public health organizations in the light of standards established by Italy’s national health system, which “assures religious assistance respectful of the citizen’s will and freedom of conscience” (art. 38, law n. 833 of December 1978). Though the training of chaplains may vary, they are almost always Catholic priests who have received a theological education. Alongside the more traditional forms of training, there has been evidence for several years now of Italian chaplains receiving more specific teaching to enable them to interact with the social and religious diversity in the country today, and thus respond to the requirements of a pastoral care provider. These specialists should become an integral part of any multidisciplinary care team, taking part in all phases of patient care and cooperating closely with the other members of the team in a project to respond to the multifaceted needs of people who are suffering.
A specific example is the Youth Project dedicated to adolescent patients with cancer established at the pediatric oncology unit of the Istituto Nazionale dei Tumori in Milan, Italy (39, 40). Along with clinical aims, the Youth Project provides age-specific spaces and initiatives to give young patients the tools to regain a sense of normalcy, tell their stories (to express their feelings, hopes and fears) and face the traumatic experience of cancer as best they can (41-42-43-44-45-46-47).Since for adolescent patients spirituality is a fundamental aspect of their psychological well-being, the Youth Project has developed also a model of spiritual support that underscores the importance of the daily presence of a chaplain on the hospital ward: the chaplain works at the pediatric oncology department on a daily basis, together with the medical team and in close cooperation with the psychologists (6). Such a model, however, is not the standard of care. A survey conducted by the Italian Society for Adolescents with Oncological and Hematological Diseases (SIAMO; Società Italiana Adolescenti con Malattie Onco-ematologiche) at pediatric oncology centers in Italy and Spain showed that the role of the spiritual counselor in pediatric oncology is still neither well-established nor based on standardized operating methods. For instance, the study reported that chaplains were generally present in pediatric oncology wards but rarely cooperated with caregivers and usually had received exclusively theological training (14).
Integrating religious and spiritual aspects in the provision of health care can focus more attention on and offer a more effective response to patients’ personal suffering. In settings where value is attributed to the emotional and spiritual well-being of people who are ill (and their families and health care providers too), there is room to expand the traditional role and activities of pastoral care providers. It would be a good idea to base efforts to provide support for patients’ spiritual needs on the early identification of these needs, to assess their impact on decisions relating to medical treatments, to offer pastoral counseling, to enable networking action (possibly involving local parish communities too), and so on. For hospital chaplains to be able to perform these functions, it is essential that they receive thorough training that covers conceptual study, specific notions regarding the health care setting, and adequate self-awareness (the outcome of introspection and serious personal accompaniment). It is the authors’ opinion that in the hospital setting the chaplain should be a constant presence along the pathway of care.
The chaplain visits the ward and the outpatient clinic/day hospital daily, meets daily with the psychologists on staff, and attends biweekly meetings with doctors and/or nurses (6, 16). Some of the chaplain’s time is spent on religious procedures such as celebrating mass, giving blessings, saying prayers, and administering sacraments. In addition to these general practices, the chaplain’s daily talks with staff members enable him to assess the spiritual needs of patients and their families and to identify cases that warrant particular attention and counseling (
Aims and tasks of the chaplain’s activity
|- Deliver, as part of a multidisciplinary clinical team, spiritual care and support to the patient’s needs|
|- Conduct daily visits to the ward and the outpatient clinic/day hospital|
|- Work in connection with psychiatrists, psychologists and social workers|
|- Attend periodical meetings with doctors and/or nurses|
|- Give attention to the spiritual needs of patients based on the different religious and cultural traditions of individuals|
|- Ensure religious worship, rituals and sacraments according to the religious tradition of everyone|
|- Encourage connection with the religious communities of patients|
|- Act as a supervisor for volunteers working at the hospital and in social housing|
|- Organize and participate in teaching programs for health professionals|
|- Promote research programs on spiritual care|
A particular problem attracting attention in Italy concerns the sizing of pastoral care services, the main criterion adopted being a numerical relationship with the number of hospital beds. However, it is also important to consider the spiritual and/or religious needs typical of different contexts, and to distinguish, for instance, between general hospitals, cancer referral centers and hospitals for long-term stay, which obviously have different needs and criticalities. Adopting a quantitative criterion alone does not seem to meet the need to allow for the particular spiritual conditions of different types of patients, and to help them embark on their personal spiritual course.
The world of spiritual needs has become so complex and differentiated that the traditional pastoral care formats and modalities (conceived as a parallel service rather than part of the work done by a patient care team) need to be revised, experimenting with the chaplains’ greater involvement in the models of patient care. This should counter the risk of patients being denied an appropriate response to their spiritual needs, which the scientific literature has come to recognize as an essential part of the provision of care (48, 49).
- Proserpio, Tullio [PubMed] [Google Scholar] 1, 2
- Ferrari, Andrea [PubMed] [Google Scholar] 1
- Veneroni, Laura [PubMed] [Google Scholar] 3, * Corresponding Author (email@example.com)
- Arice, Carmine [PubMed] [Google Scholar] 4
- Massimino, Maura [PubMed] [Google Scholar] 3
- Clerici, Carlo Alfredo [PubMed] [Google Scholar] 5, 6
Pastoral Care Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan - Italy
Department of Nanomedicine, Houston Methodist Institute for Academic Medicine (IAM), Houston - USA
Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan - Italy
Office for Health Pastoral Care, Italian Episcopal Conference, Rome - Italy
Clinical Psychology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan - Italy
Department of Oncology and Hematology, University of Milan, Milan - Italy