{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T20:57:51Z","timestamp":1792011471265,"version":"4.4.0"},"reference-count":55,"publisher":"American Medical Association (AMA)","issue":"1","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Netw Open"],"abstract":"\n Importance<\/jats:title>\n Proton therapy reduces radiation exposure to the heart, lungs, and contralateral breast compared with conventional photon-based breast radiotherapy. However, its clinical benefit\u2014particularly relative to photon deep inspiration breath-hold (DIBH)\u2014remains uncertain, and its high cost raises questions about cost-effectiveness.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n To evaluate the cost-effectiveness of proton therapy compared with photon-based radiotherapy, including DIBH and free breathing (FB), among patients with breast cancer in Belgium.<\/jats:p>\n <\/jats:sec>\n \n Design, Setting, and Participants<\/jats:title>\n This economic evaluation using state-transition microsimulation cost-effectiveness analysis was conducted between December 2024 and February 2025 from the Belgian health care payer perspective. The model incorporated patient-specific probabilities of complications, including cardiovascular disease, secondary malignant tumors, and radiation pneumonitis, derived from normal tissue complication probability models and representative national data. Deterministic and probabilistic sensitivity analyses were conducted. Participants were a simulated cohort of Belgian women with breast cancer, reflecting national incidence and survival data, stratified by baseline cardiovascular risk, smoking status, and age.<\/jats:p>\n <\/jats:sec>\n \n Exposures<\/jats:title>\n Comparison of proton therapy vs photon therapy delivered via DIBH or FB. Scenarios were analyzed based on tumor laterality, regional nodal irradiation, and varying cost assumptions for proton therapy.<\/jats:p>\n <\/jats:sec>\n \n Main Outcomes and Measures<\/jats:title>\n The primary outcome was incremental cost-effectiveness ratio (ICER), expressed in euros per quality-adjusted life-year (QALY) gained. Cost-effectiveness defined by a willingness-to-pay threshold of \u20ac45\u202f000 per QALY.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n The simulated cohort included 1 million patients (310\u202f000 aged 60 to 69 years [31.0%]). Proton therapy was not cost-effective in any scenario under base case assumptions. The greatest potential benefit was observed in patients with moderate to high baseline cardiovascular risk receiving left-sided irradiation with regional nodal irradiation, with an ICER of \u20ac292\u202f438 (95% CI, \u20ac290\u202f598-294\u202f299) per QALY for proton therapy compared with photon free breathing. Under the most optimistic cost scenario (full treatment capacity and a 15% reduction in proton therapy costs), proton therapy was cost-effective compared with photon free breathing in approximately 36\u202f000 of 1\u202f000\u202f000 simulated patients (3.6%), but it was not cost-effective compared with photon deep inspiration breath-hold in any subgroup, with ICERs exceeding \u20ac700\u202f000 per QALY across all comparisons.<\/jats:p>\n <\/jats:sec>\n \n Conclusions and Relevance<\/jats:title>\n Findings from this economic evaluation of proton therapy for breast cancer suggest that proton therapy is unlikely to be cost-effective for most Belgian patients under current cost conditions, except for a small subset of high-risk patients, especially when DIBH is available.<\/jats:p>\n <\/jats:sec>","DOI":"10.1001\/jamanetworkopen.2025.54888","type":"journal-article","created":{"date-parts":[[2026,1,22]],"date-time":"2026-01-22T16:30:50Z","timestamp":1769099450000},"page":"e2554888","source":"Crossref","is-referenced-by-count":1,"title":["Cost-Effectiveness of Proton Therapy Compared With Photon Therapy in Breast Cancer"],"prefix":"10.1001","volume":"9","author":[{"given":"Sara-Lise","family":"Busschaert","sequence":"first","affiliation":[{"name":"Research Centre on Digital Medicine, Department of Public Health, Vrije Universiteit Brussel, Brussels, Belgium"},{"name":"Department of Radiation Oncology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eva","family":"Kimpe","sequence":"additional","affiliation":[{"name":"Research Centre on Digital Medicine, Department of Public Health, Vrije Universiteit Brussel, Brussels, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thierry","family":"Gevaert","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mark","family":"De Ridder","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Koen","family":"Putman","sequence":"additional","affiliation":[{"name":"Research Centre on Digital Medicine, Department of Public Health, Vrije Universiteit Brussel, Brussels, Belgium"},{"name":"Department of Radiation Oncology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"10","published-online":{"date-parts":[[2026,1,22]]},"reference":[{"issue":"8","key":"zoi251463r1","doi-asserted-by":"publisher","first-page":"R155","DOI":"10.1088\/0031-9155\/60\/8\/R155","article-title":"The physics of proton therapy.","volume":"60","author":"Newhauser","year":"2015","journal-title":"Phys Med Biol"},{"issue":"6","key":"zoi251463r2","doi-asserted-by":"publisher","first-page":"427","DOI":"10.1097\/CCO.0000000000000228","article-title":"New frontiers in proton therapy: applications in breast cancer.","volume":"27","author":"Orecchia","year":"2015","journal-title":"Curr Opin Oncol"},{"issue":"1","key":"zoi251463r3","doi-asserted-by":"publisher","first-page":"46","DOI":"10.1016\/j.ijrobp.2015.11.035","article-title":"Proton therapy for breast cancer: getting to the heart of the matter.","volume":"95","author":"MacDonald","year":"2016","journal-title":"Int J Radiat Oncol Biol Phys"},{"issue":"2","key":"zoi251463r4","doi-asserted-by":"publisher","first-page":"138","DOI":"10.1016\/j.semradonc.2017.11.009","article-title":"Potential morbidity reduction with proton radiation therapy for breast cancer.","volume":"28","author":"Braunstein","year":"2018","journal-title":"Semin Radiat Oncol"},{"issue":"2","key":"zoi251463r5","doi-asserted-by":"publisher","first-page":"337","DOI":"10.1016\/j.ijrobp.2021.05.110","article-title":"Proton therapy for breast cancer: a consensus statement from the particle therapy cooperative group breast cancer subcommittee.","volume":"111","author":"Mutter","year":"2021","journal-title":"Int J Radiat Oncol Biol Phys"},{"key":"zoi251463r6","doi-asserted-by":"publisher","DOI":"10.3389\/fonc.2023.1133909","article-title":"Proton versus photon radiation therapy: a clinical review.","volume":"13","author":"Chen","year":"2023","journal-title":"Front Oncol"},{"issue":"4","key":"zoi251463r7","doi-asserted-by":"publisher","first-page":"247","DOI":"10.1016\/j.clon.2021.12.007","article-title":"Model-based selection for proton therapy in breast cancer: development of the national indication protocol for proton therapy and first clinical experiences.","volume":"34","author":"Boersma","year":"2022","journal-title":"Clin Oncol (R Coll Radiol)"},{"key":"zoi251463r8","doi-asserted-by":"publisher","first-page":"19","DOI":"10.1016\/j.ctrv.2017.11.006","article-title":"Proton therapy for locally advanced breast cancer: a systematic review of the literature.","volume":"63","author":"Kammerer","year":"2018","journal-title":"Cancer Treat Rev"},{"issue":"2","key":"zoi251463r9","doi-asserted-by":"publisher","first-page":"179","DOI":"10.1016\/j.radonc.2005.03.006","article-title":"Economic evaluation of proton radiation therapy in the treatment of breast cancer.","volume":"75","author":"Lundkvist","year":"2005","journal-title":"Radiother Oncol"},{"issue":"8","key":"zoi251463r10","doi-asserted-by":"publisher","first-page":"850","DOI":"10.1080\/02841860500341157","article-title":"Proton therapy of cancer: potential clinical advantages and cost-effectiveness.","volume":"44","author":"Lundkvist","year":"2005","journal-title":"Acta Oncol"},{"issue":"7383","key":"zoi251463r11","doi-asserted-by":"publisher","first-page":"256","DOI":"10.1136\/bmj.326.7383.256","article-title":"Mortality from cardiovascular disease more than 10 years after radiotherapy for breast cancer: nationwide cohort study of 90 000 Swedish women.","volume":"326","author":"Darby","year":"2003","journal-title":"BMJ"},{"issue":"5","key":"zoi251463r12","doi-asserted-by":"publisher","first-page":"e819","DOI":"10.1016\/j.clbc.2018.05.010","article-title":"A systematic review of heart dose in breast radiotherapy.","volume":"18","author":"Drost","year":"2018","journal-title":"Clin Breast Cancer"},{"issue":"4","key":"zoi251463r13","doi-asserted-by":"publisher","first-page":"845","DOI":"10.1016\/j.ijrobp.2015.07.2292","article-title":"Exposure of the heart in breast cancer radiation therapy: a systematic review of heart doses published during 2003 to 2013.","volume":"93","author":"Taylor","year":"2015","journal-title":"Int J Radiat Oncol Biol Phys"},{"issue":"1","key":"zoi251463r14","doi-asserted-by":"publisher","first-page":"11","DOI":"10.1016\/j.ijrobp.2016.02.031","article-title":"Establishing cost-effective allocation of proton therapy for breast irradiation.","volume":"95","author":"Mailhot Vega","year":"2016","journal-title":"Int J Radiat Oncol Biol Phys"},{"key":"zoi251463r15","doi-asserted-by":"publisher","DOI":"10.3389\/fmed.2022.938927","article-title":"Cost-effectiveness of using protons for breast irradiation aiming at minimizing cardiotoxicity: a risk-stratification analysis.","volume":"9","author":"Li","year":"2022","journal-title":"Front Med (Lausanne)"},{"issue":"1","key":"zoi251463r16","doi-asserted-by":"publisher","first-page":"44","DOI":"10.1002\/jmrs.416","article-title":"Individualised selection of left-sided breast cancer patients for proton therapy based on cost-effectiveness.","volume":"68","author":"Austin","year":"2021","journal-title":"J Med Radiat Sci"},{"issue":"4","key":"zoi251463r17","doi-asserted-by":"publisher","first-page":"514","DOI":"10.1016\/j.jaccao.2024.04.009","article-title":"Deep inspiration breath hold in left-sided breast radiotherapy: a balance between side effects and costs.","volume":"6","author":"Busschaert","year":"2024","journal-title":"JACC CardioOncol"},{"key":"zoi251463r20","doi-asserted-by":"publisher","first-page":"v74","DOI":"10.1093\/annonc\/mdz240.044","article-title":"Pneumonitis and fibrosis after breast cancer radiation.","volume":"30","author":"Karlsen","year":"2019","journal-title":"Ann Oncol"},{"issue":"15","key":"zoi251463r21","doi-asserted-by":"publisher","first-page":"1641","DOI":"10.1200\/JCO.2016.72.0722","article-title":"Estimating the risks of breast cancer radiotherapy: evidence from modern radiation doses to the lungs and heart and from previous randomized trials.","volume":"35","author":"Taylor","year":"2017","journal-title":"J Clin Oncol"},{"issue":"11","key":"zoi251463r22","doi-asserted-by":"publisher","first-page":"987","DOI":"10.1056\/NEJMoa1209825","article-title":"Risk of ischemic heart disease in women after radiotherapy for breast cancer.","volume":"368","author":"Darby","year":"2013","journal-title":"N Engl J Med"},{"issue":"2","key":"zoi251463r23","doi-asserted-by":"publisher","first-page":"112","DOI":"10.1016\/j.prro.2023.11.001","article-title":"Partial breast irradiation for patients with early-stage invasive breast cancer or ductal carcinoma in situ: an ASTRO clinical practice guideline.","volume":"14","author":"Shaitelman","year":"2024","journal-title":"Pract Radiat Oncol"},{"key":"zoi251463r24","doi-asserted-by":"publisher","first-page":"111","DOI":"10.1016\/j.radonc.2020.03.022","article-title":"Estimating lung cancer and cardiovascular mortality in female breast cancer patients receiving radiotherapy.","volume":"152","author":"Mulliez","year":"2020","journal-title":"Radiother Oncol"},{"issue":"25","key":"zoi251463r25","doi-asserted-by":"publisher","first-page":"2439","DOI":"10.1093\/eurheartj\/ehab309","article-title":"SCORE2 risk prediction algorithms: new models to estimate 10-year risk of cardiovascular disease in Europe.","volume":"42","author":"SCORE2 Working Group","year":"2021","journal-title":"Eur Heart J"},{"issue":"25","key":"zoi251463r26","doi-asserted-by":"publisher","first-page":"2455","DOI":"10.1093\/eurheartj\/ehab312","article-title":"SCORE2-OP risk prediction algorithms: estimating incident cardiovascular event risk in older persons in four geographical risk regions.","volume":"42","author":"SCORE2-OP Working Group","year":"2021","journal-title":"Eur Heart J"},{"issue":"28","key":"zoi251463r27","doi-asserted-by":"publisher","first-page":"2544","DOI":"10.1093\/eurheartj\/ehad260","article-title":"SCORE2-Diabetes: 10-year cardiovascular risk estimation in type 2 diabetes in Europe.","volume":"44","author":"SCORE2-Diabetes Working Group","year":"2023","journal-title":"Eur Heart J"},{"issue":"2","key":"zoi251463r28","doi-asserted-by":"publisher","first-page":"328","DOI":"10.1093\/eurjpc\/zwaa128","article-title":"Prediction of recurrent event in patients with coronary heart disease: the EUROASPIRE risk model.","volume":"29","author":"De Bacquer","year":"2022","journal-title":"Eur J Prev Cardiol"},{"issue":"12","key":"zoi251463r29","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pmed.1001764","article-title":"Evaluation of the lung cancer risks at which to screen ever- and never-smokers: screening rules applied to the PLCO and NLST cohorts.","volume":"11","author":"Tammem\u00e4gi","year":"2014","journal-title":"PLoS Med"},{"key":"zoi251463r30","doi-asserted-by":"publisher","first-page":"27","DOI":"10.1186\/1742-4682-8-27","article-title":"Site-specific dose-response relationships for cancer induction from the combined Japanese A-bomb and Hodgkin cohorts for doses relevant to radiotherapy.","volume":"8","author":"Schneider","year":"2011","journal-title":"Theor Biol Med Model"},{"issue":"3","key":"zoi251463r31","doi-asserted-by":"publisher","first-page":"724","DOI":"10.1016\/S0360-3016(02)03986-X","article-title":"Comparing different NTCP models that predict the incidence of radiation pneumonitis. Normal tissue complication probability.","volume":"55","author":"Seppenwoolde","year":"2003","journal-title":"Int J Radiat Oncol Biol Phys"},{"issue":"2","key":"zoi251463r32","doi-asserted-by":"publisher","first-page":"516","DOI":"10.3390\/cancers15020516","article-title":"Costs of newly funded proton therapy using time-driven activity-based costing in the Netherlands.","volume":"15","author":"Chen","year":"2023","journal-title":"Cancers (Basel)"},{"issue":"1","key":"zoi251463r33","doi-asserted-by":"publisher","first-page":"51","DOI":"10.1332\/174426410X482999","article-title":"A web-based tool for adjusting costs to a specific target currency and price year.","volume":"6","author":"Shemilt","year":"2010","journal-title":"Evid Policy"},{"key":"zoi251463r34","doi-asserted-by":"publisher","DOI":"10.1016\/j.radonc.2022.11.021","article-title":"Clues to address barriers for access to proton therapy in the Netherlands.","volume":"178","author":"Thijssen","year":"2023","journal-title":"Radiother Oncol"},{"key":"zoi251463r35","doi-asserted-by":"publisher","DOI":"10.1016\/j.ctro.2023.100670","article-title":"Patients\u2019 needs in proton therapy: a survey among ten European facilities.","volume":"43","author":"Mazzola","year":"2023","journal-title":"Clin Transl Radiat Oncol"},{"issue":"28","key":"zoi251463r36","doi-asserted-by":"publisher","first-page":"7074","DOI":"10.1200\/JCO.2005.06.032","article-title":"Impact of patient distance to radiation therapy on mastectomy use in early-stage breast cancer patients.","volume":"23","author":"Schroen","year":"2005","journal-title":"J Clin Oncol"},{"issue":"4","key":"zoi251463r37","doi-asserted-by":"publisher","first-page":"1095","DOI":"10.1245\/s10434-014-4093-8","article-title":"Effect of travel distance and time to radiotherapy on likelihood of receiving mastectomy.","volume":"22","author":"Goyal","year":"2015","journal-title":"Ann Surg Oncol"},{"issue":"4","key":"zoi251463r38","doi-asserted-by":"publisher","first-page":"324","DOI":"10.1016\/j.breast.2011.02.020","article-title":"Geographic proximity to treatment for early stage breast cancer and likelihood of mastectomy.","volume":"20","author":"Boscoe","year":"2011","journal-title":"Breast"},{"issue":"5","key":"zoi251463r39","doi-asserted-by":"publisher","first-page":"271","DOI":"10.1016\/j.clon.2017.11.002","article-title":"Too big to fail? The current status of proton therapy in the USA.","volume":"30","author":"Zietman","year":"2018","journal-title":"Clin Oncol (R Coll Radiol)"},{"issue":"8","key":"zoi251463r40","doi-asserted-by":"publisher","first-page":"775","DOI":"10.1038\/s41416-018-0324-2","article-title":"Can proton therapy be considered a standard of care in oncology? Lessons from the United States.","volume":"120","author":"Zietman","year":"2019","journal-title":"Br J Cancer"},{"issue":"1","key":"zoi251463r41","doi-asserted-by":"publisher","first-page":"S37","DOI":"10.1053\/clon.2002.0174","article-title":"The relative costs of proton and X-ray radiation therapy.","volume":"15","author":"Goitein","year":"2003","journal-title":"Clin Oncol (R Coll Radiol)"},{"issue":"2","key":"zoi251463r42","doi-asserted-by":"publisher","first-page":"150","DOI":"10.1016\/j.semradonc.2017.11.007","article-title":"Can technological improvements reduce the cost of proton radiation therapy?","volume":"28","author":"Schippers","year":"2018","journal-title":"Semin Radiat Oncol"},{"issue":"1","key":"zoi251463r43","doi-asserted-by":"publisher","first-page":"148","DOI":"10.1016\/j.radonc.2017.11.022","article-title":"Exposure of the lungs in breast cancer radiotherapy: A systematic review of lung doses published 2010-2015.","volume":"126","author":"Aznar","year":"2018","journal-title":"Radiother Oncol"},{"issue":"4","key":"zoi251463r44","doi-asserted-by":"publisher","first-page":"331","DOI":"10.1667\/RADE-23-00014.1","article-title":"Trends in radiation dose to the contralateral breast during breast cancer radiation therapy.","volume":"200","author":"Watt","year":"2023","journal-title":"Radiat Res"},{"issue":"4","key":"zoi251463r45","doi-asserted-by":"publisher","first-page":"869","DOI":"10.1016\/j.ijrobp.2023.02.023","article-title":"Proton beam therapy for early breast cancer: a systematic review and meta-analysis of clinical outcomes.","volume":"117","author":"Holt","year":"2023","journal-title":"Int J Radiat Oncol Biol Phys"},{"key":"zoi251463r46","doi-asserted-by":"publisher","first-page":"126","DOI":"10.1016\/j.ctro.2021.01.012","article-title":"Selection criteria for early breast cancer patients in the DBCG proton trial\u2014 the randomised phase III trial strategy.","volume":"27","author":"Stick","year":"2021","journal-title":"Clin Transl Radiat Oncol"},{"issue":"10","key":"zoi251463r47","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2018-025556","article-title":"Pragmatic randomised clinical trial of proton versus photon therapy for patients with non-metastatic breast cancer: the radiotherapy comparative effectiveness (RadComp) Consortium trial protocol.","volume":"9","author":"Bekelman","year":"2019","journal-title":"BMJ Open"},{"issue":"6","key":"zoi251463r48","doi-asserted-by":"publisher","first-page":"347","DOI":"10.1016\/j.clon.2023.02.015","article-title":"Proton beam therapy in breast cancer patients: the UK PARABLE trial is recruiting.","volume":"35","author":"Kirby","year":"2023","journal-title":"Clin Oncol (R Coll Radiol)"},{"issue":"3","key":"zoi251463r49","doi-asserted-by":"publisher","first-page":"691","DOI":"10.1016\/j.ijrobp.2006.06.041","article-title":"Accelerated partial-breast irradiation using proton beams: initial clinical experience.","volume":"66","author":"Kozak","year":"2006","journal-title":"Int J Radiat Oncol Biol Phys"},{"issue":"5","key":"zoi251463r50","doi-asserted-by":"publisher","first-page":"1084","DOI":"10.1016\/j.ijrobp.2019.04.015","article-title":"Quantification of Acute Skin Toxicities in Patients With Breast Cancer Undergoing Adjuvant Proton versus Photon Radiation Therapy: A Single Institutional Experience.","volume":"104","author":"DeCesaris","year":"2019","journal-title":"Int J Radiat Oncol Biol Phys"},{"issue":"3","key":"zoi251463r51","doi-asserted-by":"publisher","first-page":"493","DOI":"10.1016\/j.ijrobp.2014.04.008","article-title":"Long-term cosmetic outcomes and toxicities of proton beam therapy compared with photon-based 3-dimensional conformal accelerated partial-breast irradiation: a phase 1 trial.","volume":"90","author":"Galland-Girodet","year":"2014","journal-title":"Int J Radiat Oncol Biol Phys"},{"issue":"1","key":"zoi251463r52","doi-asserted-by":"publisher","first-page":"115","DOI":"10.1007\/s10549-013-2508-z","article-title":"The impact of breast cosmetic and functional outcomes on quality of life: long-term results from the St. George and Wollongong randomized breast boost trial.","volume":"139","author":"Hau","year":"2013","journal-title":"Breast Cancer Res Treat"},{"issue":"2","key":"zoi251463r53","doi-asserted-by":"publisher","first-page":"479","DOI":"10.1007\/s10549-019-05470-y","article-title":"Patient-reported cosmetic satisfaction and the long-term association with quality of life in irradiated breast cancer patients.","volume":"179","author":"Batenburg","year":"2020","journal-title":"Breast Cancer Res Treat"},{"key":"zoi251463r54","doi-asserted-by":"publisher","DOI":"10.1016\/j.radonc.2023.109734","article-title":"ESTRO-ACROP guideline: recommendations on implementation of breath-hold techniques in radiotherapy.","volume":"185","author":"Aznar","year":"2023","journal-title":"Radiother Oncol"},{"issue":"14","key":"zoi251463r55","doi-asserted-by":"publisher","first-page":"2979","DOI":"10.1016\/j.ejca.2013.04.028","article-title":"Contralateral breast cancer after radiotherapy among BRCA1 and BRCA2 mutation carriers: a WECARE study report.","volume":"49","author":"Bernstein","year":"2013","journal-title":"Eur J Cancer"},{"key":"zoi251463r18","unstructured":"Belgian Cancer Registry. Cancer fact sheet 2022: breast cancer. Accessed December 9, 2025. https:\/\/kankerregister.org\/sites\/default\/files\/2024\/Cancer_Fact_Sheet_Female%20Breast%20Cancer_2022.pdf"},{"key":"zoi251463r19","unstructured":"Belgische Federale Overheidsdiensten. 7 MAI 2004\u2014Loi relative aux exp\u00e9rimentations sur la personne humaine. Published May 18, 2004. Accessed December 26, 2025. https:\/\/www.ejustice.just.fgov.be\/cgi_loi\/change_lg.pl?language=fr&la=F&cn=2004050732&table_name=loi"}],"container-title":["JAMA Network Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/articlepdf\/2844173\/busschaert_2026_oi_251463_1768415282.4389.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,1,22]],"date-time":"2026-01-22T16:30:52Z","timestamp":1769099452000},"score":1,"resource":{"primary":{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/fullarticle\/2844173"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,1,22]]},"references-count":55,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2026,1,2]]}},"URL":"https:\/\/doi.org\/10.1001\/jamanetworkopen.2025.54888","relation":{},"ISSN":["2574-3805"],"issn-type":[{"value":"2574-3805","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,1,22]]}}}