"Safe Foods" or "Fear Foods": the implications of food avoidance in college students from low- and middle-income countries

PURPOSE

The primary objective of this study was to explore if self-reported food avoidance (fats, carbohydrates and protein) exists among college students in low- and middle-income countries (LMICs) and its relationship with body mass index (BMI), dieting, mood/anxiety symptoms, physical activities and general health knowledge.

METHODS

This study is a subset (N = 6096) of a larger 26 LMICs cross-sectional survey, which consisted of 21,007 college students. We ascertained socio-demographic information, food avoidance, physical activities, dieting behaviours, depressive and PTSD symptoms, and recorded anthropometric measurements. Chi-square analyses assessed the relationship between predictor variables and food categories eliminated from participants' diet. Multiple logistic regression assessed if food avoidance predicts outcome variables such as binge drinking, high physical activity, being underweight, exhibiting significant depressive and PTSD symptoms.

RESULTS

Food avoidance exists in as many as one-third of college students in low- and middle-income countries, with this being more likely in persons who are trying to lose weight whether by dieting or otherwise. Food avoidance was associated with higher BMI, depressive symptoms, and high intensity exercises, as well as the level of health knowledge influencing the types of food avoided. A significant difference was noted between lower middle-income and upper middle-income countries with respect to the foods they avoided.

CONCLUSION

Despite being knowledgeable about health-related behaviours, we found that college students in our sample were not that different from those in developed countries and may be influenced by a similar advice given by non-experts about macronutrients. These results hold implications for intervention programmes and policy makers.

LEVEL OF EVIDENCE

Level V, descriptive cross-sectional survey.

Abstract AP18: FUNCTIONAL GENOMIC SCREEN FOR ATTACHMENT AND INVASION IN METASTATIC OVARIAN CANCER

PURPOSE: To perform a biologically relevant functional genomic screen for genes involved in attachment and early invasion incorporating tumor microenvironment cells cultured from human omentum.

METHODS: Primary fibroblasts cultured from the human omentum were plated as one component to recapitulate the tumor microenvironment. An arrayed small interfering RNA (siRNA) panel targeting 719 genes encoding kinases was used. Each well contained 2 oligos per gene. Three ovarian cancer cells with known metastatic capabilities (OVCAR8, ES2, and A2780) were selected and stably labeled with GFP. Following exposure to siRNA, ovarian cancer cells are overlaid upon a mixed submesothelial matrix (NOFs, collagen I, and fibronectin). After 72 hours of attachment/early invasion, a wash step was performed, and the functional readout of the intensity of fluorescence was performed. Cell death due to the siRNA was evaluated by staining with resazurin. Data was analyzed by expressing the effect of increased or decreased attachment using the median average deviation (MAD).

RESULTS: MAD values were generated for each gene. A baseline MAD value of 0 was used and positive MAD values denoted genes that influenced an increase in adhesion when knocked down whereas negative values represented genes that had decreased adhesion when knocked down. Negative controls for adhesion/early invasion were used and found to have a MAD value of 0.52 for mock transfection reagent control and 2.45 for siNEG control. Positive controls for adhesion/early invasion had a MAD value of -6.13 for siB1- integrin and -8.91 for a known inhibitor of attachment – canthardin. The transfection efficiency control, siDEATH, had a MAD value of -8.8. Of the 719 genes encoding kinases, we found 17 genes with MAD values above +3 and 19 genes with MAD values below -3. Of these hits, JAK1 and Wee1 were identified. JAK1 has been found to contribute to ovarian cancer invasion, migration, and metastasis in preclinical models. Wee1 is involved in cell cycle progression, and a Wee1 inhibitor is currently in a Phase II trial in relapsed ovarian cancer. Both targets confirm that biologically-relevant genes can be identified through this screen by incorporating stromal cells cultured from human omentum. Additionally, across 3 cell lines, we identified kinases that overlapped in at least 2 cell lines with a MAD lower range of -1.85. There were 94 kinases identified: 9 with a role in adhesion, 7 in immune response, 17 in proliferation, 6 in apoptosis, 16 in metabolism, 33 in cell cycle, 2 in migration, 3 in ribosomal, 1 in autophagy, and 23 genes with overlapping functions.

CONCLUSIONS: By incorporating the tumor microenvironment into a functional genomic screen, biologically relevant genes for ovarian cancer cell attachment and early invasion can be identified and will be validated as potential novel therapeutic targets.

Citation Format: Katherine Fuh, Anne Gibson, Daniel Wilke, Maxene Ilagan, Andrea Hagemann, Carolyn McCourt, Premal Thaker, David Mutch, Matthew Powell, and Gregory Longmore. FUNCTIONAL GENOMIC SCREEN FOR ATTACHMENT AND INVASION IN METASTATIC OVARIAN CANCER [abstract]. In: Proceedings of the 11th Biennial Ovarian Cancer Research Symposium; Sep 12-13, 2016; Seattle, WA. Philadelphia (PA): AACR; Clin Cancer Res 2017;23(11 Suppl):Abstract nr AP18.

FGFR2 mutations are associated with poor outcomes in endometrioid endometrial cancer: An NRG Oncology/Gynecologic Oncology Group study

PURPOSE

Activating FGFR2 mutations have been identified in ~10% of endometrioid endometrial cancers (ECs). We have previously reported that mutations in FGFR2 are associated with shorter disease free survival (DFS) in stage I/II EC patients. Here we sought to validate the prognostic importance of FGFR2 mutations in a large, multi-institutional patient cohort.

METHODS

Tumors were collected as part of the GOG 210 clinical trial "Molecular Staging of Endometrial Cancer" where samples underwent rigorous pathological review and had more than three years of detailed clinical follow-up. DNA was extracted and four exons encompassing the FGFR2 mutation hotspots were amplified and sequenced.

RESULTS

Mutations were identified in 144 of the 973 endometrioid ECs, of which 125 were classified as known activating mutations and were included in the statistical analyses. Consistent with FGFR2 having an association with more aggressive disease, FGFR2 mutations were more common in patients initially diagnosed with stage III/IV EC (29/170;17%) versus stage I/II EC (96/803; 12%; p=0.07, Chi-square test). Additionally, incidence of progression (progressed, recurred or died from disease) was significantly more prevalent (32/125, 26%) among patients with FGFR2 mutation versus wild type (120/848, 14%; p<0.001, Chi-square test). Using Cox regression analysis adjusting for known prognostic factors, patients with FGFR2 mutation had significantly (p<0.025) shorter progression-free survival (PFS; HR 1.903; 95% CI 1.177-3.076) and endometrial cancer specific survival (ECS; HR 2.013; 95% CI 1.096-3.696).

CONCLUSION

In summary, our findings suggest that clinical trials testing the efficacy of FGFR inhibitors in the adjuvant setting to prevent recurrence and death are warranted.

Abstract P5-09-09: Functional IGF1R variant predicts preeclampsia protection from invasive breast cancer: Novel California teachers study findings

Many studies have reported lower breast cancer risk in women who develop hypertension in pregnancy with a meta-analysis reporting hazard ratios of 0.86 for preeclampsia and 0.83 for gestational hypertension. Our prior work in the Marin Women's Study (MWS) demonstrated both a lower breast density and a lower risk of breast cancer in women with pregnancy-induced hypertension (PIH) if they possess the TT genotype of IGF1R SNP rs2016347.

Breast cancer in MWS women with PIH by IGF1R genotypers2016347 genotype# with genotype# breast cancer cases% breast cancer casesGG9188.79%GT195147.18%TT8800.00%Fisher's exact = 0.008

The current study was designed to validate and expand upon these findings in the larger California Teachers Study (CTS) which consists of &gt;130,000 female educators. From original participants a case-control study was established in 2012 consisting of all non-Hispanic white women with DNA samples that became cases since entry into the study (N = 2030) and controls without invasive or in situ breast cancer (N = 1552). The current study nests within this case control study. All participants with a self-reported history of preeclampsia were selected (81 cases/56 controls). IGF1R SNP rs2016347 was assessed by Taqman assay.

Results: Women with the TT genotype had an odds ratio (OR) of 0.38 when compared to the GG genotype after adjusting for potential confounders. Stratification by HR+/HR- cases and by age of first birth (AFB) resulted in statistically significant adjusted OR's of 0.26 for HR+ positive cases and 0.15 for women with AFB &lt;30. Both showed significant trend effect for number of T alleles as shown below:

Preeclampsia and breast cancer in CTSrs2016347 genotypeAll cases (N=137)HR+ cases (N=118)AFB &lt;30 (N=106)TT vs GG0.38 (0.13, 1.14)0.26 (0.07, 0.89)*0.15 (0.04, 0.56)*GT vs GG0.53 (0.19, 1.46)0.57 (0.19, 1.74)0.34 (0.12, 1.12)Trend analysisp = 0.09p = 0.03*p = 0.005** p &lt; .05

Overall in the CTS, the adjusted hazard ratio for women with vs without preeclampsia was 0.94 (0.81, 1.08).

Conclusions: These results suggest significant breast cancer protection in women with preeclampsia that possess the TT genotype, specifically in those women with AFB &lt;30, and for the development of HR+ breast cancer. The overall OR for all women with the TT genotype was low at 0.38 but did not reach statistical significance. This analysis in a second cohort again demonstrates a lower risk of breast cancer in women with a hypertensive disorder of pregnancy possessing the same IGF1R variant.

Recent studies have associated the rs2016347 T allele with lower normal tissue expression of IGF1R mRNA, better survival in HR+ breast cancer, and improved pathological response to neoadjuvant chemotherapy. The protective T allele creates a new microRNA (miR-432) binding site within the IGF1R 3'UTR, offering a potential functional explanation for reduced mammary gland expression of this cancer-associated growth factor. This may interact with alterations of growth and metabolic factors characteristic of preeclampsia to imprint the immature gland with a lasting protective effect from later life breast tumorigenesis. If mechanistically substantiated, these findings could lead to a novel breast cancer prevention strategy.

Citation Format: Powell M, Von Behren J, Neuhausen S, Reynolds P, Benz C. Functional IGF1R variant predicts preeclampsia protection from invasive breast cancer: Novel California teachers study findings [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-09-09.

Association between ratio indexes of body composition phenotypes and metabolic risk in Italian adults

The ratio between fat mass (FM) and fat-free mass (FFM) has been used to discriminate individual differences in body composition and improve prediction of metabolic risk. Here, we evaluated whether the use of a visceral adipose tissue-to-fat-free mass index (VAT:FFMI) ratio was a better predictor of metabolic risk than a fat mass index to fat-free mass index (FMI:FFMI) ratio. This is a cross-sectional study including 3441 adult participants (age range 18-81; men/women: 977/2464). FM and FFM were measured by bioelectrical impedance analysis and VAT by ultrasonography. A continuous metabolic risk Z score and harmonised international criteria were used to define cumulative metabolic risk and metabolic syndrome (MetS), respectively. Multivariate logistic and linear regression models were used to test associations between body composition indexes and metabolic risk. In unadjusted models, VAT:FFMI was a better predictor of MetS (OR 8.03, 95%CI 6.69-9.65) compared to FMI:FFMI (OR 2.91, 95%CI 2.45-3.46). However, the strength of association of VAT:FFMI and FMI:FFMI became comparable when models were adjusted for age, gender, clinical and sociodemographic factors (OR 4.06, 95%CI 3.31-4.97; OR 4.25, 95%CI 3.42-5.27, respectively). A similar pattern was observed for the association of the two indexes with the metabolic risk Z score (VAT:FFMI: unadjusted b = 0.69 ± 0.03, adjusted b = 0.36 ± 0.03; FMI:FFMI: unadjusted b = 0.28 ± 0.028, adjusted b = 0.38 ± 0.02). Our results suggest that there is no real advantage in using either VAT:FFMI or FMI:FFMI ratios as a predictor of metabolic risk in adults. However, these results warrant confirmation in longitudinal studies.

Territorial Justice and Thatcherism

Changes in the level of territorial justice in the construction of new dwellings during the 1980s are examined. It has been widely argued that spatial equity has declined since the 1970s, particularly in the context of the ‘north–south divide’. Thus, it may be expected that territorial justice—spatial equity at the local authority level—also declined during the Thatcher years. The general arguments and evidence on spatial equity are critically reviewed, and then the relationship between housing needs and housing provision is analysed empirically. The results indicate that there was less territorial justice in private provision, and there were conflicting trends in public provision: Territorial justice declined in the local authority sector, but increased in the housing association sector. However, in total, Thatcherism was associated with less territorial justice.

Abstract LB-060: A novel target for genetic silencing of AXL mediates taxane resistance, invasion, and migration in uterine cancer

Objectives: We investigated the role of AXL expression in chemotherapy response in uterine papillary serous cancer, and sought to reverse chemoresistance through inactivation of AXL. Methods: In vitro cell viability (XTT) assays were performed to confirm response to chemotherapy in AN3CA (taxane sensitive) and ARK1 (taxane resistant) uterine cell lines. AXL knockdown by siRNA was performed with either a traditional transfection reagent (DharmaFECT) or with a novel serum-stable, cell-penetrating, endosomolytic amphipathic peptide delivery system (p5RHH). Following knockdown of AXL using siRNA and p5RHH, chemotherapy response was assessed by XTT assay and invasion and migration assays were performed. Cell viability assays were analyzed using multiple t-tests. P &lt; 0.05 was considered statistically significant. Results: Expression of AXL was found to be associated with a worse prognosis in uterine cancer. Chemoresistance was validated with XTT assays for AN3CA and ARK1. Western blotting confirmed over-expression of AXL in the chemoresistant cell line, and lack of AXL expression in its chemosensitive counterparts. Reversal of paclitaxel resistance was achieved in ARK1 cells genetically by silencing AXL with shRNA. The novel delivery system, p5RHH, combined to siAXL, was shown to inactivate AXL in ARK1 cells at the RNA and protein level to a similar extent as traditional transfection technique (8.4-fold vs 8.7-fold decrease for RNA, respectively; 67% vs 83% knockdown at 48h and 84% vs 97% knockdown at 96 hours for protein, respectively). Reversal of paclitaxel resistance was achieved in ARK1 cells therapeutically and genetically using the p5RHH-siAXL complex. With AXL silencing using the p5RHH-siAXL complex, tumor cell invasion was inhibited by greater than 40%, and tumor cell migration was inhibited by greater than 60%. Conclusions: AXL expression is associated with chemoresistance in a uterine papillary serous cancer cells. Genetic inactivation of AXL in a taxane-resistant uterine cancer cells reverses chemoresistance. A novel siRNA nano-particle delivery system was successfully utilized to mimic genetic inactivation resulting in improved chemotherapy response and decreased invasion and migration.

Citation Format: Marguerite Palisoul, Mai Nguyen, Hua Pan, Anne Lohrey, Samuel Wickline, Matthew Powell, David Mutch, Katherine Fuh. A novel target for genetic silencing of AXL mediates taxane resistance, invasion, and migration in uterine cancer. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr LB-060.

Abstract 2350: Vaccination enhances anti-tumor immunity in ovarian cancer following repolarization of the tumor microenvironment with CCR2 blockade

Introduction: Ovarian cancer (OC) expresses the tumor associated antigen mesothelin and contains a relative abundance of T-cells. However, ovarian cancer is also infiltrated by immunosuppressive tumor associated macrophages (TAM) that dominate the tumor microenvironment (TME). The CCL2/CCR2 chemokine axis is co-opted by various human malignancies to facilitate the recruitment of bone marrow (BM) derived inflammatory monocytes (IM) to the TME where they become immunosuppressive TAMs. Herein, we explore the rationale for combination of a CCR2 inhibitor (CCR2i) with a mesothelin peptide vaccine.

Methods: Monocyte counts were obtained from preoperative CBCs under IRB approval. Mice were vaccinated with a dual eight-mer peptide (50 nM/vaccination) on days 0 and 7 with an irradiated peptide pulsed dendritic cell boost on day 14. Mice were challenged with 4 million syngeneic OC cells (ID8) on day 15. CCR2 inhibitor (Tocris) and CCR2 KO mice were used.

Results: Preoperative monocyte counts of human ovarian cancer patients were stratified into low (&gt;1 SD below mean), mid (within 1 SD of mean), and high (&gt;1 SD above the mean) groups. Patients with a high monocyte count (n = 15) had a significantly decreased median survival of 1.2 years compared to 4.8 years in the low monocyte group (n = 15). The mid group (n = 69) had a median survival of 3.5 years (p 0.001). The hazard ratio between the low and high groups was 0.24 (0.05-0.39). Flow cytometry of peripheral blood from these patients demonstrated that the majority of these monocytes were CCR2+ inflammatory monocytes. Human OC overexpresses CCL2 compared to normal ovarian tissue and analysis of the TME from resected human OC patients revealed an abundance of CCR2+ TAM, which greatly outnumbered tumor infiltrating lymphocytes (TIL). In a murine ID8 tumor model, which recapitulates features of human OC, CCR2i prevented IM egress from the bone marrow with a resultant decrease in TAM at the primary tumor site. Furthermore, there was an increase in TIL infiltrate following CCR2 blockade. Addition of vaccine to CCR2i caused an improvement of effector to suppressor ratio and prolonged survival compared to vaccine (p = 0.02) or CCR2i alone (p = 0.02) and control (p&lt;0.0001).

Conclusion: Thus far vaccination has not provided durable patient responses in OC. Therapies targeting the immunosuppressive TME are an attractive treatment modality to enhance vaccination and facilitate anti-tumor immunity in OC.

Citation Format: Darren Cullinan, Pratibha Binder, Timothy Nywening, Ivy Wilkinson-Ryan, Brian Belt, Peter Goedegebuure, David Linehan, Matthew Powell, William Hawkins. Vaccination enhances anti-tumor immunity in ovarian cancer following repolarization of the tumor microenvironment with CCR2 blockade. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 2350.

Intensity modulated radiation therapy for recurrent ovarian cancer refractory to chemotherapy

OBJECTIVE

To evaluate local control, survival outcomes, and toxicity after intensity modulated radiotherapy (IMRT) for recurrent chemorefractory ovarian cancer.

METHODS

Between 2006 and 2014, 33 patients were treated with IMRT for recurrent ovarian cancer. Patients received a median of 3 chemotherapy regimens prior to IMRT (range, 1-12) with 11 (33%) undergoing concurrent therapy. Local control (LC), recurrence free survival (RFS), and overall survival (OS) were calculated via Kaplan-Meier method. Toxicity was assessed using the Common Terminology Criteria for Adverse Events (CTCAE) v4.03. Impact of patient characteristics on outcomes was evaluated via Cox's proportional hazard model.

RESULTS

Median follow up was 23.7 months. Forty-nine sites were treated to a median dose of 5040cGy (range, 4500-7000). Nine (18%) of the 49 sites had in-field failures. Two year actuarial LC, RFS, and OS were 82%, 11%, and 63%, respectively. Seventeen patients had both a pre and post-treatment FDG-PET/CT; 6 (35%) had a complete metabolic response while 11 (65%) had a partial metabolic response. Acute ≥ grade 3 gastrointestinal (GI) toxicities occurred in 2 (6%) patients, late ≥ grade 3 GI toxicities occurred in 12 (36%), acute ≥ grade 3 hematological toxicities occurred in 5 (15%) and late ≥ grade 3 hematological toxicities occurred in 14 (42%).

CONCLUSIONS

IMRT for recurrent chemorefractory ovarian cancer is associated with excellent local control and limited radiation related toxicity. Future studies will be required to determine which subpopulation will benefit most from IMRT and whether alternative techniques such as stereotactic body radiotherapy may be feasible.

ESMO-ESGO-ESTRO Consensus Conference on Endometrial Cancer: diagnosis, treatment and follow-up

The first joint European Society for Medical Oncology (ESMO), European SocieTy for Radiotherapy & Oncology (ESTRO) and European Society of Gynaecological Oncology (ESGO) consensus conference on endometrial cancer was held on 11-13 December 2014 in Milan, Italy, and comprised a multidisciplinary panel of 40 leading experts in the management of endometrial cancer. Before the conference, the expert panel prepared three clinically relevant questions about endometrial cancer relating to the following four areas: prevention and screening, surgery, adjuvant treatment and advanced and recurrent disease. All relevant scientific literature, as identified by the experts, was reviewed in advance. During the consensus conference, the panel developed recommendations for each specific question and a consensus was reached. Results of this consensus conference, together with a summary of evidence supporting each recommendation, are detailed in this article. All participants have approved this final article.

Clinical Outcomes among Women with Mucinous Adenocarcinoma of the Ovary

BACKGROUND/AIMS

Patterns of metastasis and clinical behavior of mucinous ovarian cancers are poorly understood because of their rarity.

METHODS

A retrospective review of records of women identified with pure mucinous invasive ovarian/tubal/peritoneal cancer during 1992-2012 at one institution. Survival differences were compared using Kaplan-Meier methods with log-rank tests.

RESULTS

Among 42 women with mucinous adenocarcinomas, the median age was 55 (range 33-83 years). Most cancers were well differentiated (n = 26, 68%) and in stage I/II (n = 31, 74%). One of 27 women with sampled nodes had nodal metastasis; one additional woman had recurrence in a pelvic node. Most had no visible residual tumor after initial surgery, but of 10 women with stage III/IV cancer and documented residual, 8 had >2 cm residual. Except for 1 woman alive with disease at last follow-up, all who had a recurrence died of the disease. Five-year survival was 83% for stage I/II cases but 29% among stage III/IV cases. Stage was a strong predictor of survival (hazard ratio of death among women with stage III/IV cancer 7.73, 95% CI 2.33-25.66, p < 0.001 vs. women with stage I/II cancer).

CONCLUSION

Mucinous ovarian cancers have a distinct biology, such that lymphadenectomy for staging is unnecessary and metastatic cancers have poor prognosis.

Prediction model for regional or distant recurrence in endometrial cancer based on classical pathological and immunological parameters

BACKGROUND

Adjuvant therapy increases disease-free survival in endometrial cancer (EC), but has no impact on overall survival and negatively influences the quality of life. We investigated the discriminatory power of classical and immunological predictors of recurrence in a cohort of EC patients and confirmed the findings in an independent validation cohort.

METHODS

We reanalysed the data from 355 EC patients and tested our findings in an independent validation cohort of 72 patients with EC. Predictors were selected and Harrell's C-index for concordance was used to determine discriminatory power for disease-free survival in the total group and stratified for histological subtype.

RESULTS

Predictors for recurrence were FIGO stage, lymphovascular space invasion and numbers of cytotoxic and memory T-cells. For high risk cancer, cytotoxic or memory T-cells predicted recurrence as well as a combination of FIGO stage and lymphovascular space invasion (C-index 0.67 and 0.71 vs 0.70). Recurrence was best predicted when FIGO stage, lymphovascular space invasion and numbers of cytotoxic cells were used in combination (C-index 0.82). Findings were confirmed in the validation cohort.

CONCLUSIONS

In high-risk EC, clinicopathological or immunological variables can predict regional or distant recurrence with equal accuracy, but the use of these variables in combination is more powerful.

Preparedness of Ob/Gyn residents for fellowship training in gynecologic oncology

Residency training in obstetrics and gynecology is being challenged by increasingly stringent regulations and decreased operative experience. We sought to determine the perception of preparedness of incoming gynecologic oncology fellows for advanced surgical training in gynecologic oncology. An online survey was sent to gynecologic oncologists involved in fellowship training in the United States. They were asked to evaluate their most recent incoming clinical fellows in the domains of professionalism, level of independence/graduated responsibility, psychomotor ability, clinical evaluation and management, and academia and scholarship using a standard Likert-style scale. The response rate among attending physicians was 40% (n = 105/260) and 61% (n = 28/46) for program directors. Of those who participated, 49% reported that their incoming fellows could not independently perform a hysterectomy, 59% reported that they could not independently perform 30 min of a major procedure, 40% reported that they could not control bleeding, 40% reported that they could not recognize anatomy and tissue planes, and 58% reported that they could not dissect tissue planes. Fellows lacked an understanding of pathophysiology, treatment recommendations, and the ability to identify and treat critically ill patients. In the academic domain, respondents agreed that fellows were deficient in the areas of protocol design (54%), statistical analysis (54%), and manuscript writing (65%). These results suggest that general Ob/Gyn residency is ineffective in preparing fellows for advanced training in gynecologic oncology and should prompt a revision of the goals and objectives of resident education to correct these deficiencies.