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Hsieh CJ, Wu CY, Lin YH, Huang YC, Yang WC, Chen TWW, Ma WL, Lin WH, Hsu FM, Xiao F, Yang SH, Lai DM, Chen CM, Chao SY, Tsuang FY. Delay of Surgery for Spinal Metastasis due to the COVID-19 Outbreak Affected Patient Outcomes. Neurospine 2023; 20:1431-1442. [PMID: 38171309 PMCID: PMC10762398 DOI: 10.14245/ns.2346726.363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/24/2023] [Accepted: 08/25/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVE The present study is to analyze the effects of the coronavirus disease 2019 (COVID 2019) outbreak and the subsequent lockdown on the outcomes of spinal metastasis patients. METHODS The study was a retrospective analysis of data from a prospective cohort study. All patients underwent surgical intervention for spinal metastases between January 2019 and December 2021 and had at least 3 months of postoperative follow-up. The primary outcome was overall mortality during the 4 different stages (pre-COVID-19 era, COVID-19 pandemic except in Taiwan, national lockdown, lifting of the lockdown). The secondary outcomes were the oncological severity scores, medical/surgical accessibility, and patient functional outcome during the 4 periods as well as survival/mortality. RESULTS A total of 233 patients were included. The overall mortality rate was 41.20%. During the Taiwan lockdown, more patients received palliative surgery than other surgical methods, and no total en bloc spondylectomy was performed. The time from surgeon visit to operation was approximately doubled after the COVID-19 outbreak in Taiwan (75.97, 86.63, 168.79, and 166.91 hours in the 4 periods, respectively). The estimated survival probability was highest after the national lockdown was lifted and lowest during the lockdown. In the multivariate analysis, increased risk of mortality was observed with delay of surgery, with emergency surgery having a higher risk with delays above 33 hours, urgent surgery (below 59 and above 111 hours), and elective surgery (above 332 hours). CONCLUSION The COVID-19 pandemic and related policies have altered daily clinical practice and negatively impacted the survival of patients with spinal metastases.
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Affiliation(s)
- Chia-Jung Hsieh
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu County, Taiwan
- Spine Tumor Center, National Taiwan University Hospital, Taipei City, Taiwan
| | - Chun-Yu Wu
- Spine Tumor Center, National Taiwan University Hospital, Taipei City, Taiwan
- Department of Anesthesiology, National Taiwan University Hospital, Taipei City, Taiwan
- Department of Anesthesiology, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu County, Taiwan
| | - Yen-Heng Lin
- Spine Tumor Center, National Taiwan University Hospital, Taipei City, Taiwan
- Department of Medical Imaging, National Taiwan University Hospital, Taipei City, Taiwan
| | - Yu-Cheng Huang
- Spine Tumor Center, National Taiwan University Hospital, Taipei City, Taiwan
- Department of Medical Imaging, National Taiwan University Hospital, Taipei City, Taiwan
| | - Wen-Chi Yang
- Spine Tumor Center, National Taiwan University Hospital, Taipei City, Taiwan
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei City, Taiwan
| | - Tom Wei-Wu Chen
- Spine Tumor Center, National Taiwan University Hospital, Taipei City, Taiwan
- Department of Oncology, National Taiwan University Hospital, Taipei City, Taiwan
- Graduate Institute of Oncology, National Taiwan University College of Medicine, Taipei City, Taiwan
| | - Wei-Li Ma
- Spine Tumor Center, National Taiwan University Hospital, Taipei City, Taiwan
- Department of Oncology, National Taiwan University Hospital, Taipei City, Taiwan
- Graduate Institute of Oncology, National Taiwan University College of Medicine, Taipei City, Taiwan
| | - Wei-Hsin Lin
- Spine Tumor Center, National Taiwan University Hospital, Taipei City, Taiwan
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Taipei City, Taiwan
| | - Feng-Ming Hsu
- Spine Tumor Center, National Taiwan University Hospital, Taipei City, Taiwan
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei City, Taiwan
- Graduate Institute of Oncology, National Taiwan University College of Medicine, Taipei City, Taiwan
| | - Furen Xiao
- Spine Tumor Center, National Taiwan University Hospital, Taipei City, Taiwan
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei City, Taiwan
| | - Shih-Hung Yang
- Spine Tumor Center, National Taiwan University Hospital, Taipei City, Taiwan
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei City, Taiwan
| | - Dar-Ming Lai
- Spine Tumor Center, National Taiwan University Hospital, Taipei City, Taiwan
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei City, Taiwan
| | - Chang-Mu Chen
- Spine Tumor Center, National Taiwan University Hospital, Taipei City, Taiwan
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei City, Taiwan
| | - Shin-Yi Chao
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei City, Taiwan
| | - Fon-Yih Tsuang
- Spine Tumor Center, National Taiwan University Hospital, Taipei City, Taiwan
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei City, Taiwan
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Hu Z, Yang S, Xu Z, Zhang X, Wang H, Fan G, Liao X. Prevalence and risk factors of bone metastasis and the development of bone metastatic prognostic classification system: a pan-cancer population study. Aging (Albany NY) 2023; 15:13134-13149. [PMID: 37983179 DOI: 10.18632/aging.205224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/12/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND The prevalence of bone metastasis (BM) varies among primary cancer patients, and it has a significant impact on prognosis. However, there is a lack of research in this area. This study aims to explore the clinical characteristics, prevalence, and risk factors, and to establish a prognostic classification system for pan-cancer patients with BM. METHODS The data obtained from the Surveillance, Epidemiology and End Results database were investigated. The prevalence and prognosis of patients with BM were analyzed. Hierarchical clustering was used to develop a prognostic classification system. RESULTS From 2010 to 2019, the prevalence of BM has increased by 41.43%. BM most commonly occurs in cancers that originate in the adrenal gland, lung and bronchus and overlapping lesion of digestive systems. Negative prognostic factors included older age, male sex, poorer grade, unmarried status, low income, non-metropolitan living, advanced tumor stages, previous chemotherapy, and synchronous liver, lung, and brain metastasis. Three categories with significantly different survival time were identified in the classification system. CONCLUSIONS The clinical features, prevalence, risk factors, and prognostic factors in pan-cancer patients with BM were investigated. A prognostic classification system was developed to provide survival information and aid physicians in selecting personalized treatment plans for patients with BM.
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Affiliation(s)
- Zhouyang Hu
- Department of Pain Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
- Guangdong Key Laboratory for Biomedical Measurements and Ultrasound Imaging, National-Regional Key Technology Engineering Laboratory for Medical Ultrasound, School of Biomedical Engineering, Shenzhen University Medical School, Shenzhen, China
| | - Sheng Yang
- Department of Orthopedics, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- Spinal Pain Research Institute, Tongji University School of Medicine, Shanghai, China
| | - Zhipeng Xu
- Department of Pain Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
- Guangdong Key Laboratory for Biomedical Measurements and Ultrasound Imaging, National-Regional Key Technology Engineering Laboratory for Medical Ultrasound, School of Biomedical Engineering, Shenzhen University Medical School, Shenzhen, China
| | - Xiaoling Zhang
- Department of Pain Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
- Guangdong Key Laboratory for Biomedical Measurements and Ultrasound Imaging, National-Regional Key Technology Engineering Laboratory for Medical Ultrasound, School of Biomedical Engineering, Shenzhen University Medical School, Shenzhen, China
| | - Hong Wang
- Department of Pain Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
- Guangdong Key Laboratory for Biomedical Measurements and Ultrasound Imaging, National-Regional Key Technology Engineering Laboratory for Medical Ultrasound, School of Biomedical Engineering, Shenzhen University Medical School, Shenzhen, China
| | - Guoxin Fan
- Department of Pain Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
- Guangdong Key Laboratory for Biomedical Measurements and Ultrasound Imaging, National-Regional Key Technology Engineering Laboratory for Medical Ultrasound, School of Biomedical Engineering, Shenzhen University Medical School, Shenzhen, China
| | - Xiang Liao
- Department of Pain Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
- Guangdong Key Laboratory for Biomedical Measurements and Ultrasound Imaging, National-Regional Key Technology Engineering Laboratory for Medical Ultrasound, School of Biomedical Engineering, Shenzhen University Medical School, Shenzhen, China
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Raggi D, Giannatempo P, Marandino L, Pierantoni F, Maruzzo M, Lipari H, Banna GL, De Giorgi U, Casadei C, Naglieri E, Buti S, Bersanelli M, Stellato M, Santini D, Vignani F, Roviello G, Veccia A, Caffo O, Losanno T, Calabrò F, Mucciarini C, Pignata S, Necchi A, Maio MD. Role of Bone Metastases in Patients Receiving Immunotherapy for Pre-Treated Urothelial Carcinoma: The Multicentre, Retrospective Meet-URO-1 Bone Study. Clin Genitourin Cancer 2021; 20:155-164. [PMID: 35000876 DOI: 10.1016/j.clgc.2021.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 12/06/2021] [Accepted: 12/12/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Considerable numbers of patients with metastatic urothelial carcinoma (mUC) develop bone metastases (BoM). Their impact on the efficacy of immune-checkpoint inhibitors (ICIs) is not yet investigated. METHODS Between July 2014 and August 2020 data on pts treated with single-agent ICIs after failure of at least 1 previous line of chemotherapy for advanced disease, were retrospectively collected across 14 Italian centers. Overall survival (OS) and progression-free survival (PFS) were analyzed using the Kaplan-Meier method. Cox regression analysis was performed evaluating potential prognostic factors for OS and PFS. Each factor was evaluated in univariable (UVA) and multivariable analysis (MVA). RESULTS A total of 208 evaluable patients treated with ICIs were identified, including 122 (59%) without BoM (BoM-) and 86 (41%) with bone metastases (BoM+). After a median follow-up of 22.3 months, BoM+ patients showed shorter OS (median 3.9 vs 7.8 months, HR 1.59 [95%CI, 1.15-2.20], P = .005) and shorter PFS (median 2.0 vs 2.6 months, HR 1.76 [95%CI, 1.31-2.37], P < .001). Probability of being alive was 62% vs 40% after 6 months, 38% vs 23% after 1 year and 24% vs 13% after 2 years, in BoM- and BoM+ respectively. Within each Bellmunt score, OS and PFS of BoM+ patients were shorter. Both presence of BoM and higher Bellmunt risk score were significantly associated with shorter OS and PFS in UVA and MVA. CONCLUSION Patients treated with single-agent ICIs for BoM+ mUC have a dismal prognosis compared to BoM-. Further research is needed to understand the mechanism behind these outcomes.
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Affiliation(s)
- Daniele Raggi
- Department of Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Patrizia Giannatempo
- Department of Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Laura Marandino
- Department of Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Marco Maruzzo
- Department of Oncology, Istituto Oncologico Veneto, Padova, Italy
| | - Helga Lipari
- Department of Oncology, Medical Oncology Cannizzaro Hospital, Catania, Italy
| | - Giuseppe L Banna
- Department of Oncology, Medical Oncology Cannizzaro Hospital, Catania, Italy
| | - Ugo De Giorgi
- Department of Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Italy
| | - Chiara Casadei
- Department of Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Italy
| | - Emanuele Naglieri
- Department of Oncology, Policlinico di Bari Ospedale Giovanni XXIII, Bari, Italy
| | - Sebastiano Buti
- Department of Oncology, University Hospital of Parma, Parma, Italy
| | | | - Marco Stellato
- Department of Oncology, Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Daniele Santini
- Department of Oncology, Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Francesca Vignani
- Department of Oncology, University of Turin, Mauriziano Umberto I Hospital, Turin, Italy
| | | | | | - Orazio Caffo
- Department of Oncology, Santa Chiara Hospital, Trento, Italy
| | - Tania Losanno
- Department of Oncology, San Camillo Forlanini Hospital, Rome, Italy
| | - Fabrizio Calabrò
- Department of Oncology, San Camillo Forlanini Hospital, Rome, Italy
| | | | - Sandro Pignata
- Department of Urology and Gynecology, Oncologia Medica Uro-Ginecologica, Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Napoli, Italy
| | - Andrea Necchi
- Deptartment of Oncology from Vita-Salute University IRCCS San Raffaele, Milan, Italy
| | - Massimo Di Maio
- Department of Oncology, University of Turin, Mauriziano Umberto I Hospital, Turin, Italy
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- Department of Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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Wang T, Gao X, Zhang K, Yang J, Wu Z, Liu T, Jia Q, Xiao J. Role of Multimodal Treatment in Urothelial Carcinoma Spinal Metastasis: 15 Patients' Experiences in a Single Center. Cancer Manag Res 2020; 12:9003-9012. [PMID: 33061595 PMCID: PMC7522434 DOI: 10.2147/cmar.s258429] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 08/21/2020] [Indexed: 12/21/2022] Open
Abstract
Purpose Spinal metastasis from urothelial carcinoma (UC) is relatively uncommon. The aim of the present study is to explore the clinicopathological features, surgical treatments and outcomes of this rare disease. Patients and Methods Fifteen patients with UC spinal metastasis who received surgery in our center between 2009 and 2018 were retrospectively investigated. Clinical data, treatment options, and outcomes were analyzed. Results For the 15 patients (9 men and 6 women), the primary tumors were located in the upper urothelial tract in ten and lower urothelial tract in five. UC mainly metastasized to the lumbar spine in seven cases, followed by the thoracic spine in five. Pathologic fracture and soft tissue mass with dura mater compression were observed in 66.7% and 93.3% cases, respectively. Palliative resection was performed in nine cases and excisional resection in six. Eleven patients received postoperative chemotherapy, including three with a preoperative ECOG score >2. Bisphosphonates were administered in all patients. Pain was relieved remarkably in all patients, and both the neurological function and general status were improved significantly after surgery. The median overall survival was 14 months. Log rank test showed that patients receiving postoperative chemotherapy survived longer than those without chemotherapy (p=0.037). WHO grade 3 was also correlated with poorer prognosis (p=0.012). Conclusion Pathological fracture and soft tissue mass with dura mater compression is frequently observed on radiological images in patients with UC spinal metastasis. Surgery is useful to prevent deterioration of performance status and improve quality of life, which provide an opportunity for further systematic therapy. Multimodal treatments, including surgery, postoperative chemotherapy and bisphosphonates are recommended. WHO grade 2 and receiving postoperative chemotherapy were favorable prognostic factors for the overall survival of patients with UC spinal metastasis.
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Affiliation(s)
- Tao Wang
- Department of Orthopaedic Oncology, Spinal Tumor Center, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai 200003, People's Republic of China
| | - Xin Gao
- Department of Orthopaedic Oncology, Spinal Tumor Center, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai 200003, People's Republic of China
| | - Kun Zhang
- Department of Orthopaedic Oncology, Spinal Tumor Center, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai 200003, People's Republic of China
| | - Jian Yang
- Department of Orthopaedic Oncology, Spinal Tumor Center, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai 200003, People's Republic of China
| | - Zheyu Wu
- Department of Orthopaedic Oncology, Spinal Tumor Center, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai 200003, People's Republic of China.,Department of Orthopaedics, Zhongnan Hospital, Wuhan University, Wuhan, Hubei 430071, People's Republic of China
| | - Tielong Liu
- Department of Orthopaedic Oncology, Spinal Tumor Center, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai 200003, People's Republic of China
| | - Qi Jia
- Department of Orthopaedic Oncology, Spinal Tumor Center, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai 200003, People's Republic of China
| | - Jianru Xiao
- Department of Orthopaedic Oncology, Spinal Tumor Center, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai 200003, People's Republic of China
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Liaw CC, Liao TY, Tsui KH, Juan YH. Survival Benefit for Patients With Metastatic Urothelial Carcinoma Receiving Continuous Maintenance Chemotherapy. In Vivo 2019; 33:1249-1262. [PMID: 31280216 DOI: 10.21873/invivo.11597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 05/28/2019] [Accepted: 06/03/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND/AIM Urothelial carcinoma is a chemo-sensitive cancer. We investigated the contributory factors to survival benefit of metastatic urothelial carcinoma (MUC) patients receiving continuous maintenance chemotherapy. PATIENTS AND METHODS Inclusion criteria were: i) pathology-confirmed urothelial carcinoma, ii) metastatic lesions identified mainly on pre-therapy computed tomography (CT) scans, and iii) inpatient-administered chemotherapy of at least three cycles. Chemotherapy regimens included 5-fluorouracil, leucovorin, cisplatin, and gemcitabine. RESULTS A total of 139 cases were enrolled in this study. The overall objective response rate was 60% and the median survival time was 17 months. Eight-two (59%) patients had inflammation-related symptoms following the course of chemotherapy. Fifty-five (41%) patients survived more than two years. All patients exhibited various fibrosis formations. No patient experienced unfavorable metastatic conditions. Inflammation-related symptoms remained in 28 (51%) patients. We found that surgery, invasive procedures, and infection likely led to a rapid tumor progression. CONCLUSION Continuous maintenance chemotherapy targeting chemo-sensitive tumors, administered at metronomic intervals and focus on tumor microenvironment, can increase MUC survival benefits.
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Affiliation(s)
- Chuang-Chi Liaw
- Division of Hemato-Oncology, Department of Internal Medicine Chang-Gung Memorial Hospital and Chang-Gung University College of Medicine, Taoyuan, Taiwan, R.O.C.
| | - Tzu-Yao Liao
- Division of Hemato-Oncology, Department of Internal Medicine Chang-Gung Memorial Hospital and Chang-Gung University College of Medicine, Taoyuan, Taiwan, R.O.C
| | - Ke-Hung Tsui
- Department of Urology, Chang-Gung Memorial Hospital and Chang-Gung University College of Medicine, Taoyuan, Taiwan, R.O.C
| | - Yu-Hsiang Juan
- Department of Medical Imaging and Intervention, Chang-Gung Memorial Hospital and Chang-Gung University College of Medicine, Taoyuan, Taiwan, R.O.C
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Necchi A, Pond GR, Pal SK, Agarwal N, Bowles DW, Plimack ER, Yu EY, Ladoire S, Baniel J, Crabb S, Niegisch G, Srinivas S, Berthold DR, Rosenberg JE, Powles T, Bamias A, Harshman LC, Bellmunt J, Galsky MD. Bone Metastases as the Only Metastatic Site in Patients With Urothelial Carcinoma: Focus on a Special Patient Population. Clin Genitourin Cancer 2017; 16:e483-e490. [PMID: 29158079 DOI: 10.1016/j.clgc.2017.10.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Accepted: 10/23/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with exclusive bone metastatic spread from urothelial carcinoma (UC) throughout their disease course represent a rare subgroup with unique clinical features. These patients deserved special consideration in a retrospective multicenter study. PATIENTS AND METHODS Analyses were made from a pool of 1911 patients with a diagnosis of metastatic UC, from 23 centers. Baseline characteristics, access to treatment, and outcomes were analyzed according to metastatic spread. Univariable and multivariable Cox analyses were performed. RESULTS A total of 128 evaluable patients (6.7%), diagnosed between February 1997 and April 2013, were identified. Eastern Cooperative Oncology Group performance status (PS) was ≥ 2 in 33.3% versus 17.7% of the remaining patients. Seventy-three (57%) received first-line chemotherapy, that was platinum-based in 50 patients (69%). Twenty-eight (21.9%) received second-line chemotherapy (vs. 75.9% and 32.2%, respectively, of the remaining patients). In multivariable analyses, no clinical factor was significantly associated with overall survival (OS). Among platinum chemotherapy-treated patients (total evaluable n = 972), significantly different relapse-free survival (RFS) and OS were observed according to bone metastases status (no bone metastases vs. bone metastases only vs. bone and other sites, P < .001). In these groups, 2-year RFS was 37.4%, 28.8%, and 25.9%, respectively. Two-year OS was 35.5%, 15.8%, and 23%, respectively. CONCLUSION Patients with metastatic UC and bone-only metastases are less likely to receive systemic therapy than those with other metastases, likely because of their lower PS. The prognostic effect of having exclusive bone metastases or additional sites seems to be equally poor. These patients deserve new effective and tolerable agents, and improvements in the knowledge of their disease.
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Affiliation(s)
- Andrea Necchi
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy.
| | | | - Sumanta K Pal
- City of Hope Comprehensive Cancer Center, Duarte, CA
| | | | - Daniel W Bowles
- Denver Veterans Affairs Medical Center, Eastern Colorado Health Care System, Denver, CO
| | | | - Evan Y Yu
- University of Washington, Seattle, WA
| | | | | | - Simon Crabb
- University of Southampton, Southampton, United Kingdom
| | - Gunter Niegisch
- Heinrich-Heine-University, Medical faculty, Department of Urology, Düsseldorf, Germany
| | | | | | | | - Thomas Powles
- Barts Health and the Royal Free NHS Trust, Queen Mary University of London, London, United Kingdom
| | | | | | | | - Matthew D Galsky
- Mount Sinai School of Medicine, Tisch Cancer Institute, New York, NY
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