1
|
Bhati P, Thomas A, George Chandy R, Datta A, Susan Thomas D, Thomas V, Peedicayil A, Sebastian A. Secondary cytoreduction in recurrent ovarian cancer- experience from a tertiary care centre in India. Gynecol Oncol Rep 2024; 54:101463. [PMID: 39149126 PMCID: PMC11325282 DOI: 10.1016/j.gore.2024.101463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 07/03/2024] [Accepted: 07/13/2024] [Indexed: 08/17/2024] Open
Abstract
Introduction Ovarian cancer is a disease that presents in advanced stage, due to the absence of any specific or overtly dramatic symptoms. The standard of care is primary debulking surgery, followed by chemotherapy. Ovarian cancer recurrence treatment is very challenging and there is always a debate between cytoreduction vs chemotherapy. Methods The electronic medical records of all patients who underwent secondary cytoreductive surgery for recurrent ovarian cancer between January 2011 and December 2019 were retrieved the patients with platinum sensitive recurrent ovarian cancer who underwent secondary cytoreductive surgery in our department during this time period were included. Results A total of 52 patients underwent secondary cytoreductive surgery for recurrent ovarian cancer during the study period. Median treatment free interval after primary treatment was 20 months (range 6-132). The secondary cytoreductive surgery was highly complex in 4(8 %) patients,19 (37 %) had intermediate surgical complexity score, 29 (55 %) had low surgical complexity score according to the Aletti complexity score. Secondary cytoreductive surgery was complete (no macroscopic residual disease) in 31(60 %); Optimal (R1) in 17 (33 %) and suboptimal in only 4 (7 %) of the patients. Out of the 52 patients,8 expired, 16 had a second recurrence, and 10 were lost to follow up over time. Conclusion Successful surgery is possible in well selected patients, which in turn can lead to a meaningful progression free and overall survival benefit. Meticulous individualisation of cases should be done keeping in mind the patient's performance status, prior treatment history & toxicity; distribution & extent of disease, and the patient's overall life goals.
Collapse
Affiliation(s)
- Priya Bhati
- Department of Gynaecologic Oncology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Anitha Thomas
- Department of Gynaecologic Oncology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Rachel George Chandy
- Department of Gynaecologic Oncology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Amrita Datta
- Department of Gynaecologic Oncology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Dhanya Susan Thomas
- Department of Gynaecologic Oncology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Vinotha Thomas
- Department of Gynaecologic Oncology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Abraham Peedicayil
- Department of Gynaecologic Oncology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ajit Sebastian
- Department of Gynaecologic Oncology, Christian Medical College, Vellore, Tamil Nadu, India
| |
Collapse
|
2
|
Myhr AS, Bjørge L, Torkildsen CF. Secondary Cytoreductive Surgery in Relapsed Platinum-Sensitive Epithelial Ovarian Cancer: A Systematic Review of Randomized Controlled Trials. Cancers (Basel) 2024; 16:2613. [PMID: 39061251 PMCID: PMC11274640 DOI: 10.3390/cancers16142613] [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: 06/17/2024] [Revised: 07/14/2024] [Accepted: 07/19/2024] [Indexed: 07/28/2024] Open
Abstract
Secondary cytoreductive surgery is a treatment option for relapsed platinum-sensitive epithelial ovarian cancer, but no clear indications are defined for the procedure. This systematic review aims to establish clear indications and compare outcomes versus standard-of-care chemotherapy. We conducted an electronic literature search across three databases and identified 2033 articles, including three phase 3 randomized controlled trials (RCT). The review adhered to PRISMA 2020 guidelines and was registered in PROSPERO (no. CRD42022379817). Despite varying patient selection methods, surgery plus chemotherapy demonstrated significantly prolonged progression-free survival compared to chemotherapy alone. However, overall survival outcomes were inconsistent: while GOG-0213 did not show extended overall survival, recent studies with stricter defined criteria for surgery (SOC-1 and DESKTOP-III) reported improved overall survival with the addition of surgery. Morbidity and mortality rates were low, with no difference in quality of life between the surgery and no-surgery groups. In conclusion, cytoreductive surgery presents a promising option for recurrent epithelial ovarian cancer treatment. Nonetheless, well-defined selection criteria appear crucial for achieving increased overall survival compared to conventional treatment.
Collapse
Affiliation(s)
| | - Line Bjørge
- Centre for Cancer Biomarkers, Department of Clinical Science, University of Bergen, 5009 Bergen, Norway
- Department of Obstetrics and Gynecology, Haukeland University Hospital, 5009 Bergen, Norway
| | - Cecilie Fredvik Torkildsen
- Centre for Cancer Biomarkers, Department of Clinical Science, University of Bergen, 5009 Bergen, Norway
- Department of Obstetrics and Gynecology, Stavanger University Hospital, 4068 Stavanger, Norway
| |
Collapse
|
3
|
Gaba F, Blyuss O, Chandrasekaran D, Bizzarri N, Refky B, Barton D, Ind T, Nobbenhuis M, Butler J, Heath O, Jeyarajah A, Brockbank E, Lawrence A, Manchanda R, Dilley J, Phadnis S. Prognosis Following Surgery for Recurrent Ovarian Cancer and Diagnostic Criteria Predictive of Cytoreduction Success: A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2023; 13:3484. [PMID: 37998621 PMCID: PMC10670762 DOI: 10.3390/diagnostics13223484] [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: 09/06/2023] [Revised: 11/02/2023] [Accepted: 11/07/2023] [Indexed: 11/25/2023] Open
Abstract
For women achieving clinical remission after the completion of initial treatment for epithelial ovarian cancer, 80% with advanced-stage disease will develop recurrence. However, the standard treatment of women with recurrent platinum-sensitive diseases remains poorly defined. Secondary (SCS), tertiary (TCS) or quaternary (QCS) cytoreduction surgery for recurrence has been suggested to be associated with increased overall survival (OS). We searched five databases for studies reporting death rate, OS, cytoreduction rates, post-operative morbidity/mortality and diagnostic models predicting complete cytoreduction in a platinum-sensitive disease recurrence setting. Death rates calculated from raw data were pooled based on a random-effects model. Meta-regression/linear regression was performed to explore the role of complete or optimal cytoreduction as a moderator. Pooled death rates were 45%, 51%, 66% for SCS, TCS and QCS, respectively. Median OS for optimal cytoreduction ranged from 16-91, 24-99 and 39-135 months for SCS, TCS and QCS, respectively. Every 10% increase in complete cytoreduction rates at SCS corresponds to a 7% increase in median OS. Complete cytoreduction rates ranged from 9-100%, 35-90% and 33-100% for SCS, TCS and QCS, respectively. Major post-operative thirty-day morbidity was reported to range from 0-47%, 13-33% and 15-29% for SCS, TCS and QCS, respectively. Thirty-day post-operative mortality was 0-6%, 0-3% and 0-2% for SCS, TCS and QCS, respectively. There were two externally validated diagnostic models predicting complete cytoreduction at SCS, but none for TCS and QCS. In conclusion, our data confirm that maximal effort higher order cytoreductive surgery resulting in complete cytoreduction can improve survival.
Collapse
Affiliation(s)
- Faiza Gaba
- Department of Gynaecological Oncology, The Royal Marsden Hospital, London SW3 6JJ, UK
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen AB24 3FX, UK
| | - Oleg Blyuss
- Wolfson Institute of Preventive Medicine, Barts CRUK Cancer Centre, Queen Mary University of London, London EC1M 6BQ, UK
- Department of Pediatrics and Pediatric Infectious Diseases, Institute of Child’s Health, Sechenov University, 119435 Moscow, Russia
| | - Dhivya Chandrasekaran
- Department of Gynaecological Oncology, University College London Hospital, London NW1 2BU, UK
| | - Nicolò Bizzarri
- Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Basel Refky
- Department of Surgical Oncology, Mansoura University, El Mansoura 7650030, Egypt
| | - Desmond Barton
- Department of Gynaecological Oncology, The Royal Marsden Hospital, London SW3 6JJ, UK
| | - Thomas Ind
- Department of Gynaecological Oncology, The Royal Marsden Hospital, London SW3 6JJ, UK
| | - Marielle Nobbenhuis
- Department of Gynaecological Oncology, The Royal Marsden Hospital, London SW3 6JJ, UK
| | - John Butler
- Department of Gynaecological Oncology, The Royal Marsden Hospital, London SW3 6JJ, UK
| | - Owen Heath
- Department of Gynaecological Oncology, The Royal Marsden Hospital, London SW3 6JJ, UK
| | - Arjun Jeyarajah
- Department of Gynaecological Oncology, The Royal London Hospital, Barts Health NHS Trust, London E1 1FR, UK
| | - Elly Brockbank
- Department of Gynaecological Oncology, The Royal London Hospital, Barts Health NHS Trust, London E1 1FR, UK
| | - Alexandra Lawrence
- Department of Gynaecological Oncology, The Royal London Hospital, Barts Health NHS Trust, London E1 1FR, UK
| | - Ranjit Manchanda
- Wolfson Institute of Preventive Medicine, Barts CRUK Cancer Centre, Queen Mary University of London, London EC1M 6BQ, UK
- Department of Gynaecological Oncology, The Royal London Hospital, Barts Health NHS Trust, London E1 1FR, UK
| | - James Dilley
- Department of Gynaecological Oncology, The Royal London Hospital, Barts Health NHS Trust, London E1 1FR, UK
| | - Saurabh Phadnis
- Department of Gynaecological Oncology, The Royal London Hospital, Barts Health NHS Trust, London E1 1FR, UK
| | | |
Collapse
|
4
|
Baek MH, Park EY, Ha HI, Park SY, Lim MC, Fotopoulou C, Bristow RE. Secondary Cytoreductive Surgery in Platinum-Sensitive Recurrent Ovarian Cancer: A Meta-Analysis. J Clin Oncol 2022; 40:1659-1670. [PMID: 35188810 DOI: 10.1200/jco.21.02085] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE The survival impact of secondary cytoreductive surgery in patients with platinum-sensitive recurrent ovarian cancer was studied. METHODS We identified published studies from 1983 to 2021 following our inclusion criteria from MEDLINE, EMBASE, and Cochrane library. To integrate the effect size of single-arm studies, meta-analysis was performed using death rate as a primary outcome. The effect of complete cytoreduction and optimal cytoreduction on survival was evaluated using meta-regression. The pooled death rate was presented with a 95% CI. The publication bias was evaluated with the funnel plot and Egger's test, and sensitivity analysis was performed. To overcome missing death rates, the linear regression model was performed on log-transformed median overall survival (OS) time using study size as a weight. RESULTS Thirty-six studies with 2,805 patients reporting death rates were used for this meta-analysis of the 80 eligible studies. There was strong heterogeneity, with the P value of the Cochrane Q test of < 0.0001 and Higgins's I2 statistics of 86%; thus, we considered a random effect model. The pooled death rate was 44.2% (95% CI, 39.0 to 49.5), and both the complete and optimal cytoreductions were associated with better survival outcomes as significant moderators in the meta-regression model (P < .001 and P = .005, respectively). Although 14 studies were located outside the funnel plot, Egger's test indicated no publication bias (P = .327). A sensitivity analysis excluding 14 studies showed similar results. In the linear regression model on the basis of 57 studies, the median OS time increased by 8.97% and 7.04% when the complete and optimal cytoreduction proportion increased by 10%, respectively, after adjusting other variables. CONCLUSION Secondary cytoreductive surgery, resulting in maximal tumor resection, significantly prolongs OS in platinum-sensitive recurrent ovarian cancer.
Collapse
Affiliation(s)
- Min-Hyun Baek
- Department of Obstetrics and Gynecology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Eun Young Park
- Biostatistics Collaboration Team, Research Core Center, National Cancer Center, Goyang, South Korea.,Department of Statistics and Data Science, Yonsei University, Seoul, South Korea
| | - Hyeong In Ha
- Department of Obstetrics and Gynecology, Pusan National University Yangsan Hospital, Pusan, South Korea
| | - Sang-Yoon Park
- Center for Gynecologic Cancer and Center for Clinical Trials, National Cancer Center, Goyang, South Korea
| | - Myong Cheol Lim
- Center for Gynecologic Cancer and Center for Clinical Trials, National Cancer Center, Goyang, South Korea.,Rare & Pediatric Cancer Branch and Immuno-oncology Branch, Division of Rare and Refractory Cancer, Research Institute, National Cancer Center, Goyang, South Korea.,Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, South Korea
| | - Christina Fotopoulou
- Department of Gynecologic Oncology, Imperial College London, London, United Kingdom
| | - Robert E Bristow
- Division of Gynecologic Oncology, Obstetrics and Gynecology, Irvine Medical Center, University of California, Orange, CA
| |
Collapse
|
5
|
Ding T, Tang D, Xi M. The survival outcome and complication of secondary cytoreductive surgery plus chemotherapy in recurrent ovarian cancer: a systematic review and meta-analysis. J Ovarian Res 2021; 14:93. [PMID: 34256813 PMCID: PMC8278673 DOI: 10.1186/s13048-021-00842-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 06/29/2021] [Indexed: 01/09/2023] Open
Abstract
Objective The aim of this meta-analysis was to assess the effectiveness and safety of secondary cytoreductive surgery plus chemotherapy (SCS + CT) in recurrent ovarian cancer (ROC). Our secondary purpose was to analyze whether patients could benefit from complete resection. Methods We searched EMBASE, MEDLINE, the Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials, from inception to April 2021. We used appropriate scales to assess the risk of bias. Data from included studies that reported median PFS or OS were weighted by individual study sample size, and aggregated for meta-analysis. We calculated the pooled proportion of complications within 30 days after surgery. Results We identified 13 articles, including three RCTs and ten retrospective cohort studies. A total of 4572 patients were included, of which 916 patients achieved complete resection, and all patients were comparable at baseline. Compared with chemotherapy alone, SCS + CT significantly improved the PFS (HR = 0.54, 95% CI: 0.43–0.67) and OS (HR = 0.60, 95% CI: 0.44–0.81). Contrary to the results of cohort studies, the meta-analysis of RCTs showed that SCS + CT could not bring OS benefits (HR = 0.93, 95% CI: 0.66–1.3). The subgroup analysis showed the prognostic importance of complete resection. Compared with chemotherapy alone, complete resection was associated with longer PFS (HR = 0.53, 95% CI: 0.45–0.61) and OS (HR = 0.56, 95% CI: 0.39–0.81), while incomplete resection had no survival benefit. Additionally, complete resection could maximize survival benefit compared with incomplete resection (HR = 0.56, 95% CI: 0.46–0.69; HR = 0.61, 95% CI: 0.50–0.75). The pooled proportion for complications at 30 days was 21% (95% CI: 0.12–0.30), and there was no statistical difference in chemotherapy toxicity between the two groups. Conclusion The review indicated that SCS + CT based regimens was correlated with better clinical prognosis for patients with recurrent ovarian cancer, but the interpretation of OS should be cautious. The meta-analysis emphasizes the importance of complete resection, suggesting that the potential benefits of prolonging survival may outweigh the disadvantages of any short-term complications associated with surgery. Supplementary Information The online version contains supplementary material available at 10.1186/s13048-021-00842-9.
Collapse
Affiliation(s)
- Ting Ding
- Department of Obstetrics and Gynecology, West China Second Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Number 20, 3rd Section, South Renmin Road, Chengdu, 610041, Sichuan Province, China
| | - Dan Tang
- Department of Obstetrics and Gynecology, West China Second Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Number 20, 3rd Section, South Renmin Road, Chengdu, 610041, Sichuan Province, China
| | - Mingrong Xi
- Department of Obstetrics and Gynecology, West China Second University Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Number 20, 3rd Section, South Renmin Road, Chengdu, 610041, Sichuan Province, China.
| |
Collapse
|
6
|
Bacalbasa N, Balescu I, Dima S, Vilcu M, Brezean I. Extended Pelvic Resections as Part of Secondary Cytoreduction for Relapsed Ovarian Adenocarcinoma. In Vivo 2020; 34:397-400. [PMID: 31882505 DOI: 10.21873/invivo.11787] [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: 09/23/2019] [Revised: 10/07/2019] [Accepted: 10/08/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Ovarian cancer presents an aggressive tumor biology, a significant number of patients experiencing recurrent disease. The aim of this study was to examine the feasibility and effectiveness of secondary debulking surgery for relapsed ovarian cancer. PATIENTS AND METHODS Between 2014 and 2018, debulking surgery for relapsed ovarian cancer was performed in 40 cases. RESULTS Debulking surgery to no residual disease was achieved in 31 cases; among the remaining cases, an R1 resection was feasible in six cases, while in the remaining three cases an R2 resection was performed. The most commonly performed visceral resections were represented by rectosigmoidian resection, right colon resection, total or partial cystectomy and unilateral or bilateral ureteral resection. The early postoperative morbidity rate was 32.5% while the postoperative mortality rate was 2.5%. CONCLUSION Extended pelvic resections are feasible in patients with relapsed ovarian cancer and might be performed with acceptable rates of postoperative complications.
Collapse
Affiliation(s)
- Nicolae Bacalbasa
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,"I. Cantacuzino" Clinical Hospital, Bucharest, Romania.,"Fundeni" Clinical Institute - Center of Excellence in Translational Medicine, Bucharest, Romania
| | | | - Simona Dima
- "Fundeni" Clinical Institute - Center of Excellence in Translational Medicine, Bucharest, Romania
| | - Mihaela Vilcu
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,"I. Cantacuzino" Clinical Hospital, Bucharest, Romania
| | - Iulian Brezean
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,"I. Cantacuzino" Clinical Hospital, Bucharest, Romania
| |
Collapse
|
7
|
Gockley A, Melamed A, Cronin A, Bookman MA, Burger RA, Cristae MC, Griggs JJ, Mantia-Smaldone G, Matulonis UA, Meyer LA, Niland J, O'Malley DM, Wright AA. Outcomes of secondary cytoreductive surgery for patients with platinum-sensitive recurrent ovarian cancer. Am J Obstet Gynecol 2019; 221:625.e1-625.e14. [PMID: 31207237 DOI: 10.1016/j.ajog.2019.06.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 06/06/2019] [Accepted: 06/10/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Most women with advanced epithelial ovarian cancer develop recurrent disease, despite maximal surgical cytoreduction and adjuvant platinum-based chemotherapy. In observational studies, secondary cytoreductive surgery has been associated with improved survival; however its use is controversial, because there are concerns that the improved outcomes may reflect selection bias rather than the superiority of secondary surgery. OBJECTIVE To compare the overall survival of women with platinum-sensitive recurrent ovarian cancer treated at National Cancer Institute-designated cancer centers who receive secondary surgery vs chemotherapy. STUDY DESIGN This retrospective cohort study included women from 6 National Cancer Institute-designated cancer centers diagnosed with platinum-sensitive recurrent ovarian cancer between January 1, 2004, and December 31, 2011. The primary outcome was overall survival. Propensity score matching was used to compare similar women who received secondary surgery vs chemotherapy. Additional analyses examined how these findings may be influenced by the prevalence of unobserved confounders at the time of recurrence. RESULTS Among 626 women, 146 (23%) received secondary surgery and 480 (77%) received chemotherapy. In adjusted analyses, patients who received secondary surgery were younger (P = 0.001), had earlier-stage disease at diagnosis (P = 0.002), and had longer disease-free intervals (P < 0.001) compared with those receiving chemotherapy. In the propensity score-matched groups (n = 244 patients), the median overall survival was 54 months in patients who received secondary surgery and 33 months in those treated with chemotherapy (P < 0.001). Among patients who received secondary surgery, 102 (70%) achieved optimal secondary cytoreduction. There were no significant differences in complication rates between the 2 groups. In sensitivity analyses, the survival advantage associated with secondary surgery could be explained by the presence of more multifocal recurrences (if 4.3 times more common), ascites (if 2.7 times more common), or carcinomatosis (if 2.1 times more common) among patients who received chemotherapy instead of secondary surgery. CONCLUSION Patients with platinum-sensitive recurrent ovarian cancer who received secondary surgery had favorable surgical characteristics and were likely to have minimal residual disease following secondary surgery. These patients had a superior median overall survival compared with patients who received chemotherapy, although unmeasured confounders may explain this observed difference.
Collapse
Affiliation(s)
- Allison Gockley
- Division of Gynecologic Oncology, Department of Obstetrics Gynecology and Reproductive Biology, Brigham and Women's Hospital, Boston, MA.
| | - Alexander Melamed
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA
| | - Angel Cronin
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
| | - Michael A Bookman
- Division of Medical Oncology, Kaiser Permanente Northern California, San Francisco, CA
| | - Robert A Burger
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | - Jennifer J Griggs
- Department of Health Management and Policy, Division of Internal Medicine, Hematology and Oncology, University of Michigan, Ann Arbor, MI
| | - Gina Mantia-Smaldone
- Department of Surgical Oncology, Division of Gynecologic Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Ursula A Matulonis
- Division of Gynecologic Oncology, Susan F. Smith Center for Women's Cancers, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, MD Anderson Cancer Center, Houston, TX
| | - Joyce Niland
- City of Hope Comprehensive Cancer Center, Duarte, CA
| | - David M O'Malley
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Alexi A Wright
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA; Division of Gynecologic Oncology, Susan F. Smith Center for Women's Cancers, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| |
Collapse
|