1
|
Sowamber R, Lukey A, Huntsman D, Hanley G. Ovarian Cancer: From Precursor Lesion Identification to Population-Based Prevention Programs. Curr Oncol 2023; 30:10179-10194. [PMID: 38132375 PMCID: PMC10742141 DOI: 10.3390/curroncol30120741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 11/23/2023] [Accepted: 11/27/2023] [Indexed: 12/23/2023] Open
Abstract
Epithelial ovarian cancer (EOC) is a heterogeneous group of malignancies, including high-grade serous ovarian cancer (HGSC). HGSC is often diagnosed at advanced stages and is linked to TP53 variants. While BRCA variants elevate risk, most HGSC cases occur in individuals without known genetic variants, necessitating prevention strategies for people without known high-risk genetic variants. Effective prevention programs are also needed due to the lack of traditional screening options. An emerging primary prevention strategy is opportunistic salpingectomy, which involves removing fallopian tubes during another planned pelvic surgery. Opportunistic salpingectomy offers a safe and cost-effective preventative option that is gaining global adoption. With the publication of the first cohort study of patients who underwent salpingectomy, specifically for cancer prevention, attention has turned to broadening opportunities for salpingectomy in addition to more targeted approaches. Prevention opportunities are promising with increasing adoption of salpingectomy and the increased understanding of the etiology of the distinct histotypes of ovarian cancer. Yet, further research on targeted risk-reducing salpingectomy with thoughtful consideration of equity is necessary to reduce death and suffering from ovarian cancer.
Collapse
Affiliation(s)
- Ramlogan Sowamber
- Department of Gynecology and Obstetrics, University of British Columbia, Vancouver, BC V6T 1Z4, Canada;
- Department of Medical Genetics, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
- Department of Molecular Oncology, British Columbia Cancer Research Centre, Vancouver, BC V6T 1Z4, Canada
| | - Alexandra Lukey
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z4, Canada;
| | - David Huntsman
- Department of Gynecology and Obstetrics, University of British Columbia, Vancouver, BC V6T 1Z4, Canada;
- Department of Medical Genetics, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
- Department of Molecular Oncology, British Columbia Cancer Research Centre, Vancouver, BC V6T 1Z4, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
| | - Gillian Hanley
- Department of Gynecology and Obstetrics, University of British Columbia, Vancouver, BC V6T 1Z4, Canada;
| |
Collapse
|
2
|
Kahn RM, Gordhandas S, Godwin K, Stone RL, Worley MJ, Lu KH, Long Roche KC. Salpingectomy for the Primary Prevention of Ovarian Cancer: A Systematic Review. JAMA Surg 2023; 158:1204-1211. [PMID: 37672283 DOI: 10.1001/jamasurg.2023.4164] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
Importance Most ovarian cancers originate in the fimbriated end of the fallopian tube. This has led to the hypothesis that surgical resection of the fallopian tubes at the time of gynecologic and nongynecologic surgical procedures-referred to as an opportunistic salpingectomy-may prevent the development of epithelial ovarian cancer for women at an average risk of developing the disease. Objective To compile a comprehensive, state-of-the-science review examining the current landscape of performing bilateral salpingectomy for ovarian cancer prevention. Evidence Review A systematic review of the literature was performed on March 4, 2022, to identify studies examining salpingectomy for ovarian cancer prevention. This review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 statement. Four databases were selected: PubMed via the National Library of Medicine's PubMed.gov, Embase via Elsevier's Embase.com, Cochrane Central Register of Controlled Trials (CENTRAL) via Wiley's Cochrane Library, and Northern Light Life Sciences Conference Abstracts via Ovid. A total of 20 gray literature sources, including 1 database, 2 registers, 1 repository, 1 index, 1 archive, 1 preprint server, 1 agency, and 12 organizations, were also searched. Findings The initial search produced 1089 results; a total of 158 publications were included in the final review. Salpingectomy has been associated with ovarian cancer risk reduction of approximately 80%. Studies have demonstrated that salpingectomy was safe, cost-effective, and was not associated with an earlier age of menopause onset. With widespread implementation, salpingectomy has the potential to reduce ovarian cancer mortality in the US by an estimated 15%. Both physician and patient awareness regarding the adnexa as the origin for most ovarian cancers, as well as the existence of salpingectomy and its potential benefits in reducing ovarian cancer risk, has increased during the past decade. Raising awareness and developing effective implementation strategies are essential. Conclusions and Relevance The results of this systematic review suggest that bilateral salpingectomy for ovarian cancer prevention was safe and feasible and has the potential to be a cost-effective and cost-saving strategy across the population. Prospective studies to demonstrate long-term survival outcomes and feasibility in nongynecologic surgical procedures are warranted.
Collapse
Affiliation(s)
- Ryan M Kahn
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sushmita Gordhandas
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kendra Godwin
- Medical Library, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rebecca L Stone
- Department of Obstetrics and Gynecology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Michael J Worley
- Department of Surgery, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Karen H Lu
- Division of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Kara C Long Roche
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York
| |
Collapse
|
3
|
Rizvi Z, Sharma KC, Kunder V, Abreu A. Barriers of Care to Ovarian Cancer: A Scoping Review. Cureus 2023; 15:e40309. [PMID: 37448421 PMCID: PMC10337512 DOI: 10.7759/cureus.40309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/11/2023] [Indexed: 07/15/2023] Open
Abstract
Ovarian cancer is a leading cause of female cancer-related deaths, but patients continue to be diagnosed late. This subjects them to disease progression and possible death due to lack of early detection, despite earlier stage detection improving survival rates by significant percentages. Early detection and access to care are closely related. However, many barriers to high-quality care exist for patients and the majority of patients do not receive recommended care according to ovarian cancer treatment guidelines. In order to improve care for ovarian cancer patients and decrease healthcare disparities in accessing equitable care, it is important to acknowledge the current gaps in patient knowledge, healthcare availability, and physician practice. This scoping review explores the available evidence on ovarian cancer to identify these barriers to care in the effective treatment of ovarian cancer. Using both inclusion and exclusion criteria, results from the initial literature search were screened by the authors. After quality assessment and screening for relevance, 10 articles were included in the final review. The following themes emerged as barriers to care: hospital and physician-patient volumes, geographic distance from care facilities, patient and physician education, and demographic factors. Many patients were found to not receive guideline adherent care due to various barriers to care, whereas guideline adherent care was independently associated with factors such as patient proximity to a high-volume hospital, White race, and higher socioeconomic status. Several areas were identified as potential for increased patient and physician education, including treatment complications and patient resources. The evidence found that certain socioeconomic groups and racial minorities are often at higher risk for guideline non-adherent care. Additionally, the evidence showed a further need for physicians and healthcare providers to be provided with resources for post-cancer treatment, follow-up, and patient education. The findings of this review will provide health experts and patients with better insight into what barriers may exist so that guideline-adherent care can be better advocated for and met.
Collapse
Affiliation(s)
- Zehra Rizvi
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Kiran C Sharma
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Viktor Kunder
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Adrian Abreu
- Obstetrics and Gynecology, Broward Health Medical Center, Fort Lauderdale, USA
| |
Collapse
|
4
|
Gelderblom ME, Jaspers V, Akkermans RP, Slangen B, Oei ALM, van Ginkel AA, Ngo H, IntHout J, Hermens RPMG, de Hullu JA, Piek JMJ. First step in implementation of opportunistic salpingectomy for prevention of ovarian cancer: Current care and its determinants. Acta Obstet Gynecol Scand 2023; 102:257-269. [PMID: 36661074 PMCID: PMC9951340 DOI: 10.1111/aogs.14507] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 12/20/2022] [Accepted: 12/25/2022] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Opportunistic salpingectomy (OS) refers to additional removal of the fallopian tubes during abdominal surgery performed for another medical indication, as prevention for ovarian cancer. As OS has been inconsistently implemented, its clinical practice varies worldwide. To reduce this variation, insight is required into current clinical practice and its determinants. Therefore, the study aim was to determine the implementation of counseling and performance of OS between 2015 and 2018, and its patient, surgical, physician, and hospital characteristics. MATERIAL AND METHODS Retrospective study using electronic medical records from six different Dutch hospitals: two academic, two large teaching, and two non-teaching hospitals. Patients were considered eligible for OS if they underwent elective non-obstetric abdominal surgery for a gynecological indication from January 2015 through December 2018. Primary outcomes were uptake of counseling and performance of OS. Multilevel multivariable logistic regression analyses were conducted to identify characteristics associated with OS. RESULTS A total of 3214 patients underwent elective non-obstetric abdominal surgery for a gynecological indication and were eligible for OS. Counseling on OS increased significantly from 2.9% in 2015 to 29.4% in 2018. In this period, 440 patients were counseled on OS, of which 95.9% chose OS. Performance of OS increased significantly from 6.9% in 2015 to 44.5% in 2018. Counseling for and performance of OS were more likely in patients who had surgery by laparoscopic approach, were counseled by a gynecological resident, or had more than three contact moments before surgery. Additionally, OS was less likely in patients who had vaginal surgery. CONCLUSIONS Although the uptake of OS increased from 2015 to 2018, the majority of patients who were eligible for OS were not counseled and did not undergo OS. Its clinical practice varies on patient, surgery, and physician characteristics. Therefore, an implementation strategy tailored to associated determinants is recommended.
Collapse
Affiliation(s)
- Malou E. Gelderblom
- Department of Obstetrics and Gynecology, Radboud Institute for Health SciencesRadboud University Medical CenterNijmegenThe Netherlands
| | - Veerle Jaspers
- Department of Obstetrics and Gynecology and Catharina Cancer InstituteCatharina HospitalEindhovenThe Netherlands
| | - Reinier P. Akkermans
- Radboud Institute for Health Sciences, Department of IQ health careRadboud University Medical CenterNijmegenThe Netherlands,Department of Primary and Community CareRadboud University Medical CenterNijmegenThe Netherlands
| | - Brigitte Slangen
- Department of Obstetrics and GynecologyMaastricht University Medical CenterMaastrichtThe Netherlands
| | - Angele L. M. Oei
- Department of Obstetrics and GynecologyBernhoven HospitalUdenThe Netherlands
| | | | - Huy Ngo
- Department of Obstetrics and GynecologyElkerliek HospitalHelmondThe Netherlands
| | - Joanna IntHout
- Department for Health Evidence, Radboud Institute for Health SciencesRadboud University Medical CenterNijmegenThe Netherlands
| | - Rosella P. M. G. Hermens
- Radboud Institute for Health Sciences, Department of IQ health careRadboud University Medical CenterNijmegenThe Netherlands
| | - Joanne A. de Hullu
- Department of Obstetrics and Gynecology, Radboud Institute for Health SciencesRadboud University Medical CenterNijmegenThe Netherlands
| | - Jurgen M. J. Piek
- Department of Obstetrics and Gynecology and Catharina Cancer InstituteCatharina HospitalEindhovenThe Netherlands
| |
Collapse
|
5
|
Dukhovich A, Sullivan ME, Hartnett J, Rose SJ, Hines BJ. Opportunistic salpingectomy during robotic sacrocolpopexy: Data to support a widely accepted practice. Data Brief 2023; 46:108891. [PMID: 36687155 PMCID: PMC9852919 DOI: 10.1016/j.dib.2023.108891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/03/2023] [Accepted: 01/05/2023] [Indexed: 01/13/2023] Open
Abstract
While surgical outcomes of prophylactic salpingectomy as an ovarian cancer risk reducing measure at the time of hysterectomy for benign indications has already been studied, data has traditionally been extrapolated to surgery for prolapse repair. A retrospective chart review was performed from medical records of patients who had undergone a sacrocolpopexy for pelvic organ prolapse. Variables collected included operation duration, length of hospital stay, readmission within 31 days, estimated blood loss (EBL), number and size of incisions, as well as narcotic use during hospitalization. Additional procedures performed at the time of operation including vaginal or laparoscopic hysterectomy, transobturator sling, anterior or posterior colporrhaphy, cystoscopy, and robotic ventral mesh rectopexy were collected as potential confounding variables. In addition, data to allow examination of pathology results of all fallopian tubes was collected to determine the proportion of pre-malignant and malignant pathology results. Statistical analyses were performed using SAS version 8. Two cohorts were created: (1) Patients who underwent adnexal surgery (bilateral salpingectomy or salpingoopherectomy) at time of the sacrocolpopexy and (2) Patients who underwent a sacrocolpopexy without adnexal surgery. Comparisons were performed with chi-square analysis for discrete variables and group t-tests for continuous level data. Narcotics administered during the immediate post-operative period until discharge was collected for each patient and converted to morphine milligram equivalents (MME) via multiplying the administered dose by the CDC established evidence-based conversion factor. Analysis of covariance (ANCOVA) as well as logistic regression was used to control for confounding variables, including the additional procedures patients had during their operation. An omnibus p-value of 0.05 was used to determine statistical significance for all tests. Due to the exploratory nature of this analysis, there were no corrections applied for multiple comparisons. This data can be used as a basis for researchers to build upon when assessing ovarian cancer primary prevention strategies and associated treatment modalities.
Collapse
Affiliation(s)
- Anna Dukhovich
- Department of Female Pelvic Medicine and Reconstructive Surgery, Montefiore Health System, New York, New York, United States
| | - Marie E. Sullivan
- Department of Obstetrics and Gynecology, Stamford Hospital, Stamford, Connecticut, United States
| | - Josette Hartnett
- Department of Research and Discovery, Stamford Hospital, Stamford, Connecticut, United States
| | - Suzanne J. Rose
- Department of Research and Discovery, Stamford Hospital, Stamford, Connecticut, United States
- Corresponding author.
| | - Brian J. Hines
- Department of Urogynecology and Reconstructive Surgery, Stamford Hospital, Stamford, Connecticut, United States
| |
Collapse
|
6
|
Hanley GE, Niu J, Han J, Fung S, Bryant H, Kwon JS, Huntsman DG, Finlayson SJ, McAlpine JN, Miller D, Earle CC. Opportunistic salpingectomy between 2011 and 2016: a descriptive analysis. CMAJ Open 2022; 10:E466-E475. [PMID: 35640988 PMCID: PMC9177200 DOI: 10.9778/cmajo.20210219] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Opportunistic salpingectomy (OS) is the removal of fallopian tubes during hysterectomy for benign indications or instead of tubal ligation, for the purpose of preventing ovarian cancer. We determined rates of OS at the time of hysterectomy and tubal sterilization and examined how they changed over the study period. METHODS Using data from the Canadian Institute for Health Information's Discharge Abstract Database and National Ambulatory Care Reporting System for all Canadian provinces and territories (except Quebec) between the fiscal years 2011 and 2016, we conducted a descriptive analysis of all patients aged 15 years or older who underwent hysterectomy or tubal sterilization. We excluded those with diagnostic codes for any gynecologic cancer and those who underwent unilateral salpingectomy. We examined the proportion who had OS during their hysterectomy and compared the proportion of tubal sterilizations that were OS with the proportion that were tubal ligations. RESULTS A total of 318 528 participants were included in the study (mean age 42.5 yr). The proportion of hysterectomies that included OS increased from 15.4% in 2011 to 35.5% by 2016. With respect to tubal sterilization, the rate of OS increased from 6.5% of all tubal sterilizations in 2011 to 22.0% in 2016. There was considerable variation across jurisdictions in 2016, with British Columbia having the highest rates (53.2% of all hysterectomies and 74.0% of tubal sterilizations involved OS). INTERPRETATION The rates of OS increased between 2011 and 2016, but there was considerable variation across the included jurisdictions. Our study indicates room for rates of OS to increase across many of the included jurisdictions.
Collapse
Affiliation(s)
- Gillian E Hanley
- Division of Gynaecologic Oncology (Hanley, Kwon, Huntsman, Finlayson, McAlpine, Miller), Department of Gynaecology and Obstetrics, and Department of Pathology and Laboratory Medicine (Huntsman), University of British Columbia; Vancouver Coastal Health (Finlayson), Vancouver, BC; Canadian Partnership Against Cancer (Niu, Han, Fung, Bryant, Huntsman, Earle), Toronto, Ont.; Department of Community Health Sciences (Bryant) and Department of Oncology (Bryant), University of Calgary, Calgary, Alta.
| | - Jin Niu
- Division of Gynaecologic Oncology (Hanley, Kwon, Huntsman, Finlayson, McAlpine, Miller), Department of Gynaecology and Obstetrics, and Department of Pathology and Laboratory Medicine (Huntsman), University of British Columbia; Vancouver Coastal Health (Finlayson), Vancouver, BC; Canadian Partnership Against Cancer (Niu, Han, Fung, Bryant, Huntsman, Earle), Toronto, Ont.; Department of Community Health Sciences (Bryant) and Department of Oncology (Bryant), University of Calgary, Calgary, Alta
| | - Jihee Han
- Division of Gynaecologic Oncology (Hanley, Kwon, Huntsman, Finlayson, McAlpine, Miller), Department of Gynaecology and Obstetrics, and Department of Pathology and Laboratory Medicine (Huntsman), University of British Columbia; Vancouver Coastal Health (Finlayson), Vancouver, BC; Canadian Partnership Against Cancer (Niu, Han, Fung, Bryant, Huntsman, Earle), Toronto, Ont.; Department of Community Health Sciences (Bryant) and Department of Oncology (Bryant), University of Calgary, Calgary, Alta
| | - Sharon Fung
- Division of Gynaecologic Oncology (Hanley, Kwon, Huntsman, Finlayson, McAlpine, Miller), Department of Gynaecology and Obstetrics, and Department of Pathology and Laboratory Medicine (Huntsman), University of British Columbia; Vancouver Coastal Health (Finlayson), Vancouver, BC; Canadian Partnership Against Cancer (Niu, Han, Fung, Bryant, Huntsman, Earle), Toronto, Ont.; Department of Community Health Sciences (Bryant) and Department of Oncology (Bryant), University of Calgary, Calgary, Alta
| | - Heather Bryant
- Division of Gynaecologic Oncology (Hanley, Kwon, Huntsman, Finlayson, McAlpine, Miller), Department of Gynaecology and Obstetrics, and Department of Pathology and Laboratory Medicine (Huntsman), University of British Columbia; Vancouver Coastal Health (Finlayson), Vancouver, BC; Canadian Partnership Against Cancer (Niu, Han, Fung, Bryant, Huntsman, Earle), Toronto, Ont.; Department of Community Health Sciences (Bryant) and Department of Oncology (Bryant), University of Calgary, Calgary, Alta
| | - Janice S Kwon
- Division of Gynaecologic Oncology (Hanley, Kwon, Huntsman, Finlayson, McAlpine, Miller), Department of Gynaecology and Obstetrics, and Department of Pathology and Laboratory Medicine (Huntsman), University of British Columbia; Vancouver Coastal Health (Finlayson), Vancouver, BC; Canadian Partnership Against Cancer (Niu, Han, Fung, Bryant, Huntsman, Earle), Toronto, Ont.; Department of Community Health Sciences (Bryant) and Department of Oncology (Bryant), University of Calgary, Calgary, Alta
| | - David G Huntsman
- Division of Gynaecologic Oncology (Hanley, Kwon, Huntsman, Finlayson, McAlpine, Miller), Department of Gynaecology and Obstetrics, and Department of Pathology and Laboratory Medicine (Huntsman), University of British Columbia; Vancouver Coastal Health (Finlayson), Vancouver, BC; Canadian Partnership Against Cancer (Niu, Han, Fung, Bryant, Huntsman, Earle), Toronto, Ont.; Department of Community Health Sciences (Bryant) and Department of Oncology (Bryant), University of Calgary, Calgary, Alta
| | - Sarah J Finlayson
- Division of Gynaecologic Oncology (Hanley, Kwon, Huntsman, Finlayson, McAlpine, Miller), Department of Gynaecology and Obstetrics, and Department of Pathology and Laboratory Medicine (Huntsman), University of British Columbia; Vancouver Coastal Health (Finlayson), Vancouver, BC; Canadian Partnership Against Cancer (Niu, Han, Fung, Bryant, Huntsman, Earle), Toronto, Ont.; Department of Community Health Sciences (Bryant) and Department of Oncology (Bryant), University of Calgary, Calgary, Alta
| | - Jessica N McAlpine
- Division of Gynaecologic Oncology (Hanley, Kwon, Huntsman, Finlayson, McAlpine, Miller), Department of Gynaecology and Obstetrics, and Department of Pathology and Laboratory Medicine (Huntsman), University of British Columbia; Vancouver Coastal Health (Finlayson), Vancouver, BC; Canadian Partnership Against Cancer (Niu, Han, Fung, Bryant, Huntsman, Earle), Toronto, Ont.; Department of Community Health Sciences (Bryant) and Department of Oncology (Bryant), University of Calgary, Calgary, Alta
| | - Dianne Miller
- Division of Gynaecologic Oncology (Hanley, Kwon, Huntsman, Finlayson, McAlpine, Miller), Department of Gynaecology and Obstetrics, and Department of Pathology and Laboratory Medicine (Huntsman), University of British Columbia; Vancouver Coastal Health (Finlayson), Vancouver, BC; Canadian Partnership Against Cancer (Niu, Han, Fung, Bryant, Huntsman, Earle), Toronto, Ont.; Department of Community Health Sciences (Bryant) and Department of Oncology (Bryant), University of Calgary, Calgary, Alta
| | - Craig C Earle
- Division of Gynaecologic Oncology (Hanley, Kwon, Huntsman, Finlayson, McAlpine, Miller), Department of Gynaecology and Obstetrics, and Department of Pathology and Laboratory Medicine (Huntsman), University of British Columbia; Vancouver Coastal Health (Finlayson), Vancouver, BC; Canadian Partnership Against Cancer (Niu, Han, Fung, Bryant, Huntsman, Earle), Toronto, Ont.; Department of Community Health Sciences (Bryant) and Department of Oncology (Bryant), University of Calgary, Calgary, Alta
| |
Collapse
|