Surgical staging of ovarian cancer by gynaecological oncologists has been shown to be superior to that performed by non-oncological (general) surgeons, as have patient outcomes114116. Cytotoxic T cell infiltration in ovarian cancer has been shown to correlate with improvement in overall survival in several studies96,97. These NCCN Gu e | Endometrioid adenocarcinoma is characterized by gland formation that recapitulates endometrial glands and is graded based on cellular architecture and nuclear atypia. Early detection efforts are promising, with ROCA testing demonstrating increased detection of early ovarian cancers compared with no testing. Quantification of quality-of-life issues faced by women with ovarian cancer requires well-constructed, reliable PRO measures that need to be essential components of phase III studies. This is done to check the uterus, ovaries and other organs. Sample Nursing Care Plans Please enable it to take advantage of the complete set of features! National Library of Medicine This Primer also discusses patient quality of life and concludes with the examination of the future outlook for ovarian cancer, including new prevention and screening approaches and promising new therapeutic advances. 220, Elsevier. General. Epub 2018 Mar 4. However, results of the UKCTOCS study did not show an overall survival advantage to using the ROCA testing, thus no screening test exists at this time. I have other health conditions. EXO1 excises the mismatched bases, which are then repaired by DNA polymerase and DNA ligase. IP intraperitoneal; IV intravenous; NACT, neoadjuvant chemotherapy; PFS progression-free survival. However, conflicting data have been reported in other studies40. The Society for Gynecologic Oncologists (SGO), the American College of Obstetricians and Gynecologists (ACOG), and the National Comprehensive Cancer Network (NCCN) have all published guidelines for referral of patients with suspected ovarian cancer (ACOG, 2002; NCCN, 2015) (see Box 4-1 ). In these patients, alternative biomarkers, such as HE4, and/or the use of interval radiographic imaging might be of use for monitoring of recurrent cancer, but this needs further evaluation. However, STICs are not found in all patients with HGSCs, and alternative pathways for the pathogenesis of HGSC probably exist95. In recurrent cancer, chemotherapy, anti-angiogenic agents and poly(ADP-ribose) polymerase inhibitors are used, and immunological therapies are currently being tested. PROs are important as there are increasing doubts raised about the validity of data regarding adverse events collected during clinical trials; several studies have shown that the symptoms of disease and adverse effects of treatment are often under-recognized, under-reported and consequently undertreated183. Patients with Lynch syndrome-associated ovarian cancer have a mean age at presentation of 48 years (compared with a median age of ~68 years in those without Lynch syndrome), with ~50% of patients having stage I cancer. Unauthorized use of these marks is strictly prohibited. Now is a very exciting and promising time for ovarian cancer research, yet challenges remain in early detection, the identification of women who are at higher risk of developing ovarian cancer, overcoming platinum resistance and resistance to other treatments, in addition to developing rationale and effective immunotherapeutic strategies. 1 Although it is the eighth most common cancer, ovarian cancer is among the five most lethal cancers in women due to a high rate of metastasis . September 29, 2022. Promising future therapies for ovarian cancer include PARP inhibitors and antibodydrug conjugates. A systematic review reported better sensitivity, specificity and likelihood ratios for HE4 compared with CA125, but this has not yet been analysed within a screening strategy123. Reproduced with permission from REF. However, owing to the risk of developing adverse effects with continuation of monthly paclitaxel for 12 months (for example, alopecia and peripheral neuropathy), the use of paclitaxel for maintenance therapy after platinum-based chemotherapy is not commonly used; currently, the standard of care following completion of platinum-based chemotherapy is observation alone138. Palliative care teams aim to improve the quality of life for people with cancer and their families. the contents by NLM or the National Institutes of Health. Clinical question: For women newly diagnosed with ovarian cancer, what support should be offered? This trial was the first to demonstrate a PFS and overall survival benefit of the addition of paclitaxel to platinum therapy, thereby helping to establish the standard of care of a platinum plus taxane chemotherapy regimen for newly diagnosed ovarian cancer. Bethesda, MD 20894, Web Policies Consequently, understanding the mechanisms underlying platinum resistance and finding ways to overcome them are active areas of study in ovarian cancer. These data, in turn, open the pathway to improved therapeutic, early detection and risk-reducing strategies. Furthermore, cytotoxic T cell infiltration in ovarian tumours correlates with improvement in overall survival, as shown by several groups96,97. STUDY Amriati Mutmainna,S.Kep.,Ns.,MSN CHAPTER I Introduction Talk about one case in the world. Furthermore, cediranib is being tested in combination with olaparib in two actively accruing phase III studies: GY004 and GY005 (REFS 178,179). A diagnosis of ovarian cancer can be overwhelming. Moreover, germline or somatic mutations in BRCA1 or BRCA2 could lead to a favourable treatment response with improved responsiveness to chemotherapy26,65. Genetic/familial high-risk assessment: breast and ovarian, Impact of oophorectomy on cancer incidence and mortality in women with a, Influence of the gynecologic oncologist on the survival of ovarian cancer patients, Ovarian cancer in the United States: contemporary patterns of care associated with improved survival, Bristow RE, Chang J, Ziogas A & Anton-Culver H, Adherence to treatment guidelines for ovarian cancer as a measure of quality care, Chang S-J, Hodeib M, Chang J & Bristow RE, Survival impact of complete cytoreduction to no gross residual disease for advanced-stage ovarian cancer: a meta-analysis, Does aggressive surgery improve outcomes? Tubal ligation and hysterectomy are also associated with a reduction in the risk of developing ovarian cancer; tubal ligation is associated with reduction in the risk of clear-cell and endometrioid carcinomas and hysterectomy is associated with reduction in the risk of clear-cell carcinoma40,4749. Effective screening strategies for the early detection of ovarian cancer do not exist, but individuals at high risk of developing ovarian cancer, such as those with germline mutations in BRCA1 or BRCA2 (which encode proteins involved in the repair of DNA damage via homologous recombination) or other genes associated with a high risk of developing ovarian cancer can be identified. Accessed May 5, 2021. HHS Vulnerability Disclosure, Help Moreover, stage III was reclassified to account for differences in the clinical outcomes in patients with metastases to the lymph nodes who do not have peritoneal carcinomatosis compared with patients with peritoneal carcinomatosis112,113. Support needs of women with newly diagnosed ovarian cancer. Salpingectomy has gained favour as a prevention technique based on the presence of precursor lesions in the fallopian tubes of some women with ovarian cancer, as discussed above. This paper reviews the known and established inherited germline mutations that are associated with an increased risk of developing ovarian cancer. The NCCN Guidelines also include recommendations specifically for patients with less common ovarian cancers, which in the guidelines include the following: carcinosarcoma, clear cell carcinoma, mucinous carcinoma, low-grade serous, grade 1 endometrioid, borderline epithelial, malignant sex cord-stromal, and malignant germ cell tumors. Olaparib combined with chemotherapy for recurrent platinum-sensitive ovarian cancer: a randomised phase 2 trial, Combination cediranib and olaparib versus olaparib alone for women with recurrent platinum-sensitive ovarian cancer: a randomised phase 2 study, Liu JF, Konstantinopoulos PA & Matulonis UA, PARP inhibitors in ovarian cancer: current status and future promise, Poly(ADP-ribose) polymerase inhibitors: recent advances and future development, Olaparib maintenance therapy in patients with platinum-sensitive relapsed serous ovarian cancer: a preplanned retrospective analysis of outcomes by BRCA status in a randomised phase 2 trial, Olaparib monotherapy in patients with advanced cancer and a germline, {"type":"clinical-trial","attrs":{"text":"NCT01844986","term_id":"NCT01844986"}}, Safety and antitumor activity of anti-PD-1 antibody, nivolumab, in patients with platinum-resistant ovarian cancer, Antitumor activity and safety of pembrolizumab in patients (pts) with PD-L1 positive advanced ovarian cancer: interim results from a phase Ib study, Avelumab (MSB0010718C), an anti-PD-L1 antibody, in patients with previously treated, recurrent or refractory ovarian cancer: a phase Ib, open-label expansion trial, Immunologic and clinical effects of antibody blockade of cytotoxic T lymphocyte-associated antigen 4 in previously vaccinated cancer patients, {"type":"clinical-trial","attrs":{"text":"NCT01611558","term_id":"NCT01611558"}}. The presence of BRCA reversion mutations (which restore the wild-type BRCA reading frame) could result in normal BRCA function and an increase in platinum resistance67,105. In addition, clear-cell and endometrioid carcinomas can originate from endometrial tissue located outside the uterus (endometriosis). The NCCN Guidelines for Ovarian Cancer provide recommendations for the diagnosis, evaluation, treatment, and follow-up for pat The lowest stage indicates that the cancer is confined to the ovaries. With the fields of genomics yielding more genetic information about ovarian cancer, in addition to the genotype of patients and with costs of sequencing decreasing, understanding the pathophysiology of ovarian cancer and rationale design of therapeutics are poised to move forward. Demonstrating an improvement in overall survival is a requirement for regulatory approval but is difficult to demonstrate in ovarian cancer; explanations for this are not fully understood but possibly include the use of active study agents after disease progression, which dilutes the effect of the active agent on overall survival but not on PFS216,217. Creation of a successful screening strategy for ovarian cancer is challenging because this is not a common disease and includes a range of histological subtypes, each with different biological and clinical properties. Hormone replacement therapy has been shown to increase the risk of developing ovarian cancer in postmenopausal women; oestrogen-only therapy increased risk by 22% and the combined oestrogen and progesterone therapy increased risk by 10%4244. What's the most likely cause of my symptoms? Immunotherapy uses the immune system to fight cancer. The NCCN Guidelines for Ovarian Cancer provide recommendations for the diagnosis, evaluation, treatment, and follow-up for patients with ovarian, fallopian tube, and primary peritoneal cancers. FIGO, International Federation of Gynecology and Obstetrics; TNM, TNM classification of malignant tumours. Evaluation of new platinum-based treatment regimens in advanced-stage ovarian cancer: a phase III Trial of the Gynecologic Cancer Intergroup, A randomized clinical trial of cisplatin/paclitaxel versus carboplatin/paclitaxel as first-line treatment of ovarian cancer, Phase III trial of carboplatin and paclitaxel compared with cisplatin and paclitaxel in patients with optimally resected stage III ovarian cancer: a Gynecologic Oncology Group study, Phase III randomized trial of docetaxelcarboplatin versus paclitaxelcarboplatin as first-line chemotherapy for ovarian carcinoma, Survival of women with cancers of breast and genital organs in Europe 19992007: results of the EUROCARE-5 study, An international assessment of ovarian cancer incidence and mortality, Sung P-L, Chang Y-H, Chao K-C & Chuang C-M, Global distribution pattern of histological subtypes of epithelial ovarian cancer: a database analysis and systematic review, Ovarian cancer incidence trends in relation to changing patterns of menopausal hormone therapy use in the United States, Hereditary ovarian cancer: beyond the usual suspects, Mutations in 12 genes for inherited ovarian, fallopian tube, and peritoneal carcinoma identified by massively parallel sequencing, Inherited mutations in women with ovarian carcinoma. Key clinical trials in newly diagnosed ovarian cancer. The limitations of disease detection and the role of CA125 should be discussed with all patients who have completed therapy. Various combinations of therapies are being investigated for the treatment of platinum-sensitive ovarian cancer (TABLE 5), including paclitaxel and carboplatin165, carboplatin and pegylated liposomal doxorubicin166 and carboplatin and gemcitabine167. PMC Share this document Women who have given birth have a reduced risk of all subtypes of ovarian cancer compared with women who have not given birth, with the strongest risk reduction noted for clear-cell carcinomas. The publisher's final edited version of this article is available at, Can present with peritoneal carcinomatosis, ascites and/or pelvic mass, Deficiencies in homologous recombination (50% of tumours), Platinum-based chemotherapy and poly(ADP-ribose) polymerase inhibitors, Tumours are initially sensitive to platinum-based chemotherapy, but most patients with advanced-stage cancer will recur, Presents in younger patients (median reported age: 4355 years, Can be early or late stage at presentation, MEK inhibitors (currently being tested in clinical trials) and hormonal therapies, Possible hormonal therapies (not yet established), Can present with parenchymal metastases (in the liver and the lungs), Can be associated with hypercoagulability and hypercalcaemia, Can be resistant to platinum-based chemotherapy, Presents in younger patients and is typically early stage at presentation, Tends to be insensitive to chemotherapy but is still treated initially with cytotoxic chemotherapy, Crucially involved in the repair of double-strand breaks by homologous recombination, Serves as a scaffold for other proteins involved in double-strand DNA repair, mostly through defective homologous recombination, The BRCA1-BARD1 complex is essential for mutual stability, The BRCA1-BRIP1 complex is required for S phase checkpoint activation, A bridging protein that connects BRCA1 and BRCA2 at sites of DNA damage, Strand exchange proteins that bind to ssDNA breaks to form nucleoprotein filaments and initiate DNA repair, Mismatch repair proteins that recognize and repair base-pairing errors occurring during DNA replication, Mutations in mismatch repair genes are associated with Lynch syndrome, IC2: capsule ruptured before surgery or tumour on ovarian or fallopian tube surface, IC3: malignant cells in the ascites or peritoneal washings, IVA: pleural effusion with positive cytology, IVB: parenchymal metastases and metastases to extra-abdominal organs (including inguinal lymph nodes and lymph nodes outside of the abdominal cavity), Increase in PFS and overall survival with cisplatin and paclitaxel treatment, No significant difference in PFS or overall survival between treatment arms, Carboplatin and paclitaxel were not inferior to cisplatin and paclitaxel, Less neuropathy observed with carboplatin and docetaxel treatment than with carboplatin and paclitaxel, Increase in PFS and overall survival with IP treatment compared with IV treatment, Significant improvement in PFS and overall survival with dose-dense therapy in patients with suboptimally cytoreduced cancer, No difference in patients with optimally cytoreduced cancer, Higher rates of hypertension, nausea and vomiting in the IP cisplatin group than in the other study arms, NACT followed by surgical cytoreduction was not inferior to surgical cytoreduction followed by adjuvant chemotherapy, Increase in PFS with the addition of bevacizumab, No difference in PFS in intent-to-treat patients between dose-dense and 21-day dosing, Increase in PFS in patients receiving dose-dense treatment versus those receiving dosing every 21 days who were not given bevacizumab, Among patients who received bevacizumab, weekly paclitaxel did not significantly prolong PFS compared with paclitaxel administered every 3 weeks, Improved PFS with the addition of pazopanib, No difference in overall survival between groups, Improvement in PFS, but more gastrointestinal toxicities with nintedanib, Increase in PFS and overall survival with the addition of paclitaxel, Significant improvement in PFS with niraparib maintenance therapy compared with placebo, in women with germline, Significant increase in PFS with the addition of trabectedin, Significant increase in PFS with olaparib maintenance therapy, Increase in PFS with olaparib maintenance therapy, Increase in PFS when cediranib is added to olaparib compared with olaparib alone in patients with high-grade serous carcinoma, Increase in PFS and response rate with the addition of bevacizumab, Paclitaxel plus bevacizumab was the best combination increased response rate, PFS and overall survival, {"type":"clinical-trial","attrs":{"text":"NCT00866697","term_id":"NCT00866697"}}, {"type":"clinical-trial","attrs":{"text":"NCT01493505","term_id":"NCT01493505"}}, {"type":"clinical-trial","attrs":{"text":"NCT00113607","term_id":"NCT00113607"}}, {"type":"clinical-trial","attrs":{"text":"NCT00753545","term_id":"NCT00753545"}}, {"type":"clinical-trial","attrs":{"text":"NCT01081951","term_id":"NCT01081951"}}, {"type":"clinical-trial","attrs":{"text":"NCT01116648","term_id":"NCT01116648"}}. Defining the best surgical approach and determining the appropriateness of surgery before the administration of chemotherapy versus NACT are crucial. Palliative care. Amplification of the 19q12 locus, which includes CCNE1 (encoding cyclin E1, which is a cell cycle regulator), was associated with primary platinum-resistant and refractory ovarian cancers67. Other emerging therapies targeting tumours carrying mutant TP53 include COTI-2, which is thought to induce a wild-type-like conformational change in mutant p53 and is currently in clinical trials212. The annual risk of ovarian cancer in individuals of specific age groups with germline BRCA mutations and intact ovaries has been estimated to help guide clinicians and patients about appropriate timing of the risk-reducing bilateral salpingo-oophorectomy130. RAP80 is an ubiquitin-interaction motif-containing protein that associates with the breast cancer type 1 susceptibility protein (BRCA1) complex through its interaction with Abraxas (encoded by FAM175A); Abraxas is thought to function as a central adaptor protein and contains domains required for BRCA1 interactions. In one arm of this study, ROCA was the primary screening modality, with transvaginal ultrasonography used as a secondary screening measure based on CA125 levels. On the basis of these findings, a prospective study (DESKTOP-Trial III) was conducted to compare the overall survival of patients with platinum-sensitive recurrent ovarian cancer undergoing cytoreductive surgery followed by platinum-based chemotherapy, with patients receiving chemotherapy alone, the results of which are expected in 2017 (REF. What treatments are available, and what side effects can I expect? Description: ncp Full description Download now of 6 Reward Your Curiosity Everything you want to read. Please enable it to take advantage of the complete set of features! iovsk I, Min L, Felsinger M, Anton M, Bednakov M, Hausnerov J, Jandkov E, Weinberger V. Ceska Gynekol. Improvements in PFS or overall survival in trials might excite clinical scientists but be of less value to patients experiencing treatment-related adverse effects; because of this, many phase III studies have incorporated standardized, validated measures of quality of life (commonly referred to as patient-reported outcome (PRO) end points) into studies181,182. Although the CA125 test alone as a screening marker has been deemed ineffective, the UKCTOCS study evaluated longitudinal measurements of CA125 levels for the screening of ovarian cancer in an algorithm termed risk of ovarian cancer algorithm (ROCA)10. 2016 May-Jun;36(3):918-32. doi: 10.1148/rg.2016150130. Treatment of Rare Epithelial Ovarian Tumors. In patients with HGSC, one study showed that inactivation of genes by disruption of transcriptional units (gene breakage) can inactivate the tumour suppressors RB1, NF1, RAD51B and PTEN, which probably contributes to increasing chemotherapy and platinum resistance67. Establishing uniform criteria for the definition of the site of origin of HGSCs, based on specific pathology findings, is being called for by consensus statements193. Ovarian cancer including fallopian tube cancer and primary peritoneal cancer, Intraperitoneal cisplatin and paclitaxel in ovarian cancer, Dose-dense paclitaxel once a week in combination with carboplatin every 3 weeks for advanced ovarian cancer: a phase 3, open-label, randomised controlled trial. In patients with indicative symptoms, diagnostic work-up includes physical examination of the patient, which consists of pelvic examination and rectovaginal examination, in addition to radiographic imaging (for example, trans vaginal ultrasonography, abdominal ultrasonography, CT (FIG. Additional recurrent molecular alterations identified in HGSC include defective Notch, phosphoinositide 3-kinase (PI3K), RASMEK and forkhead box protein M1 (FOXM1) signalling pathways, as well as a high level of somatic copy number alterations in the genes encoding proteins in these pathways65. Before Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, Massachusetts 02215, USA. Any device. MSH2 and MSH6 form a heterodimeric complex, which initially identifies mismatched bases and initiates DNA repair. Mao YN, Zeng LX, Li YH, Liu YZ, Wu JY, Li L, Wang Q. Zhonghua Fu Chan Ke Za Zhi. For these individuals, strategies to reduce the risk of ovarian cancer have been implemented through risk-reducing surgery, such as bilateral salpingo-oophorectomy (removal of the ovaries and the fallopian tubes). Primary chemotherapy versus primary surgery for newly diagnosed advanced ovarian cancer (CHORUS): an open-label, randomised, controlled, non-inferiority trial, Predictors of optimal cytoreduction in patients with newly diagnosed advanced-stage epithelial ovarian cancer: time to incorporate laparoscopic assessment into the standard of care, Neoadjuvant chemotherapy cannot be regarded as adequate routine therapy strategy of advanced ovarian cancer, Neoadjuvant chemotherapy in ovarian cancer revisited, Maintenance chemotherapy in the management of epithelial ovarian cancer, Maintenance chemotherapy for ovarian cancer, Phase III randomized trial of 12 versus 3 months of maintenance paclitaxel in patients with advanced ovarian cancer after complete response to platinum and paclitaxel-based chemotherapy: a Southwest Oncology Group and Gynecologic Oncology Group Trial, Incorporation of pazopanib in maintenance therapy of ovarian cancer, Rustin GJ, Marples M, Nelstrop AE, Mahmoudi M & Meyer T, Use of CA-125 to define progression of ovarian cancer in patients with persistently elevated levels, Posttreatment surveillance and diagnosis of recurrence in women with gynecologic malignancies: Society of Gynecologic Oncologists recommendations, Early versus delayed treatment of relapsed ovarian cancer (MRC OV05/EORTC 55955): a randomised trial, Ovarian cancer: relevant therapy, not timing, is paramount, Surgical cytoreduction for recurrent epithelial ovarian cancer, {"type":"clinical-trial","attrs":{"text":"NCT00565851","term_id":"NCT00565851"}}, Surgery in recurrent ovarian cancer: the Arbeitsgemeinschaft Gynaekologische Onkologie (AGO) DESKTOP OVAR trial, {"type":"clinical-trial","attrs":{"text":"NCT01166737","term_id":"NCT01166737"}}. Cigarette smoking was associated with a significantly lower risk of clear-cell carcinoma but an increased risk of mucinous carcinoma40. Combining PARP inhibitors with chemotherapy has already proved challenging owing to overlapping myelosuppression associated with both therapies. Standard treatments for newly diagnosed cancer consist of cytoreductive surgery and platinum-based chemotherapy. Recurrent ovarian cancer is generally incurable, but rare exceptions to this exist, such as patients with isolated metastatic cancer in whom the disease can be fully resected after secondary cytoreductive surgery or treatment with localized radiotherapy. Histologically and clinically, low-grade endometrioid carcinoma and low-grade serous carcinoma (LGSC) are different compared with their high-grade counterparts; HGSC is similar to high-grade endometrioid carcinoma13. Palliative care is provided by a team of doctors, nurses and other specially trained professionals. In time you'll find ways to cope with your feelings, but in the meantime, you might find it helpful to: Start by making an appointment with your family doctor or gynecologist if you have any signs or symptoms that worry you. Both the location of the BRCA mutation within the gene and the type of mutation might also influence the risk of developing ovarian cancer; the risk of developing breast cancer or ovarian cancer, as well as the median age at diagnosis, can vary according to the mutation type, the nucleotide position and the functional consequence of the mutation in patients with germline BRCA1 or BRCA2 mutations29. Advances in new therapeutics for recurrent ovarian cancer treatment include angiogenesis inhibitors, poly(ADP-ribose) polymerase (PARP) inhibitors (which block the repair of DNA damage) and immunotherapy agents. Carboplatin and gemcitabine are approved for use in the United States. a | The double-stranded DNA break and homologous repair process begins with recognition and sensing of double-strand breaks (DSBs) by the meiotic recombination 11 homologue 1 (MRE11)RAD50Nijmegen breakage syndrome protein 1 (NBS1) (MRN) complex, which acts as an activation site for the serine-protein kinase ATM. Cancel anytime. BMC Womens Health. Screening strategies in women with an average risk of developing ovarian cancer have primarily focused on the biomarker CA125 (also known as mucin 16) and the use of transvaginal ultrasonography. Thorough monitoring using validated instruments in clinical trials is needed to compile a database of the trajectory and severity of issues, such as adverse effects of treatment as well as emotional distress, permitting better evaluation of the benefits and harms of therapies, but also to establish the case for more research to develop therapies to reduce the adverse effects. In addition, some groups have argued that the overall survival and PFS outcomes used in the aforementioned randomized trials of NACT versus upfront surgical cytoreduction145,146 are inferior to other trials and that inferior complete resection rates were observed in the primary surgery control group, particularly in the CHORUS study146,149. National Comprehensive Cancer Network. If NACT is to be administered, a biopsy is needed to confirm pathology consistent with an ovarian, tubal or peritoneal primary cancer, before chemotherapy can be commenced. Abbreviations; Appendix 3 . Response rates using platinum doublets in patients with platinum-sensitive recurrent cancer are ~50%138,165167, although the length of the PFI decreases with subsequent platinum use168. For example, in one study (GOG 182), patients with stage III or stage IV ovarian cancer with optimal cytoreduction, R1 had a worse prognosis than patients with no evidence of residual macroscopic disease (R0) following platinum-based chemotherapy. Accessed May 5, 2021. Moreover, obesity is associated with an increased risk of endometrioid and mucinous carcinomas, but not HGSCs53. The changing view of high-grade serous ovarian cancer, Whole-genome characterization of chemoresistant ovarian cancer. Two trials have demonstrated comparable outcomes for first-line surgery with adjuvant chemotherapy compared with NACT followed by surgery and postoperative chemotherapy, with less morbidity and mortality but similar outcomes in PFS and overall survival in the group that received NACT145,146.
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