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Due to the increasing cost of cancer treatment, the demand for value-based healthcare is increasing. Although several value frameworks have been developed recently in the field of oncology, the nononcological benefits of minimally invasive surgery have not been addressed. This study aimed to estimate how patients value nononcological benefits in minimally invasive cancer surgery.The value that patients placed on various benefits of cancer surgery was termed throughout the study as patient value (PV). To quantize PVs for the benefits of cancer surgery, a one-tiered analytic hierarchy process model was constructed. The model includes 6 well-known surgical outcomes, including nononcological benefits. The study participants included 303 patients with cancer and family caregivers who participated in a questionnaire survey.The PVs for "decreased operation time," "reduced length of hospital stay," and "improved cosmetic results" were 0.050, 0.044, and 0.045, respectively, whereas the PVs for "increased survival," "prevention of disease recurrence," and "avoidance of complications" were 0.366, 0.292, and 0.203, respectively. The PV placed on nononcological benefits from minimally invasive surgery was one-tenth (10.2%) of the total value.Nononcological benefits arising from minimally invasive surgery were relatively small but nonnegligible. This value should be considered in the process of developing a value framework for cancer surgery and shared decision making.

Through the wide adaptation of next-generation sequencing (NGS) technology within clinical practice, molecular profiling of the tumor has been the principal component of personalized treatment. In our study, we have generated a large collection of cancer genomes on East Asian epithelial ovarian carcinoma (EOC) patients and demonstrate the feasibility and utility of NGS platforms to explore the dynamic interrelations of major cancer driver alterations and their impacts on clinical prognosis and management. A total of 652 EOC patients have undergone clinical NGS panels to determine the prevalence of germline and somatic mutations. Notably, TP53 was the most frequently altered event (73%), followed by both BRCA1 and BRCA2 (22% each) and MYC (19%) through pan-EOC analysis. When analyzed based on individual histopathological levels, TP53 mutation was highly dominant in high-grade serous and mucinous histology, whereas mutations in PIK3CA and ARID1A were mostly observed in clear cell carcinoma, and KRAS, BRAF, and CDKN2A mutations were enriched in endometrioid, low-grade serous, and mucinous tumors, respectively. The network-based probabilistic model showed significant co-occurrences of TP53 with BRCA1 and ALK with BRCA2, NOTCH1, and ROS1, whereas mutual exclusivity of TP53 with KRAS and PIK3CA was evident. Furthermore, we utilized machine-learning algorithms to identify molecular correlates that conferred increased sensitivity to platinum and olaparib treatments including somatic mutations in BRCA1, ATM, and MYC. Conversely, patients with ALK mutation were considerably resistant to both treatment modalities. Collectively, our results demonstrate the clinical feasibility of prospective genetic sequencing to facilitate personalized treatment opportunities for patients with EOC.

An "ovarian cancer cluster region" (OCCR) has been reported in both BRCA1 and BRCA2. However, the clinical significance of the OCCR of BRCA1/2 has not yet been investigated.The medical records of 991 patients with epithelial ovarian, primary peritoneal, and fallopian tube cancer who underwent genetic testing for BRCA1 and/or BRCA2 from January 1, 2006, to August 31, 2019, were retrospectively reviewed. Sanger and next-generation sequencing analyses were used to test the BRCA1 and BRCA2 mutation status. Progression-free survival (PFS) and overall survival (OS) were compared according to the mutation location (OCCR vs. non-OCCR region). Survival outcomes were determined using Kaplan-Meier survival analysis.A total of 162 patients had BRCA1 pathogenic variants (PVs), and 76 had BRCA2 PVs. Patients with BRCA1 PV that in the OCCR region showed shorter PFS than those with BRCA1 PV outside the OCCR (22.6 months vs. 27.6 months, P = 0.038). In the platinum-sensitive subgroup of BRCA1, patients with BRCA1 PV in the OCCR region showed shorter PFS than those in the non-OCCR group (P = 0.0197). On the other hand, BRCA2 variants did not exhibit any particular trend (32.8 months vs. 27.9 months, P = 0.468). However, no significant differences were detected in OS between patients with BRCA1/2 PVs, regardless of the location of the variants.Patients with BRCA1 PV in the OCCR had shorter PFS than those outside the OCCR. This tendency was more pronounced in the platinum-sensitive subgroup. To our knowledge, this is the first study of BRCA1/2 mutations based on the OCCR.

Background This study aimed to validate the performance of the Korean Gynecologic Oncologic Group (KGOG)-1024 risk model in predicting the risk of distant failure after chemoradiation in patients with locally advanced cervical cancer (LACC). Methods In a retrospective cohort of 297 patients who received concurrent chemoradiation for advanced cervical cancer, individual risk was calculated using the KGOG-1024 risk model. The cohort was categorized into three risk groups (low-, intermediate-, and high-risk groups) according to the calculated risk. The means of the calculated and observed risks were compared within each group. Results The study population was classified into low-, intermediate-, and high-risk groups according to the KGOG-1024 risk model (27.2%, 49.3%, and 23.5% of patients, respectively). The calculated and observed 5-year cumulative incidence rates were 12.4% vs. 16.4% in the low-risk group, 23.2% vs. 25.9% in the intermediate-risk group, and 50.7% vs. 36.3% in the high-risk group. Overall, the calculated and observed risk was 26.7% vs. 25.6%. Conclusions The KGOG-1024 risk assessment model accurately predicted distant recurrence after chemoradiation in patients with LACC, especially in the low- and intermediate-risk groups. The model may be helpful for identifying patients for future trials assessing the possible benefit of adjuvant systemic treatment after chemoradiation.

PurposeThe BRCA1 or BRCA2 gene is transmitted in an autosomal dominant fashion, and genetic testing of first-degree relatives of patients with family-specific mutation (FSM) is recommended. This study examined factors affecting the uptake of FSM testing among relatives of patients with peritoneal, ovarian, or fallopian tube (POFT) cancer with confirmed BRCA1 or BRCA2 germline mutation.Materials and MethodsData from medical charts of 392 eligible patients and their relatives who had undergone outpatient genetic counseling/testing were retrospectively reviewed. Clinical factors were compared between family members who had and had not undergone genetic counseling/testing.ResultsThe uptake of FSM testing was 30.5% (129/423) among first-degree living relatives and 53.5% (69/129) within the overall family unit. The average time from genetic testing of the proband to the first FSM test within a family was 168 days (range, 23 to 681 days). Having a living father (33.8% vs. 13.3%, p=0.007) and daughter (79.4% vs. 60.3%, p=0.019) increased the uptake of FSM testing. FSM testing was more likely among female than among male relatives of cancer patients (40.9% vs. 17.6%, p < 0.001).ConclusionApproximately one-third of first-degree relatives of patients with a POFT cancer with BRCA1 or BRCA2 mutation underwent FSM testing. Having a living father or daughter was a factor affecting the uptake of FSM testing, which was higher among female than among male relatives of the proband. This discrepancy might be due to a misconception that the BRCA gene is associated with women rather than with men.

Background We examined the actionable genomic alterations in ovarian cancer by analysing the nationwide registry of next-generation sequencing (NGS) data. Methods From March 2017 to December 2018, 16,458 patients with cancer underwent NGS testing under the interim coverage programme for NGS provided by the National Health Insurance of Korea. Among these patients, 779 patients had advanced ovarian cancer. Fifty-eight mutations were reported as pathogenic variants, which included likely pathogenic variants, and 55 theoretically actionable genes were analysed. Results The prevalence of pathogenic mutations in the population was 81.5%, whereas 11.6% of the population had neither a pathogenic mutation nor a variant of unknown significance. Common pathogenic mutations shared by at least 3% of the study population were mutations in TP53 (61.5%), BRCA1 (12.2%), PIK3CA (10.4%), KRAS (10.3%), BRCA2 (9.6%) and PTEN (3.7%). BRCA1/2 pathogenic mutations were found in 14.0% (42 of 300, 95% confidence interval = 10–18%) of the patients with TP53 wild-type tumours, comprising approximately one-quarter (25.9%) of the total observed BRCA1/2 pathogen mutations. At least one pathogenic mutation in a theoretically actionable gene was found in 49.2% of patients. Among patients without a BRCA1/2 pathogenic mutation, mutations were frequently observed in KRAS (12.2%), PIK3CA (10.4%) and PTEN (4.2%). PTCH1 mutations were correlated with ATM, NF1, ERBB2 and MTOR mutations (adjusted p = 0.0054, p = 0.0035, p = 0.0010 and p = 0.0003, respectively). Conclusions Almost half of patients with ovarian cancer could be estimated as theoretical candidates for genomic medicine. Substantial BRCA1/2 pathogenic mutations were observed in patients not harbouring a TP53 mutation.

We conducted a prospective phase II study on whether extended-field irradiation (EFI) confers survival benefits depending on hypoxic markers in locally advanced uterine cervical cancer (LAUCC). RNA-seq was performed to identify immune and hypoxic gene signatures. A total of 288 patients were randomized to either EFI or pelvic radiotherapy (PRT). All patients completed chemoradiotherapy. Overall, significantly higher 5-year para-aortic recurrence free survival (PARFS) rate occurred in EFI (97.6%) than in PRT group (87.2%), with marginal tendency to improve disease-free survival (DFS; 78% vs 70%, P = .066). Subgroup analyses were performed based on carbonic anhydrase 9 (CA9)-only positive, CA9/hypoxia-inducible factor (HIF) double positive and CA9 negative. In the CA9-only positive, EFI successfully increased 5-year PARFS (100% vs 76.4%, P = .010), resulting in significantly improved long-term DFS (85.7% vs 54.7%, P = .023) compared to the PRT, while there was no such benefit of EFI in the CA9/HIFs double positive. RNA-seq analysis identified distinct immunesuphigh/supsubgroup with negative correlation with hypoxia gene signatures (R = -.37, P lt; .01), which showed a higher 5-year DFS than the immunesuplow/sup(P = .032). Hypoxia-related genes were upregulated in the CA9/HIFs double positive compared to CA9 negative (P lt; .05). Only 17.4% of patients in CA9-negative group showed immunesuplow/supsignatures, while 40.0% of patients in the double-positive group exhibited immunesuplow/supsignatures. In conclusion, EFI improved PARFS significantly in all patients, but therapeutic efficacy of EFI in terms of improved DFS was solely observed in CA9-only positive LAUCC, and not in CA9/HIFs double-positive subgroup. RNA-seq analysis suggested that hypoxia-induced immunosuppression may be related to treatment resistance in LAUCC.

Purpose We investigated the effect of ovary preserving surgery in early International Federation of Obstetrics and Gynecology (FIGO) stage endometrial cancer patients. Methods Medical records were retrospectively reviewed for 539 patients who were diagnosed with early stage endometrial cancer between Jan 2006 and Dec 2017. Patients were categorized into ovary preservation and ovary removal groups. Demographics, recurrence free survival (RFS), and five-year overall survival (OS) rate were compared, and the clinical factors affecting survival were evaluated by univariate and multivariate analysis. Results The median follow-up period was 85 months (range, 6–142 months), and the median age was 52.7 years. The mean age was higher in the ovary removal group than in the ovary preservation group (54.4 vs 40.94 years; P P = 0.0264). There was a greater incidence of adjuvant chemotherapy administration in the removal group. There were no statistical differences in other baseline characteristics. When comparing the RFS and OS rates, there were no statistical differences between the preservation and removal groups. (recurrence free rate 98.5% vs 92.7%, p = 0.4360, and 5-year survival rate 98.6% vs 93.0%, p = 0.0892, respectively). Endometrioid histology (p = 0.006) and post-operative adjuvant chemotherapy (p = 0.0062) were related to OS, and adjuvant chemotherapy (p ) and radiotherapy (p = 0.005) were related to RFS. Conclusions Ovary preservation in early stage endometrial cancer is worth considering, as it does not affect survival in early stage endometrial cancer patients.

The importance of managing depressive symptoms is frequently underestimated in the clinic. In this study, the effects of depressive symptoms on health utility value (HUV) in gynecologic cancer patients are evaluated. In addition, the effects were compared with those of performance status and physical symptoms.Patient-reported outcome data from 274 gynecologic cancer patients were prospectively collected. HUV was measured using the 3-level version of the EuroQoL 5-dimension descriptive system (EQ-5D-3L) and the EuroQoL visual analog scale (EQ-VAS). The Patient Health Questionnaire-9 (PHQ-9) was used to measure the severity of depressive symptoms. The impact of depressive symptoms on HUV was analyzed using the generalized linear model.Moderate-severe depressive symptoms were significantly associated with a decrease in HUV in gynecologic cancer patients (p 0.0001 for the EQ-5D-3L and EQ-VAS). Severe fatigue and severe pain were also associated with a decrease in HUV (p = 0.018 and p 0.0001 for the EQ-5D-3L and EQ-VAS; p 0.0001 for the EQ-5D-3L, respectively), and the effect sizes were comparable to that of moderate-severe depressive symptoms. In addition to the patients with moderate-severe depressive symptoms, the patients with mild depressive symptoms also experienced a significant decrease in HUV (p 0.0001 for the EQ-5D-3L and EQ-VAS). The effect size for mild depressive symptoms was comparable to those for mild fatigue or mild pain.Even mild depressive symptoms may significantly compromise HUV in gynecologic cancer patients, and the effect is comparable to that of performance status or physical symptoms. Gynecologic oncologists should put more effort into properly preventing, detecting, and managing depressive symptoms.

ObjectiveThe aim of this study was to compare the clinical outcomes of chemoradiotherapy with or without bevacizumab in patients with newly diagnosed International Federation of Gynecology and Obstetrics (FIGO) stage IVB cervical cancer.Methods41 patients with stage IVB cervical cancer who underwent chemoradiotherapy between August 2015 and December 2017 were retrospectively analyzed. This study included 11 patients who received bevacizumab before or after radiotherapy (group A) and 30 patients who received conventional chemoradiotherapy without bevacizumab (group B). We excluded the following patients: those with dual primary cancers; those whose pathologic diagnosis was neither squamous cell carcinoma nor adenocarcinoma; those who did not undergo radiotherapy; or those from whom follow-up data could not be collected. We analyzed the treatment responses, toxicities, progression-free survival, and overall survival rates.ResultsA total of 41 patients were included in the analysis. The median follow-up was 19 months (range 3–108). The response rates at 3 months after treatment were 90.9% in group A and 83.3% in group B (p=0.54). After completing all treatments, the complete response rates were 81.8% in group A and 47% in group B (p=0.04). Grade ≥3 gastrointestinal toxicities, including bleeding, fistula, perforation, and obstruction, were more frequent in group A (54.5%) than in group B (6.7%) (p=0.003). The 12 month progression-free survival and overall survival rates were similar in both arms (12 month progression-free survival: 45.5% vs 46.7%, respectively, p=0.22; 12 month overall survival: 81.8% vs 72.9%, respectively, p=0.57). Patients with node-only metastasis had better 12 month progression-free survival in group B than in group A (59.1% vs 42.9%, respectively, p=0.04). However, the responses to both treatments did not differ in patients with organ metastasis.ConclusionsBevacizumab for stage IVB cervical cancer is associated with higher complete response rates. However, patients treated with bevacizumab experienced more bowel toxicities. Bevacizumab did not improve progression-free survival among patients with node-only metastasis.

Objective To evaluate clinical factors that can help determine the extent of lymphadenectomy required in endometrial cancer patients and confirm the differences of metastatic lymph node regions based on the risk factors for endometrial cancer patients. Methods The medical records of 468 endometrial cancer patients were retrospectively reviewed between January 2006 and December 2018. Patients were categorized into pelvic lymph node dissection (PLND) and pelvic plus para-aortic lymph nodes dissection (PPALND) groups. Demographics, recurrence-free survival, and 5-year overall survival rates were compared, and the clinical factors affecting survival were evaluated using Cox proportional hazards model. Results The median follow-up period was 55 months (range, 6–142 months). The mean age was higher in the PPALND group than in the PLND group (51.0 vs. 54.5 years; P P = 0.001) than the PLND group. The PPALND group had higher 5-year recurrence-free and overall survival rates than the PLND group. While comparing lymph node (LN) metastasis confirmed pathologically, the group with confirmed metastasis showed a higher number of high-risk group patients than lymph node-negative patients. However, no difference was observed in pelvic LN metastasis, pelvic plus para-aortic LN metastasis, and isolated para-aortic LN metastasis groups. Conclusions When treating patients with endometrial cancer, risk group evaluation is an important factor for determining LN dissection. Our study found no differences in clinical factors of metastatic LN regions.

Objective To determine the maximal tolerated dose (MTD) of modulated electro-hyperthermia (mEHT) treatment and to reveal whether mEHT treatment is feasible and effective as second-line therapy in recurrent and progressive ovarian cancer. Methods Patients were treated with mEHT with dose escalation during the first cycle (two sessions each week for three weeks) to determine the MTD. Additional cycles were carried out with the determined dose. Dose limiting toxicity (DLT) was defined grade ≥ 2: skin burns and inability to endure the hyperthermic state of the study. The Fact-O quality of life scale was used to assess health-related well-being. Results Nineteen patients with recurrent and progressive ovarian cancer were enrolled. In the first cycle of mEHT treatment, no patient developed DLT with applied power up to 110 W, 130 W, and 150 W/day; the 150 W was the maximal applied power. Stable disease was observed in only one patient (12.5%). With median progression of 4.0 months (range, 2-17 months), 18 patients (95%) demonstrated disease progression. With median overall survival of 8.0 months (range, 2-32 months), 18 patients (95%) had died. Physical well-being scores were significantly decreased over the study period, although social, emotional, and functional well-being scores did not significantly change. Conclusions The mEHT treatment was feasible in patients with recurrent or progressive ovarian cancer without any complication and optimal dose of mEHT treatment was up to 150 W for 1 hour/day.

9134 Background: Next-generation sequencing (NGS) has been covered by Korean national health insurance since March 2017 for patients with advanced non-small cell lung cancer (NSCLC). We explored the clinical and socioeconomic impact of NGS compared with that of a single gene test (SGT) alone. Methods: From the nationwide database, we identified patients who 1) are diagnosed with advanced NSCLC classified as a distant disease using Summary Stage between March 1, 2017, and December 31, 2018; 2) had NGS or SGT within 2 months after diagnosis of advanced NSCLC. Patients with squamous cell carcinoma were excluded. We conducted multivariate logistic regression to identify factors (e.g., age, sex, Charlson comorbidity index, insurance type, year of diagnosis, and region and type of hospital with the initial diagnosis) affecting the performance of NGS. Further, we divided the cohort into subgroups based on whether patients received treatment targeting epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) mutations (group A) or not (group B). We conducted 1:5 propensity score matching for each group to minimize the impact of confounding factors. The median overall survival and the adjusted hazard ratio (aHR) for death were estimated using the Kaplan-Meier method and the Cox proportional hazard model, respectively. We calculated the total medical cost, and per patient per year (PPPY) cost adjusted for the survival period. Results: Among 10,247 patients with advanced NSCLC, 768 patients were identified as group A and 1,596 as group B after matching. Old age, low household income, and rural region were factors negatively impacting on having NGS tests. In Group A, we did not find a significant difference in survival outcome between the NGS cohort and the SGT cohort (median survival 31.6 vs. 27.5 months, P =.331; aHR 0.80, P =.204). In contrast, significantly favorable survival was observed for the NGS group in Group B (median survival 14.1 vs. 9.5 months, P =.023; aHR 0.80, P =.009). Although the total medical cost was higher in the NGS group ($39,145) than the SGT group ($36,207) for Group B, the PPPY cost was lower in the NGS group ($57,502 and $63,293, respectively). Conclusions: Socioeconomic factors hampering the implementation of NGS were identified. Lowering the barrier by covering the NGS cost publicly in a specific clinical setting may have survival and cost-benefit in patients with advanced NSCLC.

3602 Background: Next-generation sequencing (NGS) has been covered by Korean national health insurance since March 2017 for patients with advanced colorectal cancer (CRC). We explored the clinical and socioeconomic impact of NGS compared with that of a single gene test (SGT) alone. Methods: From the nationwide database, we identified patients who 1) are diagnosed with advanced CRC classified as a distant disease using Summary Stage between March 1, 2017, and December 31, 2018; 2) had NGS or SGT within 2 months after diagnosis of advanced CRC. Multivariate logistic regression with covariates including age, sex, Charlson comorbidity index, insurance type, year of diagnosis, and region and type of hospital with the initial diagnosis was conducted to identify factors affecting the performance of NGS. We conducted 1:3 propensity score matching to minimize the impact of confounding factors. The median overall survival and the adjusted hazard ratio (aHR) were estimated using the Kaplan-Meier method and the Cox proportional hazard model, respectively. We calculated the total medical cost, and per patient per year (PPPY) cost adjusted for the survival period. Results: Among 5,029 patients with advanced CRC, 655 patients were identified as NGS group and 1,995 as SGT group after matching. Old age, low household income, rural location, and non-tertiary hospital were all characteristics that reduced the likelihood of obtaining an NGS test. The NGS group showed significantly favorable survival compared to the SGT group (median survival 29.2 vs. 24.9 months, P =.031; adjusted hazard ratio [HR] 0.86, P =.034). The total medical cost was lower in the NGS group ($55,445) than the SGT group ($57,989), and the PPPY cost was also lower in the NGS group ($44,879 and $49,734, respectively). Conclusions: We found that some socioeconomic factors such as age, insurance type, region, and hospital type may hamper the implementation of NGS. Also, lowering the barrier of NGS tests by reimbursing NGS in a specific clinical setting may have survival and cost-benefit in patients with advanced CRC.

The authors would like to add the following information to the “Funding” section of their paper published in the International Journal of Environmental Research and Public Health [...]

This study assessed the knowledge and attitude of patients with ovarian cancer (OC) toward OC and next generation sequencing (NGS). The data, including characteristics of patients, their knowledge about OC and their knowledge and attitude of NGS, were collected from June to October 2018. Of the 103 participants, 70.9% (n = 73) had cancer within the second-degree relatives, and 18.4% (n = 19) had BRCA pathogenic mutations. The percentage of right answer for the knowledge about OC and NGS was 64.7% (11/17) and 50% (6/12), respectively. The median number of patients who had positive expectations for the genetic test was 34 (range, 22–44). Based on a first-degree familial history, patients had a different degree of knowledge about OC (11 vs. 8.5, p = 0.026) and NGS (6.5 vs. 5, p = 0.011), but patients with a BRCA pathogenic mutation did not have a different degree of knowledge about OC and NGS panel testing. High-income families had a more positive attitude towards the genetic test than low-income families (p = 0.005). Women with OC do not have enough knowledge about OC (11/17, 64.7%) and NGS (6/12, 50%) but they showed a positive attitude toward the NGS test. These women need OC and NGS educational intervention.

Backgrounds We aimed to evaluate the prognosis in patients with synchronous endometrial and ovarian cancer (SEOC) by comparing the differences between double primary cancer (DPC) and metastatic cancer (MC). Methods The medical records of 47 patients diagnosed synchronously with endometrial and ovarian cancer between January 2006 and December 2018 were retrospectively reviewed. Twenty-eight and 19 patients were diagnosed with DPC and MC, respectively. Demographics, recurrence-free survival (RFS), and 5-year overall survival (OS) were compared. The clinical factors affecting survival were evaluated using univariate and multivariate analyses. Results The demographics were not different between both groups. Endometrioid histology and the International Federation of Gynecology and Obstetrics grade were higher in the MC group than in the DPC group (42.1% vs. 10.7%; P = 0.018, P = 0.002, respectively). The ratio of post-operative adjuvant therapy was not different in both groups. Recurrence occurred in five patients with DPC and seven with MC. The difference in RFS was not significantly different (P = 0.131) but the OS was different between both groups (P = 0.020). Histology and para-aortic lymph node metastasis were associated wtih RFS in univariate analysis, but no difference was found in multivariate analysis. Conclusions Although DPC patients had longer OS, multivariate analysis did not identify any influential factors. Focus should be placed on defining the appropriate adjuvant treatment for high-risk patients, which will improve prognosis, rather than on discriminating between DPC and MC.

Objective To investigate the surgical effort of endometriosis the in the surgical management of early ovarian cancer. Design: A retrospective study Setting National Cancer Center Population All women who underwent cytoreductive surgery between January 2001 and July 2008 Method: Retrospective medical chart review Main Outcomes Measure Requirement of the rectosigmoid colon and pathological outcome of resected the rectosigmoid colon Results: Of the 37 stage I and 15 stage II ovarian cancer women, twelve cases (23.1%) were serous carcinomas and 40 (76.9%) were non-serous carcinomas (9 mucinous, 11 endometrioid, 14 clear cell, 2 transitional cell, and 4 mixed carcinomas). Co-existence of endometriosis was identified in 28.8% of the patients at adnexa, pelvic peritoneum, and rectum. Resection of the rectosigmoid colon to completely resect all suspicious lesions was required in 15 patients (28.8%). Cancer and endometriosis were identified in 6 (40%) and 5 (33%) patients, respectively. Fibrosis and/or adhesion were identified in 4 (27%) patients. Complications related resection of the rectosigmoid colon such as fistula or leakage were not identified with a median follow up of 50 months. Conclusions: Resection of the rectosigmoid colon with adjacent pelvic peritonectomy is required in approximately one-third of the patients with early ovarian cancer for complete removal of all suspicious metastatic lesions in the pelvis. Cancer invasion, endometriosis, and fibrosis and/or adhesion are the causes to perform resection of the rectosigmoid colon in such patients.

PURPOSE Salvage second-line chemotherapy is usually recommended for patients with advanced epithelial ovarian cancer (AEOC) who develop progressive disease (PD) after neoadjuvant chemotherapy (NAC). Herein, we investigated the role of cytoreductive surgery (CRS) for such patients. MATERIALS AND METHODS We retrospectively reviewed the medical records of 36 patients with AEOC who developed PD after receiving NAC at two tertiary academic centers with different treatment strategies between 2001 and 2016. Patients who developed PD after NAC were consistently treated with CRS at one hospital (group A; n=13) and second-line chemotherapy at another (group B; n=23). The clinical characteristics and treatment outcomes were compared between the groups. RESULTS Overall survival (OS) was longer in group A than in group B (19.4 months vs. 7.9 months; p=0.011). High-grade serous histology was associated with longer OS than non-high-grade serous types. In group A, optimal surgery resection (

Since South Korea’s 5-year policy of increasing National Health Insurance (NHI) coverage began in 2017, related pharmaceutical expenditures have increased by 41%. Thus, there is a critical need to examine society’s willingness to pay (WTP) for increased premiums to include new anticancer drugs in NHI coverage. Participants aged 20–65 were invited to a web-based online survey. The acceptable effectiveness threshold for a new anticancer drug to be included in NHI coverage and the WTP for an anticancer drug with modest effectiveness were determined by open-ended questions. A total of 1817 respondents completed the survey. Participants with a family history of cancer or a higher perceived risk of getting cancer had significantly higher WTPs (RR [relative risk] = 1.17 and 1.21, both P = 0.012). Participants who agreed on adding coverage for new anticancer drugs with a life gain of 3 months had a higher WTP (RR = 1.70, P < 0.0001). These associations were greater among the employed and low-income groups. The adjusted mean of acceptable effectiveness for a new anticancer drug was 21.5 months (interquartile range [IQR] = 19.3 to 24.0, median = 21.9). The WTP for a new anticancer drug with a life gain of 3 months was $5.2 (IQR = 4.0 to 6.0, median = 4.6). The unrealistic expectations in Korean society for new anticancer agents may provoke challenging issues of fairness and equity. Although Korean society is willing to accept premium increases, our data suggest that such increases would benefit only a small proportion of advanced cancer patients.

// Jung-Yun Lee 1 , Yun Hwan Kim 2 , Jong-Min Lee 3 , Kidong Kim 4 , Sokbom Kang 5 , Myong Cheol Lim 5 , Beob-Jong Kim 6 , Bang Hyun Lee 7 and Jae Weon Kim 8 1 Department of Obstetrics and Gynecology, Institute of Women’s Life Medical Science, Yonsei University College of Medicine, Seoul, Korea 2 Department of Obstetrics and Gynecology, Ehwa University College of Medicine, Seoul, Korea 3 Department of Obstetrics and Gynecology, Kyung Hee University College of Medicine, Seoul, Korea 4 Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea 5 Gynecologic Oncology Research Branch, Research Institute and Hospital, and Department of Cancer Control and Public Health, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Korea 6 Department of Obstetrics and Gynecology, Korea Cancer Hospital, Korea Cancer Institute of Radiological and Medical Sciences, Seoul, Korea 7 Department of Obstetrics and Gynecology, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea 8 Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea Correspondence to: Jong-Min Lee, email: kgo02@hanmail.net Keywords: endometrial cancer; guideline; low risk; lymphadenectomy; magnetic resonance imaging Received: July 04, 2017 Accepted: October 30, 2017 Published: November 20, 2017 ABSTRACT Preoperative identification of individuals at low risk of lymph node metastasis is key to the proper management of endometrial cancer. This study evaluated the role of preoperative assessment based on magnetic resonance imaging (MRI) and histological analysis in identifying a group having a low risk of lymph node metastasis. Data of 529 patients with endometrial cancer were obtained from a prospective multicenter database, between January 2012 and December 2014. Clinical staging, based on MRI and histological analysis, was compared with final pathology results after the surgical staging procedure. The preoperative low-risk criteria, based on current guidelines from Korea, France, and Canada, and criteria used for fertility-sparing therapies, were applied to our multicenter cohort and the accuracy of each set of criteria for identifying group at low risk of lymph node metastasis was evaluated. When considering grades or MR stages separately, the overall agreement between preoperative and postoperative findings was poor (Kappa 0.45 for grades; 0.41 for stages). However, when combining these two parameters, the low-risk group, as defined by any of the guidelines, had an acceptable rate of lymph node metastasis (below 3%). The French guidelines identified 249 patients (47.1%) as being in the low-risk group. Criteria used to define fertility-sparing therapy candidates identified 48 patients (9.1%) among the study population, only one of whom had extra-uterine disease. This study shows that the current guidelines, using preoperative assessment based on MRI and histological analysis, can identify low-risk patients, who may be candidates for omitting lymphadenectomy.

Recently, a dualistic carcinogenesis model of ovarian cancer has emerged. We aimed to investigate differences in the glycolytic phenotypes of type I and type II ovarian carcinoma on the basis of FDG uptake and in the pathological features according to tumour grade and histology.In total, 386 epithelial ovarian carcinoma patients underwent debulking surgery, and the histopathological results of the patients were retrospectively reviewed from 2003 to 2017. Among these patients, 170 patients had histopathological data that were available due to primary cytoreductive surgery and could be analysed regarding FDG avidity in type I and type II ovarian cancer. The FDG uptake of the tumour (SUVmax), metabolic tumor volume (MTV) and total lesion glycolysis (TLG) were analysed according to the tumour grade, histology and type of ovarian carcinogenesis (type I and II) and prognosis.Among the 386 patients, there was a significant difference in SUVmax among ovarian cancer subtypes. There was a significant increase in SUVmax as the tumour grade increased (8.08 ± 0.63, 10.5 ± 0.40, and 12.7 ± 0.38 for grades I, II and III, respectively, Kruskal-Wallis test, p 0.0001). Among the 90 type I and 80 type II ovarian carcinoma patients, there was a significant difference in SUVmax (type I and II, 9.47 ± 0.54 and 12.97 ± 0.70, respectively, Mann-Whitney test, p = 0.0003). However, no significant change in SUVmax was observed between BRCA-positive and BRCA-negative patients (N = 80, 13.8 ± 5.78 and 12.4 ± 6.30, Student's t-test, p = 0.3075). Among clinicopathologic and metabolic parameters, type of ovarian cancer, MTV and CA125 were significant factors in the prediction of recurrence.The glycolytic phenotype was related to tumour grade and histological subtype, with significant differences between type I and II ovarian cancer. SUVmax of the ovarian cancer would be considered in the differentiation of type I and II ovarian cancer.

BACKGROUND Previously proposed criteria for preoperatively identifying endometrial cancer patients at low risk for lymph node metastasis remain to be verified. For this purpose, a prospective, multicenter observational study was performed. METHODS Eligible patients with histologically confirmed endometrial cancer underwent magnetic resonance imaging (MRI) and serum cancer antigen 125 (CA 125) testing before surgery. The following criteria were used to identify low-risk patients: 1) endometrioid-type cancer, 2) no evidence of deep myometrial invasion on MRI, 3) no enlarged lymph nodes on MRI, 4) no suspicious metastasis out of the uterine corpus, and 5) serum CA 125 levels less than 35 U/mL. Systematic pelvic and/or para-aortic lymphadenectomy was performed for all patients. The primary endpoint was estimation of the negative predictive value (NPV). RESULTS From January 2012 to December 2014, 529 patients from 20 hospitals in 3 Asian countries were consecutively enrolled. According to our criteria, 272 patients (51.4%) were categorized into the low-risk group. Fifty-three of the 529 patients (10.0%) had lymph node metastases; these patients included 8 (2.9%) falsely categorized as low-risk. The sensitivity and specificity of the criteria were 84.9% and 55.5%, respectively. The NPV of 97.1% was higher than the predefined target endpoint of 96%. CONCLUSIONS The low-risk criteria based on preoperative tests were confirmed to be reliable and accurate for identifying patients at low risk for lymph node metastasis. These criteria may facilitate patient counseling and surgical decision making. Cancer 2017;123:263–272. © 2016 American Cancer Society.

Objectives We conducted a systematic review and meta-analysis to summarize current evidence regarding the association of parity and duration of breastfeeding with the risk of epithelial ovarian cancer (EOC). Methods A systematic search of relevant studies published by December 31, 2015 was performed in PubMed and EMBASE. A random-effect model was used to obtain the summary relative risks (RRs) and 95% confidence intervals (CIs). Results Thirty-two studies had parity categories of 1, 2, and ≥3. The summary RRs for EOC were 0.72 (95% CI, 0.65 to 0.79), 0.57 (95% CI, 0.49 to 0.65), and 0.46 (95% CI, 0.41 to 0.52), respectively. Small to moderate heterogeneity was observed for one birth (p13 months. The summary RRs were 0.79 (95% CI, 0.72 to 0.87), 0.72 (95% CI, 0.64 to 0.81), and 0.67 (95% CI, 0.56 to 0.79), respectively. Only small heterogeneity was observed for

Purpose This study was conducted to investigate the incidence and survival outcomes of second primary cancers after the diagnosis of cervical cancer. Materials and methods Data from the Korea Central Cancer Registry between 1993 and 2010 were reviewed and analyzed. Standardized incidence ratios (SIRs) of second primary cancers among women with cervical cancer were analyzed. Kaplan-Meier survival curves were constructed for cervical cancer patients with or without a second primary cancer. Results Among 72,805 women with cervical cancer, 2,678 (3.68%) developed a second primary cancer within a mean follow-up period of 7.34 years. The overall SIR for a second cancer was 1.08 (95% confidence interval, 1.04 to 1.12). The most frequent sites of second primary cancers were the vagina, bone and joints, vulva, anus, bladder, lung and bronchus, corpus uteri, and esophagus. However, the incidence rates of four second primary cancers (breast, rectum, liver, and brain) were decreased. The 5-year and 10-year overall survival rates were 78.3% and 72.7% in all women with cervical cancer, and for women with a second primary cancer, these rates were 83.2% and 65.5% from the onset of cervical cancer and 54.9% and 46.7% from the onset of the second primary cancer, respectively. Conclusion The incidence rates of second primary cancers were increased in women with cervical cancer compared to the general population, with the exception of four decreasing cancers. The 10-year overall survival rates were decreased in cervical cancer patients with a second primary cancer.

This multicenter study aimed to evaluate the performance of CA 125 and risk of ovarian malignancy algorithm (ROMA) in differentiating epithelial ovarian cancer (EOC) from benign adnexal mass. We consecutively enrolled 782 patients referred to tertiary hospitals with adnexal mass requiring surgical treatment. A total 322 of patients with benign adnexal disease and 327 patients with EOC were included in the analysis. Using reference cut-off values in premenopausal women, ROMA had better specificity (0.926 vs. 0.787, P0.001) and accuracy (0.875 vs. 0.777, P0.001) than CA 125 alone and comparable sensitivity (0.707 vs. 0.747, P = 0.549). Using optimum cut-off values in premenopausal women, CA 125 and ROMA had comparable specificity (0.922 vs. 0.947, P0.001) and accuracy (0.871 vs. 0.868, P = 0.879); however, sensitivity for CA 125 was inferior to that of ROMA (0.707 vs. 0.613, P = 0.039). In postmenopausal women, sensitivity, specificity, and accuracy were comparable between CA 125 alone and ROMA using either reference cut-off values or optimum cut-off values.ROMA showed better diagnostic performance in differentiating EOC from benign adnexal tumors among premenopausal women. However, in postmenopausal women, ROMA did not show any benefit over CA 125 alone.