Ovarian cancer: Should I have my ovaries removed to prevent ovarian cancer?

You may want to have a say in this decision, or you may simply want to follow your doctor's recommendation. Either way, this information will help you understand what your choices are so that you can talk to your doctor about them.

Ovarian cancer: Should I have my ovaries removed to prevent ovarian cancer?

Get the facts

Your options

  • Have surgery to remove your ovaries and fallopian tubes.
  • Don't have surgery.

This decision aid is for women who are at high risk for ovarian cancer and are thinking of having their ovaries removed to prevent it. If you are wondering whether to have your ovaries removed when you have a hysterectomy, see:

Click here to view a Decision Point. Hysterectomy: Should I also have my ovaries removed?

Key points to remember

  • You can't make this decision until you know how high your risk is for ovarian cancer. Your doctor or a genetic counselor can help you. If your risk isn't high, removing your ovaries is not recommended.
  • Women who have a strong family history of ovarian cancer have a higher chance of getting it themselves. (Family history means having relatives with the disease.)
  • For some women who have inherited a BRCA gene change, doctors recommend removing the ovaries to help prevent cancer.1, 2 Most women do not have this gene change.
  • Your decision will depend on how high your risk is. It also depends on your health, your age, and your personal feelings.
  • Having the ovaries removed greatly lowers a woman's chances of getting ovarian cancer. The fallopian tubes are removed at the same time. This is another place where cancer can start.3
  • It's possible to get cancer even after your ovaries are removed.
  • If you haven't yet started menopause, having your ovaries removed will cause you to start it. It will also take away your ability to get pregnant.
FAQs

How do you know if you are at high risk for ovarian cancer?

Your risk depends on your medical and family history. For example, having one relative with ovarian cancer means you are more likely than average to get it. But if you have more than one relative with this cancer, your chances of getting it are higher. You may want to talk to a genetic counselor. See who is at high risk for ovarian cancer.

To understand how a family history of ovarian cancer can affect your chances of getting it, look at the numbers below. Remember that everyone’s case is different. These numbers may not show what will happen in your case.

  • Out of 100 average women, 1 or 2 will get ovarian cancer.
  • That risk goes up to 4 or 5 out of 100 for women with one family member who has had this cancer. The risk is 7 out of 100 for women with two relatives who have had it. And if at least two first-degree relatives (meaning mother, sister, or daughter) have had it, the risk is 25 to 50 out of 100.4
  • The risk also goes up for women who inherit a BRCA gene change. Out of 100 women who have the BRCA1 gene change, 20 to 60 will get ovarian cancer. Out of 100 women who have the BRCA2 gene change, 10 to 35 will get ovarian cancer.5
    Click here to view a Decision Point.Breast cancer risk: Should I have a BRCA gene test?

See a picture that may help you understand how much having a family history can increase your risk.

If you don't know whether you are at high risk, talk to your doctor. A genetic counselor can also help you.

What are the benefits of having your ovaries removed?

Studies show that if you are at high risk for ovarian cancer, surgery may lower that risk by 85% to 95%. This means that it may lower your risk so that it is the same as or only slightly higher than the average woman's risk. The numbers below may help you understand.

Having your ovaries removed can lower your risk

 

Chances of getting ovarian cancer (without surgery)

Chances of getting ovarian cancer after surgery

Average woman

1 or 2 out of 100

(There is no reason for the average woman to have this surgery.)

Woman with a strong family history

Up to 50 out of 1004

2 to 7 out of 100

Woman with a BRCA gene change

Up to 60 out of 1005

3 to 9 out of 100

What are the risks of having your ovaries removed?

  • Removing your ovaries makes you start menopause if you haven't started it already. Menopause often has symptoms like hot flashes and vaginal dryness. And it raises your risk for heart disease and osteoporosis.
  • When your ovaries are removed, you can no longer get pregnant.
  • Removing the ovaries does not always prevent cancer. Sometimes a woman already has cancer before the surgery but doesn't know it because she has no symptoms. And the cancer cells may already have begun to spread outside the ovaries. In that case, removing the ovaries will not remove all of the cancer cells. Cancer can also start in the belly after the ovaries are removed, but this is rare.
  • One recent study showed that women younger than 45 who have their ovaries removed and who do not take estrogen are more likely than other women to die of heart disease, mental disorders, or diseases of the nervous system.6

What other choices do you have?

Being at higher risk for ovarian cancer does not mean you will definitely get it. This is why some women choose not to have surgery. If you decide not to have surgery, you have two other options:

  • Birth control pills. Studies have found that taking birth control pills for more than 5 years lowers a woman's chances of getting ovarian cancer. The results are not clear on whether this helps women who have BRCA gene changes.
  • Extra checkups and testing. The goal is to find any cancer as early as possible, when the chances of treating it successfully are higher.

There is no proof that having extra screening tests helps women live longer by finding ovarian cancer early. Still, experts say that women who have inherited a BRCA gene change and have not had their ovaries removed should have these tests at least once a year, starting at age 35:2

  • Transvaginal ultrasound. Ultrasound uses sound waves to make pictures of body parts. A small handheld device is passed back and forth over the area in question. In a transvaginal ultrasound, the device fits into a woman's vagina. The test is used to look for tumors in and around the ovaries.
  • CA-125 blood test. CA-125 is a protein in your blood. Having more of it than normal can mean you have cancer. The test is usually used to check how well treatment for ovarian cancer is working or to see if the cancer has returned.

Women who have inherited a BRCA1 gene change (not a BRCA2 gene change) may want to start having these regular tests as early as age 25.2

Why might your doctor recommend that you have your ovaries removed?

Your doctor might recommend this if:

  • You have a very strong family history of ovarian cancer.
  • A gene test shows that you have inherited a BRCA gene change.
  • You are done having children.

Compare your options

Compare

What is usually involved?









What are the benefits?









What are the risks and side effects?









Have surgery to remove your ovaries Have surgery to remove your ovaries
  • You will be asleep during the operation.
  • If the operation is laparoscopic (done with very small cuts), you will likely go home the same day. Otherwise you will stay in the hospital for 2 to 3 days.
  • Surgery greatly lowers your chances of getting ovarian cancer.
  • You will not be able to get pregnant.
  • You will go into menopause right away.
  • You could still get cancer.
  • If you have your ovaries removed before age 45, your risk is higher than average for heart disease, mental disorders, and diseases of the nervous system unless you take estrogen replacement.
Don't have surgery Don't have surgery
  • You consider other options, such as:
  • Women of childbearing age can still have children.
  • You will go into menopause at your normal time.
  • You will continue to have a high risk for ovarian cancer.

Personal stories

Are you interested in what others decided to do? Many people have faced this decision. These personal stories may help you decide.

Personal stories about having the ovaries removed to prevent ovarian cancer

These stories are based on information gathered from health professionals and consumers. They may be helpful as you make important health decisions.

I am from one of those families with lots of cancer—including ovarian cancer—in parents, aunts, and cousins. It was a hard decision to have my ovaries removed, but it was logical for me. I did a lot of research before I made the decision, and now I just feel safer.

Sandra, age 35

I had my ovaries removed last year because I have a very strong family history of breast and ovarian cancer. I wish I had thought more ahead of time about what can happen when your ovaries are gone. I went into menopause at age 40 and have had a pretty miserable time of it. I seem to have all the worst symptoms of menopause: hot flashes, mood changes, night sweats, and loss of sex drive.

Keiko, age 40

I have a couple of relatives with breast or ovarian cancer, but I'm not going to have my ovaries removed. Surgery seems like too drastic a step. I would rather take my chances and hope that cancer is not in the cards for me. I know some people couldn't live with the "threat" of cancer hanging over them, but I'm okay with it.

Dee, age 28

I have had genetic testing and am BRCA-positive, so my risk for ovarian cancer is very high. I had my ovaries removed because I want to do everything I can possibly do to keep from getting the cancer that runs in my family.

Amaia, age 31

My grandmother died of ovarian cancer, and I have a cousin who was just diagnosed with breast cancer. I thought that meant that I was definitely going to get one or both cancers. But I talked to my doctor and found out it's not a definite thing. I don't want to have my ovaries removed, but I am going to have regular checkups and testing. And I have started to take birth control pills too.

Salma, age 27

If you need more information, see the topic Ovarian Cancer.

What matters most to you?

Your personal feelings are just as important as the medical facts. Think about what matters most to you in this decision, and show how you feel about the following statements.

Reasons to have your ovaries removed

Reasons not to have your ovaries removed

I want to do everything I can to keep from getting ovarian cancer.

The thought of surgery scares me more than the thought of getting cancer.

More important
Equally important
More important

The idea of early menopause doesn't bother me.

I don't want to go into menopause any earlier than I have to.

More important
Equally important
More important

I am done having children.

I still want to have children.

More important
Equally important
More important

My other important reasons:

My other important reasons:

More important
Equally important
More important

Where are you leaning now?

Now that you've thought about the facts and your feelings, you may have a general idea of where you stand on this decision. Show which way you are leaning right now.

Having my ovaries removed

NOT having my ovaries removed

Leaning toward
Undecided
Leaning toward

What else do you need to make your decision?

Check the facts

1.

A decision about whether to have my ovaries removed depends a lot on how strong my family history of ovarian cancer is.

  • True That’s right. You can't begin to make this decision until you find out all you can about how strong your family history is. Your doctor will help you figure this out.
  • False No, that's not correct. In fact, finding out all you can about your family history is the first thing you need to do. This information will tell you how high your chances are of getting ovarian cancer.
  • I'm not sure It may help to go back read “Key points to remember.” Finding out all you can about your family history is very important.
2.

If I have a strong family history of ovarian cancer, having my ovaries removed will not lower my chances of getting the disease.

  • True No, that's not right. In fact, the opposite is true. Studies show that this surgery may lower your risk of ovarian cancer so that you have the same risk as the average woman, or only slightly higher.
  • False You are right. Studies show that this surgery may lower your risk of ovarian cancer so that you have the same risk as the average woman, or only slightly higher.
  • I'm not sure It may help to go back and read "What are the benefits of having your ovaries removed?" This surgery greatly lowers your chances of getting ovarian cancer.
3.

If I haven't started menopause yet, having my ovaries removed will send me into menopause. This means I could start having menopause symptoms and I won't be able to get pregnant.

  • True You're right. Without ovaries, you can't get pregnant. And taking out your ovaries will send you into menopause if you haven't already started it.
  • False Sorry, that's wrong. After your ovaries are removed, you won't be able to get pregnant. And you will go into menopause if you haven't already started it.
  • I'm not sure It may help to go back and read “What are the risks of having your ovaries removed?” Removing the ovaries will send you into menopause if you haven't already started it.

Decide what's next

1.

Do you understand the options available to you?

2.

Are you clear about which benefits and side effects matter most to you?

3.

Do you have enough support and advice from others to make a choice?

Certainty

1.

How sure do you feel right now about your decision?

Not sure at all
Somewhat sure
Very sure
3.

Use the following space to list questions, concerns, and next steps.

Your summary

Here's a record of your answers. You can use it to talk with your doctor or loved ones about your decision.

Your decision  

Next steps

Which way you're leaning

How sure you are

Your comments

Your knowledge of the facts  

Key concepts that you understood

Key concepts that may need review

Getting ready to act  

Patient choices

Credits and references

Credits
Author Cynthia Tank
Editor Katy E. Magee, MA
Associate Editor Michele Cronen
Primary Medical Reviewer Joy Melnikow, MD, MPH - Family Medicine
Specialist Medical Reviewer Ross Berkowitz, MD - Obstetrics and Gynecology

References
Citations
  1. National Comprehensive Cancer Network and American Cancer Society (2008). Genetic/Familial High-Risk Assessment: Breast and Ovarian, version 1. Available online: http://www.nccn.org/professionals/physician_gls/PDF/genetics_screening.pdf.
  2. National Cancer Institute (2007). Genetics of Breast and Ovarian Cancer (PDQ)—Health Professional Version. Available online: http://www.cancer.gov/cancertopics/pdq/genetics/breast-and-ovarian/healthprofessional.
  3. American Cancer Society (2006). Overview: Ovarian Cancer: Can Ovarian Cancer Be Prevented? Available online: http://www.cancer.org/docroot/CRI/content/CRI_2_2_2X_Can_ovarian_cancer_be_prevented.asp?sitearea=.
  4. Ozols RF, et al. (2005). Epithelial ovarian cancer. In WJ Hoskins et al., eds., Principles and Practice of Gynecologic Oncology, 4th ed., chap. 25, pp. 895–987. Philadelphia: Lippincott Williams and Wilkins.
  5. Cannistra SA, et al. (2008). Ovarian cancer, fallopian tube carcinoma, and peritoneal carcinoma. In VT DeVita Jr et al., eds., DeVita, Hellman and Rosenberg’s Cancer: Principles and Practice of Oncology, 8th ed., vol. 2, pp. 1568–1594. Philadelphia: Lippincott Williams and Wilkins.
  6. Rocca WA, et al. (2006). Survival patterns after oophorectomy in premenopausal women: a population-based cohort study. Lancet Oncology, 7(10): 821–828.

Ovarian cancer: Should I have my ovaries removed to prevent ovarian cancer?

You can use it to talk with your doctor or loved ones about your decision.
  1. Get the facts
  2. Compare your options
  3. What matters most to you?
  4. Where are you leaning now?
  5. What else do you need to make your decision?

1. Get the facts

Your options

  • Have surgery to remove your ovaries and fallopian tubes.
  • Don't have surgery.

This decision aid is for women who are at high risk for ovarian cancer and are thinking of having their ovaries removed to prevent it. If you are wondering whether to have your ovaries removed when you have a hysterectomy, see:

Click here to view a Decision Point. Hysterectomy: Should I also have my ovaries removed?

Key points to remember

  • You can't make this decision until you know how high your risk is for ovarian cancer. Your doctor or a genetic counselor can help you. If your risk isn't high, removing your ovaries is not recommended.
  • Women who have a strong family history of ovarian cancer have a higher chance of getting it themselves. (Family history means having relatives with the disease.)
  • For some women who have inherited a BRCA gene change, doctors recommend removing the ovaries to help prevent cancer.1, 2 Most women do not have this gene change.
  • Your decision will depend on how high your risk is. It also depends on your health, your age, and your personal feelings.
  • Having the ovaries removed greatly lowers a woman's chances of getting ovarian cancer. The fallopian tubes are removed at the same time. This is another place where cancer can start.3
  • It's possible to get cancer even after your ovaries are removed.
  • If you haven't yet started menopause, having your ovaries removed will cause you to start it. It will also take away your ability to get pregnant.
FAQs

How do you know if you are at high risk for ovarian cancer?

Your risk depends on your medical and family history. For example, having one relative with ovarian cancer means you are more likely than average to get it. But if you have more than one relative with this cancer, your chances of getting it are higher. You may want to talk to a genetic counselor. See who is at high risk for ovarian cancer.

To understand how a family history of ovarian cancer can affect your chances of getting it, look at the numbers below. Remember that everyone’s case is different. These numbers may not show what will happen in your case.

  • Out of 100 average women, 1 or 2 will get ovarian cancer.
  • That risk goes up to 4 or 5 out of 100 for women with one family member who has had this cancer. The risk is 7 out of 100 for women with two relatives who have had it. And if at least two first-degree relatives (meaning mother, sister, or daughter) have had it, the risk is 25 to 50 out of 100.4
  • The risk also goes up for women who inherit a BRCA gene change. Out of 100 women who have the BRCA1 gene change, 20 to 60 will get ovarian cancer. Out of 100 women who have the BRCA2 gene change, 10 to 35 will get ovarian cancer.5
    Click here to view a Decision Point.Breast cancer risk: Should I have a BRCA gene test?

See a picture that may help you understand how much having a family history can increase your risk.

If you don't know whether you are at high risk, talk to your doctor. A genetic counselor can also help you.

What are the benefits of having your ovaries removed?

Studies show that if you are at high risk for ovarian cancer, surgery may lower that risk by 85% to 95%. This means that it may lower your risk so that it is the same as or only slightly higher than the average woman's risk. The numbers below may help you understand.

Having your ovaries removed can lower your risk

 

Chances of getting ovarian cancer (without surgery)

Chances of getting ovarian cancer after surgery

Average woman

1 or 2 out of 100

(There is no reason for the average woman to have this surgery.)

Woman with a strong family history

Up to 50 out of 1004

2 to 7 out of 100

Woman with a BRCA gene change

Up to 60 out of 1005

3 to 9 out of 100

What are the risks of having your ovaries removed?

  • Removing your ovaries makes you start menopause if you haven't started it already. Menopause often has symptoms like hot flashes and vaginal dryness. And it raises your risk for heart disease and osteoporosis.
  • When your ovaries are removed, you can no longer get pregnant.
  • Removing the ovaries does not always prevent cancer. Sometimes a woman already has cancer before the surgery but doesn't know it because she has no symptoms. And the cancer cells may already have begun to spread outside the ovaries. In that case, removing the ovaries will not remove all of the cancer cells. Cancer can also start in the belly after the ovaries are removed, but this is rare.
  • One recent study showed that women younger than 45 who have their ovaries removed and who do not take estrogen are more likely than other women to die of heart disease, mental disorders, or diseases of the nervous system.6

What other choices do you have?

Being at higher risk for ovarian cancer does not mean you will definitely get it. This is why some women choose not to have surgery. If you decide not to have surgery, you have two other options:

  • Birth control pills. Studies have found that taking birth control pills for more than 5 years lowers a woman's chances of getting ovarian cancer. The results are not clear on whether this helps women who have BRCA gene changes.
  • Extra checkups and testing. The goal is to find any cancer as early as possible, when the chances of treating it successfully are higher.

There is no proof that having extra screening tests helps women live longer by finding ovarian cancer early. Still, experts say that women who have inherited a BRCA gene change and have not had their ovaries removed should have these tests at least once a year, starting at age 35:2

  • Transvaginal ultrasound. Ultrasound uses sound waves to make pictures of body parts. A small handheld device is passed back and forth over the area in question. In a transvaginal ultrasound, the device fits into a woman's vagina. The test is used to look for tumors in and around the ovaries.
  • CA-125 blood test. CA-125 is a protein in your blood. Having more of it than normal can mean you have cancer. The test is usually used to check how well treatment for ovarian cancer is working or to see if the cancer has returned.

Women who have inherited a BRCA1 gene change (not a BRCA2 gene change) may want to start having these regular tests as early as age 25.2

Why might your doctor recommend that you have your ovaries removed?

Your doctor might recommend this if:

  • You have a very strong family history of ovarian cancer.
  • A gene test shows that you have inherited a BRCA gene change.
  • You are done having children.

2. Compare your options

  Have surgery to remove your ovaries Don't have surgery
What is usually involved?
  • You will be asleep during the operation.
  • If the operation is laparoscopic (done with very small cuts), you will likely go home the same day. Otherwise you will stay in the hospital for 2 to 3 days.
  • You consider other options, such as:
What are the benefits?
  • Surgery greatly lowers your chances of getting ovarian cancer.
  • Women of childbearing age can still have children.
  • You will go into menopause at your normal time.
What are the risks and side effects?
  • You will not be able to get pregnant.
  • You will go into menopause right away.
  • You could still get cancer.
  • If you have your ovaries removed before age 45, your risk is higher than average for heart disease, mental disorders, and diseases of the nervous system unless you take estrogen replacement.
  • You will continue to have a high risk for ovarian cancer.

Personal stories

Are you interested in what others decided to do? Many people have faced this decision. These personal stories may help you decide.

If you need more information, see the topic Ovarian Cancer.

Personal stories about having the ovaries removed to prevent ovarian cancer

These stories are based on information gathered from health professionals and consumers. They may be helpful as you make important health decisions.

"I am from one of those families with lots of cancer—including ovarian cancer—in parents, aunts, and cousins. It was a hard decision to have my ovaries removed, but it was logical for me. I did a lot of research before I made the decision, and now I just feel safer."

— Sandra, age 35

"I had my ovaries removed last year because I have a very strong family history of breast and ovarian cancer. I wish I had thought more ahead of time about what can happen when your ovaries are gone. I went into menopause at age 40 and have had a pretty miserable time of it. I seem to have all the worst symptoms of menopause: hot flashes, mood changes, night sweats, and loss of sex drive."

— Keiko, age 40

"I have a couple of relatives with breast or ovarian cancer, but I'm not going to have my ovaries removed. Surgery seems like too drastic a step. I would rather take my chances and hope that cancer is not in the cards for me. I know some people couldn't live with the "threat" of cancer hanging over them, but I'm okay with it."

— Dee, age 28

"I have had genetic testing and am BRCA-positive, so my risk for ovarian cancer is very high. I had my ovaries removed because I want to do everything I can possibly do to keep from getting the cancer that runs in my family."

— Amaia, age 31

"My grandmother died of ovarian cancer, and I have a cousin who was just diagnosed with breast cancer. I thought that meant that I was definitely going to get one or both cancers. But I talked to my doctor and found out it's not a definite thing. I don't want to have my ovaries removed, but I am going to have regular checkups and testing. And I have started to take birth control pills too."

— Salma, age 27

3. What matters most to you?

Your personal feelings are just as important as the medical facts. Think about what matters most to you in this decision, and show how you feel about the following statements.

Reasons to have your ovaries removed

Reasons not to have your ovaries removed

I want to do everything I can to keep from getting ovarian cancer.

The thought of surgery scares me more than the thought of getting cancer.

More important
Equally important
More important

The idea of early menopause doesn't bother me.

I don't want to go into menopause any earlier than I have to.

More important
Equally important
More important

I am done having children.

I still want to have children.

More important
Equally important
More important

My other important reasons:

My other important reasons:

More important
Equally important
More important

4. Where are you leaning now?

Now that you've thought about the facts and your feelings, you may have a general idea of where you stand on this decision. Show which way you are leaning right now.

Having my ovaries removed

NOT having my ovaries removed

Leaning toward
Undecided
Leaning toward

5. What else do you need to make your decision?

Check the facts

1. A decision about whether to have my ovaries removed depends a lot on how strong my family history of ovarian cancer is.

  • True
  • False
  • I'm not sure
That’s right. You can't begin to make this decision until you find out all you can about how strong your family history is. Your doctor will help you figure this out.

2. If I have a strong family history of ovarian cancer, having my ovaries removed will not lower my chances of getting the disease.

  • True
  • False
  • I'm not sure
You are right. Studies show that this surgery may lower your risk of ovarian cancer so that you have the same risk as the average woman, or only slightly higher.

3. If I haven't started menopause yet, having my ovaries removed will send me into menopause. This means I could start having menopause symptoms and I won't be able to get pregnant.

  • True
  • False
  • I'm not sure
You're right. Without ovaries, you can't get pregnant. And taking out your ovaries will send you into menopause if you haven't already started it.

Decide what's next

1. Do you understand the options available to you?

2. Are you clear about which benefits and side effects matter most to you?

3. Do you have enough support and advice from others to make a choice?

Certainty

1. How sure do you feel right now about your decision?

Not sure at all
Somewhat sure
Very sure

2. Check what you need to do before you make this decision.

  • I'm ready to take action.
  • I want to discuss the options with others.
  • I want to learn more about my options.

3. Use the following space to list questions, concerns, and next steps.

Credits
Author Cynthia Tank
Editor Katy E. Magee, MA
Associate Editor Michele Cronen
Primary Medical Reviewer Joy Melnikow, MD, MPH - Family Medicine
Specialist Medical Reviewer Ross Berkowitz, MD - Obstetrics and Gynecology

References
Citations
  1. National Comprehensive Cancer Network and American Cancer Society (2008). Genetic/Familial High-Risk Assessment: Breast and Ovarian, version 1. Available online: http://www.nccn.org/professionals/physician_gls/PDF/genetics_screening.pdf.
  2. National Cancer Institute (2007). Genetics of Breast and Ovarian Cancer (PDQ)—Health Professional Version. Available online: http://www.cancer.gov/cancertopics/pdq/genetics/breast-and-ovarian/healthprofessional.
  3. American Cancer Society (2006). Overview: Ovarian Cancer: Can Ovarian Cancer Be Prevented? Available online: http://www.cancer.org/docroot/CRI/content/CRI_2_2_2X_Can_ovarian_cancer_be_prevented.asp?sitearea=.
  4. Ozols RF, et al. (2005). Epithelial ovarian cancer. In WJ Hoskins et al., eds., Principles and Practice of Gynecologic Oncology, 4th ed., chap. 25, pp. 895–987. Philadelphia: Lippincott Williams and Wilkins.
  5. Cannistra SA, et al. (2008). Ovarian cancer, fallopian tube carcinoma, and peritoneal carcinoma. In VT DeVita Jr et al., eds., DeVita, Hellman and Rosenberg’s Cancer: Principles and Practice of Oncology, 8th ed., vol. 2, pp. 1568–1594. Philadelphia: Lippincott Williams and Wilkins.
  6. Rocca WA, et al. (2006). Survival patterns after oophorectomy in premenopausal women: a population-based cohort study. Lancet Oncology, 7(10): 821–828.

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Last Updated: June 15, 2009

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