{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,30]],"date-time":"2026-10-30T03:54:33Z","timestamp":1793332473213,"version":"4.5.0"},"reference-count":23,"publisher":"Springer Science and Business Media LLC","issue":"3","license":[{"start":{"date-parts":[[2025,12,9]],"date-time":"2025-12-09T00:00:00Z","timestamp":1765238400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2025,12,9]],"date-time":"2025-12-09T00:00:00Z","timestamp":1765238400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/100000892","name":"Prostate Cancer Foundation","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100000892","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Prostate Cancer Prostatic Dis"],"published-print":{"date-parts":[[2026,9]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Purpose<\/jats:title>\n                    <jats:p>Genomic classifiers are endorsed by guidelines and commonly used to inform prognosis in prostate cancer. We aimed to understand the distribution of genomic risk within the validated staging collaboration for cancer of the prostate (STAR-CAP) and propose a system integrating genomic and clinicopathologic risk. We hypothesized that genomic heterogeneity would have implications on risk estimates and may inform treatment decisions.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Materials and methods<\/jats:title>\n                    <jats:p>\n                      Genomic risk was assessed using the Decipher genomic classifier in two separate multi-institutional, prospectively collected population-based registries: (1) Decipher Genomics Resource for Intelligent Discovery (GRID) [\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u200950,891] and (2) Michigan Urological Surgery Improvement Collaborative (MUSIC-Decipher) [\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u20091602]. The primary endpoint was estimated prostate cancer-specific mortality (PCSM), and secondary endpoint was distant metastasis (DM). Marginal risk estimates provided by STAR-CAP were combined with hazard ratios of Decipher to calculate integrated risk estimates.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Median age and PSA was 68 years and 6.2\u2009ng\/mL in GRID, and 66 years and 10.5\u2009ng\/mL in MUSIC. The GRID population had 50.2%, 18.5%, and 31.4% with low-, intermediate-, and high-Decipher risk, compared to 48.0%, 16.2%, and 35.8% in MUSIC. Decipher-based genomic risk varied across STAR-CAP stages in both registries. Estimates of 10-year PCSM (0.1% to 48.8%) and DM (0.3%-72.9%) varied widely after integration of clinical-genomic risk. Use of an integrated Decipher-STAR-CAP system led to significant stage reclassification, including 23.4% upstaging and 45.6% downstaging at least one stage.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>These findings suggest integration of genomic and clinicopathologic risk may lead to more nuanced risk assessment in prostate cancer and may help individualize treatment consideration.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1038\/s41391-025-01062-8","type":"journal-article","created":{"date-parts":[[2025,12,9]],"date-time":"2025-12-09T12:51:18Z","timestamp":1765284678000},"page":"570-577","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Characterizing population-wide genomic risk distribution for development of a novel clinical-genomic risk system for prognostication in patients with clinically localized prostate cancer"],"prefix":"10.1038","volume":"29","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3928-9476","authenticated-orcid":false,"given":"Udit","family":"Singhal","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ralph","family":"Jiang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"James A.","family":"Proudfoot","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elizabeth","family":"Chase","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Krithika","family":"Suresh","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elai","family":"Davicioni","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tudor","family":"Borza","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael J.","family":"Zelefsky","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brian J.","family":"Davis","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brad J.","family":"Stish","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"R. Jeffrey","family":"Karnes","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8104-6419","authenticated-orcid":false,"given":"Stephen J.","family":"Freedland","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3843-7270","authenticated-orcid":false,"given":"Martha K.","family":"Terris","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"William J.","family":"Aronson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4339-6685","authenticated-orcid":false,"given":"Matthew R.","family":"Cooperberg","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3407-9215","authenticated-orcid":false,"given":"Fabio Y.","family":"Moraes","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alejandro","family":"Berlin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4846-6486","authenticated-orcid":false,"given":"Curtiland","family":"Deville","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nicholas G.","family":"Zaorsky","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6617-5522","authenticated-orcid":false,"given":"Soumyajit","family":"Roy","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0812-2614","authenticated-orcid":false,"given":"Angela Y.","family":"Jia","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jonathan E.","family":"Shoag","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"William C.","family":"Jackson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5973-4741","authenticated-orcid":false,"given":"Daniel E.","family":"Spratt","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthew","family":"Schipper","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1140-0603","authenticated-orcid":false,"given":"Todd M.","family":"Morgan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robert T.","family":"Dess","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,12,9]]},"reference":[{"key":"1062_CR1","doi-asserted-by":"publisher","first-page":"1547","DOI":"10.1056\/NEJMoa2214122","volume":"388","author":"FC Hamdy","year":"2023","unstructured":"Hamdy FC, Donovan JL, Lane JA, Metcalfe C, Davis M, Turner EL, et al. Fifteen-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer. N Engl J Med. 2023;388:1547\u201358. https:\/\/doi.org\/10.1056\/NEJMoa2214122.","journal-title":"N Engl J Med"},{"key":"1062_CR2","doi-asserted-by":"publisher","first-page":"2084","DOI":"10.1001\/jama.2024.6695","volume":"331","author":"LF Newcomb","year":"2024","unstructured":"Newcomb LF, Schenk JM, Zheng Y, Liu M, Zhu K, Brooks JD, et al. Long-Term Outcomes in Patients Using Protocol-Directed Active Surveillance for Prostate Cancer. JAMA. 2024;331:2084\u201393. https:\/\/doi.org\/10.1001\/jama.2024.6695.","journal-title":"JAMA"},{"key":"1062_CR3","doi-asserted-by":"publisher","first-page":"2319","DOI":"10.1056\/NEJMoa1807801","volume":"379","author":"A Bill-Axelson","year":"2018","unstructured":"Bill-Axelson A, Holmberg L, Garmo H, Taari K, Busch C, Nordling S, et al. Radical Prostatectomy or Watchful Waiting in Prostate Cancer \u2014 29-Year Follow-up. New Engl J Med. 2018;379:2319\u201329. https:\/\/doi.org\/10.1056\/NEJMoa1807801.","journal-title":"New Engl J Med"},{"key":"1062_CR4","doi-asserted-by":"publisher","first-page":"245","DOI":"10.3322\/caac.21391","volume":"67","author":"MK Buyyounouski","year":"2017","unstructured":"Buyyounouski MK, Choyke PL, McKenney JK, Sartor O, Sandler HM, Amin MB, et al. Prostate cancer \u2013 major changes in the American Joint Committee on Cancer eighth edition cancer staging manual. CA: A Cancer J Clinicians. 2017;67:245\u201353. https:\/\/doi.org\/10.3322\/caac.21391.","journal-title":"CA: A Cancer J Clinicians"},{"key":"1062_CR5","doi-asserted-by":"publisher","first-page":"5039","DOI":"10.1002\/cncr.26169","volume":"117","author":"MR Cooperberg","year":"2011","unstructured":"Cooperberg MR, Hilton JF, Carroll PR. The CAPRA-S score: A straightforward tool for improved prediction of outcomes after radical prostatectomy. Cancer. 2011;117:5039\u201346. https:\/\/doi.org\/10.1002\/cncr.26169.","journal-title":"Cancer"},{"key":"1062_CR6","doi-asserted-by":"publisher","first-page":"969","DOI":"10.1001\/jama.280.11.969","volume":"280","author":"AV D\u2019Amico","year":"1998","unstructured":"D\u2019Amico AV, Whittington R, Malkowicz SB, Schultz D, Blank K, Broderick G, et al. Biochemical Outcome After Radical Prostatectomy, External Beam Radiation Therapy, or Interstitial Radiation Therapy for Clinically Localized Prostate Cancer. JAMA. 1998;280:969\u201374. https:\/\/doi.org\/10.1001\/jama.280.11.969.","journal-title":"JAMA"},{"key":"1062_CR7","doi-asserted-by":"publisher","first-page":"140","DOI":"10.6004\/jnccn.2024.0019","volume":"22","author":"EM Schaeffer","year":"2024","unstructured":"Schaeffer EM, Srinivas S, Adra N, An Y, Bitting R, Chapin B, et al. NCCN Guidelines\u00ae Insights: Prostate Cancer, Version 3.2024: Featured Updates to the NCCN Guidelines. J Natl Compr Cancer Netw. 2024;22:140\u201350. https:\/\/doi.org\/10.6004\/jnccn.2024.0019.","journal-title":"J Natl Compr Cancer Netw"},{"key":"1062_CR8","doi-asserted-by":"publisher","first-page":"1912","DOI":"10.1001\/jamaoncol.2020.4922","volume":"6","author":"RT Dess","year":"2020","unstructured":"Dess RT, Suresh K, Zelefsky MJ, Freedland S, Mahal B, Cooperberg M, et al. Development and Validation of a Clinical Prognostic Stage Group System for Nonmetastatic Prostate Cancer Using Disease-Specific Mortality Results From the International Staging Collaboration for Cancer of the Prostate. JAMA Oncol. 2020;6:1912\u201320. https:\/\/doi.org\/10.1001\/jamaoncol.2020.4922.","journal-title":"JAMA Oncol"},{"key":"1062_CR9","doi-asserted-by":"publisher","first-page":"241","DOI":"10.1016\/j.eururo.2022.12.021","volume":"83","author":"TM Seibert","year":"2023","unstructured":"Seibert TM, Garraway IP, Plym A, Mahal B, Giri V, Jacobs M, et al. Genetic Risk Prediction for Prostate Cancer: Implications for Early Detection and Prevention. Eur Urol. 2023;83:241\u20138. https:\/\/doi.org\/10.1016\/j.eururo.2022.12.021.","journal-title":"Eur Urol"},{"key":"1062_CR10","doi-asserted-by":"publisher","first-page":"444","DOI":"10.1016\/j.eururo.2018.05.014","volume":"74","author":"MR Cooperberg","year":"2018","unstructured":"Cooperberg MR, Erho N, Chan JM, Feng FY, Fishbane N, Zhao SG, et al. The Diverse Genomic Landscape of Clinically Low-risk Prostate Cancer. Eur Urol. 2018;74:444\u201352. https:\/\/doi.org\/10.1016\/j.eururo.2018.05.014.","journal-title":"Eur Urol"},{"key":"1062_CR11","doi-asserted-by":"publisher","first-page":"326","DOI":"10.1016\/j.eururo.2014.05.039","volume":"67","author":"MR Cooperberg","year":"2015","unstructured":"Cooperberg MR, Davicioni E, Crisan A, Jenkins RB, Ghadessi M, Karnes RJ. Combined Value of Validated Clinical and Genomic Risk Stratification Tools for Predicting Prostate Cancer Mortality in a High-risk Prostatectomy Cohort. Eur Urol. 2015;67:326\u201333. https:\/\/doi.org\/10.1016\/j.eururo.2014.05.039.","journal-title":"Eur Urol"},{"key":"1062_CR12","doi-asserted-by":"publisher","first-page":"581","DOI":"10.1200\/JCO.2017.74.2940","volume":"36","author":"DE Spratt","year":"2018","unstructured":"Spratt DE, Zhang J, Santiago-Jim\u00e9nez M, Dess R, Davis JW, Den RB, et al. Development and Validation of a Novel Integrated Clinical-Genomic Risk Group Classification for Localized Prostate Cancer. J Clin Oncol. 2018;36:581\u201390. https:\/\/doi.org\/10.1200\/JCO.2017.74.2940.","journal-title":"J Clin Oncol"},{"key":"1062_CR13","doi-asserted-by":"publisher","first-page":"677","DOI":"10.1038\/s41391-021-00428-y","volume":"25","author":"RA Vince","year":"2022","unstructured":"Vince RA, Jiang R, Qi J, Tosoian JJ, Takele R, Feng FY, et al. Impact of Decipher Biopsy testing on clinical outcomes in localized prostate cancer in a prospective statewide collaborative. Prostate Cancer Prostatic Dis. 2022;25:677\u201383. https:\/\/doi.org\/10.1038\/s41391-021-00428-y.","journal-title":"Prostate Cancer Prostatic Dis"},{"key":"1062_CR14","doi-asserted-by":"publisher","first-page":"646","DOI":"10.1038\/s41391-020-0226-2","volume":"23","author":"JJ Tosoian","year":"2020","unstructured":"Tosoian JJ, Birer SR, Jeffrey Karnes R, Zhang J, Davicioni E, Klein EE, et al. Performance of clinicopathologic models in men with high risk localized prostate cancer: impact of a 22-gene genomic classifier. Prostate Cancer Prostatic Dis. 2020;23:646\u201353. https:\/\/doi.org\/10.1038\/s41391-020-0226-2.","journal-title":"Prostate Cancer Prostatic Dis"},{"key":"1062_CR15","doi-asserted-by":"publisher","first-page":"1991","DOI":"10.1200\/JCO.2016.70.2811","volume":"35","author":"DE Spratt","year":"2017","unstructured":"Spratt DE, Yousefi K, Deheshi S, Ross AE, Den RB, Schaeffer EM, et al. Individual Patient-Level Meta-Analysis of the Performance of the Decipher Genomic Classifier in High-Risk Men After Prostatectomy to Predict Development of Metastatic Disease. JCO. 2017;35:1991\u20138. https:\/\/doi.org\/10.1200\/JCO.2016.70.2811.","journal-title":"JCO"},{"key":"1062_CR16","doi-asserted-by":"publisher","first-page":"521","DOI":"10.1016\/j.ijrobp.2022.12.035","volume":"116","author":"PL Nguyen","year":"2023","unstructured":"Nguyen PL, Huang HC(Rebecca), Spratt DE, Davicioni E, Sandler HM, Shipley WU, et al. Analysis of a Biopsy-Based Genomic Classifier in High-Risk Prostate Cancer: Meta-Analysis of the NRG Oncology\/Radiation Therapy Oncology Group 9202, 9413, and 9902 Phase 3 Randomized Trials. International J Radiat Oncol Biol Phys. 2023;116:521\u20139. https:\/\/doi.org\/10.1016\/j.ijrobp.2022.12.035.","journal-title":"International J Radiat Oncol Biol Phys"},{"key":"1062_CR17","doi-asserted-by":"publisher","first-page":"370","DOI":"10.1016\/j.ijrobp.2023.04.010","volume":"117","author":"DE Spratt","year":"2023","unstructured":"Spratt DE, Liu VYT, Michalski J, Davicioni E, Berlin A, Simko JP, et al. Genomic Classifier Performance in Intermediate-Risk Prostate Cancer: Results From NRG Oncology\/RTOG 0126 Randomized Phase 3 Trial. International J Radiat Oncol Biol Phys. 2023;117:370\u20137. https:\/\/doi.org\/10.1016\/j.ijrobp.2023.04.010.","journal-title":"International J Radiat Oncol Biol Phys"},{"key":"1062_CR18","doi-asserted-by":"publisher","first-page":"374","DOI":"10.1016\/j.eururo.2020.11.021","volume":"79","author":"NK Jairath","year":"2021","unstructured":"Jairath NK, Dal Pra A, Vince R, Dess RT, Jackson WC, McBride SM, et al. A Systematic Review of the Evidence for the Decipher Genomic Classifier in Prostate Cancer. Eur Urol. 2021;79:374\u201383. https:\/\/doi.org\/10.1016\/j.eururo.2020.11.021.","journal-title":"Eur Urol"},{"key":"1062_CR19","doi-asserted-by":"publisher","unstructured":"Salami SS, Hovelson DH, Kaplan JB, Mathieu R, Udager AM, Curci NE, et al. Transcriptomic heterogeneity in multifocal prostate cancer. JCI Insight. 2018;3. https:\/\/doi.org\/10.1172\/jci.insight.123468.","DOI":"10.1172\/jci.insight.123468"},{"key":"1062_CR20","doi-asserted-by":"publisher","first-page":"736","DOI":"10.1038\/ng.3315","volume":"47","author":"PC Boutros","year":"2015","unstructured":"Boutros PC, Fraser M, Harding NJ, de Borja R, Trudel D, Lalonde E, et al. Spatial genomic heterogeneity within localized, multifocal prostate cancer. Nature Genet. 2015;47:736\u201345. https:\/\/doi.org\/10.1038\/ng.3315.","journal-title":"Nature Genet"},{"key":"1062_CR21","doi-asserted-by":"publisher","first-page":"498","DOI":"10.1016\/j.eururo.2018.08.009","volume":"75","author":"M L\u00f8vf","year":"2019","unstructured":"L\u00f8vf M, Zhao S, Axcrona U, Johannessen B, Bakken AC, Carm KT, et al. Multifocal Primary Prostate Cancer Exhibits High Degree of Genomic Heterogeneity. Eur Urol. 2019;75:498\u2013505. https:\/\/doi.org\/10.1016\/j.eururo.2018.08.009.","journal-title":"Eur Urol"},{"key":"1062_CR22","doi-asserted-by":"publisher","first-page":"367","DOI":"10.1038\/ng.3221","volume":"47","author":"CS Cooper","year":"2015","unstructured":"Cooper CS, Eeles R, Wedge DC, Van Loo P, Gundem G, Alexandrov LB, et al. Analysis of the genetic phylogeny of multifocal prostate cancer identifies multiple independent clonal expansions in neoplastic and morphologically normal prostate tissue. Nature Genet. 2015;47:367\u201372. https:\/\/doi.org\/10.1038\/ng.3221.","journal-title":"Nature Genet"},{"key":"1062_CR23","doi-asserted-by":"publisher","unstructured":"Morgan TM, Daignault-Newton S, Spratt DE, Dunn RL, Singhal U, Okoth LA, et al. Impact of Gene Expression Classifier Testing on Adjuvant Treatment Following Radical Prostatectomy: The G-MINOR Prospective Randomized Cluster-crossover Trial. European Urology. Published online, 2024. https:\/\/doi.org\/10.1016\/j.eururo.2024.09.011.","DOI":"10.1016\/j.eururo.2024.09.011"}],"container-title":["Prostate Cancer and Prostatic Diseases"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.nature.com\/articles\/s41391-025-01062-8.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.nature.com\/articles\/s41391-025-01062-8","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.nature.com\/articles\/s41391-025-01062-8.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,13]],"date-time":"2026-08-13T21:44:56Z","timestamp":1786657496000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.nature.com\/articles\/s41391-025-01062-8"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,12,9]]},"references-count":23,"journal-issue":{"issue":"3","published-print":{"date-parts":[[2026,9]]}},"alternative-id":["1062"],"URL":"https:\/\/doi.org\/10.1038\/s41391-025-01062-8","relation":{},"ISSN":["1365-7852","1476-5608"],"issn-type":[{"value":"1365-7852","type":"print"},{"value":"1476-5608","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,12,9]]},"assertion":[{"value":"17 July 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"6 November 2025","order":2,"name":"revised","label":"Revised","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"18 November 2025","order":3,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"9 December 2025","order":4,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"The authors declare no competing interests.","order":1,"name":"Ethics","label":"Competing interests","group":{"name":"EthicsHeading","label":"Ethics"}},{"value":"In lieu of a formal ethics committee, the principles of the Helsinki Declaration were followed. Given the retrospective nature of the analysis, no informed consent for deidentified patient data was required and the study was deemed exempt from the institutional IRB committee.","order":2,"name":"Ethics","label":"Ethics","group":{"name":"EthicsHeading","label":"Ethics"}}]}}