American College of Surgeons

Importance:A unified salivary gland carcinoma (SGC)-specific tumor-node-metastasis (TNM) classification can enhance prognostic accuracy, support clinical decision-making, and improve the quality of patient care. Objective:To derive and validate an SGC-specific pTNM classification with improved prognostic accuracy and optimized stage distribution for version nine of the American Joint Committee on Cancer/Union for International Cancer Control staging protocol. Design, Setting, and Participants:This retrospective prognostic cohort study derived a novel pTNM classification using data from the National Cancer Database (NCDB) of patients with surgically treated major SGC (2012-2017) and validated it in an international major SGC cohort (2008-2021) and a single-institution minor SGC cohort (Memorial Sloan Kettering Cancer Center; 1985-2016). Data were analyzed from June to November 2024. Exposures:Surgery with or without postoperative radiotherapy or chemoradiotherapy. Main Outcomes and Measures:The primary end point was overall survival (OS). Cox proportional hazards multivariable analysis was used to confirm the prognostic importance of pathologically positive lymph node (LN) number and extranodal extension (pENE) and derive an optimal pTNM classification. Results:The NCDB dataset included 8409 patients with SGC: 7659 with M0 disease (5748 with pN0 disease and 1911 with pN+ disease) and 750 with M1 disease. Among the 7659 patients with M0 disease, the median (IQR) age was 60 (48-71) years, and 3861 (50.4%) were male. The median (IQR) follow-up was 88.4 (72.3-108.5) months. The 5-year OS was 87.2% (95% CI, 86.3-88.0) for N0 disease, 68.2% (95% CI, 63.9-72.8) for 1 positive LN without pENE, 60.2% (95% CI, 53.5-67.5) for 2 positive LNs without pENE, 68.4% (95% CI, 58.0-76.6) for 3 positive LNs without pENE, 47.5% (95% CI, 41.6-52.8) for more than 3 positive LNs without pENE, and 41.4% (38.1-44.8) for pENE-positive LNs. Multivariable analysis confirmed the independent prognostication of LN count compared with pN0 disease (1 positive LN: adjusted hazard ratio [aHR], 1.70; 95% CI, 1.44-2.01; 2 positive LNs: aHR, 1.61; 95% CI, 1.31-1.98; 3 positive LNs: aHR, 2.10; 95% CI, 1.65-2.68; 4 positive LNs : aHR, 2.46; 95% CI, 1.87-3.24; more than 4 positive LNs: aHR, 2.07; 95% CI, 2.08-2.91) and pENE-positive LNs compared with pENE-negative LNs (aHR, 1.27; 95% CI, 1.10-1.48). The proposed pN classification were pN1 for 1 to 3 positive LNs and pENE negativity and pN2 for more than 3 positive LNs or pENE positivity. Model fit improved with the proposed pN classification vs the current pN classification (Akaike Information Criterion, 26 442 vs 26 483). Based on the aHR model, the following stage groups were proposed: stage I: T1N0 (1 [reference]); stage II: T2N0 (aHR, 1.34; 95% CI, 1.11-1.61); stage IIIA: T1-2N1 or T3-4N0 (aHR, 2.36; 95% CI, 1.99-2.80); stage IIIB: T1-2N2 or T3-4N1-2 (aHR, 5.15; 95% CI, 4.38-6.06); and stage IV: M1 disease (aHR, 13.61; 95% CI, 11.37-16.29). The C index values were similar (proposed classification: 0.792; current classification: 0.790), while the AIC improved slightly (proposed classification: 26 441; current classification: 26 482). Stage-specific OS differences were evident in both the international major SGC cohort (n = 1015) and Memorial Sloan Kettering Cancer Center minor SGC cohort (n = 444). Conclusions and Relevance:This unified, SGC-specific staging system improved prognostic accuracy and sample size balance and was applicable to both major and minor SGCs.

PURPOSE:Smoking cessation after a cancer diagnosis improves survival, but widespread adoption of evidence-based cessation assistance has not been demonstrated. American College of Surgeons' accredited cancer programs participated in the nationwide Beyond ASK quality improvement (QI) initiative to increase the proportion of currently smoking patients with cancer offered cessation assistance as part of cancer care delivery. METHODS:A national QI project was employed between January 2023 and January 2024 following the Plan-Do-Study-Act methodology, and five longitudinal surveys were administered. Participating programs received educational webinars, an online practice change package that contained information about evidence-based smoking assessment and cessation assistance tools, training opportunities, and electronic health record guidance. Primary outcomes included identification of current smoking among patients with newly diagnosed cancer and rate of providing cessation assistance among currently smoking patients. RESULTS:A total of 324 programs (164 [50.8%] community programs) enrolled in Beyond ASK. Participation rates were high with 300 (92.6%) programs completing all five surveys. Among 446,015 reported patients newly diagnosed with cancer, 52,794 (11.8%) were identified as currently smoking of which 33,638 (63.7%) received cessation assistance. The mean assist rate increased from 48.0% (95% CI, 43.7 to 52.2) at baseline to 67.5% (95% CI, 63.6 to 71.3) at final. Full adoption was reported by 65.4% of programs. Delivery of cessation assistance increased over time for in-office brief counseling (33.9%-65.8%, P = .0002), in-office behavioral counseling (7.1%-18.5%, P = .02), referral to in-house program (14.5%-27.3%, P = .02), referral to community program (12.1%-29.5%, P = .002), and referral to web-based programs (12.2%-33.9%, P = .0002). CONCLUSION:Scaled improvement in smoking cessation assistance across accredited cancer programs is feasible and achievable relatively quickly. Findings provide a framework to guide national adoption for smoking cessation assistance as standard care for all patients with newly diagnosed cancer.

This Viewpoint describes the safety, access, and financial risks of eliminating Medicare’s Inpatient Only list and proposes that the Centers for Medicare & Medicaid Services instead strengthen their review process.

BACKGROUND:Surgeons face distinctive workplace demands, including prolonged work hours, unpredictable emergency duties, and institutional obligations extending beyond individual patient care. These conditions, compounded by productivity pressures, administrative burden, and limited control over clinical resources, have resulted in high rates of burnout and attrition within the surgical workforce. Although several medical specialties have established formal workload and well-being standards, surgery lacks broadly accepted parameters defining sustainable clinical practice. STUDY DESIGN:Developed via consensus-based collaboration, this article proposes a structured framework for the development of specialty-specific workplace standards for surgeons. RESULTS:The recommendations address call coverage, access to the operating room and clinic, inpatient census limits, clinical support, fatigue mitigation, and institutional accountability. CONCLUSIONS:The goal of this framework is to align surgeon well-being with patient safety and system efficiency while promoting career longevity and workforce stability within the surgical profession.

Importance Sampling of at least 3 mediastinal and at least 1 hilar nodal stations during lung cancer resection was adopted by the American College of Surgeons (ACS) Commission on Cancer (CoC) as Operative Standard 5.8 to ensure appropriate staging, guide adjuvant systemic therapy, and potentially improve overall survival. Early assessments suggested difficulty with reaching goal hospital-level compliance rates of at least 80%. Objective The objective of this study was to compare compliance with Standard 5.8 before and after participation in the Lung NODES National Quality Improvement (QI) Collaborative. Design, Setting, and Participants This quality improvement study reports findings from a prospective national QI collaborative led by the ACS CoC, Lung NODES, which enrolled CoC-accredited programs across the US from March 2024 to December 2024. Programs actively participated in guided root cause analyses, educational webinars, peer-to-peer learning, and the development and implementation of strategies to increase compliance. Data were collected on patients aged 18 years or older undergoing curative intent lung resection. Main Outcomes and Measures Adjusted multilevel logistic regression models, with hospital as a random effect, investigated variables associated with compliance with Standard 5.8. Differences in hospital-level compliance, at baseline compared to final data collection, were assessed using Wilcoxon signed rank tests. Results Among 354 participating programs, the number of programs achieving at least 80% compliance with Standard 5.8 increased from 144 (40.7%) at baseline to 238 (67.2%) after participation. Hospital-level median compliance increased from 67.8% (IQR, 42.9%-90.0%) to 90.5% (IQR, 70.0%-100%) (P < .001). All hospital types had an increase in median compliance, with the largest absolute increase, of 37.1%, seen for community programs. On adjusted multilevel analyses, compared to baseline, lung cancer resections performed after participation were associated with increased odds of compliant lymph node assessment (adjusted odds ratio, 2.50; 95% CI, 2.19-2.86). Conclusions and Relevance Participation in the Lung NODES National QI Collaborative was associated with higher compliance with Standard 5.8 irrespective of hospital characteristics. National QI collaboratives may represent an effective large-scale approach to address gaps in the delivery of high-quality cancer care.