This Viewpoint evaluates the Agency for Healthcare Research and Quality report on prehospital blood transfusion and fluid interventions for hemorrhagic shock and argues that its claims of scientific equipoise stem from methodologic challenges instead of clinical equivalence of blood transfusion and crystalloid therapy.
This quality improvement study assesses if the 2018 Surgical Collaborative of Wisconsin initiative to reduce unnecessary margin re-excisions in women undergoing breast-conserving surgery had an enduring impact on postsurgery margin re-excisions.
Importance:Early liver metastasis (early-LiM) after pancreatectomy represents an aggressive biological phenotype of pancreatic ductal adenocarcinoma (PDAC) and is associated with markedly poor survival. Reliable preoperative biomarkers to identify occult hepatic micrometastasis remain lacking. Objective:To develop and externally validate a circulating exosomal microRNA (exo-miRNA)-based machine learning model for preoperative detection of occult early-LiM in PDAC. Design, Setting, and Participants:This multicenter retrospective case-control study included 3 phases: genome-wide discovery using exo-miRNA sequencing (discovery cohort), model development (training cohort), and independent external validation (2 validation cohorts). The study took place at 4 medical centers in China, Japan, and South Korea. A total of 372 patients were enrolled between 2011 and 2024. Data were analyzed from July 2024 to November 2025. Exposures:Circulating plasma-derived exosomal miRNA expression profiles. Main Outcomes and Measures:The primary outcome was early-LiM, defined as liver recurrence within 6 months after curative-intent resection. Model performance was evaluated using the area under the receiver operating characteristic curve (AUC) and survival outcomes were assessed using Kaplan-Meier analysis. Results:Among 372 patients with PDAC (median [IQR] age, 67 [59-73] years; 229 [61.6%] male and 143 [38.4%] female; median follow-up among survivors, 969 days),early-LiM was associated with significantly worse overall survival compared with other recurrence patterns (median OS, 9.1 months vs 26.6-31.8 months; log-rank P < .001). A 7-exo-miRNA extreme gradient boosting model demonstrated discrimination in the training cohort (AUC, 0.899; 95% CI, 0.822-0.976) and maintained performance in external testing cohorts (AUC, 0.876; 95% CI, 0.846-0.951 and AUC, 0.862; 95% CI, 0.744-0.981). The exo-miRNA panel score remained an independent identifier of early-LiM in multivariable analysis (odds ratio, 26.49; 95% CI, 18.45-55.28; P < .001) and stratified overall survival (log-rank P < .001). Decision curve analysis suggested improved net clinical benefit compared with conventional clinicopathologic variables. Conclusion and Relevance:In this multicenter study, a circulating exo-miRNA-based machine learning model enabled preoperative detection of occult early liver metastasis risk in PDAC. These findings support the potential of exosomal biomarkers to inform biology-guided treatment sequencing and warrant prospective validation.
Importance:Surgeon workload is substantial, but data characterizing perceived burden are scarce, limiting workforce planning, surgeon well-being, and patient safety. Objective:To characterize surgeon workload and factors associated with perceived burden. Design, Setting, and Participants:This was a national, anonymous, cross-sectional survey distributed to US surgeon members of the American College of Surgeons (ACS) between September and November 2024 through the ACS listserv. The study included clinically active US surgeon associates and/or fellows on the ACS email distribution list. Exposures:Cumulative workload across clinical and nonclinical domains during scheduled and unscheduled work hours. Main Outcomes and Measures:Scheduled and unscheduled workload, and perceived burden (not enough, just right, or too much). Multivariable ordinal logistic regression and conditional inference classification tree analyses were used. Results:Of 24 937 surgeons who opened the survey, 5329 responded (21.2%). Most respondents were male (2140 [65.6%]) or female (1002 [30.7%]), with more than half (1741 [52.4%]) in practice for 20 or more years. The largest specialties were critical care, trauma, and/or acute care surgery (571 [17.2%]) and general surgery (509 [15.3%]). Median (IQR) scheduled workload was 68.1 (68.1-94.8) hours per week; respondents also worked outside scheduled hours a median (IQR) of 5.0 (2-7) days per week. Overall, of the participants reporting perceived work burden, 712 (58.3%) reported workload as too much and 447 (36.6%) as just right. Perceived burden was independently associated with cumulative workload, years in practice (6-10 years: odds ratio [OR], 1.85; 95% CI, 1.12-3.07; 20-29 years: OR, 1.96; 95% CI, 1.22-3.14; P < .001), female gender (OR, 1.8; 95% CI, 1.33-2.45; P < .001), and select subspecialties such as pediatric surgery (OR, 5.19; 95% CI, 1.95-13.80) and urology (OR, 3.85; 95% CI, 1.43-10.40). Conditional inference tree analysis identified years in practice as the root node, or primary predictor, of perceived burden, followed by workload thresholds (66.0 and 46.2 hours/week) and, respectively, subspecialty and gender among surgeons with 29 years or less and greater than 30 years in practice. Conclusions and Relevance:Results suggest that surgical workload was high, heterogeneous, and predominantly reported as excessive. Time (in years) spent in practice was the strongest predictor of perceived burden, followed by workload, subspecialty, and gender. These findings provide potential empirical benchmarks for targeted workforce planning and surgeon well-being efforts.
Importance Clinicians, people living with dementia (PLWD), and their caregivers face clinical, ethical, and psychosocial challenges when making surgical decisions. Objective To explore clinician experiences with surgical decision-making when a patient has dementia. Design, Setting, and Participants This qualitative study uses case studies compiled from interviews, surveys, and resource review across 12 sites and 178 clinicians. Interviews were conducted between November 2021 and May 2023, while analysis of interview data and associated survey data continued until December 2024. Exposure One interview. Main Outcomes and Measures The primary outcome was themes describing clinician experiences with surgical decision-making when a patient has dementia. Results Among 178 participants (64 surgeons, 100 other clinicians, and 14 hospital leaders), mean (SD) age was 47 (10.9) years, and 92 participants (51.7%) were female. Three main themes were identified. The first theme found that challenges with clinician identification of dementia and assessment of capacity in the surgical setting were barriers to optimal surgical decision-making. Furthermore, inconsistent documentation of cognitive impairment in electronic health records (EHR) and/or lack of EHR interoperability across health systems made it difficult to rely on medical records to identify dementia in a patient’s history. Theme 2 identified that caregivers and nonsurgical clinicians were key contributors to surgical decision-making, but misaligned expectations, caregiver burden, and limited preparation complicated the process. Given the lack of EHR documentation for PLWD, clinicians needed to rely on caregivers to provide a sufficient picture of patients’ cognitive and physical functioning, as well as their goals and values that were relevant to the surgical decision. The third theme found that clinician appraisal of the relevance of dementia to surgical outcomes variably shaped the surgical decision-making process with PLWD and their caregivers. Clinicians commonly perceived that dementia negatively impacts surgical outcomes and recovery among PLWD, yet participants rarely referenced evidence, such as published data or care guidelines, supporting these views. Conclusions and Relevance Results of this qualitative study suggest that clinicians face challenges to surgical decision-making for PLWD, including limited documentation or resources to support identification of dementia, variable caregiver involvement, and constrained access to dementia care specialists who can support the decision-making process. Addressing these challenges may include improving communication pathways with longitudinal clinicians, EHR documentation for older adults, routine and meaningful inclusion of caregivers, and access to nonsurgical clinicians who can support surgical decision-making.
Importance Many patients are diagnosed with atypical lesions or lobular carcinoma in situ (LCIS); however, evidence- and consensus-based guidelines for the management of many of these lesions are limited. Observations The American Society of Breast Surgeons, in collaboration with the Society of Breast Imaging and College of American Pathology, assembled a steering group to create guidelines for the management of atypical lesions and LCIS, inclusive of flat epithelial atypia (FEA), atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), classic LCIS (C-LCIS), and the variant LCIS forms pleomorphic LCIS (P-LCIS) and florid LCIS (F-LCIS). The natural history of ADH, ALH, and C-LCIS suggests that these lesions are associated with an elevated future breast cancer risk; therefore, patients diagnosed with these lesions should be recommended to undergo comprehensive risk assessment and counseling about breast cancer risk-reducing strategies. The magnitude of future breast cancer risk associated with P-LCIS and F-LCIS remains uncertain, yet if these lesions are determined to be hormone receptor positive, risk-reducing medications should be considered. There is no evidence that FEA is associated with an elevated future breast cancer risk. A second pathology review confirmation is recommended for ADH, should be considered for FEA, and is not necessary for ALH or LCIS. Currently available evidence supports the need to diagnostically excise most ADH, P-LCIS, and F-LCIS cases identified on core biopsy, although some ADH cases fulfilling strict criteria and multidisciplinary consensus can be observed. P-LCIS and F-LCIS require a negative margin, but ADH does not. ALH and C-LCIS can be safely observed if the core biopsy diagnosis is concordant with imaging features (ie, radiographic-pathologic concordance is established). Provided radiologic-pathologic concordance is confirmed, diagnostic excision is generally not indicated after a diagnosis of FEA alone. Conclusions and Relevance These guidelines provide evidence-informed, consensus-based recommendations for the management of atypical lesions of the breast, including ADH, ALH, FEA, C-LCIS, P-LCIS, and F-LCIS. Practicing clinicians who treat patients with atypical breast lesions or LCIS should consider integrating these guidelines into clinical management.
Importance Modulating perioperative inflammation could be associated with fewer postoperative complications and better outcomes in major digestive surgery. The clinical benefit of corticosteroids with this purpose remains controversial. Objective To assess whether preoperative high-dose corticosteroids improve postoperative outcomes after surgery for digestive cancer. Design, Setting, and Participants This double-blind, placebo-controlled, superiority randomized clinical trial included patients undergoing elective surgery with curative intent for digestive cancer. This was a multicenter trial with the participation of 23 French hospitals working as a reference for digestive surgical oncology. Among patients referred for major digestive surgery to the participating centers, those undergoing surgery for digestive cancer with a curative intent between 2019 and 2023 were randomized. Patients undergoing only hepatic surgery without digestive anastomosis were excluded. Interventions Patients included were randomized to receive either 20 mg/kg of intravenous methylprednisolone at the time of anesthesia or a placebo with an identical aspect. Main Outcomes and Measures The primary end point was the onset of major postoperative complications within 30 days after surgery. Secondary end points were postoperative infections, intra-abdominal infections, wound infections, unsatisfactory wound healing within 30 days after surgery, and the length of hospital stay after surgery. Results Among 2461 patients referred for major digestive surgery, 1210 patients (mean [SD] age, 65.9 [11.3] years; 762 male [63%]) undergoing surgery for digestive cancer were randomized. Among the 1188 patients with follow-up at postoperative day 30 (594 per arm), major postoperative complications did not significantly differ between the 2 groups (139 of 594 [23%] receiving methylprednisolone vs 119 of 594 [20%] receiving placebo; P = .16). Secondary outcomes did not differ either between the group receiving methylprednisolone and the group receiving placebo (postoperative infections: 182 of 594 [31%] vs 177 of 594 [30%]; P = .75; intra-abdominal infections: 142 of 594 [24%] vs 126 of 594 [21%]; P = .27; unsatisfactory wound healing: 87 of 594 [15%] vs 69 of 594 [12%]; P = .13; mean [SD] length of hospital stay: 13.21 [8.59] days vs 12.97 [8.1] days; P = .93). Conclusions and Relevance A preoperative pulse dose of corticosteroids had no benefit on postoperative outcomes in elective digestive cancer surgery and should not be recommended in routine practice. Trial Registration ClinicalTrials.gov Identifier: NCT03875690
Importance:As cancer care becomes increasingly complex, patients may experience prolonged delays between diagnosis and definitive surgical management. While consolidation and expansion of health systems, along with centralization of care, may further amplify these delays, a comprehensive assessment of contemporary waiting times within cancer surgery care pathways in the US is lacking. Objective:To evaluate national trends and predictors of delays from diagnosis to initiation of first-course therapy among patients ultimately undergoing cancer surgery. Design, Setting, and Participants:This retrospective cohort study included patients with nonmetastatic, clinical stage I through III breast, colon, lung, pancreatic, gastric, or esophageal cancer in the National Cancer Database from January 2012 to December 2023 who underwent definitive surgical resection. Waiting time from diagnosis to first-course therapy, defined as up-front surgery or neoadjuvant therapy preceding surgery, was assessed. Data were analyzed from August 2025 to June 2026. Main Outcomes and Measures:The primary outcome was the waiting time from diagnosis to first-course therapy. Secondary outcomes included factors associated with prolonged (≥30 days) or extreme (≥60 days) delays. Results:A total of 2 731 059 patients were identified. Mean (SD) patient age was 63.5 (12.8) years, and 2 325 110 patients (85%) were female. From 2012 to 2023, median (IQR) time from diagnosis to first-course therapy increased across all malignancies (breast: 34 days [22-50] in 2012-2015 to 45 days [32-64] in 2022-2023; colon: 20 days [7-34] to 31 days [15-49]; lung: 41 days [27-60] to 53 days [35-77]; pancreas: 23 days [14-35] to 32 days [22-44]; gastric: 35 days [21-51] to 49 days [33-70]; and esophageal: 38 days [27-54] to 48 days [35-66]; P value for trend <.001 for all) and among both patients undergoing up-front surgery and those receiving neoadjuvant therapy prior to surgery. Delays were more pronounced at academic compared with community hospitals and among patients referred for care. Predictors of longer waiting time included Medicaid insurance (5 of 6 cancers), lowest-quartile income (6 of 6 cancers), Black race (5 of 6 cancers), increased travel distance (4 of 6 cancers), care in the West region (6 of 6 cancers), and treatment at academic institutions (6 of 6 cancers). Receipt of robotic operations was linked with longer waiting times for nonbreast malignancies (5 of 5 cancers). Conclusions and Relevance:Among patients undergoing cancer surgery, waiting times to initiation of first-course therapy have steadily increased since 2012, particularly at high-volume academic centers and among patients referred for definitive care. With continued consolidation and expansion of health systems, system-level strategies are urgently needed to monitor and mitigate delays in the delivery of surgical care for cancer.
