INTRODUCTION:Multidisciplinary collaboration is essential to deliver optimal care for complex diseases such as pancreatic ductal adenocarcinoma (PDAC). We sought to determine the association between medical and surgical oncologists' collaboration and long-term outcomes among patients with PDAC. METHODS:We identified all patients with PDAC who underwent pancreatectomy using the SEER-Medicare database between 2015 and 2019. Patients were excluded if a primary treating medical or surgical oncologist was not identified. Collaboration between medical and surgical oncologists was measured as the number of patients shared between specialists over the study period. Primary outcomes of interest include long-term overall survival (OS) and cancer-specific survival (CSS). RESULTS:A total of 2902 PDAC patients were seen by 1577 medical oncologists and underwent pancreatectomy from 736 different surgeons, representing 2295 unique surgeon-medical oncologist pairs. The average age of diagnosis was 72 y (interquartile range: 68, 77), and approximately one-half were female (n = 1,447, 49.9%). Two-thirds of patients (n = 1930, 67%) received care from a unique surgeon-medical oncologist pair (i.e., did not share any other patient). Patients treated by the highest quartile of patient load volume of surgeons shared patients more frequently with medical oncologists than those treated by low-volume surgeons (n = 365, 38% versus n = 354, 19%; P < 0.001). Each doubling of shared patients (i.e., 1 to 2, 2 to 4) was associated with improved OS (hazard ratio [HR] = 0.94, 95% confidence interval [CI]: 0.89-0.99, P = 0.012) and CSS (HR = 0.96, 95% CI: 0.91-1.01, P = 0.110) in the unadjusted analysis. However, after adjustment for patient- and physician/hospital-level confounders, there was no association with OS (HR = 1.01, 95% CI: 0.94-1.08, P = 0.811) or CSS (HR = 1.02, 95% CI: 0.95-1.09, P = 0.570). CONCLUSIONS:Collaboration between medical and surgical oncologists is not associated with long-term survival among patients with PDAC after adjustment for patient, physician, and hospital-level confounders. These data suggest that patient and treatment-related variables largely drive long-term outcomes rather than interprofessional collaboration between specialists.

Backgrounds/Aims: The role of surgery for pancreatic ductal adenocarcinoma (PDAC) with synchronous liver metastases remains controversial. Previous studies assessing the outcomes of combined surgery for primary PDAC and liver metastases have been limited by the inconsistent application of neoadjuvant chemotherapy (NAC). Methods: We identified patients with PDAC and fewer than three liver metastases who received at least six months of NAC and underwent simultaneous pancreas and liver resection between January 2018 and March 2023 at a single institution. Additionally, we queried the National Cancer Database (NCDB) from 2010 to 2019 to identify patients with synchronous metastatic PDAC to the liver who received NAC before simultaneous resection, serving as a comparison group. Results: Ten patients met the inclusion criteria for the institutional case series, with seven ultimately undergoing simultaneous resection. Among 224 patients in the NCDB who underwent simultaneous pancreas and liver resection, 70 patients (31.2%) received NAC. After a median follow-up of 59 months in the institutional cohort, five patients experienced recurrence, resulting in a median disease-free survival of four months (95% confidence interval [CI] 3, not reached). After controlling for confounding factors in the NCDB cohort, the administration of NAC was associated with improved survival (hazard ratio: 0.44, 95% CI 0.29-0.65, p < 0.001) compared to those who underwent upfront surgery. Conclusions: Neoadjuvant therapy followed by simultaneous liver and pancreas resection for metastatic PDAC is safe and feasible, and it may provide a survival benefit in carefully selected patient populations.

BACKGROUND:Minimally-invasive approaches to pancreatic surgery are increasingly utilized. We aimed to evaluate the implementation of robotic pancreatoduodenectomy (RPD) across the United States. METHODS:The National Cancer Database was queried for all patients undergoing pancreatoduodenectomy (PD) for pancreatic cancer in the United States between 2010 and 2020. The primary outcome was utlization of robotic PD. Secondary outcomes included perioperative outcomes following PD. RESULTS:There were 48,781 patients who underwent PD with 78.0 % and 5.2 % performed by an open and robotic approach, respectively. Utilization of RPD increased from 1.1 % to 10.3 % between 2010 and 2020 (p < 0.001). Robotic converted to open PD decreased from 22.2 % to 11.1 % over the study period (p = 0.006). Patients undergoing open or RPD had similar R0 resection, 30-day unplanned readmission, and 90-day mortality. The 10 highest volume centers for RPD performed 41.8 % of all RPD and had lower rates of conversion to open, post-operative length of stay, and a higher number of lymph nodes examined compared with other centers performing RPD (all p < 0.001). CONCLUSION:Robotic PD is increasingly utilized in the United States but still represents a small fraction of patients undergoing PD. Given improved outcomes observed in high-volume centers, deliberate initiatives to expand RPD programs while ensuring continued centralization are important.

Colorectal cancer (CRC) peritoneal metastasis (PM) accounts for 25-35% of stage IV cases. CRC PM carries a median overall survival of 16 months with systemic chemotherapy and an almost 0% 5-year survival rate. The molecular mechanisms driving CRC PM remain poorly defined. CRC heterogeneity is classified into four Consensus Molecular Subtypes (CMS1-4), with CRC PM predominantly exhibiting the CMS4 signature-characterized by increased stromal/mesenchymal enrichment and cellular plasticity-features linked to frequent disease progression and therapeutic resistance. Here, we investigated the molecular mechanisms driving CRC PM and CMS4 signature. TWIST1 was identified to be significantly upregulated in CRC PM. We established TWIST1-SPON2 as a novel transcriptional axis contributing to CRC PM tumorigenesis, through mediating tumor-stroma interactions. We identified SPP1, secreted by the tumor stroma, as an upstream regulator of the TWIST1-SPON2 cascade via AKT activation in tumor cells in vitro and in vivo. This defined SPP1-TWIST1-SPON2 signaling circuit is pivotal in shaping the tumor microenvironment and promoting CRC PM progression. The findings establish the SPP1-TWIST1-SPON2 axis as potential biomarkers and therapeutic targets in CRC PM.

INTRODUCTION:Obstructive sleep apnea (OSA) has been associated with higher incidence of multiple cancers, including pancreatic adenocarcinoma (PDAC) and worse pathologic prognostic features in resected PDAC. However, its impact on clinical outcomes following surgical resection remains unknown. METHODS:Adult patients with PDAC who underwent surgical resection and systemic chemotherapy from 2015 to 2019 were identified using the Surveillance, Epidemiology, and End Results-Medicare database. OSA was identified within the 12 mo preceding PDAC diagnosis. Primary outcomes included overall survival, cancer-specific survival, and 90-d postoperative outcomes following propensity score-matched analysis. RESULTS:A total of 4005 patients were included for analysis, with a mean age of 72.7 years (interquartile range: 68-77). The majority of patients were White (90%, n = 3596), with a balanced sex distribution. OSA prevalence was 10.8% (n = 431). After covariate adjustment, OSA was associated with high odds of 90-d readmission (49% versus 40%; odds ratio = 1.28, 95% confidence interval [CI]: 1.01-1.62, P = 0.038) and postoperative infection, including surgical site infection and intraabdominal abscess (7.7% versus 4.3%; odds ratio 1.85, 95% CI 1.13-3.00; P = 0.013). Overall survival (2.33 versus 2.25 y; hazard ratio = 0.97, 95% CI: 0.83-1.14; P = 0.71) and cancer-specific survival (2.67 versus 2.50 y; hazard ratio = 0.99, 95% CI: 0.83-1.17, P = 0.88) were comparable between groups. CONCLUSIONS:OSA was not independently associated with survival outcomes following PDAC resection. The observed associations with readmission and postoperative infection warrant cautious interpretation given modest effect sizes.

670 Background: Pancreatic ductal adenocarcinoma (PDAC) is an aggressive cancer requiring multi-modality treatment. Radiotherapy (RT) may improve local control and resection rates, particularly in patients with borderline resectable or locally advanced disease. This study aimed to characterize international practice patterns and provider perspectives on RT use in PDAC and to identify factors associated with its utilization. Methods: A 39-item electronic survey was distributed between June 2025 and August 2025 via the Radiosurgery Society, International Hepato-Pancreato-Biliary Association, and Pancreas Club listservs to providers who have treated at least one PDAC patient in the last 5 years. The questionnaire was developed based on expert consensus and pilot tested to address institutional characteristics, multidisciplinary team access, patient volumes, and RT practices. Results: A total of 176 PDAC providers from six continents completed the survey, with the majority practicing in Europe ( n = 74, 43%), North America ( n = 67, 37%), and Asia ( n = 20, 11%). Respondents included mostly surgeons ( n = 143, 80%) and radiation oncologists ( n = 27, 15%), with 80% ( n = 143) practicing in academic centers. Nearly 1 in 5 respondents did not offer or consider any indication for neoadjuvant ( n = 30, 17%) or adjuvant ( n = 45, 31%) RT. The most commonly cited indication for neoadjuvant RT was for locally advanced disease ( n = 89, 51%) or local tumor progression on chemotherapy ( n = 80, 46%), while the use of adjuvant RT was primarily for positive surgical margins ( n = 90, 63%) and positive nodal disease ( n = 41, 28%). Compared to Europe, providers in North America were more likely to offer neoadjuvant RT for patients with resectable (24.4% vs. 56.1%), borderline (25.3% vs. 55.2%), and locally advanced PDAC (30.3% vs. 48.7%) (all p < 0.005). Conclusions: Significant variation exists in the use of RT for PDAC globally. These findings underscore the need for consensus guidelines based on prospective data to guide RT utilization in PDAC patients.

Colorectal cancer mortality is primarily driven by hepatic metastasis, with 50-60% of patients relapsing following liver metastasis resection due to micro-metastases or tumor cell dissemination. Surgery-induced immunologic disturbances contribute to liver recurrence. Exercise modulates immune responses, yet its role in surgical stress-promoted liver metastasis remains unclear. We demonstrate that 4 weeks of preoperative exercise (PEx) limits tumor growth in a murine model of surgical stress-promoted liver metastasis by shifting Kupffer cells toward an anti-tumor phenotype. PEx promotes Kupffer cell cytotoxic cytokines release and enhances CD8+ T cells recruitment and activation via the CXCL9-CXCR3 axis. Elevated CXCL9 levels are observed in murine and patient sera post exercise, with Kupffer cells identified as the primary source. Furthermore, exercise-induced butyrate accumulation in Kupffer cells inhibits histone deacetylase 3 activity, promoting CXCL9 expression. These findings suggest that PEx may serve as a non-invasive strategy to reduce recurrence and provide potential targets for exercise-mimetic therapies.

Introduction As pancreatic surgery becomes concentrated at high-volume centers, there is greater potential for patients with pancreatic cancer (PC) to receive multimodal therapy across multiple institutions. This study evaluated the association of fragmented care (FC) on clinical outcomes among patients with PC. Methods A retrospective analysis was performed of patients diagnosed with nonmetastatic PC receiving upfront chemotherapy who then underwent surgical evaluation at a high-volume center between 2018 and 2022. A 1:1 nearest neighbor propensity score match was used to balance cohorts between patients who received FC and those treated only at the high-volume center. Key outcomes included delay in chemotherapy initiation and time to resection or surgical decision, and overall survival. Results Of 329 eligible patients, over one-third of patients received FC (n = 124). Patients receiving FC were more likely to live further away from the center (median 80 versus 32 miles, P < 0.001), lived in rural areas (50.0% versus 21.3%, P < 0.001), and in the most disadvantaged areas according to the national area deprivation index (46.8% versus 29.3%, P = 0.003). After matching, FC patients had a higher prevalence of delayed chemotherapy initiation >8 wks from diagnosis (17.6% versus 5.6%, P = 0.006), though there was no significant difference between cohorts regarding time to surgical decision or resection (both P > 0.05). There was no significant difference in survival between cohorts (hazard ratio: 0.79, 95% confidence interval: 0.54, 1.05, P = 0.10). Conclusions FC can help alleviate some of the burdens associated with frequent traveling for systemic therapy and was not associated with lower resection rates or long-term survival in pancreatic cancer.

673 Background: Optimal care for pancreatic adenocarcinoma (PDAC) involves multimodal treatment from numerous providers, which requires complex and timely care coordination. Each healthcare interaction contributes to time toxicity, or the time spent pursuing healthcare. This analysis aimed to calculate a comprehensive measurement of time toxicity and assess predictors of prolonged time toxicity for patients with metastatic PDAC. Methods: We conducted a retrospective analysis of metastatic PDAC patients treated at a high-volume center between 2018 and 2022. Patients receiving care at multiple facilities were excluded. Time toxicity was defined as cancer-related healthcare encounter days (inpatient, outpatient, emergency room) divided by overall survival (OS). Time in hospice care was not included. Beta regression was utilized to identify significant predictors of time toxicity, using OS as a scaling factor to account for differences in survival. Tested predictors included demographic, socioeconomic, and medical factors. Average marginal effects were calculated to facilitate the interpretation of the beta regression coefficients. Secondary outcomes included receipt of systemic therapy in the last 30 days of life, transitioning to hospice after hospitalization, and patients expiring while inpatient. Results: A total of 177 patients were identified, with a median age of 66 years, 57.1% male (n=101), and 81.9% White (n=145). Almost all patients received palliative chemotherapy (n=175, 98.9%) a majority received a palliative care consultation (n=107, 60.5%). The median total time toxicity of the entire cohort was 20% (IQR: 15-28%), with median inpatient time toxicity being 7% (IQR: 3-16%) and ambulatory care time toxicity being 10% (IQR: 8%-13%). A total of 69 patients (39.0%) received systemic therapy in the last 30 days of life, 75 (42.4%) transitioned to hospice after a hospitalization, and 21 (14.8%) expired while inpatient. Following multivariate beta regression, age at diagnosis, rural/urban residence, and chemotherapy regimen were significant predictors of overall time toxicity (all p<0.05). A one-year increase in age decreased time toxicity by approximately 0.29%; living in an urban residence increased time toxicity by 2.01% in comparison to a rural residence, and receiving multiple types of chemotherapy regimens was associated with a significant decrease of 8.65% in total time toxicity compared to receiving only a fluorouracil-based regimen. Conclusions: Approximately one in five days of overall survival is spent interacting with the healthcare system for patients with metastatic PDAC. Demographic, socioeconomic, and medical factors all influence overall time toxicity. These data can help inform patients with metastatic PDAC more effectively and promote patient-centered care.

Purpose: Coaching provides an avenue to review individualized feedback and develop strategies to improve performance, yet structured coaching programs in surgical residencies remain limited. Methods: We conducted a survey-based needs assessment of general surgery residents at a tertiary academic center. The survey evaluated satisfaction with feedback, desired coaching focus areas, and preferred coaching program structure. Descriptive statistics were applied to quantitative items, and content analysis was applied to short-answer responses. Results The response rate was 42.9% (n = 27/63), with junior residents representing 44.4% (n = 12) of the entire cohort. Overall, 70.3% (n = 19) were not satisfied with the feedback received on rotations. Senior residents preferred faculty over peer feedback related to technical skills (46.7% vs. 16.7%; p = 0.033), medical knowledge (40% vs. 8.3%; p = 0.023), and clinical decision-making (53.3% vs. 0.0%; p = 0.003). Leadership (mean 2.30; SD = 0.72) was the domain with the least feedback. Junior residents rated coaching as more impactful for clinical skills than senior residents (4.33 vs. 3.33; p = 0.003). Career planning (4.26; SD = 0.71) was the area where coaching was seen as most beneficial. Most respondents (92.6%, n = 25) supported a peer coaching design between junior and senior residents. Content analysis revealed that respondents viewed peer coaching as beneficial for the coaches through reflection and development as a teacher, as well as potentially a method to indirectly reduce burnout. Conclusions There is a large unmet need for coaching within general surgery residency. Implementation of a peer coaching program may address development gaps within the current educational structure of a general surgery residency program.

143 Background: The use of neoadjuvant chemoradiation (NCRT) for upper rectal cancer remains controversial. Our aim was to determine whether NCRT was associated with improved outcomes. Methods: The US Rectal Cancer Consortium was queried for patients who underwent resection of non-metastatic upper rectal cancer (≥12cm from anal verge) from 2007-2017. Primary outcomes were recurrence-free (RFS) and overall survival (OS). Secondary outcomes were postoperative complications. Results: 193 pts met inclusion criteria; 100 (52%) did not receive NCRT and 93 (48%) did. Median age was similar between groups (non-NCRT: 62 yrs; NCRT: 57 yrs; p=0.71). Patients in each group had similar gender and pathological stage (non-NCRT: 22% stage I, 32% stage II, 36% stage III; NCRT: 21% stage I, 23% stage II, 33% stage III; p=0.143). Median follow-up was 31 months (non-NCRT) and 34 months (NCRT). On Kaplan-Meier analysis, NCRT was not associated with improved RFS compared to non-NCRT (3-year RFS 85% vs. 80%; p=0.34) or OS (3-year OS 88% vs. 90%; p=0.49). This finding persisted on multivariable cox regression. R0 resection rate was similar between groups at 99% (non-NCRT) and 97% (NCRT; p=0.27). Anastomotic leak occurred in 11% of both cohorts. Creation of a diverting loop ileostomy (DLI) was nearly 3 times higher in NCRT (82%) versus non-NCRT patients (29%; p<0.001). Conclusions: Among patients with non-metastatic upper rectal cancer, NCRT did not improve survival or recurrence rates, but was associated with a nearly threefold higher DLI rate. Although NCRT is a mainstay of treatment for lower rectal cancer, our results do not support its use in upper rectal cancer. [Table: see text]

Imaging is often an essential component of cancer surveillance following curative-intent surgery but can be distressing for some patients. While this phenomenon has been studied among patients undergoing active cancer treatment and screening, the frequency and severity of “scanxiety” among patients undergoing surveillance after curative-intent cancer surgery is poorly understood. A cross-sectional mixed-methods analysis of patients with a history of resected gastrointestinal (GI) or hepatopancreatobiliary (HPB) cancer undergoing routine cancer surveillance was conducted. After their imaging was completed but before meeting with their provider, patients completed the Impact of Events Scale-revised (IES-r) and the Hospital Anxiety and Depression Scale (HADS) anxiety subscale surveys. IES-r and HADS-anxiety scores ≥ 24 (scale 0–88) and ≥ 11 (scale 0–22), respectively, were considered clinically meaningful. Semi-structured interviews were conducted among a convenience sample of patients, which were subsequently transcribed and then coded using an inductive approach. Among 101 participants, mean age was 62 ± 13.9 years old and 52

Neoadjuvant therapy (NT) is increasingly used for gastrointestinal (GI) and hepatopancreatobiliary (HPB) cancers. Risk factors for surgical attrition during NT are poorly understood. A planned secondary analysis of patient-reported outcomes (PROs) from a prospective cohort study of patients undergoing NT was performed to identify factors associated with surgical attrition. Adult patients with GI/HPB cancer receiving NT were provided a mobile phone application administering QOL assessments every 30 days and measuring mood/symptoms until NT completion. Univariate and multivariate logistic regression were performed to determine the association between demographic, clinical characteristics, and PROs with surgical attrition (no surgery (NS) versus surgery or watchful waiting (SWW)). Mixed-effects regression models evaluated trends of QOL and symptoms between the cohorts. Among 104 enrolled patients, mean age was 60.5 ± 11.5 years, 57 (55

Metastatic uveal melanoma (mUM) has a poor prognosis, with liver metastases typically presenting a therapeutic challenge. Melphalan/Hepatic Delivery System (Melphalan/HDS) is a drug/medical device combination used for liver-directed treatment of unresectable mUM patients. This study assessed efficacy and safety of Melphalan/HDS versus best alternative care (BAC). Eligible patients with unresectable mUM were randomized (1:1) to receive Melphalan/HDS (3 mg/kg ideal body weight) once every 6 to 8 weeks for a maximum of 6 cycles or BAC. Due to slow enrollment and patient reluctance to receive BAC treatment, the study design was amended to a single-arm Melphalan/HDS study, and all efficacy analyses of the randomized study were treated as exploratory. The study enrolled 85 patients. Eligible patients were randomized to receive Melphalan/HDS (n = 43) or BAC (n = 42), and 72 patients received study treatment (Melphalan/HDS [n = 40]; BAC [n = 32]). Exploratory analyses of efficacy endpoints showed numerical differences consistently favoring the Melphalan/HDS arm versus BAC (median overall survival: 18.5 vs. 14.5 months; median progression-free survival: 9.1 vs. 3.3 months; objective response rate: 27.5% vs. 9.4%; and disease control rate: 80.0% vs. 46.9%). Serious adverse events (SAEs) occurred in 51.2% of Melphalan/HDS and in 21.9% of BAC patients. The most common (>5%) SAEs included thrombocytopenia (19.5%), neutropenia (9.8%), leukopenia (9.8%) and febrile neutropenia (7.3%) in Melphalan/HDS patients and cholecystitis, nausea and vomiting (6.3% each) in BAC patients. No treatment-related deaths were observed. Treatment with Melphalan/HDS shows clinically meaningful efficacy and demonstrates a favorable benefit-risk profile in patients with unresectable mUM as compared to BAC.

Unlike advanced cancer populations, for whom early and routine specialty palliative care (PC) referral has demonstrated clear benefits for quality of life and symptom control, evidence supporting PC for patients undergoing curative-intent cancer surgery has been inconclusive. A systematic review of the PubMed, Embase, Cochrane Library, and MEDLINE databases was performed to identify all studies evaluating the role of PC for patients undergoing curative-intent surgery for cancer. Among the 12,886 publications initially retrieved, 14 met all inclusion criteria: two cross-sectional studies comprised of physician surveys, four cohort studies, five qualitative studies, one prospective trial, and two randomized controlled trials (RCTs). In non-randomized studies, PC was associated with increased advanced care planning and symptom control; however, both the PERIOP-PC and SCOPE RCTs found no significant improvement in quality of life with routine perioperative PC among patients undergoing major abdominal cancer surgery. Qualitative studies characterized patient experiences and physician perspectives of PC. This systematic review summarizes the existing literature on the role of PC in surgical oncology, highlighting the unique considerations and unmet needs of surgical patients that differ from those with advanced cancer. While the routine use of perioperative PC for patients undergoing cancer surgery is not supported, future research should focus on identifying high-risk patients who would most benefit from specialty PC and innovative methods of delivering supportive care in surgical oncology.

BACKGROUND: Due to the complexity of pancreatic surgery, patients diagnosed with pancreatic ductal adenocarcinoma (PDAC) may seek out the opinion of more than 1 surgeon. Little is known regarding how second surgical opinions impact the likelihood of pancreatectomy and perioperative outcomes. Our study aimed to determine the impact of obtaining second surgical opinions on pancreatectomy rates and to assess its impact on surgical outcomes. STUDY DESIGN: Patients who were diagnosed with PDAC between 2013 and 2020 were identified using 100% Medicare Inpatient and Outpatient Standard Analytic Files. Data collected included the number of surgeons consulted and geographic region. Receipt of pancreatectomy and perioperative outcomes were compared between patients who received only 1 and more than 1 surgical consultation. RESULTS: Of 116,072 patients diagnosed with PDAC, 10,640 (9.2%) underwent pancreatectomy. A total of 4,913 (4.2%) patients received a second surgical opinion, of whom 1,906 (17.9%) patients underwent pancreatectomy after the second opinion visit. Patients receiving a second surgical opinion were more likely to undergo pancreatectomy (adjusted odds ratio 6.17; 95% CI 5.78 to 6.59). Patients who received a second opinion and underwent surgery had equivalent length of stay and complication rates compared to those who underwent surgery without seeking a second opinion (both p > 0.05). CONCLUSIONS: Among Medicare patients who underwent pancreatectomy for pancreatic cancer, approximately 1 in 7 patients received a second surgical opinion. Further research is needed to determine how patient motivations, referral patterns, disease characteristics, and treatments all interplay to affect clinical outcomes for patients undergoing pancreatectomy for PDAC.

Informed decision-making is an essential component of shared decision-making between patients and their cancer teams that promotes patient comprehension of their disease and available treatment options. The complex nature of multidisciplinary treatment for pancreatic cancer (PC) presents unique challenges for informed decision-making, for which barriers and facilitators are poorly understood. In this qualitative study, semi-structured interviews were conducted with PC patients seeking treatment at a Midwestern, high-volume, academic medical center to examine various aspects of informed decision-making, including patients’ understanding of treatment options, challenges in obtaining information, and how a decision aid may improve decision-making. Purposive sampling was used for recruitment and continued until thematic saturation was achieved. All interviews were audio-recorded, transcribed, and coded by the research team. Qualitative analysis was completed using an integrative approach involving both inductive and deductive methods. Across 20 PC patients interviewed, the median age was 67 years, with 30

BACKGROUND:Neoadjuvant therapy (NT) is increasingly used for patients with pancreatic ductal adenocarcinoma (PDAC). Disease progression, toxicity, and failure to undergo surgical resection are common during NT, yet little research has focused on efforts to optimize care delivery. We sought to define and validate a novel composite outcomes metric that characterizes the successful delivery of NT. STUDY DESIGN:All patients with localized PDAC receiving NT in an intention-to-treat fashion between 2018 and 2023 were retrospectively evaluated. A textbook neoadjuvant experience (TNE) was defined as the absence of mortality, disease progression, or hospital admission during NT as well as the completion of all intended NT and successful surgical resection. RESULTS:Among 306 patients with localized PDAC, the median age was 66 years and 58.5% were men. Overall, only 85 (28%) experienced a TNE which was more common among patients with potentially resectable (45 of 96, 47%) than borderline resectable (33 of 112, 29%) or locally advanced (7 of 98, 7%) disease. Patients with a TNE experienced greater overall survival than those individuals without a TNE (median not reached vs 16.4 months [95% CI 14.9 to 17.9 months], p < 0.001). On multivariable Cox regression analysis, a TNE was the strongest predictor of improved overall survival (hazard ratio 0.33, 95% CI 0.20 to 0.54, p < 0.001). CONCLUSIONS:A TNE is infrequently achieved among patients with PDAC undergoing NT but is significantly associated with improved long-term outcomes. Future research aimed at optimizing outcomes of NT delivery should incorporate this novel composite metric that may more accurately reflect patient and provider expectations of treatment.