Citations

This guideline has been updated. This ASCO Living Guideline is reviewed on an eight-week cycle. Please see the online dynamic version for the latest updates. Living guidelines are developed for selected topic areas with rapidly evolving evidence that drives frequent change in recommended clinical practice. Living guidelines are updated on a regular schedule by a standing expert panel that systematically reviews the health literature on a continuous basis, as described in the ASCO Guidelines Methodology Manual . ASCO Living Guidelines follow the ASCO Conflict of Interest Policy Implementation for Clinical Practice Guidelines . Living Guidelines and updates are not intended to substitute for independent professional judgment of the treating clinician and do not account for individual variation among patients. See appendix for disclaimers and other important information (Appendix I and Appendix II). Updates are published regularly and can be found on the ASCO Publications website .

Purpose To describe whether subspecialty training, specifically arthroscopic fellowship training, influences intraoperative range‐of‐motion (ROM) gains, postoperative ROM retention, and lysis of adhesions (LOA) complication rates. Methods Between August 1989 and May 2025, all patients who underwent arthroscopic LOA for stiffness after primary total knee arthroplasty (TKA) at a single multisite academic institution with a minimum follow‐up of 3 months were reviewed. Cases were stratified by the surgeon's training: 1 group with arthroscopic fellowship training and another with nonarthroscopic or no fellowship training. Primary outcomes were intraoperative ROM change and postoperative ROM retention compared with intraoperative and pre‐TKA baseline values. Revision and periprosthetic joint infection rates were also collected. Results A total of 94 LOA cases were identified, where 48 (51.1%) were performed by nonarthroscopically trained surgeons. Intraoperative ROM improvements were similar between groups in both knee flexion (35.2° arthroscopic vs 31.1° nonarthroscopic, P = .130) and extension (2.43° vs 3.91°, P = .079). Compared with the intraoperative ROM, procedures performed by arthroscopically trained surgeons showed significantly better long‐term retention of both flexion (loss of 4.85° vs 15.98°, P = .006) and extension (gain of 0.50° vs loss of 1.58°, P = .036) at postoperative follow‐up. When compared with preprimary TKA baseline ROM, flexion at follow‐up was slightly improved in the arthroscopic group but declined significantly in the nonarthroscopic group (gain of 1.66° vs loss of 21.76°, P < .001). Eight revision TKAs (8.51%) occurred after LOA, 6 of which involved nonarthroscopic surgeons, and 1 periprosthetic joint infection case was reported. Conclusions LOA performed by arthroscopic fellowship‐trained surgeons results in significantly better retention of postoperative ROM than nonfellowship‐trained surgeons when used for arthrofibrosis after TKA. Level of Evidence Level III, retrospective comparative study.

Objective Hospitalization, particularly for surgery, represents a period of heightened stress. We evaluated how frailty attenuates the association of rheumatoid arthritis (RA) with negative health outcomes after elective noncardiac surgery. Methods We conducted a cross‐sectional study using the National Inpatient Sample (2018 to 2020), including adults (aged ≥18 years) with elective hospitalizations with noncardiac surgery. Frailty was measured using the Hospital Frailty Risk Score (HFRS). Surgeries were categorized by risk level. Outcomes included discharge health resources need (DHRN), composite adverse clinical events (CACE), and death. Results Among 8,800,359 hospitalizations (2.14% among patients with RA), 73.36% underwent intermediate‐risk surgery and 62.25% had HFRS above 0. DHRN occurred in 28.9%, CACE occurred in 0.93%, and all‐cause mortality occurred in 0.17%. A 10‐point increase in HFRS was associated with a 3.8‐fold increased DHRN, 8.5‐fold increased CACE, and 22.8‐fold increased mortality. RA was not independently associated with CACE (adjusted odds ratio [aOR] 0.91; 95% confidence interval [CI] 0.82–1.01; P = 0.08) or death (aOR 0.90; 95% CI 0.71–1.15; P = 0.41) but was significantly associated with DHRN (aOR 1.28, 95% CI 1.25–1.31; P < 0.001) after adjusting for confounders and frailty. In sensitivity analysis, RA had 10% higher relative odds of DHRN following orthopedic (aOR 1.10; 95% CI 1.07–1.13; P < 0.001) but not nonorthopedic intermediate‐risk surgery (aOR 1.10; 95% CI 0.98–1.23; P = 0.11). Conclusion RA was associated with higher odds of DHRN after orthopedic intermediate‐risk surgery but not CACE or inpatient mortality. Moreover, HFRS was associated with DHRN, CACE, and death. These findings underscore the need for disease‐specific clinical considerations and highlight the potential utility of HFRS in discharge planning.

Abstract Objective This study was conducted to review and synthesize current evidence on anti‐calcitonin gene‐related peptide (CGRP) therapies in women with menstrual‐related migraine, during pregnancy and lactation, and while using hormonal contraception. Background Migraine disproportionately affects women, with prevalence peaking during reproductive years when hormonal fluctuations modulate neurovascular and nociceptive pathways, including CGRP signaling, that contribute to migraine susceptibility. Despite the established efficacy of anti‐CGRP therapies—including monoclonal antibodies (erenumab, fremanezumab, galcanezumab, and eptinezumab) and gepants (ubrogepant, rimegepant, atogepant, and zavegepant)—evidence regarding their use across critical reproductive health contexts remains limited. Methods A systematic search of MEDLINE and Embase was conducted using MeSH terms and keywords related to migraine, CGRP‐targeted therapies, and reproductive health contexts. Studies were screened independently by two reviewers. Data were extracted using standardized forms and synthesized narratively by clinical domain. Results Sixteen studies met inclusion criteria. For menstrual‐related migraine, post hoc analyses and observational studies demonstrate that CGRP monoclonal antibodies reduce migraine frequency both during and outside the perimenstrual window (galcanezumab: −5.1 vs. −3.2 days, p < 0.001), although the perimenstrual period remains a time of relatively higher headache burden despite treatment. Pregnancy data are limited to pharmacovigilance analyses and case reports of unintended exposures, which have not identified specific patterns of maternal, fetal, or neonatal toxicity. Phase 1 pharmacokinetic studies demonstrate minimal gepant transfer into breast milk (relative infant doses, 0.04%–0.19%), well below the 10% safety threshold, although no human lactation data exist for CGRP monoclonal antibodies. No studies specifically evaluated anti‐CGRP therapies in women using hormonal contraceptives. Conclusion Substantial evidence gaps exist across all reproductive health contexts examined. Prospective trials in menstrual‐related migraine, pregnancy registries, lactation studies assessing infant outcomes, and research examining interactions with hormonal contraceptives are needed to optimize migraine care for women.

Objective This study aimed to compare longitudinal cephalometric growth, speech outcomes, and secondary surgeries after 1-stage versus 2-stage palatoplasty in patients with non-syndromic unilateral cleft lip and palate (UCLP). Design Retrospective single-institution cohort study. Setting Tertiary academic craniofacial center. Patients/Participants Sixty-eight patients with non-syndromic UCLP treated between 1992 and 2015 who underwent primary palatal repair and had long-term clinical and radiographic follow-up. Forty-eight underwent 1-stage palatoplasty, and 20 underwent 2-stage palatoplasty. Interventions One-stage palatoplasty versus staged palatoplasty with initial soft palate repair followed by delayed hard palate closure. Main Outcome Measures Longitudinal cephalometric measurements at approximately 10 and 16 years, speech outcomes at 5, 10, 13, and 16 years, oronasal fistula, velopharyngeal insufficiency surgery, and need for continued speech follow-up after age 10. Results Mean follow-up was 15.2 ± 4.4 years. Linear fixed-effects modeling showed significant age-related worsening in sagittal skeletal relationships in both groups, including decreases in sella-nasion-A point angle (SNA), A point-nasion-B point angle (ANB), and Wits appraisal, without significant effects of palatoplasty strategy or age-by-strategy interaction for key sagittal outcomes. Speech outcomes were comparable between groups across all timepoints, including hypernasality, nasal emission, compensatory articulation, intelligibility, and Cleft Audit Protocol for Speech-Augmented (CAPS-A) scores. Rates of secondary velopharyngeal surgery and continued speech follow-up after age 10 did not differ significantly. Oronasal fistula occurred more frequently after 2-stage palatoplasty than 1-stage palatoplasty (30% vs 9%, P = .02). Conclusion One-stage and 2-stage palatoplasty demonstrated similar long-term growth and speech outcomes through adolescence. Two-stage repair was associated with a higher oronasal fistula rate but not greater secondary velopharyngeal or speech burden.

ABSTRACT Melanoma in skin of color (SOC), defined as Fitzpatrick skin tones IV‐VI, presents unique epidemiologic, diagnostic, and therapeutic challenges compared to non‐Hispanic White (NHW). Although SOC patients have a lower incidence of melanoma, they experience higher melanoma‐specific fatality rates, which may be attributable to later‐stage diagnoses, differences in the distribution patterns of melanoma subtypes, and systemic barriers to care. SOC patients, particularly non‐Hispanic Black individuals, have a higher proportion of acral lentiginous and mucosal melanomas, which arise in non‐sun‐exposed areas, carry lower mutational burdens, and respond less favorably to immunotherapy and BRAF/MEK‐targeted therapies. These anatomic and biological differences contribute to delayed recognition and reduced treatment efficacy. Concurrently, the rising incidence of melanoma in situ across racial and ethnic groups without corresponding decreases in invasive disease or similarly increased mortality rates raises concern for overdiagnosis. Artificial intelligence‐based diagnostic tools show promise in NHW populations but are limited by the underrepresentation of SOC in training datasets and diminished positive predictive value in low‐prevalence populations. The estimated number needed to screen to prevent one melanoma death in SOC populations ranges from approximately 46,000 to 201,000, underscoring the challenge of melanoma screening in this group. Suggested solutions and improvements include expanding healthcare access through patient navigators, developing culturally tailored education programs focused on identifying early invasive disease, diversifying AI training datasets to include acral and mucosal melanoma, biobanking rare melanoma subtypes, and decentralizing clinical trials into community settings. A multifaceted approach is essential to addressing overdiagnosis and improving melanoma outcomes in the SOC populations. image

Background: Robotic cholecystectomy use is increasing, but comparisons with laparoscopic cholecystectomy have largely excluded bailout procedures, limiting assessment of difficult acute cholecystitis. We compared bailout use, downstream outcomes, and 1-year costs between approaches. Study Design: This retrospective cohort study used Healthcare Cost and Utilization Project databases from New York and Florida (2012–2021) to identify adults undergoing inpatient, unscheduled robotic or laparoscopic cholecystectomy for acute cholecystitis. Bailout included conversion to open, subtotal cholecystectomy, or cholecystostomy tube placement. Multilevel regression evaluated bailout, and postoperative outcomes were assessed through 1 year. Results: Among 384,617 patients, 4% underwent robotic and 96% laparoscopic cholecystectomy. Robotic cholecystectomy had higher bailout rates (1.7% vs 1.4%; adjusted OR 1.38, 95% CI 1.21-1.58), including higher odds of conversion to open (OR 1.61, 95% CI 1.28-2.03) and subtotal cholecystectomy (OR 2.02, 95% CI 1.68-2.43), but lower odds of cholecystostomy tube placement (OR 0.42, 95% CI 0.28-0.62). Bile duct injury rates were similar (1.6% for both; p=0.998). Among 5,448 patients requiring bailout, robotic cholecystectomy was associated with fewer postoperative endoscopic biliary (3.1% vs 7.7%; p=0.007) and surgical interventions (2.3% vs 7.5%; p=0.002). Median 1-year cumulative costs remained higher with robotic cholecystectomy ($29,702 vs $24,483; p=0.002). Conclusions: Robotic cholecystectomy was associated with marginally higher bailout use and similar bile duct injury rates but fewer downstream interventions after bailout. These potential benefits did not offset higher 1-year costs.

Many hormones and substances acting through G-protein coupled receptors and protein kinase A (PKA) activation inhibit the salt-inducible kinases (SIKs) by phosphorylation. SIKs tonically phosphorylate CREB-regulated transcriptional coactivators (CRTC1, 2 and 3), sequestering them in the cytoplasm and, thus, preventing their translocation into the nucleus. Once in the nucleus, CRTCs bind CREB family member transcription factors and enhance their activity. We and others have shown that parathyroid hormone (PTH) activation of PKA and resultant SIK2/3 inhibition allows CRTC2/3 nuclear translocation. One of the major actions of CRTC2/3 in the osteoblast lineage is the regulation of transcription of Rankl, as well as other PTH-controlled genes. However, little is known about the role of these co-activators in the osteoblast lineage in vivo. Here, we have investigated whether there are basal effects in vivo on bone examined at 2 different ages of conditional deletion of these two co-activators in the osteoblast lineage using Col2.3-Cre. We found significant increases in body weight, length, bone mineral density, bone volume/total volume, trabecular thickness and number with decreased trabecular separation in young (2 months old) male mice, all of which dissipated by 6 months of age. Female mice showed minimal changes in the bone phenotype at either age. Nevertheless, there were gene expression changes in bones of both sexes at both ages, and in particular decreases in Rankl, Runx2 and Sost, and accompanying changes in Wnt pathway genes. These effects may explain the changes in the bone phenotype in the young male mice, but it is notable that there is a sexual dimorphism in the action of CRTC2 and CRTC3. Overall, the work supports the data from research in vitro and forms a basis for investigation of the role of these co-activators in PTH action in vivo.