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Sievers MT, Neevel A, Diaz A, Rouanet E, Sheetz K, Brophy D, Dimick JB, Chhabra KR. Private Equity Investment in Surgical Care. Ann Surg 2024:00000658-990000000-00782. [PMID: 38372276 DOI: 10.1097/sla.0000000000006238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
OBJECTIVE To characterize the extent of private equity investment affecting surgical care. SUMMARY BACKGROUND DATA Over the last decade, investor-backed, for-profit private equity groups have invested in healthcare at an unprecedented rate, but the breadth of these investments affecting surgical practice remains largely unknown. METHODS Four nationally representative databases were used to identify all merger/acquisitions involving surgical practices between 2015-2019, determine private equity investment in those transactions, and link the acquisitions with a physician dataset. RESULTS 1,542 unique transactions were identified, of which 539 were financed by private equity. 58 transactions were then classified into their respective categories within surgical care: digestive disease, orthopedics, urology, vascular surgery, and plastic/cosmetic surgery. These transactions accounted for 199 practice sites and 1,405 physicians, averaging 24.2 physicians per transaction. Acquisition activity peaked in 2017 with a total of 63 practices involved. Digestive disease, urology, and orthopedic surgery accounted for the most activity. General surgeons were involved in a small share of the digestive disease practice acquisitions. Three "surgery-adjacent" categories were also identified: anesthesiology, ambulatory surgery centers, and surgical staffing firms. Among these, anesthesia was the largest category in terms of practices (194) and physicians (2,660) involved in transactions across the study period. Medical Service Organizations (MSOs) were a key mechanism through which private equity firms invested in surgical care. CONCLUSIONS Private equity has engaged in substantial investment within surgical specialties, creating increased practice consolidation. These investments affect all levels of medical care and have notable implications for patients, practitioners, and policymakers.
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Heindel P, Feliz JD, Fitzgibbon JJ, Rouanet E, Belkin M, Hentschel DM, Ozaki CK, Hussain MA. Comparative effectiveness of bovine carotid artery xenograft and polytetrafluoroethylene in hemodialysis access revision. J Vasc Access 2023:11297298231170654. [PMID: 37125779 DOI: 10.1177/11297298231170654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
BACKGROUND When hemodialysis arteriovenous accesses fail, autogenous options are often limited. Non-autogenous conduit choices include bovine carotid artery xenografts (BCAG) and expanded polytetrafluoroethylene (PTFE), yet their comparative effectiveness in hemodialysis access revision remains largely unknown. METHODS A cohort study was performed from a prospectively collected institutional database from August 2010 to July 2021. All patients undergoing an arteriovenous access revision with either BCAG or PTFE were followed for up to 3 years from their index access revision. Revision was defined as graft placement to address a specific problem of an existing arteriovenous access while maintaining one or more of the key components of the original access (e.g. inflow, outflow, and cannulation zone). Outcomes were measured starting at the date of the index revision procedure. The primary outcome was loss of secondary patency at 3 years. Secondary outcomes included loss of post-intervention primary patency, rates of recurrent interventions, and 30-day complications. Pooled logistic regression was used to estimate inverse probability weighted marginal structural models for the time-to-event outcomes of interest. RESULTS A total of 159 patients were included in the study, and 58% received access revision with BCAG. Common indications for revision included worn out cannulation zones (32%), thrombosis (18%), outflow augmentation (16%), and inflow augmentation (13%). Estimated risk of secondary patency loss at 3 years was lower in the BCAG group (8.6%, 3.9-15.1) compared to the PTFE group (24.8%, 12.4-38.7). Patients receiving BCAG experienced a 60% decreased relative risk of secondary patency loss at 3 years (risk ratio 0.40, 0.14-0.86). Recurrent interventions occurred at similar rates in the BCAG and PTFE groups, with 1.86 (1.31-2.43) and 1.60 (1.07-2.14) interventions at 1 year, respectively (hazard ratio 1.22, 0.74-1.96). CONCLUSIONS Under the conditions of this contemporary cohort study, use of BCAG in upper extremity hemodialysis access revision decreased access abandonment when compared to PTFE.
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Affiliation(s)
- Patrick Heindel
- Department of Surgery, Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Jessica D Feliz
- Department of Surgery, Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - James J Fitzgibbon
- Department of Surgery, Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Eva Rouanet
- Department of Surgery, Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Michael Belkin
- Department of Surgery, Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Dirk M Hentschel
- Department of Medicine, Division of Renal Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - C Keith Ozaki
- Department of Surgery, Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Mohamad A Hussain
- Department of Surgery, Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
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Fitzgibbon JJ, Heindel P, Feliz JD, Rouanet E, Wu W, Huynh C, Hentschel DM, Belkin M, Ozaki CK, Hussain MA. Staged autogenous to prosthetic hemodialysis access creation strategy to maximize forearm options. J Vasc Surg 2023; 77:1788-1796. [PMID: 36791894 DOI: 10.1016/j.jvs.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 02/02/2023] [Accepted: 02/04/2023] [Indexed: 02/15/2023]
Abstract
OBJECTIVE When an adequate cephalic vein is not available for fistula construction, surgeons often turn to basilic vein or prosthetic constructions. Single-stage forearm prosthetic hemodialysis accesses are associated with poor durability, and upper arm non-autogenous access options are often limited by axillary outflow failure, which inevitably drives transition to the contralateral arm or lower extremity. We hypothesized that initial creation of a modest flow proximal forearm arterial-venous anastomosis to dilate ("develop") inflow and outflow vessels, followed by a planned second-stage procedure to create a cannulation zone with a prosthetic graft in the forearm, would result in reliable and durable hemodialysis access in patients with limited options. METHODS We performed an institutional cohort study from 2017 to 2021 using a prospectively maintained database supplemented with adjudicated chart review. Patients without traditional autogenous hemodialysis access options in the forearm underwent an initial non-wrist arterial-venous anastomosis creation in the forearm as a first stage, followed by a second-stage interposition graft sewn to the existing inflow and venous outflow segments to create a useable cannulation zone in the forearm while leveraging vascular development. Outcomes included time from second-stage access creation to loss of primary and secondary patency, frequency of subsequent interventions, and perioperative complications. RESULTS The cohort included 23 patients; first-stage radial artery-based (74%) configurations were more common than brachial artery-based (26%). Mean age was 63 years (standard deviation, 14 years), and 65% were female. Median follow-up was 340 days (interquartile range [IQR], 169-701 days). Median time to cannulation from second-stage procedure was 28 days (IQR, 18-53 days). Primary, primary assisted, and secondary patency at 1 year was 16.7% (95% confidence interval [CI], 5.3%-45.8%), 34.6% (95% CI, 15.2%-66.2%), and 95.7% (95% CI, 81.3%-99.7%), respectively. Subsequent interventions occurred at a rate of 3.02 (IQR, 1.0-4.97) per person-year, with endovascular thrombectomy with or without angioplasty/stenting (70.9%) being the most common. There were no cases of steal syndrome. Infection occurred in two cases and were managed with antibiotics alone. CONCLUSIONS For patients without adequate distal autogenous access options, staged prosthetic graft placement in the forearm offers few short-term complications and excellent durability with active surveillance while strategically preserving the upper arm for future constructions.
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Affiliation(s)
- James J Fitzgibbon
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - Patrick Heindel
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - Jessica D Feliz
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - Eva Rouanet
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - Winona Wu
- Division of Vascular and Endovascular Surgery at Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA
| | - Cindy Huynh
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - Dirk M Hentschel
- Division of Renal Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - Michael Belkin
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - C Keith Ozaki
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - Mohamad A Hussain
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA.
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Sinyard RD, Veeramani A, Rouanet E, Anteby R, Petrusa E, Phitayakorn R, Gee D, Terhune K. Gaps in Practice Management Skills After Training: A Qualitative Needs Assessment of Early Career Surgeons. J Surg Educ 2022; 79:e151-e160. [PMID: 35842404 DOI: 10.1016/j.jsurg.2022.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 05/23/2022] [Accepted: 06/18/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE Shifts in American healthcare delivery mechanisms pose significant hurdles to new physicians. Surgeons are particularly susceptible to these changes, but surgical residency educational efforts primarily focus on technical and clinical training to the exclusion of business and management practices. This study conducted a needs assessment of perceived gaps in practice management skills among early career surgeons to guide future training curricula. METHODS This study was an exploratory qualitative study following the Consolidated Criteria for Reporting Qualitative Research. Purposive sampling was used to identify early career (<5 years following fellowship completion) surgeons across the United States. A semi-structured interview guide was created from interviews with surgical administrators and physician administrative curricula. Transcripts were de-identified and analyzed using a constructivist grounded theory approach. RESULTS Ten surgeons from 6 specialties and 6 institutions were interviewed along with 3 surgeon administrators. Three major domains of need were identified: (1) fundamentals of procedural coding, clinical billing, & compliance, (2) finding/building a practice, and (3) navigating organizational challenges. First, surgeons thought trainees would benefit from a better understanding of reimbursement schema and the basics of health policy. They also thought that more exposure to malpractice litigation, especially for handling case review or expert witness requests, would be helpful for discerning how to handle such issues early in their career. In addition, early career surgeons expressed a desire to have dedicated mentorship time, a primer on evaluating job offers with simulated contract negotiation, and guidance regarding administrative roles. Finally, surgeons requested training in change management techniques, care pathway construction, and the basics of staffing decisions. CONCLUSIONS There are significant practice management gaps in surgical training which may be amenable to targeted educational efforts during a residency or fellowship program. Future research will test the generalizability of these findings as well as build curricula that adequately meet these needs.
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Affiliation(s)
- Robert D Sinyard
- Massachusetts General Hospital, Department of Surgery; Boston, Massachusetts.
| | | | - Eva Rouanet
- Brigham & Women's Hospital, Department of Surgery; Boston, Massachusetts
| | - Roi Anteby
- Massachusetts General Hospital, Department of Surgery; Boston, Massachusetts
| | - Emil Petrusa
- Massachusetts General Hospital, Department of Surgery; Boston, Massachusetts
| | - Roy Phitayakorn
- Massachusetts General Hospital, Department of Surgery; Boston, Massachusetts
| | - Denise Gee
- Massachusetts General Hospital, Department of Surgery; Boston, Massachusetts
| | - Kyla Terhune
- Department of Surgery, Vanderbilt University Medical Center; Nashville, Tennessee
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Ross AB, Rouanet E, Murphy AJ, Weldon CB, Weil BR. Complications associated with totally implantable access ports in children less than 1 year of age. J Pediatr Surg 2022; 57:463-468. [PMID: 34991865 DOI: 10.1016/j.jpedsurg.2021.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 11/24/2021] [Accepted: 12/01/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Long term central venous access is necessary for the treatment of several conditions affecting young children. Totally implantable access ports (ports) offer the advantage of containing no external components, thus simplifying their care and maintenance. However, there is no consensus on the safety of port placement in infants (birth to 1-year of age). The aim of this study was to describe complications associated with port placement in infants, including which specific factors may be associated with risk for developing complications among these patients, and thereby assess the safety of port placement in this young population. METHODS A two-institution, retrospective cohort study identified patients under 1-year old who underwent port placement. Intraoperative, early postoperative (within 30 days), and late postoperative (greater than 30 days) complications were recorded. Multivariate logistic regression models were employed to assess factors associated with port-related complications. RESULTS Among 121 patients who received a port, 36 (30%) experienced a complication with a median time to complication of 299.5 days [IQR 67.5-440.75]. Of those, 26 required unplanned port removal. Only 3 patients (2.5%) experienced an intraoperative complication, and 3 patients (2.5%) experienced a complication within 30 days of port placement. A diagnosis of cancer was found to be protective against early catheter malfunction (OR=0.31, p = 0.03). A non-statistically significant trend associated with increased complications for large caliber devices (>6.0Fr) and weight <7-kg (OR 2.20, p = 0.06 and OR=2.26, p = 0.11 respectively) was observed. CONCLUSIONS Port placement appears to be safe for most infants with low or acceptable rates of intra- or post-operative complications. Smaller patient size (< 7 kg) and larger-sized catheters (> 6.0Fr) may be associated with an increased risk for complications among this population. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Aaron B Ross
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, United States.
| | - Eva Rouanet
- Department of Surgery, Boston Children's Hospital/Harvard Medical School, Boston, MA 02115, United States; Department of Surgery, Brigham & Women's Hospital/Harvard Medical School, Boston, MA 02115, United States
| | - Andrew J Murphy
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN 38105, United States
| | - Christopher B Weldon
- Department of Surgery, Boston Children's Hospital/Harvard Medical School, Boston, MA 02115, United States; Department of Pediatric Oncology, Dana-Farber Cancer Institute/Harvard Medical School, Boston, MA 02115, United States; Department of Anesthesiology, Critical Care & Pain Medicine, Children's Hospital/Harvard Medical School, Boston, MA 02115, United States
| | - Brent R Weil
- Department of Surgery, Boston Children's Hospital/Harvard Medical School, Boston, MA 02115, United States; Department of Pediatric Oncology, Dana-Farber Cancer Institute/Harvard Medical School, Boston, MA 02115, United States
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Lu PW, Atkinson RB, Rouanet E, Cho NL, Melnitchouk N, Kuo LE. Representation of women in speaking roles at annual surgical society meetings. Am J Surg 2020; 222:464-470. [PMID: 33334570 DOI: 10.1016/j.amjsurg.2020.12.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 12/05/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Women are disproportionately underrepresented in American academic surgery and surgical society leadership; we investigated the proportion of speaking roles held by women across a wide variety of surgical society meetings. METHODS Publicly-available data on invited speakers, panelists, and moderators at 23 national surgical societies' annual meetings from 2002 to 2019 were collected. Mixed effects logistic regression was used to evaluate the adjusted trend of gender representation over time for each role. RESULTS 15.9% of invited speakers were women. Adjusted analysis showed an 8% increase in odds of having female speakers per year (OR1.08, p = 0.002, 95%CI 1.03-1.14). 24.4% of moderators and 22.5% of panelists were female; there was increasing trend in adjusted analysis for both moderators (OR1.09, p < 0.001, 95%CI 1.07-1.11) and panelists (OR1.13, p < 0.001, 95%CI 1.11-1.43). CONCLUSIONS There is a wide range in speaking roles held by women at surgical society meetings, but an encouraging trend towards greater parity was seen overall.
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Affiliation(s)
- Pamela W Lu
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rachel B Atkinson
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eva Rouanet
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nancy L Cho
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nelya Melnitchouk
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lindsay E Kuo
- Temple University Lewis Katz School of Medicine, Philadelphia, PA, USA.
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Henrix RJ, Rouanet E, Schultz K, Ali T, Switzer BA, Bathini VG, Whalen GF, Lafemina J. Effect of surgical resection on survival following neoadjuvant chemotherapy in patients with stage I-II pancreatic adenocarcinoma. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.4_suppl.255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
255 Background: Pancreatic adenocarcinoma (PDAC) is a lethal malignancy, representing the 4th leading cause of cancer deaths. Our 2011 institutional protocol guides that patients with Stage I/II PDAC receive neoadjuvant chemotherapy (FOLFIRINOX or gemcitabine- nab-paclitaxel); a similar protocol is followed with patients with Stage III disease. The aim of the study is to determine if potentially curative surgery provides added survival benefit, compared to neoadjuvant chemotherapy alone. Methods: Patients who received neoadjuvant chemotherapy and who were diagnosed with stage I-III PDAC from 2011-2017 at a tertiary medical center were included in this prospectively-collected, retrospective analysis. The primary endpoint was overall survival (OS). Kaplan-Meier curves are compared using Log-rank. Cox proportional hazards were used to adjust for confounders. Results: 105 patients met inclusion criteria: 38 (36%) had Stage I disease (n = 18 had neoadjuvant chemotherapy and surgery [N+S], n = 20 had neoadjuvant chemotherapy [N] alone), 44 (42%) had stage II (N+S n = 20, N n = 24), 23 (22%) had stage III (N+S n = 4, N n = 19). There was no difference in 5-year OS regardless of treatment regimen in patients with Stage I (median OS N+S 22.5 mo vs N 27.9 mo; p = 0.99, HR 1.00, 95%CI 0.74-1.35) or Stage II disease (median OS N+S 28.7 mo vs N 27.6 mo; p = 0.69; HR 1.06, 95%CI 0.79-1.41). There is a trend towards improved OS with N+S in those with Stage III disease (median OS N+S 46.0 mo vs N 14.5 mo, p = 0.08), but the number who underwent resection is low (17%), limiting this analysis. Conclusions: In patients with Stage I-II PDAC, potentially curative surgery may not provide additional survival benefit beyond that afforded by modern day neoadjuvant chemotherapy. Stage III outcomes are limited by small numbers, and the impact of surgery is unclear. It may be possible that the locally unresectable tumor that is rendered resectable with neoadjuvant chemotherapy may be associated with a more favorable biology, such that surgery offers added survival benefit. Additional large-scale trials are needed to confirm whether newer therapies may obviate the need for resection in select patients.
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Affiliation(s)
| | - Eva Rouanet
- University of Massachusetts Medical School, Worcester, MA
| | - Kurt Schultz
- University of Massachusetts Medical School, Worcester, MA
| | - Tasneem Ali
- University of Massachusetts Memorial Medical Center, Acton, MA
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