Search Results (49)

Background/Objectives: The International Dysphagia Diet Standardisation Initiative (IDDSI) introduced Level 1 (slightly thick) as a new intermediate consistency between thin liquid (Level 0) and mildly thick (Level 2). Although over-thickening is associated with reduced hydration and impaired medication absorption, the specific clinical utility of Level 1 has not been quantified. We aimed to determine the clinical benefit of Level 1 and identify the proportion of dysphagia patients for whom Level 1 is the minimum sufficient consistency. Methods: We retrospectively analyzed 163 consecutive patients undergoing a videofluoroscopic swallowing study (VFSS) in a single rehabilitation department, including a pre-specified stroke subgroup (n = 87). A de-escalation protocol was used (IDDSI Level 3 → 2 → 1 → 0) with stepwise bolus volumes (2–3 mL followed by 5 mL at each consistency), and testing was discontinued at thinner consistencies once aspiration (Penetration–Aspiration Scale [PAS] ≥ 6) was observed. PAS values at untested thinner levels following aspiration were imputed (assigned an assumed value reflecting the expected clinical outcome) as 8 in the primary analysis. We quantified Level 1 effectiveness using absolute risk reduction (ARR), relative risk reduction (RRR), and number needed to treat (NNT). Results: In paired analyses, Level 1 reduced aspiration versus Level 0 by 12.0 percentage points (RRR 31.5%, NNT 8.4) in the full cohort and 13.7 percentage points (RRR 38.5%, NNT 7.3) in the stroke subgroup. Incremental escalation from Level 1 to Level 2 yielded only modest additional benefit (incremental NNT 18.4 and 38.5). Patient-level classification identified 13.7% (full) and 16.5% (stroke) of patients as “Level 1-sufficient”, defined as unsafe on thin liquid but safe on Level 1. Conclusions: IDDSI Level 1 provides substantial aspiration protection compared to thin liquid (NNT ≈ 7–8) with diminishing returns from further escalation, supporting Level 1 as a clinically useful and underutilized first-line thickened liquid option that may help avoid the nutritional and hydration drawbacks of over-thickening. Full article

Background: Resistant hypertension poses a significant therapeutic challenge, often leading to severe polypharmacy. Renal denervation (RDN) has re-emerged as a valuable adjunctive intervention for blood pressure control. Case Presentation: We report the case of a 64-year-old man (body mass index [BMI] 34 kg/m²) with long-standing resistant hypertension (RH), after previous percutaneous coronary intervention (PCI) to the left anterior descending artery, heart failure with preserved ejection fraction (HFpEF), and prior nephron-sparing surgery for clear cell renal carcinoma. Despite treatment with an extensive antihypertensive regimen encompassing nine pharmacological classes including diuretic therapy (angiotensin-converting enzyme inhibitor; calcium channel blocker, thiazide diuretic, β-blocker, α1-blocker, central α2-agonist, mineralocorticoid receptor antagonist, loop diuretic, long-acting nitrates), blood pressure remained severely uncontrolled on both home and office measurements. Persistent hypertension was accompanied by exertional dyspnoea and episodes of exertional chest discomfort. Following comprehensive evaluation and exclusion of secondary causes of hypertension, the patient underwent catheter-based renal denervation using the SymplicitySpyral™ (Medtronic) multi-electrode radiofrequency system. The procedure was associated with substantial and sustained improvement in blood pressure control, with mean 24 h ambulatory blood pressure measurements decreasing to 130/80 mmHg at six-month follow-up. Importantly, successful blood pressure reduction enabled major simplification of pharmacotherapy, including complete discontinuation of clonidine, loop diuretic therapy, and long-acting nitrates, together with marked dose reduction in doxazosin. Conclusions: This case illustrates the potential clinical utility of renal denervation in carefully selected patients with true resistant hypertension and pronounced sympathetic overactivity. Beyond achieving satisfactory blood pressure control, RDN may facilitate meaningful reduction in medication burden, potentially improving treatment adherence, quality of life, and long-term cardiovascular risk. Written informed consent was obtained from the patient for both the procedure and the publication of this case report. Full article

Background/Objectives: Epidermal growth factor receptor (EGFR)-mutant non-small cell lung cancer (NSCLC) has undergone rapid therapeutic evolution. However, heterogeneous outcomes persist, driven by mutations, central nervous system (CNS) involvement, and dynamic tumor burden reflected in part by circulating tumor DNA (ctDNA). As such, this review aims to summarize the most recent risk stratification frameworks in treating EGFR-mutant NSCLC, evaluate evidence supporting treatment intensification strategies and managing adverse effects, and explore the evolving role of ctDNA in guiding personalized therapy. Methods: A comprehensive literature search was conducted using major medical databases with a focus on key relevant studies on the workup and management of EGFR-mutant NSCLC. All authors reviewed the literature, assessed study quality, and interpreted the results from each study. Results: Molecular co-alterations, such as TP53 and RB1, as well as central nervous system (CNS) involvement, are consistently associated with inferior outcomes, supporting consideration of upfront treatment intensification. Combination strategies, including osimertinib plus chemotherapy or amivantamab-based regimens, demonstrate improved progression-free survival and delayed CNS progression when compared against osimertinib monotherapy. Intensification, however, is associated with a higher risk of increased toxicity, including dermatologic adverse events and infusion-related reactions. Finally, the utilization of circulating tumor DNA (ctDNA) has emerged as a strong prognostic marker, with ongoing trials investigating its predictive role for both escalation and de-escalation of therapy. Conclusions: The treatment paradigm for EGFR-mutant NSCLC is gradually evolving beyond first-line osimertinib to include a more integrated approach that considers molecular features, CNS involvement, and early ctDNA response. Although intensified regimens offer meaningful efficacy gains for high-risk patients, proactive toxicity management is essential to preserving quality of life. ctDNA-guided strategies represent a new and promising frontier for escalation and de-escalation of therapy, with results from ongoing trials poised to further refine personalized treatment algorithms. Full article

Background/Objectives: Clinical pharmacists contribute pharmacotherapy expertise to antimicrobial stewardship (AMS), but antimicrobial prescribing remains a multidisciplinary process led by treating clinicians. In physician-centered hospital systems, pharmacists’ contributions may be integrated into prescribing decisions to varying degrees depending on the organizational structures, interprofessional relationships, workflow integration, and prescribing cultures. This study aimed to explore how contextual and interprofessional factors shape the integration of clinical pharmacists’ antimicrobial stewardship contributions within multidisciplinary prescribing decisions in Jordanian hospitals. Methods: A multi-site qualitative study was conducted across nine Jordanian hospitals. Semi-structured interviews were conducted with 26 clinical pharmacists involved in antimicrobial reviews in intensive care and general medical units. Interviews incorporated the critical incident technique to elicit examples of accepted and rejected stewardship recommendations. Data were analyzed using a realist-informed approach to develop context–mechanism–outcome configurations explaining variations in pharmacists’ reported AMS contribution. Results: Pharmacotherapy expertise was necessary but not sufficient for pharmacists’ recommendations to shape antimicrobial prescribing. Leadership endorsement, structured multidisciplinary rounds, and formal documentation pathways activated mechanisms of legitimacy, credibility, and workflow visibility, supporting reported uptake of dose optimization, therapeutic drug monitoring, and selected de-escalation recommendations. In contrast, prescriber-led hierarchies, limited documentation pathways, workload pressures, and defensive prescribing cultures activated mechanisms of self-limitation, risk aversion, and limited recommendation uptake, particularly for discontinuation, duration control, and narrowing of broad-spectrum therapy. Conclusions: Strengthening AMS requires not only formal committees and guidelines but also team-based structures that integrate pharmacists’ pharmacotherapy expertise into antimicrobial review while preserving clinicians’ ultimate prescribing responsibility. Full article

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor remains the cornerstone of antithrombotic management after myocardial revascularization. However, the traditional “one-size-fits-all” approach to DAPT duration and intensity fails to account for marked interindividual variability in drug response—driven by genetic polymorphisms, notably CYP2C19 variants like CYP2C19*2, which reach a frequency of up to 75% in specific groups like the Melanesian population—comorbidities such as diabetes and chronic kidney disease, and dynamic clinical factors including age and concomitant medications. We examine the current landscape of precision medicine tools for individualizing DAPT, including platelet function testing, point-of-care genotyping, validated clinical risk scores, and emerging artificial intelligence (AI)–based predictive models. Evidence from landmark trials is synthesized to evaluate escalation, de-escalation, and duration-tailoring strategies within the ischemic–bleeding trade-off framework. Special populations requiring individualized approaches are reviewed, including patients with atrial fibrillation, the elderly, and those requiring urgent noncardiac surgery with perioperative bridging. Future directions, including multi-omics integration, novel antiplatelet agents, and AI-driven clinical decision support systems, are also explored. As a narrative review, conclusions should be interpreted as reflective of current evidence synthesis rather than systematic-review-grade evidence, given the absence of formal risk-of-bias scoring or meta-analytic pooling. Personalized DAPT guided by complementary genetic and phenotypic testing, integrated with dynamic risk stratification, offers a paradigm shift from empiric therapy toward precision-guided antithrombotic management with the potential to simultaneously reduce ischemic and bleeding complications. Full article

Workplace violence and hetero-aggressive behavior represent significant occupational hazards in mental health settings, particularly for psychiatry and psychology trainees who are frequently exposed yet often insufficiently prepared. This scoping review aimed to map and critically describe existing educational approaches to violence risk assessment, prevention, and management in mental health training programs, with a focus on psychiatry and psychology education. A scoping review identified 17 eligible studies examining curricular content, pedagogical modalities, and training outcomes related to violence education. Included studies encompassed surveys, curricular descriptions, and educational interventions employing didactic, simulation-based, and blended learning formats. Overall, the literature revealed variability and fragmentation in training, with most programs lacking structured or longitudinal curricula. Didactic approaches improved conceptual understanding but were consistently perceived as insufficient for skill acquisition and confidence. In contrast, blended and simulation-based modalities, particularly those using standardized patients and structured debriefing, were associated with greater gains in applied skills, confidence, and perceived clinical readiness. Core competencies emphasized across curricula included de-escalation strategies, violence risk assessment frameworks, communication skills, and, less consistently, legal and institutional considerations. These findings highlight persistent educational gaps and support the integration of experiential, longitudinal, and system-informed training models to better prepare mental health trainees for violence-related clinical challenges. Full article

Background/Objectives: Multiple Sclerosis (MS) is a chronic disease with significant clinical and radiological heterogeneity. This fact, together with the increased number of disease-modifying treatments available, poses challenges in the therapeutic decisions and for the overall management of the disease. In this study, an expert panel on MS from Greece aimed to formulate a consensus, in order to provide recommendation on disease-modifying treatment (DMT) initiation and switching, as well as de-escalation strategies in Relapsing MS (RMS). Methods: The study followed two-round voting based on a modified Delphi setting. A questionnaire was constructed by a subgroup of five experts (core group) and was subsequently administered in a printed form to a group of 12 MS experts in total (panel) in a face-to-face meeting. Consensus required at least 80% agreement within the panel in order to signify strong consensus. Results: The panel agreed that the overall therapeutic plan (DMT choice) must take into consideration the degree of disease activity (low/moderate/high). In certain cases with suboptimal response to a moderate-efficacy DMT, a horizontal switch to another moderate-efficacy DMT may be a valid strategy. However, in cases exhibiting disability accumulation, therapy escalation should be preferred. The concept of de-escalation was suggested as an alternative strategy for cases with stable disease receiving a high-efficacy long-term DMT in the long term. Due to the possibility of rebound phenomena with certain medications (such as fingolimod and natalizumab), a bridging strategy could be applied in cases of family planning and drug-related adverse events (such as lymphopenia and hepatotoxicity), especially in PwMS with recent inflammatory activity. Conclusions: Although novel biomarkers may soon help clinicians predict future disability accumulation, currently, regular and detailed patient monitoring seems to be the optimal way to guide clinicians’ decisions on treatment changes. Full article

Objective: To develop an individual assessment for patients suffering from medication-related osteonecrosis of the jaw (MRONJ), we developed a scoring system that integrates anamnestic, clinical, and radiological parameters to facilitate the process of therapeutic decisions during MRONJ therapy. Methods: In this study, clinical data as well as diagnostic CT scans from 41 MRONJ patients undergoing antiresorptive therapy were analyzed to develop an Osteonecrosis Scoring Clinical Assessment and Radiological Report (OSCAR). Results: Total OSCAR scores ranged from 4 to 30, with lower scores demonstrating less severe disease progression following a de-escalated therapy. OSCAR scores above 15 were associated with higher bone density and an increased need for surgical intervention, with 70% of Denosumab and 71% of bisphosphonate patients requiring surgical intervention. Conclusions: Patients with an OSCAR below 12 were unlikely to require multiple surgical interventions. Since OSCAR parameters are routinely collected during hospitalization, this opens the possibility for future AI-assisted patient assessment and treatment planning. Full article

Background: Necrotizing fasciitis (NF) is a rapidly progressive, life-threatening soft tissue infection characterized by fascial necrosis, with mortality rates of 20–30%. Despite its rarity, NF is increasingly encountered due to the rising prevalence of predisposing factors. Data from Southern European tertiary centers remain scarce. Methods: We retrospectively reviewed all patients ≥18 years with radiological and/or surgical diagnosis of NF managed at IRCCS Policlinico San Matteo, Pavia, Italy, between November 2018 and August 2023. Clinical, microbiological, and treatment data were extracted from electronic medical records. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was calculated retrospectively. The Charlson Comorbidity Index was computed for each patient. Given the small sample size, we adopted a purely descriptive analytical approach without inferential testing. Results: Thirteen patients met inclusion criteria (median age 58 years, IQR 44.5–79.5; 69.2% male). The most common comorbidities were diabetes mellitus (6/13, 46.2%), renal failure (4/13, 30.8%), and chronic liver disease (4/13, 30.8%). The age-adjusted Charlson Index ranged from 0 to 11 (median 4). Lower limbs were the most frequently affected anatomic site (5/13, 38.5%), followed by the perineal/genital region (Fournier gangrene, 4/13, 30.8%). Type II (monomicrobial) NF predominated (9/13, 69.2%). Microbiological cultures were positive in 8/13 patients (61.5%): Gram-positive cocci were isolated in 5/8 (62.5%) and mixed aerobic/anaerobic flora in 3/8 (37.5%). Empirical antibiotic regimens included a piperacillin–tazobactam backbone in 6/12 (50.0%) patients and a meropenem-based combination in 5/12 (41.7%); 6/12 patients underwent targeted de-escalation after culture results. Two patients (15.4%) died in hospital, both with Fournier gangrene and Type I infection (mortality 2/4, 50.0% in Type I vs. 0/9 in Type II). The median length of stay was 26 days (IQR 17–28.5). All patients had LRINEC ≥6 at admission, with 9/13 (69.2%) classified as high risk (≥8). Conclusions: In this small retrospective Italian cohort, NF was most frequently associated with diabetes and high comorbidity burden. Type I (polymicrobial) infections, predominantly involving the perineal region, showed worse outcomes than Type II infections. The clinical experience accumulated during this study period subsequently informed the development of an institutional empirical antimicrobial protocol for skin and soft tissue infections at our hospital. Full article

Background: Blood cultures are frequently obtained in the emergency department (ED), yet organism identification and subsequent antibiotic optimization commonly occur after hospital admission. Inappropriate empiric therapy remains common and is associated with adverse outcomes. MALDI-TOF MS can shorten the time to organism identification; however, real-world effectiveness may depend on laboratory cadence and stewardship support, and evidence for once-daily batch workflows without active antimicrobial stewardship is limited. Method: We performed a retrospective before–after cohort study at a tertiary medical center in central Taiwan, comparing positive blood cultures (PBCs) obtained in the ED before MALDI-TOF MS implementation (1 May–31 July 2018; conventional identification) and after implementation (1 September–30 November 2018; MALDI-TOF MS). Primary endpoints were appropriate antibiotic therapy at 24, 48, and 72 h after the first PBC report. Secondary endpoints included timing, location, and classification (escalation vs. de-escalation) of the first antibiotic modification. Results: After exclusions, 323 unique PBCs were analyzed (182 pre-implementation; 141 post-implementation). Baseline characteristics and clinical outcomes were similar, including in-hospital mortality (14.8% vs. 14.9%). Time to the initial positive report (Gram stain) and the final report (identification with antimicrobial susceptibility testing) did not differ significantly between periods. Appropriate antibiotic use at 24/48/72 h was comparable (75.3% vs. 76.6%, 82.4% vs. 80.1%, and 86.3% vs. 84.4%). The timing and pattern of the first antibiotic modification were also similar. In a secondary stratified analysis, patients modified before culture positivity had higher acuity and worse outcomes. Conclusions: Once-daily MALDI-TOF MS implementation was not associated with improved antibiotic appropriateness or modification patterns in ED bacteremia without active real-time stewardship oversight. Higher-frequency processing and real-time stewardship linkage may be required to translate faster diagnostics into timely therapeutic action. Full article

Background: Among individuals with type 2 diabetes (T2D), lifestyle improvements can restore glycemic control, yet few studies have examined deprescribing in settings where it was necessitated by improvements in health. This study aimed to (1) identify instances of medication deprescribing among adults with T2D in a primary care setting where patients had access to lifestyle medicine (LM), (2) document lifestyle changes among deprescribed patients, (3) assess changes in body mass index (BMI), glucose, and hemoglobin A1c (HbA1c) following deprescribing, and (4) assess the safety of deprescribing in the context of LM-informed care by identifying adverse events. Methods: A retrospective review of electronic health records (EHR) was conducted among 650 adults with a diagnosis of T2D per ICD-10 code at two primary care practices. To be included in the study, individuals had to be seen at least two times during the study period, from 2014 to 2023. Using a previously developed deprescribing framework, records were reviewed to identify deprescribing events. Among patients who were identified as deprescribed, BMI, glucose, and HbA1c, were extracted from the EHR, and age-, sex-, and time-adjusted differences in least squares means were calculated. Mentions of lifestyle change in provider notes in the EHR were also extracted pre- vs. post-deprescribing. Results: Forty-one deprescribing events were confirmed, totaling 6.3% of the study population. The most common medication changes included metformin dose reduction 34%, metformin discontinuation 19.5%, and insulin dose reduction 19.5%. Among patients with follow-up data, mean BMI decreased by 2.25 kg/m², p = 0.0003. Mean decreases of 25% in glucose and 13% in HbA1c were also observed, p < 0.0003 and p < 0.0013, respectively. Lifestyle modifications were specifically cited in 51% of records among deprescribed patients, most frequently related to diet and exercise. No serious adverse events were identified in patients who were deprescribed. Conclusions: In a primary care setting where patients had access to lifestyle medicine, a subset of adults with T2D experienced meaningful health improvements and were able to reduce glucose-lowering medications without any serious adverse events noted in the EHR. Full article

Background: There is growing recognition that certain medical conditions, such as type 2 diabetes (T2D), can be effectively addressed through comprehensive lifestyle changes, thereby reducing reliance on medications; however, little guidance exists on deprescribing following lifestyle change. This study aimed to develop a framework that can be used to better define and standardize across research studies which medication changes in T2D care can be classified as deprescribing. Methods: An iterative development process began with a review of medication data exported from electronic health records (EHR) for n = 650 patients with T2D, 18–89 years, from two primary care practices with LM board-certified physicians. Included patients were seen during the period of 15 May 2014 to 13 March 2023. All reported T2D medications were grouped into the following categories: insulin, non-insulin, or metformin. A consensus-based review process was employed, facilitated by weekly meetings with the research team, whereby patients were classified as “potentially deprescribed,” “not deprescribed,” or “unclear” (not enough information based on limited, exported EHR data). Patients identified as potentially deprescribed or “unclear” were then further assessed through a more detailed review of their EHR. Results: Using the results of this chart review, a framework was developed to identify types of deprescribing, as follows: (1) insulin dose reduced; (2) change from insulin to other non-insulin medication; (3) insulin discontinued; (4) non-insulin T2D medication stopped; (5) dose reduced of the same non-insulin T2D medication; (6) change from any non-insulin medication to metformin or multiple medications + metformin to metformin only; (7) metformin stopped; (8) metformin dose reduced. A total of n = 193 patients were identified as having been potentially deprescribed based on the exported EHR data, and after a more detailed review of individual EHR records, 41 were confirmed as deprescribed. Conclusions: This study is the first to present a novel framework for classifying deprescribing in the context of positive health outcomes. The framework will facilitate future research evaluating the impact of lifestyle changes on diabetes management and promote comparability across settings for medication outcomes. Future research is needed to apply this framework to quantify deprescribing across various settings with greater precision. Full article

Background: Statins are central to primary and secondary prevention of atherosclerotic cardiovascular disease but are often underutilized due to myopathy and intolerance. While individual pharmacogenetic (PGx) variants, particularly in SLCO1B1, are linked to statin-associated muscle symptoms, the real-world impact of both clinical and cumulative PGx burden on regimen modification and adverse outcomes remains unclear. We aimed to evaluate the existing uncertainty regarding whether combined PGx scores can effectively guide statin dose titration and regimen modification, thereby filling a key clinical gap. Methods: A retrospective cohort study of 911 statin-treated patients with coronary artery disease was conducted from the Qatar Cardiovascular Biorepository with available whole-genome sequencing data. Variants in SLCO1B1, ABCG2, and CYP2C9 were combined into a functional PGx burden score, and their associations with statin regimen modification, intolerance, myopathy, liver injury, adherence, and composite adverse events were evaluated. The composite adverse events were defined as the occurrence of any statin-related adverse event, including statin-associated myopathy, liver injury, or poor medication adherence, during the follow-up period. Patients were classified as having experienced the composite outcome if at least one of these events occurred. Results: Over 12 months following statin initiation, 10.2% of patients underwent dose escalation, 11.4% de-escalation, and 78.4% remained on the same regimen. PGx burden is not statistically significantly associated with statin intolerance (OR 1.14; 95% CI: 0.73–1.76), composite adverse outcome (OR 1.08; 95% CI 0.82–1.42), or time to regimen change (HR 1.02; 95% CI 0.77–1.35). However, higher PGx burden showed a directional tendency toward dose de-escalation (RRR 1.18, 95% CI 0.76–1.84) and lower likelihood of escalation (RRR 0.93, 95% CI 0.56–1.54). Conclusions: Clinical factors, particularly statin intensity and myopathy, were the primary determinants of regimen modification. The PGx burden contributes to vulnerability to statin-related adverse effects in a context-dependent manner but does not independently drive statin regimen modification in routine clinical practice. Prospective studies are warranted to assess the clinical utility of PGx-guided workflows in statin therapy. Full article

Background: Breast cancer is frequently diagnosed in older women. However, the impact of surgery on survival is not well studied and prognosis for women ≥ 80 years of age is progressively depending on comorbidities. Methods: Medical records of consecutive women aged ≥ 80 years diagnosed with primary breast cancer treated with upfront surgery at two Breast Centers from 2011 to 2021 were retrospectively analyzed. Results: A total of 553 consecutive women with a median age of 83 years and a median tumor diameter of 21 mm were analyzed (574 lesions). Clinical Stages II or III were found in 263/574 (46%) and 101/574 cases (18%), respectively. Axillary staging was completely omitted for 94/542 invasive lesions (17%), and this increased over time from 2% to 33% (p < 0.001). Adjuvant hormone therapy and radiotherapy were omitted in 134/490 (27%) and in 122/420 patients (29%), respectively, while only 26/195 (13%) of patients with a clear clinical indication received adjuvant chemotherapy. At a median follow-up of 61 months (6–147) the 5- and 10-years overall survival (OS) were 64% and 21%, while breast cancer-specific survival (BCSS) at 5 and 10 years were 94% and 78%, respectively. Adjuvant therapies were not associated with a significant improvement in BCSS, while worse OS was associated with older age or more comorbidities as measured by the Charlson Comorbidity Index (CCI) (p < 0.001 and p = 0.012, respectively). Conclusions: Breast surgery, when possible, has a primary role even for women > 80 years of age, and it is associated with a reasonable BCSS. De-escalation of adjuvant therapies should be considered in this setting because survival is largely determined by age and co-morbidities. Full article

The concept of “more is better” has long dominated cancer treatment, emphasizing aggressive therapies despite their toxicity. However, the rise of personalized medicine has fostered treatment de-escalation strategies aimed at minimizing toxicity, improving quality of life, and reducing costs. This position paper highlights key applications of de-escalation in medical oncology, with a primary focus on breast cancer and notable examples in colorectal, head and neck, ovarian, lung, and prostate cancers. Various approaches, including dose reduction, treatment duration shortening, and regimen optimization, have demonstrated efficacy without compromising clinical outcomes. Advances in molecular diagnostics, such as Oncotype Dx in breast cancer and circulating tumor DNA (ctDNA) analysis in colorectal cancer, have facilitated patient selection for de-escalation. While these strategies present promising results, challenges remain, particularly in balancing treatment intensity with oncologic control. The review underscores the need for further prospective trials to refine de-escalation approaches and ensure their safe integration into standard oncologic care. Full article