# Supplementary Material S3 — AMSTAR-2 Full Quality Assessment

**Tool:** AMSTAR-2 (Shea BJ, Reeves BC, Wells G, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. *BMJ* 2017;358:j4008. doi:10.1136/bmj.j4008).

**Number of systematic reviews assessed:** 33 (25 with meta-analysis; 8 narrative SR only).

> **Important caveat — pilot abstract-based scoring.** The scoring presented here was performed against the PubMed abstract plus the local annotation card for each review. Items 5, 6, 7, 12, and 16 routinely require the full text. Where the abstract is silent on a methodological detail, we coded "Cannot tell" rather than "No". **Full-text rescoring will be performed before final manuscript submission**, with two reviewers working independently and discrepancies adjudicated by a third reviewer. The final published table is expected to upgrade several reviews currently flagged "Critically Low" to "Low" or "Moderate".

**Items (Shea 2017):**
1. PICO components in research question
2. Pre-registered protocol *(critical)*
3. Justification for study designs included
4. Comprehensive search strategy *(critical)*
5. Duplicate study selection
6. Duplicate data extraction
7. List of excluded studies with reasons *(critical)*
8. Description of included studies in adequate detail
9. Risk-of-bias assessment of included primary studies *(critical)*
10. Reported funding sources of included studies
11. Appropriate statistical methods for combining results *(critical)* — N/A for narrative SRs
12. Impact of risk of bias on the meta-analysis result
13. Risk of bias in the interpretation of results *(critical)*
14. Heterogeneity discussed satisfactorily
15. Investigation of publication bias *(critical)* — N/A for narrative SRs
16. Conflicts of interest reported

---

## 1. Distribution of overall confidence ratings (pilot, abstract-based)

| Confidence       | n  | %   |
|------------------|---:|----:|
| High             |  0 | 0.0% |
| Moderate         |  0 | 0.0% |
| Low              |  0 | 0.0% |
| Critically Low   | 33 | 100.0% |
| **Total**        | **33** | **100%** |

---

## 2. Top 10 highest-quality SRs (by Yes + ½·Partial Yes)

| # | First author | Year | Journal | PMID | Confidence | Yes | Partial | No | Cannot tell | Critical flaws | Justification for "Cannot tell" |
|---|---|---|---|---|---|---:|---:|---:|---:|---:|---|
| 1 | Ma | 2023 | Front Oncol | 37064127 | Critically Low | 5 | 2 | 5 | 4 | 4 | Items 5, 6, 12, 16 — abstract does not state dual selection/extraction, RoB-impact, or COI; no RoB or PB assessment reported |
| 2 | Yu | 2024 | Breast Cancer | 38826850 | Critically Low | 4 | 3 | 3 | 6 | 3 | Items 5, 6, 7, 10, 12, 16 — abstract does not describe dual processes, excluded-study list, funding, RoB-impact, or COI |
| 3 | Wang | 2025 | Oncology | 39899993 | Critically Low | 3 | 4 | 3 | 6 | 3 | Items 5, 6, 7, 10, 12, 16 — same set of fields not derivable from abstract |
| 4 | Samiei | 2021 | JAMA Surg | 33881478 | Critically Low | 4 | 1 | 7 | 4 | 5 | Items 7, 10, 12, 16 — pooled-analysis design, abstract details N/I; no RoB tool described in abstract |
| 5 | Kelly | 2009 | Acad Radiol | 19345896 | Critically Low | 3 | 2 | 5 | 6 | 5 | Items 5, 6, 7, 10, 12, 16 — older SR, abstract scant on methodology |
| 6 | Mocellin | 2015 | Int J Cancer | 26084763 | Critically Low | 3 | 2 | 5 | 6 | 5 | Items 5, 6, 7, 10, 12, 16 |
| 7 | van Nijnatten | 2015 | Eur J Surg Oncol | 26329781 | Critically Low | 2 | 3 | 5 | 6 | 5 | Items 5, 6, 7, 10, 12, 16 |
| 8 | Geng | 2016 | PLoS One | 27606623 | Critically Low | 2 | 3 | 5 | 6 | 5 | Items 5, 6, 7, 10, 12, 16 |
| 9 | de Wild | 2024 | Br J Surg | 38531689 | Critically Low | 2 | 3 | 3 | 5 | 3 | Items 5, 6, 7, 10, 16 — narrative SR (no MA → 11, 12, 15 N/A) |
| 10 | Abdulla | 2026 | Ann Surg Oncol | 41545613 | Critically Low | 2 | 3 | 5 | 6 | 4 | Items 5, 6, 7, 10, 12, 16 |

---

## 3. Top 10 lowest-quality SRs (by critical-flaw count)

| # | First author | Year | Journal | PMID | Critical flaws | Major gaps |
|---|---|---|---|---|---:|---|
| 1 | Tan | 2011 | J Surg Oncol | 21456092 | 6 | No protocol; search not described; no RoB; no PB |
| 2 | Boland | 2025 | Eur J Surg Oncol | 40009931 | 6 | No protocol; search not described; no RoB; no PB |
| 3 | El Hage Chehade | 2016 | Am J Surg | 27671032 | 6 | No protocol; search not described; no RoB; no PB |
| 4 | Xing | 2006 | Br J Surg | 16329089 | 6 | No protocol; search not described; no RoB; no PB |
| 5 | Gnant | 2022 | Curr Opin Oncol | 36083127 | 5 | Narrative SR; no protocol; search not described; no RoB |
| 6 | Mamounas | 2012 | J Clin Oncol | 23032615 | 5 | Narrative SR; no protocol; search not described; no RoB |
| 7 | Vázquez | 2022 | Clin Transl Oncol | 36153763 | 5 | Narrative SR; no protocol; search not described; no RoB |
| 8 | Banys-Paluchowski | 2023 | Scand J Surg | 36642957 | 5 | Narrative SR; no protocol; search not described; no RoB |
| 9 | Nagaraja | 2014 | J Gastrointest Oncol | 24772341 | 5 | No protocol; no RoB; no PB |
| 10 | Lin | 2022 | Ann Surg Oncol | 35018590 | 5 | No protocol; no RoB; no PB |

---

## 4. Methodological observations across the body of evidence

Frequency of unreported / inadequate items (out of 33 SRs):

| Item | Description | n "No" | n "Cannot tell" | n problematic | % problematic |
|---:|---|---:|---:|---:|---:|
| 1 | PICO components | 0 | 0 | 0 | 0% |
| 2 | Pre-registered protocol *(C)* | 32 | 0 | 32 | 97% |
| 3 | Justified study designs | 31 | 0 | 31 | 94% |
| 4 | Comprehensive search *(C)* | 8 | 0 | 8 | 24% |
| 5 | Duplicate selection | 0 | 31 | 31 | 94% |
| 6 | Duplicate extraction | 0 | 31 | 31 | 94% |
| 7 | List of excluded studies *(C)* | 0 | 33 | 33 | 100% |
| 8 | Detailed description of included studies | 10 | 0 | 10 | 30% |
| 9 | Risk-of-bias assessment *(C)* | 29 | 0 | 29 | 88% |
| 10 | Funding sources of included studies | 0 | 33 | 33 | 100% |
| 11 | Appropriate statistical methods *(C)* | 0 | 0 | 0 | 0% |
| 12 | Impact of RoB on results | 0 | 25 | 25 | 76% |
| 13 | RoB in interpretation *(C)* | 31 | 0 | 31 | 94% |
| 14 | Heterogeneity discussion | 23 | 0 | 23 | 70% |
| 15 | Publication bias *(C)* | 24 | 0 | 24 | 73% |
| 16 | Conflicts of interest | 0 | 33 | 33 | 100% |

*(C) = critical item per AMSTAR-2 algorithm.*

The most consistently unreported items are #7 (list of excluded studies), #10 (funding of included studies), and #16 (COI of underlying primary studies) — none of the 33 SRs reported these in their abstracts. Items #5, #6, and #12 will most likely move from "Cannot tell" to "Yes" or "Partial Yes" in the majority of post-2015 SRs once full text is consulted.

---

## 5. Recommendation for evidence synthesis

**Primary synthesis (Moderate + High confidence):** 0 SRs at pilot scoring.

*(none meet the High/Moderate threshold based on abstract-only scoring; full-text rescoring is essential and is expected to lift several reviews — particularly Samiei 2021, de Wild 2024, Wang 2025, Yu 2024, Ma 2023, Abdulla 2026 — into the Low or Moderate band.)*

**Sensitivity analysis only (Low + Critically Low):** 33 SRs at pilot scoring.

---

## 6. Per-SR full scoring — sortable table (by year)

| PMID | First author | Year | Journal | Design | I1 | I2 | I3 | I4 | I5 | I6 | I7 | I8 | I9 | I10 | I11 | I12 | I13 | I14 | I15 | I16 | Yes | Partial | No | C/T | Crit. flaws | Confidence |
|---|---|---:|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---:|---:|---:|---:|---:|---|
| 16329089 | Xing | 2006 | Br J Surg | MA | Y | N | N | N | C/T | C/T | C/T | PY | N | C/T | Y | C/T | N | PY | N | C/T | 2 | 2 | 6 | 6 | 6 | Critically Low |
| 19345896 | Kelly | 2009 | Acad Radiol | SR | Y | N | N | PY | C/T | C/T | C/T | PY | N | C/T | Y | C/T | N | Y | N | C/T | 3 | 2 | 5 | 6 | 5 | Critically Low |
| 19716287 | van Deurzen | 2009 | Eur J Cancer | SR | Y | N | N | PY | C/T | C/T | C/T | PY | N | C/T | NMA | NMA | N | N | NMA | C/T | 1 | 2 | 5 | 5 | 4 | Critically Low |
| 21456092 | Tan | 2011 | J Surg Oncol | MA | Y | N | N | N | C/T | C/T | C/T | N | N | C/T | PY | C/T | N | N | N | C/T | 1 | 1 | 8 | 6 | 6 | Critically Low |
| 23032615 | Mamounas | 2012 | J Clin Oncol | SR (inferred) | PY | N | N | N | C/T | C/T | C/T | PY | N | C/T | NMA | NMA | N | N | NMA | C/T | 0 | 2 | 6 | 5 | 5 | Critically Low |
| 22938899 | Moody | 2012 | Surgery | MA | Y | N | N | PY | C/T | C/T | C/T | PY | N | C/T | PY | C/T | N | N | N | C/T | 1 | 3 | 6 | 6 | 5 | Critically Low |
| 24772341 | Nagaraja | 2014 | J Gastrointest Oncol | MA | Y | N | N | PY | C/T | C/T | C/T | N | N | C/T | PY | C/T | N | N | N | C/T | 1 | 2 | 7 | 6 | 5 | Critically Low |
| 25458227 | Schipper | 2014 | Eur J Radiol | SR | Y | N | N | PY | C/T | C/T | C/T | PY | N | C/T | NMA | NMA | N | N | NMA | C/T | 1 | 2 | 5 | 5 | 4 | Critically Low |
| 26084763 | Mocellin | 2015 | Int J Cancer | MA | Y | N | N | PY | C/T | C/T | C/T | PY | N | C/T | Y | C/T | N | Y | N | C/T | 3 | 2 | 5 | 6 | 5 | Critically Low |
| 26329781 | van Nijnatten | 2015 | Eur J Surg Oncol | MA | Y | N | PY | PY | C/T | C/T | C/T | PY | N | C/T | Y | C/T | N | N | N | C/T | 2 | 3 | 5 | 6 | 5 | Critically Low |
| 27671032 | El Hage Chehade | 2016 | Am J Surg | MA | Y | N | N | N | C/T | C/T | C/T | PY | N | C/T | PY | C/T | N | N | N | C/T | 1 | 2 | 7 | 6 | 6 | Critically Low |
| 27606623 | Geng | 2016 | PLoS One | MA | Y | N | N | PY | C/T | C/T | C/T | PY | N | C/T | PY | C/T | N | Y | N | C/T | 2 | 3 | 5 | 6 | 5 | Critically Low |
| 29383405 | Krug | 2018 | Strahlenther Onkol | SR | PY | N | PY | Y | C/T | C/T | C/T | PY | N | C/T | NMA | NMA | N | N | NMA | C/T | 1 | 3 | 4 | 5 | 4 | Critically Low |
| 30311642 | Tee | 2018 | Br J Surg | MA | Y | N | N | PY | C/T | C/T | C/T | PY | N | C/T | PY | C/T | N | N | N | C/T | 1 | 3 | 6 | 6 | 5 | Critically Low |
| 30312200 | Simons | 2019 | Ann Surg | MA | Y | N | N | PY | C/T | C/T | C/T | PY | N | C/T | PY | C/T | N | PY | N | C/T | 1 | 4 | 5 | 6 | 5 | Critically Low |
| 33881478 | Samiei | 2021 | JAMA Surg | Pooled | Y | N | N | PY | Y | Y | C/T | N | N | C/T | Y | C/T | N | N | N | C/T | 4 | 1 | 7 | 4 | 5 | Critically Low |
| 33810544 | Swarnkar | 2021 | Cancers | Pooled | Y | N | N | Y | C/T | C/T | C/T | PY | N | C/T | PY | C/T | N | N | N | C/T | 2 | 2 | 6 | 6 | 5 | Critically Low |
| 34325383 | Cao | 2021 | Breast | MA | Y | N | N | PY | C/T | C/T | C/T | PY | N | C/T | PY | C/T | N | N | N | C/T | 1 | 3 | 6 | 6 | 5 | Critically Low |
| 35018590 | Lin | 2022 | Ann Surg Oncol | MA | Y | N | N | PY | C/T | C/T | C/T | N | N | C/T | PY | C/T | N | N | N | C/T | 1 | 2 | 7 | 6 | 5 | Critically Low |
| 35502768 | Song | 2022 | Cancer Med | MA | Y | N | N | PY | C/T | C/T | C/T | PY | N | C/T | PY | C/T | N | PY | N | C/T | 1 | 4 | 5 | 6 | 5 | Critically Low |
| 36083127 | Gnant | 2022 | Curr Opin Oncol | SR (inferred) | PY | N | N | N | C/T | C/T | C/T | N | N | C/T | NMA | NMA | N | N | NMA | C/T | 0 | 1 | 7 | 5 | 5 | Critically Low |
| 36153763 | Vázquez | 2022 | Clin Transl Oncol | SR | Y | N | N | N | C/T | C/T | C/T | N | N | C/T | NMA | NMA | N | N | NMA | C/T | 1 | 0 | 7 | 5 | 5 | Critically Low |
| 36560842 | Pantiora | 2023 | Br J Surg | MA | PY | N | N | PY | C/T | C/T | C/T | N | PY | C/T | PY | C/T | N | N | N | C/T | 0 | 4 | 6 | 6 | 4 | Critically Low |
| 36642957 | Banys-Paluchowski | 2023 | Scand J Surg | SR (inferred) | PY | N | N | N | C/T | C/T | C/T | N | N | C/T | NMA | NMA | N | PY | NMA | C/T | 0 | 2 | 6 | 5 | 5 | Critically Low |
| 37064127 | Ma | 2023 | Front Oncol | Pooled | Y | Y | N | PY | Y | Y | C/T | PY | N | C/T | Y | C/T | N | N | N | C/T | 5 | 2 | 5 | 4 | 4 | Critically Low |
| 38531689 | de Wild | 2024 | Br J Surg | SR | Y | N | N | PY | C/T | C/T | C/T | PY | PY | C/T | NMA | NMA | N | Y | NMA | C/T | 2 | 3 | 3 | 5 | 3 | Critically Low |
| 38826850 | Yu | 2024 | Breast Cancer | MA | Y | N | N | PY | C/T | C/T | C/T | PY | PY | C/T | Y | C/T | N | Y | Y | C/T | 4 | 3 | 3 | 6 | 3 | Critically Low |
| 39742366 | Vasigh | 2024 | Breast J | MA | Y | N | N | PY | C/T | C/T | C/T | N | N | C/T | PY | C/T | N | N | N | C/T | 1 | 2 | 7 | 6 | 5 | Critically Low |
| 39899993 | Wang | 2025 | Oncology | MA | Y | N | N | PY | C/T | C/T | C/T | PY | PY | C/T | Y | C/T | PY | Y | N | C/T | 3 | 4 | 3 | 6 | 3 | Critically Low |
| 40009931 | Boland | 2025 | Eur J Surg Oncol | MA | PY | N | N | N | C/T | C/T | C/T | PY | N | C/T | PY | C/T | N | N | N | C/T | 0 | 3 | 7 | 6 | 6 | Critically Low |
| 40186790 | Man | 2025 | Breast Cancer | Pooled | Y | N | N | PY | C/T | C/T | C/T | PY | N | C/T | Y | C/T | N | N | N | C/T | 2 | 2 | 6 | 6 | 5 | Critically Low |
| 40317154 | Ding | 2025 | J Cancer Res Ther | Pooled | Y | N | N | PY | C/T | C/T | C/T | N | N | C/T | Y | C/T | N | N | N | C/T | 2 | 1 | 7 | 6 | 5 | Critically Low |
| 41545613 | Abdulla | 2026 | Ann Surg Oncol | MA | Y | N | N | PY | C/T | C/T | C/T | PY | N | C/T | Y | C/T | PY | N | N | C/T | 2 | 3 | 5 | 6 | 4 | Critically Low |

**Legend.** Y = Yes; PY = Partial Yes; N = No; C/T = Cannot tell; NMA = No meta-analysis (item not applicable for narrative SR). Critical items: 2, 4, 7, 9, 11, 13, 15.

---

## 7. Sortable summary by AMSTAR-2 confidence (and within stratum, by year)

All 33 SRs are currently in the **Critically Low** band (pilot scoring). Within the band, ranking by ascending number of critical flaws (lower is better):

| Rank | PMID | First author | Year | Journal | Design | Critical flaws |
|---:|---|---|---:|---|---|---:|
| 1 | 38531689 | de Wild | 2024 | Br J Surg | SR | 3 |
| 2 | 38826850 | Yu | 2024 | Breast Cancer | MA | 3 |
| 3 | 39899993 | Wang | 2025 | Oncology | MA | 3 |
| 4 | 19716287 | van Deurzen | 2009 | Eur J Cancer | SR | 4 |
| 5 | 25458227 | Schipper | 2014 | Eur J Radiol | SR | 4 |
| 6 | 29383405 | Krug | 2018 | Strahlenther Onkol | SR | 4 |
| 7 | 36560842 | Pantiora | 2023 | Br J Surg | MA | 4 |
| 8 | 37064127 | Ma | 2023 | Front Oncol | Pooled | 4 |
| 9 | 41545613 | Abdulla | 2026 | Ann Surg Oncol | MA | 4 |
| 10 | 19345896 | Kelly | 2009 | Acad Radiol | SR | 5 |
| 11 | 22938899 | Moody | 2012 | Surgery | MA | 5 |
| 12 | 23032615 | Mamounas | 2012 | J Clin Oncol | SR (inferred) | 5 |
| 13 | 24772341 | Nagaraja | 2014 | J Gastrointest Oncol | MA | 5 |
| 14 | 26084763 | Mocellin | 2015 | Int J Cancer | MA | 5 |
| 15 | 26329781 | van Nijnatten | 2015 | Eur J Surg Oncol | MA | 5 |
| 16 | 27606623 | Geng | 2016 | PLoS One | MA | 5 |
| 17 | 30311642 | Tee | 2018 | Br J Surg | MA | 5 |
| 18 | 30312200 | Simons | 2019 | Ann Surg | MA | 5 |
| 19 | 33810544 | Swarnkar | 2021 | Cancers | Pooled | 5 |
| 20 | 33881478 | Samiei | 2021 | JAMA Surg | Pooled | 5 |
| 21 | 34325383 | Cao | 2021 | Breast | MA | 5 |
| 22 | 35018590 | Lin | 2022 | Ann Surg Oncol | MA | 5 |
| 23 | 35502768 | Song | 2022 | Cancer Med | MA | 5 |
| 24 | 36083127 | Gnant | 2022 | Curr Opin Oncol | SR (inferred) | 5 |
| 25 | 36153763 | Vázquez | 2022 | Clin Transl Oncol | SR | 5 |
| 26 | 36642957 | Banys-Paluchowski | 2023 | Scand J Surg | SR (inferred) | 5 |
| 27 | 39742366 | Vasigh | 2024 | Breast J | MA | 5 |
| 28 | 40186790 | Man | 2025 | Breast Cancer | Pooled | 5 |
| 29 | 40317154 | Ding | 2025 | J Cancer Res Ther | Pooled | 5 |
| 30 | 16329089 | Xing | 2006 | Br J Surg | MA | 6 |
| 31 | 21456092 | Tan | 2011 | J Surg Oncol | MA | 6 |
| 32 | 27671032 | El Hage Chehade | 2016 | Am J Surg | MA | 6 |
| 33 | 40009931 | Boland | 2025 | Eur J Surg Oncol | MA | 6 |

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*Generated from `02_amstar2/amstar2_scores.csv` (machine-readable). Re-scoring on full text scheduled before manuscript submission.*
