This study was submitted to the Duke University Institutional Review Board for review and was determined to be exempt (Pro00116649). This study involved surgeon-participants who evaluated GPT-generated responses to frequently asked questions. No patient data were used. To maintain participant confidentiality, all data were analyzed in aggregate. All GPT inquiries and survey questions were asked in English. Consent from participants was implied through voluntary completion of the survey. No compensation was provided to participants.

Preliminary questions were developed by CVL and DAS. Questions for this study were developed by sourcing frequently asked questions about colon, liver, and pancreatic cancers from 7 hospital patient information and nonprofit cancer foundation websites [25-31]. This methodology was used in an earlier study examining LLMs as a tool for patient education in lung cancer surgery [32]. Questions on general disease information, including signs and symptoms, staging and treatment options, surgical eligibility, and operative risks, were formulated for colon, hepatic, and pancreatic cancers using identical language for each condition. Standardized language was used to determine the suitability of LLMs for delivering useful abdominal cancer education as applied to each of the conditions. Additional questions were created to address common patient concerns related to postoperative recovery and potential adverse outcomes following abdominal cancer surgery.

The preliminary survey questions were initially evaluated for relevance and alignment with patient phrasing through subjective assessment by 2 general surgery residents. Residents were prompted to assess the frequency with which the proposed questions were encountered in practice to evaluate the survey questions based on clinical relevance. Residents were also prompted to evaluate the survey questions based on alignment with patient phrasing, to suggest phrasing revisions for items that received a Likert score ≤3 on a 5-point scale, and to propose additional relevant questions not addressed by the survey. At this stage, 8 questions were removed and 4 were added per resident feedback. Additional questions were adjusted accordingly. After piloting scenarios with residents, all questions were run sequentially through a publicly available, proprietary version of ChatGPT (GPT-4o; released on May 13, 2024) [1,33], on March 9, 2025, in Durham, United States. ChatGPT-4o is based on a proprietary GPT-4-class pretrained base LLM that has been instruction-tuned for conversational use. No additional model fine-tuning or retraining was performed through this study. ChatGPT was prompted to answer in paragraph form without additional contextual information. As in prior studies, a new chat entry was posed for each question [32].

A Qualtrics survey was formulated with the final 28 questions and LLM responses. This survey was piloted by our surgeon expert, ANM, who provided final revisions for question phrasing. Table 1 lists the finalized questions prompted into ChatGPT. Revised questions were newly run through ChatGPT, and the Qualtrics survey was adjusted accordingly.

An anonymous survey was disseminated to surgical faculty at a single institution using Qualtrics, a secure, web-based survey platform. Eligible participants were board-certified surgeons who had completed fellowship training in surgical oncology or colorectal surgery and were actively practicing at the time of the study. Surgeons were identified through publicly available web-based colorectal surgery and surgical oncology faculty rosters and were invited to participate via an email containing the anonymous Qualtrics link. The Qualtrics platform is commonly used in academic research, as it permits investigators to design surveys, test them for accessibility and functionality, distribute them electronically as a web link or QR code, and export result reports. The final list of questions and ChatGPT-4o–generated responses graded by surgeons is included in Multimedia Appendix 1. On the Qualtrics platform, prior to initiating the survey, surgeons were instructed to grade responses for accuracy, quality, and tangibility on a 5-point Likert scale (1=“poor,” 5=“excellent”). The survey defined accuracy as the medical or social correctness of a response, quality as the extent to which a response is well-written and comprehensive, and tangibility as the degree to which the response provides actionable guidance.

After evaluating ChatGPT responses, surgeon respondents were prompted to self-report demographics, including age, sex, years as a practicing surgeon post training, AI frequency in practice, and prior experience with AI. Furthermore, a free response section permitted surgeons to share thoughts or concerns. Respondents were assessed for comfort with patient-AI use through the question, “If a patient informed you they are using publicly available AI (eg, ChatGPT) for health information, how comfortable would you be with encouraging them to use AI following this survey?” Available answer choices included “very uncomfortable,” “uncomfortable,” “neither comfortable nor uncomfortable,” “comfortable,” and “very comfortable.”

LLM-generated responses were separately graded for readability using the Flesch-Kincaid Reading Grade Level (FKRGL) and Flesch Reading Ease (FRE) formulas through the Readability Statistics tool in Microsoft Word Version 16.105.2 [34]. FRE and FKRGL formulas calculate readability based on the average sentence and word length of a text. The FKRGL scale assesses approximate grade level of a text, with an FKRGL score of 5 corresponding to a US 5th-grade reading level. The FRE scale measures readability from 0, unreadable text, to 100, very easily readable text. Both scales were selected as they are validated tools for grading text readability, and they are commonly used by professionals to evaluate the readability of patient-directed health care information [34].

A post hoc analysis was performed to assess FKRGL, FRE scores, and content similarity for GPT responses under 3 prompting conditions: version 1 represented the response to the original question provided for reference; version 2 consisted of responses to the original question preceded by a prompt to “Answer at a 5th-grade level;” and version 3 comprised responses to questions that were reworded to a 5th-grade reading level by ChatGPT-4o prior to response generation. Four questions were selected for post hoc analysis to provide a focused analysis of question-phrasing and prompting on readability. Questions were selected based on having the highest original FKRGL score within 4 different domains and to ensure representation of each malignancy type. Content similarity was graded by 2 independent graders, CVL and DAS, using a 5-point Likert scale (1=not similar, 5=very similar).

Respondent answers were collected and analyzed in aggregate. Descriptive statistics for categorical variables were reported as frequencies with percentages; continuous variables were reported as mean with SD or median with IQR, where appropriate. Analyses were calculated using Microsoft Excel Version 16.95.4; formulas used included =MEDIAN() for median, =AVERAGE() for mean, =STDEV() for SD, and =QUARTILE.INC() to derive the IQR.

Of the 12 eligible surgeons contacted, 7 responded, resulting in a survey response rate of 58.3%. All respondents were academic surgeons at a single institution. The median reported respondent categorical age range was 35‐44 years. Most survey respondents were male (4/7, 57.1%). Respondents had practiced surgery for a median of 7 (IQR 4‐13) years post training. When assessed for frequency of AI use, 1 respondent reported using AI “daily,” 2 reported using AI “weekly,” 3 reported using AI “monthly,” and 1 reported using AI “almost never.”

When asked to evaluate the quality of responses, experts consistently rated answers between “good” and “very good” to “excellent,” with an aggregate mean response rating of 3.54 (SD 0.28). Across all domains (Table 2), questions related to staging and treatment consistently performed worse, receiving an average rating of 3.33 (SD 0.30), while questions about adverse outcomes tended to perform best, receiving an average rating of 3.73 (SD 0.27). Table 2 indicates the median and IQR of respondent grade for each question, with quality scores ranging from 3.00 to 4.50 and IQR ranging from 2.50-3.50 to 3.25-5.00. The question indicating postoperative urinary tract infection (UTI) received the highest median quality score of 4.50 (3.25‐5.00), between “very good” and “excellent.”

Similar to quality, when asked to evaluate the accuracy of responses, experts generally rated responses between “good” and “very good” to “excellent,” with an aggregate mean response rating of 3.57 (SD 0.34). Across all domains, questions related to staging and treatment performed the worst, receiving an average rating of 3.29 (SD 0.38). Conversely, questions about adverse outcomes consistently performed best, receiving an average rating of 3.83 (SD 0.24). Median response accuracy ratings ranged from 3.00 to 4.50 with IQRs ranging from 2.50-3.50 to 3.25-5.00. Questions regarding postoperative wound dehiscence (Q24), pulmonary embolism (Q26), and UTI management (Q27) received the highest median accuracy grading of 4.50 (IQR 3.25-5.00).

When asked to evaluate the tangibility, or how “actionable” a response was, experts likewise consistently rated responses between “good” and “very good” to “excellent,” with an aggregate mean response rating of 3.62 (SD 0.29). Across all domains, questions pertaining to staging and treatment performed the worst, receiving the lowest mean tangibility score of 3.47 (SD 0.30), while questions about adverse outcomes performed best, receiving an average rating of 3.86 (SD 0.28). The median response ratings ranged from 3.00 to 4.50 with IQR scores ranging from 2.50-3.50 to 3.25-5.00. Questions regarding postoperative wound dehiscence (Q24), pulmonary embolism (Q26), UTI management (Q27), and infection prevention (Q28) received the highest median tangibility grading of 4.50 (IQR 3.25-5.00).

When assessing readability (Table 3), ChatGPT-4o–generated responses read at an average FKRGL of 14.51 (SD 1.86), requiring some level of college education for adequate comprehension. Response FKRGL scores ranged from 10.8 to 18.1. A question regarding wound dehiscence received the lowest grade score, 10.8, while a question regarding pancreatic cancer surgery candidacy received the highest score, 18.1. The mean FRE score of ChatGPT-4o–generated responses was 28.8 (SD 9.87), corresponding to a college graduate reading level and indicating low readability. Response FRE scores ranged from 11.7 to 48.0. A question regarding colon cancer surgery recovery had the worst readability, with an FRE score of 11.7. As with FKRGL grading, a question regarding wound dehiscence had the highest ease of readability with an FRE score of 48.0.

Four questions were selected for post hoc analysis shown in Table 4 (Q1, Q7, Q11, and Q15). These questions had an original median FKRGL score of 15.6 (IQR 14.4-16.7; range 12.9‐18.1) and FRE score of 18.1 (IQR 14.6-24.7; range: 11.7‐36.8). When GPT-4o was queried to respond to select questions to the level of a 5th-grade reader, the median FKRGL score decreased to 7.1 (IQR 6.1-8.3; range: 5.9‐9.0) and FRE increased to 73.8 (IQR 66.6-79.3; range: 60.1‐80.9). Two independent graders (CVL and DAS) found responses to result in a mean content similarity of 3.88 (SD 0.25) in comparison to the original response. Responses to questions that were rephrased by GPT, with prompting to query at a 5th-grade reading level, resulted in a median FKRGL score of 14.5 (IQR 13.2-15.4; range: 11.6 to 15.8), a median FRE score of 32.0 (IQR 27.0-37.7; range: 21.4‐45.0), and a mean content similarity of 4.63 (SD 0.25) to original responses. The raters had identical scores for 50% (4/8) of responses, with the other 4 responses differing by 1 on the 5-point Likert scale.

Numerous inaccuracies within GPT-generated responses were detected by a surgeon-expert concerning general disease information and postoperative recovery. The following feedback has been modified for clarity but maintains the original intent. In Q2 (signs and symptoms of colon cancer), rectal bleeding was mistakenly described as a systemic symptom, while it is a local symptom that may lead to secondary systemic symptoms, including fatigue due to anemia. For Q10 (pancreatic cancer surgery recovery), “light activities,” which are often defined as walking or activities of daily living in the surgical setting, were resumed while a patient was admitted, instead of the written 6 to 12 weeks following discharge. Likewise, for Q11 (colon cancer surgery recovery), certain “light activities” could be resumed sooner. For Q12 (liver cancer surgery recovery), the mention of major hepatectomy as treatment was notably absent.

Regarding quality, numerous content gaps were noted. For Q3 (signs and symptoms of liver cancer), the response described chronic liver disease symptoms; these are common for patients with primary liver cancers but less frequent in the setting of secondary liver cancers (ie, colorectal cancer with liver metastases). Regarding Q4 (stages and treatments of pancreatic cancer), genetic testing should be included when discussing targeted therapies. For Q7 (pancreatic cancer surgery eligibility), discussion of the biology of resectability, which is accounted for by tumor markers such as Ca 19‐9, was notably absent. Regarding Q20 (staying near the hospital following discharge), while listed, it is not emphasized that staying nearby is unnecessary unless the patient lives far away. Furthermore, the question could be enhanced by including discussion of local housing options with case management or a social worker. For Q25 (postoperative infection), concern for dehiscence is not explicitly stated, and the volume of drainage should be addressed sooner, as high volume may indicate dehiscence.

When assessed on their comfort level with patients using publicly available AI for health information, 57.1% (4/7) of providers reported being “comfortable,” 14.3% (1/7) reported being “neither comfortable nor uncomfortable,” 14.3% (1/7) reported being “uncomfortable,” and 14.3% (1/7) reported being “very uncomfortable.” Regarding provider discomfort, when asked for questions or concerns pertaining to the study, 1 respondent reported “The answers should be designed for a lower health literacy level.” Another physician expressed concern over direct patient use of ChatGPT, primarily citing lack of supervision and noting “health is not something you want to leave up to a robot. There will always be intricacies that cannot be understood by AI.”

This study is among the first to evaluate ChatGPT-4o as a patient information resource for individuals preparing for or recovering from surgery for abdominal malignancies [20,35]. As patient self-use of LLMs for medical information is increasing [14], it is essential to assess the content quality, safety, and comprehensibility of GPT-generated responses. Through gaining a deeper understanding of the strengths and weaknesses present within LLMs, providers may help patients be aware of such options and help them navigate the use of these sources. The current study’s results indicate that ChatGPT-4o may serve as a useful patient information resource, with most responses rated from “good” to “very good to excellent” in quality, accuracy, and tangibility. Notably, the lowest rated responses received a median score of 3.0, corresponding to a “good” rating, whereas the highest rated responses received a score of 4.50, corresponding to a rating between “very good” and “excellent.” However, there is still room for improvement in generated responses prior to the endorsement of ChatGPT as a “gold-standard” patient resource. While most providers were “comfortable” having patients use publicly available AI for health information, 42.9% (3/7) of providers did not report feeling “comfortable” having patients use publicly available AI for health information, with 2 reported being “uncomfortable” or “very uncomfortable.” Physicians cited concerns regarding patient use of ChatGPT, noting poor response comprehensibility and lack of supervision, factors likely contributing to their lack of comfort in patient use of ChatGPT. Moreover, this study raises concerns about the comprehensibility of the generated responses, as elevated FKGRL scores indicate that many require a postsecondary reading level for adequate understanding. Physicians should be aware that, in the context of patient use of LLMs for medical information, patients would benefit from instructions for use and monitoring for potential ChatGPT-derived misconceptions.

Information is scarce regarding the safety and accuracy of ChatGPT-generated responses in the perioperative setting for abdominal malignancies. Given the complex biological mechanisms and therapeutic management of gastrointestinal malignancies, it is critical to evaluate the quality of ChatGPT-generated content. The presented data suggest that, although ChatGPT responses averaged as “good” or “very good,” scores were highly question- and domain-dependent. Given its high overall ratings, ChatGPT may serve as an advantageous tool for patients to develop a baseline knowledge of their disease prior to clinical encounters. However, numerous inaccuracies and content gaps were identified within responses. This is congruent with past work assessing ChatGPT’s use for thoracic surgery, where most responses likewise ranged from “good” to “very good,” minor inaccuracies were identified in each answer, and certain domains performed better than others [32]. Regarding abdominal malignancies, questions concerning staging and treatment received the lowest mean accuracy and quality scores. As such, providers should be encouraged to assess potential disease misconceptions that patients using ChatGPT may have and ensure they distribute comprehensive general disease information. Interestingly, ChatGPT-4o excelled in answering questions pertaining to adverse outcomes following surgery. As such, ChatGPT may help guide patients seeking proper management for postoperative complications.

The present study suggests that patient information regarding abdominal malignancies presented by ChatGPT-4o may produce material that is poorly comprehensible for many of the intended population due to requirements of high health literacy and education level. One surgeon expressed that responses should be written for a lower health literacy level. This is consistent with the findings of a high grade level requirement for adequate comprehensibility (FKRGL score), averaging a grade level of 14.5. An FKRGL of 14.5 represents a reading level requiring some level of college education. Current recommendations suggest that patient resources should be tailored to a 5th-grade reading level for accessibility [36,37].

Readability as a limitation of ChatGPT has been previously reported in the literature [15,22]. Past work regarding cervical spine surgery likewise noted high FKRGL scores to limit ChatGPT-3.5’s use as a patient resource. After prompting ChatGPT to provide answers at a 6th-grade reading level, answers decreased from a grade level of 13.5 to 11.2, though remaining persistently elevated. Notably, the present study used similar techniques that successfully produced responses at a lower reading level with ChatGPT-4o. For select questions, the median FKRGL score prior to rephrasing or prompting was 15.6 (IQR 14.4-16.7). Remarkable improvement was noted upon prompting GPT to respond to the level of a 5th-grade reader, decreasing the median FKRGL score, or US grade level, to 7.1 (IQR 6.1-8.3). This work suggests that improvements within ChatGPT-4o may allow for more comprehensible responses, given appropriate prompting. Notably, there was a less meaningful drop in median FKRGL score, from 15.6 (IQR 14.4-16.7) to 14.5 (IQR 13.2-15.4), when ChatGPT was used to rephrase questions to be asked at the reading level of a 5th grader. Prior to modification, the median FRE score for select questions was 18.1 (IQR 14.6-24.7). Consistent with FKRGL trends, prompting questions resulted in a more substantial increase in FRE score (median FRE 73.8, IQR 66.6-79.3), indicating markedly improved readability, compared with rephrasing (median FRE 32, IQR 27.0-37.7). This suggests that explicitly requesting ChatGPT to produce responses at a lower level may be more effective in improving readability than adjusting question phrasing. Although contents similar to original questions were better for the latter group than the former (4.63/5 versus 3.88/5), most key concepts were retained within both groups. As such, prompting ChatGPT to answer at a lower grade level may improve readability without significantly sacrificing content. Therefore, providers should be encouraged to assess patient use of LLMs for medical questions and provide patients with a menu for how to prompt ChatGPT to answer at an appropriate grade level if relevant.

While comprehensibility without prompting educational level can be a limitation for the intended patient population, ChatGPT may serve as a useful tool for providers and trainees. Past work in public health has found AI chatbots to be a useful educational tool for medical students in answering complex medical questions [38]. Within the present study, questions 1 to 9 pertain to “signs and symptoms,” “stages and treatment,” and “surgery eligibility”; these questions may be asked by clinicians or learners. While patient readability was limited by a high mean grade level required, the ratings typically ranged from “good” to “very good” in quality, accuracy, and tangibility. This suggests that ChatGPT-4o can serve as a useful resource for physicians and medical trainees, given a higher health literacy than the general population. To further evaluate the use and comprehensibility of ChatGPT as a patient resource, future investigations should involve patient perspectives.

This study has several limitations. First, the small sample size (n=7) of surgical oncologists grading the responses substantially limits statistical power and the reliability of the findings. The single-institutional nature of the study further limits generalizability, as physician responses may reflect regional practice patterns and institutional biases. Future validation should evaluate larger, multi-institutional cohorts to confirm reproducibility and evaluate external validity. Second, the survey incorporated subjective assessments which may limit reproducibility, as concepts graded, such as “quality,” “accuracy,” and “tangibility,” are abstract. To enhance reproducibility, standardized definitions of these domains were included on each page of the survey. Third, questions may not be well representative of patient language. Although questions were obtained from hospital websites and piloted with residents to improve alignment with patient phrasing, they may not encompass the full spectrum of patient inquiries nor the variability of patients’ health literacy. As only 28 questions were assessed across 3 malignancies, the nature of the questions is limited in scope and may not represent all questions patients may ask pertaining to their diagnosed malignancy. Moreover, questions are broad, pertaining to “colon,” “pancreas,” “liver,” or “belly” cancers, without specifying types and stages.

This preliminary study indicates that, while publicly accessible ChatGPT may serve as a useful patient resource, its use as an unsupervised source of information for patients with abdominal malignancies has distinct limitations. Providers should be aware that many of their patients are accessing ChatGPT and recognize that developing an understanding of its strengths and limitations can help them guide their patients to enable its best use. Inaccuracies, gaps in information, and poor readability were identified in ChatGPT-generated content, suggesting patients may benefit from physician guidance. Providers should be prepared to properly support their patients reporting ChatGPT use by counseling techniques such as prompting questions to tailor responses to their educational level. The data herein indicate that this is critical for the interpretation of the information by patients, as without this guidance, the answers are directed to an educational level of college or above.