Advertisement

Assessment of Textbook Outcome After Surgery for Stage I/II Non-small Cell Lung Cancer

      Outcomes after cancer resection are traditionally measured individually. Composite metrics, or textbook outcomes, bundle outcomes into a single value to facilitate assessments of quality. We propose a composite outcome for non–small cell lung cancer resections, examine factors associated with the outcome, and evaluate its effect on overall survival. We queried the National Cancer Database for patients with stage I/II non-small cell lung cancer who underwent sublobar resection, lobectomy, or pneumonectomy from 2010 to 2016. We defined the metric as margin-negative resection, sampling of ≥10 lymph nodes, length of stay <75th percentile, no 30-day mortality, no readmission, and receipt of indicated adjuvant therapy. Multivariable logistic regression, Cox proportional hazards modeling, survival analyses, and propensity score matching were used to identify factors associated with the outcome and overall survival. Of 88,208 patients, 70,149 underwent lobectomy, 14,922 underwent sublobar resection, and 3,137 underwent pneumonectomy. Textbook outcome was achieved in 26.3% of patients. Failure to achieve the outcome was most commonly driven by inadequate nodal assessment. Textbook outcome was more likely after minimally invasive surgical approaches (aOR = 1.47; P< 0.001) relative to open resection and less likely after sublobar resection (aOR = 0.20; P< 0.001) relative to lobectomy. Achievement of textbook outcome was associated with an 9.6% increase in 5-year survival (P< 0.001), was independently associated with improved survival (aHR = 0.72; P < 0.001), and remained strongly associated with survival independent of resection extent after propensity matching. One in 4 patients undergoing non-small cell lung cancer resection achieve textbook outcome. Textbook outcome is associated with improved survival and has value as a quality metric.

      GRAPHICAL ABSTRACT

      Keywords

      Abbreviations:

      LOS (Length of stay), NSCLC (Non-small cell lung cancer), US (United States), TO (Textbook outcome), NCDB (National Cancer Database), CoC (Commission on Cancer), MIS (Minimally invasive surgery)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Seminars in Thoracic and Cardiovascular Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      REFERENCES

        • Fong Y.
        Textbook outcome nomograms as multivariate clinical tools for building cancer treatment pathways and prognosticating outcomes.
        JAMA Surg. 2019; 154 (-e190572)e190572
        • Dimick J.B.
        • Staiger D.O.
        • Baser O.
        • et al.
        Composite measures for predicting surgical mortality in the hospital.
        Health Affairs. 2009; 28: 1189-1198
        • Dimick J.B.
        • Staiger D.O.
        • Osborne N.H.
        • et al.
        Composite measures for rating hospital quality with major surgery.
        Health Serv Res. 2012; 47: 1861-1879
        • Kolfschoten N.E.
        • Kievit J.
        • Gooiker G.A.
        • et al.
        Focusing on desired outcomes of care after colon cancer resections; Hospital variations in 'textbook outcome'.
        Eur J Surg Oncol. 2013; 39: 156-163
        • van der Kaaij R.T.
        • de Rooij M.V.
        • van Coevorden F.
        • et al.
        Using textbook outcome as a measure of quality of care in oesophagogastric cancer surgery.
        Br J Surg. 2018; 105: 561-569
        • van Roessel S.
        • Mackay T.M.
        • van Dieren S.
        • et al.
        Textbook outcome: nationwide analysis of a novel quality measure in pancreatic surgery.
        Ann Surg. 2020; 271: 155-162
        • Ten Berge M.G.
        • Beck N.
        • Steup W.H.
        • et al.
        Textbook outcome as a composite outcome measure in non-small-cell lung cancer surgery.
        Eur J Cardiothorac Surg. 2020; 59: 92-99
        • Dijs-Elsinga J.
        • Otten W.
        • Versluijs M.M.
        • et al.
        Choosing a hospital for surgery: The importance of information on quality of care.
        Med Decis Making. 2010; 30: 544-555
        • Commission on Cancer
        National Cancer Database.
        American College of Surgeons. Quality Programs, Chicago, IL2020
        • American College of Surgeons, American Cancer Society
        Lung participant user file.
        Commission on Cancer. ed. National Cancer Database: Commission on Cancer, Chicago, IL2017
        • Edge S.B.
        • Byrd D.R.
        • Carducci M.A.
        • et al.
        AJCC Cancer Staging Manual.
        Springer, New York2010
        • Greene F.
        • Page D.
        • Fleming I.
        • et al.
        AJCC Cancer Staging Manual.
        sixth edition. Springer, Chicago2002
        • Busweiler L.A.
        • Schouwenburg M.G.
        • van Berge Henegouwen M.I.
        • et al.
        Textbook outcome as a composite measure in oesophagogastric cancer surgery.
        Br J Surg. 2017; 104: 742-750
        • Sweigert P.J.
        • Eguia E.
        • Baker M.S.
        • et al.
        Assessment of cancer center variation in textbook oncologic outcomes following colectomy for adenocarcinoma.
        J Gastrointestinal Surg. 2020; 25: 775-785
        • Network NCC
        Non Small Cell Lung Cancer (Version 6.2020).
        in: NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). 2020
        • Krell R.W.
        • Girotti M.E.
        • Dimick J.B.
        Extended length of stay after surgery: complications, inefficient practice, or sick patients?.
        JAMA surg. 2014; 149: 815-820
        • Cancer ACoSCo
        Lung measure specifications.
        Cancer Programs Practice Profile Reports. Cancer Co, ed. American College of Surgeons, Chicago2020
        • Gridelli C.
        • Langer C.
        • Maione P.
        • et al.
        Lung cancer in the elderly.
        J Clin Oncol. 2007; 25: 1898-1907
        • Morgensztern D.
        • Samson P.S.
        • Waqar S.N.
        • et al.
        Early mortality in patients undergoing adjuvant chemotherapy for non–small cell lung cancer.
        J Thoracic Oncol. 2018; 13: 543-549
        • R Core Team
        R: A Language and Environment for Statistical Computing.
        3.6.1 ed. R Foundation for Statistical Computing, Vienna, Austria2019
        • RStudio Team
        RStudio: Integrated Development for R.
        RStudio, PBC., 2019 (1.2.1335 ed. Boston, MA)
        • Kulshrestha S.
        • Bunn C.
        • Patel P.M.
        • et al.
        Textbook oncologic outcome is associated with increased overall survival after esophagectomy.
        Surgery. 2020;
        • Sweigert P.J.
        • Eguia E.
        • Baker M.S.
        • et al.
        Assessment of textbook oncologic outcomes following pancreaticoduodenectomy for pancreatic adenocarcinoma.
        J Surg Oncol. 2020; 121: 936-944
        • Wiseman J.T.
        • Ethun C.G.
        • Cloyd J.M.
        • et al.
        Analysis of textbook outcomes among patients undergoing resection of retroperitoneal sarcoma: A multi-institutional analysis of the US Sarcoma Collaborative.
        J Surg Oncol. 2020; 122: 1189-1198
        • Aquina C.T.
        • Truong M.
        • Justiniano C.F.
        • et al.
        Variation in adequate lymph node yield for gastric, lung, and bladder cancer: Attributable to the surgeon, pathologist, or hospital?.
        Ann surg oncol. 2020; 27: 4093-4106
        • Yan T.D.
        • Black D.
        • Bannon P.G.
        • McCaughan B.C.
        Systematic review and meta-analysis of randomized and nonrandomized trials on safety and efficacy of video-assisted thoracic surgery lobectomy for early-stage non-small-cell lung cancer.
        in: Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]: Centre for Reviews and Dissemination (UK). 2009
        • Paul S.
        • Altorki N.K.
        • Sheng S.
        • et al.
        Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: A propensity-matched analysis from the STS database.
        The J Thoracic and Cardiovasc Surg. 2010; 139: 366-378
        • Whitson B.A.
        • Groth S.S.
        • Duval S.J.
        • Swanson S.J.
        • Maddaus M.A.
        Surgery for early-stage non-small cell lung cancer: A systematic review of the video-assisted thoracoscopic surgery versus thoracotomy approaches to lobectomy.
        The Ann Thoracic Surg. 2008; 86: 2008-2018
        • Abdelsattar Z.M.
        • Allen M.S.
        • Shen K.R.
        • et al.
        Variation in hospital adoption rates of video-assisted thoracoscopic lobectomy for lung cancer and the effect on outcomes.
        The Ann Thoracic Surg. 2017; 103: 454-460
        • Tsilimigras D.I.
        • Mehta R.
        • Merath K.
        • et al.
        Hospital variation in Textbook Outcomes following curative-intent resection of hepatocellular carcinoma: an international multi-institutional analysis.
        HPB. 2020; 22: 1305-1313
        • Yendamuri S.
        • Dhillon S.S.
        • Groman A.
        • et al.
        Effect of the number of lymph nodes examined on the survival of patients with stage I non–small cell lung cancer who undergo sublobar resection.
        The J Thoracic and Cardiovasc Surg. 2018; 156: 394-402
        • Asamura H.
        • Okada M.
        • Saji H.
        • et al.
        Randomized Trial of Segmentectomy Compared to Lobectomy in Small-Sized Peripheral Non-Small Cell Lung Cancer.
        in: American Association for Thoracic Surgery 101st Annual Meeting, Virtual2021
        • Altorki N.K.
        • Wang X.
        • Wigle D.
        • et al.
        Perioperative mortality and morbidity after sublobar versus lobar resection for early-stage non-small-cell lung cancer: Post-hoc analysis of an international, randomised, phase 3 trial (CALGB/Alliance 140503).
        The Lancet Respiratory Med. 2018; 6: 915-924
        • Darling G.E.
        • Allen M.S.
        • Decker P.A.
        • et al.
        Number of lymph nodes harvested from a mediastinal lymphadenectomy: Results of the randomized, prospective american college of surgeons oncology group Z0030 trial.
        Chest. 2011; 139: 1124-1129
        • Ijsseldijk M.A.
        • Shoni M.
        • Siegert C.
        • et al.
        Oncological outcomes of lobar resection, segmentectomy, and wedge resection for T1a non–small-cell lung carcinoma: A systematic review and meta-analysis.
        Sem in Thoracic and Cardiovasc Surg. 2020; 32: 582-590
        • Darling G.E.
        • Allen M.S.
        • Decker P.A.
        • et al.
        Randomized trial of mediastinal lymph node sampling versus complete lymphadenectomy during pulmonary resection in the patient with N0 or N1 (less than hilar) non-small cell carcinoma: Results of the American College of Surgery Oncology Group Z0030 Trial.
        J Thorac Cardiovasc Surg. 2011; 141: 662-670

      Linked Article

      • Commentary: Quality vs. conformity
        Seminars in Thoracic and Cardiovascular SurgeryVol. 34Issue 4
        • Preview
          A prevailing metric of surgical quality within healthcare systems striving for recognition as highly reliable organizations is conformity to established pathways of care delivery. Deviation from the agreed upon standards raises concern for suboptimal or potentially unsafe medical care. A common example is adherence to early recovery after surgery (ERAS) protocols with the understanding that complications are reduced corresponding with shorter lengths of stay. On a grander scale, establishment of textbook surgeries for common operations extrapolates similar concepts throughout the country.
        • Full-Text
        • PDF
      • Commentary: Using the National Cancer Database to Create a Surgical Outcomes Composite Index. Is this Textbook or Cliffs Notes?
        Seminars in Thoracic and Cardiovascular SurgeryVol. 34Issue 4
        • Preview
          The term “textbook outcome” (TO) was coined in 2012 by Kolfschoten and colleagues to describe a summarizing measure for short-term outcomes after colon cancer resections.1 This measure is binary, awarded only when 6 distinct “desirable”measures are all accomplished (30 day survival, R0 resection, no reintervention, no colostomy, no complications and hospitalization of 14 days or less). The name choice for this index is, however, misleading. A textbook provides a comprehensive analysis of a problem and does not abbreviate.
        • Full-Text
        • PDF