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Observational Study
. 2017 May;103(5):1557-1565.
doi: 10.1016/j.athoracsur.2017.01.098. Epub 2017 Mar 31.

Prognostic Value of National Comprehensive Cancer Network Lung Cancer Resection Quality Criteria

Raymond U Osarogiagbon  1 , Meredith A Ray  2 , Nicholas R Faris  3 , Matthew P Smeltzer  4 , Carrie Fehnel  3 , Cheryl Houston-Harris  3 , Raymond S Signore  3 , Laura M McHugh  3 , Paul Levy  5 , Lynn Wiggins  6 , Vishal Sachdev  7 , Edward T Robbins  3
Affiliations
Observational Study

Prognostic Value of National Comprehensive Cancer Network Lung Cancer Resection Quality Criteria

Raymond U Osarogiagbon et al. Ann Thorac Surg. 2017 May.

Abstract

Background: The National Comprehensive Cancer Network (NCCN) surgical resection guidelines for non-small cell lung cancer recommend anatomic resection, negative margins, examination of hilar/intrapulmonary lymph nodes, and examination of three or more mediastinal nodal stations. We examined the survival impact of these criteria.

Methods: A population-based observational study was done using patient-level data from all curative-intent, non-small cell lung cancer resections from 2004 to 2013 at 11 institutions in four contiguous Dartmouth Hospital referral regions in three US states. We used an adjusted Cox proportional hazards model to assess the overall survival impact of attaining NCCN guidelines.

Results: Of 2,429 eligible resections, 91% were anatomic, 94% had negative margins, 51% sampled hilar nodes, and 26% examined three or more mediastinal nodal stations. Only 17% of resections met all four criteria; however, there was a significant increasing trend from 2% in 2004 to 39% in 2013 (p < 0.001). Compared with patients whose surgery missed one or more criteria, the hazard ratio for patients whose surgery met all four criteria was 0.71 (95% confidence interval: 0.59 to 0.86, p < 0.001). Margin status and the nodal staging criteria were most strongly linked with survival.

Conclusions: Attainment of NCCN surgical quality guidelines was low, but improving, over the past decade in this cohort from a high lung cancer mortality region of the United States. The NCCN quality criteria, especially the nodal examination criteria, were strongly associated with survival. The quality of nodal examination should be a focus of quality improvement in non-small cell lung cancer care.

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Figures

Figure 1
Figure 1
National Comprehensive Cancer Network lung cancer resection quality criteria attainment by year: a) anatomic resection; b) negative margins; c) hilar lymph node examination; d) examination of 3 or more mediastinal lymph node stations; e) all four criteria.
Figure 1
Figure 1
National Comprehensive Cancer Network lung cancer resection quality criteria attainment by year: a) anatomic resection; b) negative margins; c) hilar lymph node examination; d) examination of 3 or more mediastinal lymph node stations; e) all four criteria.
Figure 1
Figure 1
National Comprehensive Cancer Network lung cancer resection quality criteria attainment by year: a) anatomic resection; b) negative margins; c) hilar lymph node examination; d) examination of 3 or more mediastinal lymph node stations; e) all four criteria.
Figure 1
Figure 1
National Comprehensive Cancer Network lung cancer resection quality criteria attainment by year: a) anatomic resection; b) negative margins; c) hilar lymph node examination; d) examination of 3 or more mediastinal lymph node stations; e) all four criteria.
Figure 1
Figure 1
National Comprehensive Cancer Network lung cancer resection quality criteria attainment by year: a) anatomic resection; b) negative margins; c) hilar lymph node examination; d) examination of 3 or more mediastinal lymph node stations; e) all four criteria.
Figure 2
Figure 2
Survival impact of attaining National Comprehensive Cancer Network resection quality criteria: a) anatomic resection; b) negative margins; c) hilar node examination; d) three or more mediastinal stations.
Figure 2
Figure 2
Survival impact of attaining National Comprehensive Cancer Network resection quality criteria: a) anatomic resection; b) negative margins; c) hilar node examination; d) three or more mediastinal stations.
Figure 2
Figure 2
Survival impact of attaining National Comprehensive Cancer Network resection quality criteria: a) anatomic resection; b) negative margins; c) hilar node examination; d) three or more mediastinal stations.
Figure 2
Figure 2
Survival impact of attaining National Comprehensive Cancer Network resection quality criteria: a) anatomic resection; b) negative margins; c) hilar node examination; d) three or more mediastinal stations.
Figure 3
Figure 3
Survival impact of attaining National Comprehensive Cancer Network lung cancer resection quality criteria stratified by: a) the number of criteria met; b) whether, or not, all four criteria were met.
Figure 3
Figure 3
Survival impact of attaining National Comprehensive Cancer Network lung cancer resection quality criteria stratified by: a) the number of criteria met; b) whether, or not, all four criteria were met.
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