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

Abstract

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.

Keywords: non-small cell lung cancer; quality; textbook outcome.

Figure 1:

Graphical abstract of textbook outcome after surgery for stage I/II non-small cell lung cancer. Textbook outcomes are achieved in 26.4% of patients and are associated with improved overall survival. Textbook outcome is a useful composite metric that can assist in comparisons of surgeon and facility performance for non-small cell lung cancer resections.

Figure 2:

Percent of patients achieving textbook outcome after resections for NSCLC, 2010–2016. X-axis represent years of period of study, Y-axis depicts percentage of annual operations achieving textbook outcome.

Figure 3:

Textbook outcome per parameter and composite rates for resections for NSCLC. Bars represent per parameter rate for each component criterion of textbook outcome. Line represents percentage of patients meeting each criterion and all criteria previous to it. LOS = length of stay.

Figure 4:

Unadjusted Kaplan-Meier survival analysis comparing patients with and without textbook outcome undergoing lobectomy and sublobar resections. Curve indicates survival with 95% confidence interval.

Figure 5:

Kaplan-Meier survival analysis comparing patients with and without textbook outcome undergoing lobectomy and sublobar resections after propensity match analysis. Curve indicates survival with 95% confidence interval.