Closing the gap: Contribution of surgical best practices to outcome differences between high‐ and low‐volume centers for lung cancer resection

• Published in: Cancer medicine (Malden, MA) Vol. 9; no. 12; pp. 4137 - 4147
• Main Authors: Itzstein, Mitchell S., Lu, Rong, Kernstine, Kemp H., Halm, Ethan A., Wang, Shidan, Xie, Yang, Gerber, David E.
• Format: Journal Article
• Language: English
• Published: United States John Wiley & Sons, Inc 01.06.2020; John Wiley and Sons Inc; Wiley
• Subjects: Aged; Best practice; Cancer therapies; Carcinoma, Non-Small-Cell Lung - pathology; Carcinoma, Non-Small-Cell Lung - surgery; Clinical Cancer Research; Comorbidity; Female; Follow-Up Studies; guidelines; Hispanic people; Histology; Hospitals, High-Volume - statistics & numerical data; Hospitals, Low-Volume - statistics & numerical data; Humans; lobectomy; Lung cancer; Lung Neoplasms - pathology; Lung Neoplasms - surgery; Lymph Node Excision - mortality; Lymph nodes; Lymphatic system; Male; Medical screening; Metastasis; National Cancer Database (NCDB); Non-small cell lung carcinoma; Original Research; Pneumonectomy - mortality; Practice Patterns, Physicians' - standards; Prognosis; Retrospective Studies; Small cell lung carcinoma; Surgical outcomes; Survival Rate; thoracic surgery; Variables; volume‐outcome relationship; United States > US; guidelines; lobectomy; volume-outcome relationship; National Cancer Database (NCDB); thoracic surgery
• ISSN: 2045-7634; 2045-7634
• DOI: 10.1002/cam4.3055

Background Clinical outcomes for resected early‐stage non‐small cell lung cancer (NSCLC) are superior at high‐volume facilities, but reasons for these differences remain unclear. Understanding these differences and optimizing outcomes across institutions are critical to the management of the increasing incidence of these cases. We evaluated the extent to which surgical best practices account for resected early‐stage NSCLC outcome differences between facilities according to case volume. Methods We performed a retrospective cohort study for clinical stage 1 or 2 NSCLC undergoing surgical resection from 2004 to 2013 using the National Cancer Database (NCDB). Surgical best practices (negative surgical margins, lobar or greater resection, lymph node (LN) dissection, and examination of > 10 LNs) were compared between the highest and lowest quartile volumes. Results A total of 150,179 patients were included in the cohort (89% white, 53% female, median age 68 years). In a multivariate model, superior overall survival (OS) was observed at highest volume centers compared to lowest volume centers (hazard ratio (HR) = 0.89; 95% CI, 0.82‐0.96; P = .002). After matching for surgical best practices, there was no significant OS difference (HR = 0.95; 95% CI, 0.87‐1.05; P = .32). Propensity score‐adjusted HR estimates indicated that surgical best practices accounted for 54% of the numerical OS difference between low‐volume and high‐volume centers. Each surgical best practice was independently associated with improved OS (all P ≤ .001). Conclusion Quantifiable and potentially modifiable surgical best practices largely account for resected early‐stage NSCLC outcome differences observed between low‐ and high‐volume centers. Adherence to these guidelines may reduce and potentially eliminate these differences. High‐volume facilities have been observed to be associated with improved outcomes compared to low‐volume facilities for non‐small cell lung cancer surgery. We found that controlling for surgical quality measures minimizes outcome differences between facility types, suggesting that high‐quality care provision for lung cancer surgery requires compliance with surgical quality measures.