Impact of Minimally Invasive Approach on Attainment of a Textbook Oncologic Outcome Following Gastrectomy for Gastric Cancer: A Review of the National Cancer Database

BACKGROUND

Textbook oncologic outcome (TOO) is a composite outcome measure realized when all desired short-term quality metrics are met following an oncologic operation. This study examined whether minimally invasive gastrectomy (MIG) is associated with increased likelihood of TOO attainment.

METHODS

The 2010-2016 National Cancer Database was queried for patients with gastric cancer who underwent gastrectomy. Surgical approach was described as open (OG), laparoscopic (LG), or robotic (RG). TOO was defined as having met five metrics: R0 resection, AJCC compliant lymph node evaluation (n ≥ 15), no prolonged length of stay (< 75th percentile by year), no 30-day readmission, and receipt of guideline-accordant systemic therapy.

RESULTS

Of 21,015 patients identified, 5708 (27.2%) underwent MIG (LG = 21.9%, RG = 5.3%). Patients who underwent RG were more likely to have met all TOO criteria, and consequently TOO. Logistic regression models revealed that patients undergoing MIG were significantly more likely to attain TOO. MIG was associated with a higher likelihood of adequate LAD, no prolonged LOS, and concordant chemotherapy. Patients who underwent LG and achieved TOO had the highest median OS (86.7 months), while the OG non-TOO cohort experienced the lowest (34.6 months). The median OS for the RG TOO group was not estimable; however, the mortality rate (.7%) was the lowest of the six cohorts.

CONCLUSION

RG resulted in a significantly increased likelihood of TOO attainment. Although TOO is associated with increased OS across all surgical approaches, attainment of TOO following MIG is associated with a statistically significantly higher median OS.

Impact of safety-net hospital burden on achievement of textbook oncologic outcomes following resection in for stage I-IV colorectal cancer

BACKGROUND AND OBJECTIVES

Textbook oncologic outcome (TOO) is a benchmark for high-quality surgical cancer care but has not been studied at safety-net hospitals (SNH). The study sought to understand how SNH burden affects TOO achievement in colorectal cancer.

METHODS

The National Cancer Database was queried for colorectal cancer patients who underwent resection for stage I-III plus stage IV with liver-only metastases (2010-2019). TOO was defined as R0 resection, AJCC-compliant lymphadenectomy (>12 nodes), no prolonged LOS, no 30-day mortality/readmission, and receipt of stage-appropriate adjuvant chemotherapy.

RESULTS

Of 487,195 patients, 66.7% achieved TOO. Lower achievement was explained by adequate lymphadenectomy (87.3%), non-prolonged LOS (76.3%), and receipt of adjuvant chemotherapy in stage III (60.3%) and IV (54.1%). Treatment at high burden hospitals (HBH, >10% Medicaid/uninsured) was a predictor of non-TOO (Stage I/II: OR 0.83, III: OR 0.86, IV: OR 0.83; all p < 0.001). Achieving TOO was associated with decreased mortality (Stage I/II: HR 0.49, III: HR 0.48, IV: HR 0.57; all p < 0.001), and HBH treatment was a predictor of mortality (Stage I/II: HR 1.09, III: HR 1.05, IV: HR 1.07; all p < 0.05).

CONCLUSIONS

Treatment at higher SNH burden hospitals was associated with less frequent TOO achievement and increased mortality. Quality improvement targets include receipt of adjuvant chemotherapy and avoidance of prolonged LOS.

Textbook oncologic outcomes and regionalization among patients undergoing hepatic resection for intrahepatic cholangiocarcinoma

BACKGROUND AND OBJECTIVES

Textbook oncologic outcome (TOO) and its association with regionalization of care for intrahepatic cholangiocarcinoma (ICC) have not been evaluated.

METHODS

We identified patients who underwent hepatic resection for ICC between 2004 and 2018 from the National Cancer Database. Facilities were categorized by annual hepatectomy volume for ICC. TOO was defined as no 90-day mortality, margin-negative resection, no prolonged hospitalization, no 30-day readmission, receipt of appropriate adjuvant therapy, and adequate lymphadenectomy. Multivariable regression was used to evaluate the association between annual hepatectomy volume and TOO.

RESULTS

A total of 5359 patients underwent liver resection for ICC. TOO was achieved in 11.2% (n = 599) of patients. Inadequate lymphadenectomy was the largest impediment to achieving TOO. After adjusting for patient, pathologic, and facility characteristics, high volume facilities had 67% increased odds of achieving TOO (Ref.: low volume; high volume: odds ratio 1.67, 95% confidence interval: 1.24-2.25; p < 0.001). Patients treated at high-volume centers who achieved a TOO had better overall survival (OS) versus patients treated at low-volume facilities (low volume vs. high volume; median OS, 47.3 vs. 71.1 months, p < 0.05).

CONCLUSIONS

A composite oncologic measure, TOO, provides a comprehensive insight into the performance of liver resection and regionalization of surgical care for ICC.

Surgical treatment of gastric adenocarcinoma: Are we achieving textbook oncologic outcomes for our patients?

BACKGROUND AND OBJECTIVES

Composite measures are increasingly used to assess quality of care in surgical oncology. We sought to define the incidence of "textbook oncologic outcome" (TOO) following resection of gastric adenocarcinoma among a large, international cohort of patients.

METHODS

Gastric adenocarcinoma patients undergoing resection between 2000 and 2020 were identified from an international database. TOO was defined as margin-negative resection, examination of ≥16 lymph nodes, no prolonged length-of-stay (LOS), no 30-day mortality, and stage-appropriate receipt of chemotherapy.

RESULTS

Among a total of 910 patients, 321 patients (35.3%) achieved a postoperative TOO. While failure to evaluate ≥16 lymph nodes (n = 591, 65.0%) and receipt of chemotherapy (n = 651, 71.5%) had the greatest negative impact on the ability to obtain a TOO, no 30-day mortality (n = 880, 96.7%), margin-negative resection (n = 831, 91.3%), and no extended LOS (n = 706, 77.6%) were more commonly achieved. No postoperative complications (OR: 0.44; 95% CI: 0.31-0.63) and T1a/T1b-stage disease (OR: 2.87; 95% CI: 1.59-5.18) were independently associated with achieving a TOO (p < 0.05). The odds of achieving a TOO improved over time (p-trend < 0.05), which was largely attributable to improved odds of evaluating ≥16 lymph nodes (2010-2014 vs. 2000-2004: OR, 5.21; 95% CI: 3.22-8.45).

CONCLUSIONS

Only about one in three patients achieved a TOO following resection of gastric adenocarcinoma. Odds of TOO increased over time, largely due to improved lymph node evaluation.