Lymph Node Harvest as a Measure of Quality and Effect on Overall Survival in Esophageal Cancer: A National Cancer Database Assessment

Surgical therapy for esophageal cancer is the cornerstone of treatment, and the highest quality operation should lead to the highest cure rate. Evaluated lymph node (ELN) count is one quality measure that has been championed. The objective of this study was to explore ELN in esophagectomy, examine predictors of harvesting ≥12 nodes, and determine whether higher ELN improves overall survival (OS). ELN was examined in patients with resected esophageal cancer using the National Cancer Database from 2004 to 2013. In this study, 41,746 patients met the inclusion criteria. Fifty-two per cent of patients had 12 or more nodes harvested. Academic programs were most likely to harvest ≥12 nodes (58% of cases) compared with other programs (43-56% of cases). Seventy per cent of cases with ≥12 nodes harvested were performed at high-volume centers. Preoperative radiation or preoperative chemoradiation led to lower ELN (46% and 48%) versus preoperative chemotherapy alone (66%). Multivariate analysis showed that patients who had ≥12 nodes removed had better OS (Hazard Ratio 0.843 [95 confidence interval 0.820-0.867]). In addition, care at a high-volume facility, care at an academic facility, private insurance, and income ≥$63,000 were all associated with improved OS. Higher ELN count is associated with OS in patients with esophageal cancer. Patients who receive care at high-volume centers and academic centers are more likely to undergo more extensive lymphadenectomy. All centers should strive to examine at least 12 nodes to provide a quality esophagectomy.

Lymph Node Harvest as a Measure of Quality and Effect on Overall Survival in Esophageal Cancer: A National Cancer Database Assessment

Surgical therapy for esophageal cancer is the cornerstone of treatment, and the highest quality operation should lead to the highest cure rate. Evaluated lymph node (ELN) count is one quality measure that has been championed. The objective of this study was to explore ELN in esophagectomy, examine predictors of harvesting ≥12 nodes, and determine whether higher ELN improves overall survival (OS). ELN was examined in patients with resected esophageal cancer using the National Cancer Database from 2004 to 2013. In this study, 41,746 patients met the inclusion criteria. Fifty-two per cent of patients had 12 or more nodes harvested. Academic programs were most likely to harvest ≥12 nodes (58% of cases) compared with other programs (43–56% of cases). Seventy per cent of cases with ≥12 nodes harvested were performed at high-volume centers. Preoperative radiation or preoperative chemoradiation led to lower ELN (46% and 48%) versus preoperative chemotherapy alone (66%). Multivariate analysis showed that patients who had ≥12 nodes removed had better OS (Hazard Ratio 0.843 [95 confidence interval 0.820–0.867]). In addition, care at a high-volume facility, care at an academic facility, private insurance, and income ≥$63,000 were all associated with improved OS. Higher ELN count is associated with OS in patients with esophageal cancer. Patients who receive care at high-volume centers and academic centers are more likely to undergo more extensive lymphadenectomy. All centers should strive to examine at least 12 nodes to provide a quality esophagectomy.

Adherence to the BCLC guidelines and impact on overall survival

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Background: Multiple studies exist that validate the prognostic value of the Barcelona Clinic Liver Cancer (BCLC) staging. However, none have established a survival benefit to the treatment recommendations. The aim of this study was to evaluate the adherence to the BCLC guidelines at a rural tertiary care center, and to determine the effect of following the treatment recommendations on overall survival. Methods: A retrospective chart review was conducted for 97 patients newly diagnosed with hepatocellular carcinoma (HCC) from 2000 to 2012. The treatment choice was compared with the BCLC guidelines and percentage adherence calculated. Overall survival was estimated using the Kaplan-Meier method and the log rank test was used to test the difference between the two groups. Cox regression tests were used to determine independent effects of stage, treatment aggressiveness, and guideline adherence on survival. A p-value <0.05 was considered statistically significant. Results: Of 97 patients, 75% (n=73) were male. Median overall survival was 12.9 months. In 59.8% (n=58) of the patients, treatment was adherent to stage specific guidelines proposed by the BCLC classification. There was no significant difference in overall survival between the adherent and non-adherent groups (11.2 vs 14.1 months, p<0.98). However on stage specific survival analysis, we noted a significant survival benefit for adherence to the guidelines for early stage HCC (27.9 vs 14.1 months, p<0.05), but a decrease in survival for adherence in the end stage (20 days vs 9.3 months, p<0.01). On univariate analysis, more aggressive treatment was associated with increased survival (hazard ratio [HR], 0.4; 95% confidence interval [CI], 0.22 to 0.87; p = 0.018). Multivariate analysis revealed that adherence did not independently affect survival when stage and aggressiveness of treatment were included in the model (HR, 1.3; 95% CI, 0.76 to 2.2, p = 0.34). Conclusions: Although the BCLC guidelines serve as a practical guide to the management of patients with HCC, they are not universally practiced. These results indicate that survival of patients with hepatocellular cancer is determined by stage and aggressiveness of treatment, not adherence to BCLC guidelines.