Adherence to evidence-based surgical metrics improves outcomes in lung cancer.

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Adherence to evidence-based surgical metrics improves long-term outcomes in patients with early-stage lung cancer, but adherence varies widely among thoracic surgeons. These are among the key findings of a study published in JAMA Surgery that looked at the association between adherence to surgical quality metrics and overall survival among US veterans with early-stage non–small cell lung cancer (NSCLC).1 “Our study demonstrates that what happens in the operating room can substantially affect patient outcomes,” says lead author Brendan Heiden, MD, MPHS, a resident physician and research fellow in the Division of Cardiothoracic Surgery at Washington University in St. Louis, Missouri. Despite established guidelines on surgical quality metrics for optimizing long-term outcomes for patients undergoing curative-intent resection of NSCLC, adherence varies among thoracic surgeons. The impact this can have on long-term outcomes is demonstrated by the finding that patients had improved overall survival rates when medical staff adhered to intraoperative quality metrics. In the study, Dr Heiden and his colleagues retrospectively analyzed data on 9628 veterans who underwent surgical treatment for early NSCLC between 2006 and 2016 to first look at the quality of curative-intent resection delivered to each patient on the basis of adherence to five surgical quality metrics recommended in current treatment guidelines. The five metrics included timely surgery, use of a minimally invasive surgical approach, anatomic resection, adequate lymph node sampling, and negative surgical margins. To assess the association between adherence to surgical quality metrics and overall survival, they developed and used a surgical quality score called the Veterans Affairs Lung Cancer Operative Quality (VALCAN-O) score. The score ranges from 0 (no quality metrics met) to 13 (all quality metrics met), with a higher score representing progressively better overall survival adjusted for other risk factors (e.g., a history of smoking). Overall, 68.9% of the patients received timely surgery, 41.4% received a minimally invasive approach, 71.1% had a lobectomy, 5.5% had a segmentectomy, 34% had adequate lymph node sampling, and 96.7% had a negative surgical margin. At a median follow-up of 6.2 years, researchers found a substantial difference in median overall survival based on the VALCAN-O score: 2.6 years with a score of 0–5, 4.3 years with a score of 6–8, 6.3 years with a score of 9–11, and 7 years with a score of 12–13. These results were validated in a community cohort of more than 100,000 patients. “While several patient-, tumor-, and surgeon-specific factors may explain some of this variability, further efforts to standardize surgical quality are clearly needed in practice settings throughout the the US,” says Dr Heiden. “Adherence to data-driven surgical quality metrics will continue to be essential for optimizing lung cancer care as well as new and exciting multimodal treatment options on the horizon in early-stage lung cancer.”