The Fable of Babel and Building a Foundation for Quality

Abstract

There is no question that accurate staging, particularly of the mediastinum, plays a central role in our current approach to lung cancer. The status of nodal involvement has a profound impact on prognosis, and it is a critical decision point in our treatment algorithms. One could equate initiating a treatment plan without clearly defining the mediastinal node status with setting out on a journey without knowing exactly where one is trying to go, as opposed to programming a global positioning system for the shortest, fastest (or perhaps most cost-effective?) route. There is also no question that, at least in North America, we have not done a good job of assessing nodes in lung cancer. An assessment of surgical lung cancer cases in 2001 found that only 27% of patients underwent preoperative invasive mediastinal staging, and in half of the mediastinoscopies not even a single node was sampled.1 A more recent study associated better long-term outcomes with a greater extent of preoperative staging. 2 There are data that addressing variations in care would save many times more lives than what we hail as “breakthrough advances” in new drugs. 2‐4