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Understanding the Role of Textbook Oncologic Outcomes in Pathologic Nodal Disease After Lobectomy for NSCLC
Ahmed Alnajar1, Karishma Kodia1, Nestor Villamizar1, Dao Nguyen1, Syed Razi2.
1University of Miami, Miami, FL, USA, 2Memorial Healthcare System, Hollywood, FL, USA.

Background:Textbook oncologic outcome (TOO) is a composite metric for quality of oncologic care. We aim to understand how TOO could improve non-small cell cancer (NSCLC) survival outcomes. Methods:We queried the National Cancer Database between 2010 and 2017. Inclusion criteria included lobectomy for NSCLC with tumor size < 7 cm and pathologic node positive disease (N1 and N2). Exclusion criteria included neoadjuvant chemotherapy. TOO was defined as complete surgical resection with negative margins, receipt of adjuvant chemotherapy within 3 months, no 30-day mortality, no prolonged hospital stay, and no unplanned readmission. Using logistic regression, we identified factors associated with TOO. We evaluated the effect of TOO on overall survival using Kaplan-Meier and Cox regression analyses. Results:We identified 11,274 patients, of whom 48% achieved TOO. Adjusting for confounders, TOO achievement was associated with minimally invasive surgery (MIS) and higher volume centers. Patients with Medicare/Medicaid, higher Charlson-Deyo comorbidity indices, lymphovascular invasion, or conversion from MIS were less likely to achieve TOO. Notably, facility type (academic vs. comprehensive community) did not correlate with TOO.  Five-year overall survival (OS) was 53% in TOO and 44% in non-TOO patients. Using multivariable analysis, TOO patients had higher overall survival (HR=0.81, 95% CI [0.76-0.86]; p< 0.001). Conclusions:Pathologic nodal disease after lung cancer resection has improved survival outcomes in patients who achieve TOO. TOO should be used as a quality benchmark at the institutional, regional, and national level to improve oncologic outcomes in node positive lung cancers.
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Table 1:

CharacteristicOR195% CI1p-value
age_cat
<60
>801.100.94, 1.290.2
60-690.990.89, 1.11>0.9
70-790.920.82, 1.040.2
sex
Male
Female1.070.99, 1.150.10
race_eth
Non-hispanic White
Hispanic0.970.77, 1.210.8
Non-hispanic Asian1.170.94, 1.450.2
Non-hispanic Black0.720.62, 0.83<0.001
Other/Unkown1.120.80, 1.580.5
insurance
Private Insurance
Medicare/Medicaid0.820.75, 0.90<0.001
Not Insured0.760.56, 1.030.074
Other0.970.74, 1.280.8
no_hsd
3
41.251.13, 1.38<0.001
10.870.77, 0.970.015
20.870.79, 0.970.009
cdcc_total_best
0
10.810.74, 0.88<0.001
20.720.63, 0.81<0.001
>=30.730.60, 0.890.002
appr_mini_convo
Open/Unspecified
MIS1.371.26, 1.49<0.001
MIS Converted0.840.70, 1.000.051
Year of Diagnosis0.960.94, 0.98<0.001
facility_type_cd
Community Cancer Program
Comprehensive Community Cancer Program1.030.85, 1.260.7
Academic/Research Program1.020.83, 1.260.9
Integrated Network Cancer Program0.980.79, 1.220.9
lymph_vasc
Not Present
Present0.960.89, 1.030.3
hospital_v
Low
High1.611.41, 1.83<0.001
Moderate1.301.17, 1.44<0.001
Very High1.881.54, 2.31<0.001
1OR = Odds Ratio, CI = Confidence Interval

Kaplan-Meier Survival:

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