Prognostic Value of National Comprehensive Cancer Network Lung Cancer Resection Quality Criteria

Abstract

Background The National Comprehensive Cancer Network (NCCN) surgical resection guidelines for non-small-cell lung cancer (NSCLC) recommend anatomic resection, negative margins, examination of hilar/intrapulmonary lymph nodes, and examination of 3 or more mediastinal nodal stations. We examined the survival impact of these guidelines. Methods Population-based observational study using patient-level data from all curative-intent NSCLC resections from 2004–2013 at 11 institutions in 4 contiguous Dartmouth Hospital Referral Regions in 3 US states. We used an adjusted Cox proportional hazards model to assess the overall survival impact of attaining NCCN guidelines. Results Of 2,429 eligible resections,91% were anatomic, 94% had negative margins, 51% sampled hilar nodes, and 26% examined three or more mediastinal nodal stations. Only 17% of resections met all four criteria, however there was a significant increasing trend from 2% in 2004 to 39% in 2013 (p<0.001). Compared to patients whose surgery missed one or more parameters, the hazard ratio for patients whose surgery met all four criteria was 0.71 (95% confidence interval: 0.59–0.86, p<0.001). Margin status and the nodal staging parameters were most strongly linked with survival. Conclusions Attainment of NCCN surgical quality guidelines was low, but improving, over the past decade in this cohort from a high lung cancer mortality region of the US. The NCCN quality criteria, especially the nodal examination criteria, were strongly associated with survival. The quality of nodal examination should be a focus of quality improvement in NSCLC care.

Visiting an old foe: distant recurrence following R0 lobectomy for pathological N0 lung adenocarcinoma

“…Similar findings were observed in a meta-analysis by Mollberg and colleagues of patients with stage I NSCLC (13). As per NCCN guidelines, LVI is a "high-risk factor" that may provide the basis for consideration of adjuvant therapy on a case-by-case basis, although isolated LVI is currently not an indication for adjuvant therapy (level 2A evidence) (10,11,14).…”

Image‐guided surgery in cancer: A strategy to reduce incidence of positive surgical margins

“…Numerous groups recommend obtaining negative margins for surgical resection of lung cancer, including the International Association for the Study of Lung Cancer (IASLC) (Rami‐Porta, Wittekind, & Goldstraw, ) and the NCCN (National Comprehensive Cancer Network, ). However, compliance with surgical guidelines is poor, as 6–18% of patients undergoing surgery for lung cancer have positive margins, and a further 74% do not undergo sampling of stations, potentially leaving residual disease (Little et al, ; Osarogiagbon et al, ; Predina et al, ; Wakeam et al, ). Patients with PSMs have worse overall survival (OS) by about 50% across all stages (Hancock et al, ; Osarogiagbon et al, ).…”

Progress in the Management of Early-Stage Non–Small Cell Lung Cancer in 2017

“…101 2017 brought evidence that directly linked specific process measures (attainment of the NCCNrecommended quality of resection [anatomic resection, negative margins, examination of N1 lymph nodes and examination of a minimum of three mediastinal nodal stations] and the ratio of the observed-to-expected rate of incomplete resection) to survival: two readily measured surgical quality benchmarks. 102,103 Adjuvant and Neoadjuvant Therapies Treatment with 4 cycles of cisplatin-based chemotherapy following complete surgical resection in patients with stage II-IIIA NSCLC remains the standard of care in the adjuvant setting, offering an approximately 5% overall survival (OS) benefit. 26,104 Patients with stage I disease and tumors >4 cm likely also derive benefit from adjuvant chemotherapy.…”