Response to the Comment on “Textbook Outcome and Survival in Patients with Gastric Cancer: An Analysis of the Population Registry of Esophageal and Stomach Tumours of Ontario (PRESTO)”

Abstract

To examine the association between Textbook Outcome (TO)-a new composite quality measurement-and long-term survival in gastric cancer surgery. Background: Single-quality indicators do not sufficiently reflect the complex and multifaceted nature of perioperative care in patients with gastric adenocarcinoma. Methods: All patients undergoing gastrectomy for nonmetastatic gastric adenocarcinoma registered in the Population Registry of Esophageal and Stomach Tumours of Ontario (PRESTO) between 2004 and 2015 were included. TO was defined according to negative margins; >15 lymph nodes sampled; no severe complications; no re-interventions; no unplanned ICU admission; length of stay 21 days; no 30-day readmission; and no 30-day mortality. Three-year survival was estimated using the Kaplan-Meier method. A marginal multivariable Cox proportional-hazards model was used to estimate the association between achieving TO metrics and long-term survival. E-value methodology was used to assess for risk of residual confounding. Results: Of the 1836 patients included in this study, 402 (22%) achieved all TO metrics. TO patients had a higher 3-year survival rate compared to non-TO patients (75% vs 55%, log-rank P < 0.001). After adjustments for covariates and clustering within hospitals, TO was associated with a 41% reduction in mortality (adjusted hazards ratio 0.59, 95% confidence interval 0.48, 0.72, P < 0.001). These results were robust to potential residual confounding. Conclusions: Achieving TO is strongly associated with improved long-term survival in gastric cancer patients and merits further focus in surgical quality improvement efforts.

Surgical treatment of gastric adenocarcinoma: Are we achieving textbook oncologic outcomes for our patients?

“…For example, examination of an adequate number of lymph nodes (i.e., ≥16) was only achieved in less than two-thirds of patients. The proportion of patients who had guideline-compliant lymph node evaluation in the current study was slightly higher than in the study by Busweiler et al (54%) and the report by Levy et al (57%) 20,39. However, unlike the current study, these authors utilized 15 lymph nodes as a cut-off value to define an adequate lymphadenectomy.…”

“…Similarly, in the cohort from the PRESTO, the odds of achieving a TOO increased by approximately 8% every year from 2004 to 2015, with patients undergoing surgery in 2015 being 88% more likely to achieve it than patients treated in 2004. 39 In a separate Dutch study, the authors also noted that odds of achieving TOO increased over time from approximately 15% in 2000−2004 to nearly 54% in 2015−2020. 20 In aggregate, data from the current -the increase in lymph node evaluation.…”

“…38 and no 30-day mortality. 39 Of note, in the cohort from the PRESTO study, achieving a TOO was associated with improved long-term outcomes: TOO patients had a higher 3-year survival rate and a consistent reduction in mortality compared with non-TOO patients.…”

Current and future strategies for radiation therapy in gastric cancer

“…Importantly, technical details and quality matters, especially for local modalities such as surgery and radiotherapy. Quality indicators for surgery including resection margin status, adequacy of nodal sampling, and extent of nodal dissection has been well described 7 . There is consensus that D2 dissection represent the gold standard of clinical care 8,9 .…”

“…Quality indicators for surgery including resection margin status, adequacy of nodal sampling, and extent of nodal dissection has been well described. 7 There is consensus that D2 dissection represent the gold standard of clinical care. 8,9 We will discuss the role of radiotherapy within the expectation that state of the art surgery (i.e., R0 and D2 dissection) is used.…”