ASO Author Reflections: Variation in Adequate Lymph Node Yield: Current Status and Where Do We Go from Here?
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ASO AUTHOR REFLECTIONS
ASO Author Reflections: Variation in Adequate Lymph Node Yield: Current Status and Where Do We Go from Here? Christopher T. Aquina, MD, MPH1,2
, and Adan Z. Becerra, PhD3
1
Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY; 2Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH; 3Social and Scientific Systems, Silver Spring, MD
PAST
PRESENT
Numerous studies have demonstrated evidence of an association between higher lymph node yield and longer survival following potentially curative resection of numerous malignancies. Historically, there have been two contending viewpoints regarding the role of lymphadenectomy during oncologic resection. The Halstedian point of view states that lymph node dissection is important for both staging and survival. In contrast, the Cady-Fisher viewpoint disputes that cancer is a systemic disease, and lymphadenectomy is only valuable in obtaining more accurate staging and does not have a direct impact on survival. An additional argument is that lymph node yield is a quantifiable quality measure in that it acts as a surrogate for quality of surgical resection and overall cancer care, and thus indirectly affects survival.1 Regardless of the true underlying etiology, numerous organizations, including the American Joint Committee on Cancer (AJCC), National Comprehensive Cancer Network (NCCN), National Quality Forum (NQF), and American College of Surgeons’ Commission on Cancer (CoC), have released recommendations regarding the minimum number of lymph nodes that should be removed and assessed for various solid tumors, including lung (C 10), esophageal (C 15), stomach (C 15), pancreatic (C 12), colon (C 12), and bladder (C 2) cancer.2–4
Despite recommendations from national groups, obtaining an adequate lymph node yield has remained a problem with only modest improvement over time. In comparing 2004–2006 and 2012–2014 in New York State, there was a significant improvement in adequate lymph node yield for gastric cancer (39 vs 68%) but only a small improvement for lung (33 vs 38%) and bladder (65 vs 71%) cancer. Furthermore, wide variation in the rate of adequate lymph node yield was present across surgeons, pathologists, and hospitals following gastric (surgeons: 6–91%; pathologists: 6–87%; hospitals: 4–87%), lung (surgeons: 2–72%; pathologists: 5–67%; hospitals: 4–61%), and bladder (surgeons: 65–73%; pathologists: 63–77%; hospitals: 64–77%) cancer resection.5 Similarly, wide variation in the rate of adequate lymph node yield was also observed following colectomy for colon cancer (surgeons: 59–82%; pathologists: 26–91%; hospitals: 4–98%).6 Interestingly, the amount of variation attributable to differences between surgeons, pathologists, and hospitals appears to differ across organ systems. After adjusting for patient-level factors, the majority of variation is attributable to the hospital level for gastric (86%), lung (54%
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