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A 21-Year Analysis of Lymph Node Trends in Colon Cancer: Do Quality Measures Really Matter?
Danielle M. Hari*1, Alexander Stojadinovic2,3, Anna M. Leung1, Connie Chiu1, Myung-Shin Sim1, Anton Bilchik4,5
1Surgical Oncology, John Wayne Cancer Institute, Santa Monica, CA; 2Surgery, Walter Reed National Military Medical Center, Bethesda, MD; 3Surgery, United States Military Cancer Institute, Bethesda, MD; 4Surgery, California Oncology Research Institute,, Santa Monica, CA; 5Surgery, David Geffen School of Medicine at University of California, Los Angeles, CA
Background: Lymph node (LN) number has been endorsed as a quality measure (QM) in colon cancer (CC) because of the impact on survival. However, the current mandate requiring > 12 LNs has been questioned. We evaluated whether compliance of this QM has improved and whether this has impacted overall survival (OS).
Methods: The Surveillance, Epidemiology, and End Results (SEER) Database was queried to identify patients (pts) with pathologically confirmed, localized and regional CC (Stage I-III) diagnosed between 1988 and 2008. Interval trends in lymph node (LN) harvest and OS were evaluated over time (Year Strata (YS): 1988-1993, 1994-1998, 1999-2003 and 2004-2008).
Results: For pts with local and regional CC, 181,035 had confirmed LN examinations. For Stages I-III, there has been a dramatic improvement in compliance for pts with > 12 LNs harvested over the recent two 5-yr periods (19, 21, 18% respectively, p<0.0001) whereas previously only a 5-7% increase occurred over time (see Table). This rise in compliance had the greatest effect on the increased survival trend for stage II CC with minimal change for those with Stage I and Stage III CC. Irrespective of LN examined there has been a significant increase in OS for all stages over time (p<.0001).
Conclusions: In the largest time-dependent assessment of LN examination in CC, significant improvements in surgical quality measures have occurred over the past decade for Stage I, II and III. These measures have translated into improvements in OS particularly for Stage II disease. LN yield alone is not an adequate QM for pts with stage I and III CC.
| 1988-1993 | 1994-1998 | 1999-2003 | 2004-2008 | | > 12 LN (% Pts) | 5-yr OS | > 12 LN (% Pts) | 5-yr OS | > 12 LN (% Pts) | 5-yr OS | > 12 LN (% Pts) | 5-yr OS | | Stage I | 15.84% | 76.45% | 19.04% | 78.22% | 25.72% | 80.54% | 44.44% | 83.27% | | Stage II | 36.16% | 68.69% | 40.79% | 70.24% | 46.21% | 71.67% | 66.88% | 74.26% | | Stage III | 50.57% | 45.54% | 47.13% | 48.57% | 52.80% | 52.80% | 70.65% | 56.96% |
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