Abstract
Background
Evaluation of ≥12 lymph nodes after colon cancer resection has been adopted as a hospital quality measure, but compliance varies considerably. We sought to quantify relative proportions of the variation in lymph node assessment after colon cancer resection occurring at the patient, surgeon, pathologist, and hospital levels.
Methods
The 1998–2005 Surveillance, Epidemiology, and End Results—Medicare database was used to identify 27,101 patients aged 65 years and older with Medicare parts A and B coverage undergoing colon cancer resection. Multilevel logistic regression was used to model lymph node evaluation as a binary variable (≥12 versus <12) while explicitly accounting for clustering of outcomes.
Results
Patients were treated by 4,180 distinct surgeons and 2,656 distinct pathologists at 1,113 distinct hospitals. The overall rate of 12-lymph node (12-LN) evaluation was 48%, with a median of 11 nodes examined per patient, and 33% demonstrated lymph node metastasis on pathological examination. Demographic and tumor-related characteristics such as age, gender, tumor grade, and location each demonstrated significant effects on rate of 12-LN assessment (all P < 0.05). The majority of the variation in 12-LN assessment was related to non-modifiable patient-specific factors (79%). After accounting for all explanatory variables in the full model, 8.2% of the residual provider-level variation was attributable to the surgeon, 19% to the pathologist, and 73% to the hospital.
Conclusion
Compliance with the 12-LN standard is poor. Variation between hospitals is larger than that between pathologists or surgeons. However, patient-to-patient variation is the largest determinant of 12-LN evaluation.
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References
Jemal A, Siegel R, Xu J, Ward E. Cancer statistics, 2010. CA: a cancer journal for clinicians 2010;60:277–300.
Sargent D, Sobrero A, Grothey A, et al. Evidence for cure by adjuvant therapy in colon cancer: observations based on individual patient data from 20,898 patients on 18 randomized trials. J Clin Oncol 2009;27:872–7.
Chen SL, Bilchik AJ. More extensive nodal dissection improves survival for stages I to III of colon cancer: a population-based study. Annals of surgery 2006;244:602–10.
Le Voyer TE, Sigurdson ER, Hanlon AL, et al. Colon cancer survival is associated with increasing number of lymph nodes analyzed: a secondary survey of intergroup trial INT-0089. J Clin Oncol 2003;21:2912–9.
Swanson RS, Compton CC, Stewart AK, Bland KI. The prognosis of T3N0 colon cancer is dependent on the number of lymph nodes examined. Annals of surgical oncology 2003;10:65–71.
Bui L, Rempel E, Reeson D, Simunovic M. Lymph node counts, rates of positive lymph nodes, and patient survival for colon cancer surgery in Ontario, Canada: a population-based study. Journal of surgical oncology 2006;93:439–45.
National Quality Forum: National voluntary consensus standards for quality of cancer care: a consensus report. (Accessed at http://www.qualityforum.org/pdf/reports/Cancer_Nonmember_Report.pdf.)
Baxter NN, Virnig DJ, Rothenberger DA, Morris AM, Jessurun J, Virnig BA. Lymph node evaluation in colorectal cancer patients: a population-based study. Journal of the National Cancer Institute 2005;97:219–25.
Wright FC, Law CH, Berry S, Smith AJ. Clinically important aspects of lymph node assessment in colon cancer. J Surg Oncol 2009;99:248–55.
Tekkis PP, Smith JJ, Heriot AG, Darzi AW, Thompson MR, Stamatakis JD. A national study on lymph node retrieval in resectional surgery for colorectal cancer. Dis Colon Rectum 2006;49:1673–83.
Bilimoria KY, Stewart AK, Palis BE, Bentrem DJ, Talamonti MS, Ko CY. Adequacy and importance of lymph node evaluation for colon cancer in the elderly. Journal of the American College of Surgeons 2008;206:247–54.
Etzioni D, Spencer M. Nodal harvest: surgeon or pathologist? Dis Colon Rectum 2008;51:366–7; author reply 8.
Wang J, Kulaylat M, Rockette H, et al. Should total number of lymph nodes be used as a quality of care measure for stage III colon cancer? Ann Surg 2009;249:559–63.
Warren JL, Klabunde CN, Schrag D, Bach PB, Riley GF. Overview of the SEER-Medicare data: content, research applications, and generalizability to the United States elderly population. Med Care 2002;40:IV-3-18.
Nathan H, Pawlik TM. Limitations of claims and registry data in surgical oncology research. Ann Surg Oncol 2008;15:415–23.
Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. The New England journal of medicine 2002;346:1128–37.
Schrag D, Bach PB, Dahlman C, Warren JL. Identifying and measuring hospital characteristics using the SEER-Medicare data and other claims-based sources. Medical care 2002;40:IV-96-103.
Hollenbeck BK, Hong J, Zaojun Y, Birkmeyer JD. Misclassification of hospital volume with Surveillance, Epidemiology, and End Results Medicare data. Surg Innov 2007;14:192–8.
Rabe-Hesketh S, Skrondal A. Multilevel and longitudinal modeling using STATA (ed 2). College Station: STATA; 2008.
Larsen K, Merlo J. Appropriate assessment of neighborhood effects on individual health: integrating random and fixed effects in multilevel logistic regression. Am J Epidemiol 2005;161:81–8.
Wong SL, Ji H, Hollenbeck BK, Morris AM, Baser O, Birkmeyer JD. Hospital lymph node examination rates and survival after resection for colon cancer. Jama 2007;298:2149–54.
Baxter NN. Is lymph node count an ideal quality indicator for cancer care? J Surg Oncol 2009;99:265–8.
Johnson PM, Porter GA, Ricciardi R, Baxter NN. Increasing negative lymph node count is independently associated with improved long-term survival in stage IIIB and IIIC colon cancer. J Clin Oncol 2006;24:3570–5.
Galon J, Costes A, Sanchez-Cabo F, et al. Type, density, and location of immune cells within human colorectal tumors predict clinical outcome. Science 2006;313:1960–4.
Pages F, Berger A, Camus M, et al. Effector memory T cells, early metastasis, and survival in colorectal cancer. N Engl J Med 2005;353:2654–66.
Rieger NA, Barnett FS, Moore JW, et al. Quality of pathology reporting impacts on lymph node yield in colon cancer. J Clin Oncol 2007;25:463; author reply-4.
Ostadi MA, Harnish JL, Stegienko S, Urbach DR. Factors affecting the number of lymph nodes retrieved in colorectal cancer specimens. Surg Endosc 2007;21:2142–6.
Johnson PM, Malatjalian D, Porter GA. Adequacy of nodal harvest in colorectal cancer: a consecutive cohort study. J Gastrointest Surg 2002;6:883–88; discussion 9–90.
Evans MD, Barton K, Rees A, Stamatakis JD, Karandikar SS. The impact of surgeon and pathologist on lymph node retrieval in colorectal cancer and its impact on survival for patients with Dukes’ stage B disease. Colorectal Dis 2008;10:157–64.
Lemmens VE, van Lijnschoten I, Janssen-Heijnen ML, Rutten HJ, Verheij CD, Coebergh JW. Pathology practice patterns affect lymph node evaluation and outcome of colon cancer: a population-based study. Ann Oncol 2006;17:1803–9.
Pheby DF, Levine DF, Pitcher RW, Shepherd NA. Lymph node harvests directly influence the staging of colorectal cancer: evidence from a regional audit. J Clin Pathol 2004;57:43–7.
Donabedian A. The quality of care. How can it be assessed? Jama 1988;260:1743–8.
Bull AD, Biffin AH, Mella J, et al. Colorectal cancer pathology reporting: a regional audit. J Clin Pathol 1997;50:138–42.
Miller EA, Woosley J, Martin CF, Sandler RS. Hospital-to-hospital variation in lymph node detection after colorectal resection. Cancer 2004;101:1065–71.
Morris EJ, Maughan NJ, Forman D, Quirke P. Identifying stage III colorectal cancer patients: the influence of the patient, surgeon, and pathologist. J Clin Oncol 2007;25:2573–9.
Kelder W, Inberg B, Plukker JT, Groen H, Baas PC, Tiebosch AT. Effect of modified Davidson’s fixative on examined number of lymph nodes and TNM-stage in colon carcinoma. Eur J Surg Oncol 2008;34:525–30.
Bilimoria KY, Bentrem DJ, Stewart AK, et al. Lymph node evaluation as a colon cancer quality measure: a national hospital report card. J Natl Cancer Inst 2008;100:1310–7.
Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 2004; 350(20):2050–9.
Acknowledgments
This study used the linked SEER-Medicare database. The interpretation and reporting of these data are the sole responsibility of the authors. The authors acknowledge the efforts of the Applied Research Program, NCI; the Office of Research, Development and Information, CMS; Information Management Services (IMS), Inc.; and the Surveillance, Epidemiology, and End Results (SEER) Program tumor registries in the creation of the SEER-Medicare database.
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Nathan, H., Shore, A.D., Anders, R.A. et al. Variation in Lymph Node Assessment After Colon Cancer Resection: Patient, Surgeon, Pathologist, or Hospital?. J Gastrointest Surg 15, 471–479 (2011). https://doi.org/10.1007/s11605-010-1410-9
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DOI: https://doi.org/10.1007/s11605-010-1410-9