US hospitals fail to meet critical esophagectomy benchmark

A study has shown that most US hospitals fail to ensure that surgeons examine at least 15 lymph nodes during esophagectomy for cancer, and are therefore failing to meet guideline recommendations for detecting metastases.

Of 13,995 patients who underwent esophagectomy between 1998 and 2007, only 28.7% had at least 15 lymph nodes examined as per the National Comprehensive Cancer Network advice. Furthermore, only 7% of hospitals reported that surgeons examined a median of 15 lymph nodes, potentially hindering patient prognosis and treatment decisions.

The authors believe their study, published in the Archives of Surgery, is the first to report on the adequacy of lymph node examination after esophagectomy for cancer across the USA.

"Our findings suggest that although there has been some improvement over time, the quality of lymph node examination based on a 15-lymph node threshold was marginal overall but more frequently achieved at academic and high-volume centers," say David Bentrem (Northwestern University, Chicago, Illinois, USA) and colleagues.

Using data from the National Cancer Data Base, which records 70% of newly diagnosed malignant neoplasms, the percentage of patients having at least 15 nodes examined rose from 23.5% in 1998 to 2001 to 34.4% in 2005 to 2007.

The authors found that, in the most recent period (2005 to 2007), patients were a third more likely to have 15 lymph nodes or more examined if they were treated at an academic center (38.9%) as opposed to a community center (28%). High-volume centers were more effective than low-volume centers, examining at least 15 lymph nodes in 44.1% of patients compared with 29.3%.

Patients were also more likely to have the recommended number of examinations if their tumor was stage II or III, and less likely if they were treated in the South or Midwest, had severe comorbidity, or had tumors in the lower esophagus.

Based on their findings, the authors urge hospitals to improve internal processes to ensure guideline adherence: "There is opportunity for improvement in lymph node staging at most hospitals in the United States regardless of hospital type, volume status, or geographic region."

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