title: Should total number of lymph nodes be used as a quality of care measure for stage III colon cancer?
abstract: OBJECTIVE
  To assess whether TNODS is an independent prognostic factor after adjusting for the lymph node ratio (LNR).
  
  
  BACKGROUND
  The medical literature has suggested that the TNODS is associated with better survival in stage II and III colon cancer. Thus TNODS was endorsed as a quality measure for patient care by American College of Surgeons, National Quality Forum. There is, however, little biologic rationale to support this linkage.
  
  
  METHODS
  : A total of 24,477 stage III colon cancer patients were identified from Surveillance, Epidemiology, and End Results cancer registry and categorized into 4 groups, LNR1 to LNR4, according to LNR interval: <0.07, 0.07 to 0.25, 0.25 to 0.50, and >0.50. Patients were also stratified according to TNODS into high TNODS (> or = 12) and low TNODS (<12) groups. The method of Kaplan-Meier was used to estimate the 5-year survival and the log-rank test was used to test the survival difference among the different groups.
  
  
  RESULTS
  Patients with high TNODS have better survival compared with those with low TNODS (5-year survival 51.0% vs. 45.0%, P < 0.0001). However, after stratifying by LNR status, there was no significant survival difference between patients with high TNODS and those with low TNODS within strata LNR2 (5-year survival 56.3% vs. 56.0%, P = 0.26). Ironically, patients with high TNODS had significantly worse survival than those with low TNODS within strata LNR3 (5-year survival 41.2% vs. 47.4%, P = 0.0009) and LNR 4 (5-year survival 22.0% vs. 32.1%, P < 0.0001).
  
  
  CONCLUSIONS
  The previously reported prognostic effect of TNODS on node-positive colon cancer was confounded by LNR. This observation calls into question the use of TNODS as a quality measure for colon cancer patients' care.
authors.affiliation: Department of Surgery, Buffalo General Hospital, 100 High St, Buffalo, NY 14203, USA. wang_buffalo@yahoo.com
authors.forename: Jiping
authors.initials: J
authors.lastname: Wang
authors.forename: Mahmoud
authors.initials: M
authors.lastname: Kulaylat
authors.forename: Howard
authors.initials: H
authors.lastname: Rockette
authors.forename: James
authors.initials: J
authors.lastname: Hassett
authors.forename: Ashwani
authors.initials: A
authors.lastname: Rajput
authors.forename: Kelli Bullard
authors.initials: KB
authors.lastname: Dunn
authors.forename: Merril
authors.initials: M
authors.lastname: Dayton
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000704:Analysis of Variance; D003110:Colonic Neoplasms / Q000401:mortality* / Q000473:pathology* / Q000628:therapy; D003131:Combined Modality Therapy; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D008197:Lymph Node Excision; D008198:Lymph Nodes / Q000473:pathology* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness / Q000473:pathology*; D009367:Neoplasm Staging; D011237:Predictive Value of Tests; D011336:Probability; D011379:Prognosis; D016016:Proportional Hazards Models; D019984:Quality Indicators, Health Care; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D018426:SEER Program; D012680:Sensitivity and Specificity; D012737:Sex Factors; D016019:Survival Analysis; D016896:Treatment Outcome; D055815:Young Adult