title: The role of the cancer center when using lymph node count as a quality measure for gastric cancer surgery.
abstract: OBJECTIVE
  Cancer center recognition, offered as accreditation by the American College of Surgeons Commission on Cancer or the National Cancer Institute, and quality measure reporting purport to improve the quality of cancer care. For surgically resectable gastric cancer, removal of 15 or more lymph nodes has been associated with improved outcomes and has been endorsed as a gastric cancer quality measure.
  
  
  OBJECTIVE
  To determine whether cancer center classification is associated with compliance with the lymph node-count quality measure and the effect of compliance with the measure on overall survival.
  
  
  METHODS
  A retrospective review of prospectively collected population-based data from the Surveillance, Epidemiology, and End Results Cancer Registry of Greater California and California Cancer Registry was conducted. Participants included patients who underwent surgery for stage I to III gastric adenocarcinoma between January 1, 2004, and December 31, 2010.
  
  
  METHODS
  Compliance with removal of 15 or more lymph nodes and overall survival.
  
  
  RESULTS
  Of 3321 gastric cancer cases, 42.3% had a minimum of 15 lymph nodes removed. Hospitals with cancer program recognition treated 69.9% of the cases. In hospitals without cancer program approval, 34.8% of the patients had 15 or more lymph nodes removed compared with 45.5% in the facilities with cancer program approval. Logistic regression analysis demonstrated that patients undergoing gastrectomy had significantly higher odds of having 15 or more lymph nodes removed if they were younger (trend P < .001), Asian/other race/ethnicity (adjusted odds ratio [AOR], 1.24; 95% CI, 1.03-1.50), or non-Hispanic black (AOR, 1.37; 95% CI, 1.03-1.82) compared with non-Hispanic white, received diagnosis at a progressively higher stage (trend P < .001), or received diagnosis in a more recent year (trend P < .001). Removal of 15 or more lymph nodes was associated with cancer program recognition (vs no recognition) (odds ratio, 1.48; 95% CI, 1.25-1.74). Cox proportional hazards regression showed that improved survival was predicted by removal of 15 or more lymph nodes (hazard ratio [HR], 0.70; 95% CI, 0.63-0.78) but not by cancer program recognition (HR, 1.03; 95% CI, 0.92-1.15).
  
  
  CONCLUSIONS
  Although adequate lymph node retrieval is more likely in hospitals with a recognized cancer program, survival outcome is associated with the lymph node count rather than with cancer program classification. Less than half of the cases reviewed in this study met the minimum lymph node-count guideline, indicating the need for process improvement for all hospitals.
authors.affiliation: School of Public Health, Loma Linda University, Loma Linda, California2Surveillance, Epidemiology, and End Results Cancer Registry, Cancer Registry of Greater California and California Cancer Registry, Sacramento.
authors.forename: John W
authors.initials: JW
authors.lastname: Morgan
authors.affiliation: School of Public Health, Loma Linda University, Loma Linda, California.
authors.forename: Liang
authors.initials: L
authors.lastname: Ji
authors.affiliation: Department of Surgery, Division of Surgical Oncology, School of Medicine, Loma Linda University, Loma Linda, California.
authors.forename: Garrett
authors.initials: G
authors.lastname: Friedman
authors.affiliation: Department of Surgery, Division of Surgical Oncology, School of Medicine, Loma Linda University, Loma Linda, California.
authors.forename: Maheswari
authors.initials: M
authors.lastname: Senthil
authors.affiliation: Surveillance, Epidemiology, and End Results Cancer Registry, Cancer Registry of Greater California and California Cancer Registry, Sacramento.
authors.forename: Crickett
authors.initials: C
authors.lastname: Dyke
authors.affiliation: Surveillance, Epidemiology, and End Results Cancer Registry, Cancer Registry of Greater California and California Cancer Registry, Sacramento3Department of Surgery, Division of Surgical Oncology, School of Medicine, Loma Linda University, Loma Linda, Cali.
authors.forename: Sharon S
authors.initials: SS
authors.lastname: Lum
mesh_terms: D000293:Adolescent; D000368:Aged; D002140:California; D002173:Cancer Care Facilities / Q000592:standards*; D016001:Confidence Intervals; D018572:Disease-Free Survival; D005260:Female; D005743:Gastrectomy / Q000379:methods / Q000401:mortality; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D016015:Logistic Models; D008197:Lymph Node Excision / Q000706:statistics & numerical data; D008198:Lymph Nodes / Q000473:pathology* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness / Q000473:pathology; D009367:Neoplasm Staging; D011379:Prognosis; D016016:Proportional Hazards Models; D019984:Quality Indicators, Health Care; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D012380:Role; D018426:SEER Program; D013274:Stomach Neoplasms / Q000401:mortality* / Q000473:pathology / Q000601:surgery*; D016019:Survival Analysis; D016896:Treatment Outcome; D055815:Young Adult