title: Prognostic Value of National Comprehensive Cancer Network Lung Cancer Resection Quality Criteria.
abstract: BACKGROUND
  The National Comprehensive Cancer Network (NCCN) surgical resection guidelines for non-small cell lung cancer recommend anatomic resection, negative margins, examination of hilar/intrapulmonary lymph nodes, and examination of three or more mediastinal nodal stations. We examined the survival impact of these criteria.
  
  
  METHODS
  A population-based observational study was done using patient-level data from all curative-intent, non-small cell lung cancer resections from 2004 to 2013 at 11 institutions in four contiguous Dartmouth Hospital referral regions in three US states. We used an adjusted Cox proportional hazards model to assess the overall survival impact of attaining NCCN guidelines.
  
  
  RESULTS
  Of 2,429 eligible resections, 91% were anatomic, 94% had negative margins, 51% sampled hilar nodes, and 26% examined three or more mediastinal nodal stations. Only 17% of resections met all four criteria; however, there was a significant increasing trend from 2% in 2004 to 39% in 2013 (p < 0.001). Compared with patients whose surgery missed one or more criteria, the hazard ratio for patients whose surgery met all four criteria was 0.71 (95% confidence interval: 0.59 to 0.86, p < 0.001). Margin status and the nodal staging criteria were most strongly linked with survival.
  
  
  CONCLUSIONS
  Attainment of NCCN surgical quality guidelines was low, but improving, over the past decade in this cohort from a high lung cancer mortality region of the United States. The NCCN quality criteria, especially the nodal examination criteria, were strongly associated with survival. The quality of nodal examination should be a focus of quality improvement in non-small cell lung cancer care.
authors.affiliation: Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee. Electronic address: rosarogi@bmhcc.org.
authors.forename: Raymond U
authors.initials: RU
authors.lastname: Osarogiagbon
authors.affiliation: Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, Tennessee.
authors.forename: Meredith A
authors.initials: MA
authors.lastname: Ray
authors.affiliation: Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee.
authors.forename: Nicholas R
authors.initials: NR
authors.lastname: Faris
authors.affiliation: Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee; Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, Tennessee.
authors.forename: Matthew P
authors.initials: MP
authors.lastname: Smeltzer
authors.affiliation: Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee.
authors.forename: Carrie
authors.initials: C
authors.lastname: Fehnel
authors.affiliation: Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee.
authors.forename: Cheryl
authors.initials: C
authors.lastname: Houston-Harris
authors.affiliation: Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee.
authors.forename: Raymond S
authors.initials: RS
authors.lastname: Signore
authors.affiliation: Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee.
authors.forename: Laura M
authors.initials: LM
authors.lastname: McHugh
authors.affiliation: North East Arkansas Baptist Memorial Hospital, Jonesboro, Arkansas.
authors.forename: Paul
authors.initials: P
authors.lastname: Levy
authors.affiliation: St. Bernard's Regional Medical Center, Jonesboro, Arkansas.
authors.forename: Lynn
authors.initials: L
authors.lastname: Wiggins
authors.affiliation: North Mississippi Medical Center, Tupelo, Mississippi.
authors.forename: Vishal
authors.initials: V
authors.lastname: Sachdev
authors.affiliation: Multidisciplinary Thoracic Oncology Program, Baptist Cancer Center, Memphis, Tennessee.
authors.forename: Edward T
authors.initials: ET
authors.lastname: Robbins
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D019985:Benchmarking; D002289:Carcinoma, Non-Small-Cell Lung / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008175:Lung Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D008198:Lymph Nodes / Q000473:pathology; D008297:Male; D000072662:Margins of Excision; D008875:Middle Aged; D009367:Neoplasm Staging / Q000592:standards*; D011013:Pneumonectomy; D017410:Practice Guidelines as Topic; D011379:Prognosis; D016016:Proportional Hazards Models; D058996:Quality Improvement; D012189:Retrospective Studies; D014481:United States