Samson Pamela, Puri Varun, Broderick Stephen, Patterson G Alexander, Meyers Bryan, Crabtree Traves
Division of Cardiothoracic Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri.
Division of Cardiothoracic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Ann Thorac Surg. 2017 Apr;103(4):1101-1108. doi: 10.1016/j.athoracsur.2016.09.032. Epub 2017 Jan 18.
Quality measures for patients with early and locally advanced esophageal cancer undergoing esophagectomy have been made by national organizations. The rate of adherence to these measures as well as their association with overall survival are unknown.
Esophagectomy patients were abstracted from the National Cancer Database. Because neoadjuvant status was available since 2006, the analysis of locally advanced patients began at this time point. Selected measures included: R0 resection, evaluation of 15 or more lymph nodes, and induction therapy for locally advanced tumors. Multivariate models identified variables associated with achieving quality measures. A Cox proportional hazards model evaluated factors associated with mortality.
From 1998 to 2012, 4,908 of 16,040 (30.6%) early-stage esophageal cancer patients (clinical T1A to T2N0 <2cm, well-differentiated) underwent esophagectomy. Of 4,672 patients 4,518 (96.7%) achieved R0 resection and 1,395 of 4,686 (29.8%) had 15 or more lymph nodes sampled. High-volume center type (>20 esophagectomies/year) was independently associated with meeting both measures (odds ratio [OR] 2.2, 95% confidence interval [CI]: 1.9 to 2.5). From 2006 to 2012, 7,747 of 20,437 (37.9%) locally advanced patients (clinical Stage IIB to IIIB) received esophagectomy. Of 6,966 patients 5,977 (85.8%) received induction therapy, 6,394 (91.8%) had R0 resection, and 2,852 (40.9%) had 15 or more lymph nodes sampled. High-volume center type was, again, associated with increased likelihood of meeting all quality measures (OR 2.17, 95% CI: 1.92 to 2.46). Meeting all quality measures was associated with the largest decrease in mortality for both early-stage (hazard ratio [HR] 0.27, 95% CI: 0.18 to 0.39) and locally advanced (HR 0.54, 95% CI: 0.40 to 0.73) esophageal cancer patients.
Adherence to recommended quality measures is independently associated with improved overall survival in both early and locally advanced stages of esophageal cancer. Currently, few patients are receiving care in accordance with these recommendations.
国家组织已制定了针对接受食管切除术的早期和局部晚期食管癌患者的质量指标。这些指标的依从率及其与总生存期的关联尚不清楚。
从国家癌症数据库中提取食管切除术患者的数据。由于自2006年起可获取新辅助治疗状态信息，因此对局部晚期患者的分析从该时间点开始。选定的指标包括：R0切除、评估15个或更多淋巴结以及对局部晚期肿瘤进行诱导治疗。多变量模型确定了与达到质量指标相关的变量。Cox比例风险模型评估了与死亡率相关的因素。
1998年至2012年，16040例早期食管癌患者（临床T1A至T2N0<2cm，高分化）中有4908例（30.6%）接受了食管切除术。在4672例患者中，4518例（96.7%）实现了R0切除，4686例中的1395例（29.8%）有15个或更多淋巴结被采样。高手术量中心类型（每年>20例食管切除术）与满足这两项指标独立相关（优势比[OR]2.2，95%置信区间[CI]：1.9至2.5）。2006年至2012年，20437例局部晚期患者（临床IIB至IIIB期）中有7747例（37.9%）接受了食管切除术。在6966例患者中，5977例（85.8%）接受了诱导治疗，6394例（91.8%）实现了R0切除，2852例（40.9%）有15个或更多淋巴结被采样。高手术量中心类型再次与满足所有质量指标的可能性增加相关（OR 2.17，95%CI：1.92至2.46）。满足所有质量指标与早期（风险比[HR]0.27，95%CI：0.18至0.39）和局部晚期（HR 0.54，95%CI：0.40至0.73）食管癌患者死亡率的最大降低相关。
坚持推荐的质量指标与食管癌早期和局部晚期患者的总生存期改善独立相关。目前，很少有患者按照这些建议接受治疗。
