Assessment of textbook oncologic outcomes following pancreaticoduodenectomy for pancreatic adenocarcinoma

Abstract

Background Composite outcomes may more accurately reflect patient and provider expectations around optimal care. We sought to determine the impact of achieving a so‐called “textbook oncologic outcome” (TOO) among patients undergoing resection of pancreatic adenocarcinoma (PDAC). Methods Patients undergoing pancreaticoduodenectomy (PD) for PDAC between 2006 and 2016 were identified in the National Cancer Database (NCDB). TOO was defined by: margin negative resection, compliant lymph node evaluation, no prolonged length‐of‐stay, no 30‐day readmission/mortality, and receipt of adjuvant chemotherapy. Factors associated with TOO and overall survival (OS) were evaluated using multivariable logistic and Cox regression models, respectively. Results Among 18 608 patients who underwent PD at 782 hospitals, many patients successfully achieved certain TOO factors such as R0 margin (77.9%) and no 30‐day mortality (96.9%), while other TOO criteria such as receipt of adjuvant therapy (48.2%) were achieved less frequently. Overall, only 3124 (16.8%) patients achieved a TOO. Factors associated with lower odds of TOO included: older age, Black race, Medicaid insurance, Community facility, and low PD facility (<20 PD/y) (all P < .05). Achievement of a TOO was associated with lower risk of mortality (HR 0.74; 95% CI, 0.70‐0.77). Conclusions While TOO was associated with improved long‐term survival, TOO was only achieved in 16.8% of patients undergoing PD.

Textbook oncologic outcome: A promising summary metric of high‐quality care, but are we on the same page?

“…It is also more reflective of the potential outcomes following surgery and is useful in setting patient expectations. For example, the low observed frequency of TOO (16.8%) among patients undergoing PD observed here portrays a much different outlook than the observed 30‐day mortality (3.1%) or readmission rate (8.1%) 1 …”

“…And though TOO represents a promising outcome measure in oncologic surgery, care must be taken in how this composite measure is popularized. 1,2,5,13,14 While hospital level data contributing to TOO are important for empowering patient decision making and driving quality improvement efforts, dissemination of TOO data without consensus regarding its definition or validity could easily lead to patient confusion and even variable reimbursement. Agreement regarding TOO definitions, and then studying the validity of these composite measures prospectively is necessary before broader dissemination and integration into quality measurement, hospital marketing, and negotiations with payers.…”

“…served 30-day mortality (3.1%) or readmission rate (8.1%) 1. Though TOO is a potentially useful means of communicatingoutcomes information surrounding complex oncologic procedures, there are challenges with its construction.…”

“…This month's issue of Journal of Surgical Oncology includes two articles exploring the concept of textbook oncologic outcome (TOO) in multiple cancer types. Sweigert et al 1 apply TOO to patients undergoing pancreaticoduodenectomy (PD), while Mehta et al 2 correlate TOO rates with U.S. News and World Report ranking for patients undergoing surgery for colorectal, lung, esophagus, liver, and pancreatic malignancies. Undoubtedly, traditional surgical quality metrics have had a significant impact on the delivery of surgical care in the United States; examples include regionalization of complex oncologic surgery due to widely recognized volume/mortality relationships and readmission being used as a marker of hospital quality 3,4 .…”

Analysis of textbook outcomes among patients undergoing resection of retroperitoneal sarcoma: A multi‐institutional analysis of the US Sarcoma Collaborative

“…10,[12][13][14][15][16] Recent investigations have proposed a novel composite metric known as "textbook outcome" (TO) to describe when all desired perioperative outcomes have been met (ie, as described in the textbooks). 7,[15][16][17][18][19][20][21][22][23][24][25][26] Since a TO includes the most essential/integral outcome parameters of the surgical process, it provides an accurate accounting of the overall quality of care. While recent studies have introduced the concept of a TO for measuring postoperative outcomes in other complex procedures, 7,21,22,24,25 the incidence and importance of a TO have not been characterized among patients undergoing resection of RPS using a large, multi-institutional database.…”