Surgical Quality Metric Scoring and Survival Among U.S. Veterans With Early-Stage NSCLC

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In a study reported in JAMA Surgery, Heiden et al developed a surgical quality metric scoring system—the Veterans Affairs Lung Cancer Operative quality (VALCAN-O) score—that was associated with overall survival in U.S. veterans undergoing curative-intent surgery for early-stage non–small cell lung cancer (NSCLC).

Study Details

The study involved a cohort of 9,628 patients with clinical stage I NSCLC who underwent definitive surgical treatment between October 2006 and September 2016. A set of five quality metrics (QMs) was defined, consisting of:

  • Timely surgery (within 12 weeks of radiographic suspicion)
  • Minimally invasive approach
  • Anatomic resection (via lobectomy or segmentectomy)
  • Adequate lymph node sampling (≥ 10 nodes)
  • Negative surgical margin.

The VALCAN-O scoring system of 0 (no QMs met) to 13 (all QMs met) was constructed to reflect progressively better risk-adjusted overall survival.

Key Findings    

In the veterans cohort, the rates of QMs met were: 68.9% (n = 6,633) for timely surgery; 41.4% (n = 3,986) for minimally invasive approach; 76.6% (n = 7,375) for anatomic resection (71.1% [n = 6,843] with lobectomy and 5.5% [n = 532] with segmentectomy); 34.0% (n = 3,278) for adequate lymph node sampling; and 96.7% (n = 9,312) for negative surgical margin.

Median follow-up was 6.2 years (interquartile range = 2.5–11.4 years). Median overall survival by QM score category was: 2.6 years (interquartile range (IQR) = 1.0–5.7 years) for a score of 0 to 5 points (n = 231); 4.3 years (IQR = 1.7–8.6 years) for 6 to 8 points (n = 983); 6.3 years (IQR = 2.6–11.4 years) for 9 to 11 points (n = 5,030); and 7.0 (IQR = 3.0–12.5 years) for 12 to 13 points (n = 3,343; overall P < .001). Risk-adjusted recurrence-free survival was found to improve with higher score. Adjusted hazard ratios were 0.62 (95% confidence interval [CI] = 0.48–0.79, P < .001) for 6 to 8 vs 0 to 5 points, and 0.39 (95% CI = 0.31–0.49, P < .001) for 12 to 13 vs 0 to 5 points.

The scoring system was validated using data from a cohort of 107,674 nonveteran patients from the National Cancer Database. As in the veterans cohort, marked differences in median overall survival were observed according to score group: 3.8 years (IQR = 1.4–8.4 years) for 0 to 5 points; 5.9 years (IQR = 2.6–9.2 years) for 6 to 8 points; 7.6 years (IQR = 3.4 years to not reached) for 9 to 11 points; and 8.7 years (IQR = 4.4 years to not reached) for 12 to 13 points (overall P < .001).

The investigators concluded, “The findings of this study suggest that adherence to intraoperative QMs may be associated with improved overall survival and [recurrence-free survival]. Efforts to improve adherence to surgical QMs may improve patient outcomes following curative-intent resection of early-stage lung cancer.”

Brendan T. Heiden, MD, MPHS, of the Division of Cardiothoracic Surgery, Washington University School of Medicine in St. Louis, is the corresponding author for the JAMA Surgery article.

Disclosure: The study was supported by the U.S. Department of Veterans Affairs and the National Institutes of Health. For full disclosures of the study authors, visit

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