Variation in Lymph Node Examination After Esophagectomy for Cancer in the United States

Objectives: To evaluate the quality of lymph node examination after esophagectomy for cancer in the United States based on current treatment guidelines (>= 15 nodes) and to assess the association of patient, tumor, and hospital factors with the adequacy of lymph node examination. Design: Retrospective observational study from 1998 to 2007. Setting: National cancer database. Patients: Patients with stage I through III esophageal cancer undergoing esophagectomy and not treated with neoadjuvant chemoradiotherapy. Main Outcome Measure: Rate of adequate lymph node examination (>= 15 nodes). Results: A total of 13 995 patients were identified from 639 hospitals. Overall, 4014 patients (28.7%) had at least 15 lymph nodes examined, which increased from 23.5% to 34.4% during the study period. At the hospital level, only 45 centers (7.0%) examined a median of at least 15 lymph nodes. In the most recent period (2005-2007), at least 15 nodes were examined in 38.9% of patients at academic centers vs 28.0% at community hospitals and in 44.1% at high-volume centers vs 29.3% at low-volume centers. On multivariable analysis, hospital type, surgical volume status, and geographic location remained significant predictors of having at least 15 lymph nodes examined. Conclusions: Fewer than one-third of patients and fewer than 1 in 10 hospitals met the benchmark of examining at least 15 lymph nodes. Hospitals should perform internal process improvement activities to improve guideline adherence.