National trends in the quality of segmentectomy for lung cancer

Objective: Segmentectomy has become an accepted procedure for the treatment of non-small cell lung cancer. Adequate lymph node sampling, sufficient margins, and proper tumor size selection are factors vital for achieving outcomes comparable to lobectomy. Previous studies have demonstrated poor adherence to lymph node sampling guidelines. However, national trends in the quality of segmentectomy and implications on survival are unknown. Methods: The National Cancer Database was used to identify patients with clinical stage I to IIA non-small cell lung cancer surgically treated between 2004 and 2018. Facility-level trends in extent of resection and segmentectomy odds of adherence to (1) 2014 Commission on Cancer guidelines of sampling 10 or more lymph nodes, (2) negative (R0) resection margins, and (3) tumor size 2 cm or less were determined. Propensity score matching was based on segmentectomy adherence to (4) a composite of all measures, and survival was evaluated with Cox models and Kaplan-Meier survival estimates. Results: The study included 249,391 patients with 4.4% (n - 11,006) treated with segmentectomy. The proportion of segmentectomies performed annually increased from 3.3% in 2004 to 6.1% in 2018 (P <.001). Overall, 12.6% (n - 1385) of patients who underwent segmentectomy between 2004 and 2018 were adherent to all measures, and adherence was more likely at academic programs (odds ratio, 1.56; 95% confidence interval, 1.14-2.15) than nonacademic programs ( P <.001, reference). Adherence to all measures was associated with improved survival (hazard ratio, 0.67; 95% confidence interval, 0.56-0.79). Conclusions: As segmentectomy is increasingly established as a valid oncological option for the treatment of non-small cell lung cancer, it is important that quality remains high. This study demonstrates that continued improvement is needed.