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.