What is quality and does it matter

The Surveillance, Epidemiology and End Results database is designed to provide a generalized cross-section of cancer care in the United States. It is increasingly being used to study patterns of care and how they relate to outcomes. This approach is an avenue of research that will certainly play a greater role in the future. Instead of a tightly controlled prospective study in a limited and highly selected cohort of patients, this avenue explores relationships in a completely uncontrolled, but very large group of patients. The fact that the results can be generalized, by definition, and the large number of patients involved overcomes to a large extent the limitations of incomplete data, and the fact that the reasons for changes in the patterns of care can usually not be clearly identified. In this edition of the Journal of Thoracic Oncology, Farjah et al. 1 have analyzed staging interventions for non-small cell lung cancer (NSCLC) using the Surveillance, Epidemiology and End Results database, linked to the medicare database. The study encompasses almost 44,000 patients over age 65 who were diagnosed with NSCLC from 1998 to 2002 with follow-up extending through 2005. Fifty percent of the patients were age 75, and 50% had a comorbidity index of 0. Only 23% were over age 80, and only 21% had a comorbidity index 2. No treatment was given to 27%, and 51% had either stage IV disease or had incomplete staging information. Therefore, at least half of the study cohort can be reasonably assumed to be candidates for standard curative therapy, and only about 25% were likely poor or marginal candidates for standard therapy. The study investigated whether patients had only single modality staging (radiographic, i.e., chest computed tomography), bimodality staging (radiographic plus either metabolic or positron emission tomography [i.e., positron emission tomography, or PET] or invasive staging), or trimodality staging (radiographic, metabolic and invasive) within 3 months of the diagnosis (before or after). Most of patients underwent only single modality staging, although the incidence of this decreased from 90 to 67% during the course of the study. There was a corresponding increase in the proportion undergoing bimodality staging (from 10 to 30%), which was almost exclusively due to an increase in the use of PET (from 2 to 31%). Invasive staging was used in 10% of patients and did not change significantly during the course of the study. Exclusion of patients for whom extensive staging may have been inappropriate did not substantially affect these results (i.e., patients who were stage IV, died within 30 days, or were not treated). Furthermore, the predominance of limited staging was seen broadly and not markedly concentrated among patients who were older (80) or had multiple comorbidities. The study by Farjah et al. therefore, suggests that we have a major problem with the quality of staging in the United States. Radiographic staging alone has been shown to be inaccurate in many instances in patients with NSCLC. Even though guidelines with respect to PET scanning were not available at the beginning of the study, the data at the time justified the use of invasive staging in the majority of stage II and III patients. It is astonishing just how widespread the practice of limited staging was in this study, but in fact a similar degree of poor quality of staging for NSCLC has been reported by others as well. 2,3 The correlation of poor staging with such factors as socioeconomic status, level of education, marital status, and geographic region is consistent with other reports associating such factors with therapeutic interventions in patients with lung cancer. 4,5 Together,