Use of a national registry to define a composite quality metric for rectal cancer

Published:November 30, 2022DOI:


      • In this first description of a CQM in Rectal Cancer, we found that CQM has the potential to be a useful metric of quality care. Achieving CQM is associated with improved overall survival. The most likely reason for failing to reach CQM is inadequate nodal assessment. As surgeons continue to strive to improve quality of care such metrics may prove to be a relevant measure of optimal care.



      Quality assessment in oncologic surgery has traditionally involved reporting discrete metrics that may be difficult for patients and referring providers to interpret. We define a composite quality metric (CQM) for resection in rectal cancer.


      We queried the National Cancer Database to identify patients undergoing low anterior resection for clinical stage II-III rectal adenocarcinoma between 2010 and 2017. CQM was defined as appropriate neoadjuvant therapy, margin-negative resection, appropriate lymph node assessment, postoperative length of stay (LOS) < 75th percentile, and no 30-day readmission or mortality.


      19,721 patients met inclusion criteria; 8,083 (41%) had a CQM. The most common reasons for failure to achieve CQM: inadequate node assessment (27%), prolonged LOS (26%). On Cox modeling, CQM (aHR 0.70, 95% CI [0.66, 0.75]) was associated with improved overall survival.


      CQM is independently associated with improved survival in rectal cancer and may be an effective measure of quality.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Dietz D.W.
        • Rectal CC for OST of
        Multidisciplinary management of rectal cancer: the OSTRICH.
        J Gastrointest Surg. 2013; 17: 1863-1868
        • Kolfschoten N.E.
        • Kievit J.
        • Gooiker G.A.
        • et al.
        Focusing on desired outcomes of care after colon cancer resections; hospital variations in “textbook outcome.
        European J Surg Oncol Ejso. 2013; 39: 156-163
      1. LeapFrog. Complex adult and pediatric surgery.
        • Gooiker G.A.
        • Kolfschoten N.E.
        • Bastiaannet E.
        • et al.
        Evaluating the validity of quality indicators for colorectal cancer care.
        J Surg Oncol. 2013; 108: 465-471
        • Birkmeyer J.D.
        • Dimick J.B.
        • Birkmeyer N.J.
        Measuring the quality of surgical care: structure, process, or outcomes?.
        J Am Coll Surg. 2004; 198: 626-632
        • Merath K.
        • Chen Q.
        • Bagante F.
        • et al.
        Textbook outcomes among Medicare patients undergoing hepatopancreatic surgery.
        Ann Surg. 2020; 271: 1116-1123
        • Busweiler L.A.
        • Schouwenburg M.G.
        • van Henegouwen M.I.B.
        • et al.
        Textbook outcome as a composite measure in oesophagogastric cancer surgery.
        Br J Surg. 2017; 104: 742-750
        • Sweigert P.J.
        • Eguia E.
        • Baker M.S.
        • et al.
        Assessment of textbook oncologic outcomes following pancreaticoduodenectomy for pancreatic adenocarcinoma.
        J Surg Oncol. 2020; 121: 936-944
        • Marks J.H.
        • Valsdottir E.B.
        • Rather A.A.
        • Nweze I.C.
        • Newman D.A.
        • Chernick M.R.
        Fewer than 12 lymph nodes can be expected in a surgical specimen after high-dose chemoradiation therapy for rectal cancer.
        Dis Colon Rectum. 2010; 53: 1023-1029
        • Amajoyi R.
        • Lee Y.
        • Recio P.J.
        • Kondylis P.D.
        Neoadjuvant therapy for rectal cancer decreases the number of lymph nodes harvested in operative specimens.
        Am J Surg. 2013; 205 (discussion 292): 289-292
        • You Y.N.
        • Hardiman K.M.
        • Bafford A.
        • et al.
        The American society of colon and rectal surgeons clinical practice Guidelines for the management of rectal cancer.
        Dis Colon Rectum. 2020; 63: 1191-1222
        • Fleshman J.
        • Branda M.E.
        • Sargent D.J.
        • et al.
        Effect of laparoscopic-assisted resection vs open resection of Stage II or III rectal cancer on pathologic outcomes. The ACOSOG Z6051 randomized clinical trial.
        JAMA. 2015; 314: 1346-1355
        • Fleshman J.
        • Branda M.E.
        • Sargent D.J.
        • et al.
        Disease-free survival and local recurrence for laparoscopic resection compared with open resection of stage II to III rectal cancer: follow-up results of the ACOSOG Z6051 randomized controlled trial.
        Ann Surg. 2019; 269: 589-595