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Study Shows Quality of Treatment for Veterans with Early-Stage Lung Cancer Varies Widely and is Associated with Survival

For functionally fit patients diagnosed with early-stage lung cancer, the preferred treatment is surgical resection. Most lung cancer treatment guidelines recommend several surgical quality metrics (QMs) that should be met for all patients diagnosed with early-stage non-small cell lung cancer (NSCLC). Researchers identified five QMs for successful NSCLC surgery: 1) timely surgery, 2) determining the appropriate amount of lung tissue to remove, 3) sampling multiple lymph nodes to confirm the cancer has not spread, 4) using minimally invasive surgery, and 5) ensuring that no cancer is left within the body. These five measures are referred to as the VALCAN-O (VA Lung Cancer Operative quality) components. This retrospective cohort study sought to determine the association between adherence to these metrics and overall survival and recurrence-free survival among Veterans with early-stage NSCLC. Using VA data, investigators identified 9,628 Veterans (96% male) who underwent surgical treatments for NSCLC from October 2006 through September 2016. Using data from the National Cancer Database, findings were then validated in a cohort of 107,674 non-Veteran patients.


  • Adherence to VALCAN-O measures improved substantially over the study period; however, there was significant regional variation. For example, the proportion of patients receiving the highest quality operations in VISN 19 increased from 33% to 67%. Conversely, in VISN 15 the numbers remained stagnant (27% in 2006-2009 vs. 29% in 2017-2019).
  • Researchers found poor quality adherence to several quality measures in both groups (VA and non-VA patients). Only 34% of patients received adequate lymph node sampling (defined as >10 lymph nodes), and only 41% received minimally invasive surgery. On the other hand, most patients received timely surgery (69%), and most operations attained negative surgical margins (97%).
  • Increasing scores on a 13-point quality measure were associated with longer overall survival following treatment, with higher scores reflecting progressively better risk-adjusted overall survival. For example, the proportion of patients receiving highest-quality operations (VALCAN-O score ≥12) in VISN 19 increased from 33% (2006-2009) to 67% (2017-2019).


  • Findings suggest that efforts to improve adherence to surgical quality metrics (i.e., VALCAN-O) may improve patient outcomes following curative-intent resection of early-stage lung cancer, especially within a closed practice environment such as the VA healthcare system.


  • VALCON-O metrics cannot be met in every situation due to individual patient needs or restrictions.
  • A specific cause of death – a potentially more important end point – was unavailable.

This study was partly funded by HSR&D (IIR 17-063). Drs. Heiden, Eaton, and Puri are part of the VA St. Louis Healthcare System.

Heiden B, Eaton D, Chang S-H, Yan Y, Baumann A, Schoen M, Tohmasi S, Rossetti N, Patel M, Kreisel D, Nava R, Meyers B, Kozower B, and Puri V. Association between Surgical Quality Metric Adherence and Overall Survival among US Veterans with Early-Stage Non-Small Cell Lung Cancer. JAMA Surgery. March 1, 2023;158(3):293-301.

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HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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