Modifiable Factors That Influence Colon Cancer Lymph Node Sampling and Examination

IntroductionColorectal cancer is the fourth most common malignancy in the United States. Its single most important prognostic factor is lymph node involvement. Multiple guidelines recommend sampling a minimum of 12 nodes, to ensure accurate staging and treatment. However, this standard of care is not always achieved. The objective of this study was to identify potential modifiable factors that may explain this inadequacy between the optimal approach and routine practice.Patients and MethodsThe medical charts of all patients treated for colorectal cancer stages I-III at the Albert Einstein Medical Center from 1999-2007 were reviewed. Associations between multiple surgical and pathologic variables and the presence of ≥ 12 lymph nodes in the final pathology report were examined.ResultsIn total, 337 patients were included in this study. The mean number of nodes reported was 12.7 (standard deviation, ± 7.6), and 173 patients (51%) had ≥ 12 lymph nodes. Regarding patients' demographic characteristics, 78% were more than 60 years of age; 47.8% were male; and 27% were white, 67% were African American, and 6% were of other ethnic groups. Using a univariate analysis, several variables were statistically associated with the ≥ 12 lymph nodes reported: colon length (Pearson r = 0.384; P < .001); thickness of the mesocolon (Pearson r = 0.294; P < .001); size of tumor (Pearson r = 0.154; P = .005); site of tumor (right vs. left, P < .001); type of surgery (right or subtotal colectomy vs. others, P < .001), experience of pathologist (P = .02); pathologist's assistant (P = .006); and experience of surgeon (P < .001). Using a multivariate logistic regression analysis, adjusting for age, sex, and race, colon length (P = .001), type of surgery (odds ratio [OR], 3.37; 95% confidence interval [CI], 2.0-5.6; P < .001), surgeon's experience (OR, 2.33; 95% CI, 1.4-3.9; P = .001), pathologist's experience (OR, 1.9; 95% CI, 1.1-3.2; P = .01), and role of the pathologist's assistant (OR, 2.5; 95% CI, 1.4-4.3; P = .001) remained as significant predictors.ConclusionThis study showed that multiple factors influence the number of lymph nodes sampled. The roles of the surgeon, the pathologist, and especially the pathologist's assistant comprise significant variables that could be modified with appropriate education.