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Invited Commentary
April 24, 2019

Textbook Outcome Nomograms as Multivariate Clinical Tools for Building Cancer Treatment Pathways and Prognosticating Outcomes

Author Affiliations
  • 1Department of Surgery, City of Hope Medical Center, Duarte, California
JAMA Surg. 2019;154(6):e190572. doi:10.1001/jamasurg.2019.0572

Outcomes research in cancer surgery has traditionally been segregated into perioperative outcome and long-term survival outcome studies. In recent years, it has also become clear that perioperative outcome parameters, such as transfusion1 and complications,2 can influence recurrence and long-term mortality. Increasingly, investigators have been seeking standards for outcomes that include parameters that matter most for both perioperative and long-term survival. The article examining intrahepatic cholangiocarcinoma by Merath et al3 in this issue of JAMA Surgery selects variables as parameters for a so-called textbook outcome (TO): negative margins, no perioperative transfusion, no postoperative surgical complications, no prolonged length of stay, no readmissions within 30 days after discharge, and no postoperative mortality. Furthermore, the authors3 created a nomogram that includes demographics (age), tumor characteristics (T stage, N stage, and vascular invasion), and treatment parameters (neoadjuvant chemotherapy, extent of surgery, and bile duct resection) that is highly accurate in assessing the likelihood of TO. These steps of (1) defining the TO and (2) producing a tool for prognosticating the achievement of TO are an important process that should be performed for all surgically treated tumors. This process will be invaluable for future academic studies as well as for defining clinical treatment pathways.

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