Textbook oncologic outcome in endometrial cancer surgery: A quality measure to improve survival and address disparities

Objective: Textbook Oncologic Outcome (TOO) is a composite quality measure in surgical oncology associated with improved overall survival (OS). This study evaluated the prognostic impact of TOO and identified factors associated with achieving TOO in endometrial cancer (EC). Methods: Patients undergoing surgery for presumed early-stage EC between 2018 and 2020 were identified in the National Cancer Database. TOO was defined as achieving all six of the following metrics: minimally invasive hysterectomy, required lymph node assessment, hospital stay ≤1 day, no unplanned 30-day hospital readmission, appropriate adjuvant therapy, and no 90-day mortality. Kaplan-Meier and Cox regression analyses were used to evaluate 5-year OS by TOO status. Logistic regression was used to identify factors associated with TOO. Results: Among 66,416 patients, 81.0 % achieved TOO (TOO+). TOO+ patients had significantly improved 5-year OS (90.3 % vs 76.4 %; adjusted hazard ratio 0.46, 95 % CI 0.43–0.49). Factors associated with lower likelihood to achieve TOO included age > 75 years (vs <60; adjusted odds ratio [aOR] 0.58, 95 % CI 0.54–0.62), Black race (vs White, aOR 0.74, 95 % CI 0.69–0.79), government insurance (vs private; aOR 0.68, 95 % CI 0.65–0.72), and non-endometrioid histology (aOR 0.62, 95 % CI, 0.58–0.67). Higher hospital volume was associated with a higher likelihood of achieving TOO (median ≥84 vs ≤32 cases/year; aOR 1.54, 95 % CI 1.45–1.64). Conclusion: TOO in EC surgery is strongly associated with overall survival and may serve as a benchmark goal for assessing quality of care. Disparities related to race, insurance status, and hospital volume highlight the need to expand access to high-quality care nationally.