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. Author manuscript; available in PMC: 2025 Dec 30.
Published in final edited form as: J Thorac Cardiovasc Surg. 2025 May 3;170(4):926–932. doi: 10.1016/j.jtcvs.2025.04.041

Early compliance with lung cancer lymph node standard 5.8: An analysis of 2022 and 2023 Commission on Cancer site reviews

Alison S Baskin a,b, Elizabeth C Funk c, Amanda B Francescatti c, Brandy R Sinco b,d, Bryan E Palis c, Tina J Hieken c,e, Matthew H G Katz c,f, Judy C Boughey c,e, Ronald J Weigel c,g, Lesly A Dossett b,c,d,h, Daniel J Boffa i,j
PMCID: PMC12745405  NIHMSID: NIHMS2127644  PMID: 40324749

Abstract

Objective:

To address variability in nodal staging during curative-intent lung cancer resections, the Commission on Cancer implemented Standard 5.8 in 2021, requiring lymph nodes be sampled from ≥3 mediastinal stations and ≥1 hilar station and documented in a synoptic pathology report. We assessed compliance data from recent site reviews to evaluate the early implementation of Standard 5.8 through a federally funded collaborative.

Methods:

Hospital compliance rates with Standard 5.8 were extracted from a repository of site reviewers’ documentation of Commission on Cancer site visits performed during 2022 and 2023. Each review included up to 7 randomly selected pathology reports eligible for the standard. For a site to be compliant, 5 of 7 pathology reports reviewed in 2022 must have met Standard 5.8, which increased to 6 of 7 reports in 2023 and beyond.

Results:

Overall, 652 site visits occurred in 2022 and 2023. Sites without eligible cases (n = 148 [23%]) were excluded. Among 504 eligible sites, 272 (54%) were found compliant, and 232 (46%) were found noncompliant. Of noncompliant sites, the median percentage of pathology reports meeting the standard was 29%. From 2022 to 2023, the median percentage of adherent pathology reports increased; however, overall compliance rates dipped in 2023 as the threshold needed for site compliance rose.

Conclusions:

With almost half of Commission on Cancer-accredited sites noncompliant, there is a real opportunity to improve the quality of surgical lymph node evaluations. This aligns with growing efforts to support hospitals and surgeons with quality improvement tools and resources for Standard 5.8.

Keywords: Commission on Cancer, Operative Standard, lymph node staging, lung cancer, quality improvement, compliance, accreditation

Graphical Abstract

graphic file with name nihms-2127644-f0001.jpg

High-quality lymph node evaluations are a fundamental component of the surgical management of lung cancer. Beyond the therapeutic effect of removing potentially cancer-bearing lymph nodes, accurate staging of hilar and mediastinal nodal stations informs prognosis and can guide treatment. More specifically, patients found to have lymph node metastases may benefit from additional systemic therapies, which are associated with improved survival.1–3 Moreover, several studies have demonstrated that less complete lymph node evaluations are associated with worse survival.4–6

Despite the known importance of lymph node staging in lung cancer, the completeness of lymph node evaluations at the time of primary tumor resection has varied widely in the United States. Numerous studies have shown that lymph node yield and rates of upstaging (detecting occult microscopic nodal disease) differ by surgeon, hospital volume, hospital type, surgical approach, and extent of surgical resection.7–11 Another potential factor contributing to this variation has been the lack of a universally accepted best practice for surgical lymph node evaluation among a range of different approaches.

To address variability in the quality of cancer operations, the American College of Surgeons (ACS) published the Operative Standards for Cancer Surgery: Volume I in 2015, which is a series of best practices on cancer surgery techniques critical to achieving optimal outcomes.12 Based on the best-available evidence and expert opinion, these standards included consensus recommendations for ensuring high-quality lung cancer surgery. In 2021, the Commission on Cancer (CoC) formally incorporated an updated version of the operative standards for nodal staging in lung cancer as part of its hospital accreditation process.13,14 This guideline, known as CoC Standard 5.8, establishes a minimum threshold for adequate lymph node evaluation, requiring the sampling of lymph nodes from at least 3 different mediastinal nodal stations and at least 1 hilar nodal station.15,16 Over the past several years, hospital-level compliance with Standard 5.8 has been closely monitored through CoC accreditation site reviews.

To study the implementation and influence of the CoC Operative Standards, including Standard 5.8, the ACS formed a federally funded collaboration with investigators at the University of Michigan and Yale in 2024.17 Data from CoC accreditation site reviews conducted in 2022 and 2023 were made available through this collaboration. This study establishes compliance rates with Standard 5.8 from the first phase of its implementation across CoC-accredited sites to identify potential opportunities for improving compliance with this standard.

METHODS

Repository of Site Review Data

Through the accreditation of more than 1400 hospitals nationwide, the CoC aims to improve the quality of cancer care by establishing standards and measuring compliance with those standards.18,19 Every 3 years, CoC sites undergo an accreditation site review to evaluate their compliance with these standards. A repository of data from CoC site reviews was accessed through a federally funded research collaboration. The University of Michigan Institutional Review Board determined this work to be nonhuman subjects research (HUM0026037); therefore, informed consent was not required. This study is reported in accordance with the Strengthening the Reporting of Observation Studies in Epidemiology reporting checklist.20

Standard 5.8 Case Eligibility and Compliance

Standard 5.8, implemented on January 1, 2021, applies to primary pulmonary resections performed with curative intent for non–small cell lung cancer, small cell lung cancer, and carcinoid tumors of the lung.14 Standard 5.8 does not apply when primary resection specimens have no residual cancer (eg, after neoadjuvant therapy).21 Cases are eligible regardless of the operative approach (ie, video-assisted thoracoscopy, robotic-assisted thoracoscopy, or open thoracotomy) or the extent of resection (ie, wedge resection, segmentectomy, lobectomy, and pneumonectomy).15 Standard 5.8 applies to all CoC program types, except for Pediatric Cancer Programs and Veterans Affairs Cancer Programs.22

Documentation is a key component of compliance with Standard 5.8. Not only must the defined number of lymph node stations be sampled (3 or more mediastinal and 1 or more hilar), but also, these named and/or numbered stations must be documented by the examining pathologist in a synoptically formatted pathology report according to the College of American Pathologists cancer protocol template.

During site visits, reviewers examined up to 7 randomly selected pathology reports from qualifying lung cancer operations. If there were fewer than 7 cases, all eligible pathology reports were reviewed.23 Sites without any eligible cases were exempt from Standard 5.8 during their accreditation review. For network cancer programs (ie, large organizations composed of multiple smaller, individual facilities), site reviewers examined up to 7 pathology reports per individual facility participating in the network. Network programs were then rated cumulatively, adding together the number of pathology reports that met the standard (ie, were adherent) from each individual facility.23

A CoC site is considered compliant with Standard 5.8 when it has met the CoC’s required threshold for the minimum proportion of pathology reports adherent to the standard’s criteria. Following an initial grace period in the first year of the standard’s implementation, this threshold has increased over time. Specifically, during 2022, 70% of the evaluated pathology reports must have been adherent for the hospital to be considered compliant (eg, 5 of 7 pathology reports). For site visits conducted in 2023 and beyond, this threshold became 80% (eg, 6 of 7 pathology reports). This threshold compliance rate is intended to account for inevitable clinical situations in which the standard is not able to be achieved (eg, the surgeon finds no lymph nodes to remove or the patient clinically decompensates).23

Programs found noncompliant with Standard 5.8 are required to resolve their deficiencies through an internal audit process defined by the CoC.23 If a program does not resolve its deficiency, it could potentially lose accreditation. The CoC review board evaluates situations like these on a case-by-case basis.

Data Extraction and Analysis

In this study, compliance data were extracted from the repository of site reviewers’ documentation of accreditation visits conducted in 2022 and 2023. De-identified CoC site data were managed using Research Electronic Data Capture software (Solera).24 Hospitals without any eligible cases were identified and excluded from subsequent analysis. Given the low number of Hospital Associate Cancer Programs and National Cancer Institute-Designated Network Cancer Programs, these programs were reported in an Other category to protect facility privacy.

Average percentages of pathology reports meeting Standard 5.8 were calculated for compliant and noncompliant sites and reported as median (interquartile range). Site compliance was compared by site visit year (2022 vs 2023) using the Pearson χ2 test and by type of CoC site designation using Fisher exact test. Wilcoxon rank-sum test with pairwise comparisons was used to compare medians. All P values were 2-sided. All statistical analyses were performed using Stata statistical software version 18.0 (StataCorp).

RESULTS

CoC Site Eligibility for Standard 5.8

A total of 652 site visits occurred, including 329 in 2022 and 323 in 2023 (Figure 1). Of these, 148 sites (22.7%), including 72 in 2022 and 76 in 2023, had no qualifying lung cancer cases and were exempt from Standard 5.8. Community-based cancer programs accounted for the majority of exempt sites (81.7%; 121 out of 148). Specifically, more than half (57.4%; 85 out of 148) of Community Cancer Programs had no eligible cases. A total of 504 sites had at least 1 case eligible for Standard 5.8, including 257 in 2022 and 247 in 2023.

FIGURE 1.

FIGURE 1.

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Compliance with Commission on Cancer (CoC) Standard 5.8 in 2022 and 2023.

Rates of Compliance

Among the eligible sites, 272 (54.0%) were found compliant with Standard 5.8 and 232 (46.0%) were found noncompliant (Table 1). Data on the percentage of pathology reports meeting the standard was available in the repository for 86.2% (200 out of 232) of sites found noncompliant. Of sites found noncompliant, the proportion of pathology reports meeting standard criteria was 25.0% (0 to 42.9%) in 2022 and 40.0% (14.3%−57.1%) in 2023.

TABLE 1.

Commission on Cancer (CoC) site characteristics by compliance status

Site characteristic or measure CoC sites with eligible cases (N = 504) Compliant (n = 272 [54.0%]) Noncompliant (n = 232 [46.0%]) P value*
Site visit year .066
 2022 257 149 (58.0) 108 (42.0)
 2023 247 123 (49.8) 124 (50.2)
CoC site designation† .022
 ACAD 98 56 (57.1) 42 (42.9)
 CCCP 233 128 (54.9) 105 (45.1)
 CCP 63 26 (41.3) 37 (58.7)
 INCP 77 37 (48.1) 40 (52.0)
 NCIP 29 21 (72.4) 8 (27.6)
 Other 4 4 (100) 0 (0)
No. of eligible pathology reports reviewed‡
 Mean ± SD 7.7 ± 5.5 7.5 ± 4.8 7.8 ± 6.1
 Median (IQR) 7 (7–7) 7 (7–7) 7 (6.5–7.5)
No. of adherent pathology reports
 Mean ± SD 4.3 ± 4.4 6.8 ± 4.2 2.6 ± 3.5
 Median (IQR) 4 (1–6) 7 (6–7) 2 (0–4)
% adherent pathology reports‡
 Mean ± SD 59.8 ± 36.4 92.7 ± 10.0 30.9 ± 24.6
 Median (IQR) 71.4 (28.6–100) 100 (85.7–100) 28.6 (0–50)
% adherent pathology reports by year§
 2022 64.0 (25–100) 100 (85.7–100) 25.0 (0–42.9)
 2023 71.4 (33.3–100) 100 (85.7–100) 40.0 (14.3–57.1)
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Values are presented as n (%) or median (interquartile range). ACAD, Academic Comprehensive Cancer Program; CCCP, Comprehensive Community Cancer Program; CCP, Community Cancer Program; INCP, Integrated Network Cancer Program; NCIP, National Cancer Institute-Designated Comprehensive Cancer Center Program.

*

Statistical tests: Pearson χ2 test for site visit year and Fisher exact test for CoC site designation.

†

Sites designations with<5 programs were included in the Other category.

‡

Data on the number of pathology reports reviewed, the number of adherent reports, and the percentage of adherent reports were not available for all sites.

§

Among available data (n = 179 in 2022; n = 197 in 2023).

Compliance Differences Between 2022 and 2023

From 2022 to 2023, the proportion of adherent pathology reports increased from 64.0% (25%−100%) to 71.4% (33.3%−100%). However, because the threshold for compliance also increased during this time (from 70% to 80%), the rate of site compliance fell from 58.0% during 2022 to 49.8% during 2023.

Compliance Differences Across Varying Site Designations

Compliance rates varied across the different CoC site designations. National Cancer Institute-Designated Comprehensive Cancer Center Programs had the highest percentage of compliance (21 out of 29; 72.4% of sites), followed by Academic Comprehensive Cancer Programs (56 out of 98; 57.1% of sites). In pairwise comparison testing, National Cancer Institute-Designated Comprehensive Cancer Center Programs were significantly more compliant than Community Cancer Programs (72.4% vs 41.3%; P = .005) and Integrated Network Cancer Programs (72.4% vs 48.1%; P = .025) (Figure 2). Similarly, Academic Comprehensive Cancer Programs were significantly more compliant than Community Cancer Programs (57.1% vs 41.3%; P = .049).

FIGURE 2.

FIGURE 2.

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Forest plot for compliance with Standard 5.8 by CoC site type. ACAD, Academic Comprehensive Cancer Program; CCCP, Comprehensive Community Cancer Program; CCP, Community Cancer Program; INCP, Integrated Network Cancer Program; NCIP, National Cancer Institute-Designated Comprehensive Cancer Center Program.

DISCUSSION

This study is the first assessment of national compliance with CoC Standard 5.8 across more than 500 CoC-accredited hospitals. Our findings suggest Standard 5.8 has a broad reach across the CoC membership, as most CoC hospitals perform at least some lung cancer surgery. This is consistent with prior studies illustrating roughly 80% to 85% of CoC-accredited hospitals perform lung cancer surgery.25,26

Only 54% of hospitals were found compliant with Standard 5.8. This is not entirely surprising given the somewhat mixed response to the standard from the thoracic surgery community. The national compliance rate aligns with several single-center studies, reporting that Standard 5.8’s lymph node sampling criteria were met in only a minority of lung cancer cases.11,27,28 The CoC’s perspective is distinctly important because the majority (75%) of lung cancer is managed at CoC-accredited hospitals in the United States.29

The etiology of the low compliance rates is not entirely clear. Perhaps there is uncertainty over the benefits of comprehensive lymph node staging in all patients. However, several studies have associated completeness of lymph node staging with improved survival, including recent prospective research emphasizing the importance of sampling at least 3 mediastinal nodal stations regardless of the extent of resection.30–32 One obvious advantage of accurate staging is the ability to identify patients who could benefit from additional systemic therapies after surgery. The importance of this information has increased dramatically during the era of targeted treatments and immunotherapies that have proven to be incredibly effective in selected patients in the adjuvant setting.1,2

Another potential contributor to low compliance may be reduced surgeon familiarity with the anatomy and procedures associated with complete nodal evaluations. The recent shift toward nonanatomic parenchymal sparing resections (eg, wedge resections) could broaden the range of surgical specialties that feel comfortable performing lung cancer resections. However, long-term cancer outcomes remain closely tied to the completeness of intraoperative nodal staging for these smaller resections.7,33 In response to potential differences in surgeon experience, the ACS Cancer Surgery Standards Program, the Society of Thoracic Surgeons, and other entities have created resources to help surgeons comply with this standard.34–36 Additionally, in 2024, the ACS Cancer Programs launched the Standard 5.8 Lung Nodal, Operative, Dissection, Evaluation, and Staging National Quality Improvement project aiming to improve compliance by helping surgeons and programs identify and respond to root causes of noncompliance.37 This quality improvement project also provides a mechanism for noncompliant sites to satisfy the corrective action requirements set forth by the CoC.

Finally, some surgeons who recognize the importance of accurate nodal evaluation may disagree with technical aspects of the standard. For example, some questions have been raised around pretest probability because the likelihood of up-staging may vary widely among patients with lung cancer. Others have questioned whether transbronchial nodal evaluations could replace the standard, which excludes nodes exclusively biopsied with endobronchial ultrasound from its requirements.37 Resio and colleagues38 examined the Society of Thoracic Surgeons General Thoracic Surgery Database to address this question and found that negative preoperative nodal evaluations did not prevent upstaging, reaffirming the value of thorough surgical lymph node evaluation and validating Standard 5.8’s intent to minimize the risk of false negative preoperative staging.

Limitations

Our study was limited by the scope of data currently available in the repository of site reviewers’ documentation. Although our study includes only half of all CoC-accredited sites, hospital characteristics and surgical case mix are normally distributed across accreditation site visit years, minimizing the risk of selection bias. Additionally, reviewing just 7 pathology reports per site introduces potential sampling error, which may not fully represent overall site performance. However, despite this possibility, given the substantial proportion of sites found to be noncompliant, we believe the message that we need to improve the quality of lymph node evaluations remains clear. Given Standard 5.8 is a new initiative, establishing baseline compliance rates has been critical because this has enabled the CoC to identify opportunities for program improvement. In response to recent concerns, modifications to the implementation and evaluation of Standard 5.8 have been made; for example, beginning in 2025, the number of pathology reports reviewed per site increased from 7 to 15. Lastly, our study lacks the long-term outcomes (eg, cancer recurrence) needed to characterize the potential influence of Standard 5.8. However, further investigation is underway through a CoC Special Study led by our investigators in collaboration with the ACS and National Cancer Database.39

CONCLUSIONS

In this first report on national compliance with Standard 5.8, most CoC-accredited sites were shown to perform lung cancer surgery, highlighting the broad potential reach of this standard. Given nearly half of the reviewed sites were found noncompliant with Standard 5.8, there appears to be a real opportunity to improve the quality of surgical lymph node evaluations in lung cancer. This aligns with growing efforts to support hospitals and surgeons with quality improvement tools and resources to support improved implementation of Standard 5.8. Efforts to ensure high quality surgical nodal evaluations may become increasingly important as the shift toward sublobar resections re-expands the range of surgical practices for managing lung cancer. Finally, the potential influence of systemic therapy in patients with lymph node metastases has dramatically improved with novel systemic therapies, further emphasizing the need to exclude radio-graphically occult disease.

CENTRAL MESSAGE.

CoC Standard 5.8 addresses lymph node sampling in lung cancer. Compliance data from 2022 and 2023 demonstrate nearly half of CoC-accredited sites were noncompliant with the standard.

PERSPECTIVE.

During 2021, the CoC implemented Operative Standard 5.8 to improve lymph node staging in lung cancer surgery across all CoC-accredited hospitals. Compliance with Standard 5.8 over the initial implementation period has not yet been documented. Through a federally funded collaborative, we report the compliance of more than 650 CoC-accredited sites evaluated during 2022 and 2023.

Acknowledgments

Dr Baskin is supported by the National Cancer Institute (NCI) (T32 CA2366215). This work is supported by a grant from the NCI (R01 CA288625).

Abbreviations and Acronyms

ACS

American College of Surgeons

CoC

Commission on Cancer

Footnotes

Informed consent: The University of Michigan IRB determined this work to be nonhuman subjects research (HUM0026037), therefore informed consent was not required.

Read at the 105th Annual Meeting of the American Association for Thoracic Surgery, Seattle, Washington, May 2–5, 2025.

To view the AATS Annual Meeting Webcast, see the URL next to the webcast thumbnail.

Webcast

You can watch a Webcast of this AATS meeting presentation by going to: https://www.aats.org/resources/early-compliance-with-lung-can-9588.

Audio

Audio Recording: You can listen to the audio recording of the presentation and discussion associated with this paper: https://doi.org/10.1016/j.jtcvs.2025.04.041.

Conflict of Interest Statement

Dr Baskin serves as a clinical scholar for the American College of Surgeons (ACS). Ms Francescatti serves as senior manager of the ACS Cancer Research Program and Cancer Surgery Standards Program. Dr Hieken serves as chair of the ACS Cancer Surgery Standards Program and has unrelated research funding from Genentech and SkylineDX BV. Dr Katz serves as immediate past chair of the ACS Cancer Surgery Standards Program. Dr Boughey serves as chair of the ACS Cancer Research Program and also reports grant funding paid to her institution from Eli Lilly and SimBioSys and is on the Data Safety Monitoring Board for Cairn Surgical. Dr Weigel serves as medical director of the ACS Cancer Programs. Dr Dossett leads the ACS Cancer Research Program Implementation Research Committee. Dr Boffa serves as vice chair of the Commission on Cancer Executive Committee. All other authors reported no conflicts of interest.

The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

References

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