Textbook Outcome After Oral Cancer Surgery as a Composite Measure for Survival and Quality-of-Care Evaluation

Objective: To enhance survival outcomes for oral cavity cancer (OCC) surgery, a composite measure has been developed: “textbook outcome” (TO). Three studies have reported on this concept in OCC, but the need for population-level results remains. This study investigates OCC surgery, focusing on survival and hospital-level results. Study Design: Cohort study. Setting: National multicenter study. Methods: All first primary OCC patients who underwent curative tumor resection between 2018 and 2021 were selected from the Dutch Head and Neck Audit database. Resections were categorized as local or extensive, the latter including neck dissection and/or free or pedicled flap reconstruction. TO was defined as the absence of 30-day mortality, hospital readmission, prolonged length-of-stay, severe complications, surgical margins <1 mm, and <18 lymph nodes per side. Adjusted hazard ratios (aHRs) were determined for 2-year overall survival (OS) and disease-free survival (DFS). Results: TO was reached in 81.1% and 46.9% after local (1039 patients) and extensive (1227 patients) resection, respectively. Reduced TO rates were observed in females, non-squamous cell carcinoma, cT3-T4, and floor of mouth compared to tongue. Obtaining TO was significantly associated with less adjuvant therapy and improved 2-year survival after local (aHR 0.55 OS P =.004, 0.70 DFS P =.085) and extensive (aHR 0.61 OS P ≤.001, 0.69 DFS P =.002) surgery. After correction for population differences, no interhospital variation in TO remained. Conclusion: Achieving TO is strongly linked to improved survival, highlighting its importance as a short-term composite quality-of-care indicator. The separate outcomes that were influential to the hospital's TO score differed between hospitals, indicating opportunities to improve outcomes.