Textbook outcome and long-term survival after pulmonary resection for non-small cell lung cancer: a retrospective cohort study

BACKGROUND: Textbook outcome is a composite measure reflecting an ideal perioperative course by integrating multiple care-quality indicators. While its use has been reported internationally for non-small cell lung cancer (NSCLC) resection, it has not previously been evaluated in the Australian setting. This study aimed to determine the proportion of patients achieving a textbook outcome after NSCLC resection, identify the components that most commonly prevented its attainment, and evaluate its association with long-term overall survival. METHODS: A retrospective cohort study was conducted of adults undergoing lung resection for primary NSCLC at a tertiary Australian centre (2011–2023). Textbook outcome was defined according to the Dutch Lung Cancer Audit–Surgery criteria, requiring negative margins, complete lymph node dissection, absence of major complications, no 30-day mortality or reintervention, no prolonged ICU/high-dependency stay, no prolonged hospitalisation, and no readmission. Multivariable logistic regression identified predictors of textbook outcome, and Kaplan–Meier analysis was used to assess long-term survival. RESULTS: Of 731 patients, 163 (22.3%) met all textbook outcome criteria. Failure to achieve the composite outcome was most commonly caused by incomplete lymph node dissection (67.6%), reintervention (22.5%), major complications (20.2%), or prolonged stay (13.2%). Male sex (OR 0.53, 95% CI 0.36–0.77) and open surgery (OR 0.54, 95% CI 0.35–0.83) were associated with lower odds of meeting the criteria, while carcinoid histology increased the odds (OR 1.91, 95% CI 1.04–3.45). Patients who met the textbook outcome criteria had higher survival (5-year: 89.7% vs. 70.8%; 10-year: 82.0% vs. 60.7%; log-rank p < 0.001). CONCLUSION: Textbook outcome was achieved in approximately one-fifth of patients and was strongly associated with improved long-term survival. Enhancing lymph node dissection and wider adoption of minimally invasive surgery may help increase textbook outcome rates and represents a potential focus for future quality-improvement initiatives. TRIAL REGISTRATION: This study was retrospectively registered in the Australian-New Zealand Clinical Trials Registry (ACTRN12625000913471).