The lung surgeons I work with are competitive, and the patients they treat are better for it.  They monitor how many lymph nodes they are able collect from the mediastinoscopies and lung cancer surgeries they do, competing against their own targets and each other.  Why? Because there's evidence that nodal yield is related to better outcomes, perhaps because the better surgeons often happen to collect more nodes, perhaps because their patients are more accurately staged, and probably in part because there's a value in removing cancer-involved lymph nodes, rather than relying on post-surgical treatments to cure them.  

But these same surgeons also note that they are only part of the process of nodal yield, which also depends on how well the pathologists do their job of retrieving lymph nodes from the tissue they're given, and how meticulously they look for cancer in the nodes they find.  While my first instinct was to think, "it's the poor carpenter who blames his tools", I of course realize that pathology is actually very skill dependent.  And now a study coming from the University of Tennessee in Memphis and just published in the Journal of Clinical Oncology provides clear evidence that expertise and meticulous care really count.

  The authors had noted that many patients they saw in Memphis appeared to be understaged because of less than expert surgical care and/or interpretation of the pathology material submitted.  While the deficiencies of surgery by many people who are doing lung cancer resections has been studied and are well known (though still painful to consider, as so many patients do far worse than they should because of substandard surgical attention and skill in the US), the contribution of the pathologist's role to staging is less clear.  The authors used internal controls in which the results from the initial pathology from 73 patients who underwent routine pathologic examination then had their pathology material processed by a more detailed process by an expert pathologist and assistant.

   What they found was that a total of 514 additional LNs were retrieved from the lung tissue of 66 of the 73 patients (90%), with cancer in 56 (11%) of those nodes.  Among 50 who were considered node negative, six (12%) patients were actually found to have nodal involvement with more detailed evaluation, and three additional patients had previously undetected satellite tumor nodules.  In total, the pathologic stage was upgraded in eight of the 73 patients (11%).  

   The point is that for those patients, accurate staging would likely be the difference between a recommendation for adjuvant chemo or not, and for a more accurate assessment of prognosis.  Moreover, while this was an evaluation of N1 nodes, the stakes are even higher if evaluation of mediastinal nodes aren't accurate, and I strongly suspect that a similar gap in accuracy applies there too.  

   All in all, this work further emphasizes the theme that expertise and meticulous care matter and can easily lead to important differences in treatment recommendations...and likely also help to explain why we so often find that patients treated by people with more expertise do better.