Textbook outcome in cancer surgery and its prognostic value: a systematic review and meta-analysis

Textbook outcome is a composite metric for evaluating surgical quality and prognosis in cancer surgery, yet its definition varies across cancer types. Existing systematic reviews mainly focus on colorectal cancer, necessitating a broader analysis. This study assesses textbook outcome achievement rates and its prognostic value for recurrence-free survival (RFS), disease-free survival, and overall survival (OS) across multiple cancers. Databases (PubMed, Embase, Web of Science, and Cochrane Library) were searched up to November 2024. Sixty-three cohort studies (393 073 patients) were included. Study quality was appraised using the Newcastle-Ottawa Scale. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using random/fixed-effects models. The sources of heterogeneity were investigated through subgroup analysis, meta-regression analysis, and sensitivity analysis. Patients not achieving textbook outcome had worse OS (HR = 1.51, 95% CI: 1.44-1.58, P  < 0.001), disease-free survival (HR = 1.65, 95% CI: 1.46-1.87, P  < 0.001), and RFS (HR = 1.35, 95% CI: 1.28-1.42, P  < 0.001). Subgroup analysis confirmed the prognostic value of textbook outcome for colorectal, esophageal, and liver cancers ( P  < 0.05) but not for pancreatic (OS: HR = 1.04, 95% CI: 0.68-1.60), gallbladder (OS: HR = 1.06, 95% CI: 0.80-1.39), or ampullary cancers (OS: HR = 1.61, 95% CI: 0.84-3.10). Cancer type was associated with heterogeneity, and the sample size was also associated with heterogeneity in RFS outcomes (meta-regression P  = 0.039). Funnel plots indicated publication bias for RFS (Egger's P  = 0.007). Achieving textbook outcome is correlated with improved survival in most cancers, though the prognostic utility varies by cancer biology and definitions of textbook outcome. Standardizing the criteria of textbook outcome and validating findings in larger cohorts are essential for clinical application.