ASO Author Reflections: Writing the Textbook on "Textbook Outcomes" in Surgical Oncology.

Abstract

This article reflects on the evolution, current state, and future direction of “textbook outcome” as a quality metric in surgical oncology. Originating from Ernest Codman’s early advocacy for tracking surgical outcomes, textbook outcome emerged in 2010 as a composite, all-or-nothing measure designed to capture the complete perioperative experience rather than isolated metrics. The concept gained rapid adoption in surgical oncology literature due to its patient-centered approach to outcomes. A systematic review of 86 surgical oncology articles encompassing 116 disease sites revealed significant problems with this metric. No single component was universally included across all studies examined. While mortality, complications, length of stay, and readmission appeared in approximately 90% of definitions, substantial variation existed in how these criteria were operationalized. Mortality cutoffs ranged from in-hospital to 90-day measurements, complication grading systems varied between classification schemes, and length of stay thresholds employed different methodological approaches. Most troublingly, many studies failed to explicitly define their textbook outcome criteria, forcing readers to infer definitions from contextual clues or leaving definitions entirely unclear. This definitional heterogeneity renders cross-study comparisons unreliable and undermines the metric’s utility for quality improvement. Identical patient cohorts could yield vastly different textbook outcome rates depending on definition selection, obscuring true performance differences between institutions. The authors advocate for disease-specific definitions developed through expert consensus and standardized reporting requiring explicit articulation of all components within methods sections. Such standardization would transform textbook outcome from a heterogeneous collection of institutional preferences into a reliable, comparable measure capable of advancing surgical quality improvement.