The American College of Surgeons Commission on Cancer: CLP Frequently Asked Questions

Q. Does the Cancer Liaison Physician have to be a doctor? A surgeon?

A. Yes. The Cancer Liaison Physician (CLP) must be a medical doctor on staff, however, does not have to be a surgeon. Approximately 45% of CoC Cancer Liaison Physicians are multidisciplinary.

Q. Does the Community Outreach Coordinator have to be the Cancer Liaison Physician?

A. Effective immediately, the CoC no longer requires that the CLP serve as the Community Outreach Coordinator, and is allowing facilities the flexibility to choose the most appropriate person to serve in this role. The CoC does, however, recommend that the CLP serve in a leadership role on the cancer committee, acting as either the cancer committee chair or one of the four designated coordinators in the areas of quality improvement, community outreach, cancer conference, and quality control of cancer registry data.

Please keep in mind that a physician should be involved in facilitating community outreach activities and contribute expertise to identify special needs in the communities based on facility, state, and national data. These needs may include, but are not limited to screening, prevention and early detection, disparities, support services, pain/symptom control, palliative care, and clinical trials.

Q. Can a facility have two cancer liaison physicians?

A. The Commission on Cancer recommends that one physician fill the role of the Cancer Liaison Physician. This will ensure that the CoC maintains communication with one individual who can then, in turn, share these communications with the cancer committee. The CoC often uses the Cancer Liaison Physician as the gateway to the cancer program, therefore it works most effectively when one person serves as the direct contact for CoC initiatives.

Exceptions for the appointment of two Cancer Liaison Physicians are made for larger facilities and for those facilities where the physicians are unable to handle the responsibilities due to time constraints. If a facility chooses to appoint two Cancer Liaison Physicians, written documentation of the reason for appointment must be submitted to and approved by the CoC. Note: If an additional Cancer Liaison Physician is appointed, the facility must enter this additional contact information in the Facility Information Profile System (FIPS).

Q. Can the Cancer Liaison Physician serve as the Cancer Committee Chair?

A. Yes. It is permissible for the CLP to also serve as the cancer committee chair. Bottom line, the CLP should exhibit leadership within the cancer program, and either serve as the Chair, or in a coordinator role that he/she is interested in.

Q. Can the Cancer Liaison Physician serve in more than one coordinator role?

A. The CoC does not recommend that the CLP serve in more than one coordinator role. Additionally, the CLP should not fill the role of the chair and a coordinator role. For instance, the CLP should not serve as the cancer committee chair and the coordinator of community outreach. Because the chair has distinct responsibilities from those of the four coordinators, it is recommended that separate individuals fill these positions. Having four coordinators on the cancer committee promotes team involvement and shared responsibility. This increased participation benefits the cancer program by bringing fresh ideas, innovative thinking, credibility, and visibility to the program. To review job descriptions of the chair position and each of the four coordinators, go to http://www.facs.org/cancer/coc/resourcetools.html.

Q. What qualities should a Cancer Liaison Physician possess?

A. The critical quality required of a Cancer Liaison Physician is leadership, someone that will support the facility's efforts in complying with and maintaining the CoC's standards, facilitate activities with the interests of the cancer patients, facility, and the community in mind, and dedicated to improving the quality of care delivered to the cancer patient.

Q. What are the responsibilities of the Cancer Liaison Physician?

A. The main activities we ask Cancer Liaison Physicians to be involved in include the following: working with staff to promote the facility's CoC approval and make the program visible; attending and contributing to the cancer committee; using NCDB data to study cancer care, improvement initiatives and opportunities; spearheading initiatives to comply with CoC standards (i.e. quality data submission and review and cancer staging accuracy); and finally, facilitating the relationship with the American Cancer Society (ACS) Note: Web conferences on the role of the CLP are scheduled every other month – details can be found at http://www.facs.org/cancer/coc/liaison.html.

Q. What does the Cancer Liaison Physician report to the cancer committee?

A. The Cancer Liaison Physician should give the cancer committee regular updates on Commission on Cancer activities. These topics of discussion can be pulled from recently attended CoC meetings or meeting minutes (i.e. Clinical Congress), Cancer Liaison Physician updates (sent out quarterly), CoC Flash newsletters (sent monthly), miscellaneous communications sent from the CoC by e-mail or postal mail, and communications received from the State Chair.

The Cancer Liaison Physician should also share collaborative activities with the American Cancer Society, or other local cancer agencies. Reports should be given on the progress, results, and success of cancer programs as well as new initiatives the facility is pursuing in relation to cancer care in the community.

Q. Does a facility have to wait until the end of the three-year term to replace a Cancer Liaison Physician?

A. No. Upon approval of the cancer committee, CLPs can be replaced at any point during their three-year term. Once an application is submitted, a notice of appointment will be given to the hospital administrator (if e-mail is on file), cancer committee chair, cancer registrar, and the Cancer Liaison Physician within three weeks.

Q. How does a facility replace a Cancer Liaison Physician?

A. If the facility would like to replace the currently appointed Cancer Liaison Physician, a discussion must be held with the cancer committee and approval obtained from the cancer committee chair. Upon recommendation of a candidate or interested party, complete the application found on the Commission on Cancer Web site at http://www.facs.org/cancer/coc/liaison.html. Once the CoC approves the application, the facility must modify the Cancer Liaison Physician's contact information in FIPS.

Q. How many terms can a Cancer Liaison Physician serve?

A. Cancer Liaison Physicians (CLPs) serve a three-year term, and are eligible to serve an unlimited number of terms based on performance and evaluation data collected at the time of survey. The Commission on Cancer processes expiring terms every January and July. Upon expiration of a term, the CoC will send a letter of reappointment/replacement to the cancer committee chair and the cancer registrar. The cancer committee must determine whether the current CLP is appropriately serving in the role or decide if another candidate would better suit the position. The CoC does recommend that CLPs rotate after terms in order to bring new leadership and ideas to the cancer committee. However, this is at the discretion of the cancer committee.

Q. What is the Cancer Liaison Physician's role in the survey process?

A. The Cancer Liaison Physician should play an integral role in the survey process. The Cancer Liaison Physician should work with the cancer committee to ensure compliance with the CoC's 36 standards and serve as an advocate for the cancer program. In addition to attending the survey, the Cancer Liaison Physician has a number of tasks in which he/she can be a part of. These include playing host to the Surveyor, taking the Surveyor on a tour of the facility, organizing the meeting agenda and participants, and spending one-on-one time to discuss cancer committee activities and collaborations with the American Cancer Society.

Q. If two Cancer Liaison Physicians are appointed, how is the Survey Application Record (SAR) completed?

A. If two individuals serve as Cancer Liaison Physicians, they should fill out the Cancer Liaison Physician Activity Report collaboratively. If the Activity Report does not permit the documentation of all activities both of the CLPs are involved in, please note these in the comments box on the activity record page.

Q. How is the American Cancer Society (ACS) structured? Which office do we collaborate with?

A. The American Cancer Society National Headquarters is located in Atlanta, Georgia with 14 Divisions located across the country. Divisions are made up of either a single state or composed of multiple states in a regional setting (i.e. Midwest Division - Iowa, Minnesota, South Dakota and Wisconsin; Illinois Division - Illinois). Within each state are local, or regional, offices, which are located within a community. These are the offices and staff CoC approved facilities and Cancer Liaison Physicians will have partnerships with. In contrast, State Chairs primarily maintain the relationship with the ACS at the Division level.

To locate the ACS office nearest you, log on to the ACS Web site at www.cancer.org and enter your zip code on the homepage under the section titled In My Community. Contact information for your local office will appear.

Q. Who does the Cancer Liaison Physician contact at the American Cancer Society?

A. When establishing first contact with an office, you should ask to speak with the Vice President or Supervisor of the local office. Once introductions are made, you will most likely be assigned to work with a cancer control representative. This field staff will be your primary contact for partnership and implementation of programs and services at the facility. This is also the staff member that the facility may choose to invite to cancer committee meetings.

If you are unsure of where and whom to call, a list of ACS Division Staff is listed on our Web site at http://www.facs.org/cancer/coc/physresource.html. These are the contacts at the Division level that primarily work with the State Chairs, and those who oversee the relationship and activities between the CoC and ACS at the state level. They will be able to connect you to someone at the community level.

Q. What is the role of the American Cancer Society staff in this partnership?

A. The ACS staff member should work with the facility to discuss opportunities for collaboration on cancer control projects. The cancer committee can request ACS staff to present available programs and services, and work with ACS staff to ensure that they are implemented and monitored properly. The ACS staff should provide the cancer program with general cancer education materials, pamphlets and brochures describing ACS services and support programs. In conjunction with the Community Outreach Coordinator, the Cancer Liaison Physician and ACS staff member should meet on a regular basis to discuss potential partnership activities (i.e. screening programs, activities around cancer awareness months, etc.). It would be beneficial in the planning of collaborative initiatives if the ACS staff would share its community assessment data to identify gaps in cancer control activity. ACS staff can be a great resource and this relationship should be established early to gain the most benefit for the cancer patients in the community.

Q. Is the disclosure of patient identifiable information permitted by hospitals and physicians to ACS assistance programs?

A. ACS assistance programs obtain or receive varying amounts of information about a patient from hospitals and physicians. In most cases, hospitals and physicians provide patient information directly to ACS or refer the patient to ACS because they believe ACS assistance programs will be valuable to the patient and his or her family in dealing with their cancer experience. Under the Privacy Rule, the transfer of patient information to ACS assistance programs providing healthcare and related services is a "permitted" disclosure when done for treatment purposes. Hospitals and physicians are permitted to disclose protected health information to ACS assistance programs because the disclosure is for the treatment purposes of the hospital or physician and the ACS assistance program is providing healthcare and related services to the patient.

Source: Associate Chief Counsel of the American Cancer Society; Approved and validated by Secretary Tommy Thompson

Q. Is there a need for a business associate contract under the Privacy Rule?

A. The disclosure from a covered entity to an ACS assistance program does not create a business associate relationship or trigger the need for a business associate contract. Because services are for the benefit of the patient, this relationship does not require a business associate agreement. By not entering into a business associate contract, the risk of liability and noncompliance is reduced for hospitals and physicians.

Source: Associate Chief Counsel of the American Cancer Society; Approved and validated by Secretary Tommy Thompson.

Q. What if our facility's bylaws do not prohibit an outside party to participate in cancer committee meetings?

A. If a facility's bylaws prohibit external visitors from attending cancer committee meetings due to the confidential nature of the contents, ask that the visitor present his/her material either at the end or beginning of the meeting. For instance, should an external party attend the meeting to present on local resources and/or services then ask that person to exit the meeting once the presentation is over. Therefore, the participant is not present during the discussion of sensitive patient issues.

If you have questions pertaining to the Cancer Liaison Program, please submit these to Kate Phair, Cancer Liaison Program Administrator, at kphair@facs.org or Carolyn Jones, Cancer Liaison Program Coordinator, at cjones@facs.org.

Revised July 20, 2005

Cancer Liaison Program