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Become a member and receive career-enhancing benefits

Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.

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Implementation of Operative Standards into Surgical Practice

Linda Zheng; Susan Deming; Amanda Francescatti, MS; Rebecca A. Snyder, MD, MPH, FACS; Matthew H.G. Katz MD, FACS

April 1, 2022

The first two volumes of the Operative Standards for Cancer Surgery were published in 2015 and 2019, respectively, to present recommendations for surgical techniques critical to the conduct of cancer operations.1,2 Immediate Past-Executive Director of the American College of Surgeons (ACS) David B. Hoyt, MD, FACS, states in the foreword to Volume 1, “When evidence and experience demonstrate a technique that is essential for optimal outcomes, it is essential to teach that technique with precision and put it forth as an evidence-based standard.”1

Nine disease sites are covered in these two manuals: breast, lung, pancreas, colon, thyroid, stomach, rectum, esophagus, and skin (melanoma). Experts determined the oncologically critical portions of each major operation relevant to each of these disease sites, performed comprehensive literature reviews and evaluated existing data informing the conduct of these operative elements, and provided evidence-based recommendations intended to improve quality of life and longevity.

The Commission on Cancer (CoC) has incorporated six of the manuals’ recommendations into the 2020 accreditation standards, collectively referred to as the “CoC Operative Standards.” Standards 5.3 through 5.8 set requirements for sentinel lymph node biopsy and axillary lymph node dissection for breast cancer, wide local excision for primary cutaneous melanoma, colon resection, total mesorectal excision, and pulmonary resection.3 By the time these standards are fully implemented in 2023, CoC-accredited programs will have taken the first step toward raising the bar for cancer operations in the US, including Puerto Rico.

The goals of the Operative Standards for Cancer Surgery include educating surgeons and surgical trainees and enhancing the quality of surgical oncology care. To support these efforts, the ACS Cancer Research Program (CRP) sponsored the Technical Standards for Cancer Surgery: Bringing Evidence into Practice Didactic Course at Clinical Congress 2021. Furthermore, the ACS Cancer Surgery Standards Program (CSSP) has been developing comprehensive protocols with synoptic operative reports for cancer surgery documentation. These protocols include the required data elements and responses from the new CoC Operative Standards and additional recommendations from the Operative Standards for Cancer Surgery. Volume 3 of the Operative Standards for Cancer Surgery, which includes standards for sarcoma, adrenal, neuroendocrine, peritoneal, urothelial, and hepatobiliary cancers, will be published later this year. These initiatives work together to improve oncologic outcomes by implementing operative standards into practice.

The Technical Standards for Cancer Surgery: Bringing Evidence into Practice course was presented in a longitudinal format. Participants viewed prerecorded presentations in advance of a live, interactive discussion at the conference. Participants were invited to join a follow-up discussion 6 weeks later.

Matthew H.G. Katz, MD, FACS, Chair, ACS CSSP, and Kelly K. Hunt, MD, FACS, Vice-Chair, CSSP, moderated the session. Prerecorded talks by Sandra L. Wong, MD, FACS, chair, department of surgery, and professor of surgery, Dartmouth Geisel School of Medicine, Hanover, NH, and Thomas A. Aloia, MD, FACS, vice-president and director of Oncology Services at Ascension, focused on the value of care and data supporting standards development. Karl Y. Bilimoria, MD, FACS, Vice-Chair, quality, department of surgery, and John B. Murphy Professor of Surgery, Northwestern University, Chicago, IL, described how surgeons can use operative standards and outcome metrics to improve surgical quality.

Elizabeth G. Grubbs, MD, FACS, professor of surgical oncology, The University of Texas MD Anderson Cancer Center, Houston, demonstrated that operative standards can be an important part of education for surgical trainees. By focusing on adherence to evidence-based standards, trainees enter the workforce with expertise in best practices in cancer surgery. The live, interactive discussion with course participants and speakers was led by Judy C. Boughey, MD, FACS, Chair, ACS CRP Education Committee; Fabian Johnston, MD, FACS, associate professor of surgery and division chief, gastrointestinal oncology The Johns Hopkins Hospital, Baltimore, MD; Nicole Lopez, MD, FACS, associate professor of surgery, University of California San Diego; and Heidi Nelson, MD, FACS, Medical Director, ACS Cancer Programs.

The Technical Standards for Cancer Surgery: Bringing Evidence into Practice Didactic Course is available for enrollment through May 1, 2022. New participants can view the prerecorded presentations as well as recordings of the interactive discussions with faculty and attendees through September 30, 2022. This course represents an opportunity to learn how to take technical standards from theoretical constructs to fundamental components of surgical practices and programs. Register at facs.org/clincon2021/postgraduate-courses.

The implementation of the CoC Operative Standards represents a paradigm shift in how surgical procedures are performed and documented. Four of the accreditation standards, Standards 5.3 through 5.6, require certain details regarding the operation to be documented using specific data elements and responses in synoptic format in operative reports. The other two, Standards 5.7 and 5.8, contain similar synoptic formatting requirements for specified data items in pathology reports. CoC-accredited programs already are required to use the synoptic reporting format defined by the College of American Pathologists (CAP) for 90% of eligible cancer pathology reports.3 Standards 5.7 and 5.8, therefore, took effect January 1, 2021.

The CAP Cancer Reporting Protocols are used to facilitate comprehensive pathology reporting of the critical elements of cancer specimens.4 Recognizing the need for a surgical counterpart to the CAP Cancer Reporting Protocols, the CSSP is creating protocols for cancer surgery documentation. Best practice oncologic technique combined with synoptic operative reporting will allow for more precise staging, tailored multidisciplinary care, and improved efficiency and accuracy in documentation.

Further, by using a standardized format, critical operative details can be communicated effectively within clinical practice and can be evaluated programmatically to improve local, regional, and national cancer care. Three protocols have been developed to date for operations performed for colon cancer, breast cancer, and melanoma. Similar to CAP Cancer Reporting Protocols, CSSP protocols present a comprehensive list of data fields in a synoptic operative reporting template, followed by explanatory notes with additional reference material.

Cancer surgery protocols from the CSSP are intentionally designed to replace the need for narrative reports. In addition to fulfilling the requirements of CoC Standards 5.3 through 5.6 and capturing critical elements of cancer surgery, the templates contain universal surgical data elements and information that other accrediting organizations require. American Joint Committee on Cancer staging and National Cancer Database coding information also are built into each protocol, and recommendations from the Operative Standards for Cancer Surgery are referenced throughout the explanatory notes. The first three CSSP cancer surgery protocols will be available for purchase in the amazon.com Kindle Store later this year.

Together, the ACS CRP and CSSP continue to work to implement standards for the technical conduct of cancer surgery. Over the next several months, CoC programs can look forward to the publication of the third volume of the Operative Standards for Cancer Surgery as well as protocols for cancer surgery documentation for pancreas and thyroid cancer. CSSP protocols for lung cancer and additional disease sites will follow.

These resources are an asset to surgical oncologists and general surgeons alike, making it easier to incorporate evidence into clinical practice. For more information on the Operative Standards for Cancer Surgery manuals, visit facs.org/oscs. For resources to assist with the implementation of the CoC Operative Standards, visit the Operative Standards Toolkit at facs.org/opstandardtoolkit. Questions about these resources can be directed to cssp@facs.org.


  1. Nelson H. American College of Surgeons. Alliance for Clinical Trials in Oncology. Operative Standards for Cancer Surgery, Volume 1. Philadelphia, PA: Wolters Kluwer Health; 2015.
  2. Katz MH. American College of Surgeons. ACS Clinical Research Program. Operative Standards for Cancer Surgery, Volume 2. Philadelphia, PA: Wolters Kluwer Health; 2018.
  3. American College of Surgeons. Optimal Resources for Cancer Care (2020 standards). Available at: https://www.facs.org/-/media/files/quality-programs/cancer/coc/optimal_resources_for_cancer_care_2020_standards.ashx. Accessed October 15, 2021.
  4. College of American Pathologists. Cancer protocols. Available at: https://www.cap.org/protocols-and-guidelines/cancer-reporting-tools/cancer-protocols. Accessed October 15, 2021.