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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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ACS Cancer Research Programs

NAPRC Stays the Course in Quest to Improve Rectal Cancer Care

Steven D. Wexner, MD, FACS

September 11, 2023

Approaching its 10th anniversary, the National Accreditation Program for Rectal Cancer (NAPRC) is updating its strategic approach and expanding on verification and quality improvement initiatives that have been its hallmark for the past decade. 

Discussion about NAPRC formation began in 2011, and in August of that year, an inaugural meeting of stakeholders was held. 

This interdisciplinary group featured acclaimed experts representing the ACS Commission on Cancer (CoC), College of American Pathologists (CAP), American College of Radiology (ACR), American Society of Colon and Rectal Surgeons (ASCRS), Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Society for Surgery of the Alimentary Tract (SSAT), and the Society of Surgical Oncology (SSO).  

Over the next 3 years, the case was built through lectures and studies in the peer-reviewed literature that a national accreditation program for rectal cancer was necessary. Data, primarily from the National Cancer Database (NCDB), confirmed the wide disparity in rectal cancer care in the US.1,2

Moreover, it was clear that the outcomes of rectal cancer surgery in the US, confirmed by rates of permanent colostomy creation, circumferential resection margin positivity, and local recurrence, were far below levels achieved in European countries. 

The common denominator among the countries that outperformed the US in rectal cancer care was the presence of an interdisciplinary care model, particularly in high-volume centers. Patient outcomes data in Scandinavia, the United Kingdom, and elsewhere in Europe showed that adopting a team approach and, in many cases, centralizing services helped improve care while increasing patient volume.

After 3 years of data collection and dissemination, a formal request was made in May 2014 during a presentation to the CoC Accreditation Committee, which then unanimously recommended creation of the NAPRC. Following ACS Executive Committee approval, the ACS Board of Regents unanimously approved funding for the program in June 2014.  

The governance structure of the NAPRC includes Executive, Standards, Accreditation, and Education Committees. Each committee includes one representative from the constituent organizations—ACR, ASCRS, CAP, SAGES, SSAT, and SSO—as well as four ACS Fellows and requested representation from the ACS Resident and Associate Society and Young Fellows Association. 

Stakeholders spent the first 3 years after formation developing a set of rectal cancer care standards. The standards were used to beta test six sites varying in location and practice type. Ultimately, the accreditation process for the NAPRC began in March 2018. Between 2018 and 2022, 77 programs were accredited. 

In 2022, the first reaccreditation visits began, and in April of this year, a strategic retreat was held to begin updating the standards and introducing standards on two new topics: local excision and wait and watch. Other standards such as postoperative adjuvant chemotherapy were retired due to changes in practice. 

In the short time since the program’s inception, numerous changes have occurred in the evaluation and management of rectal cancer. For example, rectal ultrasound has been replaced by thin-slice rectal cancer protocol MRI; synoptic reports are widely accepted and, in fact, are required by the CoC; and adjuvant chemotherapy, which was initially replaced by neoadjuvant chemotherapy, now has been supplanted by total neoadjuvant therapy.  

In addition, the “wait and watch” approach has morphed from a practice that occasionally was used to an approach that now is embedded into the standard of care for rectal cancer surgery. Immunotherapy will undoubtedly accelerate in its indications and acceptance, and innovations in rectal cancer care mean the NAPRC standards will continue to be fluid to accommodate continued advances in the field.  

The next phase of NAPRC growth will be to confirm its value-base proposition of improving rectal cancer outcomes for patients throughout the US. At least nine studies have been published so far validating its value.3-5 

In addition, NCDB data will be used to focus on additional variables that could demonstrate the value of accreditation. Such variables might include rates of permanent stoma creation, anastomotic leak, and local recurrence, as well as patient-reported outcomes. Different types of accreditation models also will be explored.

Updates about the NAPRC will be included in ACS communications such as Cancer News, the ACS Brief, and the Bulletin. Learn more about NAPRC accreditation at facs.org/naprc

Dr. Steven Wexner is the director of the Ellen Leifer Shulman and Steven Shulman Digestive Disease Center and chair of the Department of Colorectal Surgery at Cleveland Clinic Florida. For the ACS, he is Chair of the CoC NAPRC. 


  1. Wexner SD, Berho ME. The rationale for and reality of the new National Accreditation Program for Rectal Cancer. Dis Colon Rectum. 2017;60(6):595-602.
  2. Rickles AS, Dietz DW, Chang GJ, et al. High rate of positive circumferential resection margins following rectal cancer surgery: A call to action. Ann Surg. 2015;262(6):891-898. 
  3. Brady JT, Xu Z, Scarberry KB, et al. Evaluating the current status of rectal cancer care in the US: Where we stand at the start of the Commission on Cancer’s National Accreditation Program for Rectal Cancer. [published correction appears in J Am Coll Surg. 2018 Oct;227(4):484-487]. J Am Coll Surg. 2018;226(5):881-890.
  4. Brady JT, Bingmer K, Bliggenstorfer J, et al. Could meeting the standards of the National Accreditation Program for Rectal Cancer in the National Cancer Database improve patient outcomes? Colorectal Dis. 2023;25(5):916-922.
  5. Raman S, Tsoraides SS, Sylla P, et al. Analysis of patterns of compliance with accreditation standards of National Accreditation Program for Rectal Cancer. J Am Coll Surg. 2022;234(3):368-376.