CoC Operative Standards Drive Improvements in Cancer Surgery

Approximately 60% of patients diagnosed with cancer in the US undergo surgery to treat or stage their disease.¹ By achieving complete primary resection and accurate lymph node staging to guide adjuvant therapy, high-quality cancer surgery can improve oncologic outcomes. Despite these core approaches to treatment, variation in the technical quality of cancer surgery persists, potentially contributing to differences in survival across hospitals and patients nationwide.

To help reduce variation in cancer surgery and improve oncologic outcomes, the ACS published the first of its three-volume series of Operative Standards for Cancer Surgery manuals in 2015. This series includes 134 standards for high-quality cancer operations based on the best available evidence.²

In 2020, the ACS Commission on Cancer (CoC) incorporated six of these operative standards into its national accreditation process. Standards 5.3-5.8 address either primary resection and/or lymph node staging for cancers of the breast, cutaneous melanoma, colon, rectum, and lung (see Table below). Compliance with these standards is determined during accreditation site visits, in which trained CoC site reviewers randomly select up to 15 eligible patient cases and review the operative or pathology reports. Since 2023, CoC-accredited sites have been required to achieve 80% compliance with each of these six standards.

The CoC includes 1,400 accredited hospitals nationwide, which collectively treat more than 70% of cancer cases. As such, the CoC Operative Standards have broad potential to impact patients and surgeons across the country. It is therefore essential to determine whether adherence to these standards improves oncologic outcomes to guide future surgical cancer quality improvement efforts.

Multi-Institutional Study Assesses CoC Operative Standards

The National Cancer Institute (NCI) has funded the Assessing the Effectiveness and Significance of the Operative Standards Program (AESOP) study. AESOP is a 5-year, multi-institutional initiative led by co-principal investigators Lesly A. Dossett, MD, MPH, FACS, from the University of Michigan in Ann Arbor, and Daniel J. Boffa, MD, MBA, FACS, from the Yale School of Medicine in New Haven, Connecticut, in collaboration with co-investigators Ronald Weigel, MD, PhD, MBA, FACS, Medical Director of the ACS Cancer Programs, Judy C. Boughey, MD, FACS, Chair of the ACS Cancer Research Program, Samantha Hendren, MD, MPH, FACS, from Indiana University in Bloomington, and Tina Hieken, MD, FACS, Chair of the ACS Cancer Surgery Standards Program.

The AESOP grant seeks to evaluate the implementation and impact of the CoC Operative Standards through three primary aims: (1) evaluate compliance with the CoC Operative Standards across cancer and hospital types, (2) assess guideline- and organizational-level barriers and facilitators of implementation, and (3) determine the impact of the CoC Operative Standards on oncologic outcomes, such as 2-year cancer recurrence (see Figure below).

In the first 18 months of funding, the AESOP study team focused on the grant’s first aim by evaluating facility-level compliance data gathered during scheduled CoC accreditation site visits. For example, in The Journal of Thoracic and Cardiovascular Surgery, the team reported that in the first 2 years of implementation (2022 and 2023), only 54% of hospitals were compliant with CoC Standard 5.8 on lymph node sampling for lung cancer.³

Further, they revealed that compliance rates varied across different CoC site designations, with NCI-designated comprehensive cancer center programs having the highest percentage of compliance (72%), which was significantly more compliant than community cancer programs (41%). These data were in concordance with another recently published study in the Annals of Surgery which evaluated the initial compliance rates across all six standards.⁴ Our ongoing analyses will similarly assess associations between compliance and hospital characteristics, including program type and surgical case volume. 

Future Work Will Examine Underlying Causes of Variation in Compliance

While these preliminary studies have elucidated variation in compliance rates across institutions, future work will focus on understanding the etiologies of this variation. A qualitative study by the AESOP team analyzed semi-structured interviews with CoC site reviewers surrounding perceived barriers to compliance with the operative standards.⁵

The second aim of the grant will expand on this initial work and probe more deeply into the barriers to program uptake through surveys and interviews with Cancer Liaison Physicians (CLPs). Each CoC-accredited site designates a CLP who serves as a leader on their cancer committee and is responsible for monitoring their program’s performance on CoC quality measures.

Beginning in early 2026, the AESOP study team will survey and interview CLPs to identify factors contributing to variation in compliance with the CoC Operative Standards. Survey results will be linked to accreditation performance and analyzed to identify common roadblocks to implementation. Similarly, compliance data from the first aim will inform the selection of interview participants to ensure a range of experiences is captured. As frontline leaders in implementing the CoC Operative Standards, the CLPs offer unique perspectives that are expected to reveal key factors influencing hospital compliance.

For the third aim, the AESOP study team will evaluate the impact of the CoC Operative Standards on cancer outcomes, including 2-year cancer recurrence, using the CoC Special Study mechanism. Using the ACS National Cancer Database® (NCDB) and in collaboration with the CoC, the study team will collect data from all 1,400 CoC-accredited programs to compare outcomes among patients treated before and after implementation of the operative standards. A pilot study will launch in 2026 with plans for the full national evaluation to follow in 2027.

With these aims and with the support of the ACS, the AESOP study seeks to generate valuable insights into how implementation of the CoC Operative Standards influences cancer surgery practices and oncologic outcomes. Ultimately, the goal is that these findings will help guide future quality improvement efforts in cancer surgery and beyond.

Questions may be submitted to AESOP@facs.org.

Dr. Christina Fleischer is a general surgery resident at the University of Michigan in Ann Arbor and an ACS Designated Scholar.

References

1. Siegel RL, Miller KD, Wagle NS, Jemal A. Cancer statistics, 2023. CA Cancer J Clin. 2023;73(1):17-48.
2. Nelson HD, Hunt KK, Oncology AfCTi. Operative standards for cancer surgery: Lippincott Williams & Wilkins; 2015.
3. Baskin AS, Funk EC, Francescatti AB, Sinco BR, et al. Early compliance with lung cancer lymph node standard 5.8: An analysis of 2022 and 2023 Commission on Cancer site reviews. J Thorac Cardiovasc Surg. 2025;170(4):926-932.
4. Katz MHG,  Francescatti AB, Mullett TW, Harris J, et al. First national effort to optimize the performance of cancer surgery by the American College of Surgeons Commission on Cancer and Cancer Surgery Standards Program: Early results after implementation of the Operative Standards. Ann Surg. 2025;282(3):371-381.
5. Baskin AS, Kravchenko T, Funk EC, Francescatti AB. Site reviewer perspectives on the implementation of the Commission on Cancer Operative Standards. J Am Coll Surg. July 2025. 8:10.1097/XCS.0000000000001462. Epub ahead of print.