Cancer Programs News: July 24

Commission on Cancer Study Results Published in the British Medical Journal

A new observational study published in The British Medical Journal examines cancer outcomes in women without upfront surgery for ductal carcinoma in situ (DCIS). The analysis was completed under the work of the 2018 Commission on Cancer Special Study on DCIS. The findings highlight the importance of effective risk stratification tools and shared decision-making for specific patient populations.

For more information, contact crp@facs.org.

Rapid Cancer Reporting System Multifactor Authentication Starts August 9

The ACS is implementing multifactor authentication (MFA) for all registries, including the Rapid Cancer Reporting System (RCRS). Beginning August 9, all users accessing RCRS, which is hosted by IQVIA, will receive a six-digit MFA code by email each business day or anytime a new browser is used. Users must enter the MFA code before logging into the RCRS. To see an overview of how the MFA will work, view the instructions.

Before August 9, anyone using RCRS as a report viewer or uploader should login to the Quality Portal and confirm that the email used for RCRS is accurate by doing the following:

• After logging in, click on your name in the upper right corner.
• Click “My Profile” in the drop-down menu.
• Click “My Profile” in the lefthand navigation.
• Scroll down to see the email address that will be used for the MFA code. If needed, email updates may be made there.

For more information, contact CoC@facs.org.

CoC Releases Standard 7.1 Quality Measure Performance Benchmarks

Programs must comply with Commission on Cancer (CoC) Standard 7.1: Quality Measures starting this year.

The 2025 cancer committee activities will be reviewed during the 2026 site visits. Programs must have reviewed their performance on the selected quality measures, identified any potential deficiencies, and documented their review and any appropriate actions in the cancer committee minutes. The CoC selected four quality measures as part of Standard 7.1 compliance that must be reviewed with the cancer committee starting with calendar year 2025.

The four required quality measures include:

• C12RLN: For patients undergoing a colon resection for colon cancer, at least 12 regional lymph nodes are removed and pathologically examined at time of resection.
• ACT: For patients under the age of 80 with surgically-managed pathologic stage III colon cancer (N>0), adjuvant chemotherapy is initiated within 4 months (120 days) of diagnosis, or recommended.
• LCT: For patients with surgically managed NSCLC, pathologically staged T2 and >4cm, or T>=3, or N>0, systemic therapy (chemotherapy, immunotherapy or targeted therapy) was initiated within the 4 months prior to surgery or after surgery, or was recommended.
• BCSdx: For patients with AJCC Clinical Stage I-III breast cancer, the first therapeutic surgery in a non-neoadjuvant setting is performed within and including 60 days of diagnosis.

The program’s expected performance benchmark for each quality measure can be found in the Rapid Cancer Reporting System (RCRS). The performance benchmarks set by the CoC for Standard 7.1 quality measures are as follows:

• C12RLN: 95%
• ACT: 90%
• LCT: 70%
• BCSdx: 70%

Programs can achieve compliance with Standard 7.1 through one of two pathways: (1) program performance meets the expected performance benchmark for each quality measure; or (2) if the performance benchmark is not met, through the development and implementation of an action plan to improve performance.

RCRS quality measure reports are being updated to display the program’s performance rate and expected performance benchmark for each quality measure using a three-color coding system: green, yellow, and red.

• When the program achieves or exceeds the expected performance benchmark for a quality measure, the program’s performance rate will be shown in green. 
• When the program’s performance rate is below the established benchmark, but the upper confidence interval is above the benchmark, the dashboard will be color-coded in yellow. Yellow does not require a documented action plan for Standard 7.1 compliance, but it may indicate an area of program focus for quality improvement, especially if there are multiple yellow indicators within a quality measure over a three-year period. 
• If both the performance rate and upper confidence interval are below the benchmark, the dashboard will show red, and the program will be responsible for developing a corrective action plan to be considered compliant with standard 7.1. 

Example:

The CoC website lists the current quality measures, but only the benchmarks for the above four measures will be used for Standard 7.1 compliance. The website also includes details regarding Standard 7.1.  

For reference, the following are the years that will be evaluated at future site visits for Standard 7.1:

Learn More about CoC Standards in the Standards Resource Library

The Standards Resource Library (SRL), accessible via the Resources page in the Quality Portal, provides information to help programs better understand Commission on Cancer standards. The SRL is formatted in alignment with the nine chapters of Optimal Resources for Cancer Care (2020 Standards) and by standard within each chapter of the standards manual. The tenth chapter includes documents that address more than one standard and general topics. At the end of each chapter, a Frequently Asked Questions section is included under “General Resources.”

The SRL is reviewed throughout the year to verify that all links and documents are relevant to the current standards. As new resources become available, either through the ACS or from outside organizations, they are added to the appropriate sections within the SRL.

NAPRC Gap Analysis Tool for 2026 Compliance Is Available

The National Accreditation Program for Rectal Cancer (NAPRC) released the updated resource, Optimal Resources for Rectal Cancer Care Gap Analysis Tool, for compliance with the 2026 NAPRC Standards. The NAPRC Gap Analysis Tool is designed to assist rectal cancer programs with assessing their readiness to apply for NAPRC accreditation for the first time.

The Gap Analysis Tool contains the following information for each accreditation standard in Optimal Resources for Retal Cancer Care (2026 Standards):

• Standard requirements
• Documentation requirements
• Fields for tracking the program’s compliance status and any necessary action plans
• Available resources to assist in achieving compliance
• Required templates for documenting compliance
• Recommended templates for RC-MDT patient presentation and discussion 
  

For more information on the NAPRC Gap Analysis Tool, contact NAPRC@facs.org.

ASCRS Updates Course Required for NAPRC Accreditation 

The American Society of Colon & Rectal Surgeons updated its Fundamentals of Rectal Cancer Surgery course. Completion of this course is required for all surgeons within a National Accreditation Program for Rectal Cancer-accredited program for compliance with Standard 8.1: Rectal Cancer Program Education. Surgeons who have completed the previous version of the course do not need to retake the updated course for compliance with Standard 8.1.

Questions related to the course itself may be submitted to ascrs@fascrs.org. Questions on Standard 8.1 compliance may be submitted to the CAnswer Forum.

Prepare for Site Visit Success with NAPRC Webinar

The National Accreditation Program for Rectal Cancer (NAPRC) will host the webinar NAPRC Site Visit Process: Success Using the New Standards at 4:00 pm CT on August 19. Speakers will discuss how revised and new standards in Optimal Resources for Rectal Cancer Care (2026 Standards) will impact the site visit process and review strategies for demonstrating compliance. 

The NAPRC applied for Continuing Education credits for this webinar with the National Cancer Registrars Association and California Board of Registered Nursing.

Visit the Cancer Programs website to view additional educational resources.

CoC Recognizes Accredited Sites

The ACS CoC recognizes the following cancer sites for demonstrating their commitment to providing high-quality, patient-centered cancer care to patients and the community by recently earning CoC reaccreditation:

AdvocateAurora Central Chicagoland INCP
Downers Grove, IL

HCA Florida Trinity Hospital
Trinity, FL

Henry Ford Metro East
Grosse Pointe, MI

James J. Peters VA Medical Center
Bronx, NY

Johnston Health
Smithfield, NC

Medical City of Plano
Plano, TX

Overlake Medical Center & Clinics
Bellevue, WA

Penn Presbyterian Medical Center
Philadelphia, PA

Rush University Medical Center
Chicago, IL

Saint Peter's University Hospital
New Brunswick, NJ

WVU Cancer Institute Wheeling Hospital
Wheeling, WV

NAPBC Recognizes Accredited Sites

The ACS NAPBC recognizes the following breast sites for demonstrating their commitment to providing high-quality, patient-centered cancer care to patients and the community by recently earning NAPBC reaccreditation:

AdventHealth Daytona Beach
Daytona Beach, FL

Aurora Medical Center Oshkosh Comprehensive Breast Program
Oshkosh, WI

Breast Cancer Program at Upstate
Syracuse, NY

The Breast Center at Saint Peter's University Hospital
New Brunswick, NJ

Cheshire Medical Center / Dartmouth Hitchcock- Keene
Keene, NH

Lakeland Regional Cancer Center
Lakeland, FL

The Outer Banks Hospital
Nags Head, NC

Sarah Cannon Cancer Institute at Johnston Willis Hospital
Richmond, VA

WellSpan Adams Cancer Center
Gettysburg, PA

NAPRC Recognizes Accredited Sites

The ACS NAPRC recognizes the following cancer sites for demonstrating their commitment to providing high-quality, patient-centered cancer care to patients and the community by recently earning NAPRC accreditation:

BILH Lahey Hospital & Medical Center - Colon & Rectal Surgery Department
Burlington, MA

Cleveland Clinic
Cleveland, OH

Henry Ford Hospital Detroit
Detroit, MI

Munson Medical Center
Traverse City, MI

University of California Irvine
Orange, CA

Wesley Medical Center
Wichita, KS

Mark Your Calendars

August 19: NAPRC Site Visit Process: Success Using the New Standards

September 18: NAPBC: Breast Screening: What Every Physician Needs to Know

October 4–7: ACS Clinical Congress 2025, Chicago, IL

October 21: NAPRC: QI for NAPRC Programs

October 28: CoC Smoking Cessation Standard

November 13: NAPBC: Auxiliary Surgical Management

November 18: NAPRC: Case Studies and Process Improvement: Promoting Success in NAPRC Programs