American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

August 2014 CoC Source

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CoC News

ACS Seeks to Fill Eight Vacancies on Commission on Cancer

It is the time of year when we look for the next group of Commissioners on the Commission on Cancer (CoC).

The American College of Surgeons (ACS) is seeking eight Fellows to fill vacancies on the CoC. The initial term of appointment is for three years with eligibility for re-election to a second term. Members may hold office or serve as a vice-chair of a committee or subcommittee during their second term. New members will be recommended by the Nominating Committee, selected in October by the Executive Committee, and then brought before the full CoC membership for approval at the CoC Annual Meeting. The ACS Board of Regents will confirm the final list of new members, and the CoC will announce the new members in late October.
Surgeons who meet the criteria below and are interested in becoming a member of the CoC should contact Lynda Watt at to receive an application. The completed application, curriculum vitae, and any letters of recommendation must be sent to Lynda Watt by Monday, September 1.    
CoC member criteria include: 

  • Full ACS Fellowship status
  • Staff appointment at a CoC-accredited cancer program and participate in cancer program activities
  • Service as an effective State Chair or Cancer Liaison Physician
  • Knowledge of the CoC’s goals and initiatives
  • Represent a surgical specialty, geographic area, or diverse group not currently represented on the CoC  
  • Interest in contributing to and enhancing CoC programs and committee work
  • Ability to serve as a member on at least one CoC committee  
  • Attendance and participation in at least two in-person meetings annually
  • Attendance and participation in committee conference calls  

Please contact Lynda Watt at if you have any questions.

Advocacy Update

CoC Participates in OVAC's Lobby Day

One Voice Against Cancer (OVAC) participation

One Voice Against Cancer (OVAC), a collaboration of national not-for-profit organizations representing millions of Americans, delivered a unified message to Congress on the need for increased cancer-related appropriations. As an OVAC member, the CoC sent a contingent of CoC members and volunteers to the 2014 Lobby Days on July 7–8.  Attendees representing the CoC included Balazs I. Bodai, MD, FACS; Charles Cheng, MD, FACS; Patrick Gavin RPh; James Hamilton, MD, FACS; Rowena Schwartz, PharmD, BCOP; and Alan Thorson, MD, FACS.

OVAC recognizes the importance of federal funding for cancer research, early detection, prevention, drug development, nurse education, and childhood cancer registries. By making these lifesaving programs a priority, progress continues in the fight against cancer. The CoC contingent visited with senators and representatives from their respective states and districts and called on Congress to increase funding for the fight against cancer.

Accreditation Corner

Reminder: Annual Update Ends September 30th

An initial e-mail notification describing the Annual Update process was sent to all accredited programs scheduled for survey in 2015 and 2016 on June 30 and a reminder will be sent on August 15.

The Annual Update is active from July 1 through September 20. Please note that no extensions will be given.  

Your participation in the Annual Update process enables the CoC to:

  • Maintain accurate contact information for your cancer program staff and leadership, which facilitates communication between your program and the CoC
  • Gather current resources and services information for your cancer program, which is displayed in the CoC Hospital Locator
  • Track and evaluate the activities and concerns of your program’s Cancer Liaison Physician (CLP)

This year we are asking that you update the following areas of the CoC Datalinks Activity Menu.

  • Manage Staff Contacts

Review and update contact information for current cancer program staff and leadership, add new contacts, and review and delete outdated information.
Updating Contact Information
1.    Log into CoC Datalinks. Click on “Manage Staff Contacts” in the Main Facility Activity menu.
2.    Ensure that all names, titles, and e-mail addresses are up to date and correct.
3.    Remember to remove the names of staff members who are no longer part of the cancer program.

  • Eligibility Requirement
    • Upload policies and procedures or other documentation that have been revised during the last 12 month period.
    • Record the date the cancer committee reviewed the revised policies and procedures or other documentation.
    • Review and update the resources and services provided by your program.  This information is displayed in the CoC Hospital Locator so it is important that the information is up to date.
    • Remember to delete previous versions of the policies and procedures or other documentation before uploading the revised version.
    • Remember to delete the previously recorded cancer committee review date before adding a new date.
    • If there have been no changes to the information recorded and attachments previously uploaded to the Eligibility Requirements section, then no action on your part is needed.
  • CLP Activity Report
    • The CLP is to complete this report based on 2013activities

It is recommended that you review compliance with Standards 5.5 and 5.6 (National Cancer Data Base [NCDB] submissions) now and address any questions or issues directly with NCDB staff at Please do not wait until the time of your survey. 


The 2014 Program Activity Record (PAR) will remain open for program use after the Annual Update period closes and we encourage you to continually update the Survey Application Record (SAR) after this date as a record-keeping tool to document program activities as they occur.

Questions about the PAR or the Annual Update should be submitted to  Questions regarding your CoC Datalinks user ID and password should be submitted to

Chapter 4 - Patient Outcomes: Standards 4.1 and 4.2

Prevention and screening activities are vital components of a robust cancer program. As defined by the CoC, prevention programs (Standard 4.1) identify risk factors and use strategies to modify attitudes and behaviors to reduce the chance of developing cancer.  Screening programs (Standard 4.2), on the other hand, apply screening guidelines to detect cancers at an early stage, which improves the likelihood of increased survival and decreased morbidity. Within this framework, a number of well-established and preeminent cancer advocacy organizations provide a multiplicity of initiatives that focus on these two meritorious domains of high-quality cancer care. Notwithstanding, and for good cause, a number of cancer programs have chosen to partner with these entities, who are similarly guided by the same principles that promulgate good cancer care.

However, cancer programs must also be cognizant of the rubric by which the CoC determines that programs have met the criteria set forth in these two standards. Simply partnering with an external entity alone will not meet the standards as codified. Themes that are essential criteria to both standards include:

  • The cancer committee, which forms the governance structure of cancer programs, must annually identify cancer prevention and screening initiatives based on a community needs assessment.
  • Cancer prevention and screening initiatives may extend into a subsequent year(s) but, there must be a different prevention and screening activity identified each year.
  • The community needs assessment must be clearly documented in the cancer committee minutes, which serves as an essential document to measure compliance with the standards.
  • The cancer committee must select at least one cancer prevention program and at least one cancer screening program each year, that is (a) focused on decreasing the number of patients with a specific type of cancer and that is (b) targeted to decreasing the number of patients with late-stage disease, respectively.  
  • Both the prevention and the screening program(s) selected annually must be consistent with evidence-based national guidelines (and with screening programs also based on evidence-based interventions).
    • The CoC standards manual, Cancer Program Standards 2012 (V1.2.1), provides a partial list of resources for evidence-based national guidelines and evidence-based interventions to assist cancer programs.
  • The evidence-based national guidelines and interventions that were used in the selection of the annual prevention and screening program(s) must also be clearly documented in the minutes of the cancer committee.
  • The cancer committee must annually evaluate the effectiveness of the prevention and screening program(s), and this discussion must be clearly recorded in committee minutes.
  • For screening programs, in particular, a process must be developed to follow-up on all positive findings to ensure that these findings are addressed, and this mechanism (and data that demonstrates that positive findings were tracked by the cancer committee) must be clearly documented in cancer committee minutes.

At the time of survey, relevant activity, minutes and documentation in the SAR will be reviewed, combined with discussions with the surveyor(s) that include the designated coordinator and members of the cancer committee to assist in determining if a program has fulfilled these standards. 

We appreciate your cancer program’s commitment to high-quality cancer care and participation in the CoC accreditation program! 

Written on behalf of the Program Review Subcommittee

Addressing Questions

*Please include your facility name and Facility Identification Number (FIN) in all e-mails.

National Cancer Data Base News

Follow-Up, Reference Date, and Survival

Successful follow-up is an essential part of quality patient care. The original purpose of annual follow-up by the CoC was to ensure the patient receives annual post-treatment care. Current requirements do not directly enforce that, but do require that registries obtain positive information about the patient’s cancer and vital status annually. Accurate follow-up for cancer status and vital status is necessary for accurate calculation of overall and cancer-free survival rates.

Successful Follow-Up While the Patient Is Alive

Has the patient had any recurrence of the cancer? Or was the patient never cancer-free? What is the patient’s current cancer status? 

  • One way to obtain this information for patients who return to the hospital is to monitor the hospital’s own medical records for readmissions, regardless of the reason. A routine mechanism for tracking readmission of all cancer patients should be in place. To the extent the hospital’s records are digitalized, manual follow-up time can be reduced by automating the procedure for passing electronic readmission information to the registry for final abstracting. If a readmission is found, update treatment (if relevant), first recurrence (if needed), cancer status, and vital status. The date of last contact is the date the patient was last there.
  • When a list of patients who have not had follow-up is generated for investigation, each patient on this follow-up list should be investigated not only for vital status, but for cancer status and evidence of recurrence.
  • Letters to physicians should include specific questions asking about cancer status, and whether there has been a cancer recurrence.
  • Most patients will continue medical care with physicians outside the hospital. Programs that have the most successful automated follow-up are those that have arranged access from within the registry to electronic medical records in the offices of physicians or clinics that see substantial numbers of their patients. If the patient is found, update treatment (if relevant), first recurrence (if needed), cancer status, and vital status. The date of last contact is the date the patient was last seen there or the date the patient died.
  • Other programs have found that patient navigators who maintain personal contact with patients after their treatment get excellent follow-up information that they can pass on to the registry. In that case, patients are routinely contacted by someone they already know and trust to be interested in their condition. When the patient is contacted, update treatment (if relevant) and first recurrence (if needed). The date of last contact is the date the patient was contacted. Vital status remains “living.” If a family member or a caretaker was reached instead, the date of last contact is the date the informant last saw the patient alive (or the date the patient died).
  • Consider establishing routine proactive exchange of information with registries in nearby hospitals to share the information required for follow-up. When the second registry abstracts a case that was previously seen at the other hospital for cancer care, a simple message can be sent automatically to the originating hospital with the date of discharge, vital status, cancer status, and whether the patient was there due to a newly diagnosed recurrence (if so, the nature and date of the recurrence). This arrangement is also useful to identify later first-course treatment at the second hospital, transmitting treatment types, and dates. Proactively share only the information registries routinely need to obtain from other hospitals in order to avoid issues of competition (and remember, the purpose of HIPAA is to facilitate communication among practitioners caring for the same patient; sharing this information does not violate its provisions).
  • Standards 5.3 and 5.4 do not require continued follow-up of patients older than 100 years with whom no contact was recorded in the preceding 12 months. Other than that, the CoC does not recognize a number of follow-up attempts after which further follow-up attempts cease, though the resources used to locate these patients may change after unsuccessful attempts. Records for patients about whom no information is found are not changed, and the date of last contact is not updated. Until such patients are located in the future, they are lost to follow-up.

Implementing new, more effective procedures is dependent on action by the cancer committee to plan and champion innovations with the hospital’s administration and outside groups.

Correction in NCDB Completeness Reports

An alert registrar noticed a calculation error in the Completeness and Default Overuse Reports for 2012 Diagnoses Submitted in 2014.  The subset for Lymph-vascular Invasion (All Sites Diagnostic screen) failed to take Behavior into account.  The report has been updated, and now the denominator is correctly computed for cases with Behavior Code 3 and Surgical Procedure of the Primary Site at This Facility = 20-90.


Educational Programs and Resources

Register Today for Accreditation 101

Registration is now open for Accreditation 101 - Learning the Basics of CoC Accreditation and Standards, taking place in San Antonio, TX on Friday, September 12, 2014.  

The first Accreditation 101, held in February 2014, was well-attended and a huge success. In order to accommodate a waitlist as well as numerous requests, we are repeating the program. Register now to attend the only program developed by the professionals involved in CoC standards development and the survey process.  

View the program agenda to learn about the rich content that will be presented to help you meet the standards and prepare for your accreditation survey.  Review the program brochure and see for yourself why the February program sold-out!   Register today and do not forget to make your hotel reservation while space is still available. 

Early registration (on or before August 11): $395 
Registration after August 11: $450

Hotel rate: $189 per night if you book by August 21

Contact Andréa Scrementi at for further information on this workshop. Contact Eunice Oh at for exhibit opportunities. 

News from ACoS Cancer Programs


Registrar Resources

The AJCC offers a number of complimentary educational presentations for registrars.

The Collaborative Stage (CS) Education page is the hub for CS Moments—a series of brief videos addressing frequently asked staging questions. Visit our archive to view all CS Moments.

The CS Education page also provides links to educational resources offered by our partner organizations—National Cancer Registrars Association, the North American Association of Central Cancer Registries, the the Surveillance, Epidemiology, and End Results (SEER) Program,  the Center for Clinical Cancer Research,  National Program of Cancer Registries, and the CoC.

The American College of Surgeons Cancer Programs Online Education Portal features a number of webinars hosted by prominent physicians. Simply follow the instructions to create an account to access free AJCC content.

The AJCC YouTube channel features AJCC Staging Moments and CS Moments, as well as a series of favorite videos that we find useful for our users.


NAPBC Wants to Hear from You

The National Accreditation Program for Breast Centers (NAPBC), a quality program of the American College of Surgeon (ACS), is looking for your feedback regarding future educational program topics and locations. Regardless of your current NAPBC accreditation status (currently NAPBC accredited, in the process of reaccreditation, in the application phase, or considering NAPBC accreditation), your input is valuable. Please take a few minutes to help us set the future direction of NAPBC education by responding to the three-question survey

The NAPBC is on Twitter: @NAPBC_ACS

The NAPBC is on Twitter!  You can follow us, @NAPBC_ACS, for instant access to program updates and news from the NAPBC.  

Twitter is also a great way for an NAPBC-accredited center to connect with the public and spread the word that accreditation makes a difference. If your breast center is accredited and has a Twitter account, please follow us and tweet your @NAPBC_ACS accreditation to show your commitment to providing high-quality breast care.

News from the Oncology Community


NCRA Call for Abstracts Now Open

Share your expertise with the cancer registrar community at the National Cancer Registrars Association (NCRA) 41st annual educational conference, May 20–23, 2015, in San Antonio, TX. NCRA is accepting abstracts July 15–September 12. All submissions will be acknowledged and reviewed by the 2015 Program Committee. Selected presenters will be notified by October 30. To download the submission guidelines and access the link to the online collection center, go to If you have any questions, please contact Mary Maul, manager of NCRA's Education Programs, at or call at 703-299-6640 ext. 314.

Last 2014 CTR Exam Testing Window Deadline

The deadline to submit an application to take the Certified Tumor Registrar (CTR) exam in fall 2014 is September 19. The last 2014 testing window is October 18–November 8. Learn more and download the 2014 CTR Exam Candidate's Handbook at

NCRA Seeks to Establish a SOC Code for Medical Registrars

NCRA is establishing a distinct, detailed occupation code of "Medical Registrar" in the Standard Occupational Classification (SOC) system. This will allow medical registrars to be classified under a more accurate occupational code. NCRA strongly believes that a specific code for medical registrars would help ensure:

  • Statistics on the medical registry workforce will be more accurate, providing a clearer understanding of the current and future workforce needs
  • Correct salary information will help recruit and retain qualified individuals to this important profession
  • Qualified personnel will be hired to fill cancer registrar positions at the central and hospital levels

The SOC is revised every 10 years to coincide with the U.S. Census. The revision is a multiyear review that begins a few years after the previous SOC has been published and ends a few years before the next census. This method ensures that the occupations listed to describe the workforce are current and that the revised SOC is able to be used for the next census.

The SOC revision to inform the 2020 census is now underway. NCRA is submitting a formal application, along with letters of support, by the July 21, deadline. An extensive review process will be conducted over the next several years with a decision made in 2018. Stay tuned for updates.

Learn More About the Role of Physical Therapists in Cancer Survivorship Programs

The American Physical Therapy Association, a member organization of the American College of Surgeons Commission on Cancer recently published an article on the role of the Physical Therapist in cancer survivorship programs.