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

February 2014 CoC Source

(HTML Version)

Accreditation Corner

What's In a Name? Survey SAR Versus Non-Survey SAR

Which Survey Application Record (SAR) link should I use? Where is it located? The SAR won’t let me save any changes or additions. What am I doing wrong?

There are four separate links for the different types of SARs located on the CoC Datalinks activity menu:

  • 2014 Survey SAR for those programs preparing for a 2014 survey.
  • Program Activity Record (PAR) (formerly known as Annual Update SAR) for accredited cancer programs to record cancer program activity during non-survey years.
  • Survey SAR from 2013 surveys. Read-only format.
  • Historical SAR is the 2012 SAR using 2009 Standards. Read-only format.

Only the first two SARs listed above should be accessed by cancer programs to record cancer program activity beginning in 2012.

The term “Annual Update SAR” became too confusing with the survey SAR so the CoC staff changed the name of the SAR document for use during non-survey years. The new name, Program Activity Record (PAR), aligns itself more closely with its real purpose, entering program activity during non-survey years.

We hope this document name change will alleviate any further confusion about which SAR should be accessed and when.

SAR Icons

The 2014 SAR will have two working icons to assist users with completing and understanding the SAR screens for each standard.

The “i” icon is located on the upper left side of the standard screen. The “i” is for information, which includes the definition and requirements from the Cancer Program Standards 2012, Version 1.2.1: Ensuring Patient-Centered Care.

The “?” icon is located on the upper right side of the standard screen. The “?” represents helpful hints, appropriate examples, and explanations of how to complete the SAR. The information should provide answers based on frequently asked questions CoC staff have received over the last year. This icon will be updated as needed based on questions or issues received from the users.

Please note that the SAR entries for both icons are a work in progress and are still being completed. If you have questions regarding the SAR, please contact SAR@facs.org.

CORRECTION to January 27, 2014 Special CoC Source Announcement

“Note: The attendance requirement is based on the cancer committee’s meeting schedule. If the committee meets monthly, then attendance at 9 meetings is required to meet the standard. If the committee meets every other month, then attendance at 5 meetings is required.” We apologize for this inconvenience or confusion caused by the 1.3 special CoC Source.

If you have any other questions please contact the Accreditation Program at accreditation@facs.org or call 312-202-5085.


NCDB News

Now That You Submitted Your Data to NCDB: What's Next?

Submitting data to the National Cancer Data Base (NCDB) has much in common with paying taxes online: you need to send everything required, meet the deadline, and monitor to assure that processing goes smoothly (sorry, no refund checks!). Monitoring NCDB submissions is easy, but every year a few registries are surprised at survey time about an unnoticed late, missing, or incomplete submission.

For monitoring, NCDB sends two automated notifications and provides two website summaries of your submission. The first notification is sent to the person who submitted the data before the file is even opened. It shows the name of the file, the date and time it was received, and the receipt ID that NCDB uses to track the file. Once the file is opened, a second notification is sent to the person identified as the Registrar in Datalinks. This notification includes the number of cases in the file by diagnosis year along with the number of cases that passed edits, the number with edit problems, and the number that were rejected outright. In rare cases, it may notify you of a problem that prevented processing the data at all.

  • First check the number of cases for each diagnosis year. Is the number sufficient? Review “Determining Submission Completeness” in the June 2013 CoC Source for factors to look for.
  • Next, check the number of data quality problems. These are edit errors that do not cause the record to be rejected. Standard 5.6 requires that cases diagnosed in 2003 or later with data quality problems be corrected and resubmitted to NCDB by the April 1, 2014, deadline for compliance. If possible, please resubmit the data before the April 1 deadline. NCDB encourages you to edit and correct cases diagnosed prior to 2003 as well for proper maintenance of your registry and for optimal NCDB data quality.
  • Finally, check the number of rejected cases. These are cases whose edit error is so egregious that the case cannot be added to the NCDB database; in effect, they were never submitted. For example, the case has a missing diagnosis date or an invalid histology code. These rejected cases must be corrected and resubmitted by April 1, regardless of diagnosis date. Other cases are rejected because they should not have been selected for submission at all. For example, the case was diagnosed before the program’s reference date or the case is non-analytic. Those cases should not be resubmitted.
  • If any cases have data quality problems or are rejected, run GenEDITS Plus with the applicable NCDB submission metafile and configuration files to identify the underlying problem and make the appropriate corrections.

Always keep the automated notifications until the respective submission period has been reviewed in a survey.

Two websites within the secure Datalinks site provide similar information.

  • The link “NCDB: Data Submission History and Edits” under the heading “National Cancer Data Base (NCDB) Data Transmission” is convenient for tracking recent submissions. Every submission by the program is listed, with the most recent first. Click “details” from that table for submission-specific information.
  • The table in the SAR for Standards 5.5 and 5.6 shows the number of cases submitted by diagnosis year for each submission of any cases diagnosed that year, with a count of edit quality problems and rejections. This table makes it easier to compare submissions made over the most recent three to four years, covering a full survey cycle.

Files submitted after January 23 should be fully processed by February 14. All others should be fully processed now. Questions about NCDB submissions and processing should be addressed to NCDB@facs.org. The data submission requirements are described on NCDB submission website for registrars.

Update to the Hematopoietic and Lymphoid Neoplasm Coding Manual and Database

The latest update of the Hematopoietic and Lymphoid Neoplasm Coding Manual and Database has been posted on the Surveillance, Epidemiology, and End Results Program (SEER) website. This update replaces the 2010 and 2012 versions of the manuals and databases. The previous versions are no longer available.

This latest update is applicable for all cases diagnosed starting January 1, 2010 and forward. SEER has also posted about the major changes to the Hematopoietic Project. A new user guide is also available for navigating the new format of the database.

To access the Hematopoietic and Lymphoid Neoplasm Coding Manual, open the database and select one of the current codes (not an obsolete code) to open the information for that code. Find the “Help me code for dx year” dropdown. If you select 2010 or forward (default is 2014 for current codes), a link to the coding manual will appear. Click on the link and open the manual. At that time you can save a PDF copy to your computer. If you choose years 2001–2009, the information for coding multiple primaries applicable for those years will appear.

If you have any questions regarding the changes, please submit your questions to Ask a SEER Registrar.


Resources for Cancer Liaison Physicians

Cancer Liaison Physician Facts

  • Each appointed Cancer Liaison Physician (CLP) receives an e-mail with a user ID and password to CoC Datalinks. If the CLP has problems logging on, please e-mail cocdatalinks@facs.org to obtain the user ID and password or to have a new one issued. Please be sure that the CLP has a working e-mail address on file that is checked regularly.
  • You can contact us at clp@facs.org to get the term dates for your current CLP at any time.
  • If the cancer committee has made a decision to retain the current CLP for another term before that CLP’s term has expired, a request may be made through an e-mail to clp@facs.org. Make sure the current e-mail address of the CLP is included.
  • A CLP’s term is for three years. However, we realize that circumstances arise that may prevent a CLP from serving a full term. It is permissible for the cancer committee to recommend another physician to take over the CLP term in this case. Please send an e-mail to clp@facs.org in this event.
  • CLPs serving in their role for less than six months do not have to complete the CLP activity report in the SAR. The former CLP should complete this report before being replaced.

New Webinar: Making the Most of Your CoC Survey

Robert Sticca, MD, FACS, Vice-Chair of the CoC Accreditation Committee, presents the 45-minute prerecorded webinar “Secrets to Success: Making the Most of Your CoC Survey.” CoC-accredited cancer programs monitor their cancer program activity throughout the three-year accreditation period so that they can be prepared for the surveyor’s onsite visit. This in-depth presentation describes strategies for documenting and discussing their activity, as well as creating an educational and evaluative survey environment.

This webinar is complimentary to CoC-accredited cancer program staff using their Datalinks user ID and is $50 for all other participants. You can find more information on how to use your Datalinks user ID on the Education Portals FAQs page.

Be sure to bookmark the new American College of Surgeons Cancer Programs Online Education Portal to access all CoC webinars.


News from ACoS Cancer Programs

AJCC News

New FIGO Rules to Be Included In Next Edition of AJCC Staging System

The International Federation of Obstetricians and Gynecologists (FIGO) has developed new staging rules for ovarian, fallopian tube, and primary peritoneal cancers.

These new cancer staging rules will be incorporated into the 8th edition of the AJCC Cancer Staging System, which is scheduled for release in fall 2016, with an effective date of January 1, 2017.

Until that time, all nationally collected U.S. cancer statistics data are based on the current AJCC Cancer Staging Manual (7th edition).

Read more information about the staging changes from FIGO. Questions for AJCC can be submitted to the CAnswer Forum.

AJCC 7th Edition Staging Rules Adopted for Uveal Melanoma

In a recent article published in Brachytherapy, the American Brachytherapy Society’s Ophthalmic Oncology Task Force adopted the AJCC staging rules for melanoma of the uvea.

"[The] AJCC uveal melanoma T-staging system has been shown to predict metastasis in more than 7,000 cases...the use of tumor, node, and metastasis staging brings ophthalmic oncology into the mainstream of general oncology. Clearly, universal staging promotes multicenter cooperation and data analysis."

Cancer staging rules published in the 7th edition of the AJCC Cancer Staging Manual were made effective for all cancer cases diagnosed on or after January 1, 2010.

Paul T. Finger, MD, New York University, chaired the AJCC Ophthalmic Expert Panel for the 7th edition, and will serve as Chair for the 8th edition. Sarah Coupland, MBBS, PhD, Royal Liverpool University, will serve as Vice-Chair.

The 8th edition is scheduled for release in fall 2016.

NAPBC News

Pursuing Excellence Through Accreditation Workshop

Mark your calendar. The National Accreditation Program for Breast Centers (NAPBC) has scheduled a full-day workshop, Pursuing Excellence through Accreditation, to be held at the American College of Surgeons’ headquarters in Chicago on Friday, May 23. This workshop will provide detailed information related to the NAPBC components and standards, survey process, the quality measures, and related requirements for 2014 and beyond. Attendance at this workshop will assist centers applying for accreditation as well as centers due for re-accreditation in 2014.

Detailed information will be presented by NAPBC board members, surveyors, and staff. Most importantly, there will be a detailed presentation specific to the NAPBC components and standards; including what is required in order to meet compliance with each standard. The workshop will also incorporate any recent changes to the standards so that there is a clear understanding of what is expected and how it will be measured. Another detailed presentation, What to Expect on the Day of Survey, will walk you through a site visit from a surveyor’s perspective. Learn about what the surveyor is looking for during different aspects of the survey.

The Pursuing Excellence Through Accreditation Workshop is designed for individuals involved in the delivery of multidisciplinary breast health care, including physicians, nurses, administrators, cancer registry professionals, and others involved in the day-to-day operations of the breast center.

If you have questions, please contact the NAPBC office at 312-202-5185, or by e-mail at napbc@facs.org. Online registration will open on March 10 at www.napbc-breast.org. If you wish to request early registration, please email napbc@facs.org.

These workshops are always well-attended and seating is limited. Enrollment will be on a first- come, first-served basis.

NAPBC Exhibit Schedule

The NAPBC will have an exhibit at the following meetings:

Multidisciplinary Symposium of Breast Disease
February 13-16, 2014
Ritz Carlton Amelia Island
Amelia Island, FL

Breast Cancer Coordinated Care (BC3)
February 20-22, 2014
Mandarin Oriental
Washington, DC

National Consortium of Breast Centers
March 15-19, 2014
Caesars Palace
Las Vegas, NV

American Society of Breast Surgeons
April 30-May 5, 2014
Bellagio
Las Vegas, NV

National Cancer Registrars Association
May 15-18, 2014
Gaylord Opryland Resort and Convention Center
Nashville, TN

If you will be attending these meetings and have questions, or wish to pick up an NAPBC Information Kit, stop by any of these exhibits.


News from the Oncology Community

Monthly Spotlight

American Society of Plastic Surgeons

The CoC regularly collaborates with more than 50 member organizations in its mission to provide quality cancer care. This month we focus on the American Society of Plastic Surgeons (ASPS).

The ASPS' mission is to support its members’ efforts to provide the highest-quality patient care and maintain professional and ethical standards through education, research, and advocacy of socioeconomic and other professional activities.

Though plastic surgery has many facets, the ASPS mission is most evident in the society’s advocacy, public education, and research initiatives that focus on breast reconstruction. As part of the team approach to breast cancer patient care, plastic surgeons are available to offer information and surgical options to women seeking to mitigate the physical effects of breast cancer following mastectomy.

ASPS has long championed the rights of women—mainly through a longstanding, robust advocacy program responsible for driving passage of the Women’s Health and Cancer Rights Act of 1998, which isfederal legislation requiring insurance providers to cover breast reconstruction following mastectomy. The society also champions the rights of breast cancer patients to have knowledge of their treatment options, through its support of the Breast Cancer Patient Education Act, which was introduced last year in the U.S. House of Representatives and Senate (with similar legislation having been enacted in several states).

The society also remains dedicated to promoting education, research, and public awareness through its annual Breast Reconstruction Awareness Day (BRA Day USA), which features events across the country each third Wednesday of October. Teaming with singer/songwriter Jewel as its national spokesperson, ASPS members hosted more than 150 BRA Day USA events in 2013 as breast cancer patients, families, friends, and other groups joined together to improve awareness among breast cancer patients of their breast reconstruction options. The Plastic Surgery Foundation (The PSF), the research and charitable arm of the ASPS, established the BRA Fund for the purposes of funding important research related to breast reconstruction and for helping organizations provide charitable care and raising public awareness. /p>

The PSF is also active in the development of several national registries and clinical studies to improve patient safety. To learn more about these ongoing studies, please visit ThePSF.org. Through these initiatives and more, ASPS remains committed to promoting innovation in treatment and patient safety while advocating for the rights of women with breast cancer to know their surgical options and receive the treatment that best fits their recovery goals.

Event Information
BRA Day USA: Wednesday, October 15
For more information, visit www.bradayusa.org

Recent Publications and/or Products

Plastic and Reconstructive Surgery (scientific journal): prsjournal.com
PRS Global Open
(open-access journal): prsgo.com
Plastic Surgery News
(news publication)

For more information on this organization, please contact:
American Society of Plastic Surgeons, 444 E. Algonquin Road, Arlington Heights, IL
Phone: 847-228-9900
Website: www.plasticsurgery.org

NCRA News

NCRA’s Annual Conference: Registration Now Open!

The National Cancer Registrars Association (NCRA) will hold its 40th annual conference, May 15–18, 2014, at the Gaylord Opryland Resort & Convention Center in Nashville, TN. The theme is Working in Harmony to Deliver Excellence. NCRA marks its 40th anniversary in 2014, and the conference provides an opportunity to celebrate cancer registrars, registry professionals, and the association’s many achievements.

Otis W. Brawley, MD, FACP, chief medical officer for the American Cancer Society, will deliver the keynote address, during which he will outline the future of cancer research and treatments. The conference will also include plenary and breakout sessions covering cutting-edge topics as well as an exhibit hall, showcasing the newest in cancer registry products and services. Cancer registrars may attend the more than 40 sessions of the conference, where they can earn up to 20 AMA PRA Category 1 Credits™. Sessions fall into four topic areas: Commission on Cancer Standards and Application, Cancer Registry Management, Professional Development and Data Use, and Central Cancer Registry. The tracks provide attendees with a wide range of choices to meet individual educational needs. To learn more, visit the NCRA conference website.

NCRA Offers Online CTR Exam Prep Workshop

Developed and facilitated by a team of experienced Certified Tumor Registrars (CTRs) and allied health educators, NCRA’s new online CTR Prep workshop provides a review of all aspects of the exam’s six domains of practice. The workshop includes ten 90-minute online webinars designed to provide a comprehensive review of exam topics with hands-on exercises and instructor interaction.

Topics include:

  • Abstracting-Data Fields in FORDS (January 28)
  • Casefinding, ICD-O-3 Coding, MPH Coding Rules, Hematopoietic Manual and Database (January 30)
  • Core Knowledge: Types of Treatment, Staging Systems, Grade, Site Examples (February 4)
  • Collaborative Stage, Follow-Up, Survivorship, Outcomes (February 6)
  • AJCC Staging and Quality Assurance (February 11)
  • Analysis and Data Usage (February 12)
  • Operations and Management, HIPAA, Confidentiality and Privacy (February 18)
  • CoC Standards, Cancer Committee and Cancer Conference (February 20)
  • Central Cancer Registries (February 25)
  • Summary and Test Taking Strategies (February 27)

Exam candidates can register for the full workshop or individual webinars. To learn more and register, visit the NCRA CTR Prep website.

LIVESTRONG Foundation Announces Community Impact Project (CIP) Application Process

LIVESTRONG Foundation announces their Community Impact Project (CIP) application process. Every year LIVESTRONG funds community clinics/organizations to implement evidence-based cancer care programs that help support cancer survivors, their caregivers, and/or providers.

Through the annual Community Impact Project, the LIVESTRONG Foundation will spread three established cancer care programs to 39 sites in the U.S. in 2014. They are funding the replication of the Jeffrey Frank Wacks Music Therapy Program, Pablove Shutterbugs of The Pablove Foundation, and VitalHearts: Secondary Trauma Resiliency. These three programs were selected for their proven ability to provide necessary programming and support to cancer survivors and their families both during and post treatment.

The application process to bring one of these programs to hospitals, cancer centers and community organizations is now open. The deadline to apply for the one of the Community Impact Project model programs is Friday, Feb. 14 at 5 p.m. CST. Accepted applicants then move onto the project's online voting campaign, March 24-April 9, which allows the public to determine where the money goes among eight U.S. regions. The awarded sites will be announced on April 15.

"These programs have shown the ability to provide tremendous care and support across the cancer continuum," said LIVESTRONG Foundation Vice President of Programs and Strategy, Ruth Rechis, PhD. "Now in partnership with the Community Impact Project, they will have a chance to scale and improve the lives of more cancer patients, survivors and caregivers than ever before. We hope that cancer centers, hospitals and community organizations take advantage of the application period and apply for one of these valuable programs."

About the programs:
Since its formal inception in 2002, the Jeffrey Frank Wacks Music Therapy Program has become an essential component of the Carol G. Simon Cancer Center's integrative approach to caring for cancer patients. The program's overarching goal is to facilitate relaxation, decrease anxiety and stress, enhance wellness, improve pain management, and provide comfort and support for cancer patients and their caregivers. Music therapy is proven to reduce stress and pain levels associated with illness and hospitalization. For many patients, the simple act of listening to music provides a therapeutic release, promoting healing and overall wellbeing. Clinical music therapy services are provided on both an inpatient and outpatient basis. Two part-time music therapists conduct sessions with patients either at the bedside or in common (environmental) areas of the cancer center. Over the last decade, the program has served 2,175 patients/caregivers and conducted 5,842 sessions.

Pablove Shutterbugs, the signature arts program of The Pablove Foundation, teaches children living with cancer to develop their creative voice through the art of photography. Many of the students are removed from school during their illness and treatment, which leads to a disruption in their daily routines. Through Shutterbugs' carefully designed curriculum, students have the opportunity to develop pride and an enhanced self-esteem as they learn challenging, new skills. Trained professional photography mentors guide its students through a series of lessons created specifically to encourage photographic creativity. They gain hands-on experience while learning the principles and techniques of photography including the basics of composition, lighting and perspective. Each of their students keeps their point-and-shoot camera kit at the end of the program to encourage them to go out and see the world differently and continue practicing their art form as young photographers. The goals for the students include: increasing their sense of joy, encouraging their creative thinking, fostering their self-esteem and developing their independence.

VitalHearts' mission is caring for cancer treatment providers who suffer from secondary or vicarious trauma, which is a significant, although hidden problem. Secondary Traumatic Stress includes such reactions as: depression, anxiety, persistent trauma imagery, sleep disturbances, mistrust of their organization, isolating from family/friends, frequent illness and loss of mission optimism, among other symptoms, due to the deep exposure to suffering that care providers are exposed to. VitalHearts' program, the Secondary Trauma Resiliency Training (STRT), revitalizes care providers, often saving careers of those who work with cancer patient and survivors by making them more resilient. This allows institutions to better retain their staff expertise, which gives crucial value to patients.

Organizations chosen to implement one of the model programs will receive up to $15,600 to support the implementation. They will also receive a toolkit consisting of facilitator manuals, participant materials and evaluation forms; training and support from the model program's staff; access to additional tools and resources; and a full report on the historical replication of this program upon completion.

Registration Now Open for Conference Focused on Implementing Psychosocial Quality Care Standards

Registration for the 11th Annual Conference of the American Psychosocial Oncology Society is now open. Designed to help cancer care professionals implement the new Commission on Cancer’s psychosocial quality care standards, the conference will be held February 13-15, 2014, in Tampa, Florida. The meeting will open with a plenary session focused on the Commission on Cancer’s psychosocial distress screening quality care standard. Other plenary sessions will include lectures on implementing psychosocial standards across the lifespan. One two-day track will be devoted entirely to psychosocial oncology quality care standards, with sessions on screening measures and tools, elements of distress screening programs, and implementation of distress screening programs. Other concurrent sessions will focus on the psychosocial oncologic care of pediatrics, adults, and special populations. In addition to these sessions, several pre-conference workshops will help you enhance your survivorship program. Check out the full conference program at http://apos-society.org/apos2014/index.html.

Come to Tampa in February and gain the skills you need to meet the Commission on Cancer’s new psychosocial quality care standards by attending the 11th Annual Conference of the American Psychosocial Oncology Society. Register here.

Save-the-Date: Cancer Survivorship Research Conference

Please hold the dates June 18-20, 2014, for the Seventh Biennial Cancer Survivorship Research Conference: Advancing Survivorship through Multilevel Collaborations.

The meeting will be held at the Westin Peachtree Plaza in Atlanta, Georgia and is co-sponsored by the American Cancer Society, National Cancer Institute, LIVESTRONG Foundation and the Centers for Disease Control and Prevention. More information can be found on our website.

There will also be training at the conference on implementing survivorship care from the LS Center of Excellence Network, including Care Plans.