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

March 2014 CoC Source

(HTML Version)

CoC News

CQIP Report Now Available from Datalinks

The Cancer Quality Improvement Program (CQIP) report is now available! This new resource is an annual report that provides your CoC-accredited program with extensive data related to the quality of cancer care that your patients received. You can use the analysis of the data your program has provided to the National Cancer Data Base (NCDB) and comparisons with national data from more than 1,500 CoC-accredited programs to develop plans and processes to ensure that your program continues to provide high-quality, patient-centered cancer services to prevent, screen, diagnose, treat, and monitor the population you serve. We hope that you and your team will incorporate this information into your quality assurance and quality improvement initiatives.

The CQIP is only available to CoC-accredited programs and is accessed through CoC Datalinks. If you do not have access to CoC Datalinks, contact your registrar or cancer program administrator to request access. Only a current CoC Datalinks user may request additional staff access.

Your program has access to the CQIP report as well as a number of other Web-based data resources that provide retrospective and concurrent reviews of the care provided to all cancer patients.

The CQIP 2013 report will be provided for the following CoC-accredited programs: individual programs, network Facility Identification Number (FIN), and merged facility FIN. Programs under the merged FIN will not receive a CQIP report since their data is reported under the merged FIN.

CoC Legislative Briefing

The CoC held a Legislative Briefing on Tuesday, February 11 at the Rayburn House Office Building, Washington DC. The briefing was titled, Ensuring High-Quality, Patient-Centered Cancer Care.

Panelists included

  • Daniel McKellar, MD, FACS, CoC Chair, Greenville, OH
  • Christopher Pezzi, MD, FACS, Past-Chair, CoC Quality Integration Committee, Abington, PA
  • James Hamilton, Jr., MD, FACS, CoC Advocacy Committee member, Topeka, KS
  • Nina Miller, MSSW, OSW-C, ACS Cancer Programs staff

The briefing agenda provided more than 50 legislators, staffers, and guests with an overview of the work of the CoC and the role of the CoC in monitoring accredited programs’ compliance with quality measures and standards of care. The National Cancer Data Base (NCDB) was highlighted and the new Cancer Quality Improvement Program (CQIP) report was previewed. Participants discussed a plan for adding quality outcome measures to the NCDB’s Quality Reporting Tools. They also discussed the focus on patient-centered care as the basis for the accreditation standards as well as the CoC’s plans for participating in public reporting.

CoC Datalinks Update

CoC Datalinks has been modified to better meet facility needs. Up to three hospital co-registrars can now be added per facility. This adjustment will increase the amount of users with the ability to edit and submit data. To add co-registrars for your facility, please visit the Staff Management web page.

Please direct any questions or concerns to


Last Chance to Correct NCDB Call for Data Edit Problems

Tuesday, April 1, at midnight (CT) is the deadline for correction of edit problems in the ongoing NCDB Call for Data. This will be your only reminder. According to Standard 5.6, all cases diagnosed in 2003 or later must be corrected by that date. If no registrar is available to check submission results, the program should assign someone to conduct the review.

There are three ways to check whether your submission had edit problems requiring correction.

  1. An automated notification is sent to the program’s Datalinks-identified registrar that identifies whether any cases failed edits.
  2. The link to NCDB: Data Submission History and Edits in the NCDB Data Transition section provides a history of submissions, including edit detail, which is arranged by order of submission.
  3. In Datalinks, the Survey Application Record (SAR) Standards 5.5/5.6 section provides similar information, which is organized by diagnosis year.

All rejected records must be corrected and resubmitted by April 1 for compliance with Standard 5.6, unless the reason for rejection was that the case should not have been submitted (for example, cases diagnosed before the program’s Reference Date do not need to be resubmitted because they should not have been submitted at all).

All records with data quality problems diagnosed in 2003 or later must be corrected and resubmitted by April 1. Run the file you submitted through the applicable edits using GenEDITS Plus to determine which cases need correction. NCDB welcomes corrections to cases diagnosed prior to 2003, but it is not required for compliance with Standard 5.6.

Resubmissions are made the same way as submissions for the Call for Data. Data submitted by April 1, 2014, will be used for NCDB reports during the coming year. Please direct questions about NCDB submissions to

Resources for Cancer Liaison Physicians

Who Is Your State Chair?

As a cancer liaison physician (CLP), there will be no greater resource than your State Chair. Your State Chair has either been a CLP or is currently serving as one in his or her facility. Many of them have served in the role of CLP for many years and have mastered the changes and improvements that have occurred within the role. If you have not been in touch with your State Chair, please check the contact list on the CLP information board or e-mail

Education Programs and Resources

Important Accreditation Facts Webinar

Learn about CoC accreditation and standards from one of the more recent webinars available on the Cancer Programs Online Education Portal.

M. Asa Carter, CTR, Manager, CoC Accreditation and Standards, presents a new pre-recorded webinar on: Important Accreditation Facts: Cancer Program Standards 2012 This webinar provides important information on the patient-centered Standards, including the rationale for the change, expected improvements in classification and comparison, and a description of how the programs will be affected.

Webinars are complimentary to CoC-accredited cancer program staff accessing them through their Datalinks user ID and cost $50 for all other participants. Find more information on using your Datalinks user ID on the Education Portal's FAQs page.

Be sure to bookmark the new American College of Surgeons Cancer Programs Online Education Portal where you will find all of your CoC educational webinars and more.

News from ACoS Cancer Programs


Registrar Resources

Grab your popcorn! The American Joint Committee on Cancer (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 (NCRA); North American Association of Central Cancer Registries, Inc. (NAACCR); Surveillance, Epidemiology, and End Results Program (SEER); Center for Childhood Cancer Research (CCCR); the National Program of Cancer Registries (NPCR); and the Commission on Cancer (CoC).

The ACS 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.

Update: AJCC-NCRA Education Needs Assessment

Beginning with cases diagnosed on January 1, 2016, the standard-setters in the U.S. and Canada will require AJCC TNM and Summary Stage coding to be recorded in the cancer registry abstract. Collaborative Stage will no longer be used.

To ensure the cancer surveillance community is prepared for this change, the AJCC has asked the National Cancer Registrars Association (NCRA) to prepare an education needs assessment. The assessment should identify gaps in knowledge and skills in order to determine the training and education needed to prepare for the 2016 shift in staging process.

Below is a summary of activity to date:

Late November 2013

Two separate surveys for hospital and central registrars distributed

December 10, 2013

Surveys closed

December 2013 – January 2014

Response analysis

January 31, 2014

Meeting of AJCC, NCRA, CoC, SEER, and NAACCR to discuss analysis and develop action plan

Full results of the AJCC-NCRA Education Needs Assessment will be presented on Friday, May 14, 2014 from 2:15-3:00 PM at the NCRA Annual Educational Conference in Nashville, TN.

Please contact with any questions about the needs assessment.


New Ohio Law Incorporates NAPBC Standards

A law that incorporates the National Accreditation Program for Breast Centers (NAPBC) standards relating to mastectomy and reconstructive surgery will take effect in Ohio on March 20. Under this law, also known as the Lizzie B. Byrd Act, a surgeon or a health care professional designated by a surgeon, who performs a mastectomy in a hospital must guide the patient through provided or referred services in a manner consistent with NAPBC standards.

Additionally, if breast reconstruction is deemed appropriate, the surgeon or designated person must offer the patient a preoperative referral to a reconstructive or plastic surgeon, according to NAPBC standards. View more information online regarding the Lizzie B. Byrd Act.

Pursuing Excellence Through Accreditation Workshop

Mark your calendar. The 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 Online registration will open on March 10 at If you wish to request early registration, please email

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:

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

American Society of Breast Surgeons
April 30-May 5, 2014
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


April Fritz to Present NCRA Webinar on Confidentiality in the Registry on March 5

One of the most important responsibilities of cancer registry professionals is to protect the confidentiality of cancer patient information. To meet this obligation, registrars must know the relevant laws and policies and be able to implement them. The National Cancer Registrars Association (NCRA) has created a one-hour webinar on “Confidentiality in the Registry” scheduled for Wednesday, March 5, at 2:00 pm. Presenter April Fritz, RHIT, CTR, will review critical rules and regulations, outline the challenges facing registrars, and highlight ways to ensure compliance. The webinar is designed for those new to the field and seasoned professionals who want to ensure they are up to date on confidentiality laws and regulations. Participants earn one continuing education (CE) credit. To learn more and to register, please visit NCRA’s learning management system, the Center for Cancer Registry Education.

NCRA Announces Spring 2014 Webinar Series on Treatment Modalities

The growing complexity of cancer treatments requires cancer registrars to better understand the specifics of the disease and the variety of treatments in order to accurately code and create a thorough abstract for each patient. To that end, NCRA has developed a three-part webinar series on treatment modalities. Each webinar will focus on the anatomy of the specific site, treatments and specific rules applicable to the site, and possible conflicts of coding or challenges of coding the various treatments.

The series is designed for cancer registrars who have advanced experience with the abstracting process and are comfortable analyzing detailed medical reports. Knowledge of regional nodal systems, Collaborative Stage, and Tumor Node Mestasis (TNM) Staging will enhance learning. The three webinars include

  1. Prostate/Bladder, March 19, presented by Jessica Dohler, CTR
  2. Lung, April 23, presented by SuAnn McFadden, CTR
  3. Colon, April 30, presented by Carolyn Ingram, CTR

The one-hour webinars are scheduled for 2:00 pm (ET), and participants earn one CE credit per webinar. To learn more, visit NRCA’s Center for Cancer Registry Education.

Establishing a Comprehensive Psychosocial Support Program in Your Hospital

As identified by the American College of Surgeons Commission on Cancer (CoC), the American Society of Clinical Oncology, the Association of Community Cancer Centers, the Community Oncology Alliance, the Institute of Medicine, the National Comprehensive Cancer Network and others, social and emotional support for patients and their loved ones touched by cancer is a critical element of comprehensive cancer care. Evidence indicates that this support is as important as the biomedical care a patient receives. While the benefits are well documented, the question of how to implement a program in the hospital, clinic, or large practice remains a question for some. It is important to realize that organizations do not have to create programs and services like these starting from scratch. Community-based solutions are a meaningful way to partner in delivering comprehensive care to patients and families.

An example of such a partnership is the Cancer Support Community (CSC), an affiliated network of more than 50 local centers, 100 satellite locations, online support communities, and a telephone helpline. In as many years, two hospital systems have chosen to partner in a novel, hospital-based approach that leverages CSC’s 50+ years of experience delivering a comprehensive array of evidence-based, personalized services to cancer survivors, families and caregivers. Greenville, SC, Hospital System and UF Health Cancer Center at Orlando Health, FL, are premier partnerships that bring together the medical expertise of their teams with the psychosocial expertise of a community-based organization—the CSC.

“This is an exciting step forward for cancer care in Central Florida,” said Diane Robinson, PhD, director of integrative oncology, UF Health Cancer Center at Orlando Health. “CSC had all the elements we were looking for, including distress screening. This partnership accelerated our timeline, by providing plug-and-play evidenced-based programming.”

“The partnership has been the catalyst for distress screening, educational activities, support groups, and individual counseling in our new Center for Integrative Oncology and Survivorship,” said Mark O’Rourke, MD, medical director, Greenville Health System. “In our work with CSC, we have been able to connect with patients to reduce distress, cope with challenges, and increase patient satisfaction.”

Providing comprehensive, quality cancer care is of the upmost priority for anyone working in the field of oncology. Given the unique challenges of an aging population, increasing number and complexity of cancer care options, and a changing health care environment, partnering is an effective means of achieving optimal patient care. For more information on these partnerships, please contact Jay Lockaby at or 202-650-5378.

SEER*Educate Learn by Doing Series: New Modules


With a new diagnosis year, comes a new coding structure. SEER*Educate has added coding exercises for 16 site groups using CSv02.05. There are 10 cases per site group. The Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute has requested 5 CE credits per site group from NCRA.

2014 Heme

SEER recently published a new Hematopoietic and Lymphoid Neoplasm Manual and Database. Assess your understanding of the coding and reportability rules by coding the case scenarios. Receive a detailed step-by-step rationale that walks you through the process using the new manual and database. The Heme 2014 Practical Application section has six sets of coding exercise—five exercises in each set. SEER has requested 2.5 CE credits from NCRA for each set of heme coding exercises.

CTR Prep—Cancer Registry Management

The Cancer Registry Management Principles & Practice for Hospitals and Central Registries 3rd Edition textbook is one of the standard registry resources listed on

Material from this textbook is used in the closed book section of the Certified Tumor Registrar (CTR) exam. CTR-eligible candidates may test themselves with 12 tests, 50 questions on each test. The material has been broken into three major topics:

  1. Planning and Design of Registries and Informatics (four tests)
  2. Operations (four tests)
  3. Standard Setters, Central and Other Registries, and Uses of Registry Data (four tests)

The CTR Prep series do not qualify for CE hours. The purpose of this material is to assist non-credentialed registrars and students in preparing for the CTR exam.

SEER*Educate Helpdesk

Fred Hutchinson Cancer Research Center

Visit SEER*Educate at | Email us at

Monthly Spotlight


The CoC regularly collaborates with more than 50 member organizations in its mission to provide quality cancer care. This month we focus on the LIVESTRONG Foundation.

The LIVESTRONG Foundation improves the lives of people affected by cancer now. We provide free patient navigation services to help people affected by cancer cope with the financial, emotional, and practical challenges that accompany a diagnosis of the disease.

At, we provide hundreds of topics and stories for health care professionals to share with their patients. Additionally, we provide access to the LIVESTRONG Care Plan powered by Penn Medicine’s OncoLink, which is a one-of-a-kind tool for adult survivors that provides an individualized survivorship care plan for use by the patient and the health care team.

This year, the Foundation is initiating a new program expanding on our experience in survivorship to build a comprehensive, international model for patient-centered cancer care. In addition, we are developing new online tools to reach and serve people affected by cancer and improve their lives now.

The Foundation collaborates with the CoC on a variety of initiatives that support cancer patients and survivors. We are proud to be an advocate member of CoC and excited about the work underway to ensure that the Patient-Centered Standards are implemented by 2015. These standards represent ideas that are important to us, ensuring that cancer patients receive high-quality, coordinated care, which includes supportive services and resources that address the full continuum of care.

LIVESTRONG Foundation helps sites implement the Continuum of Care Services using online resources, via the telephone, and in your community. For more information about partnering with LIVESTRONG Foundation to implement Continuum of Care Services, e-mail Rebekkah Schear.

Event Information

We invite you to attend the LIVESTRONG Essential Elements of Survivorship Care Pre-Conference Workshop on June 18, at the 2014 Biennial Cancer Survivorship Research Conference, in Atlanta, GA. This workshop is designed to help survivorship care providers develop sustainable cancer survivorship programs. Drawing from their expertise in implementation and research, directors of the LIVESTRONG Survivorship Center of Excellence Network, will lead an interactive training to help participants develop, implement, and improve survivorship programs that provide the Essential Elements of Survivorship Care and addresses cancer survivors’ needs. Additionally, the workshop will focus on key requirements in current guidelines for delivering survivorship care, such as survivorship care plan delivery, psychosocial care, and patient navigation processes.

Recent Publications and/or Products

Our research program is unique in that we hear—and respond to—the voices of people affected by cancer, whether from constituents who follow us online, participate in events and initiatives, or use our navigation services. Some of our most recent research and publications include:

Survivors' Experience with Survivorship Care Plans Brief

Rechis R, Beckjord EB, Nutt, S. Potential benefits of treatment summaries for survivors' health and information needs: Results from a LIVESTRONG Survey. J Oncol Pract. 2014 Jan;10(1)75-78. doi:10.1200/JOP.2013.000973

Beckjord EB, Reynolds KA, van Londen GJ, et al. Population-Level Trends in Post-Treatment Cancer Survivors’ Concerns and Associated Receipt of Care: Results from the 2006 and 2010 LIVESTRONG Surveys. J Psychosoc Oncol, 2013 Dec. [Epub ahead of print]

For more information on this organization, please contact:
LIVESTRONG Foundation, 2201 East Sixth Street, Austin, TX 78702
Phone: 855-220-7777 | Website:

Monthly Spotlight

National Cancer Registrars Association

The CoC regularly collaborates with more than 50 member organizations in its mission to provide quality cancer care. This month we focus on the National Cancer Registrars Association (NCRA).

The NCRA is celebrating its 40th anniversary this year. The CoC was an early ally in the formation of the association. The CoC assisted an ad hoc committee of registrars back in 1972 to survey registrars and CEOs in facilities with approved cancer programs to determine the need, and likelihood of participation, if an organization were established. Following mounting interest and support, the National Tumor Registrars Association was chartered on May 14, 1974. The organization changed its name to the National Cancer Registrars Association in 1993. However, the primary purpose has remained the same: to promote research and education in cancer registry administration and practice, and to provide standardized credentialing to provide greater service to the cancer patient.

The NCRA will celebrate its 40th anniversary at its annual education conference May 15–18, at the Gaylord Opryland Resort & Convention Center in Nashville, TN.

For more information on this organization, please contact:
National Cancer Registrars Association, 1330 Braddock Place, Suite 520, Alexandria, VA 22314
E-mail: | Website:

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.