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

April 2015 CoC Source

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Advocacy Update

Join Us for OVAC Lobby Days to Encourage Cancer Research Funding

The First Amendment of the U.S. Constitution guarantees the rights of citizens to petition our government. 

All of us in the Commission on Cancer (CoC) know the importance of funding cancer research as we unlock the genetic secrets of cells altered by cancer, and we embrace the newly discovered drugs and treatments that alter the lives of our patients. 

At a time when we finally have the ability to understand and potentially cure the underlying genetic causes of cancer, our federal funding of cancer research has declined in real dollars over the last decade.

CoC standards support the inclusion of patients in clinical trials so that we may learn what works for our patients. We are doing our part in caring for our patients, but it is time for us to do our part in petitioning our government on their behalf. One Voice Against Cancer (OVAC), a coalition of cancer fighting groups that includes the CoC, is that voice for our patients and our programs.

As members of the CoC, we are asking you to join us at OVAC Lobby days in Washington, DC, on June 8–9, 2015 to petition our government on behalf of our patients. With more than 1,500 CoC programs in all 50 states, imagine the impact on our elected officials if every program sent just one representative. Better yet, imagine the future impact for our patients.

Every citizen should experience this opportunity to meet with your representatives and senators, and to learn in person how Washington works. We have a just cause, a great message, and all that is lacking is our participation. Exercise your First Amendment rights, and petition our government in the fight against cancer.

Join the fight at OVAC Lobby Days on June 8–9 in Washington, DC. Watch this space for a link to register to attend. Right now, mark these dates on your calendar. 

James J. Hamilton, Jr., MD, FACS

Chair, Advocacy Committee

Commission on Cancer

PS: Every life is touched by cancer. My surgical practice partner’s husband, who is a dear personal friend, died this past February of Stage IV colon cancer. He was in his early 50s. Let’s make a difference for him and for all who are impacted by this disease. 

Accreditation Corner

What You Need to Know About the SAR and PAR

The 2014 Survey Application Record (SAR) and Program Activity Record (PAR) applications are now closed for editing. Cancer programs can only access the 2015 SAR or PAR. Within the 2015 SAR and PAR, you will be able to edit 2012, 2013, and 2014 data and documents. You do not need to go back and populate the old 2014 SAR or PAR.

Do NOT delete the 2012 cancer program activity. For cancer programs that have already been surveyed on this activity year, please do not delete any data. All 2012 information will be transferred from the SAR/PAR next year when 2016 fields will be added.

Every year the CoC makes enhancements to the SAR/PAR document based on feedback from internal and external users. Therefore, the 2015 SAR/PAR has new fields and tables to better reflect the standard requirements. You are required to complete the fields and tables with activity from 2012, 2013, and 2014 information for 2015 surveys.  

Remember: The SAR is to be completed 30 calendar days before the confirmed survey date, so that the surveyor can begin doing a pre-review. Two weeks before survey, the SAR will officially be closed for access to cancer programs.  The Accession List link (located on the SAR menu) and the table in Standard 2.1 (pathology report review) will remain open during these two weeks.

Helpful Hints

If you are finding that your entry or document is not saving, make sure all fields in the table are completed, the document is not more than 20MB, and that you have selected dates from the date fields. Some date fields are drop-down boxes and others have you select the date from a calendar. From the calendar, make sure you select the year, month, and date (in that order), and then save the date.

If you are having any difficulties or questions about the SAR/PAR, please e-mail Include your facility name, facility identification number (FIN), Standard number, and the specific field/table that is causing an issue.

Survey-related questions can be sent to Please include your name, facility name, FIN, and be specific with your question. 

Standard-related questions can found in or submitted to the CAnswer Forum

Cancer Committee Meeting Minutes Template Available

One of the most important components of CoC accreditation documentation is the cancer committee meeting minutes. The CoC’s Accreditation Committee and Surveyor Team have discussed the need to provide cancer programs with a minutes template and how well-documented cancer committee meeting minutes help surveyors confirm compliance to the standards.

The CoC recommends and endorses using this standardized template or a similar version (although does not require it). 

The document—Tips for Cancer Committee Agenda and Minutes/Templates—contains three resources: 

1) Page 1: Helpful tips and notes about agendas and minutes

2) Pages 2–4: Samples of minutes and a meeting summary

3) Pages 5–8: A tracking calendar that programs can edit to be sure they are covering all required components of compliance throughout the year

You can locate the minutes template and tip sheet here or within the Standards Resource Library under Chapter 1 – Standard 1.4. 

CAnswer Forum User Information

You must be a registered user of the CAnswer Forum to utilize the new Standards Resource Library located on the Home page. If you are not a registered user of the CAnswer Forum,  please follow the registration process. Once you complete a one-time registration, the system will send you an e-mail asking you to confirm your registration by visiting the link provided. After you have confirmed your registration, you will have full access to the CAnswer Forum, including the Standards Resource Library.  If you don’t confirm your registration, when you try to log on, you will be notified that you have been banned from the system, and you will not have access.

Abstention of Consent Agendas Beginning April 2015

This is a follow-up to the article regarding agendas in the March 2015 CoC Source issue

The Program Review Subcommittee (PRS) has discussed and reached a decision to prohibit the utilization of a consent agenda for cancer committee meetings.

In the framework of the current CoC Standards, cancer programs must not only track implementation of policies, procedures, and action plans, but also monitor the progress and effectiveness of plans implemented to demonstrate full compliance with the standard(s). A consent agenda format does not lend itself well to the mandatory documentation (in the minutes) required by cancer programs to affirm that they are fulfilling their governance role and their fiduciary duty.  

The consent agenda concept allows members of the cancer committee to vote on a group of items without discussion. Notably, for Standards 1.5, 1.7, 1.8, 4.1, 4.2, 4.6, and 4.8, it is a requirement that a discussion (regarding monitoring and/or effectiveness) is documented in the minutes.  In order to document compliance with the standard, using a consent agenda for standards such as these will not capture the essence of any discussion in which a cancer committee must engage.  The minutes will simply reflect that the items listed on the consent agenda were ratified, but not what comprised the discussion. This does not provide enough documentation to demonstrate compliance.

The CoC will be granting a grace period for cancer programs that have used consent agendas in the past. Beginning in April 2015 and onward, those programs will not be penalized by the surveyor at the time of survey if they have transitioned away from the consent agendas format.  

Any program’s consent agendas that were utilized before April 2015 may still be at risk for noncompliance ratings for applicable standards if they do not contain the proper discussion, documentation, and standard requirement criteria.

If you have additional questions:

Note: Please include your facility name FIN in ALL e-mails.

75 Cancer Programs Earn the Outstanding Achievement Award

The Commission on Cancer (CoC), a Quality Program of the American College of Surgeons (ACS), has presented the 2014 Outstanding Achievement Award (OAA) to 75 CoC-accredited cancer programs in the U.S.

Established in 2004, the OAA recognizes cancer programs that demonstrate excellence by earning commendation for all applicable standards and providing quality care to patients with cancer. A program earns the OAA by completing the accreditation survey and receiving a Performance Report that indicates an accreditation award of “Three-Year with Commendation” outlining the  commendation ratings for the seven commendation-level standards and no deficiencies.

Currently, there are seven commendation standards:

  • Standard 1.9 - Clinical Trial Accrual
  • Standard 1.11 – Cancer Registrar Education
  • Standard 1.12 – Public Reporting of Outcomes
  • Standard 2.1 – College of American Pathologists (CAP) Protocols
  • Standard 2.2 – Nursing Care
  • Standard 5.2 – Rapid Quality Reporting System (RQRS) Participation
  • Standard 5.6 – Accuracy of Data

These 75 programs received the OAA as a result of surveys performed in 2014, and represent approximately 15 percent of cancer programs surveyed during this period. The majority of recipients are community-based facilities; however, there are also academic hospitals, integrated networks, and a Veterans Affairs facility that also received this year's award. New programs undergoing initial survey and National Cancer Institute (NCI)-designated programs are not eligible to earn the OAA.

The CoC press release and the finalized list of OAA recipients are now online. More details regarding accessing the marketing materials and OAA trophy will be e-mailed directly to the Cancer Program Administrator (CPA) at each facility by March 25.

Any OAA questions should be sent to the Accreditation team.

National Cancer Data Base News

CP3R Updates Released

Cancer Program Practice Profile Reports (CP3R) were released on March 30 including 15 quality measures covering six primary sites and updates to current measures. 

The following four new measures will be introduced: 

Quality Improvement Measure

  • Rectum—Preoperative chemotherapy and radiation are administered for clinical AJCC T3N0, T4N0, or Stage III; or Postoperative chemotherapy and radiation are administered within 180 days of diagnosis for clinical AJCC T1-2N0 with pathologic AJCC T3N0, T4N0, or Stage III; or treatment is considered for patients under the age of 80 receiving resection for rectal cancer. (RECRTCT replaces current rectal measure RECRT)

Surveillance Measures

  • Cervix—Use of brachytherapy in patients treated with primary radiation with curative intent in any stage of cervical cancer. (CBRRT)
  • Cervix—Radiation therapy completed within 60 days of initiation of radiation among women diagnosed with any stage of cervical cancer. (CERRT)
  • Lung—Surgery is not the first course of treatment for cN2, M0 cases. (LNoSurg)

Measure Specification Updates 
Users may notice differences in the estimated compliance rates for current measures. Changes to the measure specifications will be applied with this release of CP3R based on feedback from CoC programs and the NCDB clinical leadership. 

Breast—Image- or palpation-guided needle biopsy (core or FNA) is performed to the primary site to establish diagnosis of breast cancer. (nBx)

  • The measure will exclude males and patients with metastatic disease.
  • Surgery is not required for a patient to be eligible for this measure.
  • An additional manual exclusion will be allowed for “Discordant biopsy results compared to suspicious imaging.”

Breast—Combination chemotherapy is considered or administered within four months (120 days) of diagnosis for women under 70 with AJCC T1cN0, or stage IB-III hormone receptor negative breast cancer. (MAC)

  • Cases that are ER/PR negative and HER 2 positive diagnosed after 2012 will be considered compliant with the measure if single agent chemotherapy is administered and BRM is considered or administered within 120 days of diagnosis. 

Lung—Systemic chemotherapy is administered within four months to day preoperatively or day of surgery to six months postoperatively, or it is considered for surgically resected lung cases with pathologic, lymph node-positive (pN1) and (pN2) NSCLC. (LCT)

  • Allow for unknown day of treatment fields. Incomplete dates will be compliant if we can determine that they fall within the range; otherwise, they will still be incomplete.

Colon—At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer. (12RLN)

  • The previous change to include all resected colon cancer cases instead of first or only cancer diagnoses will be applicable only for cases diagnosed in 2012 and later. 

For more information on the quality measures, please view the CoC Quality Measures website

For more information on CP3R, please view the CP3R website

Other questions may be directed to 

Last Call for the NCDB Call for Data 2015

REMINDER!  The NCDB submission window will close at midnight Central time the night of April 1 (tonight!)

If you have forgotten to submit your data altogether, it is not too late---you can still submit so that your data can be assessed for Standard 5.6.  In addition, resubmissions to correct edit problems in the initial submission are made the same way as initial submissions. It is desirable to submit only cases that required correction, but full diagnosis year resubmissions are acceptable.

Resources for Cancer Liaison Physicians

What's New for CLPs?

A new video on Quality Measures will be available on the Cancer Liaison Physician (CLP) website.  Be sure to check back within the next two weeks. 

80% by 2018 Initiative - Take Action Now

The Commission on Cancer, a Quality Program of the American College of Surgeons, is a member of the National Colorectal Cancer Roundtable (NCCRT), established in 1997 by the American Cancer Society and the Centers for Disease Control and Prevention.  The NCCRT is a national coalition of organizations and individuals dedicated to eliminating colorectal cancer as a major public health problem.  The NCCRT has embarked on 80% by 2018, an initiative to increase colorectal cancer screening rates in the U.S. from the current rate of 65% to 80% by 2018.  

The NCCRT is committed to work toward increasing the number of people screened for colorectal cancer. By working together, demanding more of ourselves, and collectively pushing harder, we will make greater progress, prevent more cancers, and save more lives.

The NCCRT has multimedia resources available to guide you when making a presentation or leading or participating in a colorectal screening initiative.

If you have not already watched the 80% by 2018 video recorded by Daniel P. McKellar, MD, FACS, Commission on Cancer Chair, and Richard C. Wender, MD, American Cancer Society’s Chief Cancer Control Officer, this is an important message and well worth 15 minutes of your time or showing at your next cancer committee meeting.  

Take the first step and find out what the colorectal cancer screening rates are in your state and bring cancer programs and primary care providers together to join this initiative.  

Remember, colon cancer is the third-leading cause of cancer deaths in the U.S. and the second-leading cause when combining men and women, yet it can be prevented or detected at an early stage with evidence-based screening tests.

Save the Date! Attention All CLPs

This year the Committee on Cancer Liaison will hold two breakfast meetings for Cancer Liaison Physicians (CLPs) to hear new initiatives and to network with CLPs from across the U.S.  

The first CLP breakfast meeting will be held in conjunction with the 2015 American Society of Clinical Oncology ”Transforming Data Into Learning” annual meeting at 6:30 am on Monday, June 1, at the Hyatt Regency McCormick, Chicago, IL.  Please contact if you plan to attend and include your facility’s name.  

The second CLP breakfast meeting will be held in Chicago on Monday, October 5, in conjunction with the American College of Surgeons Clinical Congress.  

We hope to see you there!

New State Chairs

The CoC would like to extend a welcome to two new State Chairs:

Peter Huang, MD, FACS

Maine State Chair

Brian Davis, MD, FACS

South Texas State Chair

Educational Programs and Resources

Register Today for Survey Savvy and the NCDB Quality Tools Workshop

Register now for the CoC's June Education Programs. 

Special Pre-Conference Workshop 

NCDB Tools Workshop: Maximizing NCDB Data to Improve Your Cancer Program 

June 17, 2015 

Noon – 5 pm

This half-day program will review the current uses and future updates for the National Cancer Data Base (NCDB) quality tools. NCDB quality tools will be reviewed with a focus on how the data can be used to inform decisions for cancer program administration and by cancer physicians. Learn about the uses for the cancer registry and how patient navigators can use the data. Reasons and examples of tool development, expectations and current uses of the NCDB quality tools will be presented by  NCDB staff, clinical leadership, and external users. 


$300 on or before May 15

$350 after May 15

Lunch will be served at 11:30 am. 

View Agenda 


Survey Savvy 

June 18-19, 2015

Survey Savvy, provides in-depth review of the information your cancer committee needs to coordinate a high-quality, patient-centered, multidisciplinary cancer program. Developed by CoC staff and CoC committee leadership, this program addresses your cancer programs' most common questions, issues, and concerns regarding CoC standards and compliance. 

Whether your cancer program is preparing for a re-accreditation survey or looking for clarification on the standards, this program provides increased understanding of standard requirements and implementation. Through lectures, panel presentations, and the opportunity to meet and speak with experts, cancer program members will learn how to use the CoC standards as a framework to develop a comprehensive cancer care program that delivers high-quality and patient-centered care. 


$750 on or before May 15 

$850 after May 15

Visit the Survey Savvy web page for further meeting information, hotel information, and to register. Space is limited.


Please share this information with other members of your staff who would benefit from the information that is being presented. Team attendance is encouraged for this conference.

News from ACoS Cancer Programs


AJCC Curriculum for Registrars – Module I Recording + Module II Lessons Now Available

The American Joint Committee on Cancer (AJCC) is thrilled with the level of participation in the first live webinar, which had more than 900 people log in to take part in Lesson 7 of Module 1. The AJCC Curriculum for Registrars launched in January 2015 and is designed to provide education in a self-study, step-wise learning environment. This self-guided learning is most effective when participants in the live webinars have already reviewed the preceding lessons in the module before viewing the live or recorded webinars. The webinars are intended to be a summation of the entire module and reinforce the information learned in the lessons. The interactive quizzes before and after the live webinar serve as a self-assessment for the information learned throughout the module. There is a pre-education quiz included with the registration to assess the current level of knowledge; the quiz at the beginning of the live webinar assesses the knowledge level after studying the lessons, and then a follow-up post-education quiz taken about four weeks after the webinar assesses retention of that knowledge.

The AJCC listened to your feedback and extended the live webinar to include Q&A time at the end. We are excited to announce that continuing education (CE) credits are being offered for the remaining modules, II–IV. Module I was considered a basic introduction and does not qualify for CE credits.

The Module II lessons are now available, and the webinar will be held on April 21. Make sure to mark your calendar and go to the AJCC website to register to attend live! There are 1,000 spots available for the live webinar. If you are not able to participate, you can still receive CE credit for the recorded webinar. We understand that some people can't participate in the webinar during the day, and we encourage you to view the recording that is now available for Module I. The recording of the Module II webinar should be available 48 hours after the live broadcast. 

Please remember to use the CAnswer forum for questions related to the webinars, both content and logistics.


Pursuing Excellence through NAPBC Accreditation

Join us on April 24 in Denver, CO, for the National Accreditation Program for Breast Centers (NAPBC) Accreditation Pursuing Excellence through NAPBC Accreditation.

This educational workshop will help your breast center's care team successfully navigate through the process of achieving NAPBC accreditation.

Sessions in this program are taught by NAPBC surveyors and staff and include: 

  • Understanding the NAPBC components and standards and the accreditation process
  • What to expect on the day of survey 
  • The importance of quality improvement and how NAPBC is making a difference 
  • What it takes to achieve NAPBC accreditation, from an administrator's point of view 

We encourage you and other members of the breast center staff, such as physicians, nurses, administrators, cancer registrars, and navigators to attend this highly valued program, where attendees will have the opportunity to grow their professional network by interacting with NAPBC staff, surveyors, and their peers. 

For additional information, please visit We look forward to seeing you or a member of your breast center's staff at this program. 

Space is limited. Register by April 21 to receive a $50 discount!

Please share this information with other members of your staff who would benefit from attending this workshop.

If you have questions, please contact us at

American College of Surgeons Clinical Research Program News

Special Study Targeting Cancer Surveillance to Start April 1

A CoC Special Study will be launched on April 1 to investigate follow-up and recurrence after cancer treatment in hopes of tailoring follow-up based on individual risk. This study will involve analyzing data from the National Cancer Data Base (NCDB) to assess optimal post-treatment surveillance testing for the detection of new primary cancer and local/regional and distant recurrence in breast, colorectal, and lung cancers.  Another important aim of this study is to determine if it is possible to improve the reliability of the recurrence data field for routine data submission to the NCDB. Many of you have reported this as an important concern in the past and suggested that having reliable recurrence information would significantly improve the value of this important data source to all programs. Many tumor registrars are directly engaged and have already provided substantive input to help achieve these goals and we are looking forward to your participation. Based on the feedback we received from registrars during a pilot of this study, we have made improvements for users’ ease and clarity and to minimize the burden of the study on cancer registrars.

The collection of follow-up imaging and recurrence information is particularly critical to the success of this study and for improving the recurrence information within the NCDB. As many of you know, patients often receive follow-up care outside of the institution where their cancer was diagnosed or initially treated.  Consequently, registrars may need to go outside their institution to other providers or hospitals to collect patient medical records that comprehensively capture patient health care use following active treatment for their cancer. We will provide registrars with a letter template that can be used to contact external providers to request information about these patients as needed. Staff members with the Alliance/American College of Surgeons Clinical Research Program will be available as a resource for registrars and cancer liaison physicians. Thank you in advance for your participation in this important study. Send any questions to


 George J. Chang, MD, FACS, MS

 Principal Investigator

 Caprice Greenberg, MD, FACS, MPH

 Principal Investigator

 Benjamin Kozower, MD, FACS, MPH

 Principal Investigator

 Daniel McKellar, MD, FACS

 Chair, Commission on Cancer

 David Winchester, MD, FACS

Medical Director, Cancer Programs,
American College of Surgeons

This work was supported in part through Patient-Centered Outcomes Research Institute (PCORI) Program Awards (CE-1304-6543; CE-1304-6855; CE-1306-00727).

News from the Oncology Community


National Cancer Registrars Week

Cancer registrars throughout the world will join their colleagues, fellow medical professionals, and community leaders to observe the 19th Annual National Cancer Registrars Week (NCRW), April 6–10, 2015. The purpose of NCRW is to emphasize the important role cancer registrars play in capturing the data that informs cancer research, prevention, and treatment programs. Begin planning your celebrations. Go to to learn more!  

NCRA’s Postconference Workshop 

The National Cancer Registrars Association (NCRA) is offering an informatics workshop, Cancer Informatics for Registrars: From Bedside to Big Data, on May 24 in conjunction with its annual conference in San Antonio, TX. The one-day postconference workshop will bring together cancer registrars from all environments, cancer program administrators, supervisors, managers, physicians, and students from across the nation to address the practical application and use of cancer informatics. 

Agenda topics will address the registrar’s core competencies and utilization of electronic medical records systems, efficient data collection methods and reporting of quality data, and information retrieval for clinical, statistical, and strategic planning purposes. Practical and real-time case studies will demonstrate use of registry data for performance and patient care improvement, quality outcomes, cost reductions, economic and regulatory concerns, ethical challenges, and more. To learn more and register, go to

NCRA Resource to Help Registrars Prepare Abstracts

To assist registrars in preparing abstracts, NCRA’s Education Committee has created a series of informational abstracts. These site-specific abstracts provide an outline to follow when determining what text to include. The sites include: bladder, breast, colon, lung, melanoma, and prostate. The outline has a specific sequence designed to maximize efficiency and includes eight sections: Physical Exam/History; X-Rays/Scopes/Scans; Labs; Diagnostic Procedures; Pathology; Primary Site; Histology; and Treatment. A list of relevant resources is located at the end of each informational abstract to assist with research. To download this complimentary resource, go to  

Registration Now Open for the 2015 World Congress of Psycho-Oncology

Don’t miss your chance to participate and learn at this joint conference of the American Psychosocial Oncology Society (APOS) and the International Psycho-Oncology Society (IPOS). The 2015 World Congress of Psycho-Oncology, with the theme “From National to Global: Implementing the Standard of Psychosocial Care in Oncology,” promises to draw 600–800 psychologists, psychiatrists, nurses, social workers, clergy, and patient advocates from around the world, and is a unique opportunity to network and engage with psychosocial oncology clinicians, researchers, administrators, and advocates in one venue. During the conference, members of the international psycho-oncology community have the opportunity to share and learn about current science, global health initiatives, and new clinical interventions in the field of psychosocial oncology.

Through the 2015 World Congress of Psycho-Oncology, APOS and IPOS seek to engage local advocacy groups; directors of cancer centers’ psychosocial programs; medical, radiation, and surgical oncologists; and providers of psychosocial care for cancer patients across the lifespan. To this end, we have planned an exciting educational program that includes:

  • 20 half-, one-, and two-day workshop academies prior to the three-day conference
  • Concurrent and plenary educational sessions featuring world-renowned invited speakers
  • High-quality scientific oral and poster presentations
  • Exhibits promoting the latest in cancer treatment choices, developments in supportive care and cancer education, and advocacy groups 
  • Special events, including a picturesque tour of Washington, DC, via a Potomac River dinner cruise, a private tour of the Washington Cathedral, and a theater performance by New York-based “Outside the Wire” theater company.