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

May 2015 CoC Source

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CoC News

National Cancer Survivors Day

June 7 marks the 28th Annual National Cancer Survivors Day®, which brings cancer survivors together to show that there is life after receiving a diagnosis of cancer. 

The American College of Surgeons (ACS) Commission on Cancer (CoC) and the National Accreditation Program for Breast Centers (NAPBC) encourage your program to observe this day and use it as an opportunity to display or promote your CoC and NAPBC accreditation status. To help you promote this event within your program and the community, the CoC and the NAPBC have developed a poster that you can download and print. Programs that hold both CoC and NAPBC accreditations can access the poster by going to CoC Datalinks and clicking on Marketing Resources. For programs that are solely NAPBC-accredited, please use the link to the Marketing Resources website provided in your performance report email notification. 

The CoC and the NAPBC encourage you to reach out to your community and sponsor activities that:

  • Recognize cancer survivors 
  • Support patients with cancer 
  • Screen and educate community members on cancer prevention and detection 

Additional resources to promote your event are available on the National Cancer Survivors Day website. Please let us know about your celebration by sending photos and event information to Susan Rubin, Business Development Manager, ACS Cancer Programs.

Cancer Programs Exhibit Schedule

Staff from the CoC, NAPBC, and the AJCC will be exhibiting at the National Cancer Registrars Association (NCRA) Annual Meeting in San Antonio, TX, May 21–23.

Advocacy Update

Join Us for OVAC Lobby Days to Encourage Cancer Research Funding

The CoC Advocacy Committee encourages your participation in One Voice Against Cancer (OVAC) Lobby Days scheduled for June 8–9 in Washington, DC. Registration for OVAC is open. Attendees will receive comprehensive training and preparation for scheduled visits to the Hill to talk with senators and representatives and their office staff members about funding for the National Institutes of Health and National Cancer Institute as well as funding for the Centers for Disease Control and Prevention and other important cancer initiatives. If you plan to attend this event as a CoC representative, contact Nina Miller at, who will forward you all the information you need to make this a meaningful event. 

Another great reason to attend OVAC’s Lobby Days is the opportunity to attend a legislative Hill briefing, “Accreditation Matters.” This briefing, June 9 at 12:30 pm in Room B340 of the Rayburn House Office Building, is intended to educate legislators and their staffs about the CoC and the importance of accreditation and how accreditation impacts quality outcomes. 

The CoC Advocacy Committee, along with all the other CoC committees, is meeting in Chicago on May 7–8. The Advocacy Committee is interested in hearing from YOU. What are the policy issues—federal, state, or regulatory—that impact you and your patients? Contact us at

Accreditation Corner

Program Review Subcommittee Update on Standard 1.5

The Program Review Subcommittee (PRS) reviewed several examples of goals from cancer programs where the goal involved changing how the cancer program currently complies with a standard. For example, we currently refer out all palliative care services. The goal would be to bring palliative care in-house by hiring a palliative care physician and creating an in-house palliative care process. The PRS has determined that when a goal states a plan to change how you will comply with a standard is still considered a restatement of the standard and is, therefore, not accepted as a goal or quality improvement (Standard 4.8). Standards cannot be used to comply with other standards.

National Cancer Data Base News

NCDB Updates RQRS & CP3R

During the last month, the National Cancer Data Base (NCDB) updated two of its quality tools. 

Rapid Quality Reporting System (RQRS)

In April, the NCDB released updates to RQRS. Updates were also made to some specifications in RQRS to ensure the measures assessment criteria reported in RQRS exactly match those in the Cancer Program Practice Profile Report (CP3R) for the five RQRS measures listed below. 

RQRS Reported Measures


  • Radiation therapy is administered within one year (365 days) of diagnosis for women under age 70 receiving breast-conserving surgery for breast cancer. (BCS – abbreviation in RQRS)
  • Combination chemotherapy is considered or administered within four months (120 days) of diagnosis for women under 70 with American Joint Committee on Cancer (AJCC) T1cN0M0, or stage IB - III hormone receptor negative breast cancer. (MAC)
  • Tamoxifen or third-generation aromatase inhibitor is considered or administered within one year (365 days) of diagnosis for women with AJCC T1cN0M0, or stage IB - III hormone receptor positive breast cancer. (HT)


  • Adjuvant chemotherapy is considered or administered within four months (120 days) of diagnosis for patients under the age of 80 with AJCC Stage III (lymph node positive) colon cancer. (ACT)
  • At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer. (12RLN)

If the identical information is entered in both systems, programs will no longer see fluctuations in measure assessment between the CP3R and RQRS. The previous rectal measure was also removed from the system. The remaining functionality in RQRS was not changed.

Cancer Program Practice Profile Report

At the end of March, four new measures—one quality improvement and three surveillance—were added to the CP3R. They are outlined below. 

Newly Introduced Measures

Quality Improvement

Evidence from experimental studies, not randomized control trials, to support the measure. These are intended for internal monitoring of performance within an organization. 

  • Rectum—Preoperative chemo and radiation are administered for clinical AJCC T3N0, T4N0, or Stage III; or postoperative chemo 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)


Limited evidence supports the measure or the measure is used for informative purposes to accredited programs. These measures can be used to identify the status quo as well as monitor patterns and trends of care in order to guide decision-making and resource allocation.

  • 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)

Note: The new measures will not be part of the rating assessment during 2015 CoC surveys. 

More information can be found about the following topics on the CoC website:

NCDB to accept PUF Applications Summer 2015

The NCDB is accepting participant use data file (PUF) applications on a semiannual basis. In July, the NCDB will accept applications for organ site-specific files including cases diagnosed through 2013. 

The NCDB PUF is a Health Insurance Portability and Accountability Act (HIPAA) compliant data file containing cases submitted to the NCDB and complies with the terms of the Business Associate Agreement between the American College of Surgeons and cancer programs accredited by the CoC. The PUF contains de-identified patient level data. It is designed to provide investigators at CoC-accredited cancer programs with a data resource they can use to review and advance the quality of care delivered to cancer patients through analyses of cases reported to the NCDB. Prospective applicants can find more information on the PUF on the CoC website

If you have additional questions regarding the NCDB PUFs or the application process for a PUF, please contact NCDB technical staff at

GenEDITS Plus Version 4 and Pre-Editing Data for Submission to NCDB

Beginning May 1, the NCDB will no longer support the use of GenEDITS Plus version 1.2.8 to pre-edit data prior to submission to the NCDB. All data submissions should be pre-edited using GenEDITS Plus version 4. Download GenEDITS Plus 4 software

Note: Prior to submission to NCDB, GenEDITS Plus should be run on the actual data file to be submitted. 

Resources for Cancer Liaison Physicians

New State Chair

The CoC would like to extend a welcome to a new State Chair:

James Ouellette, MD, FACS

Ohio State Chair

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!

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.

Plan to Attend the Next Accreditation 101

Accreditation 101: Learning the Basics of CoC Accreditation and Standards

Friday, September 11

Baltimore, MD

  • Are you a new staff member just learning about Commission on Cancer (CoC) accreditation?
  • Is your cancer program considering CoC accreditation, and you want to learn about the CoC Standards?
  • Do you want a refresher on the CoC accreditation process and standards?

If you answered yes to any of these questions, then Accreditation 101: Learning the Basics of CoC Accreditation and Standards is for you.

Registration is set to open in mid-June and will be announced in the CoC Source and CoC Brief. Stay tuned to the CoC Meetings page for further meeting and hotel information and to register. Space is limited.

This is the only program developed and taught by CoC surveyors and staff that reviews the CoC Standards, provides practical information on how to achieve compliance, and discusses the important role you and your cancer team play throughout the continuum of cancer care. Get the information you need from the people involved in standard development and the survey process.

Registration Fee

$450 on or before July 31

$500 after July 31

This fee includes a copy of the Cancer Program Standards 2012: Ensuring Patient-Centered Care v1.2.1, ($50.00 value), resource materials, breakfast, lunch, and breaks.

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

Continuing education credit will not be offered for this program. 

News from ACoS Cancer Programs


AJCC Registrar Curriculum: Mark Your Calendars for Module III

The American Joint Committee on Cancer (AJCC) Curriculum for Registrars launched in January 2015. The curriculum was designed to provide education in a step-wise learning environment, complete with additional resources to reinforce the information and webinars with interactive quizzes to prompt discussion and serve as a self-assessment for the information learned. This is self-guided, adult learning, and you are expected to review the lessons before attending the live or recorded webinars.

Two continuing education (CE) credits are being offered for each remaining module, II–IV. The Module II recording is available for you to access. Module I Introduction is not eligible for CE credits.

Mark your calendar for May 15 when the Module III lessons will be posted. At that time, you can go to the AJCC website to register for the next live webinar on June 23. There is a limit of 1,000 spots for the live webinar. If you are not able to participate in the live webinar, you can still earn two CE credits for the recorded webinar. 

Please remember to use the CAnswer Forum for questions related to the webinars.


The NAPBC Is Social! Connect with Us on Facebook and Twitter

The National Accreditation Program for Breast Centers (NAPBC) has taken to the social media world. You can find us on Twitter, @NAPBC_ACS, and now Facebook,

The NAPBC Twitter account opened almost a year ago—May 23. In this time, the NAPBC has reached a larger audience and directly and instantly engaged and interacted with both accredited breast centers and our member organizations. Our newly accredited centers are always very active and share their accomplishments of obtaining accreditation. The NAPBC posts daily announcements and news updates regarding breast disease and treatment. The most recent workshop, Pursuing Excellence through NAPBC Accreditation, held in Denver, CO, was actively promoted on social media. There were a total of 50 clicks to the Registration page that came directly from Twitter. 

Following the success of the NAPBC Twitter account, our newest social media endeavor is Facebook.  You can “like” the NAPBC by heading to

The NAPBC will continue to utilize these social media channels to further our engagement with our accredited breast centers and member organization representatives.

Contact Us


News from the Oncology Community


Connect with NCRA through Social Media!

The National Cancer Registrars Association (NCRA) uses social media to advance the cancer registry profession by increasing NCRA’s position as a thought leader with members, industry partners, and medical registry professionals. Join the conversation and stay up to date. Get all the details on NCRA social media.

Sign Up for Digital Issues of NCRA Publications

The NCRA has launched digital issues of The Connection and Journal of Registry Management. Join the more than 700 members who now read these popular publications on their digital devices. Learn more about NCRA digital publications

NCRA Announces Two Live Webinars on AJCC TNM Stage: Breast and Bladder 

The NCRA will present two new site-specific webinars to round out its TNM Classification of Tumors and Summary Stage training that began fall 2014. The two concluding webinars will provide the essential information for using the correct classification and assigning all of the American Joint Committee on Cancer (AJCC) TNM stage elements for the breast and bladder. Andrea Spaulding, RN, CTR, will present the Assigning AJCC TNM Stage: Breast webinar on June 10. Jayne Holubowsky, CTR, will present the Assigning AJCC TNM Stage: Bladder on June 24. Both webinars are at 2:00 pm (Eastern). Earn one CE credit for each. Register today for the webinars.

NCRA Offers Complimentary Webinar: Selling Yourself Through Your Résumé

NCRA’s Mentoring Committee prepared a special webinar, Selling Yourself Through Your Résumé. Jennifer Rohleder from MedPartners shared tips on how to construct a résumé that presents a compelling portrait of your strengths and skills and includes more than your employment history. The complimentary webinar is now available on NCRA’s Center for Cancer Registry Education.

Register for NCRA’s Postconference Workshop

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 connect 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

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.