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

October 2015 CoC Source

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CoC News

NAPBC and CoC Provide Breast Cancer Awareness Month Poster

October is Breast Cancer Awareness Month. The National Accreditation Program for Breast Centers (NAPBC) and the Commission on Cancer (CoC) encourage your program to promote the event and use it as an opportunity to display or promote your accreditation status. To help you publicize this event within your program and the community, the NAPBC and the CoC have created a poster that you can download and print. Programs that are solely CoC-accredited or accredited by both the CoC and NAPBC, can access the poster by logging into CoC Datalinks and clicking on Marketing Resources.  Programs that are solely NAPBC-accredited should use the link to the Marketing Resources website provided in your performance report e-mail notification. For more information, contact Sue Rubin.

Advocacy Update

Contact Your Representative to Co-sponsor a Resolution on CoC Accreditation

New on SurgeonsVoice: Rep. Lynn Jenkins (R-KS) and Rep. Richard Neal (D-MA) will soon introduce a resolution recognizing the importance of voluntary accreditation by the American College of Surgeons Commission on Cancer (CoC) in ensuring access to high-quality cancer care. As you know, voluntary accreditation from the CoC demonstrates a cancer program's commitment to providing high-quality comprehensive care to patients and their families and allows them to continually evaluate performance and make necessary improvements. The goal of the resolution is to build greater awareness of the benefits and importance of accreditation. To help build support for the legislation, we ask each of you to reach out for support from your U.S. representative.  

Fellows, log in to SurgeonsVoice to reach out to Congress and urge your representative to become an original co-sponsor of the resolution. Non-fellows can contact the U.S. Capitol Switchboard at 202-224-3121, who will help put you in contact with your representative's office where you can leave a message asking them to contact Representative Jenkins office to sign on as a co-sponsor.

Accreditation Corner

Webinar on Upcoming CAP Cancer Protocol and eCC Release Updates

Upcoming CAP Cancer Protocol & electronic Cancer Checklist (eCC) Release Updates: What’s New in 2016 and Beyond?

Thursday, October 15, 12:00 noon– 1:00 pm (CDT)

This FREE webinar will help to inform you and your practice on the changes to the College of American Pathologists (CAP) Cancer Protocols and the electronic Cancer Checklist (eCC).

The CAP Cancer protocols are considered the gold standard for cancer pathology reporting in the U.S. and Canada. The protocols are used worldwide as a reference for best practices in standardized reporting as well as for supporting the CAP Laboratory Accreditation Program and the American College of Surgeons‘ Commission on Cancer synoptic reporting requirements. The electronic versions of these protocols, the CAP eCC, can be integrated into Anatomic Pathology/Laboratory Information System workflow to allow for the convenience of automated updates of cancer protocol content when new material is released. A major release affecting most of the CAP cancer protocols and eCCs will be available by the first quarter of 2016. 

Learning Objectives

  • Review the planned upcoming CAP cancer protocol and eCC revisions. 
  • Discuss schedules and timelines for future content updates and releases. 
  • Give insight into the development process of the American Joint Committee on Cancer 8th edition. 
  • In addition, Cancer and Pathology Electronic Reporting Committee staff will provide a brief introduction to the CAP eCC, how it incorporates cancer protocol content, and its value to pathologists and health systems. 


Thomas P. Baker, MD, FCAP

Philip R. Foulis, MD, MPH, FCAP 

Meet the CoC's New Accreditation Technical Specialist

Join us in welcoming Erin DeKoster as a new CoC Accreditation Technical Specialist. Prior to joining the CoC, Erin was a practicing attorney specializing in the defense of hospitals, physicians, and other health care providers against malpractice lawsuits and regulatory board actions. 

As an Accreditation Technical Specialist, Erin's responsibilities will be to provide technical support and evaluation on accreditation standards and facility activities for multiple CoC quality accreditation programs. More importantly, she is bringing her intelligence, strong work ethic, initiative, and an interest in quality improvement to our organization.

Erin holds a bachelor’s degree in Journalism and Mass Communication from Iowa State University. She also holds a Juris Doctor and a Master of Science in News and Information from the University of Kansas.

National Cancer Data Base News

CP3R Snapshot for CQIP

Estimated performance rates (EPRs) of all 20 measures reported in the Cancer Program Practice Profile Reports (CP3R) for cases diagnosed in 2013 will be used to populate the Cancer Quality Improvement Program (CQIP).  

Therefore the National Cancer Data Base (NCDB) recommends cancer programs begin their CP3R data validation with:

  • Cases diagnosed in 2013
  • Noncompliant cases
  • Cases with incomplete data 

Only changes completed by October 30, will be reported in CQIP 2015.  

20 Quality of Cancer Care Measures Reported in CP3R

CP3R now reports compliance with measures covering eight primary sites: breast, colon, rectum, gastric, non-small cell lung, ovary, endometrium, and cervix.  

The following five surveillance measures were introduced in September 2015:

  • Chemotherapy administered to cervical cancer patients who received radiation for stages IB2-IV cancer (Group 1) or with positive pelvic nodes, positive surgical margin, and/or positive parametrium (Group 2) (CERCT)
  • Chemotherapy and/or radiation administered to patients with Stage IIIC or IV Endometrial cancer (ENDCTRT)
  • Endoscopic or laparoscopic, robotic, or converted to open surgery performed for all Endometrial cancer (excluding sarcoma and lymphoma), for all stages except IV (ENDLRC)
  • Chemotherapy started within 42 days (before or after) the Date of Most Definite Surgery in Stages IA-IV Ovarian, Fallopian Tube, or Peritoneal cancers (OVCT)
  • Salpingo-oophorectomy with omentectomy, debulking/cytoreductive surgery, or pelvic exenteration in Stages I-IIIC Ovarian cancer (OVSAL)

The purpose of surveillance measures is to identify the status quo as well as monitor patterns and trends of care in order to guide decision making and resource allocation. Please note: EPRs for surveillance measures are not assessed in the CoC Standards.   

Measure Specification Updates 

Applicable measure specification updates were also made in both CP3R and Rapid Quality Reporting System (RQRS) in September.

Measures Effected


Potential Impact

All Breast (BCSRT, HT, MAC, BCS*, MASRT*, and nBx*)

Exclude rare tumor histologies

  • M8940/3 - Mixed tumor, malignant, NOS
  • M8950/3  - Mullerian mixed tumor
  • M8980/3 - Carcinosarcoma
  • M8981/3 - Carcinosarcoma, embryonal

Decrease in the denominator, EPR may change for some facilities.  

Breast MAC

Exclude 8200 adenoid cystic carcinoma since chemotherapy is not required for this histology

Decrease in the denominator, EPR may change for some facilities.  


Order of assessing adjuvant chemotherapy and radiation therapy receipt has been updated to include all potential cases in the denominator. 

Radiation and chemotherapy receipt required within 6 months of diagnosis. 

Cases previously labeled as incomplete may become non-compliant

Lung LNoSurg*

Cervix CERRT*

Clarification of measure status messages within CP3R case list

No change in EPR

Gastric G15RLN*

Include behavior 2 in denominator

Increase in the denominator count and EPR may change for some facilities.  

*Measure not reported in RQRS

Additional information can be found on the CoC website:

CoC Quality Measures



Specific questions may be directed to or

Resources for Cancer Liaison Physicians

Join Us at the CLP Breakfast

Plan to join us at this year’s CLP Breakfast, Monday, October 5.  We have prepared an informative program for you on the National Cancer Data Base (NCDB) tools and an update from the American Cancer Society on the 80% by 2018 initiative. The meeting takes place from 6:30–8:00 am, Regency Ballroom, Hyatt Regency McCormick Place.

CLP Activity Report

As the Cancer Liaison Physician (CLP), one of your tasks is to complete the CLP activity report. This report is found in CoC Datalinks and is part of your Survey Application Record (SAR) during your survey year and is accessible in the Program Application Record during non-survey years. Not only is it important to complete this report during the time of your program’s scheduled survey, it can be beneficial for you to complete the activity report during non-survey years to keep track of your activity on an annual basis.  

Welcome, New State Chairs!

The American College of Surgeons and the CoC announce the appointment of two new state chairs. A state chair’s term is three years and they may serve a maximum of two three-year terms.   

Paul Rider, MD, FACS
Alabama State Chair

Cliff Connery, MD, FACS
New York State Chair

Educational Programs and Resources

Information Coming Soon: 2016 CoC Workshops

In 2016, the CoC will host two Accreditation 101 workshops and the final dates and locations will be available soon. The first will be held during the early Spring and the second held in the early Fall.  Our annual Summer conference is also in development and will be held in Chicago in early June. Stay tuned to the CoC Source in the next few months for more details. 

News from ACoS Cancer Programs


AJCC Education Offerings

To assist with cancer staging education, the AJCC offers many free resources including:

  • AJCC Curriculum for Registrars 
    • Modules I, II, III, and IV recorded webinars
    • Webinars may be played for large audiences
    • Slides and handouts available for group lectures
  • AJCC Presentations 
    • Registrars Guide to Chapter 1, AJCC Seventh Edition
    • Explaining Blanks and X, Ambiguous Terminology and Support for AJCC Staging
    • Slides and handouts can be used for group lectures

Two continuing education (CE) credits are being offered for Modules II–IV. The Module I, Module II, Module III, and Module IV recordings are available to access through the AJCC website. Module I Introduction is not eligible for CE credits.

Questions on staging rules and lecture content will be answered through the CAnswer Forum.


Register Now for the NAPBC Accreditation Workshop  

November 14 | Chicago, IL

We invite you to join us on November 14 in Chicago, IL, for the National Accreditation Program for Breast Centers (NAPBC) Pursuing Excellence through NAPBC Accreditation workshop.

This educational workshop will guide you through the accreditation process—from applying through achieving NAPBC accreditation.

Sessions in this program include: 

  • Understanding the NAPBC components and standards 
  • 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 (ie, physicians, nurses, administrators, cancer registrars, and navigators) to attend this highly-valued program. Attendees will have the opportunity to enhance their professional network by interacting with NAPBC staff, surveyors, and their peers. 

The National Cancer Registrars Association (NCRA) Program Recognition Committee has determined Pursuing Excellence through NAPBC Accreditation program supports 6 continuing education (CE) hours.

Visit our website for additional information on the workshop. We look forward to seeing you or a member of your breast center's staff at this program. If you have questions, contact

Space is limited. Register by November 8 to receive a $50 discount. Please share this information with other members of your staff who would benefit from attending this workshop.

News from the Oncology Community


The American Psychosocial Oncology Society (APOS), in partnership with Yale School of Nursing, has announced the Screening for Psychosocial Distress Program. Applications for training are due by October 30.  Information is available at  

This educational program will train cancer care clinicians over two years to develop, implement, and maintain comprehensive psychosocial distress screening programs.

Program Components

The first year of the Screening for Psychosocial Distress Program will begin with a one-day workshop at the 13th APOS Annual Conference on March 3, 2016, in San Diego, CA, and will continue with video conferences featuring experts every three months. The second year will include an advanced one-day workshop at the annual APOS conference with video conferences with experts every six months.

International experts in psychosocial oncology will provide training and address such topics as communication skills, psychosocial care standards, comprehensive screening implementation, establishing a psychosocial department, using information technology resources, and quality improvement.

Who Should Apply?

Cancer care professionals who have an interest in psychosocial cancer care in their practice settings should apply. This includes chaplains, nurses, psychiatrists, psychologists, oncologists, and social workers. The program is designed to train two cancer care providers from one cancer care facility over two years, enrolling up to 18 cancer care facilities each year for a total of 36 participants. We are particularly interested in training participants in the following states: Alaska, Arkansas, Delaware, Hawaii, Idaho, Iowa, Kentucky, Maine, Michigan, Mississippi, Missouri, Nebraska, Nevada, North Dakota, Oklahoma, Oregon, Rhode Island, South Dakota, Vermont, Virginia, Washington, and Wyoming.

Information and Application

This is a joint program of the Yale School of Nursing and the American Psychosocial Oncology Society and is funded by the National Cancer Institute (R25CA177553-01) 2013-2018. Ruth McCorkle, PhD, FAAN, FAPOS, Principal Investigator.


Physician-Led Webinars on Head and Neck Cancers and Cancer of Biliary Sites

The National Cancer Registrars Association (NCRA) has designed a series of physician-led webinars on the American Joint Committee on Cancer: Tumor size, Lymph Nodes affected, Metastases (TNM) scoring system. Staging for Head and Neck Cancers and Cancer of Biliary Sites. The six, one-hour live webinars are appropriate for registrars seeking competency in assigning AJCC TNM Stage for these complex sites. The webinars include: 

  • Head and Neck Cancers presented by Ashish A. Patel, MD, DDS, October 7 at 2:00 pm
  • Pathology of Head and Neck Cancers presented by Raja Seethala, MD, October 21 at 2:00 pm
  • Treatment of Head and Neck Cancers presented by Maen Hussein, MD, November 4 at 2:00 pm
  • Cancer of the Liver presented by Michael Kluger, MD, MPH, October 28 at 4:00 pm
  • Cancer of the Intrahepatic Bile Ducts presented by Michael D. Kluger, MD, MPH, November 18 at 4:00 pm
  • Cancer of the Gallbladder presented by Steven Cunningham, MD, December 2 at 2:00 pm. 

All times are Eastern. Visit the NRCA website to learn more and register for a webinar. Group discount pricing is available for six registrants or more. E-mail for the group-pricing details. 

Apply for NCRA Danielle Chufar Conference Scholarship 

The Danielle Chufar Memorial Annual Conference Scholarship provides financial support to an NCRA member in need of funding to attend NCRA's Annual Educational Conference. The scholarship includes the conference registration fee, airfare (up to $600), and hotel accommodations for three nights. The theme for the 2016 essay is “How does education, networking, and professional development work together to create an exceptional, well-rounded CTR professional?” The deadline is December 10. Download the application at

Sharpen Your Skills with New Online Case Studies

NCRA has produced 15 online cancer case studies to provide opportunities for registrars to practice assigning AJCC TNM Stage and coding Surveillance, Epidemiology, and End Results (SEER)  Summary Stage. The correct answers and corresponding rationales are provided upon the completion of each case. The online case studies can be found on NCRA’s Center for Cancer Registry Education.

State Cancer Profiles Releases New Data

State Cancer Profiles released new and updated data from a variety of sources. New data from the National Cancer Institute’s  Surveillance, Epidemiology, and End Results (SEER) Program and the The Centers for Disease Control National Program of Cancer Registries incidence data through 2012 are now available. Additionally, the National Vital Statistics System provided updated death data through 2012. Furthermore, Small Area Estimates (SAE) were updated for 2008 to 2010. Diet and exercise data were added from the  Behavioral Risk Factor Surveillance System  (sponsored by CDC) and smoking law data were updated from the Americans for Nonsmokers’ Rights. The 2013 human papilloma virus vaccination data from the National Immunization Survey were also added. Demographic data from the American Community Survey data were updated for 2009 through 2013 and the Small Area Health Insurance Data were updated through 2013. Finally, prevalence projections were updated to show only the 2015 data.

Visit to take advantage of new and existing data.