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

May 2016 CoC Source

(HTML Version)

Updates to the CP3R and RQRS Released

The spring release brought new measures to both RQRS and CP3R.

New CP3R Measures

Cancer Program Practice Profile Reports (CP3R) now reports 23 quality measures covering 10 primary sites. The following four surveillance measures were introduced:


  • At least 10 regional lymph nodes are removed and examined in Axillary lymph node dissection (M10AxLN)
  • At least 5 regional lymph nodes are removed and examined in Inguinal lymph node dissection (M05IgLN)
  • Completion Lymph Node Dissection use after positive Sentinel Lymph Nodes biopsy (MCLND) 


  • At least two lymph nodes are removed in patients undergoing partial or radical cystectomy (BL2RLN)

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.  Not all CoC-accredited programs have cases for the melanoma and bladder measures; however they are important to assess the current status of care. Please note measure comparisons are only available if there are 30 or more cases in any aggregation, users may see a designation of ‘no data’ if there are not enough cases within a specific category for an aggregate rate to be reported.  Estimated performance rates (EPRs) for surveillance measures are not assessed in the CoC Standards.

RQRS Updates

Changes were also made in RQRS: 

  • A new breast measure was added to RQRS - Radiation therapy is recommended or administered following any mastectomy within 1 year (365 days) of diagnosis of breast cancer for women with > 4 positive regional lymph nodes (MASTRT).
  • Manual case exclusions are now allowed in RQRS. Measure exclusions are found in the RQRS case list and updated nightly.
  • The abbreviation of the RQRS “BCS” measure ‘Radiation therapy is administered within 1 year (365 days) of diagnosis for women under age 70 receiving breast conserving surgery for breast cancer’ has been updated to “BCSRT” to be more consistent with CP3R.
  • New documentation was released on the RQRS website.

RQRS data submission will be restored but submissions will not be accepted on Tuesday May 3, for scheduled maintenance.  Based on these changes the May RQRS Monthly Alerts Report will not go out until May 9th to accurately reflect the data submitted by participating programs. 

Changes in Current Measure Specifications

Users may also notice differences in EPRs for current measures. Updates to the measure specifications and notifications are made based on feedback from CoC programs and the NCDB clinical leadership. Applicable measure specification document will be updated for both CP3R and RQRS. 

Measures Affected


Potential Impact

All measures

Unknown stage designated as “Incomplete” instead of “Not Eligible”

Increase in the number of cases labeled as incomplete in need of additional review


AJCC TNM Path T of 1B has been added as a valid code

Slight change in EPRs based on increased number of cases eligible for this measure

*Measure not reported in RQRS

Updated Documentation on the NCDB Website

Measure documentation
Release notes

CoC News

Tools to Observe National Cancer Survivors Day

Sunday, June 5, marks the 29th annual National Cancer Survivors Day®, which brings cancer survivors together to show that there is life after receiving a diagnosis of cancer.

The Commission on Cancer (CoC) and the National Accreditation Program for Breast Centers (NAPBC) encourage you to observe this day and use it as an opportunity to display or promote your CoC and NAPBC accreditation statuses. To help you promote this event within your program and the community, we have created a poster that you can download and print. If your program holds accreditation from the CoC only or both the CoC and NAPBC, you can access the poster by going to CoC Datalinks and clicking on Marketing Resources. For programs that are accredited solely by NAPBC, use the link to the Marketing Resources website provided in your performance report e-mail notification. 

We 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.

Advocacy Update

CoC Priorities at Leadership & Advocacy Summit

The American College of Surgeons hosted the fifth annual Leadership & Advocacy Summit, April 9–12, at the JW Marriott in Washington, DC. The Summit is a dual meeting that offers volunteer leaders and advocates comprehensive and specialized sessions focused on the tools needed to be an effective leader, followed by interactive advocacy training and coordinated visits to DC congressional leaders.

James Hamilton, Jr., MD, FACS, Commission on Cancer (CoC), Chair, Advocacy Committee, spoke to Summit attendees urging them to discuss three CoC priority issues during visits to the Hill:

  • H.Res. 487: Resolution Recognizing CoC Accreditation
  • H.R. 1220/S. 624:  Removing Barriers to Colorectal Cancer Screening Act
  • Funding recommendations:
    • National Institutes of Health (NIH): $34.5 billion, including National Cancer Institute (NCI): $5.9 billion
    • National Institute on Minority Health and Health Disparities (NIMHD): $301 million
    • National Institute on Nursing Research (NINR): $158 million
    • Centers for Disease Control and Prevention (CDC) Cancer Programs: $514 million, including: National Comprehensive Cancer Control Program: $50 million
    • National Program of Cancer Registries: $65 million
    • National Breast and Cervical Cancer Early Detection Program: $275 million
    • Colorectal Cancer Control Program: $70 million
    • National Skin Cancer Prevention Education Program: $5 million
    • Prostate Cancer Awareness Campaign: $35 million
    • Ovarian Cancer Control Initiative: $7.5 million
    • Gynecologic Cancer and Education and Awareness (Johanna's Law): $5.5 million
    • Cancer Survivorship Resource Center: $0.9 million

Accreditation Corner

Reporting Facility Changes to the CoC

Occasionally, important programmatic changes take place within a cancer program that may affect the facility’s accreditation status or quality patient care.

It is the accredited program’s responsibility to notify the Commission on Cancer (CoC) when significant events occur, which include:

To report facility name changes, ownership changes, or mergers, click on the appropriate hyperlinks above to the application forms.

All other notifications should be e-mailed to along with an attached letter on your organization's letterhead, which has been signed by an administrator and includes the effective date of the event.

National Cancer Data Base News

Save Valuable Registrar Resources

DO NOT abstract all Collaborative Stage (CS) data items for cases diagnosed in 2016!

As previously communicated, NAACCR v16 software upgrades will be delayed this year, so the National Cancer Data Base (NCDB) strongly encourages registrars to begin abstraction of cases diagnosed in 2016 within their current NAACCR v15-compliant software. 2016 cases will continue to be accepted by the Rapid Quality Reporting System (RQRS). Registrars should continue to abstract only the CS data items required to determine case eligibility for the RQRS quality measures, which are the CS data items with continuing requirement listed below and CS Tumor Size.

At the National Cancer Registrars Association (NCRA) conference, many registrars expressed concern over the fact that when entering a case diagnosed in 2016 into NAACCR v15-compliant software, many edit errors are generated on the CS edits. This is due to the way the v15 CS edits were written; they require input of CS data items for cases diagnosed beginning with 2004 and later. At the time of the writing of these edits, the issue of beginning 2016 cases in v15 software was not considered.

IMPORTANT! Registrars are to ignore any CS edit generated for cases diagnosed in 2016 that is currently being abstracted in v15-compliant software. When these cases are appropriately edited using the NAACCR v16 edits, any case diagnosed in 2016 or later will REQUIRE all CS input data items to BE BLANK (with the exception of the data items with continuing requirement listed below). The majority of CS input data items that are currently being abstracted for 2016 cases will need to be blanked out, resulting in unnecessary extra work for the registrars.

Specific CS Data Items with Continuing Requirement

  • Regional Nodes Positive [820]
  • Regional Nodes Examined [830]
  • Lymph-vascular Invasion [1182] (Required 2009+)
  • CS Site-specific Factors [2861-2880, 2890-2930]
  • CS Version Input Original [2935]
  • CS Version Input Current [2937]

The CoC’s 2016 requirements for the Site-Specific Factors have not changed from 2015. The data items of CS Version Input Original and Current continue to be required to accommodate continued collection of the SSFs.

Great Posters at NCRA about Use of NCDB Tools

A special shout out to the registrars that submitted posters highlighting use of NCDB tools:

  • Kendra Johnson, MPH, CTR—The Rapid Quality Reporting System (RQRS): Make it Work for You!
  • Danette Clark, BS, RMA, CTR, and Danillie Clark, RMA, AAS, CTR—CP3R: An Important Tool.

Thank you for your efforts. We enjoyed your posters and hope they will inspire others to follow suit at NCRA next year.

Resources for Cancer Liaison Physicians

Comprehensive Cancer Control National Partners

The Comprehensive Cancer Control National Partnership was formed in 1998 as a collaborative group of diverse national organizations working together to build and strengthen comprehensive cancer control efforts across the nation. The partnership assists coalitions to develop and sustain implementation of comprehensive cancer control plans at the state, tribe, territory, U.S. Pacific Island Jurisdiction, and local levels.  Three focus areas currently guide the priority work of the partnership: colorectal cancer screening, HPV uptake, and tobacco cessation for cancer survivors.

The Comprehensive Cancer Control National Partners from the Spring Semi-Annual Meeting, April 13–15, 2016 at the American Cancer Society Corporate Center Office in Atlanta, GA

Seated from left to right:
Katy Gore, National Association of County and City Health Officials; Lorrie Graaf, American Cancer Society; Ena Wanliss, Centers for Disease Control and Prevention; Cindy Vinson, National Cancer Institute;  Nikki Hayes, Centers for Disease Control and Prevention; Pamela Jackson, Intercultural Cancer Council; and Mandi Pratt Chapman, GW Cancer Institute

Standing from left to right:
Sarah Shafir, American Cancer Society; Leslie Given, Strategic Health Concepts; Bill Furmanski, Truth Initiative; Margaret Farrell, National Cancer Institute; Nina Miller, American College of Surgeons Commission on Cancer; Angela Moore, Centers for Disease Control and Prevention; Citseko Staples Miller, American Cancer Society Cancer Action Network; Todd Tyler, American Cancer Society; David Chamblee, National Cancer Institute; Daphne Delgado, YMCA of the USA; Cameron Massey, Livestrong Foundation; Erica Haller-Stevenson, National Association of County and City Health Officials; Karin Hohman, Strategic Health Concepts; Aubrey Villalobos, GW Cancer Institute; Antoinette Percy-Laurry, National Cancer Institute; Annette Gardner, Centers for Disease Control and Prevention

Attention CLPs: Save the Date!

During 2016, 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 take place in conjunction with the 2016 American Society of Clinical Oncology (ASCO) “Collective Wisdom” annual meeting, 6:30 am–7:30 am, Monday, June 6 at the Hyatt Regency McCormick, Chicago, IL. All in attendance for the ASCO meeting are welcome to attend. Contact if you plan to attend this meeting. Be sure to include your facility’s name and your role (for example: CLP, registrar, cancer committee chair).

The second CLP breakfast meeting will be held in Washington, DC on Monday, October 17, in conjunction with the American College of Surgeons Clinical Congress.

We hope to see you there!

Educational Programs and Resources

Register Now for the 2016 CoC Annual Conference: Pathway to Quality

Join us June 1-3, 2016 at the Hyatt Regency O'Hare in Chicago (Rosemont), IL to learn more about how each member of the cancer committee adds value to the team to create a first-rate cancer care program. In addition, you will learn more about how to maximize the NCDB tools to make the best use of your cancer program's data. The conference addresses a cancer program's common concerns regarding CoC standards and compliance as well as comprehension of the NCDB tools application to lead quality improvement initiatives in your facility.

Speakers include those involved in CoC standard setting and evaluation, as well as those whose facilities received high marks on their surveys.

Aaron D. Bleznak, MD, FACS 
Sentara Healthcare, Norfolk, VA

Dr. Bleznak has worked with the CoC for years, currently as a surveyor and previously as Chair of the Committee on Cancer Liaison. He will discuss the value of CoC Accreditation from the administrator’s perspective. 

Michael Moore, MD, FACS
Indiana University Health, Indianapolis, IN

Dr. Moore will speak to the value of the cancer liaison physician (CLP) on the cancer committee and how they can optimize their involvement to produce best outcomes.

Learn from knowledgeable speakers at top notch facilities including:

National Cancer Institute 
Geisinger Wyoming Valley Medical Center 
Kaiser Foundation Hospital – Sacramento 
Geisinger Medical Center

To learn more and register, visit the event web page.

Fall Accreditation 101 in Chicago

The next Accreditation 101: Learning the Basics of CoC Accreditation and Standards, will be held on Friday, September 9, 2016 in Chicago, IL. Registration is set to open in mid-June.

Accreditation 101 is aimed at those who work for programs not yet CoC-accredited but seeking more information to make that decision or to prepare for their application. It is also aimed at those staff new to CoC-accredited programs to provide further information and insight into the value and benefit of CoC accreditation, as a well as a basis overview of the CoC standards.

Stay tuned to your email, the CoC website, the weekly CoC Brief, and the monthly Source for further information.

News from ACoS Cancer Programs


Dedication of the AJCC Cancer Staging Manual 8th Edition to Cancer Registrars

Las Vegas, NV, April 12, 2016—Mahul B. Amin, MD, FCAP, Editor-In-Chief, AJCC Cancer Staging Manual Eighth Edition, announced at the National Cancer Registrars Association’s (NCRA) 42nd Annual Conference in Las Vegas, NV, that the 8th edition will be dedicated to cancer registrars. Dr. Amin cited that the honor was to recognize cancer registrars’ education and unique commitment to the recording and maintenance of data that are vital for the care of the cancer patient. He noted their professionalism in the collection of factors fundamental to sustaining local, state, and national cancer registries and their dedication to the cataloging of information crucial to cancer research. He also described their leadership and support of the principles of cancer staging.

NCRA president Leah Kiesow, MBA, CTR, thanked the American Joint Committee on Cancer (AJCC) for this extraordinary honor. She noted that as the national professional organization of more than 5,800 cancer registrars, NCRA is pleased to know that the data collected by registrars play such a vital role in updating the AJCC Cancer Staging Manual. Physicians worldwide use the manual to stage a patient’s cancer and is critical in guiding treatment and determining prognosis. Kiesow stated, “Cancer registrars are elated to be acknowledged by the AJCC for the role they play in improving cancer-patient outcomes.”

Full Press Release on Behalf of NCRA


NAPBC Best Practices Conference: Updated Agenda, CE, and Hotel Reservation Date

There is still time to register for the NAPBC Best Practices Conference, May 13–14, in Orlando, FL. Breast program leaders and care team members from 16 National Accreditation Program for Breast Centers (NAPBC)-accredited breast centers will share innovative and efficient methodologies that have been successfully implemented in breast programs across the country, and will offer attendees tools for adoption of these best practices in their own centers.  Review the updated agenda. 

Continuing Education (CE)

The National Cancer Registrars Association (NCRA) Program Recognition Committee has determined Preconference Workshop: Accreditation and Standards Review program supports 3.25 CE hours. The endorsement period for this program will run from May 13, 2016 through May 13, 2019.

The NCRA Program Recognition Committee has determined NAPBC Best Practices Conference program supports 6.25 CE hours. The endorsement period for this program will run from May 14, 2016 through May 14, 2019.


The hotel reservation cut-off date has been extended.  Book your room at the B Resort & Spa by April 28 to guarantee the discounted group rate.

Book your hotel

Preconference Workshop: Accreditation and Standards Review 

There is still room in the preconference workshop on Friday, May 13. Attendees will learn how to use the NAPBC standards as a framework for developing a high-quality breast center and their role prior to, during, and after the NAPBC accreditation survey.  This preconference is a must attend for centers interested in becoming accredited. 

News from the Oncology Community

Cancer Metastasis Through the Lymphovascular System: Biology and Treatment

7th International Symposium
April 20–22, 2017
San Francisco, CA

Abstracts and Trainee Awards deadline: September 20, 2016.

The symposium follows the journey of metastasis from detection at the molecular level to genomic identification to precision treatment and survival. It is the goal of this continuing medical education (CME)-accredited program to assemble basic scientists, oncologists, surgeons, and radiologists from around the world, resulting in an exchange of ideas that will enhance the translation of basic science into clinical application—and challenge basic scientists with clinical issues.

Sponsored by Sentinel Node Oncology Foundation

Moving Toward Tobacco Cessation in Cancer Care Plans Webinar

May 11, 2016
2:00–3:00 pm (Eastern) 

Cessation of tobacco use is critical in improving outcomes for cancer survivors. Clinicians, health departments, and cancer control coalitions have roles in promoting and supporting cessation. This webinar will describe the guidelines that require incorporation of tobacco cessation into cancer survivorship care plans and present an example of the efforts in one community. Speakers will include representatives from the Centers for Disease Control and Prevention, the American Cancer Society, the American College of Surgeons, and the Michigan Department of Health and Human Services. This webinar is hosted by the Comprehensive Cancer Control National Partnership.

Register today


Second Edition of NCRA’s Cancer Case Studies Workbook Now Available

The National Cancer Registrars Association (NCRA) has produced a second edition of its popular cancer case study workbook, Cancer Case Studies: A Workbook to Practice Assigning AJCC TNM Stage and Coding SEER Summary Stage. The second edition includes 40 new cases to provide additional opportunities for registrars to practice assigning the American Joint Council on Cancer tumor, node, and metastases (TNM) Stage and coding the Surveillance, Epidemiology, and End Results (SEER) Summary Stage. The cases were prepared by Donna M. Gress, RHIT, CTR.

To learn more and order, go to

NCRA Announces Two-Part Webinar Series on Brain Tumors

The NCRA is offering a two-part webinar series, Getting to Know Brain Tumors: Clinical and Surveillance. The webinars include presenters from the Central Brain Tumor Registry of the United States (CBTRUS) who will discuss the current clinical, research, and surveillance of these complicated tumors. The webinar, Clinical: Anatomy and Characteristics of Brain Tumors, will be presented by Archie Bleyer, MD, clinical research professor, Oregon Health & Science University, Portland, on Wednesday, May 18, at  2:00 pm (Eastern). The second webinar, Surveillance: Reporting Brain Tumors, will be presented by Quinn Ostrom, MA, MPH, Case Western University, Cleveland, OH, and Carol Kruchko, president and chief mission officer, CBTRUS, on Wednesday, June 8, at 2:00 pm (Eastern). To learn more and register, go to

Access NCRA's Training on AJCC TNM Staging and Coding NCI-SEER Summary

The NCRA focused its 2014 and 2015 live webinars on creating high-quality training on the general rules of AJCC TNM Stage and NCI-SEER Summary Stage as well as specific sites. The NCRA has archived these webinars and created both a CD and online product to provide registrars quick access to first-rate training on this important subject. View the list of training and order at

NCRA Seeks Mentors

The NCRA receives many questions about the cancer registry field, the role of registrars, and the paths to the Certified Tumor Registrar credential. The best people to answer these questions are cancer registry professionals. Consider becoming a mentor. Learn more and register online to participate in the NCRA’s formal mentoring program at