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

Standard 1.3

An Update for CLPs from the Commission on Cancer of the American College of Surgeons

Standard 1.3: “Each required member or the designated alternate attends at least 75 percent of the cancer committee meetings held during any given year”

Due to the clarification of Standard 1.3 accredited and non-accredited programs are allowed to appoint a designated alternate for their Cancer Liaison Physician (CLP).

A cancer program may select a designated alternate for the CLP. The appointment of the designated alternate must be done at the first cancer committee meeting of the year and the decision should be clearly documented in the cancer committee minutes. There can be only one designated alternate for the appointed CLP.

The designated alternate for the CLP is not considered the Co-CLP, who is required to submit a formal CLP application.

The appointed CLP is responsible for:

  • Preparing four data reports for the cancer committee meetings
  • Annually completing the CLP Activity Report in the SAR
  • Attendance at 75% of cancer committee meetings
  • Attendance at survey and meeting with surveyor

The designated alternate must:

  • Meet the eligibility requirements of a CLP

The designated CLP alternate may:

  • Share in meeting the required 75% cancer committee meeting attendance for Standard 1.3
  • Deliver data reports prepared by the appointed CLP
  • Be approved for CoC Datalinks access

Note: An individual can only be selected as the alternate for one required member on the cancer committee. Alternates cannot be selected from the other required members of the cancer committee.

Note: The attendance requirement is based on the cancer committee’s meeting schedule. If the committee meets monthly, then attendance at nine (9) meetings is required to meet the standard. If the committee meets every other month, then attendance at five (5) meetings is required.


If your accredited facility does not have a Cancer Liaison Physician appointment in place, you are in jeopardy of being in noncompliance with Commission on Cancer (CoC) accreditation standards 1.3 and 4.3. It is important that an appointment be made as soon as possible and that the individual is designated as the CLP in Datalinks. If there is not a CLP appointment in Datalinks, the CoC recommends that the cancer committee chair be listed as the interim CLP until the appointment is made. 

CoC staff monitor CLP appointments on a regular basis and will notify you if the appointment remains vacant. 

The Cancer Liaison Committee and the CLP program staff recommend the following selection criteria for appointment of a CLP:  

  • Member of the medical staff
  • Willing to assume the role of liaison between the cancer program and the CoC
  • Willing to serve as a liaison with the American Cancer Society as indicated
  • Exhibits leadership qualities within the facility and within the cancer committee

The CLP monitors, interprets, and reports the program’s performance on improvements to the quality of care provision within the facility. The NCDB is a tool used to monitor performance, and the candidate should be familiar with or willing to learn the tools and the quality improvement processes being used by the facility.

If you need assistance with your CLP appointment process, please contact the CLP program staff at