Quality Measures Reported in NCDB RCRS
The multidisciplinary Commission on Cancer (CoC) through the Quality Assurance and Data Committee (QADC) convenes clinical experts from around the country to develop and maintain quality measures. These evidence-based measures are based on best practices and are designed to be assessed at the hospital or systems level. Each measure was developed using standardized cancer registry data fields with the expectation that cancer registries would be used to collect the necessary data to assess and monitor concordance with the measures. Extensive assessment and validation of the measures were performed using cancer registry data reported to the National Cancer Database (NCDB). All measures are subject to revision to reflect contemporary clinical practice as well as to conform to the periodic changes to registry data items.
For more information on the quality measures, please log in to the Rapid Cancer Reporting System (RCRS) and navigate to the user library.
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Updates to Quality Measures
The CoC under the guidance of the QADC annually reviews, and periodically recommends, clinical changes to the portfolio of quality measures reported in the RCRS. The QADC updates the portfolio to ensure all measures are contemporary with current best practices and that maximized measures are retired to make way for new measures.
As of April 25, 2025, five new quality measures were added, which includes one new primary site. On or before June 16, 2025, one quality measure (BCSRT) will be retired.
New Primary Site
New Quality Measures
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- BnoLN: For patients age >= 70, grade 1-2, hormone receptor positive and HER2 negative invasive breast carcinoma with tumor size <=2cm and AJCC clinical N0, who underwent breast conserving surgery, a sentinel lymph node biopsy or axillary lymph node dissection was not performed.
- Hp16: For patients with newly diagnosed oropharyngeal squamous cell carcinoma, p16 status by immunohistochemistry (IHC) is documented.
- HPBafp: For hepatocellular carcinoma of any stage, AFP (alpha fetoprotein) is obtained at diagnosis.
- HPBCT: For patients with stage I or II cholangiocarcinoma (BTC) or pancreatic ductal adenocarcinoma (PDAC), who had upfront curative surgery, adjuvant chemotherapy is initiated within 180 days, or recommended.
- HPBnoT: For patients with stage I or II cholangiocarcinoma (BTC) or pancreatic ductal adenocarcinoma (PDAC), who underwent curative surgery, should have no residual tumor after resection of the primary.
Newly Retired Quality Measures
- BCSRT: For patients undergoing breast-conserving surgery without adjuvant chemo or immunotherapy for stage I–III breast cancer, radiation therapy, when administered, is initiated <=60 days of definitive surgery.
Impact on CoC Standard 7.1: Quality Measures
Starting with CoC Site Visits in 2026, Standard 7.1: Quality Measures will be reinstated as an accreditation requirement. During 2025, programs must review their performance on the selected quality metrics, identify any deficiencies, and document their review and any appropriate actions in the cancer committee minutes.
The required quality measures that must be reviewed during 2025 are:
- C12RLN: For patients undergoing a colon resection for colon cancer, at least 12 regional lymph nodes are removed and pathologically examined at time of resection.
- ACT: For patients under the age of 80 with surgically-managed pathologic stage III colon cancer (N>0), adjuvant chemotherapy is initiated within 4 months (120 days) of diagnosis, or recommended.
- LCT: For patients with surgically managed NSCLC, pathologically staged T2 and >4cm, or T>=3, or N>0, systemic therapy (chemotherapy, immunotherapy or targeted therapy) was initiated within the 3 months prior to surgery or after surgery, or was recommended.
- BCSdx: For patients with AJCC Clinical Stage I-III breast cancer, the first therapeutic surgery in a non-neoadjuvant setting is performed within and including 60 days of diagnosis.
Programs can achieve compliance with standard 7.1 though one of two pathways:
- Program performance meets the performance threshold for each quality measure, or
- If the performance threshold is not met, an action plan must be developed and implemented to improve performance
The performance threshold for each quality measure will be available once the dashboard and Quality Measure Operational Reports are updated in mid-2025. Further details on RCRS quality measure reports will be announced in spring of 2025.
Questions about the requirements of Standard 7.1 may be submitted to the Standard 7.1 section of the CAnswer Forum. Questions about any quality measure should be submitted to the Quality Measures section of the CAnswer Forum.
