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

CoC Quality of Care Measures

CoC Measures for Quality of Cancer Care

Cancer registry data elements are nationally standardized and considered open source. Each of these measures was developed by the CoC 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 was performed using cancer registry data reported to the National Cancer Data Base (NCDB).

All measures are designed to assess performance at the hospital or systems-level, and are not intended for application to individual physician performance.

Primary Site

Measure Type

2015 Standard and Expected EPR

Measure Description

Initial CP3R Release

Breast

 

 

 

 

BCSRT

A

Standard 4.4

90%

(NQF #219) Radiation therapy is administered within 1 year (365 days) of diagnosis for women under age 70 receiving breast conserving surgery for breast cancer.

Fall 2008

MAC

A

Standard 4.4

90%

(NQF #0559) Combination chemotherapy is recommended or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1cN0M0, or stage IB - III hormone receptor negative breast cancer.

Fall 2008

HT

A

Standard 4.4

90%

(NQF #0220) Tamoxifen or third generation aromatase inhibitor is recommended or administered within 1 year (365 days) of diagnosis for women with AJCC T1cN0M0, or stage IB - III hormone receptor positive breast cancer..

Fall 2008

MASTRT

A

Standard 4.4

90%

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.

Spring 2014

nBx

QI

Standard 4.5

80%

(NQF #0221) Image or palpation-guided needle biopsy to the primary site is performed to establish diagnosis of breast cancer.

Spring 2014

BCS

S

Not Applicable

Breast conservation surgery rate for women with AJCC clinical stage 0, I, or II breast cancer.

Spring 2014

Colon

 

 

 

 

ACT

A

Standard 4.4

90%

(NQF #0223) Adjuvant chemotherapy is recommended or administered within 4 months (120 days) of diagnosis for patients under the age of 80 with AJCC Stage III (lymph node positive) colon cancer.

Fall 2008

12RLN

QI

Standard 4.5

85%

(NQF #0225) At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer.

Fall 2008

Rectum

 

 

 

 

RECRTCT

QI

Not Applicable

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 recommended; for patients under the age of 80 receiving resection for rectal cancer.

Spring 2015

Gastric

 

 

 

 

G15RLN

QI

Not Applicable

At least 15 regional lymph nodes are removed and pathologically examined for resected gastric cancer.

Fall 2014

Non-Small Cell Lung

 

 

 

 

10RLN

S

Not Applicable

At least 10 regional lymph nodes are removed and pathologically examined for AJCC stage IA, IB, IIA, and IIB resected NSCLC

Fall 2014

LCT

QI

Not Applicable

Systemic chemotherapy is administered within 4 months to day preoperatively or day of surgery to 6 months postoperatively, or it is recommended for surgically resected cases with pathologic, lymph node-positive (pN1) and (pN2) NSCLC.

Fall 2014

LNoSurg

QI

Not Applicable

Surgery is not the first course of treatment for cN2, M0 lung cases

Spring 2015

Cervix

 

CBRRT

S

Not Applicable

Use of brachytherapy in patients treated with primary radiation with curative intent in any stage of cervical cancer

Spring 2015

CERRT

S

Not Applicable

Radiation therapy completed within 60 days of initiation of radiation among women diagnosed with any stage of cervical cancer

Spring 2015

CERCT

S

Not Applicable

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)

Fall 2015

Ovary

 

OVSAL

S

Not Applicable

Salpingo-oophorectomy with omentectomy, debulking; cytoreductive surgery, or pelvic exenteration in Stages I-IIIC Ovarian cancer

Fall 2015

Endometrium

 

ENDCTRT

S

Not Applicable

Chemotherapy and/or radiation administered to patients with Stage IIIC or IV Endometrial cancer

Fall 2015

ENDLRC

S

Not Applicable

Endoscopic, laparoscopic, or robotic surgery performed for all Endometrial cancer (excluding sarcoma and lymphoma), for all stages except stage IV

Fall 2015

A - Accountability; QI - Quality Improvement; S- Surveillance

Breast Measure Specifications

Colon Measure Specifications

Rectum Measure Specifications

Gastric Measure Specifications

Non-Small Cell Lung Measure Specifications

Cervix Measure Specifications

Ovary Measure Specifications

Endometrium Measure Specifications

Measure Specification Modifications

Release Notes

For questions related to the release of these quality measures, please contact the NCDB at ncdb@facs.org.