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 Applicable CoC Standard and EPR Benchmark

Measure Description

Breast

 

 

 

BCSRT

Accountability

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.

MAC

Accountability

Standard 4.4

90%

(NQF #0559) Combination chemotherapy is considered 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.

HT

Accountability

Standard 4.4

90%

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

MASTRT

Accountability

Standard 4.4

90%

Radiation therapy is considered or administered following any mastectomy within 1 year (365 days) of diagnosis of breast cancer for women with ≥ 4 positive regional lymph nodes.

nBx

Quality Improvement

Standard 4.5

80%

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

BCS

Surveillance

Not Applicable

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

Colon

 

 

 

ACT

Accountability

Standard 4.4

90%

(NQF #0223) Adjuvant chemotherapy is considered 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.

12RLN

Quality Improvement

Standard 4.5

85%

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

Rectum

 

 

 

RECRCT

Quality Improvement

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

Gastric

 

 

 

G15RLN

Quality Improvement

Not Applicable

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

Non-Small Cell Lung

 

 

 

10RLN

Surveillance

Not Applicable

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

LCT

Quality Improvement

Not Applicable

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

LNoSurg

Quality Improvement

Not Applicable

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

Cervix


 


CBRRT

Surveillance

Not Applicable

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

CERRT

Surveillance

Not Applicable

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

Breast Measure Specifications

Colon Measure Specifications

Rectum Measure Specifications

Gastric Measure Specifications

Non-Small Cell Lung Measure Specifications

Cervix Measure Specifications

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