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

CoC Quality of Care Measures

Standard 4.4 and 4.5 Expected Performance Rates, 2018 Surveys

Cancer registry data elements are nationally standardized and considered open source. Five of these measures are National Quality Forum (NQF) endorsed. 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 were performed using cancer registry data reported to the National Cancer Database (NCDB).

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

Standard 4.4 states that “Each calendar year, the expected performance rate is met of each of the selected accountability measured as defined by the Commission on Cancer (CoC). The cancer committee of each accredited program monitors the selected accountability measures.

Standard 4.5 states that “Each calendar year, the expected performance rate is met for each selected quality improvement measure as defined by the CoC.”

The program’s performance rate for these Standards is expected to be equal to or greater than the expected rate specified by the CoC or the upper confidence interval is to cross that expected rate. However, the Standards are never intended to require 100% performance rate.

Primary Site

Measure Type

2018 Standard and Expected EPR

Measure Description

Initial Release

Bladder

 

 

 

 

BL2RLN

Surveillance

At least 2 lymph nodes are removed in patients under 80 undergoing partial or radical cystectomy

Spring 2016

BLCSTRI

Surveillance

 

Radical or partial cystectomy; or Tri-modality therapy (Local tumor destruction/excision with chemotherapy and radiation) for clinical T234N0M0 patients, first treatment within 90 days of diagnosis

Spring 2017

BLCT

Surveillance

 

Neo-adjuvant or adjuvant chemotherapy offered or administered for patients with muscle invasive cancer undergoing radical cystectomy

Spring 2017

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.

2006

MAC

Accountability

 

(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.

2006

HT

Accountability

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.

2006

MASTRT

Accountability

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

Quality Improvement

Standard 4.5

80%

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

Spring 2014

BCS

Surveillance

 

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

Spring 2014

Cervix


 



CBRRT

Surveillance

 

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

Spring 2015

CERRT

Surveillance

 

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

Spring 2015

CERCT

Surveillance

 

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

Colon

 

 

 

 

ACT

Accountability

 

(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.

2005

12RLN

Quality improvement

Standard 4.5

85%

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

2006

Endometrium


 



ENDCTRT

Surveillance

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

Fall 2015

ENDLRC

Surveillance

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

Fall 2015

Gastric

 

 

 

 

G15RLN

Quality Improvement

Standard 4.5

80%

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

Fall 2014

Kidney

 

 

 

 

PD1RLN

Surveillance

 

Pediatric Measure: At least 1 regional lymph node is removed and pathologically examined for primarily resected unilateral nephroblastoma

Spring 2017

Non-Small Cell Lung

 

 

 

 

10RLN

Surveillance

 

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

Fall 2014

LCT

Quality Improvement

Standard 4.5

85%

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

Quality Improvement

Standard 4.5

85%

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

Spring 2015

Ovary


 



OVSAL

Surveillance

 

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

Fall 2015

Rectum

 

 

 

 

RECRTCT

Quality Improvement

Standard 4.5

85%

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

Bladder Measure Specifications

Breast Measure Specifications

Cervix Measure Specifications

Colon Measure Specifications

Endometrium Measure Specifications

Gastric Measure Specifications

Kidney Measure Specifications

Non-Small Cell Lung Measure Specifications

Ovary Measure Specifications

Rectum Measure Specifications

Measure Specification Modifications

Measure Changes and Release Notes

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