Standard 4.4 and 4.5 Expected Performance Rates, 2019 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.
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Primary Site
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Measure Type
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2019Standard and Expected EPR
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Measure Description
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Initial Release
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Bladder
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BL2RLN
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Surveillance
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At least 2 lymph nodes are removed in patients under 80 undergoing partial or radical cystectomy
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Spring 2016
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BLCSTRI
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Surveillance
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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
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Spring 2017
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BLCT
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Surveillance
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Neo-adjuvant or adjuvant chemotherapy offered or administered for patients with muscle invasive cancer undergoing radical cystectomy
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Spring 2017
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Breast
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BCSRT
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Accountability
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Standard 4.4
90%
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(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.
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2006
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MAC
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Accountability
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(NQF #0559) Combination chemotherapy or chemo-immunotherapy (if HER2 positive) 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.
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2006
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HT
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Accountability
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Standard 4.4
90%
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(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.
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2006
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MASTRT
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Accountability
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Standard 4.4
90%
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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.
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Spring 2014
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nBx
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Quality Improvement
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Standard 4.5
80%
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Image or palpation-guided needle biopsy to the primary site is performed to establish diagnosis of breast cancer.
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Spring 2014
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BCS
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Surveillance
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Breast conservation surgery rate for women with AJCC clinical stage 0, I, or II breast cancer.
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Spring 2014
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Cervix
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CBRRT
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Surveillance
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Use of brachytherapy in patients treated with primary radiation with curative intent in any stage of cervical cancer
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Spring 2015
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CERRT
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Surveillance
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Radiation therapy completed within 60 days of initiation of radiation among women diagnosed with any stage of cervical cancer
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Spring 2015
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CERCT
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Surveillance
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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)
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Fall 2015
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Colon
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ACT
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Accountability
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(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.
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2005
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12RLN
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Quality improvement
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Standard 4.5
85%
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(NQF #0225) At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer.
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2006
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Endometrium
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ENDCTRT
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Surveillance
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Chemotherapy and/or radiation administered to patients with Stage IIIC or IV Endometrial cancer
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Fall 2015
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ENDLRC
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Surveillance
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Endoscopic, laparoscopic, or robotic surgery performed for all Endometrial cancer (excluding sarcoma and lymphoma), for all stages except stage IV
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Fall 2015
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Gastric
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G15RLN
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Quality Improvement
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Standard 4.5
80%
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At least 15 regional lymph nodes are removed and pathologically examined for resected gastric cancer.
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Fall 2014
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Kidney
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PD1RLN
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Surveillance
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Pediatric Measure: At least 1 regional lymph node is removed and pathologically examined for primarily resected unilateral nephroblastoma
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Spring 2017
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Non-Small Cell Lung
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10RLN
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Surveillance
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At least 10 regional lymph nodes are removed and pathologically examined for AJCC stage IA, IB, IIA, and IIB resected NSCLC
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Fall 2014
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LCT
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Quality Improvement
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Standard 4.5
85%
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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.
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Fall 2014
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LNoSurg
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Quality Improvement
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Standard 4.5
85%
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Surgery is not the first course of treatment for cN2, M0 lung cases
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Spring 2015
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Ovary
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OVSAL
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Surveillance
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Salpingo-oophorectomy with omentectomy, debulking; cytoreductive surgery, or pelvic exenteration in Stages I-IIIC Ovarian cancer
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Fall 2015
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Rectum
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RECRTCT
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Quality Improvement
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Standard 4.5
85%
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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.
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Spring 2015
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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.