In the Commission on Cancer (CoC) Optimal Resources for Cancer Care (2020 Standards), Standard 7.1 Accountability and Quality Improvement Measures requires CoC-accredited cancer programs to treat cancer patients according to nationally accepted accountability and quality improvement measures indicated by the CoC and included in the Rapid Cancer Reporting System (RCRS) tool.
Standard 7.1 states that each calendar year, the expected performance rate is met for each of the selected accountability and quality improvement measures as defined by the CoC, and the cancer committee of each accredited program monitors the selected accountability measures.
For 2020 and 2021, the program’s performance rate for this Standard is expected to be equal to or greater than the expected rate specified by the CoC, or the upper confidence interval should cross that expected rate for the nine (9) measures listed below. These performance rates will be reviewed during site visits beginning in 2022.
Measure Specifications can be accessed through the Quality Portal (QPort), which requires a log-in.
For questions related to the release of these quality measures, please contact the NCDB at ncdb@facs.org.
Primary Site
|
Measure Type
|
2020–2021
Standard and Expected EPR
|
Measure Description
|
Initial Measure Release
|
|
Breast
|
|
BCSRT
|
A
|
Standard 7.1
90%
|
Radiation therapy is administered within 1 year (365 days) of diagnosis for women under age 70 receiving breast conserving surgery for breast cancer.
|
2006
|
|
HT
|
A
|
Standard 7.1
90%
|
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
|
A
|
Standard 7.1
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 7.1
80%
|
Image or palpation-guided needle biopsy to the primary site is performed to establish diagnosis of breast cancer.
|
Spring 2014
|
|
Colon
|
|
12RLN
|
QI
|
Standard 7.1
85%
|
At least 12 regional lymph nodes are removed and pathologically examined for resected colon cancer.
|
2006
|
|
Gastric
|
|
G15RLN
|
QI
|
Standard 7.1
80%
|
At least 15 regional lymph nodes are removed and pathologically examined for resected gastric cancer.
|
Fall 2014
|
|
Non-Small Cell Lung
|
|
LCT
|
QI
|
Standard 7.1
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
|
QI
|
Standard 7.1
85%
|
Surgery is not the first course of treatment for cN2, M0 lung cases
|
Spring 2015
|
|
Rectum
|
|
RECRTCT
|
QI
|
Standard 7.1
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
|
A - Accountability; QI - Quality Improvement; S- Surveillance
