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Cancer Programs

NCDB Quality Measure Improvements Announced

Updated on February 1, 2024

Quality Measures Reported in NDCB RCS

The multidisciplinary Commission on Cancer (CoC) through the Quality Assurance and Data Committee (QADC) convenes clinical experts from around the country to develop and maintain quality measures.  These evidence-based measures are based on best practices and are designed to be assessed at the hospital or systems level. Each measure was developed using standardized cancer registry data fields 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 subject to revision to reflect contemporary clinical practice as well as to conform to the periodic changes to registry data items.

For more information on the quality measures, please log in to the Rapid Cancer Reporting System (RCRS) and navigate to the user library.

This work is subject to copyright. All rights are reserved by the American College of Surgeons (ACS), whether the whole or the part of the material is concerned. Without limiting the above, the contents of this page may be cited in academic publications as well as downloaded and printed for individual use. All other use is prohibited without ACS’s permission.

As of February 1, 2024

Primary Site

Measure Abbreviation

Measure Description

Breast

BCSdx

For patients with AJCC Clinical Stage I-III breast cancer, the first therapeutic surgery in a non-neoadjuvant setting is performed within and including 60 days of diagnosis.

Breast

BCSRT

For patients undergoing breast-conserving surgery without adjuvant chemo or immunotherapy for clinical stage I-III breast cancer, radiation therapy, when administered, is initiated <= 60 days of definitive surgery.

Breast

MAC

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.

Colon

ACT

For patients under the age of 80 with surgically-managed pathologic stage III colon cancer (N>0), adjuvant chemotherapy is initiated within 4 months (120 days) of diagnosis, or recommended.

Colon

C12RLN

For patients undergoing a colon resection for colon cancer, at least 12 regional lymph nodes are removed and pathologically examined at time of resection.

Gastric

G16RLN

For surgically managed gastric adenocarcinoma cancer patients, at least 16 regional lymph nodes are removed and pathologically examined during resection for curative intent therapy.

Gastric

GCTRT

For surgically managed patients age 18-79 with gastroesophageal junction or esophageal cancer cT2 with poor differentiation, or cT>3, or N>1, or gastric cancer cT>2 or N>0, neoadjuvant chemotherapy and/or chemo-radiation is administered within 120 days preoperatively, or recommended.

HeadNeck

HadjRT

For patients with surgically managed head and neck squamous cell cancer who received adjuvant radiation treatment, the radiation is initiated within 6 weeks of surgery.

Lung

LCT

For patients with surgically managed NSCLC, pathologically staged T2 and >4cm, or T>=3, or N>0, systemic therapy (chemotherapy, immunotherapy or targeted therapy) was initiated within the 3 months prior to surgery or after surgery, or was recommended.

Melanoma

MadjRx

For surgically managed pathologic stage IIIB-D melanoma patients, adjuvant systemic therapy was initiated within 6 months of surgery or recommended.

Rectum

RCRM

For patients undergoing surgical resection for rectal cancer, the Circumferential Margin is greater than 1 mm from the tumor to the inked, non-serosalized resection margin.

Rectum

RECRTCT

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.

Updates to Quality Measures

The CoC under the guidance of the QADC annually reviews, and periodically recommends, clinical changes to the portfolio of quality measures reported in the RCRS. The QADC updates the portfolio to ensure all measures are contemporary with current best practices and that maximized measures are retired to make way for new measures.

Just as select measures with high compliance and changes in practice have led to retirement for some measures, the following measures are scheduled to undergo clinical updates in 2024. Specifics related to these updates will be provided at a later date.

  • RECRTCT: 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
  • MAC: 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. 

New quality measures for 2024 will be announced shortly.

Impact on CoC Standard 7.1: Quality Measures

Due to the measure transitions planned for 2023-2024 and to allow programs time to adjust to these changes, program activity from 2023 and 2024 for Standard 7.1 will not be rated at future site visits. Additionally, 2023 site visits (which evaluate activity from 2020, 2021, and 2022) and 2024 site visits (which evaluate activity from 2021, 2022, and 2023) will not provide a compliant or non-compliant rating for Standard 7.1. However, site reviewers may discuss previous quality measure compliance and action plans with programs during these site visits.

During the calendar years 2023-2024, although programs are not being rated on this activity, they are still expected to review the new and updated measures as they are released and discuss the measures with their cancer committees.

Activity for Standard 7.1 compliance will resume in the near future. It is strongly recommended that programs keep an eye on the Cancer Program News for updates.

Questions on quality measure updates may be submitted to NCDB@facs.org. Questions on Standard 7.1 may be submitted to the CAnswer Forum.