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

Standard 2.13: Medical Oncology

Medical oncology treatment services are provided by or referred to medical oncologists who are board certified or in the process of board certification.

Definition and Requirements

Medical oncology (systemic therapy) is a primary component of multimodality treatment, and it is administered by board-certified physicians or physicians in the process of board certification in medical oncology by the American Board of Medical Specialists (ABMS) or the American Board of Internal Medicine (ABIM). Board certification for medical oncologists took effect in 1970 and is provided by the ABIM. Medical oncologists demonstrating competence and privileged by their facility prior to 1970 will also be recognized as board certified in medical oncology.

Performance Measures

The NAPBC requires the Breast Program Leadership Committee (BPLC) to review the quality of patient care using the NAPBC-identified performance measures appropriate to the patients who are treated by the center each year.

Performance Measures

Combination chemotherapy is considered or administered within four months (120 days) of diagnosis for women under the age of 70 with AJCC T1c, Stage II, or Stage III hormone-receptor-negative breast cancer

Tamoxifen or third-generation aromatase inhibitor is considered or administered within one year (365 days) of diagnosis for women with AJCC T1c, Stage II, or Stage III hormone-receptor-positive breast cancer

Process Requirements

Accession List and Data Review Requirements for the Site Visit

The center is required to provide a de-identified accession (case) list of breast cancer cases diagnosed and/or treated at the center (class of case 10–22) prior to the site visit date. Class of case is defined in the Facility Oncology Registry Data Standards (FORDS) manual.

For those medical oncologists in the process of obtaining board certification from the ABMS or the ABIM, certification should be obtained as applicable.

Combination chemotherapy is considered or administered within four months (120 days) of diagnosis for women under the age of 70 with AJCC T1c, Stage II, or Stage III hormone-receptor-negative breast cancer

Tamoxifen or third-generation aromatase inhibitor is considered or administered within one year (365 days) of diagnosis for women with AJCC T1c, Stage II, or Stage III hormone-receptor-positive breast cancer

Documentation

Complete all required standard fields in the Survey Application Record (SAR).

Provide documentation of board certification by the ABMS or the ABIM for all medical oncologists on the breast care team.

Evaluation

The surveyor will confirm board certification and review patient medical records to evaluate compliance with the medical oncology performance measures listed above during the site visit.

Rating Compliance

Compliance

  1. Medical oncology treatment services are provided by or referred to medical oncologists who are board certified or in the process of board certification.
  2. Combination chemotherapy is considered or administered within four months (120 days) of diagnosis for women under the age of 70 with AJCC T1c, Stage II, or Stage III hormone-receptor-negative breast cancer
  3. Tamoxifen or third-generation aromatase inhibitor is considered or administered within one year (365 days) of diagnosis for women with AJCC T1c, Stage II, or Stage III hormone-receptor-positive breast cancer

Noncompliance

The center does not fulfill one or more of the compliance criteria.

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