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

Standard 2.7: Pathology

The College of American Pathologists (CAP) guidelines are followed for all breast cancers, including estrogen and progesterone receptors and Her2 status for all invasive breast cancers. Estrogen receptor status is recommended for ductal carcinoma in situ (DCIS) but not required by CAP. Pathology slides from an outside/referring institution are reviewed prior to first course of treatment.

Definition and Requirements

The National Accreditation Program for Breast Centers (NAPBC) requires that all breast cancer pathology reports contain the required (core) data elements outlined on the CAP cancer protocol template and are reported in synoptic format for primary excisions or mastectomy after fine needle aspiration (FNA) or core biopsy.

Estrogen and progesterone receptors and Her2 studies need to only be performed on one specimen (such as the core biopsy or excision specimen), but must be included in the synoptic report (even if performed on the core biopsy or at an outside/referring institution).

Imaging studies are correlated with pathology when feasible.

If the biopsy is performed at an outside/referring institution, the biopsy pathology slides must be reviewed at the breast center or the affiliated pathology department prior to first course of treatment. The review may be done as an official consultation report, or verbally reported at the multidisciplinary conference.

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.

Report all breast cancer pathology in accordance with the CAP guidelines.

Report all breast cancer pathology from primary excision or mastectomy after FNA or core biopsy in synoptic format.

Review all pathology slides from an outside/referring institution prior to first course of treatment at the center. If extenuating circumstances exist that preclude the review, this is documented in the medical record.

Documentation

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

Evaluation

The surveyor will review patient medical records during the medical records review portion of the site visit to evaluate compliance with pathology reporting.

Rating Compliance

Compliance

  1. The CAP guidelines are followed for all breast cancers, including estrogen and progesterone receptors and Her2 status for all invasive breast cancers.
  2. All breast cancer pathology from the primary surgical treatment is reported in synoptic format.
  3. Pathology slides from an outside/referring institution are reviewed prior to first course of treatment.

Noncompliance

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

Resources

College of American Pathologists