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The First National Effort to Standardize the Performance of Cancer Surgery by the American College of Surgeons Commission on Cancer and Cancer Surgery Standards Program: Early Results After Implementation of Operative Standards
Matthew H. Katz1, *Amanda Francescatti
4, *Timothy W. Mullett
3, *James Harris
2, *Aaron D. Bleznak
5, Ronald J. Weigel
4, *Erin K. Reuter
4, *Bell M. Pastore
4, *Elizabeth C. Funk
4, *Kelley Chan
4, *Peter J. Carpenter
4, *William R. Burns
6, *Mediget Teshome
7, *Timothy J. Vreeland
8, Kelly Hunt
1, *Tina J. Hieken
91The University of Texas MD Anderson Cancer Center, Houston, TX; 2Western Surgical Group, Reno, NV; 3Markey Cancer Center, Lexington, KY; 4American College of Surgeons, Chicago, IL; 5Riverside Health System, Williamsburg, VA; 6Johns Hopkins Medicine, Baltimore, MD; 7UCLA Health, Santa Monica, CA; 8Brooke Army Medical Center, San Antonio, TX; 9Mayo Clinic, Rochester, MN
Background: To improve the quality of surgical care delivered to people with cancer, the American College of Surgeons Commission on Cancer (CoC) and Cancer Surgery Standards Program implemented evidence-based standards addressing the technical conduct of key components of cancer operations. These standards govern six operations performed at approximately 1,400 CoC-accredited programs which treat over 74% of patients with cancer in the USA. Here, we evaluate the first three years of compliance with the operative standards.
Methods: CoC Standards 5.3 and 5.4 (sentinel lymph node biopsy and axillary lymph node dissection for breast cancer), 5.5 (wide local excision for melanoma), 5.6 (colectomy for colon cancer), 5.7 (total mesorectal excision for rectal cancer), and 5.8 (nodal resection for lung cancer) each consist of a technical requirement that defines how a key element of the operation should be performed and a documentation requirement that defines how it should be reported. Implementation/site visits began in 2021/2022 for 5.7 and 5.8 and 2023/2024 for 5.3-5.6. Compliance with each standard was determined by evaluation of 7 operative (5.3-5.6) or pathology (5.7, 5.8) reports. Sites were non-compliant if there was a failure of technical performance, of documentation, or of both. We report compliance data from site visits conducted 1/2022-8/2024.
Results: Reviewers conducted 841 site visits (329 in 2022, 323 in 2023, 189 in 1-8/2024) of comprehensive community (42.9%), community (23.3%), academic comprehensive (15.8%), integrated network (12.3%), NCI-designated comprehensive (4.4%) and other (1.3%) cancer programs. Site compliance rates ranged from 50% for 5.5 to 88% for 5.7 (Table 1). The most common source of non-compliance was documentation for 5.3-5.6 and technical performance for 5.8. Non-compliance was split evenly across the three categories for 5.7. Compliance varied by cancer program type only for 5.8 (p=0.005) with compliance highest (72%) at NCI-designated comprehensive and lowest (39%) at community cancer programs.
Conclusions: Early compliance with operative standards in the first national effort to standardize the performance and improve quality of cancer operations was variable. This variability represents an enormous opportunity for local and large-scale, national efforts to impact operative performance and documentation of cancer surgery.
Table 1. CoC site visit data from January 2022-August 2024 for Operative Standards 5.3-5.8.
| | | | Reason for Noncompliance |
| Standard | Sites with Eligible Cases | Sites Compliant | Technical Failure | Documentation Failure | Failure of Both | Not Documented |
| 5.3 Sentinel Node Biopsy (Breast) | 186/189 (98%) | 136 (73%) | 2/50 (4%) | 27/50 (54%) | 1/50 (2%) | 20/50 (40%) |
| 5.4 Axillary Node Dissection (Breast) | 166/189 (88%) | 112 (68%) | 0/54 (0%) | 27/54 (50%) | 6/54 (11%) | 21/54 (39%) |
| 5.5 Wide Local Excision (Melanoma) | 144/189 (76%) | 72 (50%) | 1/72 (2%) | 34/72 (47%) | 6/72 (8%) | 31/72 (43%) |
| 5.6 Colectomy (Colon) | 184/189 (97%) | 94 (51%) | 1/90 (1%) | 48/90 (53%) | 6/90 (7%) | 35/90 (39%) |
| 5.7 Total Mesorectal Excision (Rectum) | 625/841 (74%) | 549 (88%) | 13/76 (17%) | 14/76 (19%) | 14/76 (19%) | 35/76 (46%) |
| 5.8 Node Dissection (Lung) | 653/841 (78%) | 354 (54%) | 122/299 (41%) | 13/299 (4%) | 44/299 (15%) | 120/299 (40%) |
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