Surgeons involved in the daily care of cancer patients are familiar with the American Joint Committee on Cancer Staging Manual and the College of American Pathologists (CAP) guidelines. The American College of Surgeons Clinical Research Program (ACS CRP) asserts that the time is right to develop a similar manual that provides details regarding surgical standards, complete with checklists (see sample checklist). The first public Town Hall meeting on this surgical standards project—Resolving Controversies in Cancer Care: American College of Surgeons Clinical Research Program: An Expert Forum and Open Discussion—will take place 7:00–7:45 am October 3, during the 2012 Clinical Congress in Chicago, IL.
Time is ripe
Many, if not all, of the essential elements of the manual have been developed in the context of either clinical trials or as part of Commission on Cancer (CoC®) standards for accreditation. This list includes standardization practices developed for sentinel lymph node harvest in breast cancer and laparoscopic colectomy studies. The introduction of the sentinel lymph node surgery for breast cancer brought to the surgical community a well-defined procedural and training program to ensure high rates of accuracy, while the introduction of laparoscopic surgery and other forms of less invasive oncologic surgery brought us surgical checklists and surgeon credentialing practices.
Some standards developed within the CoC, such as the 12 lymph node count for colon cancer, have evolved to become nationally recognized quality metrics. In essence, substantial efforts have been made to standardize surgical procedures and establish measurable metrics for those cancers covered by the National Cancer Institute’s Cooperative Groups and the CoC. Now, the ACS CRP Cancer Care Standards Development (CCSD) Committee has accepted the challenge of collating all available surgical standards to launch the first edition of a surgical standards manual.
Developing the manual
It is difficult to predict with certainty what the final draft of such a manual will look like. It may resemble previously published surgical standards projects with checklists and summary recommendations.* In an ideal world, this sort of guidebook would assess the level of evidence in support of recommended standards and suggest areas in need of more research. However, the scope of the manual will be restricted to the intraoperative experience; that is, from skin incision to skin closure. The standard will not attempt to duplicate the efforts of National Comprehensive Cancer Network guidelines, which already cover pre- and postoperative diagnostics and therapeutics. Current plans are to cover surgical procedures for the most common solid malignancies (see boxed item).
The process for developing standards will be transparent and inclusive, using input from as many relevant societies, organizations, groups, and volunteers as possible. To manage the process, three diseases at a time will undergo review with a core team from the Alliance and the CoC. Volunteers from relevant groups will be solicited, and drafts will be vetted appropriately.
If you or someone you know has an interest in participating in this process, contact Kelly Hunt, MD, FACS, co-author of this article and chair of the CCSD Committee, or Carla Amato-Martz, ACS CRP program manager.
Plan to attend the Town Hall meeting (TH11) on October 3 to get more information about our progress and offer your input.
*Nelson, H, Petrelli N, Carlin A, Couture J, Fleshman J, Guillem J, Miedema B, Ota D, Sargent D; National Cancer Institute Expert Panel. Guidelines 2000 for Colon and Rectal Cancer Surgery. J Natl Cancer Inst. 2001;93(8): 583-596.