Looking forward – June 2015

David B. Hoyt

David B. Hoyt, MD, FACS

The American College of Surgeons (ACS) has a long legacy of producing educational resources for surgeons and surgical residents seeking to deliver high-quality patient care. The latest example of these efforts came with the release of the first edition of Operative Standards for Cancer Surgery. This new manual, discussed in greater detail in the Alliance column, represents a unique benefit of the decade-long relationship between the ACS and National Cancer Institute cooperative groups.

Conceptualization and development

Operative Standards for Cancer Surgery is representative of the College’s ongoing tradition of developing protocols and educational materials to assist surgeons and other health care professionals in the delivery of safe, effective surgical care. Other examples include the Advanced Trauma Life Support® student manual; the American Joint Committee on Cancer’s Cancer Staging Manual, now in its seventh edition; our clinical guidelines program, Evidence-Based Decisions in Surgery; Resources for Optimal Care of the Injured Patient, now in its sixth edition; and an ACS quality manual that is in development for surgical quality officers, which outlines the processes that should be in place in surgical institutions to ensure the provision of quality care.

The concept for Operative Standards for Cancer Surgery was first proposed approximately three years ago by Heidi Nelson, MD, FACS, when she was Program Director of the ACS Clinical Research Program (ACS CRP), which is part of the Alliance for Clinical Trials in Oncology. The ACS CRP Cancer Care Standards Development Committee, chaired by the present Director of the ACS CRP, Kelly K. Hunt, MD, FACS, led the effort to develop the final product.


The manual was envisioned as a response to the need for minimum evidence-based standards for various cancer procedures and as a reference tool for clinical trials that include surgical interventions for four common disease sites: breast, colon, lung, and pancreas. Procedures covered in Operative Standards for Cancer Surgery include breast-conserving surgery, pancreaticoduodenectomy, and lobectomy. The focus is on describing technical elements critical to proper conduct of cancer operations where best practices can be demonstrated.

The authors have attempted to use the best evidence available, and this evidence represents the opinions of diverse and representative groups who care for cancer patients. Expert clinicians and researchers provided invaluable input that was used to develop the guidelines, and a Town Hall Meeting at the 2013 Clinical Congress provided an opportunity for attendees to learn about how the standards were created.

Benefits for researchers, clinicians, and patients

As is the case for all health care disciplines, the body of evidence of scientifically verifiable ways of performing cancer procedures is growing. This reference tool will spare clinical trial investigators the difficulties of establishing or re-establishing the basic principles of these operations with each new trial. Furthermore, having a set of protocols will minimize variability across study sites and improve adherence to best practices for patients receiving care both on and off a clinical trial.

It should also be useful in addressing variability in clinical practice. Much of clinical surgery is based on principles of ablation, correction of anatomic deficits, and reconstruction. The effectiveness of cancer operations has generally followed the principle of surgical removal of the malignancy. The technical elements that are critical to the proper conduct of a cancer operation ensure the use of best practices and optimal long-term outcomes.

When evidence and experience demonstrate that a procedure is essential for safe, effective, long-term outcomes, it is important to teach that technique with precision and put it forth as an evidence-based standard. As the project evolved, it became clear that this manual could also serve as an instructive text for surgical education and training.

Hence, this manual, using both text and illustrations, is not merely a surgical atlas, but rather is in many ways a textbook that emphasizes the critical steps in performing an operation and intraoperative decision making. It further can be used to provide a template for operative reports and it would be useful to the individual surgeon in analyzing his or her performance measures.

Defining those critical elements of each operation that are essential for surgical success is the purpose of Operative Standards for Cancer Surgery, and the areas covered have achieved this noble goal. Drs. Nelson and Hunt and the other surgeons who led the disease site groups are to be commended for the work they have done in producing this landmark approach to surgical cancer care and for this latest addition to the College’s resources for surgeons seeking to provide optimal care. This effort will become the yardstick by which cancer care is measured going forward and should be a standard for how all of surgical care is taught.

If you have comments or suggestions about this or other issues, please send them to Dr. Hoyt at lookingforward@facs.org.

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