The second volume of Operative Standards for Cancer Surgery, a collaborative manual from the American College of Surgeons (ACS) and the Alliance for Clinical Trials in Oncology, is now available for print and electronic purchase. This volume of the manual focuses on thyroid cancer, gastric cancer, rectal cancer, esophageal cancer, and melanoma, and is a follow-up publication to Volume 1, which covered cancer of the breast, colon, lung, and pancreas.
The goal of Volume 2 remains the same as it was for Volume 1—to recommend the steps that need to occur in the operating room, from skin incision to skin closure, to ensure the best oncological outcomes for patients. Recommendations from these two volumes will serve as an initial discussion point for the ACS Commission on Cancer (CoC) as it works to revise its accreditation manual and requirements. Preliminary work is being done to incorporate a portion of the recommendations into the new CoC standards for implementation by 2020.
The recommendations offered by Volume 2 are part of a shift in the way surgeons perform cancer operations to ensure the procedures are guided by the strongest-available evidence, according to the leadership of the Alliance/ACS Clinical Research Program (ACS CRP) Cancer Care Standards Development Committee, which led development of both manuals. Until recently, little critical effort had been made to define standards for the technical conduct of cancer operations.
“Unfortunately, we’ve found that some of the things that surgeons accept as gospel don’t necessarily have the best evidence behind them,” said Nirmal Veeramachaneni, MD, FACS, Vice-Chair, Cancer Care Standards Development Committee. “This project has exposed that deficiency and has offered avenues for investigation moving forward. It makes us rethink and question everything,” he said.
The history of breast cancer treatment provides an example of a lack of evidence-based treatment strategies. In the late 19th century, surgeons performed radical mastectomies, which entailed removing the patient’s entire breast as well as the underlying chest muscle, Dr. Veeramachaneni explained. This was a rather aggressive procedure, but “we used to think that doing more led to better outcomes,” he said. By the 1970s, however, surgeons were performing less extensive operations, which represented a dramatic change of course.
Matthew H.G. Katz, MD, FACS, Chair, Cancer Care Standards Development Committee, agreed that the way surgeons are taught to perform certain procedures is not always based on evidence. The goal of this manual is to define standards for how these procedures should be conducted to maximize survival and quality of life after the operations.
Volume 2 breaks down the major cancer operations for each of the five disease sites into critical steps, which teams of experts and stakeholders around the country identified as having the most significant influence on outcomes, Dr. Katz said. Then, the teams determined how each step should be performed based on a review of available literature and expert opinion. The teams also identified key questions (areas of controversy) for each site related to the technical aspects of how the operations should be performed. Dr. Katz said these questions could be used as the basis for future clinical trials.
Drs. Katz and Veeramachaneni believe their committee has more work to do in the ongoing process of improving cancer operations and outcomes. The CoC is in the process of rewriting its standards this year, and the technical recommendations in this manual will likely be part of those discussions, Dr. Katz said. A third volume of the manual focusing on seven additional disease sites is expected to be released within the next few years.
“We hope that the recommendations become actively used and achieve greater legitimacy,” Dr. Katz said.
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