No time to linger on the launch pad
Mary E. Kass, MD
I like to be right, especially in my work; it improves job security, for one
thing. So I have always liked protocols; they keep human frailty at bay. And
as a practical matter, if there’s a tool that will help me do my job better
and quicker, I’m interested.
Not everyone agrees that protocols help them work better and quicker, which
is why mandatory use of the CAP cancer protocols for all tumor registry reports
has been stirring the pot for years now. It took time to work things through,
but a new American College of Surgeons Commission on Cancer, or CoC, standard
was approved for Jan. 1, 2004 implementation. As of that date, reports from
accredited cancer programs must include all of the CAP cancer protocols’
essential data elements. (Essential elements are items in the protocol checklists
that have been scientifically validated and identified by the CAP Cancer Committee
as crucial to appropriate staging, prognosis, and treatment.)
Standardized reports will provide scientifically validated, reproducible results
that can be combined in a TNM (tumor, nodal, metastasis) staging format. Required
procedures will guarantee appropriate examination and careful documentation
of findings before gross specimens are discarded. Use of the CAP cancer protocols
will multiply the volume of scientifically validated information in our tumor
registries and ensure that reports submitted to the National Cancer Data Base
give researchers everything they need.
Each protocol lists essential elements, provides a background paper with current
references, and includes an optional checklist. Although the checklists are
not required to meet the intent of the CoC standard, there are good reasons
to use them. Clinicians like checklists because they limit the number of communication-based
treatment errors that occur when two people use different words to say the same
thing. Researchers like them because they eliminate the time-consuming process
of mining narratives for data. And pathologists like them because they expedite
their work and help them remember key findings to include in reports. Checklists
also travel well, a consideration when patients relocate or seek a second opinion.
And they are SNOMED-CT compatible.
The heart of the excitement here is the potential for improvement in patient
care. In recent years, as pathologists have seen tumors at earlier stages, we
have begun to correlate certain microscopic features with predictive models.
Standardized reporting will enable us to identify trends in incidence and prevalence,
follow the behavior of cellular elements, evaluate treatment modalities, track
clinical outcomes, and identify new diagnostic clues.
Benefits within our hospitals can be realized almost as soon as we decide to
pursue them. Consider this example. M. Elizabeth Hammond, MD, who chairs the
Department of Pathology at LDS Hospital/Intermountain Health Care in Salt Lake
City, is a former chair of the CAP Cancer Committee. Dr. Hammond has been involved
with these protocols since we started to nibble around the edge of the idea
in the 1980s. More than 10 years ago, after studying internal data and determining
that too many of its reports were incomplete, her department implemented the
early CAP protocols in checklist format and began to enter them in an in-house
data warehouse. A number of years ago, the data indicated that a few surgeons
were excising axillary nodes in up to 20 percent of breast cancer patients,
a significant variation from the national benchmark, which anticipates excision
in no more than five percent of cases. When the oncology team shared with surgeons
this information collected from the data warehouse, axillary excisions quickly
dropped to benchmark levels. Readily accessible, scientifically sound information
translated to immediate improvements in patient care. This is the kind of story
I think we will be hearing more and more often.
Dr. Hammond has created macros in Microsoft Word that generate multiple-choice
lists covering the essential elements in the protocol checklists. She has a
shareware license agreement that permits her to give this tool to anyone who
requests it at no charge. I mention this because I am told that, in some cases,
departments are investing substantial time and money to convert their computer
systems to mirror the CAP checklists. This may be a smart and forward-looking
move, but it is not required; the CoC standard concerns the content of the protocols,
not the format of the checklists. If your hospital is struggling with transition
to the CAP protocols, Dr. Hammond’s material could be a solution, and
she would be pleased to share it. Please e-mail her at firstname.lastname@example.org.
One reason that pathology is the best of all possible specialties is that,
for us, quality improvement will always be a moving target. We can never hope
to know all there is to know in our field, and, by extension, we need never
fear a day when our professional tasks become tedious. Dr. Hammond’s offer
illustrates a second reason, related to the first. In my experience, pathology
has always been a true community of learners. I couldn’t begin to count
the number of times that a fellow pathologist has reached out to give me the
benefit of his or her experience.
In that vein, we should acknowledge those who have served on the CAP Cancer
Committee during the two decades these protocols have been under development.
Members of this committee, acting under the leadership of Robert V. P. Hutter,
MD, Donald E. Henson, MD, Dr. Hammond, and now Carolyn C. Compton, MD, PhD,
have made a tremendous contribution to our science. Today, 42 protocols are
posted on the CAP Web site. In each case, surgeons, medical oncologists, and
radiation oncologists collaborated with CAP volunteers to develop documents
that met their immediate clinical needs and our long-term quality goals. These
are CAP protocols developed in a collegial framework that have met the test
of clinical application. That clinicians are now asking that they be mandated
is a credit to those who wrote them.
I believe that standardized reports will launch a dynamic new phase for pathology
marked by enormous reservoirs of good information with direct clinical utility.
As science continues to progress, treatment planning and clinical outcomes will
rely increasingly on information that the pathologist alone can provide. Leadership
from pathology will facilitate the kind of institutional introspection that
quickly yields concrete improvements in clinical outcomes. I hope every pathologist
is planning to collaborate with clinical colleagues to discover uses for this
improved database. Standardized reports could be a launch pad for a host of
new initiatives to improve patient care. There is no reason to delay.
Dr. Kass welcomes communication from members. Send your letters to her at