College of American Pathologists

  President's Desk Column




No time to linger on the launch pad

December 2003
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

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