College of American Pathologists
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  Feature Story


More time permitted to bring cancer protocols onboard

December 2002
Karen Southwick

At the request of the CAP, the American College of Surgeons Commission on Cancer has delayed for a year its plan to require the cancer programs it accredits to use the CAP’s protocols as part of their reporting.

The Commission on Cancer originally had intended to make scientifically validated portions of the cancer protocol checklists mandatory for cancer programs starting Jan. 1, 2003. That requirement will now be delayed until Jan. 1, 2004.

"We received a letter from the CAP which told us they would not be able to meet their November [2002] deadline for republishing the protocols and asking us to delay implementation," says M. Asa Carter, manager of the accreditation and standards section of the ACS’ cancer programs. "The CoC executive committee felt it was reasonable to grant the request. We did not want to implement a requirement using material in revision."

Carolyn Compton, MD, PhD, chair of the CAP Cancer Committee and chair of the Department of Pathology, McGill University, Montreal, says the protocols had to be updated because a new edition of the AJCC Cancer Staging Manual was published recently. Members of the committee also wanted to clarify which portions of the protocol checklists were scientifically proven and which were optional. And they wanted to incorporate information that was released after the protocols were finished, such as new WHO classifications of tumors.

"I am pleased with the delay" by the ACS’ Commission on Cancer, Dr. Compton says. The delay affords the CAP Cancer Committee time to update the material and gives pathology departments at cancer centers time to modify their software to accommodate the checklists.

The Cancer Committee members who worked on the protocols "have made a huge effort to update them, and we are done with that portion," Dr. Compton says. Some of the protocols were dramatically edited, she adds. "We have now defined what elements of the checklist are essential and which are not." In all cases, she says, they made the protocols "consistent with those that have been devised by other professional organizations."

Once the CAP Board of Governors approves the rewritten protocols, they will be posted on the College’s Web site ( so cancer centers can begin incorporating them into their reporting. "We’ll be considering them in batches and approving them as swiftly as possible," says M. Elizabeth Hammond, MD, a member of the Board of Governors and former chair of the Cancer Committee. Dr. Hammond is chair of the Department of Pathology, Urban Central Regional Hospitals of Intermountain Healthcare, Salt Lake City.

At its meeting in mid-November, the Board of Governors committed to a Dec. 31 deadline to approve the 23 checklists updated by the Cancer Committee. "These will be available on the CAP Web site starting in 2003," Dr. Hammond says. "They represent the vast majority of cancer specimens." Cancer Committee members are refining the other 15 protocols and will soon send them to the Board.

The Board of Governors, at its November meeting, approved the new checklists for the first batch of eight protocols. Those eight encompass the most important cancer sites: breast, colon and rectum, skin melanoma, endometrium, kidney, lung, prostate, and uterine cervix.

Those portions of the checklist that are not scientifically proven will be marked with an asterisk and won’t have to be included in the reporting, Dr. Hammond says.

The critical elements will be those that are scientifically validated and that must appear in every report pathologists issue to clinicians. For example, the critical elements for a breast biopsy are specimen type, laterality, tumor site, tumor size, histologic type, and histologic grade. "You have to provide these elements, but we don’t specify the format," Dr. Hammond says. "You can use narrative or synoptic."

The ACS Commission on Cancer has approved more than 1,430 cancer programs at hospitals and freestanding cancer centers, Carter says. The accreditation surveys are performed every three years, "but we will expect our approved programs to be in compliance with the protocols as of Jan. 1, 2004," she adds. If found deficient in a subsequent survey, a cancer program will have 12 months to resolve the deficiency.

Carter advises cancer programs to watch the CAP Web site for protocol updates. "As the information becomes available, share it with pathologists and get ready for implementation," she says.

Using the protocols "is a high-priority item for us," Carter adds. The College’s standardized checklists will make it easier for cancer registrars to locate needed information in medical records. Cancer registry data are shared with state cancer registries and the ACS’ National Cancer Data Base.

"The CoC made the decision in the first place to make it mandatory because we recognized the value of these protocols back in 2000," Carter says. "We recognized that the original deadline for implementation was unrealistic, but once we have the complete set of guidelines, we want to move forward."

Because pathologists formulated the guidelines themselves, she says, pathology departments and laboratories should accept them more readily than if another group had created them.

Karen Southwick is a writer in San Francisco.