Synoptic reporting for cancer surgery: Current requirements and future state

The operative report is a crucial component of the surgical patient’s record, capturing the key details of an operation from “wheels in” to “wheels out.” For oncologic procedures in particular, it is important that the documentation is clear, comprehensive, and can be easily interpreted. In 2020, the Commission on Cancer (CoC) launched six new accreditation standards known as the CoC Operative Standards (Standards 5.3 through 5.8). Four of these standards (Standards 5.3 through 5.6) will require cancer programs across the nation to include certain data elements in their operative reports in a synoptic format rather than the traditional narrative format, in which the entire operation is presented in prose. CoC-accredited cancer programs are now preparing to implement these synoptic operative reporting requirements before the January 1, 2023, deadline. In the future, we anticipate this evolution from narrative to synoptic reports will continue to expand far beyond meeting the current accreditation requirements.

What is synoptic reporting?

Synoptic reports present information as discrete data elements and associated responses. The synoptic report starts as a blank template, which is completed by the user. Each data element acts as a question that requires an answer selected from a list of predetermined responses. Once the template has been completed, each entry can be separately identified and extracted as a distinct unit of information (see Table 1).

TABLE 1. NARRATIVE VERSUS SYNOPTIC FORMATTING

Traditional narrative reporting can lead to missing or inadequately reported data. In addition, narrative reports often are dictated by the surgeon and must be transcribed into text, requiring additional processing times and costs. Synoptic operative reporting has been found to significantly outperform narrative reporting in both areas, leading to improved quality and efficiency.^1,2

Another benefit of synoptic reporting is the ease of data processing. Narrative reports may lock information into text format, which may require manual extraction of data from the records. The descriptions also are variable in content, accuracy, and quality. In contrast, synoptic reports ensure that each piece of information is captured in the same way, using standard language. When paired with the proper technology, synoptic reporting can automate data capture, promote interoperability, and increase opportunities for research and quality improvement. Synoptic reports may be particularly useful when accompanied by free-text sections that may allow capture of data that do not have a standard response or to allow for narrative documentation of unusual situations or technical nuances.

Collectively, the data elements in a synoptic report provide a structured checklist that allows the user to ensure all necessary information has been recorded. This checklist can be leveraged for education by reinforcing required and recommended best practices for cancer surgery. This method of reporting also helps ensure high-quality care for patients through accreditation. For instance, the College of American Pathologists (CAP) requires synoptic pathology reporting through the use of cancer reporting protocols.³ Numerous studies have shown improvement in the number of lymph nodes identified in colorectal cancer specimens (a known quality metric of pathology evaluation) after implementing synoptic pathology reporting.⁴ At present, CoC accreditation requires that 90 percent of eligible cancer pathology reports follow CAP’s synoptic reporting format.⁵ The National Accreditation Program for Rectal Cancer also includes synoptic formatting requirements for magnetic resonance imaging staging results, operative reports, and pathology reports.⁶ The inclusion of these requirements across different accreditation programs demonstrates a shift in the landscape toward routine implementation of synoptic reporting.

Current requirements

The four CoC accreditation standards that include synoptic operative reporting requirements apply to sentinel lymph node biopsy for breast cancer (Standard 5.3), axillary lymph node dissection for breast cancer (Standard 5.4), wide local excision for primary cutaneous melanoma (Standard 5.5), and colonic resection for colon cancer (Standard 5.6). These accreditation standards were developed from the evidence-based recommendations for cancer surgery detailed in the Operative Standards for Cancer Surgery manuals.^7,8

Each accreditation standard includes measures of compliance to ensure that cancer programs meet both technical specifications and documentation requirements (see Table 2).⁵ Documentation requirements specify that each operative note must include certain data elements and responses in synoptic format, and these elements and responses must appear together in one section of the operative report of record. By January 1, 2023, CoC-accredited cancer programs will need to have the tools and processes in place to meet these requirements for all eligible cancer operations.

TABLE 2. MEASURES OF COMPLIANCE FOR COC STANDARDS 5.3 THROUGH 5.6

CoC site visits taking place in 2024 will begin to review operative reports from 2023 to assess for compliance with each standard. For that year of reviews, the cancer program must meet the threshold compliance level of 70 percent for each standard by having at least five fully compliant operative reports of seven assessed reports. The threshold of compliance will increase to 80 percent starting with site visits in 2025, which will review operative reports from 2023 through 2024.

Surgeon awareness of the CoC Operative Standards

In early 2021, the Cancer Surgery Standards Program distributed an anonymous survey to surgeons at CoC-accredited cancer programs to gauge their general awareness of the CoC Operative Standards. The survey was set up so that surgeons only answered questions about the operations they performed regularly. The survey included specific questions on the technical aspects of melanoma, colorectal, breast, and lung cancer surgery, as well as separate questions on the requirements of the CoC accreditation standards.

Of the 377 respondents, the average scores for surgical technique questions were consistently more than 80 percent across all four disease site specialties, but average scores on questions specific to the accreditation standards were significantly lower (as low as 53 percent in colorectal and 54 percent in melanoma). These results indicate a need to educate surgeons and other stakeholders on the CoC Operative Standards. Future educational efforts will focus on improving knowledge of the standards.

Looking ahead

Over the next decade, operative reports will continue to evolve toward synoptic reporting. We are only in the early stage of implementation, which involves using early versions of synoptic operative reports to demonstrate compliance with the CoC accreditation standards. As we learn from this process, we aim to advance synoptic operative reports toward standardized, complete, and electronic health record-integrated reports that can be universally implemented across all cancer programs. This will allow for more interoperability, or data sharing across groups and automated data abstraction, leading to improved quality of care.

To that end, beginning in 2026, the CoC will work toward expanding requirements for synoptic operative reporting, with the future goal of transitioning to full synoptic operative reports. Additional cancer features in synoptic format will likely be required and new operative standards will be implemented for disease sites not already represented in the CoC standards for accreditation. Details on future changes to the CoC Operative Standards or synoptic operative reporting requirements will be shared with CoC-accredited cancer programs once available.

For more information, two articles on the CoC Operative Standards and synoptic reporting will be published in the coming months in the Annals of Surgical Oncology. We look forward to leading the surgical community on this journey toward synoptic operative reporting for cancer surgery and higher-quality cancer care.

References

1. Stogryn S, Hardy KM, Abou-Setta AM, Clouston KM, Metcalfe J, Vergis AS. Advancement in the quality of operative documentation: A systematic review and meta-analysis of synoptic versus narrative operative reporting. Am J Surg. 2019;218(3):624-630.
2. Eryigit Ö, van de Graaf, Floyd W, Lange JF. A systematic review on the synoptic operative report versus the narrative operative report in surgery. World J Surg. 2019;43(9):2175-2185.
3. College of American Pathologists. Cancer protocols. Available at: https://www.cap.org/protocols-and-guidelines/cancer-reporting-tools/cancer-protocols. Accessed October 15, 2021.
4. Sluijter CE, van Lonkhuijzen LRCW, van Slooten H, Nagtegaal ID, Overbeek LIH. The effects of implementing synoptic pathology reporting in cancer diagnosis: A systematic review. Virchows Archiv. 2016;468(6):639-649.
5. American College of Surgeons. Optimal Resources for Cancer Care (2020 standards). Available at: https://www.facs.org/-/media/files/quality-programs/cancer/coc/optimal_resources_for_cancer_care_2020_standards.ashx. Accessed October 15, 2021.
6. American College of Surgeons. Optimal Resources for Rectal Cancer Care (2020 standards). Available at: https://www.facs.org/-/media/files/quality-programs/cancer/naprc/optimal_resources_for_rectal_cancer_care_2020_standards.ashx. Accessed October 15, 2021.
7. Nelson H, American College of Surgeons, Alliance for Clinical Trials in Oncology. Operative Standards for Cancer Surgery, Volume 1. Philadelphia, PA: Wolters Kluwer Health; 2015.
8. Katz MH, American College of Surgeons, ACS Clinical Research Program. Operative Standards for Cancer Surgery, Volume 2. Philadelphia, PA: Wolters Kluwer Health; 2018.