Commission on Cancer: One Hundred Years, Past and Future

One hundred years, thousands of people, and one mission: Improve the quality of cancer care. The vision and framing of the Commission on Cancer (CoC) by the original founders was so true to the needs of cancer patients that it has not only withstood the test of time, but also served as a broad-based platform for programmatic growth beyond the CoC. In this issue of the Bulletin, and on the American College of Surgeons (ACS) website, we share diverse stories about how the Committee on the Treatment of Malignant Diseases (1922–1939), the Committee on Cancer (1939–1965), and the CoC (1965–present), became synonymous with quality cancer care.

In this article, we have done our best to acknowledge the founders, leaders, members, and participants who shared the vision of the founders and advanced, expanded, and modernized the principles and practices of the CoC to make it the thriving and impactful organization it is today. This look back on the past 10 decades shares the history of how the origins of cancer care coordination and end results evolved alongside modern medicine to become evidence-based standards and data-driven quality measures, which led to the growth of standards in staging, specialty care, surgery, and more.

In the beginning: Purpose and principles

In 1922, with the formal introduction of the Committee on the Treatment of Malignant Diseases, the ACS Board of Regents declared their intentions to facilitate cancer care standardization. The purpose and principles behind why and how cancer care would be improved is succinctly expressed in a 1931 issue of the Bulletin:

While recognizing that there are many unsolved problems with regard to cancer, the Board of Regents of the American College of Surgeons, on the advice of its Committee on the Treatment of Malignant Diseases, has announced its policy of emphasizing the necessity of making the benefits of contemporaneous knowledge of cancer available to each and every cancer patient in the country. The College was convinced that, while awaiting future discovery of more efficient methods of treatment of the disease, it is possible effectively to reduce the suffering and mortality from cancer by an organized application of the knowledge that already is available.¹

The approach was brilliant, not only because it was an effective and sustainable vision for the CoC, but also because the principles set forth offered a broad platform—a platform that would prove capable of supporting and facilitating the growth of several other ACS cancer programs.

To launch the Committee on the Treatment of Malignant Diseases, the ACS committed to supporting the newly formed Cancer Clinics through the following activities:

• Furnishing methods to organize cancer clinics
• Providing the College’s stamp of approval for clinics that were following the standards
• Offering opportunities for roundtable conferences at Clinical Congress to discuss administrative problems
• Furnishing to the clinics samples of uniform blanks (for example, templates) for the recording of cases

In addition, the ACS asked clinics to furnish uniform cancer data for purposes of scientific study and, in return, the ACS committed to publishing clinic study results. A common longitudinal theme within the CoC has been the emphasis on uniformity, which has not only played a major role in the implementation of accreditation standards and the standardization of staging, but also played an important role in the standardization of data definitions and coding, which facilitated the creation of the National Cancer Database (NDCB) as a computerized, central data repository.

Accreditation standards, then and now

Original cancer clinic standards

As described in the 1931 Bulletin, the ACS Board of Regents’ philosophy, approach, and support of the Committee on the Treatment of Malignant Diseases was focused on the development and implementation of cancer standards—standards that would translate contemporary knowledge into practices and ensure the optimization of cancer care and outcomes. The first six published standards (see Table 1) required cancer clinics to define an organizational structure around cancer care, including conferences and consultations involving all relevant professionals; referral of all appropriate cancer patients to the clinics; treatment of cancer patients by cancer clinic staff; standardization of cancer treatment equipment; and record keeping, including medical record documentation, as well as periodic patient follow-up for as long as five years.

It should be noted that many of the original standards have become adopted as routine cancer practices writ large—that is, both inside and outside of the CoC. For example, it has become an expectation that all appropriate disciplines should attend multidisciplinary conferences (MDCs) to promote and support shared decision-making. Further, it is expected that cancer care will be organized in centers that coordinate care and monitor outcomes. In many respects, the original CoC standards and accreditation process represent an early prototype of a cancer care delivery program. An argument could even be made that the CoC offers one of the oldest and perhaps most effective implementation approaches for supporting the adoption of best practices—an impressive legacy.

2020 Standards

Although the original six standards are still fundamental to the CoC, either as explicit standards or as routine, present-day practices, contemporary CoC standards now number 38, and they cover all aspects of cancer care from prevention to diagnosis, treatment, and surveillance (see Table 1, page 12). CoC standards, as might be expected, have evolved over the past 100 years alongside modern-day medicine and become even more relevant today as the rise in cancer rates has become a more significant source of major morbidity and mortality because of increases in life expectancy. Indeed, because cancer evolved to become such a major source of mortality and suffering over the past several decades, significant national resources have been expended to reduce the national cancer burden. As a consequence, the number of cancer-focused professionals, diagnostic opportunities, and treatment options has greatly expanded. Despite these many medical advances, the original ACS principles regarding how to best organize and deliver high-quality care have remained largely unchanged and remarkably effective.

Although the application of current knowledge and the implementation of best practices was always a priority for the CoC, it should be noted that three major paradigm shifts helped accelerate implementation efforts—namely the creation of the NCDB, greater reliance on data-driven standards, and investment in quality improvement as a driver of practice changes.

NCDB

The creation of the NCDB as a central cancer data repository was a natural outgrowth of the original end-results standard—a standard that required templated records and five years of periodic follow-up of patients treated in the cancer clinics. While many critical steps were required over decades in order for the original records standard to evolve into the creation of a central, computerized registry (covered in the article on page 44), the transition from the local hosting of cancer clinic tumor registries to the ACS hosting of a computerized data repository occurred in the 1980s. Since then, more than 40 million unique cancer cases have been entered into the NCDB.

The NCDB now serves the 1,500 accredited programs by ensuring the use of standardized data fields and the collection and reporting of aggregate data for quality improvement and benchmarking purposes. The NCDB collaboratively develops data fields with the North American Association of Central Cancer Registries and publishes the definitions in the Standards for Oncology Registry Entry (STORE) manual. Accredited-CoC programs follow the rules and definitions in the CoC standards and STORE to abstract data from local clinical records and then submit them to the NCDB. The NCDB captures more than 250 data fields for each new cancer patient and accepts 1.5 million new patient cases each year, which represents roughly 70 percent of cancer cases in the U.S.

Quality Improvement and Evidence-based Standards

Given the enduring vision of the CoC as a means to improve the quality of cancer care, and given the availability of NCDB data, it should come as no surprise that evidence and data-driven quality improvement (QI) now plays a larger role in the CoC standards. Accredited programs are expected to follow evidence-based guidelines, conduct institutional-level QI initiatives, and monitor their estimated performance rates for the NCDB quality measures and mitigate underperformance. Further to this point, patient-care standards, such as the operative standards, are all based on solid evidence to ensure that compliance with these standards will be associated with improved patient outcomes. During the coronavirus 2019 pandemic, the CoC took a bold step and launched its first national plan/do/study/act (PDSA) QI project in support of return to screening. National QI efforts will likely play a greater role within the CoC in the coming years.

Impact

It is nearly impossible to measure the full impact of the CoC over the last 100 years, but evidence clearly supports the value of CoC accreditation, starting with patient-centric MDCs first described in the 1931 standards and now part of modern-day cancer care. Unsurprisingly, the literature repeatedly demonstrates that MDCs change treatment plans by up to 50 percent and measurably improve diagnoses, staging, and adherence to practice guidelines.² A second example of how the CoC has affected cancer care comes from understanding the impact of the NCDB, starting with the many reports—such as survival curves, benchmarks, and quality measures—that it generates and provides to accredited programs. The availability of real-world cancer data from NCDB has encouraged a greater reliance on data and evidence for building new standards, including staging standards, and it facilitated the introduction of QI into the cancer standards.

While the NCDB has been dedicated to quality of care since its inception, the recent introduction of the Rapid Cancer Reporting System will accelerate the impact of NCDB in QI by facilitating real-time data abstraction and database entry, thereby overcoming the reporting delays of the recent past.

Lastly, in addition to providing routine reports to accredited programs, NCDB data have served as a rich resource for the generation of new knowledge through the Participant User File (PUF). Since its introduction in 2010, PUF investigators have contributed more than 1,363 articles to the medical literature on diverse and important topics including incidence reporting, disparities, and disease-specific outcomes.^3-5 From the patient perspective, the NCDB quality measures have most likely been the most impactful contribution of the NCDB data, as it has been clearly demonstrated that quality measures are strongly associated with best practice compliance and improved patient outcomes.^6,7

The people

Leaders

First, it must be said that the credit for the success and the sustainability of the CoC belongs to many, including the CoC program and committee leaders, committee members, accredited programs, cancer liaison physicians, registrars and administrators, state chairs, member organizations, and the ACS staff. Forty-one individuals have led the CoC and the ACS Cancer Programs over the past 100 years (see Table 2).

While biographies of all leaders are featured on the 100-year anniversary website, two leaders deserve mention. Robert Greenough, MD, FACS, served from 1922 to 1933 and so was the first to lead the Committee on the Treatment of Malignant Diseases through the early years and then transition it to the Committee on Cancer. The longest-serving Medical Director of the Cancer Programs was David P. Winchester, MD, FACS, who served from 1985 to 2018, playing a large role in the development of the NCDB.

Member organizations

The first standard on organization set the stage for multidisciplinary involvement in cancer care: “…Organization shall include…representatives of all departments of the hospital which are concerned in the diagnosis and treatment of cancer….”¹ Indeed, the CoC has developed many important relationships with diverse organizations, starting with the American Cancer Society. Over the years, and as the need for uniformity and national coding standards became apparent, relationships and support came from the American Cancer Society, National Cancer Institute (NCI), Centers for Disease Control and Prevention (CDC), and Bureau of State Services, U.S. Public Health Services.

As cancer care diagnostic and treatment options grew more complex and involved more organizations, the CoC introduced the Member Organization model in the 1950s and, since then, a wide array of diverse organizations have joined forces with the CoC (see Table 3). Recognizing the value of multidisciplinary care and instilling the influence of these parties in the structure of the CoC has been essential to maintaining relevance in cancer care, now and into the future. Representatives from these organizations serve throughout the leadership and committee membership of the CoC, functioning as subject matter experts, to better inform standard development, quality measures, and policy decisions.

The next 100 years

For the same reasons that the original framing of the CoC set the stage for success in the first 100 years, it is likely that the CoC will thrive throughout another century. Declaring a clear purpose and principles, embracing uniformity, and adapting to the times seems like an excellent and sustainable formula for an accrediting organization. Having a patient-centric purpose helps motivate participants, and having clear and solid principles helps to set priorities and realize the value of the organization. The CoC has demonstrated how uniformity and standardization can play a large role in improving cancer care. Uniform definitions facilitate accurate communications, staging, data, interpretation and comparative analyses—and the standardization of practices around best evidence saves lives. Equally important to having a purpose, principles, and uniformity is the need for any organization to be flexible and adaptive, whether it be accepting new evidence-based practices into standards or adopting new methods of delivering new practices. Adaptability has played a major role in the sustained relevance of the CoC.

For the next 100 years, the CoC will face many new opportunities and challenges. For the near term, the CoC is well-positioned to launch more consistent and impactful QI efforts, especially now that the Rapid Cancer Reporting System is functioning, and real-time data submission and reporting are feasible.

The CoC also is poised to close the gap in standardizing medical documentation in the form of developing and implementing standardized point-of-care tools. Although templates and data definitions have been standardized for recording cancer information in registries for decades, the medical record source documents have not been standardized. The literature repeatedly demonstrates that narrative medical reports are either incomplete or inaccurate 50 percent of the time and that synoptic reports can achieve nearly 100 percent accuracy and completeness for important cancer and surgical details.⁸ Given the multidisciplinary nature of cancer care and the extreme reliance on factual clinical knowledge, the CoC sees synoptic reporting as a critical next step for delivering best practices in cancer care.

The ability to develop standardized data collection from Cancer Programs and from the care of patients in these programs will now allow for customization to attend to special needs of populations at risk. Disparities in cancer care are identified in groups influenced by social determinants of health, race, ethnicity, geography, and others. Understanding the impact of these forces on cancer care delivery and patient outcomes will allow the CoC to provide tools for cancer programs to recognize, report, and repair disparities. Focusing on diversity in membership and leadership will only serve to enhance the commission’s perspective in recognizing and responding to these needs.

Lastly, in contrast to 1922, when diagnostic options were limited and primary therapies were surgery and radium, today dozens of new diagnostic and therapeutic options are approved each year. While personalized oncology is becoming a reality, the volume, velocity, and variety of emerging knowledge is exceeding our capacity to apply such knowledge in our daily practices, and so now is the time to integrate technology more fully into clinical workflow. It also is time to consider the CoC’s ability to help with the standardization of biologic markers to accelerate our understanding of how to bring disparate types of biologic information from DNA, RNA, and protein expression into a single clinical focus and therapeutic approach. It is abundantly clear that there is more that we don’t know than we do know about the future of cancer care, and we are challenged, as described by Amory Lovins: “We’ve got 21st century technology and speed colliding head-on with 20th and 19th century institutions, rules, and cultures.”⁹ That said, the CoC has been changing the practice of cancer care for 100 years, and there is no reason we cannot continue to change cancer care for the next 100 years by empowering our people and leveraging our purpose and principles.

References

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7. Nussbaum DP, Rushing CN, Sun Z, et al. Hospital-level compliance with the Commission on Cancer’s quality of care measures and the association with patient survival. Cancer Med. 2021;10(11):3533-3544.
8. Edhemovic I, Temple WJ, de Gara CJ, et al. The computer synoptic operative report—a leap forward in the science of surgery. Ann Surg Oncol. 2004;11(10):941-947.
9. Uhl-Bien M, Arena M. Complexity leadership: Enabling people and organizations for adaptability. Organizational Dynamics. 2017;46(1):9-20.