Life isn’t a matter of milestones, but of moments.*
—Rose Kennedy
The American College of Surgeons (ACS) was founded in 1913 as the Clinical Congress of Surgeons of North America. Seventeen days after this founding, the American Society for the Control of Cancer was established. This organization would later be known as the American Cancer Society. In 1921, the ACS Board of Regents authorized the formation of the Registry of Bone Sarcoma under the direction of Ernest Amory Codman, MD, FACS, of Boston, MA. It was not until 1922 that the cancer initiative of the ACS was formalized under the banner of the Committee on the Treatment of Malignant Diseases with Radium and X-ray.
In reflecting on the accomplishments of the Commission on Cancer (CoC) and its forerunner components, it is easier to survey this centennial landscape by examining the individual 10 decades that have passed since 1922, the date that officially begins our retrospective. While certainly not meant to be all-inclusive, this overview highlights those moments that have culminated in celebrating this centennial milestone, tracking them with significant cultural touchstones of the era.
1922–1932:
Dedication of the Washington, DC, Lincoln Memorial
During this first decade, the original name of the committee was changed to the Committee on the Treatment of Malignant Diseases (CTMD). This early committee included George W. Crile, MD, FACS, Cleveland, OH; John M. T. Finney, MD, FACS, Baltimore, MD; and Henry Pancoast, MD, FACS, Philadelphia, PA. The ACS Board of Regents, through the CTMD, announced a policy that emphasized the availability of the benefits of contemporaneous knowledge of cancer to every cancer patient in the U.S.
The concept of developing cancer clinics in existing general hospitals was conceived in 1927 and finally launched in 1931 with the first surveys. The first cancer clinic under the auspices of the ACS was established at the Massachusetts General Hospital, Boston, under the direction of Robert Greenough, MD, FACS. This cancer center concept included defined conferences for the discussion of patient management, the provision of surgical therapy and equipment for X-ray therapy and radium sources, appropriate record keeping on the treatment of each patient, and organized surgical divisions within the hospital to support the cancer clinics. A mandate was developed to ensure that the executive officer of each cancer clinic was a Fellow of the ACS but was later amended to allow pathologists, internists, and radiologists to assume leadership positions. The philosophy and mandates associated with the cancer clinic concept transitioned into the second decade of the CoC.
1932–1942: Amelia Earhart flies solo across the Atlantic Ocean
During this decade, the official name of the CTMD was changed to the Committee on Cancer. Needless to say, this second decade fulfilled the burgeoning cancer clinic concept when standards were created and disseminated. The CTMD developed uniform templates to achieve standardization of all established cancer clinics. Educational programs were developed at the annual ACS Clinical Congresses to provide cancer clinic directors opportunities to network and to learn from each other. Publishing and distributing clinical studies that emanated from the cancer clinics, particularly in the ACS Bulletin, continued to evolve during this second decade.
The CoC and its members recognized that not all cancer clinics should be established at large urban hospitals. Several clinics were approved at smaller, rural institutions with the understanding that patients requiring specialized cancer care would be referred to the nearest, fully equipped cancer clinic. During this second decade, the tradition of sending surgical site visitors to evaluate the cancer clinics was launched. In 1937, 296 cancer clinics were evaluated and 240 were approved, thereby creating the forerunner of the approvals and accreditation activities of the CoC in future decades.
During this decade, a significant stream of data relating to cancer management flowed from the cancer clinics to the College headquarters in Chicago, IL. The specific call for data included five-year cures, which totaled more than 29,000 cases by the end of 1937. The Cancer Committee also recommended that the College support a data warehouse for recording of cancer families. By the end of 1932, a cooperative relationship between the ACS and the fledgling National Cancer Institute (NCI) had been established. A grant from the NCI served to increase the number of field staff who would evaluate the growing number of cancer clinics. In 1938, the number of cancer clinics surveyed was 272. By 1939, the Cancer Committee selected a goal of increasing cancer clinic approvals to 50-60 percent of hospitals in the U.S. and Canada with more than 100 beds. The committee urged the ACS Regents, Governors, and College Officers to visit the cancer clinics when possible. The committee also advised surgeons to learn more about the benefits of radiation therapy as a complement to surgical management of cancer. In 1939, 307 additional cancer clinics were surveyed. At the end of this third decade, minimum standards for the cancer clinics had been codified (see Figure 1).
1942–1952: The Voice of America begins broadcasting
This decade was characterized by the difficulties of having effective ACS cancer-related activities during World War II. The assessment of new cancer clinics came to a virtual standstill, as did the in-person activities of the Cancer Committee. Later in the decade, significant strides were made in reporting cancer treatment activities to the ACS. Early in 1948, representatives from the American College of Radiology approached the Cancer Committee with the suggestion that a revision was desirable in the X-ray treatment section of the Abstract Cancer Record Forms that were widely used in cancer clinics throughout the country. This important collaboration initiated the beginning of the radiation oncology treatment summary as we know it today.
At the 1946 meeting of the Cancer Committee, Lane Adams, chairman of the board of the American Cancer Society, addressed the committee. This meeting proved to be an important one, which further strengthened the relationship between the ACS and American Cancer Society. By decade’s end, a new direction—specifically the establishment of Cancer Detection Clinics—was undertaken by the College in collaboration with the American Cancer Society.
In 1950, another important collaboration occurred. The Joint Committee on Reporting Cancer End Results was formed to include members of the ACS, the College of American Pathologists, the American College of Radiology, and the American Cancer Society. This body proved to be the forerunner of the American Joint Committee on Cancer (AJCC) established nine years later, paving the way for the entire coding structure that would become mandatory for cancer registry development and data collection in future years (see Figure 2).
1952–1962: SS United States makes her maiden voyage across the Atlantic Ocean
A landmark standard for Cancer Program accreditation was introduced by the Cancer Committee and approved by the Board of Regents in 1952, which stated that approved cancer clinics must maintain a cancer registry using the College regulations set forth in the Manual for Cancer Registries and Cancer Clinic Activities; this standard became operational December 31, 1955. The wisdom of putting emphasis on cancer data collection at the local level was one of the significant decisions of the Cancer Committee in this decade and served as the basis for the development of the National Cancer Database (NCDB) 30 years later. Unfortunately, the committee also determined that maintaining a Cancer Detection Accreditation program was unworkable and, therefore, terminated the program in 1953.
Changes also were occurring with regard to the structure of the Committee on Cancer during this decade. The committee consisted of 25 voting members who must be Fellows of the ACS. Representatives of the American Cancer Society, NCI, American College of Radiology, American College of Physicians, and College of American Pathologists were invited to appoint one nonvoting representative. An executive committee was appointed for the first time.
Under the leadership of R. Lee Clark, MD, FACS, MD Anderson Cancer Hospital, Houston, TX, the Committee on Cancer planned a series of sectional workshops to discuss cancer education and registry operations at approved Cancer Programs. In 1960, one Liaison Fellow of the ACS was appointed from each state and Canadian province. The maturation of this Liaison Program would be evident during the next decade.
1962–1972: President John F. Kennedy affirms that the U.S. will put a man on the moon
At the beginning of the decade, 937 approved programs were listed. The Executive Committee of the Committee on Cancer also recommended in 1965 that the name of the committee be changed to the Commission on Cancer and that the commission be given a permanent structure within the ACS. It was further recommended that a Committee on Accreditation be formed under the commission that would include full member representation by the American College of Radiology, College of American Pathologists, and the American College of Physicians. The Cancer Program Manual was introduced in 1966.
In this decade, the First Annual Conference on Regionalization, conceived by Murray M. Copeland, MD, FACS, then-Chair of the Cancer Commission, was convened in Houston at The University of Texas MD Anderson Cancer Hospital. The concept of having meetings of Liaison Fellows representing approved hospitals and states, along with representatives of cancer-related organizations, was first introduced at this initial annual conference, which also marked the inauguration of member organizations in the CoC structure.
1972–1982: Watergate
Early in this decade, the evaluation of the quality of cancer care as a standard for hospital approval finally went into effect. By 1979, 797 programs had been approved. At the same time, the CoC recommended that approved cancer programs be categorized based on the complexity of the institution and the number of cancer patients treated annually. By the end of the decade, 940 cancer programs in the U.S. and Puerto Rico had been approved. One important addition was the patient care evaluation studies conducted by the CoC Committee on Patient Care and Research. These studies provided information on national trends in cancer treatment and outcomes.
One of the great concerns during this decade was the increasing financial burden created by the expanding approvals program and other programmatic changes introduced by the CoC. Beginning July 1, 1981, hospitals were assessed a fee of $500 to conduct a survey. By the end of the decade, the CoC included four committees: Approvals, Education, Patient Care, and Field Liaison. In addition, the ACS, through the CoC, pioneered a software program, “CanSUR,” supported by grants from the American Cancer Society and the NCI. This software was offered at no cost to CoC-approved programs.
1982–1992: University of California Berkeley beats Stanford on a last-second touchdown through the Stanford band
The initial emphasis on the importance of cancer registries and collection of patient outcomes bore the ultimate fruit in this decade—the creation of the NCDB—as a joint venture of the ACS and American Cancer Society. This process was galvanized by the strong relationship between both organizations from their beginnings in the early 1900s. In addition to this dynamic program, the CoC initiated the concept of the Cancer Management Course in 1983 with the plan to have it offered throughout the U.S. This concept eventually led to the expansion of the course internationally. At the end of the decade, the decision was made to only offer the Cancer Management Course in international locations. To enhance hospital registries, the Data Acquisition Manual (DAM) was published, which codified patient abstracts contributed from approved programs. These codes would be critically necessary for patient data collection into the NCDB, and DAM would undergo several revisions in future years.
1992–2002: The largest shopping center in the U.S., the Mall of America, opens
The multidisciplinary structure of the CoC continued to evolve during this decade. By 1994, the CoC had 30 member organizations with representatives who could be elected for two two-year terms. By 1993, the entire membership of the CoC had grown to 100 members. As the decade began, there were 1,320 approved programs that were treating 70 percent of all cancer patients in the U.S. and Puerto Rico. Under the auspices of the CoC, a Tumor Board Textbook was developed to highlight the importance of holding multidisciplinary meetings to discuss patient management before beginning treatment. To enhance its educational mission, the CoC held its inaugural Annual Cancer Conference in 1996. Attendees included cancer registrars, hospital administrators, and other allied cancer care professionals.
For the first time, a clinical trial group was created with assistance from the CoC. The American College of Surgeons Oncology Group (ACOSOG) was led by Samuel A. Wells, MD, FACS, former Chair of the CoC. ACOSOG sought funding from NCI. The monograph, Tumor Board Case Management, was published in 1996. A new Cancer Program Standards Manual and a revision of the registry coding manual, Registry Operations and Data Standards, were published. By the decade’s end, the NCDB was proving to be a robust source of data for developing clinically focused peer-reviewed literature, with 95 articles having been published in the previous five years.
2002–2012: Department of Homeland Security is created
This decade continued the significant growth and maturation of CoC programs. Representatives from NCI Comprehensive Cancer Centers joined with the CoC in creating appropriate standards for accrediting NCI Comprehensive Centers. The importance of cancer care metrics was highlighted by launching the Cancer Program Practice Profile Reports (CP3R) initiative. The first benchmarks for assessing cancer care were developed for breast and colorectal cancer. An updated Cancer Program Standards, 2004, was introduced. To prepare for the launch of these standards in 2006, an educational program, Survey Savvy, was inaugurated. An effort was begun to increase participation among the U.S. Department of Veterans Affairs (VA) hospitals in the approvals program. Refined standards for VA hospitals were introduced.
An initial group of 40 surveyed hospitals was accorded the Outstanding Achievement Award to recognize excellence in meeting CoC standards. The National Comprehensive Cancer Network was added to the CoC as the 40th member organization. The first State Chair Outstanding Achievement Awards were presented. The first CoC Cancer Research Paper Competition winner gave her presentation at the Annual CoC Meeting in 2008. A public awareness campaign was launched through billboards in the Chicago O’Hare and Atlanta Hartsfield airports to educate the public regarding the importance of having cancer care at a CoC-approved cancer program. The NCDB celebrated its 20th year of collecting data that were used to improve overall outcomes and to enhance clinical research.
2012–2022: Encyclopedia Britannica discontinues its print edition
This decade has been characterized by the development of new and important patient-centered accreditation standards. Beginning in 2014, a workgroup revised all standards and created new benchmarks for patient navigation, quantification of psychosocial distress, and use of survivorship documents for patients. By the decade’s end, these standards were further enhanced with metrics for assessment and introduced, for the first time, the creation of benchmarks to highlight operative strategies for several of the more frequent cancer operations. The effectiveness of these standards, created with the input of many of the 59 member organizations, will resonate well into the 11th decade of the CoC.
The CoC continued to play a leadership role in developing codes for registry abstracting with the revision of the Facility Oncology Registry Data Standards manual. The new Standards for Oncology Registry Entry (commonly known as STORE) manual updated operative codes and streamlined information critical for inclusion into the NCDB.
Finally, this decade will be remembered for the coronavirus 2019 (COVID-19) pandemic that affected all aspects of the CoC footprint. Unlike World War II, during which cancer care activities virtually ceased, with the help of virtual platforms the CoC continued to highlight the work of the commission and demonstrated the creativity and nimbleness of this unique organization, its members, and the incredibly dedicated professional staff that drive the engine. With all of this as a preamble, we look forward to the next 100 years.
