Cancer Program Guidelines
Chapter 2: Cancer Committee
Section 1: Cancer Committee Leadership
The Cancer Committee provides program leadership
The Cancer Committee develops, approves, and implements the strategic plans, goals, and objectives for new programs and provides oversight for ongoing programs and services.
- The Cancer Committee is formalized by the medical staff or facility, establishing responsibility, accountability, and multidisciplinary membership required to fulfill its role.
- The Cancer Committee requests administrative leadership to obtain and maintain program approval by the American College of Surgeons’ Commission on Cancer.
- Cancer Committee members include multidisciplinary representation: physicians, clergy, nurses, social workers, nutritionists, pharmacists, rehabilitation specialists, hospital administrators, diagnostic imaging staff, quality improvement staff, and cancer registry staff. Public representation may be considered.
- The Cancer Committee meets regularly to assure that the administrative responsibilities of the cancer program leadership are carried out. In network programs, these meetings occur at least bi-monthly. In large programs, the Cancer Committee establishes subcommittees to manage specific activities, such as cancer conference activity, quality control of registry data, quality management, community outreach, and research.
- The Cancer Committee functions to:
- Promote a coordinated multidisciplinary approach to patient management at all levels.
- Assure that consultative services in all disciplines are available and that education and multidisciplinary cancer conference review activities cover all major cancer sites and issues of cancer care.
- Initiate patient care audits and review similar data supplied by other hospital committees.
- Supervise the cancer registry and assure accurate, timely abstracting, staging, and reporting of data.
- Set the frequency of the cancer conference, which encourages and helps to assure multidisciplinary involvement (The minimum percentage of cases required by the American College of Surgeons’ Commission on Cancer [Standard 2.8] is a criterion for setting the number of conferences.)
- Set the attendance requirement for the cancer conference such that multidisciplinary attendance is based on the type of cases seen in the facility and the format of the conference, such as facility- or network-wide, departmental, site focuses, or grand rounds (The Commission on Cancer [Standard 2.7] requires an annual re-evaluation.)
- Evaluate patient care outcomes, financial outcomes, resource utilization, and other designated continuous quality improvement monitors throughout the year; make improvements based on service and program goals.
- Review results of treatment at the facility as part of outcomes assessment.
- Complete and document studies initiated by the Committee that measure quality and outcomes (The requirements of the Commission on Cancer [Standards 8.1 and 8.2] are considered such that a minimum of two improvements that directly affect cancer patient care are documented. In addition, the Cancer Committee recommends and supports implementation of program enhancements or new programs. The Cancer Committee should be involved in the planning and implementation of all facility cancer programs.)
- Set annual goals and measurable objectives and implement a process for evaluating the effectiveness of its programs. [Commission on Cancer Standard 2.5]
- Designate one coordinator for areas of cancer committee activity, to include but not limited to, cancer conference, quality control of cancer registry data, quality improvement, and community outreach. [Commission on Cancer Standard 2.3. Other coordinators should be designated, especially in large programs, for activities such as research and policy development and renewal.
Please note: While every attempt has been made to ensure the accuracy of the publications, addresses, phone numbers, and websites, ACCC cannot ensure that this information has not changed. Web addresses, in particular, change frequently. If you find that a web address has changed, try to locate the publication name through an online search engine.
- American College of Surgeons. Commission on Cancer: Cancer Program Standards 2009. Available at: http://www.facs.org/cancer/coc/programstandards.html.
Phone: 312.202.5000 or 800.621.4111.
- National Cancer Registrars Association. NCRA Publications.
www.ncra-usa.org. Phone: 703.299.6640.
Section 2: The Multidisciplinary Cancer Conference
The Cancer Committee assumes accountability and responsibility for multidisciplinary cancer conference(s). Multidisciplinary cancer case presentations are conducted on a timely basis to ensure that all patients and practitioners have access to consultative services.
A multidisciplinary cancer conference provides prospective patient case review and assures quality of care evaluation related to diagnosis, treatment, symptom management, follow-up, rehabilitation, and supportive care.
- Patient management discussion includes, but is not limited to:
- Multidisciplinary participation
- Sharing of expert clinical opinions and treatment recommendations
- Treatment decision made by the attending physician and patient
- Opportunities for participation in clinical trials.
- The cancer conference is organized as described in Section 1 of this chapter:
- Accountability is assumed by the Cancer Committee.
- Responsibility for organizing the cancer conference(s) is designated by the Cancer Committee. This responsibility should rest with an individual, such as conference chairman, or the designated coordinator as described in Section 1 of this chapter. Alternatively, it could rest in the department, such as the Cancer Registry
- The cancer conference meets a minimum of monthly, more frequently if accreditation is sought through the American College of Surgeons. (See References for additional information.)
- Site-specific conferences are conducted where there are sufficient cases.
Cancer conference case presentation is prospective in nature and influences treatment choices.
Prospective case presentation assures that patients newly diagnosed or under treatment and requiring review have access to multidisciplinary evaluation, including staging, treatment management, and follow-up evaluation.
- Cases presented must be representative of the disease processes managed at the cancer center.
- All disciplines managing cancer must regularly present cases in a timely fashion and manner as stated in Guideline I of this section.
- All caregivers should have the opportunity to present and discuss individual cases in a timely fashion.
- Case presentations at conferences include:
- Comprehensive clinical summary provided by attending physician or designee
- Review of radiologic films
- Review of pathology slides
- Clinical management discussion and recommendation(s) sought
- Consideration for clinical trials.
- A record of conference dates, disease sites presented, and type of review (prospective or not) is maintained.
The cancer conference contributes to the education of all healthcare providers.
Prospective, multidisciplinary case review and discussions generate new knowledge; provide a review of basic clinical management principles; provide opportunities for discussion of research eligibility; improve effectiveness of cancer care; identify areas for audit review; identify possible community needs for education, screening, detection, and prevention; and provide a mechanism for physicians and health care providers in outlying communities to access information.
- Provide prospective case review
- Are comprised of no more than 25 percent didactic lectures
- Are based on recent literature and new information
- Provide review of basic cancer management principles
- Provide education of health professionals
- Are considered for CME and other education credits.